[Clinical and epidemiologic description of a severe outbreak of Salmonellosis in an urban nursery school]. / Descripción clínica y epidemiológica de un brote grave de salmonelosis en una escuela infantil urbana.

OBJECTIVE: We describe clinically and epidemiologically an outbreak of gastrointestinal infection by Salmonella enterica ser. (serotype) Enteritidis in an urban infant school, which led to high morbidity and significant social alarm. The immediate communication, as well as the adequate study of the outbreak, in both aspects, allowed identifying the pathogen and establishing control measures in a reasonable period of time. Controversial aspects such as the indication of antibiotherapy or the moment of closing the center are discussed. METHODS: We retrospectively collected clinical, analytical and epidemiological information and we reviewed the methodology of the outbreak study and its results. RESULTS: A total of 57 children (3-45 months), were affected and had microbiological confirmation. Diarrhea and fever were the main symptoms. 74% went to the hospital and 37% were admitted (mean stay 3.3 days). Factors associated with admission were: dehydration, significant elevation of acute phase reactants and coagulopathy. Twelve patients received parenteral cefotaxime. There were 2 complications: 1 bacteremia and 1 readmission. The initial suspicion of the origin of the outbreak was food, but the analysis of the control samples was negative. Five workers were positive (2 symptomatic). Epidemiologic Surveillance concluded that the probable origin of the outbreak was an asymptomatic carrier and improper diapers handling. The center was closed for 8 days. Cleaning and disinfection measures were carried out, as well as instruction on diaper changing, and the carriers were followed. CONCLUSIONS: Clustering in time and space of cases should be reported immediately for early control of the outbreak. Children may present severe forms of Salmonella gastroenteritis.

Documento internacional de consenso sobre apnea obstructiva del sueño / International Consensus Document on Obstructive Sleep Apnea

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). Palabras clave: Apnea obstructiva del sueño Diagnóstico Tratamiento

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). Keywords: Obstructive sleep apnea Diagnosis Treatment

International Consensus Document on Obstructive Sleep Apnea. / Documento internacional de consenso sobre apnea obstructiva del sueño.

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

Incidence of enterovirus in patients with acute gastroenteritis.

Enteroviruses (EV) have been linked to lymphocytic meningitis and exanthems, but they may also be involved in acute gastroenteritis (AGE), a condition whose aetiological agent often remains unidentified. In this work 1214 samples from individuals with AGE were studied with the aim of establishing the incidence of EV. The samples were collected between September and December in three different years and subjected to real-time genomic amplification in order to determine the viral load (VL). Of the 1214 samples studied, infection by a single virus was found in 328 cases (27%) and coinfection in 69 (5.7%). While adenoviruses (AdV) were the most frequent (14.8% of total), EV were present in 126 (10.4%) of the individuals tested. Of the 126 EV-positive samples, this virus was found as a single infection and coinfection in 76 (6.3%) and 50 (4.1%) cases, respectively. VL for EV was 5.58±1.51 log copies/ml (range 3.73-9.69) in the former and 6.27±1.75 (range 3.73-10.5) (p=0.02) in the latter. EV were identified in 97 children under 5 (16.9%) and in 29 (4.5%) patients over 5. Patients less than 5 years showed a higher VL that those more than 5 years age [6.08±1.57 (range 3.82-9.69) vs. 5.07±1.53 (range 3.73-10.58); (p=0.002)]. There was a high incidence of EV in AGE patients, and they were more frequent in those under 5, where they were found to replicate more efficiently. These results therefore indicate that testing for EV should be included in the diagnosis of AGE.

[Variability between health areas in antibiotic consumption among pediatric outpatients of Principado de Asturias, Spain (2005-2018)]. / Variabilidad entre áreas sanitarias en el consumo extrahospitalario de antibióticos de uso sistémico en la población pediátrica del Principado de Asturias, España (2005-2018).

OBJECTIVE: Antibiotics in Spain are mainly prescribed in the community sector, remarking a high variability between areas. The aim of this study is to describe the variability between health areas in the antibiotic consumption in the pediatric population of Asturias during 2005-2018 period. METHODS: Retrospective and comparative study using data about consumption of antibacterial agents for systemic use (J01C group in ATC, Anatomical Therapeutic Chemical, classification) in the pediatric outpatients of the eight health areas of Principado de Asturias between 2005 and 2018, based on defined daily dose (DDD) per 1000 inhabitants and day (DID). RESULTS: Mean antibiotic consumption in pediatric outpatients in Principado de Asturias (2005-2018) was 14 DID (CI95% 13.4 - 14.6). Consumption increased until 2009 (15.2 DID) and decreased from 2015 onwards (11.9 DID in 2018). ß-lactam penicillins was the most consumed therapeutic group (10.7 DID). There were statistically significant differences among the areas with the highest and the lowest consumption rates (Avilés, 19 DID; Oviedo, 11.5 DID). A high variability between health areas was observed when analysing data temporally (difference of 11.8 DID in 2011) and therapeutic groups. The consumption of macrolides in Langreo health area and quinolones in Jarrio health area were 2.3 and 4.1 times higher, respectively, comparing to Gijón health area. CONCLUSIONS: There is a wide quantitative and qualitative variability of antibiotic consumption in the pediatric outpatients among the different health areas of Asturias.

Quality Assessment of Real-Life Performance of Home Mechanical Ventilators / Evaluación de la calidad del funcionamiento en vida real de los ventiladores mecánicos domiciliarios

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Síndrome de Munchausen por poderes: dificultades diagnósticas y terapéuticas / Munchausen syndrome by proxy: diagnostic and therapeutic difficulties

Niña de diez años que consulta por la aparición de lesiones cutáneas diseminadas de morfología variada, asintomáticas y de carácter evanescente, de dos meses de evolución. Inicialmente fue catalogado como rash inespecífico, pero ante la persistencia de las consultas por este síntoma, se solicitan estudios para descartar vasculitis o exantema de origen vírico, con resultados normales, y una valoración dermatológica sin diagnóstico claro. Posteriormente la niña acude a urgencias con el cuero cabelludo teñido de rosa y varios mechones de pelo de este color, evidenciándose que desaparece al frotarlo con una solución alcohólica; pero tanto la madre como la niña niegan que se haya aplicado algún tipo de producto colorante (pintura, espray, maquillaje...). Ante la sospecha de una etiología no orgánica, se solicita interconsulta con Salud Mental y, tras la valoración de los síntomas referidos, de las fotografías aportadas especialmente por la madre y del perfil psicológico de esta, se llega a la impresión diagnóstica, apoyada por todos los profesionales implicados (pediatra de Atención Primaria, pediatra del Servicio de Urgencias hospitalario, dermatólogos y psiquiatra) de trastorno facticio o síndrome de Munchausen por poderes

A ten-year-old girl who consulted for the appearance of spots spread on the skin, of varied morphology, asymptomatic and of evanescent character, of two months of evolution. Initially cataloged as non-specific rash, but before the torpid evolution of the picture, studies are requested to rule out vasculitis or rash of viral origin, with normal results; and dermatological assessment without clear diagnosis. Later the girl comes with a lock of pink hair, evidencing that they disappear when rubbing it with alcoholic solution; but both the mother and the girl deny that any type of coloring product has been applied (paint, spray, makeup...). Given the suspiction of a non-organic etiology, interconsultation is requested with Mental Health and, after the hostile attitude of the mother in it, the diagnostic impression is reached, supported by all the professionals involved (primary care pediatrician, pediatrician of the hospital emergency department, dermatologists and psychiatrist) of factitious disorder or Munchhausen syndrome by proxy

Lumbalgia en un caso de púrpura de Schönlein-Henoch: de hallazgo incidental a complicación infrecuente / Back pain in a case of Schönlein-Henoch purpura: from incidental finding to uncommon complication

Introducción: La púrpura de Schönlein-Henoch (PSH) es una vasculitis de pequeños vasos sanguíneos, mediada inmunológicamente, aunque su patogenia exacta aún es desconocida. Se caracteriza por la presencia de púrpura cutánea palpable, afectación articular y gastrointestinal, pero el pronóstico a largo plazo estará determinado por la aparición de alteraciones renales. Caso clínico: Se describe el caso de una niña diagnosticada de PSH, que asoció desde el inicio del cuadro un intenso dolor lumbar sin antecedente traumático previo, y fue diagnosticada tardíamente de hematoma muscular abdominal. Discusión: La asociación de hematomas musculares en el curso de la PSH se considera una complicación muy infrecuente. Existen escasas referencias en la literatura al respecto, si bien puede causar una morbilidad importante. Conclusión: La rareza de esta complicación en la PSH infantil puede dificultar su diagnóstico precoz y su correcta interpretación

Introduction: Henoch-Schönlein purpura is a small-vessel IgA immune complex-mediated vasculitis, of unknow pathogenesis, characterized by of palpable purpura (without thrombocytopenia), abdominal pain, renal disease, and arthritis/arthralgias. It may also present with gastrointestinal bleeding. Case report: We report the case of a child with a Henoch-Schönlein purpura with a severe low back pain, without history of previous trauma, that was later diagnosed as an abdominal muscular hematoma through imaging test using ultrasound scan and lumbar radiography. Conclusion: Even though muscular affection was considered at first as an accidental finding, bibliographical research on the subject revealed published references to similar lesions in previous cases of this disease

Conventional Polysomnography Is Not Necessary for the Management of Most Patients with Suspected Obstructive Sleep Apnea. Noninferiority, Randomized Controlled Trial.

RATIONALE: Home respiratory polygraphy may be a simpler alternative to in-laboratory polysomnography for the management of more symptomatic patients with obstructive sleep apnea, but its effectiveness has not been evaluated across a broad clinical spectrum. OBJECTIVES: To compare the long-term effectiveness (6 mo) of home respiratory polygraphy and polysomnography management protocols in patients with intermediate-to-high sleep apnea suspicion (most patients requiring a sleep study). METHODS: A multicentric, noninferiority, randomized controlled trial with two open parallel arms and a cost-effectiveness analysis was performed in 12 tertiary hospitals in Spain. Sequentially screened patients with sleep apnea suspicion were randomized to respiratory polygraphy or polysomnography protocols. Moreover, both arms received standardized therapeutic decision-making, continuous positive airway pressure (CPAP) treatment or a healthy habit assessment, auto-CPAP titration (for CPAP indication), health-related quality-of-life questionnaires, 24-hour blood pressure monitoring, and polysomnography at the end of follow-up. The main outcome was the Epworth Sleepiness Scale measurement. The noninferiority criterion was -2 points on the Epworth scale. MEASUREMENTS AND MAIN RESULTS: In total, 430 patients were randomized. The respiratory polygraphy protocol was noninferior to the polysomnography protocol based on the Epworth scale. Quality of life, blood pressure, and polysomnography were similar between protocols. Respiratory polygraphy was the most cost-effective protocol, with a lower per-patient cost of 416.7€. CONCLUSIONS: Home respiratory polygraphy management is similarly effective to polysomnography, with a substantially lower cost. Therefore, polysomnography is not necessary for most patients with suspected sleep apnea. This finding could change established clinical practice, with a clear economic benefit. Clinical trial registered with www.clinicaltrials.gov (NCT 01752556).

[Healthy sleep: evidence and guidelines for action. Official document of the Spanish Sleep Society]. / Sueño saludable: evidencias y guias de actuacion. Documento oficial de la Sociedad Española de Sueño.

One of the main objectives of the Spanish Sleep Society is to promote healthy sleep in both the general population and in health professionals. This document aims to conduct a review of the current scientific literature on sleep habits that can serve as the basis on which to establish a set of general recommendations, regarding healthy sleep, for use by the general population in Spain as well as to identify the main challenges faced by research into sleep habits. The document has been developed by a multidisciplinary team made up of members of the Spanish Sleep Society who are experts in paediatric sleep medicine, clinical neurophysiology, pulmonology, neurology, chronobiology, physiology and psychology. The existing scientific literature dealing with sleep habits in the general population was reviewed, and the following aspects were addressed: the current state of sleep habits in the Spanish population; a generic review of the optimum number of hours of sleep; the impact of the environmental setting (noise, temperature, illumination, etc.), hours of sleep, diet and sport, together with several specific sections for children and teenagers, shift-workers and drivers of different vehicles. The conclusions from all the aspects addressed in this document have resulted in a set of final general recommendations that will serve as a guide for the general population and health professionals. Likewise, the principal environmental challenges and future lines of research are also discussed.

Effects of adenotonsillectomy on plasma inflammatory biomarkers in obese children with obstructive sleep apnea: A community-based study.

BACKGROUND: Obesity and obstructive sleep apnea syndrome (OSA) are highly prevalent and frequently overlapping conditions in children that lead to systemic inflammation, the latter being implicated in the various end-organ morbidities associated with these conditions. AIM: To examine the effects of adenotonsillectomy (T&A) on plasma levels of inflammatory markers in obese children with polysomnographically diagnosed OSA who were prospectively recruited from the community. METHODS: Obese children prospectively diagnosed with OSA, underwent T&A and a second overnight polysomnogram (PSG) after surgery. Plasma fasting morning samples obtained after each of the two PSGs were assayed for multiple inflammatory and metabolic markers including interleukin (IL)-6, IL-18, plasminogen activator inhibitor-1 (PAI-1), monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase-9 (MMP-9), adiponectin, apelin C, leptin and osteocrin. RESULTS: Out of 122 potential candidates, 100 obese children with OSA completed the study with only one-third exhibiting normalization of their PSG after T&A (that is, apnea-hypopnea index (AHI) ≤1/hour total sleep time). However, overall significant decreases in MCP-1, PAI-1, MMP-9, IL-18 and IL-6, and increases in adropin and osteocrin plasma concentrations occurred after T&A. Several of the T&A-responsive biomarkers exhibited excellent sensitivity and moderate specificity to predict residual OSA (that is, AHI⩾5/hTST). CONCLUSIONS: A defined subset of systemic inflammatory and metabolic biomarkers is reversibly altered in the context of OSA among community-based obese children, further reinforcing the concept on the interactive pro-inflammatory effects of sleep disorders such as OSA and obesity contributing to downstream end-organ morbidities.

[Evaluation of the efficacy of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome in children using respiratory polygraphy]. / Eficacia de la adenoamigdalectomía en el síndrome de apneas-hipopneas durante el sueño valorada mediante poligrafía respiratoria.

OBJECTIVE: To evaluate the effectiveness of adenotonsillectomy for the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) in children by respiratory polygraphy (RP). MATERIAL AND METHODS: Prospective study was conducted on children referred with clinical suspicion of OSAHS. A clinical history was taken and a general physical and ENT examination was performed on all patients. RP was performed before adenotonsillectomy and six months afterwards. Patients with craniofacial syndromes, neuromuscular disorders, and severe concomitant disease were excluded. RESULTS: We studied 150 children (67. 8% male), with a mean age of 3.74±1.80 years and a BMI of 41.70±31.75. A diagnosis of OSAHS was made if the total number of respiratory events, apneas and hypopneas, divided by the total study time (RDI) was > 4.6, using RP before undergoing adenotonsillectomy. The mean respiratory disturbance index (RDI) was 15.18±11.11, with 58.7% (88) of with severe OSAHS (RDI>10). There was a significant improvement in all clinical and polygraphic variables six months after adenotonsillectomy. The residual OSAHS was 14%. The preoperative RDI was significantly associated with persistent disease (P=.042). CONCLUSIONS: Respiratory polygraphy is useful for monitoring the efficacy of surgical treatment by adenotonsillectomy in children with OSAHS.

Novedades en el consenso español. Visión desde el experto en sueño / No disponible

El síndrome de apneas-hipopneas del sueño (SAHS) está presente en el 2-4niños de 2 a 6 años de edad(1). Afecta por igual a ambos sexos. De los niños que roncan y presentan sospecha de apnea obstructiva, sólo la mitad precisan la realización de una polisomnografía (PSG). El diagnóstico de sospecha de los trastornos respiratorios del sueño (TRS) se debería iniciar desde los primeros controles de salud incluidos en el programa del niño sano. Así, la Academia Americana de Pediatría(1) recomienda que en los controles de salud se investigue el sueño en todos los niños. Si el niño presenta ronquido y síntomas o hallazgos clínicos sugestivos de SAHS, se iniciará la escalada diagnóstica específica de TRS (AU)

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Fístula aortoentérica post-EVAR. Presentación de un caso y revisión de la literatura / Post-EVAR aortoenteric fistula. Presentation of a case and a review of the literature

El tratamiento endovascular del aneurisma de aorta abdominal (EVAR) no previene la aparición de fístula aortoentérica (FAE), rara y devastadora complicación. Su etiopatogenia es imprecisa, atribuyéndose a migración, angulación o dislocación del endoinjerto, a daño directo del intestino por erosión mecánica, o por presurización, inflamación, infección o rotura del aneurisma, pero también puede aparecer sin fallos en el dispositivo implantado y con pruebas de seguimiento de imagen normales. La clínica es larvada, por eso requiere un alto índice de sospecha. La angio-TC es el mejor método diagnóstico. El tratamiento precoz es esencial para obtener buenos resultados: consiste en la explantación del endoinjerto y la revascularización aórtica directa o extraanatómica. Presentamos el caso de un paciente varón de 73 años, portador de AAA, con alto riesgo quirúrgico, que fue tratado con endoprótesis aortomonoiliaca e injerto cruzado. Seis meses después de EVAR presentó una FAE, con evacuación del contenido aneurismático por vía digestiva.Con este se han publicado un total de 32 casos en la literatura. Es necesaria una constante vigilancia de la aparición de complicaciones en los pacientes sometidos a EVAR(AU)

Endovascular aneurysm repair (EVAR) is not immune to aorto-enteric fistulas (AEF), a rare and devastating high death rate complication. Pathogenesis is not clear, and may be attributed to graft migration, erosion, kinking, dislodging or adjacent organ injury due to mechanical forces, or aneurysm pressurisation, inflammation, infection and rupture. But AEF may appear despite accurate device placement or without stent or aortic failure in follow-up imaging studies. Symptoms are usually masked. A high level of suspiction, early recognition and treatment are essential for successful outcome. CT angiography is better than endoscopy for diagnosis. Surgical treatment consists of graft removal and direct aortic replacement or extra-anatomic bypass. A new case of post-EVAR AEF and a review of the literature reports a total o 32 cases. We emphasise the need for continued awareness in patients undergoing EVAR(AU)

[Sleep respiratory disorders, non-invasive ventilation and critical care in Archivos de Bronconeumología (June 2008-November 2009)]. / Los trastornos de la respiración durante el sueño, la ventilación no invasiva y los cuidados críticos en Archivos de Bronconeumología (junio de 2008-noviembre de 2009).

The present study analyses the works published in Archivos de Bronconeumología from June 2008 to November 2009 that mention sleep disorders, non-invasive ventilation and critical care. The methodology used was to analyse the objectives of the works submitted, with their main results and the conclusions suggested by the authors, often putting forward the possibility of conducting new research studies. The review no only includes original articles but is also a reflection on the editorials, special articles and review works.

Imagen radiológica del carbonato de lantano / No disponible

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