Venopunción en el dorso de la mano. ¿Una alternativa a la punción del talón? / Back-of-the hand venepuncture. An alternative to heel puncture?

Introducción: La determinación de pruebas metabólicas en los recién nacidos (hipotiroidismo y fenilcetonuria) mediante punción de talón es un método doloroso. La venopunción podría suponer un método alternativo de extracción. Objetivos: Evaluar la eficacia y la repuesta al dolor obtenida mediante punción venosa en el dorso de la mano en comparación con la punción de talón en la realización de pruebas metabólicas, y la detección de posibles diferencias en cuanto a los resultados de TSH. Material y métodos: Estudio observacional descriptivo aleatorizado con 607 recién nacidos consecutivos asignados a 2 grupos: grupo venopunción (n=280), y grupo punción de talón (n=327). Se estudió la respuesta al dolor utilizando una escala de dolor (escala NIPS), y latencia y duración del llanto, eficacia de la prueba valorando el número de punciones necesarias y duración de la prueba, y comparación de falsos positivos para el hipotiroidismo congénito. Resultados: La extracción por venopunción fue menos dolorosa que la realizada mediante punción de talón en la escala NIPS (scores de 2 vs 5, p<0,001). Iniciaron llanto en el primer minuto el 57,8% de los niños con venopunción frente al 90,2% de los niños con punción de talón (p<0,0001). Los niños con venopunción lloraron menos tiempo (58 s) que los niños con extracción por punción de talón (104 s). La duración de la prueba y el número de pinchazos necesarios fueron también menores con la venopunción (60 vs. 120 s). No hubo diferencias en cuanto al número de casos con TSH mayor de 5 o mayor o igual a 9 mU/ml. Conclusiones: La venopunción para la realización de pruebas metabólicas es más rápida y menos dolorosa, y no aumenta la frecuencia de falsos positivos en el cribado del hipotiroidismo(AU)

Introduction: Using heel puncture by lancets for the determination of metabolic tests (hypothyroidism and phenylketonuria) using heel puncture is a very painful procedure. Venepuncture can be used as an alternative. Objectives: To determine whether venepuncture in the dorsal side of the hand is less painful and more efficient than heel puncture in the screening test for inborn errors of metabolism, as well as comparing false positives in the hypothyroidism test. Material and methods: We tested 607 consecutives newborns in an observational, randomised study (280 with venepuncture, and 327 with heel puncture). Pain response was assessed using the Neonatal/Infant Pain Scale (NIPS), and the delay and duration of the first cry. We measured the number of punctures needed, and the time taken to complete the test, as well as the number of false positives in the hypothyroidism test. Results: Venepuncture was less painful than heel prick (NIPS 2 vs 5, P<0.001), as well as in the delay (crying in 57.8% vs 90.2%, P<0.0001) and duration of the cry (58 vs 104 seconds). Venepuncture was also faster (60 vs 120 seconds), and required less puncture attempts. There were no differences in cases with TSH greater than 5mU/mL, or greater than or equal to 9 mU/mL. Conclusions: Venepuncture is associated with less pain, is faster to perform and not is associated with more false positive cases(AU)

[Back-of-the hand venepuncture. An alternative to heel puncture?]. / Venopunción en el dorso de la mano. ¿Una alternativa a la punción del talón?

INTRODUCTION: Using heel puncture by lancets for the determination of metabolic tests (hypothyroidism and phenylketonuria) using heel puncture is a very painful procedure. Venepuncture can be used as an alternative. OBJECTIVES: To determine whether venepuncture in the dorsal side of the hand is less painful and more efficient than heel puncture in the screening test for inborn errors of metabolism, as well as comparing false positives in the hypothyroidism test. MATERIAL AND METHODS: We tested 607 consecutives newborns in an observational, randomised study (280 with venepuncture, and 327 with heel puncture). Pain response was assessed using the Neonatal/Infant Pain Scale (NIPS), and the delay and duration of the first cry. We measured the number of punctures needed, and the time taken to complete the test, as well as the number of false positives in the hypothyroidism test. RESULTS: Venepuncture was less painful than heel prick (NIPS 2 vs 5, P<.001), as well as in the delay (crying in 57.8% vs 90.2%, P<.0001) and duration of the cry (58 vs 104 seconds). Venepuncture was also faster (60 vs 120seconds), and required less puncture attempts. There were no differences in cases with TSH greater than 5mU/mL, or greater than or equal to 9 mU/mL. CONCLUSIONS: Venepuncture is associated with less pain, is faster to perform and not is associated with more false positive cases.

Análisis de las urgencias de pediatría en los hospitales comarcales de la Comunidad Valenciana / Analysis of Pediatric Emergency Departments in regional hospitals of the Community of Valencia

Introducción: Se han realizado estudios en España sobre la demanda y la asistencia en los servicios de urgencias pediátricas (SUP) en los hospitales de tercer nivel; sin embargo, son escasos los realizados en hospitales comarcales. El objetivo de este estudio es conocer el funcionamiento y la organización de las urgencias pediátricas de los hospitales comarcales de la Comunidad Valenciana. Material y métodos: Encuesta remitida por correo electrónico a los servicios de pediatría de los hospitales comarcales de la Comunidad Valenciana durante enero de 2010. La encuesta contiene 54 preguntas sobre datos de contacto, del hospital, de la guardia médica y del área pediátrica de urgencias. La información relativa a la población total y menor de 15 años correspondiente al área de cobertura de cada hospital se extrae del Sistema de Información Poblacional (SIP) de la Generalitat Valenciana. Resultados: Los 15 hospitales comarcales de la Comunidad Valenciana abarcan una población SIP total de 2.450.159 (un 46,8% del total de población de la comunidad), y 376.683 (15,5%) son menores de 15 años. El número de pediatras hospitalarios es de 121 (entre 5 y 13 por hospital). En la mayoría de hospitales (12) sólo hay un pediatra de guardia que atiende al 20-30% de los niños que acuden a urgencias. Actualmente, un 11,6% de los pediatras no realizan guardias, y se calcula que en 5 años en la mayoría de los hospitales algún pediatra estará exento de ellas. Sólo 5 hospitales disponen de residentes de pediatría y 9 cuentan con la colaboración de algún pediatra de atención primaria. La urgencia pediátrica se atiende dentro del área de urgencias generales. No existe un adecuado cumplimiento de ciertos indicadores de calidad de los SUP. Conclusiones: Casi la mitad de los niños de la Comunidad Valenciana son atendidos en departamentos donde la asistencia pediátrica especializada depende de un hospital comarcal. En la actualidad estos hospitales no disponen de recursos humanos suficientes para garantizar dicha asistencia a todos los niños que acuden a urgencias (AU)

Introduction: There are some Spanish research about the demand and assistance for PEDs in Third Level Hospitals; however, few studies have examined the issue on Regional Hospitals. The focus of this study is to acknowledge the actual situation of both, organization and functioning of the Pediatric Emergency Departments in Regional Hospitals of the Valencian Community (VC). Material and methods: A web-based survey was forwarded to all Pediatric Services in Regional Hospitals in the Valencian Community during January 2010. This survey compiled 54questions about: contact data, hospital data, medical emergency, and data on medical duty and pediatric emergency service data. Demographic data related to global and under 15 years old population corresponds to the Sanitary Coverage Area of each hospital and were obtained from the Population Information System (SIP) of the Council of the Generalitat Valenciana. Results: A total population of 2,450,159 (46.8% of the total of the Valencian Community population) is attended in 15 Regional Hospitals of the VC. 15.5% (376,683) are under 15 years of age. There are a total number of 121 pediatric physicians (PP) (5-13 per hospital). In most of the hospitals (12) there is only one pediatrician on duty that sees 20-30% of the children that go to the emergency guard. Nowadays 11.6% of the pediatricians are exempt from being on-call duty and in the next5 years there will be exempt pediatricians in most hospitals. Only 5 hospitals have Pediatric residents, Primary Attention Pediatricians contributes to Continued Attention in only nine hospitals. Pediatric Emergency is attended within the framework of General Emergencies. There is not an adequate accomplishment of some quality indicators in PEDs. Conclusions: Almost half of the children in the Valencian Community are attended in Health Departments where specialized pediatric assistance depends on a Regional Hospital. Nowadays, these hospitals do not have enough human resources to guarantee the assistance to all the children taken to PEDs (AU)

Bocio endémico en la Comunidad Valenciana / Endemic goiter in the autonomous community of Valencia (Spain)

No disponible

[Endemic goiter and iodine deficiency: are they still a reality in Spain]. / Bocio endémico y déficit de yodo: 'sigue siendo una realidad en España?

OBJECTIVE: To estimate the prevalence of goiter and iodine deficiency in a health district in the Autonomous Community of Valencia, given the absence of data in this region of Spain. MATERIAL AND METHODS: We conducted a descriptive, epidemiologic, cross-sectional study, stratified by age and sex, in four interior regions of the province of Valencia. We selected students aged from 6 to 14 years old in 20 centers. Thyroid examination was performed by means of palpation and inspection (goiter > or = 0B). Urinary iodine excretion was analyzed in a routine urine sample. Sociodemographic and anthropometric data, as well as nutritional iodine status, were recorded in a standardized survey. In children with goiter, thyroid-stimulating hormone (TSH), free T4, and antithyroid antibodies were determined. RESULTS: We studied 928 children (478 boys and 450 girls). The prevalence of goiter was 33.7 % (95 % CI: 30.7-36.9 %). There were no significant differences in the prevalence of goiter by age or sex, but an inverse correlation was detected between the prevalence of goiter and parental socioeconomic position. Mean urinary iodine excretion was 155 .g/l, with no significant correlation with the prevalence of goiter. In children with goiter, 13 had positive antithyroid antibodies, 18 had high TSH (subclinical hypothyroidism), and one had suppressed TSH (subclinical hyperthyroidism). CONCLUSIONS: There is endemic goiter in the region studied. Urinary iodine levels were in the normal range and could be interpreted as indicating a transition phase to an improvement in iodine deficiency. Autoimmune diseases would only explain 4 % of cases of goiter.

Bocio endémico y déficit de yodo: ¿sigue siendo una realidad en España? / Endemic goiter and iodine deficiency: are they still a reality in Spain?

Objetivo Determinar la prevalencia de bocio y déficit de yodo en comarcas del interior de la Comunidad Valenciana, dada la ausencia de datos en esta comunidad autónoma. Material y métodos Se trata de un estudio epidemiológico, descriptivo, transversal, estratificado por sexo y edad en cuatro comarcas del interior de la provincia de Valencia. Se estudiaron escolares de 6 a 14 años en 20 centros. La exploración tiroidea se realizó mediante palpación e inspección (bocio ≥ 0B). Se determinó la yoduria en una muestra de orina casual. Se recogieron datos de filiación, antropométricos, y una encuesta sobre el estado nutricional de yodo. En niños con bocio se determinó la hormona tiroestimulante (TSH), la tiroxina libre (T4L) y los anticuerpos antitiroideos. Resultados Se estudiaron 928 niños (478 varones y 450 mujeres). La prevalencia de bocio fue de 33,7 % (IC 95 %: 30,7-36,9). No se hallaron diferencias significativas por edad ni por sexo, aunque sí una correlación inversamente proporcional entre prevalencia de bocio y nivel instrucción paternos. La mediana de yoduria fue 155 μg/l, sin observar una correlación significativa con la prevalencia de bocio. Entre los niños con bocio 13 presentaron los anticuerpos antitiroideos positivos, 18 la TSH elevada (hipotiroidismo subclínico) y uno la TSH suprimida (hipertiroidismo subclínico). Conclusiones Existe una endemia bociosa en las comarcas estudiadas de la Comunidad Valenciana. Los valores de yodurias normales podrían interpretarse como una fase de transición hacia una mejoría del déficit de yodo en esta zona. La patología autoinmune explicaría sólo un 4 % de bocios

Objective To estimate the prevalence of goiter and iodine deficiency in a health district in the Autonomous Community of Valencia, given the absence of data in this region of Spain. Material and methods We conducted a descriptive, epidemiologic, cross-sectional study, stratified by age and sex, in four interior regions of the province of Valencia. We selected students aged from 6 to 14 years old in 20 centers. Thyroid examination was performed by means of palpation and inspection (goiter ≥ 0B). Urinary iodine excretion was analyzed in a routine urine sample. Sociodemographic and anthropometric data, as well as nutritional iodine status, were recorded in a standardized survey. In children with goiter, thyroid-stimulating hormone (TSH), free T4, and antithyroid antibodies were determined. Results We studied 928 children (478 boys and 450 girls). The prevalence of goiter was 33.7 % (95 % CI: 30.7-36.9 %). There were no significant differences in the prevalence of goiter by age or sex, but an inverse correlation was detected between the prevalence of goiter and parental socioeconomic position. Mean urinary iodine excretion was 155 μg/l, with no significant correlation with the prevalence of goiter. In children with goiter, 13 had positive antithyroid antibodies, 18 had high TSH (subclinical hypothyroidism), and one had suppressed TSH (subclinical hyperthyroidism). Conclusions There is endemic goiter in the region studied. Urinary iodine levels were in the normal range and could be interpreted as indicating a transition phase to an improvement in iodine deficiency. Autoimmune diseases would only explain 4 % of cases of goiter

Balanitis y proctitis por estreptococo del grupo A / Balanitis and proctitis caused by group A streptococcus

Se presenta un caso de enfermedad perianal estreptocócica asociada a balanopostitis (AU)

[Survey of the judicious use of antibiotics in primary care]. / Encuesta sobre el uso racional de antibióticos en atención primaria.

OBJECTIVE: To identify pediatricians' antibiotic prescribing habits in acute otitis media and tonsillopharyngitis and to determine the interaction between parents and pediatricians concerning antibiotic use in the Autonomous Community of Valencia (Spain). METHOD: Four hundred members of the Valencian Society of Pediatrics were randomly selected. A semi-structured questionnaire with non-excluding answers was sent by mail and, when responses were not obtained, a second one was sent. The confidentiality of the information was guaranteed. RESULTS: Of 400 questionnaires sent, 143 (35.8 %) were completed; 88.1 % were completed by pediatricians and 51.1 % by primary care workers. A total of 48.3 % of pediatricians used antibiotics in all cases of acute otitis media and 94.5 % prescribed them when fever and otalgia persisted for more than 48 hours. Amoxicillin-clavulanate was the most frequently prescribed antibiotic (63.6 %). Less than 10 % of pediatricians prescribed antibiotics as empirical treatment in tonsillopharyngitis; amoxicillin was the most frequently prescribed antibiotic (54.6 %). Indications for antibiotic treatment were fever, odynophagia and adenomegaly (69.5 %) and tonsillar exudate (62.5 %). Inappropriate antibiotic use was mainly due to excess workload. Providing health education to parents could be the best way of reducing inappropriate use. CONCLUSIONS: Antibiotic use is frequent in the treatment of acute otitis media. Amoxicillin-clavulanate and amoxicillin were the most frequently prescribed antibiotics in tonsillopharyngitis. Providing health education to parents and reducing pediatricians' workload would decrease inappropriate antibiotic use.

Encuesta sobre el uso racional de antibióticos en atención primaria / Survey of the judicious use of antibiotics in primary care

Objetivo: Conocer los hábitos de prescripción de antibióticos de los pediatras de la Comunidad Valenciana en la otitis media aguda (OMA) y la faringoamigdalitis y la relación padres-pediatra respecto a los antimicrobianos. Método: Se seleccionaron al azar 400 miembros de la Sociedad Valenciana de Pediatría. Cuestionario semiestructurado de respuestas no excluyentes remitido por correo y nuevo envío si no se obtuvo respuesta. Se garantizó la confidencialidad de la información. Resultados De las 400 encuestas remitidas, 143 (35,8 per cent) fueron cumplimentadas. El 88,1 per cent eran pediatras y el 51,1 per cent trabajaban en un equipo de atención primaria. En la OMA, el 48,3 per cent indicaba antibiótico en todos los casos, recetándolo el 94,5 per cent si la fiebre y la otalgia persistían más de 48 h. La amoxicilina-ácido clavulánico fue el antibiótico más prescrito (63,6 per cent). En la faringoamigdalitis, menos del 10 per cent administraban tratamiento empírico, siendo la amoxicilina el antibiótico más utilizado (54,6 per cent). La fiebre, la odinofagia y las adenopatías (69,5 per cent) o el exudado amigdalar (62,5 per cent) fueron los criterios para indicar la antibioticoterapia. El aspecto que más contribuye al uso inapropiado de antibióticos es la presión asistencial y el educar a los padres el que más ayudaría a reducir este uso inapropiado. Conclusiones La utilización de antibióticos en el tratamiento de la OMA es una práctica frecuente. La amoxicilina-ácido clavulánico para la otitis y la amoxicilina en la faringoamigdalitis fueron los antibióticos más prescritos. La educación sanitaria de los padres y reducir la presión asistencial disminuirían el consumo inadecuado de antibióticos (AU)

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

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

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

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

[The value of C-reactive protein in the diagnosis of acute appendicitis in children]. / Valor de la proteína C-reactiva en el diagnóstico de la apendicitis aguda en el niño.

OBJECTIVE: The aim of this study was to evaluate the usefulness of C-reactive protein values in the diagnosis of acute appendicitis, either as a single test or in combination with total white cell count. PATIENTS AND METHODS: Two hundred and thirty-one children with suspected appendicitis were analyzed. C-reactive protein and total white cell counts were measured and compared with the duration of symptoms and histological diagnosis. Both tests were compared by receiver-operating characteristic curves and the probability for the use of both tests together was calculated. RESULTS: Ninety out of 231 patients had abdominal pain that did not demand surgery. One hundred and forty-one children had histologically confirmed appendicitis (subgroups: 101 acute, 25 gangrenous and 15 perforated appendices). Mean C-reactive protein levels at admission were 25.1, 55 and 66.7 mg/L, respectively in these histological subgroups and 14.9 mg/L in the non-appendicitis group (p < 0.001). The total white cell count was also statistically significant. Both tests were equally valuable in patients whose symptoms had a duration of more than 12 hours. The total white cell count was more valuable in patients with less than 12 hours of symptoms. The likelihood ratio for appendicitis was 2.72 for a C-reactive protein greater than 20 mg/l and a total white cell count above 15,000/mm3. The likelihood ratio of not having appendicitis was 0.37 when both tests were below these values. CONCLUSIONS: Measurement of C-reactive protein is useful in the diagnosis of acute appendicitis, mainly in cases with more than 12 hours of evolution. The combined tests improved the predictive values.

[Measles seroprevalence in the schoolchildren of Valencia. The Measles Study Group]. / Seroprevalencia del sarampión en escolares valencianos. Grupo para el Estudio del Sarampión.

BACKGROUND: People born between 1978 and 1982 were the most affected by measles in the outbreaks occurring in the Valencian Community (Spain) in 1993. This age group has not been systematically immunized against measles and has not suffered the last large measles epidemics. HYPOTHESIS: global seroprevalence against measles in this age group is inadequate to prevent new outbreaks. METHODS: Prospective seroepidemiologic study in a sample of school-attending children, born between 1978 and 1982. Randomized sampling of all classrooms 5th to 8th grade high school of a Health Area; stratification depending on the population of the village (< 5,000, 5,001-20,000, > 20,000 inhabitants). Antecedents of measles immunization and the disease were collected. Measles IgG antibodies were measured by enzyme immunoassay, antibody titers 1:80 or higher were considered protective. RESULTS: Sample of 410 subjects, belonging to 17 classes. Measles antibody prevalence was 80.2% (95% CI: 76.6-83.8%), and was higher in less populated villages (p < 0.03). Immunization status was known in 253 subjects (61.7%). Protective titers were present in 86.1% of the vaccinated and in 68.1% of the non vaccinated (p < 0.001). CONCLUSIONS: There is a large percentage of subjects born between 1978 and 1982 unprotected against measles. Elimination of the disease will not be able unless an extraordinary vaccination campaign to include these subjects is taken.

[Survey of arterial blood pressure in children and adolescents in the population of Guadasuar]. / Estudio de la tensión arterial en niños y adolescentes en la población de Guadasuar.

Five hundred seventy-seven children (301 boys and 276 girls) from Guadasuar, whose blood pressure (BP) was taken in 1984, were reexamined over a three year period. The second of three BP readings, the most physiological, was used for the study. Among the boys, there was an increase in the systolic BP up to 16 years of age. The diastolic BP increased up to 12 years of age. For the girls, there was an increment of the systolic and diastolic BP us to 13 years of age. Our results, especially the diastolic readings, are higher than those of Sánchez (Spain) and of the Task Force (USA). The BP value at puberty could be important for the detection of future hypertension cases.