Valor de la eosinofilia y la IgE sérica total como predictores de la sensibilización a alergenos comunes en niños con asma / Eosinophilia and total serum IgE as predictors of sensitization to common allergens in children with asthma

Objetivo: Cuantificar sensibilidad (S), especificidad € y valores predictivos positivos (VPP) y negativos (VPN) para diversos puntos de corte de la eosinofilia en sangre y en moco nasal, de la IgE sérica total (en U/mL y en desviaciones estándar), como marcadores de sensibilización a alérgenos comunes en niños asmáticos. Métodos: Se midieron estos marcadores en 144 niños asmáticos, a quienes se realizó estudio alergológico individualizado. Como “patrón oro” de sensibilización se utilizó la positividad en pruebas cutáneas y/o RAST. Resultados: La eosinofilia absoluta en sangre presentaba un mejor punto de corte como sugestivo de alergia en ≥ 450 eosinófilos/mm3 , con S y E del 52 y el 71% y VPP del 61% y VPN del 63%. La eosinofilia porcentual en sangre, con el mejor punto de corte en ≥ 6%, tenía unos valores en el mismo orden del 56, 79, 70 y 67%. La eosinofilia en moco nasal, presentaba valores del 33, 89, 71 y 62% para un punto de corte de >25%. La IgE sérica total, con punto de corte en >100 U/mL, mostraba el 60, 92, 86 y 74%, y en desviaciones estándar, el mejor punto de corte era superior a +3 DE, con valores del 30, 89, 69 y 60%. Conclusiones: Aunque el valor diagnóstico de los tests es bajo, el conocimiento de sus valores predictivos para diversos puntos de corte permitirá una mejor evaluación de la actitud sobre indicación de estudio alergológico en el asma infantil (AU)

Aim: To quantify sensitivity, specifity and positive (PPV) and negative (NPV) predictive values, with several cut-off points, of eosinophlis in blood and nasal mucosa and of total serum IgE (in U/ml and standard deviations), as markers of sensitization to common allergens in asthmatic children. Methods: These markers were measured in 144 children with asthma, in whom and individualized allergologic testing was performed. Positive results in skin tests and/or RAST were used as the gold standard for sensitization. Results: A sensitivity and a specificity of 52% and 71%, respectively, were found for blood absolute eosinophilia, and the PPV blood absolute eosinophilia, and the PPV and NPV were 61% and 63%, using a cut-off point of ≥450 eosinophils/mm3. Using a cut-off point of ≥6% of blood eosinophils, these values were 56%, 79%, 70% and 67%, respectively. Nasal mucosa eosinophilia (cut-off point at 25%) had values of 33%, 89%, 71% and 62%, respectively. Total serum IgE showed values 60%, 92%, 86% and 74% respectively, for a cut –off point of >100 U/ml. In standard deviations, with a cut-off point of >+3 s.d., the sensitivity and specificity were 30% and 89%, and PPV and NPV were 69% and 60%. Conclusions: Although the diagnostic values of these tests are low, the knowledge of their predictive values for several cut-off points will allow a better evaluation for decision-making concerning when to perform allergologic tests in asthmatic children (AU)

La evaluación de la atención primaria y las hospitalizaciones por ambulatory care sensitive conditions. Marco conceptual / Primary care evaluation and hospitalisation due to ambulatory care sensitive conditions. Conceptual framework

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[Inappropriate use of pediatric hospitalization]. / Utilización inapropiada de la hospitalización pediátrica.

OBJECTIVE: Our aim was to identify the inappropriate utilization of pediatric hospitalization, its reasons and associated factors. PATIENTS AND METHODS: Three hundred twenty-three medical records were randomly selected among the patients aged 6 months to 14 years and hospitalized in 1995 in a public hospital of the Community of Valencia. The validated Spanish version of the "Pediatric Appropriateness Evaluation Protocol" was retrospectively applied. The proportions of inappropriate admissions and stays and their reasons were estimated and their association with certain factors analyzed. RESULTS: Of the admissions 17.7% (95% CI: 13.5-21.8) and 15.5% of the stays (95% CI: 11.5-19.4) were considered inappropriate. The most frequent reason for inappropriate admission was that diagnostic and therapeutic needs might have been solved by ambulatory care. Inappropriate stays were in mot cases (70%) due to that doctors did not pay attention to keeping the patient in the hospital although acute care was no longer needed. Female patients, non-elective admissions, admissions by general pediatricians or traumatology and weekend stays had significantly higher proportions of inappropriate utilization. CONCLUSIONS: A considerable proportion of inappropriate admissions and stays was observed, although it is in the lower range of those observed in other studies in pediatric patients. The most frequent reasons were attributed to an excessively conservative medical practice.

[Inappropriate utilization of pediatric hospitalization. Validation of the pediatric appropriateness evaluation protocol Spanish version]. / Uso inapropiado de la hospitalización en Pediatría. Validación de la versión española del Pediatric Appropriateness Evaluation Protocol.

OBJECTIVE: To validate the Spanish version of the Pediatric Appropriateness Evaluation Protocol (PAEP). METHODS: The protocol was applied by two independent reviewers to a sample of 104 clinical records of pediatric patients (age 6 months to 14 years) admitted to a general hospital in the Valentian Community. Reliability was tested by comparing their results. Validity was tested by comparing the results of one reviewer with the judgment of three pediatricians. The following measures were calculated: overall agreement (IO), specific agreement (IE), Cohen's κ, inappropriate use ratio, and, to evaluate the predictive value, sensitivity, specificity and positive and negative predictive value. RESULTS: Interobserver reliability was high: the IO for admissions was 94.2% and 96.2% for days of care. The IE was 66.7% and 75% respectively, and κ showed values of excellent agreement: 0.77 (95% CI 0.59-0.94) for admissions and 0.83 (95% CI 0.68-0.99) for days of care. Validity was moderate: the IO for admissions was 92.35, and 90.4% for days of care. The IE was 60% and 58.3% respectively, and κ showed values of good agreement: 0.70 (95% CI 0.51-0.90) for admissions and 0.68 (95% CI 0.50-0.86) for days of care. Inappropriate use ratio was 1.13 for admissions and 0.73 for days of care. The sensitivity and specificity were high for admissions (80% and 94% respectively), while sensitivity was lower for days of care (64% and 98%). Regarding the prevalence of inappropriate use of this study, the positive predictive value ranged between 71% and 88%, and the negative predictive value ranged between 97% and 91%. CONCLUSIONS: PAEP has a high reliability, moderate validity and good predictive value face to clinical judgment, and it is a useful instrument for assessing the inappropriate utilization of pediatric hospitalization.

[An analysis of the relationship between morbidity and the level of demand for pediatric primary care. A study on 1359 children]. / Análisis de la relación entre morbilidad y nivel de demanda en Atención Primaria pediátrica. Un estudio sobre 1.359 niños.

OBJECTIVE: To analyse the relationship morbidity and utilization in the context of paediatric primary health care. To verify if the morbidity of children who most use primary care qualitatively different from the rest of the population. PATIENTS AND METHODS: Prospective study of the utilization and morbidity over one year in two offices paediatric in a Health Center. Reasons for consulting were grouped into generic types of morbidity, analysing the different types of morbidity of each patient in relation to their level of use. RESULTS: Acute problems were the main reason behind demand. 85% of high users as opposed to 12% of low users showed recurrent morbidity and 23% as opposed to 7% showed chronic medical morbidity. 1.5% of high users as opposed to 47% of low users presented acute morbidity. Recurrent morbidity was associated with greater use due to acute morbidity and non-specific signs or symptoms. The child who only presented with acute type problems in the first half-year was less likely (relative risk: 0.57, IC 95%, 0.43-0.67) to be a high user in the second half. CONCLUSIONS: Children with high level of use group together and chronic medical morbidity whereas those with low level of demand more often present exclusively acute problems. The most part of visitor is caused by acute problems which patients who most consult present to a greater extent than the rest. Recurrent morbidity conditions greater demand due to acute and non-specific problems which are not necessarily associated from the biological point of view with the underlying illness.

[Avoidable pediatric hospitalization in the Community of Valencia and Catalonia]. / Hospitalización pediátrica evitable en la Comunidad Valenciana y Cataluña.

OBJECTIVE: To estimate the rates of avoidable pediatric hospitalization in the health areas of the Valencia Community and health sectors of Catalonia, and to analyze if they are related to socioeconomic level or development of primary care. METHOD: Available paediatric (0-14 years old) hospitalizations were analyzed using the Minimum Basic Data Set of Hospital Discharge in two Autonomous Regions: the Valencia Community and Catalonia (1993-1994). Variables analyzed included age, gender, socioeconomic level and coverage by the new model of primary care. Crude and standardized rates for age were calculated and the variation in areas and sectors was assessed. The association between rates and socioeconomic and primary care characteristics was analyzed. RESULTS: Avoidable paediatric hospitalizations represent 21% of all paediatric hospitalizations in the Valencia Community and 15% in Catalonia. Crude rates for Valencia Community ranged between 5.7 and 12.7 in 1993 and 6.6 and 17.8 in 1994; extreme quotient was 2.2 and coefficient of variation 37% in 1993 and 2.7 and 48% respectively in 1994. For Catalonia they ranged between 2.7 and 24.3 in 1993 and 1.4 and 23.8 in 1994; extreme quotient was 9 and coefficient of variation 52% in 1993, and 7 and 42% in 1994 respectively. All these differences were significant (p < 0.005). There was no significant correlation between socioeconomic level and development of primary health care and rates of avoidable paediatric hospitalization by health areas or sectors. CONCLUSIONS: Avoidable paediatric hospitalization represent a significant proportion of paediatric hospitalizations. There are differences in avoidable paediatric hospitalization rates by health areas and sectors, not associated with socioeconomic level and primary care indicators.

[Variations in hospitalization rates of non-neonatal hospital admissions to pediatric departments of three district hospitals]. / Variaciones en las tasas de hospitalización pediátrica no neonatal en tres hospitales de distrito.

Hospitalization rates of children from three health districts were analyzed. The rates ranged from 30 to 40 admissions per 1000 children. The length of hospital stay, the rates of transfers and deaths were similar. Admission rates were different for certain selected diagnoses: gastroenteritis, pneumonia, bronchiolitis, head trauma and ear, nose and throat procedures. The variations were not related to differences in physician or bed supply, nor to severity or the disease of a delay in getting medical care. The demographic and geographic characteristics and the different patterns of practice can be associated with the observed variations. The health status of these children must be determined before considering which rate is correct.

[The investigation of the contacts of the tuberculous pediatric patient]. / La investigación de contactos en el paciente tuberculoso pediátrico.

BACKGROUND: Results of contacts investigation of tuberculous pediatric patients, usually non-infectious, are shown. Their relationship to the clinical situation on index case and the intimacy of exposure is analyzed. METHODS: 714 contacts of 111 pediatric cases (53 category II and 58 category III, according to the American Thoracic Society classification). The tuberculin skin test with 2 units of PPD-RT23 was used to identify the infected persons. Chest radiography, sputum smear and culture examination were used to diagnose current pulmonary disease. According to the intimacy of exposure to index case, contacts were defined as household, close or sporadic contacts. The possible association with clinical situation of index case and intimacy of exposure was analyzed. RESULTS: 41 new cases of tuberculosis were detected, 7 of them were infectious. Prevalence of tuberculous infection among contacts was 44%. Quimioprofilaxis was indicated to 126 contacts. The prevalences of infection and disease according to clinical situation and degree of contact did not differ significantly. CONCLUSIONS: it is advisable to investigate the contacts of tuberculous pediatric patients, even in cases of tuberculous infection without disease; the investigation must include close and sporadic contacts.

[Tuberculous infection in Sagunto: infection indicators and study of tuberculin-positive children contacts]. / Infección tuberculosa en Sagunto: indicadores de infección y estudio de los contactos de los niños tuberculín-positivos.

After having ascertained their relevance, epidemiologic indicators of tuberculosis infection were calculated in the area of coverage of a district hospital. For this purpose, a tuberculinic survey was undertaken among students of 2nd. and 8th. grade (EGB) and among those of 1st. grade during two consecutive courses. A prevalence of 2.08% (+/- 1.08%) in 1st. grade (in 1986-87), of 1.18% (+/- 0.87%) in 1st. grade (in 1987-88), of 1.13% (+/- 0.79%) in 2nd. grade (in 1987-88) and of 2.19% (+/- 1.10%) in 8th grade (in 1987-88). The annual incidence of infection in the studied period was 0. The Annual Risk of Infection (ARI) was lower than 0.12% with an annual reduction of 57%. This is the first time that indicators of infection are obtained in a population of the region of Valencia, and are compared with other populations. We outline the benefits of the investigation of the source of infection and of the family contacts. Fourty-eight Mantoux (+) children were detected, of which 8 had tuberculosis, 1 had residual lesions, and the remaining ones were at the infectious stage. Among the 105 studied adults, 60 were Mantoux (+), of which 6 had tuberculosis, 2 of them were smear (+) and 5 had residual lesions. Chemoprophylaxis was initiated in 14 cases.