Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study.

BACKGROUND: The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics. METHODS: This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order. RESULTS: The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy. CONCLUSION: Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

Complicaciones intracraneales de los procesos infecciosos otorrinolaringológicos en la infancia / Intracranial com plications of head and neck infections in children

Introducción: Las complicaciones intracraneales de las infecciones otorrinolaringológicas (ORL) en niños son infrecuentes, pero potencialmente graves si no se diagnostican y tratan atiempo. Métodos: Estudio descriptivo y retrospectivo de pacientes con complicaciones intracraneales secundarias a infecciones ORL, diagnosticados en un hospital terciario entre 2005 y 2009. Resultados: Presentamos cinco casos de complicaciones intracraneales, tres infecciosas y dos vasculares. Las tres infecciosas fueron: a) absceso epidural secundario a otomastoiditis; b) petrositis con paresia del VI par secundaria a una sinusitis esfenoidal y otomastoiditis, y c) absceso subperióstico orbitario tras una sinusitis etmoidal y esfenoidal. Sólo en el primer caso se aisló el germen causal en hemocultivo (Streptococcus pyogenes). El primer caso requirió evacuación quirúrgica, y todos recibieron antibioterapia parenteral prolongada. Las complicaciones vasculares fueron dos casos de trombosis venosa del seno sigmoide, secundarios a una otomastoiditis. Se halló tambien S. pyogenes en el hemocultivo de uno de ellos. En ambos el estudio de los factores procoagulantes fue negativo. Uno de los dos no se anticoaguló y la recanalización ha sido parcial, aunque el paciente permanece asintomático. Conclusiones: Conocer las complicaciones intracraneales de las infecciones ORL nos permitirá sospecharlas ante un curso recurrente y tórpido o aparición de clínica neurológica. En estos casos se requiere un manejo multidisciplinario medicoquirúrgico, del que dependen las secuelas y el pronóstico. El uso de anticoagulación en niños con trombosis venosa cerebral aún es controvertido por sus riesgos; por ello, a pesar de las recomendaciones internacionales, con frecuencia prevalece una decisión individualizada para cada caso(AU)

Introduction: Though infrequent, intracranial complications of head and neck infections in children can have severe consequences if not diagnosed and treated early. Methods: Review of patients with secondary intracranial complications of head and neck infections diagnosed at a tertiary care hospital over a period of 4 years (2005-2009).Results: There were five cases of intracraneal complications (three non-vascular and two vascular). The three non-vascular cases were: a) epidural abscess secondary to otomastoiditis; b)petrositis with sixth nerve palsy secondary to sphenoid sinusitis and otomastoiditis, and c) subperiostic orbital abscess following ethmoid and sphenoid sinusitis. Only in the first case was the causal germ isolated in haemoculture (Streptococcus pyogenes). The first case required surgical evacuation, and all cases received prolonged parenteral antibiotherapy. The vascular complications comprised two cases of intracranial thrombosis of sinus sigmoid secondary to otomastoiditis. S. pyogenes was also found in the haemoculture of one case. In both patients, the procoagulant factors proved negative. One of the two cases was not put on anticoagulant therapy and rechanneling was partial, though it remained asymptomatic. Conclusions: Knowing these complications will lead us to suspect them in the event of torpid and recurrent disease course, or appearance of related neurological symptomatology. In such cases, multidisciplinary medical-surgical management is required and on that sequelae and prognosis depend. As it is not risk-free, the use of anticoagulation in children with intracranial sinus thrombosis is controversial, and consequently, despite international recommendations, in each case individualized and consensus-based decisions often prevail(AU)

Lactancia materna y protección contra las infecciones respiratorias en los primeros meses de vida / Breastfeeding and the protection against respiratory infections in the first months of life

Introducción: entre las ventajas de la lactancia materna (LM) se incluye su papel protector ante infecciones respiratorias (IR). Objetivos: describir el patrón de LM de una cohorte de recién nacidos (RN) y su protección contra las IR en el lactante. Material y métodos: estudio prospectivo de 316 RN, de las áreas 8 y 9 de Madrid, desde el nacimiento mediante llamadas telefónicas quincenales durante el invierno, registrando datos clínicos y epidemiológicos. Si presentaban sintomatología compatible con IR se recogió aspirado nasofaríngeo. Resultados: mil ochocientas sesenta y cinco llamadas (mediana: 4,2 [1-11]) y 106 visitas programadas. Al mes, el 56,1% recibía LM exclusiva; a los tres meses, el 39,4%, y a los cinco meses, el 31,9%. La LM exclusiva se mantuvo 65,1 días (desviación estándar: 43,49) y ningún factor se asoció a una mayor duración. Hubo 89 episodios de IR aguda. Los hermanos escolares multiplican por 1,74 (intervalo de confianza del 95% [IC 95%]: 1,12-2,72) el riesgo de IR en todos los estratos de duración de LM exclusiva. El riesgo de infección se multiplica por cinco (IC 95%: 2,07-12,19) si la LM exclusiva dura menos de un mes, por 9,8 (IC 95%: 4,06-23,66) si dura entre 30 y 60 días y por 3,4 (IC 95%: 1,28-9,19) si dura entre 60 y 90 días. Conclusiones: aunque muchos RN inician LM exclusiva, solo la tercera parte la mantiene a los cinco meses. Ningún factor se asoció a mayor duración de la misma. La LM es un factor protector de IR cuando dura más de 90 días. Se debe fomentar el mantenimiento de la LM más allá del tercer mes, especialmente en aquellos con hermanos escolares (AU)

Background: the protective role against respiratory infections is included among the advantages of breastfeeding (BF). Objective: to describe the pattern of BF in a cohort of newborns and its protective role against respiratory infections (RI) in the infant. Material and methods: a cohort of 316 newborns (NB) from Madrid Health Districts 8 and 9 was followed by telephone calls every fortnight during the winter season recording clinical and epidemiological data. Nasopharyngeal aspirate was obtained in every patient with symptoms compatible with RI. Results: one thousand, eight hundred and sixty-five phone calls [median: 4.2 (1-11)], and 106 scheduled visits were conducted. At the age of 1 month 56.1% of the infants were exclusively breastfed, at 3 months 39.4% and at 5 months 31.9%. The duration of BF was 65.1 days (SD: 43.49) and no factors were associated to a longer duration. Eighty nine acute RI were registered. The presence of siblings in school age increased the risk of RI by 1.74 (CI 95%: 1.12-2.72) in all the strata of duration of exclusive BF. The risk of RI increased by 5 (CI 95%: 2.07-12.19) if breastfeeding lasted less than 1 month, by 9,8 (CI 95%: 4,06-23,66) between 30-60 days and by 3,4 (CI 95%: 1.28-9,19) if it lasted 60-90 days. Conclusions: though many NB begin BF, only a third part of them go on with it at the age of 5 months. No covariant was associated with a longer duration. BF is a protector factor against RI when it lasts more than 90 days. So it must be promoted specially in those infants with siblings in school age (AU)

Levetiracetam as an alternative therapy for Tourette syndrome.

Tourette syndrome is a common childhood-onset neuropsychiatric disorder characterized by chronic tics and frequent comorbid conditions such as attention deficit disorder. Most currently used tic-suppressing drugs are frequently associated with serious adverse events. Thus, alternative therapeutic agents with more favorable side-effect profiles are being evaluated. New hypotheses and recent studies involving GABAergic system in the pathophysiology of Tourette syndrome suppose a reason for the evaluation of GABAergic drugs. Levetiracetam is a drug with an atypical GABAergic mechanism of action that might be expected to improve tics. Although trials performed to evaluate the efficacy of levetiracetam in the treatment of Tourette syndrome have provided conflicting results, it may be useful in some patients. The established safe profile of levetiracetam makes this drug an alternative for treatment if intolerance to currently used drugs appears, but additional evaluation with larger and longer duration controlled studies are necessary to assess the real efficacy in patients with Tourette syndrome.

Síndrome del túnel carpiano en la infancia / Carpal tunnel syndrome in childhood

Introducción. El síndrome del túnel carpiano (STC) en el niño tiene una forma de presentación clínica habitualmente diferente a la del adulto, lo que, unido a su infrecuencia en esta edad, dificulta el diagnóstico. También tiene unas características etiológicas diferentes, la mayoría de los casos descritos en la edad pediátrica ocurren en niños con enfermedades de depósito lisosomal (mucopolisacaridosis y mucolipidosis), y puede ser la primera manifestación de la enfermedad en algunos casos. Caso clínico. Presentamos 2 casos de STC idiopáticos y 1 familiar, de edades comprendidas entre los 4 y 10 años. Los idiopáticos se presentaron como episodios intermitentes de parestesias y dificultades en la manipulación, mientras que el familiar cursaba de forma más típica con parestesias y dolor. El estudio neurofisiológico confirmó el diagnóstico. En el paciente con antecedentes familiares la resonancia magnética del carpo mostró una compresión del nervio por engrosamiento del retináculo flexor. En todos los casos se descartó enfermedad lisosomal y se inició tratamiento conservador, siendo la evolución favorable en los idiopáticos, en uno de ellos con remisión prácticamente completa de la sintomatología, mientras que el paciente con STC familiar sigue un curso progresivo y está pendiente de valoración quirúrgica. Discusión. El STC en la edad pediátrica se presenta con síntomas más leves e inespecíficos que en el adulto y los hallazgos en la exploración y test de provocación suelen ser poco evidentes. Casi siempre es necesario el tratamiento quirúrgico, aunque algunos casos idiopáticos, sobre todo si no asocian engrosamiento del retináculo flexor, pueden mejorar con tratamiento conservador (AU)

Introduction. Carpal tunnel syndrome (CTS) has usually a different clinical presentation in children compared to adults. On top of this, its rarity in childhood makes it difficult to diagnose. It has also different etiologies at this age, the majority of cases occur in children with lysosomal storage diseases (mucopolysaccharidosis and mucolipidosis) which may be the first manifestation of this disease in some cases. Clinical case. In this article we describe 3 cases of children aged between 4 and 10 years, 2 with idiopathic CTS and 1 with primary familial origin. The symptoms of the former were intermittent paresthesias and handling difficulty, while the familial case presented with a more typical paresthesias and pain. The neurophysiological study confirmed the diagnosis. Concerning the patient with a history of CTS in the family, MRI showed a compression of the nerve due to the thickening of the flexor retinaculum. In all cases, lysosomal storage disease was ruled outand a conservative treatment was initiated. Evolution was favorable in the idiopathic cases, one of them with an almost complete remission of symptoms, while the patient with a familial CTS follows a progressive course and is waiting for the surgical assessment. Discussion. The CTS in pediatric age presents milder and more unspecific symptoms than in adults, and the results of the exploration and provocation tests are often unclear. Surgical treatment is almost always necessary, although some idiopathic cases, particularly if they are not associated to the thickening of the flexor retinaculum, may improve with a conservative treatment (AU)

Fármacos para el trastorno por déficit de atención/hiperactividad / Drugs for attention deficit hyperactivity disorder

Se encuentran diferencias entre los diversos fármacos aprobados en España para el trastorno por déficit de atención/hiperactividad en estudios de tipo cuantitativo. No hay claras diferencias en estudios de tipo cualitativo. El número de pacientes a tratar para que uno alcance remisión completa (NNT) del metilfenidato (MTF) es de 2,2 a 5, y el tamaño del efecto (TE), de 0,9. La atomoxetina tiene un NNT de 4 y un TE de 0,7. Las ventajas del MTF de liberación inmediata (MTF-LI) respecto al de liberación prolongada (MTF-LP) residen en su bajo coste, su flexibilidad y mejores resultados en estudios cuantitativos. Por contra, el MTF-LP presenta un menor riesgo de abuso, precisa un menor número de tomas, una menor necesidad de terceros para el control de éstas y un menor riesgo de estigmatización. La combinación o cambio de MTF-LI y MTF-LP y la combinación de MTF con atomoxetina son en ocasiones necesarias para ajustar la posología de día laborable o de fin de semana. Iniciar el tratamiento con MTF-LI para luego mantener o cambiar a MTF-LP aporta ciertas ventajas en seguridad, ajuste de dosis y posología. La atomoxetina es la mejor alternativa si hay antecedente de eventos adversos con estimulantes en dosis bajas o moderadas, o falta de respuesta a los estimulantes en dosis altas. En caso de ansiedad comórbida importante, tanto el MTF como la atomoxetina tienen igual nivel de indicación. Si hay riesgo de abuso de sustancias, tanto la atomoxetina como el MTF-LP son de primera elección. Para el resto de indicaciones, el MTF constituye la primera elección (AU)

Quantitative studies have highlighted differences in several drugs approved for use in Spain in the treatment of attention deficit hyperactivity disorder. No clear differences are observed, however, in the case of qualitative studies. The number of patients needed to be treated in order for one to reach complete remission (NNT) of methylphenidate (MTF) is from 2.2 to 5, and the effect size (ES) is 0.9. Atomoxetine has an NNT of 4 and an ES of 0.7. The advantages of immediate-release MTF (IR-MTF) over the extended-release version (ER-MTF) lie in its low cost, its flexibility and the better results obtained in quantitative studies. In contrast, ER-MTF offers a lower risk of abuse, needs to be taken fewer times with less need for third parties to control administration, and there is a lower risk of stigmatisation. Combination or changes of IR-MTF and ER-MTF and the combination of MTF with atomoxetine are sometimes necessary to adjust the weekday or weekend doses. Starting treatment with IR-MTF and then maintaining or changing to ER-MTF offers certain advantages as regards safety, dose adjustments and dosage. Atomoxetine is the best alternative if there is a background of adverse events with low or moderate doses of stimulants, or lack of response to high doses of stimulants. In cases of notable comorbid anxiety, both MTF and atomoxetine have the same level of indication. If there is a risk of substance abuse, both atomoxetine and ER-MTF are the preferred treatment. For the other indications, MTF is the preferred treatment (AU)

[Coding in neuropediatrics based on the International Classification Diseases, 9th revision (ICD-9), 5th edition (2006)]. / Codificación en neurología pediátrica basada en la Clasificación Internacional de Enfermedades, 9.(a) revisión (CIE-9), 5.(a) edición (2006).

AIMS: To analyze International Classification Diseases, 9th revision (ICD-9) coding and adapt it, on a consensus basis, to 'reasons for medical consultation', 'diagnoses' and 'procedures' in child neurology. MATERIALS AND METHODS: The most frequent reasons for medical consultation, diagnoses and procedures in neuropediatrics were selected and assigned the most appropriate ICD-9, Clinical Modification (5th ed.) (ICD-9-CM) codes in accordance with this system's coding rules. Disorders were grouped by sections, and allocated to the various members of the working group (13 child neurologists from 10 hospitals in Madrid and environs). RESULTS: Available on the web www.neurologia.com/cie-9. ICD-9-CM codes were assigned to: 158 reasons for medical consultation; 886 diagnoses; 73 diagnostic procedures; and 53 therapeutic procedures. In every case, the most appropriate ICD-9 code was sought for the respective diagnosis. No codes were invented but the working group did take certain liberties with interpretation, which nevertheless showed respect for general ICD-9-CM philosophy and are described in full in the text. CONCLUSIONS: The creation of this ICD-9 adaptation will not only enhance diagnostic coding in child neurology departments, but will also provide them with a useful tool for setting up databases to enable information to be retrospectively analyzed and shared by the different health centers.

Codificación en neurología pediátrica basada en la Clasificación Internacional de Enfermedades, novena revisión (CIE-9), quinta edición (2006) / Coding in neuropediatrics based on the international classification diseases, 9 th revision (ICD-9), 5 th edition ( 2006)

Objetivos. Análisis y adaptación consensuada de la codificación de la Clasificación Internacional de Enfermedades, 9.ª revisión (CIE-9), a los motivos de consulta, diagnósticos y procedimientos en neurología pediátrica. Materiales y métodos. Se seleccionan los motivos de consulta, diagnósticos y procedimientos más frecuentes en neuropediatría y se les asignael código más apropiado de la CIE-9-MC (5.ª ed.) según las normas de codificación de dicho sistema. Se han agrupado las patologías por secciones, las cuales se han adjudicado a los distintos miembros del grupo de trabajo (13 neurólogos pediátricos de 10 hospitales de Madrid capital y área periférica). Resultados. Se exponen en www.neurologia.com/cie-9. Se han asignadocódigos de la CIE-9-MC (5.ª ed.) a 158 motivos de consulta, 886 diagnósticos, 73 procedimientos diagnósticos y 53 procedimientos terapéuticos. Siempre se ha intentado buscar el código de la CIE-9 más apropiado para los distintos diagnósticos.No se han inventado códigos, aunque el grupo de trabajo se ha tomado algunas libertades de interpretación que respetan la filosofía general de la CIE-9-MC y que se describen en el texto. Conclusión. La creación de esta adaptación de la CIE-9 potenciará la codificación diagnóstica en los servicios de neurología pediátrica, dotándolos además de una herramienta útil parala elaboración de bases de datos que permitan el análisis retrospectivo de la información, y compartirla entre los distintos centros

Aims. To analyze International Classification Diseases, 9th revision (ICD-9) coding and adapt it, on a consensusbasis, to ‘reasons for medical consultation’, ‘diagnoses’ and ‘procedures’ in child neurology. Materials and methods. The most frequent reasons for medical consultation, diagnoses and procedures in neuropediatrics were selected and assigned themost appropriate ICD-9, Clinical Modification (5th ed.) (ICD-9-CM) codes in accordance with this system’s coding rules. Disorders were grouped by sections, and allocated to the various members of the working group (13 child neurologists from 10 hospitals in Madrid and environs). Results. Available on the web www.neurologia.com/cie-9. ICD-9-CM codes were assigned to: 158 reasons for medical consultation; 886 diagnoses; 73 diagnostic procedures; and 53 therapeutic procedures. In every case, the most appropriate ICD-9 code was sought for the respective diagnosis. No codes were invented but the workinggroup did take certain liberties with interpretation, which nevertheless showed respect for general ICD-9-CM philosophy and are described in full in the text. Conclusions. The creation of this ICD-9 adaptation will not only enhance diagnostic coding in child neurology departments, but will also provide them with a useful tool for setting up databases to enable information to beretrospectively analyzed and shared by the different health centers

[Is the incidence of parapneumonic pleural effusion increasing?]. / Está aumentando la incidencia de derrames pleurales paraneumónicos?

INTRODUCTION: Streptococcus pneumoniae is the microorganism most frequently associated with complicated pleural effusion. After the introduction of the heptavalent pneumococcal vaccine, there was a decline in the incidence of invasive pneumococcal disease and, to a lesser extent, in that of pneumonia. However, the incidence of empyema apparently increased. The antipneumococcal heptavalent vaccine was introduced in Spain in 2001. OBJECTIVES: To determine whether the incidence of pleural effusion secondary to pneumonia has increased in hospitalized patients and to examine the possible influence of the antipneumococcal heptavalent vaccine on the incidence rate of parapneumonic effusions. PATIENTS AND METHODS: Patients aged less than 16 years old admitted to our hospital with a diagnosis of pneumonia between 1999 and 2005 were retrospectively reviewed. We calculated the annual incidence rate of pleural effusion with respect to the total number of patients admitted with pneumonia and with respect to patients considered to have probable bacterial pneumonia, based on previously established criteria. RESULTS: A total of 337 patients were analyzed, of which 213 (63.2%) met the criteria for a diagnosis of probable bacterial pneumonia. Pleural effusion was found in 34 patients (15.9%), and 13 of these effusions (38%) were complicated. No clear trend was detected in the annual incidence of probable bacterial pneumonia per 100 admitted patients, although the highest numbers were detected in the last two years of the study period. The percentage of complications (effusions) remained constant (mean: 16.28%). No differences were found in the effusion rate between vaccinated and unvaccinated patients (12.5% vs 18.6%). CONCLUSIONS: The trend in the incidence of parapneumonic pleural effusions was parallel and proportional to that of probable bacterial pneumonia.

[Scrotal hair in infants]. / Vello escrotal en lactantes.

The presence of pubic hair is exceptional in healthy infants of both sexes. In most of the cases described in the literature, the process was self-limited and no etiology was found. Nevertheless, in some patients, this finding has been associated with other manifestations of hyperandrogenism related to potentially serious diseases such as congenital adrenal hyperplasia or virilizing tumors. In the present article, we describe seven infants followed-up in the Pediatric Endocrine Clinic because of scrotal hair. In all patients, the process was self-limited and resolved spontaneously and no hormonal or developmental alterations were observed. Key words: Scrotal hair, infants, virilization.

¿Está aumentando la incidencia de derrames pleurales paraneumónicos? / Is the incidence of parapneumonic pleural effusion increasing?

Introducción: Streptococcus pneumoniae es el agente etiológico aislado con más frecuencia en los derrames paraneumónicos complicados. Desde la introducción de la vacuna antineumocócica heptavalente (VCN-7), ha disminuido la enfermedad neumocócica invasiva y, en menor grado, la incidencia de neumonías, pero con un aparente aumento del empiema. En España la vacuna fue comercializada en 2001. Objetivos: Determinar si existe un aumento de la incidencia de derrames pleurales en los pacientes ingresados por neumonía y la posible influencia de la vacunación con VCN-7 sobre la incidencia de dichos derrames. Pacientes y métodos: Estudio retrospectivo de los pacientes menores de 16 años ingresados en nuestro hospital por neumonía entre 1999 y 2005. Se calculó la incidencia anual de derrames pleurales respecto al número total de neumonías ingresadas y respecto a las consideradas como de probable origen bacteriano (NPOB) según criterios establecidos. Resultados: Se analizaron 337 pacientes. De éstos, 213 cumplían criterios de NPOB (63,2 %). Un total de 34 pacientes presentaron derrame pleural (15,9 %), 13 de los cuales (38 %) fueron complicados. No se pudo objetivar en el período estudiado una tendencia clara en la incidencia anual de NPOB por 100 pacientes ingresados, aunque en los dos últimos años se detectaron las cifras más altas. La proporción de complicaciones (derrames) se mantuvo constante (media 16,28 %). No existieron diferencias en la aparición de derrames entre los pacientes vacunados con VCN-7 y los no vacunados (12,5 % frente a 18,6 %). Conclusiones: Se objetiva una evolución de la incidencia de derrames pleurales paraneumónicos paralela y proporcional a la de las neumonías bacterianas (AU)

Introduction: Streptococcus pneumoniae is the microorganism most frequently associated with complicated pleural effusion. After the introduction of the heptavalent pneumococcal vaccine, there was a decline in the incidence of invasive pneumococcal disease and, to a lesser extent, in that of pneumonia. However, the incidence of empyema apparently increased. The antipneumococcal heptavalent vaccine was introduced in Spain in 2001. Objectives: To determine whether the incidence of pleural effusion secondary to pneumonia has increased in hospitalized patients and to examine the possible influence of the antipneumococcal heptavalent vaccine on the incidence rate of parapneumonic effusions. Patients and methods: Patients aged less than 16 years old admitted to our hospital with a diagnosis of pneumonia between 1999 and 2005 were retrospectively reviewed. We calculated the annual incidence rate of pleural effusion with respect to the total number of patients admitted with pneumonia and with respect to patients considered to have probable bacterial pneumonia, based on previously established criteria. Results: A total of 337 patients were analyzed, of which 213 (63.2 %) met the criteria for a diagnosis of probable bacterial pneumonia. Pleural effusion was found in 34 patients (15.9 %), and 13 of these effusions (38 %) were complicated. No clear trend was detected in the annual incidence of probable bacterial pneumonia per 100 admitted patients, although the highest numbers were detected in the last two years of the study period. The percentage of complications (effusions) remained constant (mean: 16.28 %). No differences were found in the effusion rate between vaccinated and unvaccinated patients (12.5 % vs 18.6 %). Conclusions: The trend in the incidence of parapneumonic pleural effusions was parallel and proportional to that of probable bacterial pneumonia (AU)

Vello escrotal en lactantes / Scrotal hair in infants

La aparición de vello sexual es excepcional en los lactantes de ambos sexos. La mayoría de los casos descritos en la bibliografía constituyen procesos autolimitados, en los que su etiología no ha sido definida. Sin embargo, en algunos casos se ha asociado con otras manifestaciones de hiperandrogenismo relacionadas con procesos potencialmente graves como son la hiperplasia suprarrenal congénita y tumores productores de andrógenos. En el presente artículo se describe los casos de 7 lactantes varones que fueron vistos en la consulta de endocrinología pediátrica por vello escrotal. En todos ellos el proceso fue autolimitado, sin que se observaran alteraciones hormonales o en el desarrollo (AU)

The presence of pubic hair is exceptional in healthy infants of both sexes. In most of the cases described in the literature, the process was self-limited and no etiology was found. Nevertheless, in some patients, this finding has been associated with other manifestations of hyperandrogenism related to potentially serious diseases such as congenital adrenal hyperplasia or virilizing tumors. In the present article, we describe seven infants followed-up in the Pediatric Endocrine Clinic because of scrotal hair. In all patients, the process was self-limited and resolved spontaneously and no hormonal or developmental alterations were observed (AU)

Aditivos y trastorno del déficit de atención. Actualización / Additives and upheaval of the attention deficit. Update

En 1975 se abrió el debate sobre si el consumo de ciertos aditivos podría aumentar la hiperactividad o tener efectos perniciosos en la atención, conducta y aprendizaje, ya en población normal, ya en pacientes con trastorno por hiperactividad. Si bien los resultados han sido negativos durante decenios de investigación, desde el 2004 se ha reabierto el debate con más fuerza gracias a un nuevo metanálisis y a dos investigaciones cuyos últimos resultados se publican en septiembre del 2007. Estos artículos aportan datos positivos sobre un efecto neurobiológico leve de estos aditivos en población normal y según metanálisis también en TDA. Este efecto neurobiológico implicaría al menos un aumento de la hiperactividad. Los estudios necesitan ser replicados por otros equipos de investigadores y afinar problemas metodológicos pero por el momento cambian nuestra perspectiva sobre la influencia de estos aditivos en la hiperactividad y sobre sus efectos neurobiológicos (AU)

Artificial food colours and other food additives (AFCA) have long been suggested to affect behaviour in children.. The main putative effect of food additives is to produce overactive, impulsive, and inattentive behaviour. Despite the failure of early studies along 30 years to identify the range of proposed adverse affects, a recent meta-analysis4 of double-blinded, placebo-controlled trials and two new researches has shown a significant effect of food additives on the behaviour of children with ADHD. This effect should be to increase hyperactivity. Although these studies need to be replicated, have changed our view point about this issue (AU)

[Treatment of Tourette syndrome and its comorbidity: experience with 17 cases]. / Tratamiento del síndrome de Tourette y su comorbilidad: presentación de 17 casos.

INTRODUCTION: Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases. MATERIAL AND METHODS: We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón. RESULTS: Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged from 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53%), obsessive-compulsive disorder in 8 (48%) and anxiety in 7 (41%). Learning disorders were found in 7 patients (41%), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuroleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics. CONCLUSIONS: In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening.

Presentación clínica, comorbilidad y tratamiento habitual del síndrome de Gilles de la Tourette: estudio de 17 casos / Clinical presentation, comorbídíty and usual treatment of Gilles de la Tourette's syndrome: study of 17 cases

Introducción: El síndrome de Gilles de la Tourette (SGT) es un trastorno neuropsiquiátrico de inicio infantil caracterizado por tics vocales y motores múltiples y crónicos. Es frecuente la comorbilidad con trastornos psiquiátricos, sobre todo trastorno de déficit de atención con hiperactividad (TDAH), trastornos de ansiedad y trastorno obsesivo-compulsivo (TOC). Metodología: Estudiamos de modo retrospectivo 17 pacientes en edad pediátrica atendidos en consulta externa neuropediátrica o psiquiátrica, entre 1998 y 2003. Se estudiaron las variables: edad, sexo, síntomas clínicos, edad de inicio, antecedentes familiares, comorbilidad, tratamiento recibido y datos de evolución. Resultados: Todos los casos menos uno eran varones, de edad media 10 años pero edad media de inicio 5 años y 9 meses. Había comorbilidad en 82,3% de pacientes (TDAH 53%, trastornos de ansiedad 41,1 %, patología TOC 58,7%). Había antecedentes familiares en 72% de casos: 41,1 % tics y 17,6% patologías TOC. Los tratamientos más prescritos fueron antipsicóticos (n=15) y metilfenidato (n=7). El tratamiento con metilfenidato no aumentó los tics. Hubo efectos adversos en 16 pacientes, conduciendo a abandonar haloperidol (n=2) o pimocida (3 de los 7 casos) por efectos secundarios neurológicos o cardiacos. Risperidona y olanza pina produjeron aumento de peso y somnolencia pero fueron mejor tolerados. La tasa de remisión completa fue 64,7%. Conclusión: el tratamiento de SGT debería considerarse en los casos graves fijándonos también en trastornos comórbidos

Background: Tourette's syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by chronic multiple motor and vocal tics. Comorbid psychiatric disorders, particularly attention deficit hyperactivity disorder (ADHD), anxiety disorders and obsessive compulsive disorder (OCD) often are present. Methods: Seventeen pediatric cases attending an outpatient neuropediatric or psychiatric clinic from 1998 to 2003 and suffering from Tourette's disorder are retrospectively studied. Age, sex, clinical symptoms, age of onset, family history, comorbidity, treatment strategies and outcome data are described. Results: All but one case were male; mean age was 10 years but mean age of onset was 5 years and 9 months. Comorbidity was present in 82,3% of patients (ADHD 53%, anxiety disorders 41,1%, OCD spectrum 58,7%). Family history was positive in 72% of cases: 41,1% for tics and 17,6% for OC conditions. Treatments mostly prescribed were antipsychotics (n=15), and meti1phenidate (n=7). Treatment with meti1phenidate did not exacerbate tics. Adverse effects were present in 16 patients, allowing to withdraw ha1operido1 (n=2) or pimocide (3 out of 7 cases) because of neuro1ogic y/o heart side effects. Risperidone and o1anzapine produced weight gain and somno1ence but were better to1erated. The rate of total remission was 64,7%. Conclusion: treatment of TS should be considered in severe cases, focusing also on comorbid disorders

Tratamiento del síndrome de Tourette y su comorbilidad: presentación de 17 casos / Treatment of Tourette syndrome and its comorbidity: experience with 17 cases

Introducción. Presentamos las características clínicas y trastornos comórbidos asociados y evaluamos los resultados de los tratamientos farmacológicos empleados en 17 pacientes con síndrome de Tourette (ST). Material y métodos. Revisión retrospectiva de los pacientes pediátricos diagnosticados de ST en nuestro hospital entre 1998 y 2004. Resultados. De los 17 pacientes, 16 son varones y sólo 1 mujer, con edades actuales comprendidas entre 7 y 17 años. Los trastornos comórbidos más frecuentes fueron el trastorno por deficit de atención con hiperactividad (TDAH) en 9 pacientes (53 Ofo), conductas obsesivo-compulsivas en 8 (48 %) Y ansiedad en 7 (41 %). Presentaban problemas de aprendizaje 7 (41 %), de los cuales 5 asociaban un TDAH y 1 un trastorno obsesivo-compulsivo (TOC) severo. Encontramos efectos farmacológicos adversos severos que obligaron a la retirada de la medicación en los 2 casos tratados con haloperidol (ambos de tipo extrapiramidal) y en 3 de los 7 (43 %) de los tratados con pimozida (1 de ellos de tipo extrapiramidal). No ocurrieron efectos extrapiramidales con los neurolépticos atípicos, pero fueron frecuentes la sedación y el aumento de peso. Siete pacientes fueron tratados con metilfenidato, sin empeoramiento de los tics. Conclusiones. En nuestra serie los trastornos comórbidos más frecuentes fueron el TDAH, conductas obsesivo-compulsivas, ansiedad y dificultades en el aprendizaje. Los neurolépticos atípicos fueron mejor tolerados que los clásicos, aunque la incidencia de efectos adversos es también elevada. El metilfenidato no se ha asociado a empeoramiento de los tics

Introduction. Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases. Material and methods. We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón. Results. Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged fram 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53 %), obsessive-compulsive disorder in 8 (48 %) and anxiety in 7 (41 %). Learning disorders were found in 7 patients (41 %), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuraleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics. Conclusions. In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening

Semiología clínica del trastorno por déficit de atención con hiperactividad en función de la edad y eficacia de los tratamientos en las distintas edades / The clinical semiology of attention déficit hyperactivity disorder according to age, and the effectiveness of treatments at different ages

Introduction. Attention deficit hyperactivity disorder (ADHD) is the most important cause of poor academic performance and is also usually associated with behavioural, emotional and sociability disorders. Aim. To analyse the different clinical features and the response to psychostimulant therapy, according to the age. Subjects and methods.We reviewed the cases of 152 children referred to Neuropaediatrics owing to suspected ADHD over a 6-year period. Diagnosis and comorbidity were investigated by the looking at their case history, by examination and observation, as well as by interviewing the parents (DSM-IV criteria), and by applying Conners’ Rating Scale for parents and teachers, in addition to neuropsychological tests. In order to improve data processing, we established four groups according to the patient's age at diagnosis and when treatment was started: G1: 3-5; G2: 6-8; G3: 9-11; and G4: 12-15 years. Results. ADHD was diagnosed in 102 of the 152 children; 53% had the combined type, 26% were of the inattentional type, and 20% were hyperactive/impulsive. Poor school performance increased with age and reached 75% in G4. The same occurred with conduct disorders: at 6 years of age, 23% were found to have oppositional defiant disorder, and from the age of 9 onwards over 60% of them had conduct disorders. Up until 12 years of age they showed some improvement with psychostimulants and later the rate of dropouts from medical clinical controls and from treatment was over 40%. Conclusions. The older patients are and the later ADHD is attended, the more problems they have. If successful preventive measures are to be implemented, it would be advisable to begin treatment even before children start primary education (5 years old), so as to try and avoid the pedagogical and behavioural repercussions observed in these children at the age of 6 (AU)

Introducción. El trastorno por déficit de atención con hiperactividad (TDAH) es la causa más importante de fracaso escolar, y suele asociarse además a trastornos de conducta, emocionales y de sociabilidad. Objetivo. Analizar las distintas manifestaciones clínicas y la respuesta al tratamiento con psicoestimulantes, en función de la edad. Sujetos y métodos. Se revisan 152 niños remitidos a Neuropediatría por sospecha de TDAH en 6 años. El diagnóstico y la comorbilidad se investiga mediante anamnesis, exploración y observación, entrevista a padres (criterios DSM-IV), cuestionario de Conners para padres y profesores, y pruebas neuropsicológicas. Para mejor tratamiento de los datos, realizamos cuatro grupos según la edad al diagnóstico e inicio del tratamiento: G1: 3-5; G2: 6-8; G3: 9-11 y G4: 12-15 años. Resultados. De los 152 niños, se diagnosticó TDAH en 102; el 53% fueron de tipo combinado, el 26% inatencional, y el 20% hiperactivo/impulsivo. El mal rendimiento escolar aumenta con la edad, y un 75% es en el G4. Lo mismo sucede con los trastornos de conducta: a los 6 años ya encontramos un 23% de trastorno negativista desafiante, y a partir de los 9 años más de un 60% presentan trastornos de conducta. Mejoran con psicoestimulantes un 70% hasta los 12 años, y, después, el índice de abandono del control clínico médico y del tratamiento es de más de un 40%. Conclusiones. Cuanto mayores y más tarde se atienden los TDAH, más problemas tienen. La prevención hace conveniente empezar el tratamiento incluso antes de iniciar la educación primaria (5 años), en un intento de evitar las repercusiones pedagógicas y conductuales observadas ya a los 6 años en estos niños (AU)

Fobia a tragar: presentación clínica de una serie de nueve casos / Chocking phobia: clinical presentation of nines cases

Introducción: La fobia a tragar es un miedo a tragar sólidos y/o líquidos que suele responder a tratamiento conductual. Metodología: estudiamos nueve casos de fobia a tragar tratados ambulatoriamente. Se describen edad, sexo, historia familiar, comorbilidad, y datos sobre tratamiento y evolución, entre otros. Resultados: un 55% eran mujeres, edad media 25 años. El 33% tenía antecedentes familiares psiquiátricos,88% tenía comorbilidad con trastorno de pánico, patología obsesivo-compulsiva o personalidad evitativa. Los tratamientos eficaces fueron terapia cognitivo-conductual (n = 9), clomipramina (n = 2), paroxetina (n = 2) y benzodiacepinas (n = 5). Conclusión: la fobia a tragar tiene una alta comorbilidad con trastornos ansiosos, lo que condiciona el abordaje terapéutico

Introduction: Choking (swallowing) phobia is a fear of swallowing food and/or fluids that usually respondsto behaviour therapy.Methods: Nine cases attending an out patient clinic and suffering from choking phobia are retrospectively studied. Age, sex, family history, comorbidity, treatment strategies and outcome data are described. Results: Fifty-five percent of patients were female, mean age 25 years. A total of 33% had psychiatric family history, 88% had comorbidity with panic disorder, obsessive-compulsive disease or avoidant personality. Effective treatments were cognitive-behavioural therapy (n = 9), clomipramine (n = 2), paroxetine (n = 2) and benzodiazepines (n = 5). Conclusion: Swallowing (choking) phobia has a high comorbidity rate with anxious disorders, suggesting certain treatment strategies

[The clinical semiology of attention deficit hyperactivity disorder according to age, and the effectiveness of treatments at different ages]. / Semiología clínica del trastorno por déficit de atención con hiperactividad en función de la edad y eficacia de los tratamientos en las distintas edades

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is the most important cause of poor academic performance and is also usually associated with behavioural, emotional and sociability disorders. AIM: To analyse the different clinical features and the response to psychostimulant therapy, according to the age. SUBJECTS AND METHODS: We reviewed the cases of 152 children referred to Neuropaediatrics owing to suspected ADHD over a 6-year period. Diagnosis and comorbidity were investigated by the looking at their case history, by examination and observation, as well as by interviewing the parents (DSM-IV criteria), and by applying Conners' Rating Scale for parents and teachers, in addition to neuropsychological tests. In order to improve data processing, we established four groups according to the patient's age at diagnosis and when treatment was started: G1: 3-5; G2: 6-8; G3: 9-11; and G4: 12-15 years. RESULTS: ADHD was diagnosed in 102 of the 152 children; 53% had the combined type, 26% were of the inattentional type, and 20% were hyperactive/impulsive. Poor school performance increased with age and reached 75% in G4. The same occurred with conduct disorders: at 6 years of age, 23% were found to have oppositional defiant disorder, and from the age of 9 onwards over 60% of them had conduct disorders. Up until 12 years of age they showed some improvement with psychostimulants and later the rate of dropouts from medical clinical controls and from treatment was over 40%. CONCLUSIONS: The older patients are and the later ADHD is attended, the more problems they have. If successful preventive measures are to be implemented, it would be advisable to begin treatment even before children start primary education (5 years old), so as to try and avoid the pedagogical and behavioural repercussions observed in these children at the age of 6.

[Variability in the treatment of headaches in visits to the Neuropaediatrics service at six Spanish hospitals]. / Variabilidad en el tratamiento de las cefaleas en las consultas de Neuropediatría de seis hospitales españoles.

INTRODUCTION: Headache is one of the chief reasons for visiting Neuropaediatric units. Variability in clinical practice has been defined as variations in the rates a clinical procedure is employed. The aim of this work is to study the variability in the treatment of children's headaches in six Spanish hospitals. PATIENTS AND METHODS: We conducted a retrospective study involving patients who first visited because of a headache some time in the year 1999. Data were collected in December 2003. The following variables were analysed: type of headache, neuroimaging scans, beginning of prophylaxis, follow-up visits to clinic and number of patients who dropped out of the follow-up. RESULTS: In all, 372 children were attended. 63.4% of the headaches were considered as being migraine-type; 43% of the patients were submitted to neuroimaging and prophylaxis was established in 36.8%. Mean follow-up time in the clinic was 10.6 months and the mean number of visits was 3. 30% had dropped out of the follow-up. In the comparative analysis, significant differences were found in all the variables studied. CONCLUSIONS: Overall results are similar to those found in other series. The differences found between centres can be accounted for by differences in population, differences in health professionals' styles of medical practice or by the nonexistence of clear guidelines regarding a particular procedure.