Niños portadores de una válvula de derivación de líquido cefalorraquídeo: motivos de consulta, diagnósticos y consumo de recursos en el servicio de urgencias / Children with cerebrospinal fluid shunts: signs and symptoms, final diagnoses and use of health resources in the emergency department

Objetivos: Determinar los motivos de consulta en el servicio de urgencias de los niños portadores de válvula de derivación de líquido cefalorraquídeo (VDL), así como sus diagnósticos al alta, y comparar el consumo de recursos que generan con el de la población general. Métodos: Se revisan los datos referentes a la sintomatología, la actuación y el diagnóstico definitivo de todas las consultas realizadas en el servicio de urgencias por parte de los niños portadores de VDL, desde el 1 de abril de 2010 al 31 de marzo de 2011 (grupo 1). Se seleccionan todas las consultas generadas en el mismo año de un grupo de pacientes no portadores de VDL inmediatamente antes de las consultas de los portadores de VDL (grupo 2). El coste económico se valora mediante el número de consultas y las exploraciones complementarias. Resultados: Se incluyen 250 consultas de portadores de VDL, que corresponden a 99 pacientes (grupo 1). Los motivos de consulta más frecuentes son los vómitos, la fiebre y la cefalea, y los diagnósticos la infección respiratoria (22,6%) y la disfunción valvular (14%). El grupo 2 queda constituido por 250 niños, que realizan 549 consultas. Los pacientes del grupo 1 reciben más exploraciones complementarias por consulta que el grupo 2 (el 48 frente al 25%; p <0,001), y el coste económico que generan también es mayor (mediana de 77,9 frente a 70 Euros/consulta; p <0,001); este aumento está relacionado con las consultas por sintomatología potencialmente asociada a disfunción valvular. Conclusiones: Los niños portadores de VDL consultan a menudo por una sintomatología potencialmente asociada a disfunción valvular, pero ésta no se confirma en muchas ocasiones. El gasto sanitario que generan es superior al del resto de usuarios de urgencias, debido principalmente a las pruebas realizadas para descartar una disfunción valvular. Dada su baja frecuencia, es necesario desarrollar escalas clínicas que mejoren la selección de los pacientes a quienes deben realizarse estas pruebas (AU)

Objective: 1) To determine the reasons for consultation of children with cerebrospinal fluid shunts (CFS) to the emergency department (ED) and their final diagnoses. 2) To compare their use of health resources with that of general population. Methods: All children with CFS consulting for any reason to the ED from 1 April 2010 to March 31, 2011 were included (group 1). We recorded epidemiological data, symptoms, complementary examinations performed in the ED and final diagnosis of all patients. A group of children without CFS who had visited the ED immediately before a child with CFS (group 2) were selected. The use of health resources is assessed by the number of ED visits and the number of complementary examinations received by each patient. Results: Group 1 consisted of 99 patients that generated 250 visits to the ED. The most common symptoms were: vomiting, fever and headache and the most common diagnoses were acute respiratory infection (22.6%) and CFS malfunction (14%). Group 2 consisted of 250 patients that generated 549 visits to the ED. Children in group 1 received more complementary examinations per visit than children in group 2 (48 vs 25%; p <0.001). The use of health resources was higher in group 1 than in group 2 (median 77.9 vs 70 Euros/ED visit; p <0.001). This increase in cost is related to consultation for symptoms potentially linked to CFS malfunction. Conclusions: Children with CFS often consult ED with symptoms associated with CFS malfunction but in most cases malfunction is not confirmed. Children with CFS generate greater use of health resources than general population, primarily due to complementary examinations to rule out CFS malfunction. The high number of patients with no CFS malfunction makes it necessary to develop new clinical scales that improve the selection of children to undergo complementary examinations (AU)

Irradiación en portadores de válvula de derivación de líquido cefalorraquídeo. Seguimiento a los 2 años / Patients with cerebrospinal fluid shunt: radiation during two years of follow-up

Introducción: Las radiaciones ionizantes debido a pruebas diagnósticas y terapéuticas pueden contribuir al desarrollo posterior de neoplasias. Los pacientes portadores de válvulas de derivación líquido cefalorraquídeo (VDL) están expuestos a un mayor riesgo. Objetivo: Estimar la dosis de irradiación acumulada a las que son sometidos los pacientes portadores de VDL y los posibles factores asociados a una elevada irradiación. Métodos: Estudio descriptivo observacional. Se incluyen los niños a los que se les colocó una VDL en 2005 y 2006. Se contabilizan el número de exploraciones radiológicas realizadas para control neuroquirúrgico y por sospecha de disfunción valvular. Se determina la irradiación acumulada para cada paciente. Resultados: Se incluyen 36 pacientes con una mediana de edad de 6,1 meses (rango: 20 días-15,3 años). Se realizaron 136 tomografías craneales y 19 trayectos valvulares. La mediana de irradiación recibida por paciente fue de 6,9mSv (rango: 0-28,6mSv). El 85% de las exploraciones se realizaron para el control neuroquirúrgico. Los pacientes en los que se sospechó disfunción valvular presentaron una mediana de dosis absorbida más alta que aquellos en los que no se sospechó (9 vs. 5mSv; p=0,02). Conclusión: Es necesario ampliar el uso de técnicas no ionizantes para el control neuroquirúrgico de los pacientes portadores de VDL y desarrollar escalas clínico-diagnósticas que permitan seleccionar aquellos con mayor riesgo de disfunción valvular para reducir la potencial irradiación al que son sometidos(AU)

Background: Ionizing radiation due to diagnostic tests and treatment can contribute to the later development of cancer. The patients with cerebrospinal fluid shunts (CFS) are exposed to greater risk. Objective: To estimate the cumulative radiation dose from radiological studies in children with CFS and to determine the potential factors associated with a high level of radiation. Methods: Descriptive observational study. All children treated for hydrocephalus with a CFS between 2005 and 2006 were included. We registered the number of radiological examinations performed on these patients due to neurosurgical control or evaluation for possible shunt malfunction. The cumulative radiation dose from radiological studies was estimated for each patient. Results: Thirty-six patients were included. The median patient age was 6.1 months (range: 20 days - 15.3 years). One hundred thirty-six CT scans were performed and 19 shunt series were done. The median patient radiation was 6.9 mSv (range: 0 to 28.6 mSv); 85% of examinations were performed for neurosurgical control. The median absorbed radiation dose was higher in patients who were evaluated for some possible shunt malfunction than in patients without a suspected shunt malfunction (9 mSv vs 5 mSv, p=0.02). Conclusion: The radiation exposure from radiological examinations performed on children with CFS was considerable. The use of non-ionizing techniques would help in the neurosurgical control of patients with CSF. The development of clinical-diagnostic scales could enable patients with increased risk of shunt malfunction to be selected before a radiological test was carried out(AU)

[Patients with cerebrospinal fluid shunt: radiation during two years of follow-up]. / Irradiación en portadores de válvula de derivación de líquido cefalorraquídeo. Seguimiento a los 2 años.

BACKGROUND: Ionizing radiation due to diagnostic tests and treatment can contribute to the later development of cancer. The patients with cerebrospinal fluid shunts (CFS) are exposed to greater risk. OBJECTIVE: To estimate the cumulative radiation dose from radiological studies in children with CFS and to determine the potential factors associated with a high level of radiation. METHODS: Descriptive observational study. All children treated for hydrocephalus with a CFS between 2005 and 2006 were included. We registered the number of radiological examinations performed on these patients due to neurosurgical control or evaluation for possible shunt malfunction. The cumulative radiation dose from radiological studies was estimated for each patient. RESULTS: Thirty-six patients were included. The median patient age was 6.1 months (range: 20 days - 15.3 years). One hundred thirty-six CT scans were performed and 19 shunt series were done. The median patient radiation was 6.9 mSv (range: 0 to 28.6 mSv); 85% of examinations were performed for neurosurgical control. The median absorbed radiation dose was higher in patients who were evaluated for some possible shunt malfunction than in patients without a suspected shunt malfunction (9 mSv vs 5 mSv, p=0.02). CONCLUSION: The radiation exposure from radiological examinations performed on children with CFS was considerable. The use of non-ionizing techniques would help in the neurosurgical control of patients with CSF. The development of clinical-diagnostic scales could enable patients with increased risk of shunt malfunction to be selected before a radiological test was carried out.

Evolución de la incidencia de test de embarazo positivo en adolescentes atendidas en un servicio de urgencias / Trends in the incidence of positive pregnancy tests in adolescents seen in an emergency department

Introducción: El debate actual acerca del aborto y la edad en la que se considera la madurez suficiente para llevarlo a cabo sin el consentimiento paterno plantea la necesidad de saber la importancia real del embarazo adolescente en Urgencias. Objetivos: a) Determinar la variación de la incidencia de embarazos adolescentes diagnosticados en urgencias los últimos 12 años, y b) determinar las características de las adolescentes y cuál fue la evolución de los embarazos. Material y métodos: Estudio retrospectivo. Se incluye a las adolescentes con una prueba de embarazo positiva en urgencias entre el 1/7/1997 y el 30/6/2009. Se calcula la incidencia anual de embarazos por cada 1.000 visitas de mujeres adolescentes. Se divide el estudio en dos periodos: del 1/7/1997 al 30/6/2003 y del 1/7/2003 al 30/6/2009. Resultados: Se diagnosticaron 83 embarazos. La incidencia osciló entre 0,5 y 2,0, observándose una tendencia a aumentar en el segundo periodo. Los motivos de consulta más frecuentes fueron: metrorragia, dolor abdominal y vómitos. Sesenta y dos embarazos fueron evolutivos, 20 abortos y uno ectópico. Se conoce la evolución de 35 de las 62 gestaciones evolutivas, en 19 se llevó a cabo el parto, en 11 se produjo una interrupción voluntaria del embarazo, y en 4 un aborto espontáneo. Conclusiones: La incidencia de embarazos en adolescentes en urgencias es baja, pese a ello se observa una tendencia a incrementarse. Muchos motivos de consulta son inespecíficos constatándose la necesidad de interrogar sobre los hábitos sexuales en todas las adolescentes. Un elevado porcentaje de las gestaciones diagnosticadas no se llevan a término (AU)

Introduction: The current debate on induced abortion and the age when a young woman is considered mature to have this without parental consent, shows the need to know the real importance of adolescent pregnancy in the Emergency Department. Objectives: a) To determine the adolescent pregnancy rate variation in the Emergency Department during last 12years; b) to determine the characteristics of the pregnant adolescent and the outcome of their pregnancies. Material and methods: Retrospective study of pregnant adolescents diagnosed in the Emergency Department between July 1, 1997 and June 30, 2009. Pregnancy rates were calculated per 1000 annual female adolescent consultations. Two periods were considered: 1/from July 1, 1997 to June 30, 2003 and 2/from July 1, 2003 to June 30, 2009. Results: Eighty-three pregnancies were diagnosed in adolescents. Pregnancy rates varied from 0.5 to 2.0 per 1000 females; an increased trend in adolescent pregnancy rate was observed in the second period. Metrorrhagia, abdominal pain and vomiting were the most frequent complaints. There were 62 on-going pregnancies, 20 abortions and one ectopic pregnancy. Only 35 of the outcomes of the 62 on-going pregnancies were known: 19 ended in live birth, 11 in induced abortion and 4 in stillbirth. Conclusions: The adolescent pregnancy rate is low; nevertheless an increased trend is being observed in the last few years. Many adolescents diagnosed with pregnancy had nonspecific complaints, so it is important to ask about sexual habits in all adolescents. A high percentage of diagnosed pregnancies end in abortion (AU)

[Trends in the incidence of positive pregnancy tests in adolescents seen in an emergency department]. / Evolución de la incidencia de test de embarazo positivo en adolescentes atendidas en un servicio de urgencias.

INTRODUCTION: The current debate on induced abortion and the age when a young woman is considered mature to have this without parental consent, shows the need to know the real importance of adolescent pregnancy in the Emergency Department. OBJECTIVES: a) To determine the adolescent pregnancy rate variation in the Emergency Department during last 12 years; b) to determine the characteristics of the pregnant adolescent and the outcome of their pregnancies. MATERIAL AND METHODS: Retrospective study of pregnant adolescents diagnosed in the Emergency Department between July 1, 1997 and June 30, 2009. Pregnancy rates were calculated per 1000 annual female adolescent consultations. Two periods were considered: 1/from July 1, 1997 to June 30, 2003 and 2/from July 1, 2003 to June 30, 2009. RESULTS: Eighty-three pregnancies were diagnosed in adolescents. Pregnancy rates varied from 0.5 to 2.0 per 1000 females; an increased trend in adolescent pregnancy rate was observed in the second period. Metrorrhagia, abdominal pain and vomiting were the most frequent complaints. There were 62 on-going pregnancies, 20 abortions and one ectopic pregnancy. Only 35 of the outcomes of the 62 on-going pregnancies were known: 19 ended in live birth, 11 in induced abortion and 4 in stillbirth. CONCLUSIONS: The adolescent pregnancy rate is low; nevertheless an increased trend is being observed in the last few years. Many adolescents diagnosed with pregnancy had nonspecific complaints, so it is important to ask about sexual habits in all adolescents. A high percentage of diagnosed pregnancies end in abortion.

Utilización de la craniectomía descompresiva en el manejo de la hipertensión intracraneal refractaria en la edad pediátrica / Use of decompressive craniectomy in the management of refractory intracranial hypertension in paediatric patients

Introducción y objetivo: La hipertensión intracraneal (HITC) es la principal causa de mortalidad y secuelas de los pacientes con traumatismo craneoencefálico grave. La craniectomía descompresiva (CD) es una técnica quirúrgica que permite disminuir la presión intracraneal y mejorar la presión de perfusión cerebral (PPC). El objetivo del trabajo es presentar la experiencia con la CD para el tratamiento de la hipertensión intracraneal. Pacientes y métodos: Revisión retrospectiva de los pacientes ingresados entre los años 2005–2008 con lesión cerebral e hipertensión intracraneal incontrolable médicamente a los que se les realizó una CD como terapia. Resultados: Se incluyen 14 pacientes con traumatismo craneoencefálico grave con una mediana de edad de 14,2 años (4–20 años). Las lesiones detectadas más frecuentemente en la TC craneal de los niños con traumatismo fueron las lesiones encefálicas difusas II y III. En todos se practicó una CD por presentar cifras de presión intracraneal elevadas refractarias a la terapéutica instaurada. La evolución fue favorable en todos los pacientes salvo en 2. El 78,8% presenta una buena evolución neurológica (Glasgow Outcome Score 4 y 5) a los 6 meses de la intervención. Conclusión: La CD es una alternativa en el manejo de la hipertensión intracraneal refractaria al tratamiento médico en niños y adolescentes que han sufrido un traumatismo craneoencefálico grave y puede ser usada simultáneamente o como alternativa al coma barbitúrico sobre todo en aquellos pacientes con inestabilidad hemodinámica (AU)

Introduction and objective: Intracranial hypertension (ICH) is the main cause of morbidity and mortality in patients with severe traumatic head injuries. Decompressive craniectomy (DC) is a surgical technique that allows to reduce intracranial pressure (ICP) and to improve cerebral blood flow. Objective: To present our experience on DC for the treatment of ICH. Patients and methods: Retrospective review of patients admitted from January 2005 to December 2008 who had a traumatic brain injury (TBI) and uncontrollable intracranial hypertension despite optimal medical treatment and who needed DC. Results: Fourteen patients with severe TBI were included in this series. Mean age was 14.2 years (4–20 years). The more frequent damages detected in cranial computerized tomography were diffuse brain lesions types II and III. Indication for DC was made if ICP levels were above 25mmHg for more than 30min despite optimal medical treatment. Clinical outcome was favourable in all patients apart from two. Neurological outcome was correct in 78.8% of patients (Glasgow Outcome Score 4 and 5) six months after PICU discharge. Conclusion: DC is an alternative for the management of refractory intracranial hypertension in children and adolescents with severe TBI. It could be used simultaneously with the barbiturate coma or as an alternative, particularly in haemodynamically unstable patients (AU)

Valoración de la adecuación del traslado en ambulancia al área médica de un servicio de urgencias pediátricas / Study on the suitability of ambulance transportation to a paediatric medical emergency department

Objetivos: Determinar si el transporte en ambulancia a urgencias es adecuado y valorar si condiciona una visita preferencial y mayor gravedad de los pacientes. Pacientes y método: Se incluyen los pacientes que consultaron a urgencias de pediatría durante el 2008, se establecen 2 grupos, los que acudieron en ambulancia (Grupo 1) y los que lo hicieron por otros medios (Grupo 2). Para valorar la adecuación, se extrae del Grupo 1 una muestra aleatoria de 300 pacientes; se revisa el informe de alta y se aplica la «Pediatric Ambulance Need Evaluation Tool». Para valorar el trato preferencial, se compara la proporción de pacientes valorados en triaje, el tiempo hasta triaje y asistencia; y para determinar diferencias respecto a la gravedad, se analizan los pacientes con nivel de triaje≤3 y los que requirieron exámenes complementarios e ingreso. Resultados: Se atendieron 80.537 pacientes, el 2,5% acudieron en ambulancia, estimándose que el 31% (IC 95% 26,2–35,8%) podría haber empleado otro transporte. Los principales diagnósticos de los clasificados como transporte inadecuado fueron: trastorno epiléptico (23–24,7%), crisis de ansiedad (12–12,9%) y síndrome febril (12–12,9%). Se observó que la proporción de valorados en triaje, el tiempo hasta triaje y asistencia fue menor en el Grupo 1, y que la proporción de niños con nivel de triaje≤3, y la de pacientes que recibieron alguna exploración complementaria y/o ingresaron fue mayor que en el Grupo 2. Conclusiones: Una proporción elevada de pacientes trasladados en ambulancia podrían haber utilizado otro tipo de transporte. Sin embargo, la mayor gravedad de un número importante de pacientes justifica la visita preferencial detectada en los transportados en este medio. El uso del triaje en todos los pacientes transportados en ambulancia ayudaría a detectar los casos realmente prioritarios y mejorar el funcionamiento de los servicios de urgencias (AU)

Objectives: To evaluate the appropriateness of ambulance use as transport to Emergency Medical Services and to determine if ambulance use is associated with preferential attention and to illness severity. Patients and method: All patients attended in a Paediatric Emergency Department during 2008 were included. Two groups were defined: Group 1, patients arriving by ambulance and Group 2, patients arriving by any other means of transport. In order to evaluate the appropriateness of ambulance use, a random sample of 300 patients from the Group 1 was selected; the "Paediatric Ambulance Need Evaluation tool" was applied to final diagnosis. To assess the preferential attention, the rate of patients with triage evaluation, time to triage and time to medical attention were compared. Finally, to determine differences in the severity of illness, patients with triage level ≤3 and patients needing complementary examinations and/or hospital admission were analysed. Results: A total of 80537 patients were included, of which 2.5% arrived by ambulance. Estimation of the prevalence of inappropriate transport use was 31 % (95 CI%: 26.2–35.8%). Their main diagnoses were: epileptic attack (23–24.7%), panic attack (12–12.9%) and fever (12–12.9%). It was observed that triage evaluation, time to triage and time to medical attention was shorter in Group 1. The proportion of children with triage level ≤3, needing complementary examinations and/or hospital admission was higher in-Group 1. Conclusion: A high number of patients arriving by ambulance could have used another means of transport. However, the greater severity of a significant number of patients justifies the preferential attention given. Triage use in all patients arriving by ambulance would help in the detection of high priority cases and to improve the Emergency Department performance (AU)

[Study on the suitability of ambulance transportation to a paediatric medical emergency department]. / Valoración de la adecuación del traslado en ambulancia al área médica de un servicio de urgencias pediátricas.

OBJECTIVES: To evaluate the appropriateness of ambulance use as transport to Emergency Medical Services and to determine if ambulance use is associated with preferential attention and to illness severity. PATIENTS AND METHOD: All patients attended in a Paediatric Emergency Department during 2008 were included. Two groups were defined: Group 1, patients arriving by ambulance and Group 2, patients arriving by any other means of transport. In order to evaluate the appropriateness of ambulance use, a random sample of 300 patients from the Group 1 was selected; the "Paediatric Ambulance Need Evaluation tool" was applied to final diagnosis. To assess the preferential attention, the rate of patients with triage evaluation, time to triage and time to medical attention were compared. Finally, to determine differences in the severity of illness, patients with triage level < or =3 and patients needing complementary examinations and/or hospital admission were analysed. RESULTS: A total of 80537 patients were included, of which 2.5% arrived by ambulance. Estimation of the prevalence of inappropriate transport use was 31 % (95 CI%: 26.2-35.8%). Their main diagnoses were: epileptic attack (23-24.7%), panic attack (12-12.9%) and fever (12-12.9%). It was observed that triage evaluation, time to triage and time to medical attention was shorter in Group 1. The proportion of children with triage level < or =3, needing complementary examinations and/or hospital admission was higher in-Group 1. CONCLUSION: A high number of patients arriving by ambulance could have used another means of transport. However, the greater severity of a significant number of patients justifies the preferential attention given. Triage use in all patients arriving by ambulance would help in the detection of high priority cases and to improve the Emergency Department performance.

[Use of decompressive craniectomy in the management of refractory intracranial hypertension in paediatric patients]. / Utilización de la craniectomía descompresiva en el manejo de la hipertensión intracraneal refractaria en la edad pediátrica.

INTRODUCTION AND OBJECTIVE: Intracranial hypertension (ICH) is the main cause of morbidity and mortality in patients with severe traumatic head injuries. Decompressive craniectomy (DC) is a surgical technique that allows to reduce intracranial pressure (ICP) and to improve cerebral blood flow. OBJECTIVE: To present our experience on DC for the treatment of ICH. PATIENTS AND METHODS: Retrospective review of patients admitted from January 2005 to December 2008 who had a traumatic brain injury (TBI) and uncontrollable intracranial hypertension despite optimal medical treatment and who needed DC. RESULTS: Fourteen patients with severe TBI were included in this series. Mean age was 14.2 years (4-20 years). The more frequent damages detected in cranial computerized tomography were diffuse brain lesions types II and III. Indication for DC was made if ICP levels were above 25 mmHg for more than 30 min despite optimal medical treatment. Clinical outcome was favourable in all patients apart from two. Neurological outcome was correct in 78.8% of patients (Glasgow Outcome Score 4 and 5) six months after PICU discharge. CONCLUSION: DC is an alternative for the management of refractory intracranial hypertension in children and adolescents with severe TBI. It could be used simultaneously with the barbiturate coma or as an alternative, particularly in haemodynamically unstable patients.

Abdominalgias de causa ginecológica: una realidad en adolescentes / Gynaecological abdominal pain in adolescent females

Objetivos: Determinar la prevalencia del dolor de origen ginecológico en las adolescentes atendidas por dolor abdominal en un servicio de Urgencias de Pediatría. Valora la sintomatología acompañante del dolor, las pruebas complementarias realizadas y la evolución posterior. Métodos: Estudio descriptivo observacional. Se incluyen todas las pacientes con edad entre 12–18 años que consultaron durante el 2008 en un servicio de Urgencias de Pediatría por dolor abdominal que se orientó al alta como de origen ginecológico. Resultados: Se incluyeron 699 consultas por dolor abdominal, 54 (7,7%) se orientaron de origen ginecológico. Su edad media fue de 15,2 años (DE 1,7). El 94,4% habían tenido la menarquia. Trece (59,3%) de las 32 adolescentes a las que se les preguntó eran sexualmente activas. La mediana de tiempo de evolución del dolor fue de 2 días (p25–75: 6h–4días). Los síntomas asociados más frecuentes fueron el síndrome miccional (11; 20,4%) y los vómitos (9; 16,7%). Treinta y una (57,4%) de las adolescentes requirieron valoración por dos o más especialistas. En 42 (77,7%) se realizó alguna exploración complementaria, siendo las más frecuentes la ecografía (29; 53,7%) y el sedimento de orina (26; 48,1%). El dolor periovulatorio (16; 29,6%) y la dismenorrea (14; 25,9%) fueron los diagnósticos más frecuentes. Seis pacientes (9,3%) ingresaron y 4 (7,4%) precisaron intervención quirúrgica. Conclusiones: Aunque las principales causas de dolor abdominal en adolescentes son procesos fisiológicos, es preciso realizar una anamnesis dirigida y una exploración física completa, para descartar otras enfermedades más graves, siendo necesaria, en muchas ocasiones, una valoración multidisciplinar para un diagnóstico correcto (AU)

Objective: To determine the prevalence, the presentation, the evaluation and the evolution of abdominal pain of gynaecological cause in adolescents who came to a Paediatric Emergency Department. Methods: An observational and descriptive study was performed. All adolescent female aged 12 to 18 years who came to Emergency Service during 2008 with abdominal pain were included. The patients diagnosed with gynaecological disorders were studied. Results: Six hundred and ninety-nine adolescents with abdominal pain were evaluated and 54 (7,7%) of them were of gynaecological cause. Their mean age was 15,2 (SD 1,7) years. Fifty-one (94,4%) had had the menarche. Thirteen (59,3%) of the 32 adolescents, who were asked, said that they had had sex. The median evolution of pain was 2 days (p25–75: 6hours–4days). The most frequent associated symptoms were micturition syndrome (11; 20,4%) and vomiting (9; 16,7%). Thirty-one (57,4%) adolescents were evaluated by two or more specialists. Forty-two (77,7%) patients were subjected to complementary examinations; abdominal ultrasound (29; 53,7%) and urinary sediment (26; 48,1%) were the two most common. The main diagnoses were peri-ovular pain (16; 29,6%) and dysmenorrhoea (14; 25,9%). Six (9,3%) patients were admitted to the hospital and 4 (7,4%) needed surgery. Conclusions: Although the main causes of abdominal pain in adolescent females are physiological, an accurate anamnesis and physical examination is essential to rule out other more serious causes. A multidisciplinary evaluation is often necessary to make a correct diagnosis (AU)

Hipocalcemia sintomática secundaria a raquitismo carencial. Presentación de dos casos clínicos / Symptomatic hypocalcaemia due to nutritional rickets. A presentation of two cases

Introducción: El raquitismo nutricional es una enfermedad considerada infrecuente en los países desarrollados, y el aumento en su incidencia se relaciona con el incremento de la inmigración en nuestro medio. Debido al incremento de esta patología en España, debemos aumentar nuestra sospecha diagnóstica y ser capaces de detectarla aún cuando se presente con síntomas poco usuales. Objetivo: Se presentan 2 casos clínicos de lactantes que debutaron con hipocalcemia sintomática y que fueron diagnosticados de raquitismo carencial. Caso 1. Lactante de 6 meses que presenta episodios de convulsiones tónicas e irritabilidad, sin otros hallazgos en la exploración física, constatándose una hipocalcemia secundaria a un raquitismo carencial. Caso 2. Lactante de 7 meses que realiza episodios de hipertonía generalizada, estridor inspiratorio e irritabilidad, con el resto de la exploración física normal, en el que también se constata hipocalcemia secundaria a raquitismo. Discusión: El concepto antiguo de que el raquitismo es una entidad rara en nuestro medio nos lleva muchas veces a descartar esta patología, retrasando el diagnóstico y el tratamiento. Debemos revisar nuestros conceptos y ser capaces de detectar síntomas frecuentes y también los poco usuales del raquitismo nutricional (AU)

Introduction: The nutritional rickets is considered an uncommon disease in developed countries, but the increase in its incidence appears to be related to the increase in the number of immigrants in these countries. Thus in Spain, we must increase our diagnostic suspicion of this disease and be able to detect it, even when it appears with unusual symptoms. We describe two clinical cases of breast-fed babies who presented with symptomatic hypocalcaemia and were diagnosed with rickets. Case 1. A six month-old breast-fed baby who had episodes of tonic seizures and irritability, with no other findings in the physical examination, and diagnosed with secondary hypocalcaemia due to nutritional rickets. Case 2. A seven month-old breast-fed baby who had generalised hypertonia, stridor and irritability, with a normal physical examination, and also diagnosed with hypocalcaemia secondary to rickets. Discussion: The old concept that rickets is a rare condition in our country means that we often tend to rule out this pathology, thus delaying the diagnosis and the treatment. We must review our concepts in order to be able to detect the common and also the unusual symptoms of nutritional rickets (AU)

[Gynaecological abdominal pain in adolescent females]. / Abdominalgias de causa ginecológica: una realidad en adolescentes.

OBJECTIVE: To determine the prevalence, the presentation, the evaluation and the evolution of abdominal pain of gynaecological cause in adolescents who came to a Paediatric Emergency Department. METHODS: An observational and descriptive study was performed. All adolescent female aged 12 to 18 years who came to Emergency Service during 2008 with abdominal pain were included. The patients diagnosed with gynaecological disorders were studied. RESULTS: Six hundred and ninety-nine adolescents with abdominal pain were evaluated and 54 (7,7%) of them were of gynaecological cause. Their mean age was 15,2 (SD 1,7) years. Fifty-one (94,4%) had had the menarche. Thirteen (59,3%) of the 32 adolescents, who were asked, said that they had had sex. The median evolution of pain was 2 days (p25-75: 6hours-4days). The most frequent associated symptoms were micturition syndrome (11; 20,4%) and vomiting (9; 16,7%). Thirty-one (57,4%) adolescents were evaluated by two or more specialists. Forty-two (77,7%) patients were subjected to complementary examinations; abdominal ultrasound (29; 53,7%) and urinary sediment (26; 48,1%) were the two most common. The main diagnoses were peri-ovular pain (16; 29,6%) and dysmenorrhoea (14; 25,9%). Six (9,3%) patients were admitted to the hospital and 4 (7,4%) needed surgery. CONCLUSIONS: Although the main causes of abdominal pain in adolescent females are physiological, an accurate anamnesis and physical examination is essential to rule out other more serious causes. A multidisciplinary evaluation is often necessary to make a correct diagnosis.

[Symptomatic hypocalcaemia due to nutritional rickets. A presentation of two cases]. / Hipocalcemia sintomática secundaria a raquitismo carencial. Presentación de dos casos clínicos.

INTRODUCTION: The nutritional rickets is considered an uncommon disease in developed countries, but the increase in its incidence appears to be related to the increase in the number of immigrants in these countries. Thus in Spain, we must increase our diagnostic suspicion of this disease and be able to detect it, even when it appears with unusual symptoms. We describe two clinical cases of breast-fed babies who presented with symptomatic hypocalcaemia and were diagnosed with rickets. Case 1. A six month-old breast-fed baby who had episodes of tonic seizures and irritability, with no other findings in the physical examination, and diagnosed with secondary hypocalcaemia due to nutritional rickets. Case 2. A seven month-old breast-fed baby who had generalised hypertonia, stridor and irritability, with a normal physical examination, and also diagnosed with hypocalcaemia secondary to rickets. DISCUSSION: The old concept that rickets is a rare condition in our country means that we often tend to rule out this pathology, thus delaying the diagnosis and the treatment. We must review our concepts in order to be able to detect the common and also the unusual symptoms of nutritional rickets.

Diagnóstico de disfunción valvular en la edad pediátrica: valor predictivo de los síntomas y signos clínicos / Diagnosis of Valve dysfuntion in the paediatric age: the predictive value of the clinical sigsn and symptoms

Introducción. Las válvulas de derivación de líquido cefalorraquídeo son el tratamiento de elección en muchos delos casos de hidrocefalia infantil. La disfunción de las válvulas de derivación de líquido cefalorraquídeo habitualmente sepresenta de forma inespecífica, por lo que su diagnóstico se ve retrasado, lo que puede aumentar la morbimortalidad de estospacientes. Objetivo. Determinar los síntomas y signos más sugestivos de disfunción valvular en la población infantil. Pacientesy métodos. Estudio retrospectivo de los informes de los pacientes que consultaron al servicio de urgencias de un hospitalpediátrico de tercer nivel con clínica sugestiva de disfunción valvular. Se determinan en cada caso las manifestaciones clínicas,así como el diagnóstico o no de disfunción valvular. Se realiza un análisis univariante y posteriormente un estudio medianteregresión logística. Resultados. Se incluyeron 183 consultas. Se confirmó disfunción valvular en el 28,5%. La complicaciónmás frecuente fue la obstrucción del catéter de drenaje proximal. El análisis univariante demostró una relación significativaentre la presencia de irritabilidad, somnolencia, dolor abdominal, paresia de pares craneales y aumento del perímetrocraneal con la existencia de disfunción valvular. El modelo de regresión logística constató que somnolencia, irritabilidady dolor abdominal podían predecir disfunción valvular. Conclusiones. La somnolencia y la irritabilidad son las manifestacionesclínicas que mejor predicen una disfunción valvular, por lo que parece indiscutible que sean candidatas a estudio neurorradiológicourgente. El dolor abdominal se relaciona en la mayoría de casos con pseudoquistes abdominales. La cefalea, losvómitos y la fiebre son menos predictivos de disfunción valvular (AU)

Introduction. Cerebrospinal fluid shunt valves are the preferred treatment in many cases of childhood hydrocephalus.Cerebrospinal fluid shunt valve dysfunctions usually present in an unspecific manner, which delays their diagnosisand, consequently, can increase the morbidity and mortality rates in these patients. Aim. To determine the signs and symptomsthat are most suggestive of valve dysfunction in the childhood population. Patients and methods.We conducted a retrospectivestudy of the reports of patients who visited the emergency department of a tertiary care paediatric hospital with a clinicalpicture that suggested valve dysfunction. In each case the clinical manifestations were determined, and also whether there hadbeen a diagnosis of valve dysfunction or not. A univariate analysis and later a logistic regression study were performed.Results. In all, 183 visits were included. Valve dysfunction was confirmed in 28.5% of them. The most frequent complicationwas obstruction of the proximal drainage catheter. The univariate analysis showed a significant relation between the presenceof irritability, sleepiness, abdominal pain, paresis of the cranial nerves and increased perimeter of the skull, and the existenceof valve dysfunction. The logistic regression analysis revealed that sleepiness, irritability and abdominal pain could predictvalve dysfunction. Conclusions. Sleepiness and irritability are the clinical manifestations that best predict valve dysfunction,which means that they are almost undoubtedly candidates for an urgent neuroimaging study. In most cases the abdominal painis related to abdominal pseudocysts. Headaches, vomiting and a high temperature are less predictive of valve dysfunction (AU)

[Diagnosis of valve dysfunction in the paediatric age: the predictive value of the clinical signs and symptoms]. / Diagnóstico de disfunción valvular en la edad pediátrica: valor predictivo de los síntomas y signos clínicos.

INTRODUCTION: Cerebrospinal fluid shunt valves are the preferred treatment in many cases of childhood hydrocephalus. Cerebrospinal fluid shunt valve dysfunctions usually present in an unspecific manner, which delays their diagnosis and, consequently, can increase the morbidity and mortality rates in these patients. AIM: To determine the signs and symptoms that are most suggestive of valve dysfunction in the childhood population. PATIENTS AND METHODS: We conducted a retrospective study of the reports of patients who visited the emergency department of a tertiary care paediatric hospital with a clinical picture that suggested valve dysfunction. In each case the clinical manifestations were determined, and also whether there had been a diagnosis of valve dysfunction or not. A univariate analysis and later a logistic regression study were performed. RESULTS: In all, 183 visits were included. Valve dysfunction was confirmed in 28.5% of them. The most frequent complication was obstruction of the proximal drainage catheter. The univariate analysis showed a significant relation between the presence of irritability, sleepiness, abdominal pain, paresis of the cranial nerves and increased perimeter of the skull, and the existence of valve dysfunction. The logistic regression analysis revealed that sleepiness, irritability and abdominal pain could predict valve dysfunction. CONCLUSIONS: Sleepiness and irritability are the clinical manifestations that best predict valve dysfunction, which means that they are almost undoubtedly candidates for an urgent neuroimaging study. In most cases the abdominal pain is related to abdominal pseudocysts. Headaches, vomiting and a high temperature are less predictive of valve dysfunction.

Hipertensión arterial por esfuerzo: posible predictor de riesgo cardiovascular / Exercise-induced arterial hypertension: possible predictor of cardiovascular risk

Introducción: Durante el ejercicio se produce una elevación fisiológica de la presión arterial. Algunos sujetos previamente normotensos presentan grandes incrementos con el ejercicio, lo que podría ser un factor pronóstico adverso.Casos clínicos: Dos varones de 15 y 16 años, sin antecedentes personales de interés, remitidos por pérdida de conciencia de minutos de duración, en el primer caso, con recuperación espontánea mientras entrenaba al baloncesto y, en el segundo, con cefalea importante desencadenada durante un partido de fútbol. Se constataron cifras de presión > P99 en ambos. La exploración física era normal. Se realizaron determinaciones en condiciones de reposo, que mostraron intervalos de normalidad. Los hallazgos analíticos, función renal, metabólica y hormonal fueron normales. No se encontraron anomalías en la eco-Doppler. Se descartó afección de órganos diana. La monitorización ambulatoria de la presión arterial mostró máximos de presión > P99 coincidiendo con la realización de ejercicio; las demás lecturas estaban dentro de la normalidad. Se suprimió el ejercicio físico intenso sin requerir otro tipo de medidas.Conclusiones: Valorar la aparición de hipertensión arterial en adolescentes que practican deporte, introducir la monitorización ambulatoria de la presión arterial como cribado en revisiones médico-deportivas y suprimir el esfuerzo como única medida terapéutica(AU)

Introduction: Exercise produces a physiological increase of the blood pressure. Some previously normotensive subjects have significant increases with exercise, which could be an adverse prognostic factor.Clinical cases: Two male subjects, 15 and 16 years old, with no personal background of interest, were referred. The first one was due to loss of consciousness for several minutes with spontaneous recovery while practicing basketball. The second case was for a strong headache that occurred while playing soccer. Blood pressure values for both were > P99 and their physical examinations were normal. Tests performed at rest showed normal ranges. The laboratory findings, renal and metabolic function and hormones were normal. There were no abnormalities on the echo-Doppler. Involvement of target organs was ruled out. Ambulatory blood pressure monitoring showed tension peaks > P99, coinciding with exercise, the remaining readings being within normality. Intense physical exercise was discontinued, without requiring any other type of actions.Conclusions: Introducing ambulatory blood pressure monitoring as screening in medicalsports check-ups and suppression of exercise as the only therapeutic measures should be evaluated when faced with arterial hypertension in adolescents who practice sports(AU)