Síndrome de apnea-hipopnea obstructiva del sueño asociado a malformación de Arnold-Chiari tipo II. Beneficios de la intervención neuroquirúrgica / Obstructive sleep apnea-hypopnea syndrome associated with type II arnold-chiari malformation. Benefits of neurosurgical intervention

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Hemoptisis leve en un niño inmigrante. Puesta al día diagnóstica / Mild emoptysis immigrant child: Diagnostic up-date

Presentamos el caso de un varón de 9 años de edad, de origen peruano, con antecedentes de tos crónica y expectoración hemoptoica discontinua de tres meses de evolución en el que se detecta un infiltrado pulmonar persistente en la radiografía de tórax. Describimos la norma de actuación con este tipo de pacientes así como la problemática creada en la detección de la causa subyacente del sangrado. La hemoptisis es un signo infrecuente en la práctica pediátrica pero muy angustiante para el paciente y su familia, así como para el médico, para quién supone un reto diagnóstico-terapéutico. Su baja incidencia e n el niño puede llevar a retrasos iniciales en su diagnóstico e incluso a que este signo pase inadvertido. El espectro de entidades patológicas que pueden causarla es muy amplio y habitualmente las más frecuentes son las causas infecciosas, aunque también pueden subyacer otras enfermedades potencialmente graves. Por ello es prioritario conocer su etiología exacta y decidir la consiguiente actitud terapéutica (AU)

We present the case of a 9 year-old child form Peru with a background of chronic cough and discontinuous hemotoxic expectoration of 3 months evolution in which persistent pulmonary infiltrate was detected don the chest x-ray. We describe the action guidelines with this type of patients as well as the problems created in the detection of the underlying cause of bleeding. Hemoptysis is an uncommon sign in the pediatric practice, however it produces much anxiety for the patient and their family, as well as for the physician, for whom it supposes a diagnostic-therapeutic challenge. Its low incidence in the child may lead to initial delays in its diagnosis and this sign may even go unnoticed. The spectrum of pathological conditions that may cause it is very wide and usually the most frequent ones are infectious causes, although there may be other underlying potentially severe diseases. Therefore, it is of priority to know the exact etiology and t decide the consequent therapeutic attitude (AU)

Pericarditis recurrente secundaria a un quiste pericárdico / Recurring secondary pericarditis due to pericardial cyst

Los procesos expansivos intratorácicos son infrecuentes en la infancia, y se localizan habitualmente en el mediastino. La escasa expresión clínica inicial condiciona un diagnóstico tardío y dificulta el tratamiento efectivo. Se clasifican según la localización topográfica (anterior, media o posterior), lo que permite establecer una orientación diagnóstica basada en las estructuras de cada compartimento. La patología tumoral es la más frecuente, aunque no hay que descartar la etiología infecciosa o malformativa (quística-vascular) y la patología tiroidea opericárdica, como el caso que motiva esta publicación. La radiografía de tórax es la técnica diagnóstica inicial, aunque generalmente se requiere la realización de una tomografía computarizada (mediastino anterior y medio) o una resonancia magnética (mediastino posterior), que localizan y delimitan la lesión e informan de su consistencia y contenido. La ecografía es coste efectiva, no invasiva, está libre de radiación y permite evaluar el timo o el pericardio. Las masas pericárdicas son infrecuentes, generalmente congénitas, aunque pueden tener un origen inflamatorio; su tratamiento es conservador, y está indicada la cirugía si el tamaño es grande o la sintomatología persistente(AU)

The intrathoracic expansive mass are infrequent during infancy, being the common localization the mediastinic, the scarce clinical expression conditions to a late diagnosis obstructing the effective treatment. They are classified according to topographic localization (front, middle or back) allowing a diagnosis orientation based on the structures of each compartment. The tumoral pathology is the most frequent, not being despised the infectious etiology, malformative (cystic or vascular), the thyroid pathology or pericardial, as the case, which this articleis based on. The thorax x-ray is the initial diagnosis technique, although generally a cat scan is needed of the (front mediastinum or middle) or a magnetic resonance (back mediastinum)that localizes and defines the lesion, informing of the consistency and context. The ecography is cheap not invasive, radiation free and allows evaluating the thymus and pericardium. The pericardial masses are infrequent, generally congenital, although they might have an inflammatory origin; its treatment is conservative, surgery is indicated if the size is big or the group of symptoms is persistent(AU)

Bronquiectasias en pacientes sin fibrosis quística / Bronchiectasis in patients without cystic fibrosis

Presentamos un caso de neumonías de repetición en la misma localización en una niña de 9 años con tos productiva prácticamente diaria. La prueba del sudor fue negativa y la TC de tórax evidenció bronquiectasias localizadas. Las bronquiectasias son la secuela final de un proceso crónico originado por múltiples causas, la mayoría de ellas adquiridas. Aunque su frecuencia se ha reducido en los últimos años, hay que pensar en ellas ante la cronificación y/o recurrencia de algunas patologías respiratorias. Se analiza su etiología, sus síntomas y signos más frecuentes, así como las pruebas complementarias a realizar. El manejo ideal es el específico de la causa subyacente aunque en pocos casos es posible. Se insiste en el tratamiento médico intensivo, reservándose la cirugía en caso de mala respuesta al mismo (AU)

We present a case of repeated pneumonias in the same location in a 9-year old girl with almost daily productive cough. The sweat test was negative and the chest CT scan showed localized bronchiectasis. Bronchiectases are the final sequel of a chronic process originated by multiple causes, most of them acquired. Although their frequency has decreased in recent years, they must be considered when the condition becomes chronic and/or there is recurrence of some respiratory conditions. An analysis is made of its etiology, most frequent symptoms and signs and the complementary test to be conducted. The ideal management is that specific to the underying cause although this is only possible in a few cases. The need for intensive medical treatment is stressed, reserving surgery for when there is poor response to it (AU)

Atelectasia en niños: ¿qué es lo que parece estar detrás? / Atelectasis in children: what appears to be the cause?

Presentamos un caso de tuberculosis pulmonar en una niña de 15 meses de edad enviada a nuestra consulta para efectuar un estudio de su neumonía recurrente. La radiografía de tórax pone de manifiesto una condensación localizada en el lóbulo medio, con signos sugestivos de atelectasia. La atelectasia es un problema común en los pacientes pediátricos, generalmente secundaria a una obstrucción bronquial por tapones de moco. Se analizan los tipos de atelectasia y sus causas más comunes, y se insiste en la utilidad de ciertas técnicas consideradas agresivas, como la fibrobroncoscopia, que en realidad son pruebas sencillas y con una gran validez diagnóstica y terapéutica. El manejo de las atelectasias depende de la causa subyacente. Es primordial tratar de forma conjunta la enfermedad de base y el colapso pulmonar, y en la mayoría de los casos es suficiente mantener una actitud conservadora (AU)

We report on a case of pulmonary tuberculosis in a fifteen month-old girl who was referred to our practice for tests following recurrent pneumonia. The chest X-ray showed localized condensation in the middle lobe with signs suggestive of atelectasis. Atelectasis is a common problem in paediatric patients, and tends to be secondary to bronchial obstruction due to mucus plugs. We analyse the types of atelectasis and their most common causes. Moreover, we stress the usefulness of certain techniques that are considered to be aggressive, like the fibrobronchoscopy, but which in reality are simple tests with a high level of diagnostic and therapeutic productivity. The approach to atelectases depends on the underlying cause, and it is essential to treat both the underlying disease as well as the collapsed lung; in most cases, a conservative approach is sufficient (AU)

No todas las adenopatías hiliares son de origen tuberculoso. ¿Están justificadas pruebas complemetarias invasivas en niños con adenopatías hiliares? / Not all enlarged hilar lymph nodes have a tuberculous origin. Are complementary invasive tests justified in children with enlarged hilar lymph nodes?

Presentamos a una paciente en edad escolar con adenopatías hiliares en el contexto de neumonías de repetición. Se describe el diagnóstico diferencial razonado que se debe realizar en estos casos, y se discute si son necesarias pruebas complementarias más agresivas en los casos con buena evolución y sin datos sugestivos de enfermedad grave. Se insiste en la importancia de la historia clínica y el beneficio de pruebas complementarias básicas analíticas y de imagen. Se concluye que una actitud expectante, sin realización de pruebas invasivas y con revisiones seriadas, en un proceder útil en estos casos (AU)

We present the case of a school-aged female patient with en larged hilar lymph nodes in the context of recurrent pneumonias. The reasoned differential diagnosis that should be performed in these cases is described and it is discussed whether more aggressive complementary tests are necessary in cases having good evolution and without data suggestive of severe disease. The importance of the clinical history and the benefit of basic complementary laboratory analysis and imaging tests are stressed. It is concluded that a waiting attitude, without performing invasive test and with seriated reviews, is a useful procedure in these cases (AU)

Protocolo de actuación ante una neumonía que no se resuelve / Protocol for action in the event of non-resolving pneumonia

Las infecciones agudas del tracto respiratorio inferior son las más frecuentes en la edad pediátrica; aproximadamente el 1,5% de ellas son neumonías. La incidencia de la neumonía es difícil de establecer, al tratarse de un proceso benigno sin obligación oficial de declararse, aunque se estima en 15-40/1.000 niños al año, según la edad. Las neumonías son la principal causa de morbilidad respiratoria en el mundo y la tercera causa de muerte en los países desarrollados. Su resolución es habitual, aunque en ciertas ocasiones la evolución clínica y radiológica no es favorable a pesar de realizar un tratamiento supuestamente adecuado, lo que obliga a llevar a cabo una sistemática diagnóstica para intentar aclarar las causas de esta evolución anormal a fin de realizar un tratamiento correcto (AU)

Acute lower respiratory tract infections (LRTIs) are the most common infections in children; approximately 1.5% of those infections are pneumonias. It is difficult to establish the incidence of pneumonia since it is a benign process with no official reporting obligation, but it is estimated that there are 15 to 40cases per thousand children and year according to age. Pneumonias are the main cause of respiratory morbidity worldwide and the third cause of death in developed countries; commonly, resolution is the norm. However, in some cases the clinical and radiological evolution is not favourable in spite of a supposedly appropriate treatment. In those cases, a systematic diagnosis is required in order to clarify the causes of the abnormal evolution and establish a correct treatment (AU)

Programa de control y seguimiento de ventilación no invasiva domiciliaria en pacientes pediátricos. Unidad multidisciplinar / Non invasive home control and follow –up program in pediatric patients. A multidisciplinary Unit

La ventilación mecánica no invasiva constituye una nueva modalidad de terapia de soporte respiratorio en la que no se precisa invadir, mediante traqueostomía o intubación endotraqueal, la vía aérea. Se utiliza en pacientes con fallo respiratorio agudo o crónico como alternativa menos agresiva a la ventilación mecánica convencional, buscando evitar las complicaciones asociadas a la intubación endotraqueal y mejorar la calidad de vida del enfermo. Durante los últimos 5-10 años se ha generalizado su uso, debido en gran parte a los avances médicos y tecnológicos que han contribuido al aumento de supervivencia del paciente crítico, al mejor diagnóstico y conocimiento de enfermedades que cursan con aumento de resistencias de la vía aérea superior o con hipoventilación central o periférica así como al desarrollo de nuevos aparatos de fácil manejo adaptados al tratamiento domiciliario. La creación de un programa de control y seguimiento de ventilación no invasiva domiciliaria en pacientes pediátricos va a producir mejoras psicosociales para el paciente y su familia y beneficios económicos para el sistema de salud. En esta revisión nos vamos a referir al tratamiento ambulatorio y domiciliario de niños con insuficiencia respiratoria crónica y a la necesidad de creación de unidades especializadas multidisciplinares de intervención en este tipo de enfermos (AU)

Non-invasive mechanical ventilation is a new respiratory support therapy modality in which it is not necessary to invade the airway with tracheostomy or endotracheal intubation. It is used in patients with acute or chronic respiratory failure as a less aggressive alternative to conventional mechanical ventilation, seeking to avoid the complications associated to endotracheal intubation and to improve the patient´s quality of life. During the last 5-10 years, its use has become generalized, largely due to the medical and technological advances that have contributed to the increased survival of the critical patients, to the better diagnosis and knowledge of diseases that occur with increased resistances of the upper airway or with central and/or peripheral hypoventilation and to the development of new easily used apparatus adapted to home treatment. The creation of a control and follow-up program of non-invasive home ventilation in pediatric patients will produce psychosocial and economic benefits for the health care system. In this review, we are going to mention the out-patient and home treatment of children with chronic respiratory failure and the need to create specialized multidisciplinary intervention units in this type of patient (AU)

Infiltrados pulmonares en pacientes inmunodeprimidos / Pulmonary infiltrates in immunocompromised patients

La afección pulmonar es una complicación frecuente en los pacientes inmunodeprimidos, y en muchas ocasiones condiciona de forma significativa su evolución. Teniendo en cuenta laalta morbimortalidad de las complicaciones pulmonares, un diagnóstico precoz y un abordaje terapéutico adecuado son un auténtico reto para los pediatras que se enfrentan diariamente al cuidado de estos pacientes. En las últimas décadas, el desarrollo de nuevas terapéuticas en el tratamiento de la enfermedad oncológica, la práctica habitual de trasplantes de órganos y la mayor supervivencia de muchos de estos pacientes han condicionado que el pediatra, con independencia de su ámbito de actuación, deba conocer el abordaje del enfermo inmunodeprimido y sus complicaciones. Pretendemos que este artículo sea una herramienta útil para el adecuado manejo de las complicaciones respiratorias de estos pacientes (AU)

Pulmonary disease is a common complication in immunocompromised patients and in many cases to a large extent determines the patient’s evolution. In view of the high morbidity and mortality of pulmonary complications, its early diagnosis and an appropriate therapeutic approach are a true challenge for paediatricians faced with the care of these patients on a daily basis. In recent decades, the development of new therapeutics for the treatment of oncological disease, the usual practice of organ transplants and the increased survival of many of these patients, mean that paediatricians, independently of their field of action, must know how to approach immunocompromised patients and their complications. We aim for this article to be a useful tool for the appropriate management of respiratory complications in those patients (AU)

Manejo del síndrome aspirativo recurrente en el paciente pediátrico / Treatment of recurrent aspiration syndrome in children

El síndrome aspirativo recurrente es una causa importante de patología broncopulmonar. En su etiopatogenia intervienen alteraciones de la deglución, la presencia de reflujo gastroesofágico y la aspiración de saliva. Debido a su presentación clínica variable y a la inexistencia de criterios diagnósticos específicos, frecuentemente pasa desapercibido. El tratamiento debe plantearse en función del mecanismo implicado, evaluando los posibles factores predisponentes en cada paciente. Presentamos el caso de una niña que fue remitida a la consulta de neumología tras sufrir episodios respiratorios de repetición, con una inadecuada respuesta al tratamiento. Se hace una revisión exhaustiva de esta patología en el contexto pediátrico con el fin de definir una norma de actuación diagnóstica adecuada, evitar la realización de pruebas complementarias excesivas e inapropiadas y llevar a cabo una terapia dirigida y fundamentada (AU)

Recurrent aspiration syndrome is an important cause of bronchopulmonary pathology. Its etiopathogenesis involves wallowing alterations, the presence of gastroesophageal reflux and the aspiration of saliva. Because of its variable clinical presentation and the absence of specific diagnostic criteria, it often goes unnoticed. The treatment should be determined according to the mechanism involved, thereby evaluating the potential predisposing factors in each patient. We present the case of a girl who is referred to the Pneumology Department because of recurrent respiratory episodes and a poor response to the treatment. An in-depth review is conducted of this pathology in the field of paediatrics, with the aim of defining rules for adequate diagnostic action, there by trying to avoid excessive and inappropriate additional tests, and providing a targeted and justified therapy (AU)

Patología respiratoria en pacientes con enfermedad de células falciformes. Protocolo de actuación (y II) / Respiratory disorders in patients with sickle cell disease. Management protocol (II)

La drepanocitosis es una hemoglobinopatía que produce rigidez del eritrocito en situaciones de hipoxia, infección o deshidratación, con la consecuente oclusión microvascular y hemólisis. Es una enfermedad que afecta a múltiples órganos y sistemas, como el bazo, el sistema nervioso central, el aparato osteoarticular, los ojos, el sistema genitourinario y el aparato respiratorio. La patología respiratoria, tanto aguda como crónica, es una causa importante de morbimortalidad, aunque lo que más afecta a la calidad de vida de estos pacientes son las crisis dolorosas. En este artículo vamos a revisar las diferentes complicaciones respiratorias con el fin de realizar una prevención adecuada y efectuar un tratamiento precoz y agresivo de las mismas. También describiremos brevemente el resto de situaciones que pueden aparecer a lo largo de la evolución de la enfermedad y expondremos de forma esquemática el programa de control y seguimiento del paciente con enfermedad de células falciformes(ECF).Asimismo, revisaremos también el interés de la puesta en marcha de grupos de trabajo especializados en esta patología aún poco conocida en nuestro medio, aunque se está incrementando su detección debido a la inmigración y a la realización del cribado neonatal, que obliga a la elaboración de un plan de actuación mediante la creación de unidades multidisciplinares que van a mejorar sobremanera la supervivencia y calidad de vida de estos enfermos (AU)

Sickle cell disease is a hemoglobinopathy that produces stiffness in red cells in situations of hypoxia, infection or dehydration, with the subsequent microvascular occlusion and hemolysis. It is a disease that affects multiple organs and systems, such as the spleen, the central nervous system, the osteoarticular apparatus, the eyes, the genitourinary system and the respiratory system. The respiratory disease, both acute and chronic, is a majorcause of morbidity and mortality, although painful crises have a greater effect on the quality of life of these patients. In this article, we will elaborate upon the various respiratory complications with the aim of providing proper prevention and treating them early and aggressively. We will also briefly describe the other situations that may occur throughout the course of the disease and schematically explain a control and monitoring program for patients with sickle cell disease. This article will also stress the interest in establishing specialized workgroups in this disease, which is still not very well known in Spain, although its detection is increasing due to immigration, and due to the universal newborn screening in some autonomous regions. This circumstance makes it necessary to develop an action plan through the creation of multidisciplinary units that will greatly improve the survival and quality of life of these patients (AU)

Patología respiratoria en pacientes con enfermedad de células falciformes. Protocolo de actuación (I) / Respiratory disorders in patients with sickle cell disease: management protocol (I)

La drepanocitosis es una hemoglobinopatía que produce rigidez del eritrocito en situaciones de hipoxia, infección o deshidratación, con la consecuente oclusión microvascular y hemólisis. Es una enfermedad que afecta a múltiples órganos y sistemas, como el bazo, el sistema nervioso central, el aparato osteoarticular, los ojos, el sistema genitourinario y el aparato respiratorio. La patología respiratoria, tanto aguda como crónica, es una causa importante de morbimortalidad, aunque las crisis dolorosas afectan más a la calidad de vida de estos pacientes. Vamos a desarrollar a lo largo de este artículo las diferentes complicaciones respiratorias, con el fin de realizar una prevención adecuada y efectuar un tratamiento precoz y agresivo de ellas. También describiremos brevemente el resto de situaciones que pueden aparecer durante la evolución de la enfermedad y expondremos esquemáticamente el programa de control y seguimiento del paciente con enfermedad de células falciformes. Se resalta también el interés de la puesta en marcha de grupos de trabajo especializados en esta patología aún poco conocida en nuestro medio, aunque se está incrementando su detección debido a la inmigración y a la realización del cribado neonatal universal en algunas comunidades autónomas, lo que obliga a la elaboración de un plan de actuación mediante la creación de unidades multidisciplinarias que van a mejorar sobremanera la supervivencia y la calidad de vida de estos pacientes (AU)

Sickle-cell disease is a hemoglobinopathy that produces rigidity in red cells under conditions of hypoxia, infection or dehydration, with the subsequent microvascular occlusion and hemolysis. It is a disease that affects multiple organs and systems, such as the spleen, the central nervous system, the osteoarticular system, the eyes, the genitourinary tract and the respiratory tract. Respiratory diseases, both acute and chronic, are a major cause of morbidity and mortality, although painful crises have a greater impact on the quality of life of these patients. In this article, we will elaborate upon the various respiratory complications for the purpose of introducing proper preventive measures and initiating an early and aggressive treatment of these complications. We will also briefly describe other situations that may arise throughout the course of the disease and briefly describe a program for the control and monitoring ofpatients with sickle cell disease. This article will also highlight the interest in establishing specialized workgroups in this disease. Although it is still not very widespread among our general population, it is being detected with increasing frequency due to immigration, and due to the universal newborn screening in some autonomous regions, which calls for the development of a plan of action through the creation of multidisciplinary units that will greatly improve the survival and quality of life of these patients (AU)

Enfermedades pulmonares intersticiales difusas en el paciente pediátrico / Diffuse interstitial lung diseases in the pediatric patient

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[Evaluation of vesico-ureteral reflux in infants under 6 months of age]. / Evolución del reflujo vesicoureteral en lactantes menores de seis meses.

Forty-five infants less than 6 months old with vesicoureteral reflux have been evaluated in the Neonatology Unit of Niño Jesus Hospital. All of them have received medical treatment. We found bilateral vesicoureteral reflux in 55.6%, predominantly degree II (70%). Clinical symptoms were not specific, but it was evident that urine cultures were negative in 31.12%. After a mean follow-up of 31.5 months, kidney status was evaluated with echographic procedures. We found good growth in all but one case which was initially hypoplastic. New lesions were not demonstrated in the kidneys. We report a good prognosis for vesicoureteral reflux in infants of less than 6 months of age that have received only medical treatments. Therefore, we emphasize the importance of recognizing this pathology in infants, including those with negative urine cultures.

Interleukin-6 production by the blast cells of acute myeloblastic leukemia: regulation by endogenous interleukin-1 and biological implications.

Coordinate production of interleukin-1 beta (IL-1 beta) and granulocyte macrophage-colony stimulating factor (GM-CSF) or IL-6 by the blast cells of acute myeloblastic leukemia (AML) and normal peripheral blood leukocytes have been previously reported (van der Shoot et al.: Blood 74:2081-2087, 1989; Bradbury et al.: Leukemia 4:44-47 1990a, British Journal of Haematology 16:(in press), 1990b; Rodriguez-Cimadevilla et al.: Blood 76:1481-1489, 1990; Schindler et al.: Blood 75:40-47, 1990). In the present study, we show that IL-6 production by AML blasts is up-regulated by endogenously produced IL-1 beta. Neutralization of the endogenous source of IL-1 results in a significant decrease in IL-6 production, as determined by ELISA. Conversely, exposure of AML blasts to IL-1 alpha results in a significant increase in IL-6 production in 10 of 16 patient samples. Antibodies against IL-1 alpha and -beta also cause a drastic decrease in IL-6 and GM-CSF gene expression by the cells, suggesting that cytokine gene expression in AML blasts is driven, at least in part, by endogenous IL-1. The biologic significance of IL-6 production in culture of AML blasts has been addressed using a neutralizing antibody against IL-6. Our data indicate that IL-6 is important for the survival of clonogenic blasts in culture. In contrast, the survival of the total population of blasts is IL-6-independent, as assessed by the integrity of cellular DNA, even in the presence of anti-IL-6. These observations are consistent with the view that AML blasts might be organized as a lineage, with comparable hierarchy as in normal hemopoiesis and, perhaps, increased heterogeneity despite a homogenous appearance (McCulloch and Till: Blood Cells 7:63-77, 1981; Buick and McCulloch: Control of Animal Cell Proliferation. Academic Press, New York, vol. 1, pp. 25-57, 1985). Buick and McCulloch have identified a subpopulation of AML clonogenic cells with stem-cell-like properties, and suggested that the majority of blasts may have undergone a determination-like step. Our data indicate a marked difference in IL-6 requirement for cell survival between precursors and the majority of blasts, suggesting that IL-6 responsiveness may decrease following a determination-like event, i.e., the reduction in proliferative capacity.

Coordinate secretion of interleukin-1 beta and granulocyte-macrophage colony-stimulating factor by the blast cells of acute myeloblastic leukemia: role of interleukin-1 as an endogenous inducer.

Acute myeloblastic leukemia (AML) blasts have been shown to produce a variety of cytokines in culture such as interleukin-1 (IL-1), IL-6, granulocyte-, macrophage-, and granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF alpha). Using two sensitive and specific enzyme-linked immunosorbent assays for IL-1 beta and GM-CSF, we document in the present study that the production of the two cytokines by AML blasts in culture is coordinated. First, we observe a striking correlation between the levels of GM-CSF and IL-1 beta released by the cells. Thus, a high production of IL-1 beta is always concordant with a high production of GM-CSF and, conversely, low production of IL-1 beta is concordant with low levels of GM-CSF. Second, neutralization of intrinsic IL-1 using antibodies that are specific for IL-1 alpha and -1 beta suppresses the release of GM-CSF by the cells. Third, neutralization of the endogenous source of IL-1 also results in an abrogation of GM-CSF mRNA. Fourth, the production of both IL-1 beta and GM-CSF is up-regulated by exposing AML blasts to an exogenous source of IL-1, suggesting a positive regulation of autocrine growth factor production. Taken together, our results indicate that GM-CSF production by AML blasts is mediated by endogenously produced IL-1. Both IL-1 beta and -1 alpha are produced by AML blasts, although IL-1 beta appears to be more abundant. Spontaneous colony formation by AML blasts is abrogated by the addition of neutralizing antibodies against IL-1 beta and GM-CSF, whereas each antibody alone has little effect on blast proliferation. Taken together, our results are consistent with the view that the production of IL-1 beta by AML blasts supports autocrine growth in culture, through induction of CSFs or other cytokines that stimulate blast proliferation.

[Pediatric primary care seen through a hospital emergency service]. / La asistencia primaria pediátrica vista a través de un servicio de urgencias hospitalario.

We have studied the procedures for taking care of the 1,044 patients who arrived in the Emergency Room at the Niño Jesus Hospital on weekday mornings, in order to evaluate the operation of primary pediatric care as the possible generator of the demand for emergency hospital care. We also took into account the motivations which the parents of the children gave for not having gone to their doctors. The diagnosis and/or prior treatment were considered adequate in 83.81% of cases, and in 64.63% of cases in which these were known for a fact. 35.7% of the children were periodically checked out by their doctors even though they were not ill. Among the motives given by the parents for going directly to the Emergency Room, only 5.69% and 8.41% respectively said that it was due to an emergency situation or a worsening of the patient's state. 35.89% pointed out that their pediatricians had afternoon hours, and 20.91% that they went to the Emergency Room systematically regardless of the problem. Only 10.27% said that they were unhappy with their doctor. From our data it would seem that the demand for emergency pediatric hospital care is due more to a lack of health education of the population than to deficiencies in primary care.