Chest physiotherapy is not clinically indicated for infants receiving outpatient care for acute wheezing episodes.

AIM: To evaluate the effectiveness of chest physiotherapy (CPT), which provides slow and long expiratory flow and assisted cough techniques, in infants receiving outpatient care for acute wheezing episodes. METHODS: Forty-eight infants with moderate acute wheezing episodes were randomised to receive either salbutamol MDI with CPT (n = 25) or without CPT (n = 23). The clinical score and SpO2 levels were recorded, before and after treatment, in a blinded design. The primary outcome was discharge after the first hour of treatment: clinical score ≤5/12 and SpO2 ≥ 93%. Secondary outcomes were the number of admissions to hospital after the second hour, use of oral corticosteroid bursts and admissions to hospital on day seven. RESULTS: There were no differences between children with and without CPT in discharge rate (92% vs. 87%), clinical score (median [IQR]: 2.8 [2.2-3.3] vs. 3.4 [2.8-4.1]) and SpO2 = (96.4 [95.7-97.1] vs. 96.0 [94.9-96.5]) after the first hour of treatment or in the number of hospital admissions after the second hour. No differences were observed at days seven and 28 following treatment. CONCLUSION: There was no evidence of clinical benefits from these specific CPT techniques for infants receiving outpatient care for acute wheezing episodes.

Compositional Changes in Sediment Microbiota Are Associated with Seasonal Variation of the Water Column in High-Altitude Hyperarid Andean Lake Systems.

The lacustrine systems of La Brava and La Punta, located in the Tilopozo sector in the extreme south of Salar de Atacama, are pristine high-altitude Andean lakes found along the central Andes of South America. This shallow ecosystem suffers from permanent evaporation, leading to falling water levels, causing it to recede or disappear during the dry season. This dynamic causes physicochemical changes in lakes, such as low nutrient availability, pH change, and dissolved metals, which can influence the composition of the microbial community. In this study, we used a metataxonomic approach (16S rRNA hypervariable regions V3 to V4) to characterize the sedimentary microbiota of these lakes. To understand how the water column affects and is structured in the microbiota of these lakes, we combined the analysis of the persistence of the water column through satellite images and physicochemical characterization. Our results show a significant difference in abiotic factors and microbiota composition between La Punta and La Brava lakes. In addition, microbiota analysis revealed compositional changes in the ecological disaggregation (main and isolated bodies) and antagonistic changes in the abundance of certain taxa between lakes. These findings are an invaluable resource for understanding the microbiological diversity of high Andean lakes using a multidisciplinary approach that evaluates the microbiota behavior in response to abiotic factors. IMPORTANCE In this study, we analyzed the persistence of the water column through satellite images and physicochemical characterization to investigate the composition and diversity in High Andean Lake Systems in a hyperarid environment. In addition to the persistence of the water column, this approach can be used to analyze changes in the morphology of saline accumulations and persistence of snow or ice; for example, for establishing variable plant cover over time and evaluating the microbiota associated with soils with seasonal changes in plants. This makes it an ideal approach to search for novel extremophilic microorganisms with unique properties. In our case, it was used to study microorganisms capable of resisting desiccation and water restriction for a considerable period and adapting to survive in ecological niches, such as those with high UV irradiation, extreme drought, and high salt concentration.

Study of Wetland Soils of the Salar de Atacama with Different Azonal Vegetative Formations Reveals Changes in the Microbiota Associated with Hygrophile Plant Type on the Soil Surface.

Salar de Atacama is located approximately 55 km south of San Pedro de Atacama in the Antofagasta region, Chile. The high UV irradiation and salt concentration and extreme drought make Salar de Atacama an ideal site to search for novel soil microorganisms with unique properties. Here, we used a metataxonomic approach (16S rRNA V3-V4) to identify and characterize the soil microbiota associated with different surface azonal vegetation formations, including strict hygrophiles (Baccharis juncea, Juncus balticus, and Schoenoplectus americanus), transitional hygrophiles (Distichlis spicata, Lycium humile, and Tessaria absinthioides), and their various combinations. We detected compositional differences among the soil surface microbiota associated with each plant formation in the sampling area. There were changes in soil microbial phylogenetic diversity from the strict to the transitional hygrophiles. Moreover, we found alterations in the abundance of bacterial phyla and genera. Halobacteriota and Actinobacteriota might have facilitated water uptake by the transitional hygrophiles. Our findings helped to elucidate the microbiota of Salar de Atacama and associate them with the strict and transitional hygrophiles indigenous to the region. These findings could be highly relevant to future research on the symbiotic relationships between microbiota and salt-tolerant plants in the face of climate change-induced desertification. IMPORTANCE The study of the composition and diversity of the wetland soil microbiota associated with hygrophilous plants in a desert ecosystem of the high Puna in northern Chile makes it an ideal approach to search for novel extremophilic microorganisms with unique properties. These microorganisms are adapted to survive in ecological niches, such as those with high UV irradiation, extreme drought, and high salt concentration; they can be applied in various fields, such as biotechnology and astrobiology, and industries, including the pharmaceutical, food, agricultural, biofuel, cosmetic, and textile industries. These microorganisms can also be used for ecological conservation and restoration. Extreme ecosystems are a unique biological resource and biodiversity hot spots that play a crucial role in maintaining environmental sustainability. The findings could be highly relevant to future research on the symbiotic relationships between microbiota and extreme-environment-tolerant plants in the face of climate change-induced desertification.

Physicochemical Parameters Affecting the Distribution and Diversity of the Water Column Microbial Community in the High-Altitude Andean Lake System of La Brava and La Punta.

Due to the low incidence of precipitation attributed to climate change, many high-altitude Andean lakes (HAALs) and lagoons distributed along the central Andes in South America may soon disappear. This includes La Brava-La Punta, a brackish lake system located south of the Salar de Atacama within a hyper-arid and halophytic biome in the Atacama Desert. Variations in the physicochemical parameters of the water column can induce changes in microbial community composition, which we aimed to determine. Sixteen sampling points across La Brava-La Punta were studied to assess the influence of water physicochemical properties on the aquatic microbial community, determined via 16S rRNA gene analysis. Parameters such as pH and the concentrations of silica, magnesium, calcium, salinity, and dissolved oxygen showed a more homogenous pattern in La Punta samples, whereas those from La Brava had greater variability; pH and total silica were significantly different between La Brava and La Punta. The predominant phyla were Proteobacteria, Bacteroidetes, Actinobacteria, and Verrucomicrobia. The genera Psychroflexus (36.85%), Thiomicrospira (12.48%), and Pseudomonas (7.81%) were more abundant in La Brava, while Pseudospirillum (20.73%) and Roseovarius (17.20%) were more abundant in La Punta. Among the parameters, pH was the only statistically significant factor influencing the diversity within La Brava lake. These results complement the known microbial diversity and composition in the HAALs of the Atacama Desert.

Water deficit and abscisic acid treatments increase the expression of a glucomannan mannosyltransferase gene (GMMT) in Aloe vera Burm. F.

The main polysaccharide of the gel present in the leaves of or Aloe vera Burm.F., (Aloe barbadensis Miller) a xerophytic crassulacean acid metabolism (CAM) plant, is an acetylated glucomannan named acemannan. This polysaccharide is responsible for the succulence of the plant, helping it to retain water. In this study we determined using polysaccharide analysis by carbohydrate gel electrophoresis (PACE) that the acemannan is a glucomannan without galactose side branches. We also investigated the expression of the gene responsible for acemannan backbone synthesis, encoding a glucomannan mannosyltransferase (GMMT, EC 2.4.1.32), since there are no previous reports on GMMT expression under water stress in general and specifically in Aloe vera. It was found by in silico analyses that the GMMT gene belongs to the cellulose synthase-like A type-9 (CSLA9) subfamily. Using RT-qPCR it was found that the expression of GMMT increased significantly in Aloe vera plants subjected to water stress. This expression correlates with an increase of endogenous ABA levels, suggesting that the gene expression could be regulated by ABA. To corroborate this hypothesis, exogenous ABA was applied to non-water-stressed plants, resulting in a significant increase of GMMT expression after 48 h of ABA treatment.

Efectividad de sustancias químicas en el clareamiento y biopelícula dental aplicado en el consultorio y ambulatorio / Effectiveness of chemical substances in bleaching and dental biofilm applied in the office and outpatient

El blanqueamiento dental está considerado como pieza fundamental en el embellecimiento de los seres humanos, ya que permite la restauración de la "sonrisa perfecta". Este proceso en sí, es poco invasivo y juega como un gran papel como aliado en la restauración satisfactoria de la sonrisa y autoestima del paciente. Es un procedimiento que debe ser aplicado cuidadosamente para lograr los efectos positivos del mismo. El fundamento de esta técnica es aclarar la tonalidad que han sufrido los dientes por diversos factores: extrinsecos, intrínsecos y decoloraciones internas. Durante el procedimiento, es usual el uso de peróxido de hidrógeno (H2O2) en concentraciones que van del 10 al 32 % en volumen o el peróxido de carbamida, un compuesto conformado por peróxido de hidrógeno y urea concentraciones del 10 al 22 %. El uso de peróxido de hidrógeno se lleva a cabo fundamentalmente en los consultorios, mientras que el uso del peróxido de carbamida es un procedimiento doméstico. A pesar de los excelentes resultados que se obtiene al usar ambos blanqueadores, su uso puede ocasionar erosiones dentales y sensibilidad dentaria. El primer caso, puede llevar a la adherencia de bacterias cariogénicas como el Strepctococus mutans responsable de caries. Los resultados obtenidos, demostraron que el peróxido de hidrógeno es un agente más agresivo que el peróxido de carbamida, lo cual origina mayor sensibilidad dentaria y un mayor control bacteriano; en cambio el peróxido de carbamida fue mejor blanqueador y originó menor sensibilidad dental(AU)

Tooth whitening is considered a fundamental piece in the beautification of human beings, since it allows the restoration of the "perfect smile". This process itself is minimally invasive and plays a great role as an ally in the satisfactory restoration of the patient's smile and self-esteem. It is a procedure that must be carefully applied to achieve its positive effects. The basis of this technique is to clarify the shade that the teeth have suffered due to various factors: extrinsic, intrinsic and internal discoloration. During the procedure, the use of hydrogen peroxide (H2O2) in concentrations ranging from 10 to 32% by volume or carbamide peroxide, a compound made up of hydrogen peroxide and urea concentrations of 10 to 22%, is usual. The use of hydrogen peroxide is mainly carried out in offices, while the use of carbamide peroxide is a home procedure. Despite the excellent results obtained by using both whiteners, their use can cause dental erosion and tooth sensitivity. The first case can lead to the adherence of cariogenic bacteria such as Streptococcus mutans responsible for caries. The results obtained showed that hydrogen peroxide is a more aggressive agent than carbamide peroxide, which causes greater dental sensitivity and greater bacterial control; On the other hand, carbamide peroxide was a better whitener and caused less dental sensitivity(AU)

Recomendaciones para el manejo respiratorio de los pacientes con atrofia muscular espinal / Recommendations for respiratory management of patients with spinal muscular atrophia / Recomendações para a manipulação respiratória de pacientes com atrofia muscular espinhal

Resumen: La atrofia muscular espinal (AME) es una enfermedad del asta anterior de la médula espinal, genéticamente determinada y causada por síntesis insuficiente de la proteína de supervivencia de la motoneurona. La debilidad muscular lleva a una disminución progresiva de la capacidad vital y de flujos medibles durante la tos. La intensidad y precocidad de la expresión motora se vincula con los grados de afectación de los grupos musculares respiratorios, determinando la meseta en la capacidad vital y progresión a la insuficiencia ventilatoria, como también el compromiso de los músculos inervados bulbares. Las formas clínicas más severas de AME, en especial aquellas con presentaciones más tempranas y respiración paradojal, tienen capacidades vitales y flujos pico tosidos menores. La evaluación secuencial de estos parámetros es esencial para el pronóstico funcional y vital de estos pacientes. La subclasificación de AME tipo 1 y 2 se relaciona con momentos deseables para la realización de cuidados respiratorios no invasivos en la infancia temprana y en la edad escolar, que mejoran la sobrevida y calidad de vida. Este documento sintetiza dichas recomendaciones con especial referencia a intervenciones guiadas por etapas que incluyan apilamiento de aire (air stacking), protocolos de tos asistida y soporte ventilatorio no invasivo con alta intensidad de presiones de soporte, incluso en aquellos pacientes con pérdida de la autonomía respiratoria, minimizando el riesgo de traqueotomía. La no consideración de estas recomendaciones en la valoración regular de los pacientes resta la oferta de tratamientos oportunos.

Summary: Spinal Muscular Atrophy (SMA) is a disease of the anterior horn of the spinal cord, genetically determined, and caused by deficiency of survival motor neuron (SMN) protein. Muscle weakness leads to a progressive decrease in vital capacity and to diminished cough flows. Respiratory morbidity and mortality are a function of respiratory and bulbar-innervated muscle impairment. It can be measured by the sequential evaluation of vital capacity to determine the life time maximum (plateau) and its subsequent rate of decline, progressing to ventilatory failure. Bulbar-innervated muscle impairment can also be monitored and measured by spirometry. The more severe clinical forms of SMA, especially those with earlier onsets and paradoxical breathing, have lower vital capacities and cough peak flows. The sequential assessment of these parameters is key for the vital and functional prognosis of these patients. SMA sub-classification types 1 and 2 of SMA involve appropriate times for non-invasive respiratory interventions in early childhood and school age and improve afterlife and quality of life. This document summarizes these recommendations, as a function of SMA type, with special reference to interventions that include air stacking, manually and mechanically assisted coughing protocols and noninvasive ventilatory support techniques, even for patients who have no ventilator-free breathing ability to minimize or eliminate the need to resort to tracheotomy. Failure to properly evaluate these patients regularly reduces their survival and chances to avoid invasive airway tubes.

Resumo: A Atrofia Muscular Espinhal (SMA) é uma doença do corno anterior da medula espinhal, geneticamente determinada e causada pela síntese insuficiente da proteína de sobrevivência dos neurônios motores. A fraqueza muscular leva a uma diminuição progressiva da capacidade vital e fluxos mensuráveis durante a tosse. A intensidade e a precocidade da expressão motora estão relacionadas aos graus de envolvimento dos grupos musculares respiratórios, determinando o platô da capacidade vital e a progressão para insuficiência ventilatória, bem como o envolvimento dos músculos inervados do bulbar. As formas clínicas mais graves de SMA, especialmente aquelas com apresentações anteriores e respiração paradoxal, têm capacidades vitais mais baixas e fluxos de tosse mais baixos. A avaliação sequencial desses parâmetros é essencial para o prognóstico funcional e vital desses pacientes. A subclassificação de SMA tipo 1 e 2 está relacionada aos momentos desejáveis para cuidados respiratórios não invasivos na primeira infância e idade escolar, que melhoram a sobrevida e a qualidade de vida. Este documento resume essas recomendações com referência especial às intervenções guiadas por etapas que incluem empilhamento de ar, protocolos de tosse assistida e suporte ventilatório não invasivo com suporte pressórico de alta intensidade, mesmo em pacientes com perda de autonomia respiratória, minimizando o risco de traqueostomia. A não consideração dessas recomendações na avaliação regular dos pacientes reduz a oferta de tratamentos oportunos.

Traqueostomía en niños: los desafíos de la decanulación, revisión y propuesta de trabajo / Tracheostomy in children: the challenges of decanulation, revision and work proposal

Tracheostomy (TQT) in pediatrics is a procedure that allows maintaining permeable airways and establishes prolonged mechanical ventilation. Continuous noninvasive ventilatory support (CNVS) can always be used for patients capable of cooperating with it and mechanical insufflation-exsufflation (MIE). Despite this, TQT continues to be indicated frequently, limiting home transfer and care, conditioning additional burden of morbidity and risks. In those with upper airway obstruction (OVAS), except in <2 years, the decanulation follows similar guidelines as in adults. Small children who require even only sleep ventilation cannot be decannulated to NVS if they cannot be relied on to use it via noninvasive interfaces. So, children under age 12 should not be decannulated unless they are ventilator weaned. For adolescents and adults, the principle criterion for safe decannulation is an MIE-peak exsufflation flows (MIE-EF) over 150 L/m whereas need for tracheotomy occurs when MIE-EF decrease below 120 L/m, irrespective of extent of ventilator dependence. The following article is a critical narrative review of different decannulation alternatives to ensure that this process can be safely carried out with effectiveness and efficiency. Patients with different ages and diseases have been considered, knowing that younger children and adult in transition tracheostomized patients significantly increases the challenges.

La traqueotomía (TQT) permite mantener la vía aérea permeable y la ventilación mecánica prolongada. El soporte ventilatorio no invasivo continuo (SVNI) junto con la insuflación-exuflación mecánica (MIE), son una alternativa en la mayoría de los casos. Pese a esto, la TQT sigue indicándose frecuentemente, limitando la transferencia al hogar, condicionando carga adicional de morbilidad. En los niños con obstrucción de la vía aérea superior (OVAS), salvo en los <2 años, la decanulación sigue lineamientos similares que en adultos. Los <12 años dependientes de ventilador, aun cuando sólo sea nocturna, son decanulados o extubados a SVNI más difícilmente que adultos con dependencia continua. La mejor estrategia es evitar la TQT e indicar SVNI en los pacientes colaboradores que cumplan criterios. Excepto pacientes con estridor por OVAS grave o enfermedad de la primera motoneurona y severo compromiso miopático. Para adolescentes y adultos, el criterio para la decanulación segura es un pico flujo exuflado máximo en MIE (PFE-MIE), con o sin tos, >150 L/m, mientras que la necesidad de traqueostomía ocurre cuando el MIE (PFE-MIE) esta bajo 120 ml/min, independiente del grado de dependencia del ventilador. En menores de 12 años, el éxito del SVNI reside en obtener interfaces confiables para su entrega, de lo contrario no podrían ser decanulados. Siendo escasos los protocolos de decanulación pediátrica. Nuestro objetivo es el de ponderar alternativas seguras y eficientes para la decanulación de la TQT. Siendo considerados pacientes con edades y enfermedades distintas, sabiendo que los más pequeños, no colaboradores y dependientes de ventilación aumentan el desafío.

Actualización en el manejo respiratorio de pacientes con enfermedades neuromusculares / Update in the respiratory management of patients with neuromuscular diseases

Resumen: Los días 24 y 25 de noviembre del 2016, en Montevideo, Uruguay, tuvo lugar un encuentro de capacitación en cuidados respiratorios no invasivos con más de 200 profesionales médicos, kinesiólogos y licenciadas de enfermería. El encuentro fue presidido por el Dr. John Bach, Director Médico del Centro de Ventilación Mecánica No Invasiva en la Escuela de Medicina de Rutgers, New Jersey en Newark, New Jersey, quien es reconocido a nivel mundial por su amplia trayectoria en estudios y trabajos publicados sobre ventilación no invasiva y enfermedades neuromusculares Los cuidados respiratorios no invasivos, combinando la asistencia ventilatoria, inicialmente nocturna y luego durante las 24 horas del día, incluso en pacientes con capacidad vital mínima, y la implementación de estrategias para asistencia de la tos y respiración glosofaríngea, han contribuido a una mejor calidad de vida y sobrevida de los pacientes con enfermedades neuromusculares. Los avances tecnológicos, la capacitación de los pacientes y sus cuidadores facilitan su estadía en el hogar sin depender de instituciones o cuidados de enfermería permanentes promoviendo su autonomía e integración. Resulta esencial que los profesionales de la salud, conozcan todas las opciones terapéuticas posibles para ofrecer a sus pacientes y sus familias, de modo que, conforme avanza la enfermedad, ellos puedan expresar sus voluntades en forma anticipada y sin apremios derivados de eventos "inesperados". Es necesario impulsar un cambio de paradigma en la forma en que los profesionales de la salud ven a estos individuos. Las recomendaciones claves de ese encuentro están resumidas en este artículo.

Summary: A November 2016 Noninvasive Ventilatory Support workshop and meeting with more than 200 medical professionals, physiotherapists, respiratory therapists and nurses took place in the city of Montevideo, Uruguay. It was conducted by Dr. John Robert Bach, Medical Director of the Center for Non-Invasive Mechanical Ventilation at Rutgers New Jersey School of Medicine in Newark, New Jersey, who is recognized worldwide for his extensive background in studies and publications on noninvasive ventilation and neuromuscular diseases. Non-invasive respiratory care which combines ventilatory support initially at night and then support continuously 24 hours per day, even in patients with minimal vital capacity combined with the implementation of specifics techniques for assisted coughing and glossopharyngeal breathing have contributed to a better quality of life and survival of patients with neuromuscular diseases. Technological advances and proper training for patients and caregivers facilitates the patient's ability to stay at home and also promotes their autonomy and integration, without them having to depend on hospice or permanent nursing care. It is essential for health care professionals to know all the therapeutic possibilities available for their patients and share with both the patients and the patient's family, so as the disease progresses it will help everyone clearly understand all options during conscious decision-making. It is necessary to promote a paradigm shift in the way health professionals approach individuals with neuromuscular diseases. The key recommendations from that meeting are summarized in this article.

Cuidados respiratorios para pacientes con enfermedades neuromusculares / Respiratory care for patients with neuromuscular diseases

Non-invasive respiratory care, combining with ventilatory support, initially at night and then during 24 hours/day, even in patients with minimal vital capacity and the implementation of specifics techniques like mechanically assisted coughing, glossopharyngeal breathing and air stacking, have contributed to a better quality of life and survival of patients with neuromuscular diseases. It is essential for health care professionals to know all the therapeutic possibilities for their patients and their families, so as the disease progresses it would facilitate their decision-making. Technological advances and proper training for patients and caregivers facilitate the stay at home and promote their autonomy and integration, without depending on hospital nor permanent nursing care. In November 2016 it was carried out the Noninvasive Ventilatory Support workshop/meeting with more than 200 physicians, physiotherapists, respiratory therapists and nurses in Montevideo, Uruguay. It was conducted by Dr. John Robert Bach, Medical Director of the Center for Non-Invasive Mechanical Ventilation at Rutgers New Jersey School of Medicine in Newark, New Jersey. Dr Bach is recognized worldwide for his extensive background in studies and publications on noninvasive ventilation and neuromuscular diseases.

Los cuidados respiratorios no invasivos, combinando la asistencia ventilatoria, inicialmente nocturna y luego durante las 24 h del día, incluso en pacientes con capacidad vital mínima, más la implementación de estrategias complementarias de tos asistida, respiración glosofaríngea y apilamiento de aire (air stacking) en forma activa o pasiva han contribuido a una mejor calidad de vida y sobrevida de los pacientes con enfermedades neuromusculares. Resulta esencial que los profesionales de la salud, conozcan todas las opciones terapéuticas al informar a sus pacientes y sus familias, de modo que ellos puedan tomar sus mejores decisiones en la medida que la debilidad e hipoventilación progresen. Los avances tecnológicos, la capacitación de los pacientes y sus cuidadores facilitan su estadía en el hogar sin depender de instituciones o cuidados de enfermería permanentes, promoviendo su autonomía e integración, disminuyendo el riesgo de falla respiratoria conducente a intubación endotraqueal y/o a traqueostomia. Los días 24 y 25 de noviembre del 2016, en Montevideo tuvo lugar un encuentro de capacitación en cuidados respiratorios no invasivos con más de 200 profesionales médicos, kinesiólogos y licenciadas de enfermería, destacando los avances y experiencia consolidad por el Dr. John Bach en más de 30 años de ejercicio profesional en pacientes con síndromes de hipoventilación secundario a enfermedades neuromusculares y otras condiciones que debilitan la bomba respiratoria. Las recomendaciones claves se resumen en este articulo, destacando como estos avances requieren impulsar un cambio de paradigma en la forma en que los profesionales de la salud ven y tratan a estos individuos.

Dilemas éticos en niños con enfermedades neuromusculares y dependencias tecnológicas: Ethical dilemmas in children with neuromuscular diseases and technological dependencies

En los últimos años, los cuidados respiratorios especializados, y en particular los cuidados respiratorios no invasivos y otros avances tecnológicos han contribuido a una mejor calidad de vida y sobrevida de los pacientes con enfermedades neuromusculares. La naturaleza de las opciones terapéuticas (como ser la ventilación invasiva versus ventilación no invasiva, las cargas psicológicas, sociales y financieras) tienen ramificaciones éticas. Por lo tanto resulta esencial que los médicos comprendan todas las opciones terapéuticas y los factores psicosociales al informar a sus pacientes, en lo que tiene que ver con sus ventajas y desventajas y sus costos asociados, de modo que los padres puedan tomar decisiones informadas. Los nuevos desarrollos incluyen exámenes prenatales y neonatales más precisos, nuevas terapias genéticas y soporte respiratorio no invasivo para evitar episodios de fallas respiratorias y vías aéreas invasivas. Al empoderar a los pacientes y sus familias para educar y capacitar servicios personales de cuidados para que no deban depender de las instituciones y servicios de enfermería constante, y los recientes avances tecnológicos facilitan su permanencia en el hogar y dejan de estar atados a una vida dependiendo de la institución y los servicios de enfermería. Estos últimos infantilizan a los pacientes en lugar de promover su autonomía. Las consideraciones financieras, las terapias genéticas, el screening prenatal y las distintas opciones terapéuticas que promueven la autonomía, todos tienen implicancias éticas. Algunos de los avances discutidos en este artículo requieren un cambio de paradigma en la forma en que los médicos ven y tratan a estos individuos.

In recent years, specialized and principally noninvasive respiratory care and other technological advances have better maintained quality of life and survival of patients with neuromuscular diseases. The nature of therapeutic options i.e. invasive vs. noninvasive, psychological, social, and financial constraints all have ethical ramifications. It is therefore essential that the clinicians understand all therapeutic options and psychosocial factors when informing patients as to their advantages, disadvantages, and associated costs so that the parents can make well informed decisions. New developments include more accurate prenatal and neonatal testing, new gene therapies, and noninvasive respiratory aids to avert episodes of respiratory failure and invasive airway tubes. Empowering patients and their families to educate and train personal assistance services rather than be dependent on institutions and ongoing nursing services and recent technological advances facilitates their remaining in their homes rather than be constrained to a lifetime of institutionalization and ongoing nursing services. The latter infantilizes patients rather than promotes autonomy. Financial considerations, gene therapies, prenatal screening, and therapeutic options that promote autonomy all have ethical implications. Some of the advances discussed in this article call for a paradigm shift in the way that clinicians see and treat these individuals.

[Impact of asthma among primary attention children]. / Impacto del asma en escolares de dos centros de salud primaria.

BACKGROUND: Asthma is one of the chronic diseases that generate an impact on quality of life and major health care expenses. AIM: To evaluate the impact of asthma on primary attention expenses, the health related quality of life (HRQOL) and the sanitary resources use. MATERIAL AND METHODS: Follow up of a cohort of 56 asthmatic children aged 6 to 14 years (56% women), during 12 months. The severity and the impact of the disease on HRQOL was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) video questionnaire and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) respectively Costs were derived from the number of medical attentions, hospital admissions, medication requirements, school absenteeism among patients and work absenteeism among caregivers. RESULTS: Patients required twice the number of medical attentions than the general population. Fourteen percent of children had severe asthma. Compared with subjects without severe asthma, the latter required more attentions (3.8 and 9.7 attentions per year respectively, p< 0.01), had a lower PAQLQ score (4.1 +/-0.11 and 5.2 +/- 1 respectively, p< 0.05) and a higher school absenteeism (10 and 27 days per year respectively, p < 0.01). Medication use was not different between patients with and without severe asthma. They early cost per patient was $ 106,550 (Chilean pesos). CONCLUSIONS: Asthma has a great impact on HRQOL and the use of primary attention resources, specially those children with severe asthma.

Guías clínicas para la alimentación en pacientes con trastorno de la deglución / Clinic guidelines for feeding in-patients with swallowing disorders

Feeding is crucial for children’s development at all ages. For that reason, it is necessary to implement timely and effective diagnosis and treatment for patients that present distress in this activity. Swallowing disorders are associated to multiple pathologies and they are accompanied by serious health conditions. This is the reason why the medical approach of each of these disorders is not considered. Due to this point, it is imperative to make sure an integral management where we should consider diagnosis and treatment for patients with swallowing disorders and general feeding problems. Clinical practice guidelines (gPC) are used as a tool to generate current existing evidence to help professionals and in-patients to solve specific health problems by helping solve diagnosis or therapeutic options for a specific condition. Since 2004, minsal has developed gPC associated to the different pathologies included in ges. Hospitals have worked in generating gPC and health care protocols in order to reduce variability and improve clinical practice.

La alimentación es crucial para el desarrollo de los niños en todas las edades, es por esto, que se hace necesario implementar el diagnóstico y tratamiento, oportuno y efectivo para los pacientes que presenten dificultades en esta actividad. Los trastornos de la deglución, se asocian a múltiples patologías y en general acompañan a graves condiciones de salud, es por esto que, en el abordaje particular de cada una de las enfermedades, en ocasiones no se considera. Dado lo anterior es que se hace imperativo realizar un manejo integral de estos pacientes en el que se debe considerar el diagnóstico y tratamiento de los trastornos de la deglución y de la alimentación en general. Como herramienta para generar y difundir las evidencias existentes en la actualidad sobre algunos temas se ha considerado la generación de guías de práctica clínica (gPC) las que constituyen un conjunto de recomendaciones desarrolladas de forma sistemática para ayudar a profesionales y pacientes en la toma de decisiones sobre problemas específicos de salud, ayudando a seleccionar las opciones diagnósticas o terapéuticas más adecuadas a una condición clínica específica. Desde el año 2004, el minsal ha desarrollado gPC asociadas a las patologías que se han incluido en el régimen de garantías explicitas en salud. Paralelamente en los distintos hospitales del país, públicos y privados se ha trabajado en la generación de gPC y protocolos de atención con el fin de reducir la variabilidad y mejorar la práctica clínica.

Recomendaciones para la evaluación quirúrgica de la escoliosis en niños con enfermedad neuromuscular / Surgical evaluation of scoliosis in children with neuromuscular disease

El compromiso respiratorio de los pacientes con enfermedad neuromuscular (ENM) incide en la historia natural de la enfermedad y en la calidad de vida del niño y su familia. La falla respiratoria es responsable de un número significativo de muertes prevenibles con una intervención precoz. Frecuentemente estos pacientes tienen escoliosis, que al progresar sin un tratamiento quirúrgico oportuno, aumenta la morbimortalidad por causa respiratoria, aumenta el compromiso cardiovascular e impide lograr posicionamiento sin dolor al perder la marcha y bipedoestación. En este artículo se abordan recomendaciones para la evaluación quirúrgica en niños con ENM, haciendo especial consideración de aspectos respiratorios, como la evaluación funcional y los coadyuvantes terapéuticos perioperatorios incluyendo la asistencia ventilatoria no invasiva y el entrenamiento respiratorio.

Impacto del asma en escolares de dos centros de salud primaria / Impact of asthma among primary attention children

Background: Asthma is one of the chronic diseases that generate an impact on quality of life and major health care expenses. Aim: To evaluate the impact of asthma on primary attention expenses, the health related quality of life (HRQOL) and the sanitary resources use. Material and Methods: Follow up of a cohort of 56 asthmatic children aged 6 to 14 years (56 percent women), during 12 months. The severity and the impact of the disease on HRQOL was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) video questionnaire and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) respectively Costs were derived from the number of medical attentions, hospital admissions, medication requirements, school absenteeism among patients and work absenteeism among caregivers. Results: Patients required twice the number of medical attentions than the general population. Fourteen percent of children had severe asthma. Compared with subjects without severe asthma, the latter required more attentions (3.8 and 9.7 attentions per year respectively, p< 0.01), had a lower PAQLQ score (4.1 ±0.11 and 5.2 ± 1 respectively, p< 0.05) and a higher school absenteeism (10 and 27 days per year respectively, p < 0.01). Medication use was not different between patients with and without severe asthma. They early cost per patient was $ 106,550 (Chilean pesos). Conclusions: Asthma has a great impact on HRQOL and the use of primary attention resources, specially those children with severe asthma.

Recomendaciones para los cuidados respiratorios del niño y adolescente con enfermedades neuromusculares / Respiratory care for the children and adolescents with neuromuscular diseases

El compromiso del sistema respiratorio repercute directamente en la morbimortalidad de niños y adolescentes con enfermedades neuromusculares (ENM). Un enfoque integral que incluya la aproximación a un diagnostico neurológico específico, evaluación funcional respiratoria, de los trastornos respiratorios de sueño, comorbilidades y afecciones secundarias, permiten orientar a el tipo, grado y pronóstico respiratorio; además de otorgar herramientas objetivas para modificar la historia natural de la enfermedad. Utilizar criterios estrictos de selección, una mirada interdisciplinaria y actividades complementarias de rehabilitación; que incorporen en forma programática la ventilación no invasiva domiciliaria, protocolos de tos asistida y métodos para aumentar la capacidad máxima de insuflación, cambia la evolución, disminuye la morbimortalidad y evita la traqueostomía, en una alta proporción de niños y adolescentes portadores de ENM.

Recomendaciones prácticas para el cuidado hospitalario del niño/adolescente con necesidades especiales y dependencias tecnológicas respiratorias / Practical recommendations for hospital care of child and adolescent with special respiratory needs

Junto con el aumento de la prevalencia de enfermedades respiratorias crónicas y Neuromusculares, surgen avances tecnológicos que permiten entregar prestaciones orientadas a mejorar la calidad y expectativa de vida de niños y adolescentes. Este artículo entrega recomendaciones practicas para el manejo intrahospitalario de pacientes con necesidades especiales de atención en salud y dependencias tecnológicas en cuidados respiratorios, centrados en la ventilación mecánica prolongada, técnicas complementarias y cuidados de traqueostomía.

Guía clínica para el diagnóstico y cuidado de niños/adolescentes con bronquiolitis obliterante post-infecciosa, 2009 / Clinical guidelines for the diagnosis and care of children and adolescents with post-infectious bronchiolitis obliterans, 2009

La bronquiolitis obliterante (BO) es un síndrome clínico poco frecuente en niños, caracterizado por la obstrucción crónica al flujo de aire asociado a cambios inflamatorios y distintos grados de fibrosis en la vía aérea pequeña. Si bien existen muchas etiologías, la causa mas frecuente se asocia a infeccionesrespiratorias virales, principalmente adenovirus. No existe un consenso para establecer su diagnóstico; sin embargo, se considera un espectro de síntomas persistentes asociados a un patrón en mosaico, bronquiectasias y atelectasias persistentes. El rol de la biopsia pulmonar ha sido cuestionado por subajo rendimiento, invasividad y complicaciones. No existe un tratamiento específico por lo que elmanejo es soporte. Probablemente la mejor estrategia constituya el empleo de antibióticos en forma agresiva, soporte kinésico y nutricional constante y una precoz rehabilitación pulmonar. Estas guías clínicas representan un esfuerzo multidisciplinario, basado en evidencias actuales para brindarherramientas prácticas para el diagnóstico y cuidado de niños y adolescentes con BO post infecciosa.

Ventilación mecánica invasiva domiciliaria (VMI): una propuesta para un nuevo programa / Domiciliary invasive mechanical ventilation: proposal for a new program

El presente escrito resume las recomendaciones, que como extensión del Programa Nacional de Asistencia Ventilatoria no Invasiva Domiciliario (AVNI), se han considerado por los autores, como las más apropiadas para ser incluidas en una propuesta que permita la entrega de prestaciones de ventilación mecánica invasiva en domicilio en niños.

Estrategia educativa en el Programa Asistencia Ventilatoria no Invasiva (AVNI) / Educational strategy in the Noninvasive Ventilatory Support Program

La educación realizada a los beneficiarios del Programa Nacional de Asistencia Ventilatoria No Invasiva en domicilio, tiene como objetivo guiar en el proceso de enfermedad a los niños, cuidadores informales y familia, empoderando su accionar a través del desarrollo de habilidades y la entrega de herramientas para ejecutar acciones de autocuidado que les permitan manejar aspectos generales de la enfermedad, cuidados específicos derivados de la asistencia ventilatoria y plan de contingencia frente a alteraciones en su estado basal o falla de equipos, todo esto basado en un diagnostico de las necesidades educativas y considerando caso a caso la metodología a utilizar teniendo presente la valoración individual, familiar y social.