Point of care testing: transcutaneous bilirubinometry in neonates.

Physicians taking care of infants in the first days of life are often faced with neonatal jaundice, especially in an era where post-partum discharge occurs earlier and assessment of newborn bilirubinemia status is required prior to discharge. The Canadian Pediatric Society and the American Academy of Pediatrics have developed and published guidelines for the diagnosis and management of hyperbilirubinemia in newborns. Point of care testing refers to any test performed outside of laboratory by clinical personnel and close to the site of patient care. Based on a summary of multiple reports during the last twenty years, we realize that devices which provide a non-invasive transcutaneous bilirubin (TcB) measurement have proven to be very useful as screening tools and provide a valid estimate of the total serum bilirubin level (TSB). Published data suggest that these devices provide measurements within 30-50 micromol/L of the TSB levels and can replace laboratory measurement particularly when TSB levels are less than 260 micromol/L. At the present time, in the literature, evidence is insufficient to abandon neonatal serum bilirubin testing and replace it with TcB. Any measurement, TSB or TcB, has potential for error. However, we have evidence that TcB, can help avoiding potential errors associated with even visual assessment of jaundice and may be useful as screening device to detect significant jaundice and decrease a large number of unnecessary skin punctures. The current manuscript is based on a careful comprehensive literature review concerning neonatal hyperbilirubinemia. We consider that this manuscript will help clinicians and laboratory professionals in the management of neonatal jaundice.

[Should pulmonary computed tomography be performed in children with tuberculosis infection without apparent disease?]. / Debe realizarse una tomografía computarizada torácica a los niños con infección tuberculosa sin enfermedad aparente?

BACKGROUND: During early childhood, in particular, there is a continuum between tuberculosis infection and disease. When establishing the diagnosis in a child with suspected tuberculosis, the distinction between infection and disease frequently depends on the interpretation of the chest X-ray. Some studies have shown hilar and mediastinal lymphadenopathies on computed tomography (CT) in children with tuberculosis infection without apparent disease, i.e., asymptomatic children with a positive tuberculin skin test and normal chest X-ray. These observations raise the issue of whether pulmonary CT should be performed in children with tuberculosis infection without apparent disease and whether different types of therapy should be administered depending on the results. METHODS: We reviewed the physiopathology of tuberculosis infection and disease, diagnostic methods and treatment, and the literature on the use of pulmonary CT scan in pediatric tuberculosis. RESULTS: Modern CT scanners indicate hilar and mediastinal lymphadenopathies in many of the children with tuberculosis infection with no apparent disease on chest X-rays. However, neither the size nor the morphology of these adenopathies allows active tuberculosis to be diagnosed. The natural history of childhood tuberculosis indicates that most children show hilar lymphadenopathies after the primary infection, although progression to disease is rare and is characterized by the presence of clinical symptoms. The exceptions are children younger than 4 years old and those with immune alterations who more frequently show progression of infection to disease and who require close follow-up. In addition, the experience accumulated over many years in the treatment of tuberculosis infection with isoniazid has shown this drug to be effective in both short- and long-term prevention of active disease. Official guidelines and expert opinion do not recommend systematic pulmonary CT scan in these children or modification of treatment according to the results. CONCLUSIONS: Hilar and mediastinal lymph nodes are frequently found in the CT scans of children with tuberculosis infection without apparent disease but there is no evidence that these adenopathies indicate active disease or that these children require different treatment. Consequently, until demonstrated otherwise, pulmonary CT scanning and changes in chemoprophylaxis are not justified in children with tuberculosis infection.

¿Debe realizarse una tomografía computarizada torácica a los niños con infección tuberculosa sin enfermedad aparente? / Should pulmonary computed tomography be performed in children with tuberculosis infection without apparent disease?

Antecedentes En la infancia, la infección y la enfermedad tuberculosa forman parte de una acción continua. Cuando se hace la evaluación diagnóstica de un niño con sospecha de tuberculosis, la distinción entre infección o enfermedad recae con frecuencia en la interpretación de la radiografía de tórax. Algunos estudios han puesto de manifiesto mediante tomografía computarizada (TC) la presencia de adenopatías hiliares y mediastínicas en niños con infección tuberculosa sin aparente enfermedad, es decir, asintomáticos, con tuberculina positiva y con radiografía de tórax normal. Estos hallazgos abren el debate de si es necesario realizar TC torácica a niños con infección tuberculosa sin enfermedad aparente y si hay que administrar un tratamiento distinto según su resultado. Métodos Se analiza la fisiopatología de la infección y la enfermedad tuberculosa, su diagnóstico y tratamiento y la bibliografía existente sobre la utilización de la TC en la tuberculosis infantil. Resultados Las modernas TC helicoidales visualizan ganglios linfáticos hiliares y mediastínicos en muchos de los niños con infección tuberculosa sin aparente enfermedad. Sin embargo, ni por el tamaño ni por la morfología de estas adenopatías se puede afirmar que se correspondan con enfermedad activa. La historia natural de la tuberculosis indica que la mayoría de los niños presentan adenopatías hiliares tras la infección inicial y que la evolución a enfermedad es infrecuente y se caracteriza por la presencia de síntomas clínicos. La excepción la presentan los niños menores de 4 años y los niños con alteraciones de la inmunidad, en los que la infección progresa con mayor frecuencia a enfermedad y en los que habrá que hacer un estrecho seguimiento. Además, la experiencia acumulada durante muchos años en el tratamiento de la infección tuberculosa con isoniacida ha demostrado su eficacia a corto y a largo plazo en la prevención de la enfermedad activa. Los consensos oficiales y la opinión de expertos no recomiendan la realización de TC en estos niños ni adecuar el tratamiento a sus resultados. Conclusiones Con frecuencia se encuentran ganglios en zonas hiliares y mediastínicas al realizar una TC en niños con infección tuberculosa sin enfermedad aparente. Sin embargo, no existen evidencias de que estos hallazgos se correspondan con enfermedad activa ni de que haya que tratarlos como tal. Mientras no se demuestre lo contrario, a los niños con infección tuberculosa no es necesario realizarles una TC torácica y se les debe administrar el tratamiento actualmente recomendado

Background During early childhood, in particular, there is a continuum between tuberculosis infection and disease. When establishing the diagnosis in a child with suspected tuberculosis, the distinction between infection and disease frequently depends on the interpretation of the chest X-ray. Some studies have shown hilar and mediastinal lymphadenopathies on computed tomography (CT) in children with tuberculosis infection without apparent disease, i.e., asymptomatic children with a positive tuberculin skin test and normal chest X-ray. These observations raise the issue of whether pulmonary CT should be performed in children with tuberculosis infection without apparent disease and whether different types of therapy should be administered depending on the results. Methods We reviewed the physiopathology of tuberculosis infection and disease, diagnostic methods and treatment, and the literature on the use of pulmonary CT scan in pediatric tuberculosis. Results Modern CT scanners indicate hilar and mediastinal lymphadenopathies in many of the children with tuberculosis infection with no apparent disease on chest X-rays. However, neither the size nor the morphology of these adenopathies allows active tuberculosis to be diagnosed. The natural history of childhood tuberculosis indicates that most children show hilar lymphadenopathies after the primary infection, although progression to disease is rare and is characterized by the presence of clinical symptoms. The exceptions are children younger than 4 years old and those with immune alterations who more frequently show progression of infection to disease and who require close follow-up. In addition, the experience accumulated over many years in the treatment of tuberculosis infection with isoniazid has shown this drug to be effective in both short- and long-term prevention of active disease. Official guidelines and expert opinion do not recommend systematic pulmonary CT scan in these children or modification of treatment according to the results. Conclusions Hilar and mediastinal lymph nodes are frequently found in the CT scans of children with tuberculosis infection without apparent disease but there is no evidence that these adenopathies indicate active disease or that these children require different treatment. Consequently, until demonstrated otherwise, pulmonary CT scanning and changes in chemoprophylaxis are not justified in children with tuberculosis infection

Fiebre reumática aguda / Acute rheumatic fever

No disponible

Results and complications of Toupet partial posterior wrap: 10 years' experience.

A 270 degrees posterior wrap, described by Toupet, was performed in 112 patients with medically refractory gastroesophageal reflux (GER) over a 10-year period. The mean age was 39 months (range, 2 months to 19 years). Thirty percent of the patients were neurologically impaired (NI). The approximation of the crura, the posterior fixation of the wrap, and the posterior partial fundoplication were performed with nonabsorbable sutures, over a bougie. Thirty percent of the NI and 15% of the neurologically normal (NN) children underwent a gastrostomy. Early postoperative complications were found in 24% of NI and 18% of NN children; these were treated medically, except for two bowel obstructions. Eight patients died for reasons unrelated to surgery, and nine were lost to follow-up. The mean follow-up period for the 95 remaining patients was 3.5 years for NI and 4.9 years for NN children. The evaluation showed that 6 patients had temporary dysphagia and two had food impaction. Nine wrap herniations (10%) were found; three of them without symptoms were noted by routine upper gastrointestinal series and received no treatment. Six wrap herniations with recurrent reflux were reoperated on successfully. With 90% of patients free of symptoms, the results of the Toupet procedure compare favorably with those of the Nissen fundoplication because of the retained ability to belch or vomit.

Determinants of the Doppler flow velocity profile through the mitral valve of the human fetus.

OBJECTIVE: A normal fetal flow velocity profile through the atrioventricular valves early in gestation is characterised by a higher late peak (A) than early peak (E) velocity waveform, whereas the E/A ratio is known to increase throughout pregnancy. This study aims firstly to identify which of the two variables, E or A, is the contributory factor to the increased E/A ratio and secondly to assess the relative influence of gestational age, heart rate, and stroke volume on the flow velocity profile through the fetal mitral valve. DESIGN: Eighty normal fetuses from 18 to 38 weeks of gestation were examined by Doppler echocardiography. The variables measured were E and A waves, the early and late flow velocity integrals (EI and AI), and the total filling velocity integral (TI). The ratios E/A and EI/AI were also calculated. Transvalvar flow was obtained by multiplying TI by mitral area. Associations between Doppler variables and gestational age, heart rate, and stroke volume were assessed by multifactorial Anova and simple or multiple stepwise regression analyses. RESULTS: The results showed that the heart rates found did not affect flow velocity variables. There were only weak correlations between both A and AI values and gestational age (negative) and volume load (positive). With the advance in gestation, a significant increase in the early filling E wave was found. The E wave was also positively correlated with stroke volume. CONCLUSION: Contrary to the accepted concept that changes in fetal E/A ratio are related to an improvement in ventricular compliance, this study shows that only the E wave changes. Although these results cannot establish whether changes in the ventricular relaxation process or volume load are responsible for the progressive increase of the E wave, indirect evidence suggests that ventricular relaxation is in fact the most important contributory factor.