Variabilidad e idoneidad del tratamiento antimicrobiano de las otitis agudas pediátricas en Asturias / Variability of antibiotic treatment in paediatric acute otitis media in Asturias (Spain)

Introducción: La otitis media aguda (OMA) es la infección bacteriana más común en la edad pediátrica, y la que requiere con más frecuencia prescripción antibiótica. Objetivos: Analizar la variabilidad e idoneidad de los hábitos de prescripción de antimicrobianos en niños diagnosticados de OMA en Asturias. Métodos: Estudio descriptivo, retrospectivo y multicéntrico, que evalúa pacientes pediátricos diagnosticados de OMA en los servicios de urgencias de cinco hospitales asturianos y en las consultas de 80 pediatras de atención primaria. La idoneidad de las prescripciones antibióticas se estableció mediante comparación con estándares de referencia. Resultados: Se recogieron datos de 420 OMA pediátricas, 36,2% en atención primaria y 63,8% en urgencias hospitalarias (5,1% de las consultas pediátricas). Se prescribieron antibióticos en el 89,8% de las OMA. Los antibióticos más pautados fueron amoxicilina (41,4% de los casos que recibieron antibioterapia) y amoxicilina-clavulánico (39,8%). La prescripción antibiótica fue más frecuente en el hospital que en los centros de salud (el 93,7 frente al 82,9%; p <0,01). El tratamiento fue adecuado en el 86,4% de los casos. La idoneidad de la prescripción fue mayor en el hospital (9% inadecuados) que en atención primaria (21,7% inadecuados) (p <0,01), y también cuando la prescripción la realizaban MIR de pediatría (4,4% inadecuados), médicos de familia (6,8% inadecuados) y otros facultativos (10,2% inadecuados) que cuando la realizaban pediatras (19% inadecuados) (p <0,01). Conclusiones: Las OMA suponen el 5% de las consultas pediátricas en nuestro medio y la mayoría reciben tratamiento antibiótico. La antibioterapia pautada es mayoritariamente correcta, aunque la idoneidad es mayor en los casos atendidos en urgencias hospitalarias (AU)

Introduction: Acute otitis media (AOM) is the most frequent bacterian infection in paediatric population and accounts for the largest portion of antibiotic prescriptions in pediatric offices. Objective: The aim of the study was to analyze the variability and appropriateness of antimicrobial prescriptions in children with diagnosis of AOM in emergency departments and pediatric primary care consultations in Asturias (Spain). Methods: Multicenter descriptive study evaluating retrospectively pediatric patients with AOM diagnosis in 5 hospital emergency departments and 80 pediatric primary care clinics in Asturias. Appropriateness of prescription was established by comparing with reference standards. Results: Four hundred twenty cases of AOM (36.2% in primary care and 63.8% in hospital emergency departments) were included (5.1% of pediatric visits). Antibiotics were prescribed in 89.8% of cases. Amoxicillin and amoxicillin/clavulanate were the most frequently prescribed antibiotics (41.4 and 39.8%). Significant differences in the frequency or antibiotic prescription were found between hospital emergency departments and primary care (93.7 vs 82.9%; p <0.01). The prescribed treatment was considered appropriate in 86.4% of cases. The appropriateness of antibiotic prescription was higher in hospitals, and also when prescription was performed by pediatric Internal Medical Resident (4.4% inadequate), family doctors (6.8% inadequate) and other medical doctors (10.2% inadequate), than was performed by pediatricians (19% inadequate) (p <0.01). Conclusions: Acute otitis media acounts for 5% of pediatric visits in our area and most of them are treated with antibiotics, being amoxicillin the most frequently prescribed. Antibiotic therapy is largely correctly prescribed, with the best appropriateness in cases treated in hospital emergency departments (AU)

Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños / Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery

Introducción y objetivos: En el postoperatorio de la cirugía cardíaca se produce una respuesta inflamatoria sistémica que dificulta la identificación de complicaciones. El objetivo fue estudiar el comportamiento de la proteína C reactiva (PCR) y la procalcitonina (PCT), valorando su relación con la gravedad y analizando su utilidad para detectar complicaciones. Métodos: Se estudió prospectivamente a 59 niños intervenidos mediante cirugía cardíaca abierta. Se determinaron la PCR y la PCT al ingreso en una unidad de cuidados intensivos pediátricos, a las 24, a las 48 y a las 72h. Se analizó la relación de la PCR y la PCT con la gravedad clínica valorada mediante las escalas Pediatric Risk Mortality y Therapeutic Intervention Scoring System, y el desarrollo de complicaciones (infecciosas y hemodinámicas). Resultados: La PCR y la PCT aumentaron en las primeras 24h, disminuyendo progresivamente en los 2 días posteriores. La PCR no se relacionó con la gravedad ni con la aparición de complicaciones. La PCT tras la cirugía, a las 24 y a las 48h presentó una moderada correlación con el Pediatric Risk Mortality (r=0,548; 0,434 y 0,446, respectivamente) y una baja con el Therapeutic Intervention Scoring System. Se obtuvieron unos puntos de corte para la PCT>0,17ng/ml (sensibilidad del 73,3%, especificidad del 72,2%) al ingreso y >1,98ng/ml (sensibilidad del 57,1%, especificidad del 87%) a las 48h para detectar complicaciones. No existieron diferencias en la PCR ni en la PCT entre los pacientes con complicaciones infecciosas y hemodinámicas. Conclusiones: En el postoperatorio de la cirugía cardíaca pediátrica la PCR no se correlaciona con la gravedad ni con la presencia de complicaciones. La PCT se correlaciona con la gravedad y puede detectar complicaciones posquirúrgicas (AU)

Introduction and objectives: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. Methods: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). Results: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. Conclusions: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications (AU)

[Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]. / Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños.

INTRODUCTION AND OBJECTIVES: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. METHODS: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). RESULTS: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. CONCLUSIONS: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.

Mirando hacia los próximos 25 años / 25 years ago

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[Family impact of rotavirus gastroenteritis in children under two years]. / Impacto familiar de la gastroenteritis por rotavirus en menores de dos años.

INTRODUCTION: Acute gastroenteritis (AGE) in infants has a significant impact on the quality of life of their parents. MATERIAL AND METHODS: Cross-sectional study on the sociological family impact related to rotavirus AGE in children under 2 years. The study was carried out in 25 hospitals and 5 primary care centres in Spain. Sociodemographic, epidemiological and clinical data were recorded, as well as the symptomatology of AGE and its severity measured by the Clark scale. Stool samples were tested to determine rotavirus positive (RV+) or negative (RV-). The parents were asked to complete a a family impact questionnaire. RESULTS: Stool specimens were tested in 1087 AGE cases (584 RV+ vs 503 RV-). The 99.5 % of parents whose children were RV+ reported more worries vs. the 97.7 % of RV-, and RV+ had a higher importance score (p < 0.05). A higher percentage of RV+ parents and those with a high importance score reported more time dedicated to dehydration treatment (p < 0.05). The 82.5 % vs. 73.9 % had disruption of their household tasks, with more importance scores (p < 0.05). RV+ had a higher percentage and importance score than RV- ones in all aspects of their child's AGE symptoms, except loss of appetite. CONCLUSION: AGE produces important dysfunctional experiences in daily family life. According to parental perceptions, RV+ produces greater worries and dysfunctions in child behaviour.

Debut de colitis ulcerosa en una adolescente / Onset of ulcerous colitis in adolescent subject

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Manifestaciones gastrointestinales de alergia alimentaria / Gastrointestinal semiology in alimentary allergy

Se revisan las manifestaciones clínicas digestivas más habituales de la alergia alimentaria en pediatría existiendo tres tipos: aguda mediada por IgE (Hipersensibilidad gastrointestinal inmediata y el síndrome alérgico oral), de comienzo tardío y mecanismo mixto IgE/celular (gastroenteropatía eosinofílica ) y crónica mediada por células (enterocolitis, proctitis y enteropatía por proteínas de la dieta y enfermedad celíaca). Debe pensarse en alergia alimentaria ante reacciones alimentarias inmediatas (prurito oral, vómitos, diarrea), rectorragia mucosa en lactantes, enteropatía pierde proteínas y/o malabsorción intestinal, reacciones subagudas o crónicas (vómitos, diarrea, disfagia), dificultad para medrar, síntomas gastrointestinales en paciente atópico (por ej., dermatitis atópica), cólico refractario del lactante, constipación y finalmente reflujo gastroesofágico rebelde. El diagnóstico se hará, fundamentalmente, por la prueba de provocación controlada en el hospital, aunque otros estudios pueden apoyarlo como niveles de IgE específica, prick test, estudios in vitro para predecir la tolerancia oral y empleo de alérgenos recombinantes en las alergias IgE mediadas o bien patch test, test de proliferación linfoblastica in vitro, liberación de citocinas bajo estimulación de alimentos, determinación de citocinas proinflamatorias en suero/heces ( IL-4 IL-5 y TNF alpha) y marcadores de activación eosinofílica en heces (proteína catiónica eosinofílica), en las alergias no-IgE mediadas (AU)

Clinical signs and symptoms of digestive nature in alimentary allergy are reviewed. There are three types of process: Acute mediated by IgE ( Immediate Gastrointestinal Hypersensibility and Oral allergy Syndrome), delayed and mixed IgE/cellular mechanism ( Eosinophilic gastroenteropathy), and chronic mediated by cells ( Enterocolitis, Proctitis and enteropathy by dietary proteins and coeliac disease). We must think 'allergy' when immediate reactions to diet foods ( pruritus, vomits and diarrhea), mucoid hematochezia, protein-losing enteropathy, intestinal malabsorption, acute or chronic reactions ( vomits, diarrhoea, dysphagia), failure tio thrive, or gastrointestibnal symptoms in atopic patients ( atopic dermatitis), refractory colic in infants, constipation and finally persistent gastroesophageal reflux. Diagnosis is made basically by provocation test controlled in Hospital, although other studies can help to support it, like specific IgE, Prict test, in vitro studies to predcit oral tolerance and recombinant allergens in IgE-allergies, or 'Patch test', lymphoblastic proliferation test in vitro, cytokine liberation under food stimuly, proinflammatory citokines in sera/feces (IL-4, IL-5 and TNFalpha) and markers of eosinophilic activation in feces (cationic eosinophilic protein) in non- IgE mediated allergy (AU)

[Procalcitonin for the diagnosis of neonatal sepsis of vertical transmission]. / Procalcitonina para el diagnóstico de sepsis neonatal de transmisión vertical.

OBJECTIVE: To evaluate procalcitonin (PCT) as a diagnostic marker of neonatal sepsis of vertical transmission and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: A prospective study was conducted in 136 blood samples from 69 newborn infants admitted to a neonatal department. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured. The PCT reference range of controls from 0 to 72 hours of life was constructed, and the diagnostic efficiency of the tests was calculated, with their 95 % confidence intervals (95 % CI). RESULTS: This study included 35 controls, 24 neonates with noninfectious disorders, and 10 neonates with sepsis (5 with culture-proven sepsis). PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.696 (p = 0.009), 0.735 (p = 0.002), and 0.703 (p = 0.006), respectively, with no statistically significant differences. The accuracy of PCT, CRP, and leukocyte count improved after 24 hours of life with areas under the ROC curve of 0.813 (p = 0.007), 0.826 (p = 0.005), and 0.841 (p = 0.003), respectively. Overall, PCT detected vertically transmitted sepsis with a sensitivity of 68.4 % (95 % CI: 46.0 %-84.6 %), specificity of 82.4 % (95 % CI: 72.2 %-89.4 %), positive likelihood ratio of 3.89 (95 % CI: 2.18 %-6.96 %), and negative likelihood ratio of 0.38 (95 % CI: 0.19 %-0.76 %), similar to those of CRP. CONCLUSIONS: PCT may be a useful marker for the diagnosis of vertically transmitted sepsis. Studies with larger sample sizes are required to establish the accuracy of PCT.

[Procalcitonin for the diagnosis of nosocomial neonatal sepsis]. / Procalcitonina para el diagnóstico de sepsis neonatal de origen nosocomial.

BACKGROUND: Nosocomial sepsis is a major problem in neonatal units. Because the clinical signs are nonspecific, highly reliable diagnostic markers are required to guide diagnosis. The aim of this study was to evaluate the utility of procalcitonin (PCT) as a diagnostic marker for nosocomial neonatal sepsis, and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: Twenty neonates with nosocomial sepsis and 20 controls aged 4-30 days were included in a prospective study performed in a neonatal intensive care unit. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured at onset of signs of infection. The sensitivity, specificity, and likelihood ratio for a positive (LR+) and a negative (LR-) result were calculated. RESULTS: PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.849, 0.880, and 0.884, respectively, with no statistically significant differences. Optimal cut-off values were: PCT > or = 0.65 ng/ml (sensitivity 85 %, specificity 80 %, LR 1 4.25, LR- 0.19), PCR > or = 5 .g/ml (sensitivity 80 %, specificity 95 %, LR 1 16, LR- 0.21), and I/T > or = 0.03 (sensitivity 90 %, specificity 75 %, LR 1 3.6, LR- 0.13). CONCLUSIONS: PCT may be a useful marker for the diagnosis of nosocomial neonatal sepsis. Studies with larger samples are required to compare the accuracy of PCT with that of other markers of sepsis.

Procalcitonina para el diagnóstico de sepsis neonatal de transmisión vertical / Procalcitonin for the diagnosis of neonatal sepsis of vertical transmission

Objetivo: Evaluar la utilidad de la procalcitonina (PCT) para el diagnóstico de sepsis neonatal de transmisión vertical y comparar sus resultados con los marcadores de sepsis más utilizados. Pacientes y métodos: Estudio prospectivo sobre 136 muestras de 69 recién nacidos ingresados en un servicio de neonatología. Se midieron la PCT, proteína C reactiva (PCR), recuento leucocitario e índice de neutrófilos inmaduros/totales (índice I/T). Se construyó el rango de normalidad de la PCT entre 0 y 72 h de vida y se calculó la eficacia diagnóstica de los marcadores de infección estudiados con sus intervalos de confianza del 95 % (IC 95 %). Resultados: Se incluyeron 35 controles, 24 neonatos con procesos no infecciosos y 10 diagnosticados de sepsis (cinco con confirmación bacteriológica). PCT, PCR e índice I/T mostraron capacidad diagnóstica, con áreas bajo la curva COR de 0,696 (p 5 0,009), 0,735 (p 5 0,002) y 0,703 (p 5 0,006), respectivamente, sin diferencias estadísticamente significativas. El rendimiento mejoró a partir de las 24 h de vida para PCT, PCR y recuento leucocitario, con áreas bajo la curva COR de 0,813 (p 5 0,007), 0,826 (p 5 0,005) y 0,841 (p 5 0,003), respectivamente. Globalmente la PCT detectó sepsis de transmisión vertical con sensibilidad del 68,4 % (IC 95 %: 46,0-84,6), especificidad 82,4 % (IC 95 %: 72,2-89,4), cociente de probabilidades del positivo 3,89 (IC 95 %: 2,18-6,96) y cociente de probabilidades del negativo 0,38 (IC 95 %: 0,19-0,76), similares a la PCR. Conclusiones: La PCT puede ser una herramienta útil para el diagnóstico de sepsis de transmisión vertical. Es necesario disponer de estudios con mayor número de pacientes

Objective: To evaluate procalcitonin (PCT) as a diagnostic marker of neonatal sepsis of vertical transmission and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. Patients and Methods: A prospective study was conducted in 136 blood samples from 69 newborn infants admitted to a neonatal department. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured. The PCT reference range of controls from 0 to 72 hours of life was constructed, and the diagnostic efficiency of the tests was calculated, with their 95 % confidence intervals (95 % CI). Results: This study included 35 controls, 24 neonates with noninfectious disorders, and 10 neonates with sepsis (5 with culture-proven sepsis). PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.696 (p 5 0.009), 0.735 (p 5 0.002), and 0.703 (p 5 0.006), respectively, with no statistically significant differences. The accuracy of PCT, CRP, and leukocyte count improved after 24 hours of life with areas under the ROC curve of 0.813 (p 5 0.007), 0.826 (p 5 0.005), and 0.841 (p 5 0.003), respectively. Overall, PCT detected vertically transmitted sepsis with a sensitivity of 68.4 % (95 % CI: 46.0 %-84.6 %), specificity of 82.4 % (95 % CI: 72.2 %-89.4 %), positive likelihood ratio of 3.89 (95 % CI: 2.18 %-6.96 %), and negative likelihood ratio of 0.38 (95 % CI: 0.19 %-0.76 %), similar to those of CRP. Conclusions: PCT may be a useful marker for the diagnosis of vertically transmitted sepsis. Studies with larger sample sizes are required to establish the accuracy of PCT

Procalcitonina para el diagnóstico de sepsis neonatal de origen nosocomial / Procalcitonin for the diagnosis of nosocomial neonatal sepsis

Antecedentes: La sepsis nosocomial supone una de las mayores preocupaciones en las unidades de neonatología y, dada la falta de especificidad de sus síntomas, se hacen necesarias pruebas complementarias muy fiables para orientar el diagnóstico. El objetivo de este estudio es evaluar la utilidad de la procalcitonina (PCT) para el diagnóstico de sepsis neonatal de origen nosocomial y comparar sus resultados con los marcadores de sepsis más utilizados. Pacientes y métodos: Estudio prospectivo realizado en una unidad de cuidados intensivos neonatales. Se incluyeron 20 casos de sepsis nosocomial y 20 controles de entre 4 y 30 días de vida. Se midieron la PCT, proteína C reactiva (PCR), recuento leucocitario e índice de neutrófilos inmaduros/totales (índice I/T) en el momento de la sospecha de sepsis. Se calculó la sensibilidad, especificidad, valores predictivos y cocientes de probabilidades del positivo (CPP) y del negativo (CPN) de los marcadores de infección estudiados. Resultados: PCT, PCR e índice I/T mostraron capacidad diagnóstica, con áreas bajo la curva COR de 0,849, 0,880 y 0,884, respectivamente, sin diferencias estadísticamente significativas. Los puntos de corte óptimos fueron: PCT >= 0,65 ng/ml (sensibilidad 85%; especificidad 80%; CPP 4,25; CPN 0,19), PCR >= 5 mg/ml (sensibilidad 80%; especificidad 95%; CPP 16; CPN 0,21) e índice I/T >= 0,03 (sensibilidad 90%; especificidad 75%; CPP 3,6; CPN 0,13). Conclusiones: La PCT puede ser una herramienta útil para el diagnóstico de sepsis nosocomial en neonatos, aunque es necesario disponer de estudios con mayor número de pacientes para poder comparar su rendimiento con el de otros marcadores de sepsis neonatal

Background: Nosocomial sepsis is a major problem in neonatal units. Because the clinical signs are nonspecific, highly reliable diagnostic markers are required to guide diagnosis. The aim of this study was to evaluate the utility of procalcitonin (PCT) as a diagnostic marker for nosocomial neonatal sepsis, and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. Patients and Methods: Twenty neonates with nosocomial sepsis and 20 controls aged 4-30 days were included in a prospective study performed in a neonatal intensive care unit. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured at onset of signs of infection. The sensitivity, specificity, and likelihood ratio for a positive (LR1) and a negative (LR­) result were calculated. Results: PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.849, 0.880, and 0.884, respectively, with no statistically significant differences. Optimal cut-off values were: PCT >= 0.65 ng/ml (sensitivity 85 %, specificity 80 %, LR 1 4.25, LR­ 0.19), PCR >= 5 mg/ml (sensitivity 80 %, specificity 95 %, LR 1 16, LR­ 0.21), and I/T >= 0.03 (sensitivity 90 %, specificity 75 %, LR 1 3.6, LR­ 0.13). Conclusions: PCT may be a useful marker for the diagnosis of nosocomial neonatal sepsis. Studies with larger samples are required to compare the accuracy of PCT with that of other markers of sepsis

[Hypoacusis after the neonatal period. Situations requiring hearing assessment]. / Hipoacusia de detección posneonatal. Circunstancias que precisan evaluación auditiva.

INTRODUCTION: Because hearing plays a major role in language development, pediatric hypoacusis is especially damaging. The high frequency of hearing impairment in newborns and the need for an early diagnosis have led to the establishment of neonatal screening. Nevertheless, there are other situations which may compromise hearing quality in later stages and it is essential to identify them in order to be able to provide early and effective treatment. OBJECTIVES: To describe the most frequent reasons for referring patients for hearing evaluation to a third level hospital and to identify common situations that require hearing assessment among the pediatric population. PATIENTS AND METHODS: The clinical histories of 197 non-neonates evaluated for hypoacusis were reviewed. Clinical parameters and diagnosis were compared in patients with impaired and normal hearing. RESULTS: One hundred sixty-one patients had no previous known hypoacusis. The main reason for evaluation was suspicion by the family or child minder (53.4 %), followed by language underdevelopment. In the first examinations 78 children had hypoacusis (48.4 %), which was more frequently bilateral than unilateral. In 29.5 % of hypoacusic patients, the disease was related to recurrent otitis or adenoiditis and in 25.6 % it was genetic. The most frequent antecedent was deaf relatives in hypoacusic patients and abnormal phenotypes in children with normal hearing. Three patients with previous bacterial meningitis were studied and two of these had hypoacusis. CONCLUSIONS: Hypoacusic evaluation outside the context of newborn screening is mainly motivated by clinical suspicion of hypoacusis or language underdevelopment. Other situations such as recurrent otitis with effusion, syndromic phenotypic characteristics or bacterial meningitis are related to hearing problems and therefore require detailed evaluation.

Hipoacusia de detección posneonatal. Circunstancias que precisan evaluación auditiva / Hypoacusis after the neonatal period. Situations requiring hearing assessment

Introducción: El papel destacado de la audición en el desarrollo del lenguaje verbal hace que la existencia de hipoacusia infantil sea especialmente perniciosa. La elevada frecuencia de defectos de audición presentes en el nacimiento y la necesidad de un reconocimiento precoz han llevado a establecer una detección neonatal. Sin embargo, existen otras situaciones que pueden comprometer la audición en edades más tardías y que es preciso conocer para instaurar las medidas oportunas de forma precoz. Objetivos: Describir los motivos más frecuentes de derivación para estudio de hipoacusia en un hospital de tercer nivel. Dar a conocer situaciones comunes en pediatría con riesgo auditivo en las que es preciso evaluar. Pacientes y métodos: Revisión de las historias de 197 pacientes no neonatos con estudio de hipoacusia. Se compararon parámetros clínicos y diagnósticos en pacientes hipoacúsicos y normooyentes. Resultados: Un total de 161 pacientes no tenían hipoacusia conocida. La principal causa que motivó la evaluación fue la sospecha de hipoacusia por familiares o cuidadores (53,4 %), seguido del retraso del lenguaje. De las primeras consultas, 78 presentaban hipoacusia (48,4 %), más frecuentemente bilateral. En el 29,5 % de los niños con hipoacusia, ésta se atribuyó a otitis o adenoiditis recurrentes y en el 25,6 % a causa genética. La existencia de familiares afectados fue el antecedente más frecuente en hipoacúsicos, mientras que en normooyentes fue la presencia de fenotipo anormal. Se estudiaron tres casos con antecedentes de meningitis bacteriana; en dos de ellos existía defecto auditivo. Conclusiones: Los estudios de hipoacusia fuera de la detección neonatal están motivados, sobre todo, por sospecha clínica de hipoacusia o retraso del lenguaje. Otras situaciones, como las otitis serosas de repetición, presencia de rasgos fenotípicos sindrómicos o las meningitis bacterianas, se relacionan con problemas auditivos y requieren, por tanto, evaluación minuciosa

Introduction: Because hearing plays a major role in language development, pediatric hypoacusis is especially damaging. The high frequency of hearing impairment in newborns and the need for an early diagnosis have led to the establishment of neonatal screening. Nevertheless, there are other situations which may compromise hearing quality in later stages and it is essential to identify them in order to be able to provide early and effective treatment. Objectives: To describe the most frequent reasons for referring patients for hearing evaluation to a third level hospital and to identify common situations that require hearing assessment among the pediatric population. Patients and methods: The clinical histories of 197 non-neonates evaluated for hypoacusis were reviewed. Clinical parameters and diagnosis were compared in patients with impaired and normal hearing. Results: One hundred sixty-one patients had no previous known hypoacusis. The main reason for evaluation was suspicion by the family or child minder (53.4 %), followed by language underdevelopment. In the first examinations 78 children had hypoacusis (48.4 %), which was more frequently bilateral than unilateral. In 29.5 % of hypoacusic patients, the disease was related to recurrent otitis or adenoiditis and in 25.6 % it was genetic. The most frequent antecedent was deaf relatives in hypoacusic patients and abnormal phenotypes in children with normal hearing. Three patients with previous bacterial meningitis were studied and two of these had hypoacusis. Conclusions: Hypoacusic evaluation outside the context of newborn screening is mainly motivated by clinical suspicion of hypoacusis or language underdevelopment. Other situations such as recurrent otitis with effusion, syndromic phenotypic characteristics or bacterial meningitis are related to hearing problems and therefore require detailed evaluation

Alteración de la tolerancia glucídica en la fibrosis quística, ¿debería detectarse antes? / Glucose tolerance impairment in cystic fibrosis. Should we detect earlier?

Introducción. Las alteraciones del metabolismoglucídico (MG) en la fibrosis quística (FQ) se producende manera progresiva y se han asociado a deterioroclínico. Se consideran una manifestación tardíade la enfermedad por lo que su seguimiento serealiza habitualmente desde la segunda década dela vida.Objetivo. Este estudio pretende valorar la situacióndel MG en FQ en edad pediátrica, determinarla edad a partir de la cual aparecen alteracionesglucídicas y si se correlacionan con deterioro clínicoa esa edad.Material y métodos. Se estudiaron 17 pacientesmenores de 16 años diagnosticados de FQ. Se realizóuna valoración nutricional y respiratoria. El MGse estudió a través de un test de sobrecarga oral deglucosa (TSOG), clasificando a los pacientes segúnlos criterios actuales y comparando la situación clínicaen los diferentes grupos de tolerancia glucídica.Resultados. La edad media de los pacientes fue9,3 ± 4,2 años. Seis pacientes (35,3%) presentabantolerancia anormal, siendo 4 de ellos menores de10 años. Ningún paciente presentó diabetes mellitus(DM). No se encontraron diferencias significativasen la situación clínica entre los pacientes contolerancia normal y anormal.Conclusiones. Las alteraciones glucídicas en laFQ pueden aparecer en enfermos menores de 10años, por lo que podría ser necesario estudiar elMG a una edad más temprana para detectarlas precozmentey realizar un seguimiento oportuno.En población pediátrica la tolerancia anormal a laglucosa sin DM no parece relacionarse con una peorsituación clínica

Background. Carbohydrate metabolism (CM) alterationsin cystic fibrosis (CF) show up graduallyand have been associated with clinical impairment.They are considered a late manifestation, so its follow-up is usually done since the second decade inlife.Objective. The aims of our study were to assesscarbohydrate metabolism (CM) on paediatric CF populationand to detect how early established was itsimpairment, and if it’s correlated to clinical deterioration.Material and methods. 17 patients less than 16years old with CF were studied. A nutritional andrespiratory assessment was made. CM was studiedthrough an oral glucose tolerance test and patientswere classified according to current criteria, comparingclinical situation among different groups.Results. Mean age was 9,3 ± 4,2 year old. Sixpatients (35,3%) showed glucose tolerance impairment, with 4 under 10 years. No diabetes mellitus(DM) was found in any of them. No significant differenceswere found in clinical situation among patientswith normal or abnormal glucose tolerance.Conclusions. Glucidic alterations may appear inCF patients under 10, therefore CM should be studiedbefore this age to detect its impairment andapply the appropriate follow-up. Among pediatric populationabnormal glucose tolerance without DM seemsnot related to clinical deterioration

[Pulmonary computed tomography in children with cystic fibrosis in Asturias (Spain)]. / Tomografía computarizada pulmonar en niños con fibrosis quística en Asturias.

INTRODUCTION: The advent of computed tomography (CT) has allowed the early detection of pathological changes in patients with cystic fibrosis (CF). Description of the early pathological changes and distribution of bronchiectasis in children with CF is limited, because most studies have been performed in older children and adults with well-established lung disease. The aim of this study was to describe the distribution pattern of this disease in Asturius. MATERIAL AND METHOD: We performed a retrospective study of the medical records and CT scans of patients followed up in our Cystic Fibrosis Unit. CT scans were scored by two radiologists according to Bhalla and Nathanson scores. Pathological changes were analyzed and correlated with clinical data and pulmonary function tests. RESULTS: The 41 CT reviewed contained between 10 and 47 slices, with a median of 16. The total number of slices was 758, of which 606 (79.95%) were considered acceptable and 152 were considered unacceptable by the radiologists. The most frequent lesions found were bronchiectasis (78.38%), followed by mucous plugs (37.84%). The most frequently affected bronchopulmonary segments were S1 and S2 in the right lung. Statistically significant correlations were found between Bhalla and Nathanson scores and disease duration. No statistically significant correlations were found between Bhalla and Nathanson scores and pulmonary function tests. CONCLUSIONS: The most frequent lesions in our environment were bronchiectasis followed by mucous plugs. The upper right lobe was the first to be affected, which correlates with findings in most published studies.

Tomografía computarizada pulmonar en niños con fibrosis quística en Asturias / Pulmonary computed tomography in children with cystic fibrosis in Asturias (Spain)

Introducción: La aparición de la tomografía computarizada (TC) ha permitido la detección precoz de cambios patológicos en los pacientes con fibrosis quística. Hay poca descripción de los cambios patológicos iniciales y de la distribución de las bronquiectasias en niños pequeños con fibrosis quística, ya que la mayoría de los estudios se centran en grupos de niños mayores y adultos, con la enfermedad pulmonar bien desarrollada. El objetivo fundamental de nuestro estudio es describir el patrón de distribución de la enfermedad en Asturias. Material y método Se realizó un estudio retrospectivo de las historias clínicas y las TC de pacientes pediátricos seguidos en nuestra Unidad de Fibrosis Quística. Las TC fueron evaluadas por dos radiólogos según las escalas de Bhalla y Nathanson, y se realizó un análisis de los hallazgos patológicos, correlacionándolos con datos clínicos y espirometrías. Resultados: Las 41 TC realizadas constaban de entre 10 y 47 cortes, con una mediana de 16. El total de cortes realizados fue de 758, de los que los radiólogos consideraron que 606 (79,95 %) eran valorables, y 152 (20,05 %), no. Las lesiones halladas con más frecuencia fueron bronquiectasias (78,38 %), seguidas de tapones de moco (37,84 %). Los segmentos broncopulmonares afectados predominantemente fueron el S1 y S2 derechos. Se encontraron correlaciones estadísticamente significativas entre las escalas de Bhalla y Nathanson y el tiempo de evolución de la enfermedad. No se encontraron correlaciones estadísticamente significativas entre las escalas de Bhalla y Nathanson y las pruebas de función pulmonar. Conclusiones: Las lesiones predominantes fueron bronquiectasias y tapones de moco. El lóbulo superior derecho ha sido el primero en afectarse evolutivamente, lo que coincide con la mayoría de la literatura médica

Introduction: The advent of computed tomography (CT) has allowed the early detection of pathological changes in patients with cystic fibrosis (CF). Description of the early pathological changes and distribution of bronchiectasis in children with CF is limited, because most studies have been performed in older children and adults with well-established lung disease. The aim of this study was to describe the distribution pattern of this disease in Asturius. Material and method We performed a retrospective study of the medical records and CT scans of patients followed up in our Cystic Fibrosis Unit. CT scans were scored by two radiologists according to Bhalla and Nathanson scores. Pathological changes were analyzed and correlated with clinical data and pulmonary function tests. Results: The 41 CT reviewed contained between 10 and 47 slices, with a median of 16. The total number of slices was 758, of which 606 (79.95 %) were considered acceptable and 152 were considered unacceptable by the radiologists. The most frequent lesions found were bronchiectasis (78.38%), followed by mucous plugs (37.84 %). The most frequently affected bronchopulmonary segments were S1 and S2 in the right lung. Statistically significant correlations were found between Bhalla and Nathanson scores and disease duration. No statistically significant correlations were found between Bhalla and Nathanson scores and pulmonary function tests. Conclusions: The most frequent lesions in our environment were bronchiectasis followed by mucous plugs. The upper right lobe was the first to be affected, which correlates with findings in most published studies

[Noninvasive ventilation in a pediatric intensive care unit]. / Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe our experience of noninvasive positive-pressure ventilation (NIPPV). PATIENTS AND METHODS: We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 and PaCO2 were evaluated before and 2 hours after initiating NIPPV. RESULTS: Twenty-three patients with a mean age of 36.7 months underwent a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnic acute respiratory failure (four trials), and postextubation respiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatment vs. 34 +/- 12 breaths/min post-treatment; p = 0.001), and tachycardia (148 +/- 27 beats/min pre-treatment vs. 122 +/- 22 beats/min (after or post) post-treatment; p < 0.001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0.010). Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. CONCLUSIONS: NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children.

Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos / Noninvasive ventilation in a pediatric intensive care unit

Objetivo: Describir nuestra experiencia con la aplicación de ventilación no invasiva (VNI). Pacientes y métodos: Estudio retrospectivo, durante 18 meses, de los pacientes críticamente enfermos en los que se empleó VNI. Para valorar su eficacia se registraron la frecuencia cardíaca, frecuencia respiratoria, fracción inspiratoria de oxígeno (FiO2), presión parcial arterial de oxígeno (PaO2) y de dióxido de carbono (PaCO2) antes y 2 h después del inicio de la VNI. Resultados: La VNI se utilizó en 24 ocasiones sobre 23 pacientes con edad media de 36,7 meses. En 14 casos se indicó por insuficiencia respiratoria hipoxémica, en cuatro por insuficiencia respiratoria hipercápnica y en seis por insuficiencia respiratoria postextubación. Se utilizaron respiradores convencionales en 10 casos y respiradores específicos de VNI en 14 casos. Como interfases se utilizaron principalmente la prótesis faríngea en pacientes menores de un año y la mascarilla buconasal en los mayores de un año. En todos los grupos se observó una disminución de la dificultad respiratoria definida por una disminución de la taquipnea(45 +/- 16 resp./min pretratamiento frente a 34 +/- 12resp./min postratamiento; p = 0,001) y la taquicardia(148 +/- 27 lat./min pretratamiento frente a 122 +/- 22 lat./min postratamiento; p < 0,001) tras el inicio de la VNI. También se observó una mejoría significativa del cociente PaO2/FiO2 (190 +/- 109 pretratamiento frente a 260 +/- 118postratamiento; p = 0,010). Cinco pacientes (20,8%) precisaron intubación y ventilación mecánica convencional tras la VNI. De ellos, tres tenían menos de 6 meses. Conclusiones: La VNI puede ser una alternativa a la ventilación mecánica convencional en determinados pacientes con insuficiencia respiratoria aguda

Objective: To describe our experience of noninvasive positive pressure ventilation (NIPPV).Patients and methods We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 andPaCO2 were evaluated before and 2 hours after initiating NIPPV. Results: Twenty-three patients with a mean age of 36.7 month sunder went a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnicacute respiratory failure (four trials), and postextubationrespiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatments. 34 +/- 12 breaths/min post-treatment; p = 0,001),and tachycardia (148 +/- 27 beats/min pre-treatment vs.122 +/- 22 beats/min (after or post) post-treatment; p < 0,001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0,010).Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. Conclusions NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children

Enfermedad inflamatoria intestinal en pacientes pediátricos en Asturias (1993-2000): epidemiología y clínica / Inflammatory bowel disease in pediatric patients in Asturias, Spain, (1993-2000): epidemiology and clinical features

Objetivo: Analizar la población pediátrica de Asturias diagnosticada de enfermedad inflamatoria intestinal (EII), para determinar su distribución sociodemográfica y evolución clínica. Material y métodos: Se realiza un estudio epidemiológico, descriptivo y poblacional que incluye el registro de pacientes menores de 15 años diagnosticados de EH en el Hospital Central de Asturias, desde abril de 1993 a octubre de 2000.Resultados: La incidencia media fue de 0,25 ñ 0,08 casos por cada 100.000 habitantes al año. El 63,6 por ciento son varones, el 86,4 por ciento viven en un medio urbano, y más de tres cuartas partes son de nivel sociocultural medio-bajo. El 45,4 por ciento tiene antecedentes famillares, observándose anticipación en el diagnóstico en los pacientes del estudio de 19,6 ñ 12,05 años en la colitis ulcerosa (CU) y 20,4 ñ 17,24 años en la enfermedad de Crohn (EC). La media de edad al diagnóstico es de 7,7 años ñ 4 en la CU y 11,9 ñ 1,1 años en la EC. Entre el inicio de los síntomas y el diagnóstico pasan 7,8 ñ 5,1 meses en la CU y 11,3 ñ 12,8 meses en EC. Las rectorragias son el síntoma inicial más frecuente en la CU (66,6 por ciento) y la diarrea en la EC (53,8 por ciento). Un 64,7 por ciento refiere brotes relacionados con el estrés, y los diagnosticados entre diciembre y febrero tienen más brotes que el resto. El 90 por ciento de los niños con EC conviven con fumadores. Más del 80 por ciento de las familias consideran la calidad de vida de los pacientes buena o muy buena. Conclusiones: La EII en nuestro medio afecta sobre todo a varones, residentes en áreas urbanas y de nivel sociocultural medio-bajo. La incidencia media global es de 0,25 ñ 0,08 casos por cada 100.000 habitantes al año. La mayor parte tienen antecedentes familiares de ER y existe anticipación en el diagnóstico en ambas entidades. La EC se diagnostica más tardíamente que la CU y la mayoría de los pacientes conviven con fumadores. Una gran parte de los pacientes tienen brotes relacionados con el estrés, y la mayor parte de las familias califican la calidad de vida de los pacientes como buena o muy buena (AU)

[Follow-up of longstanding ventricular septal defects]. / Seguimiento de las comunicaciones interventriculares de larga evolución.

OBJECTIVE: Ventricular septal defect is the most frequently diagnosed congenital heart defect. The prognosis is usually good. The aim of this study was to describe this idea to general pediatricians. MATERIAL AND METHODS: We review the follow-up of 81 patients with ventricular septal defect. Defects that spontaneously closed in the first 12 months of life and those that formed part of a malformative syndrome or a complex congenital heart defect were excluded. RESULTS: Localization was perimembranous, including all defects affecting mainly the septal membrane independent of whether the surrounding tissues were involved, in 66.7 %, muscular in 29.6 % and mixed in 3.7 %. Perimembranous position was more frequent among large and medium-sized defects. Large and perimembranous defects were characterized by holosystolic murmur; in small, muscular defects, murmur was cut off in mid-systole. In 45.8 % of large defects, weight development was delayed, but there was no appreciable effect on height. Generally we observed a tendency to partial closure and to improvement. Surgical closure was required in 9.8 %. CONCLUSIONS: Because of the trend to partial or complete spontaneous closure, the prognosis of ventricular septal defect is generally good.