Practice variation among Dutch paediatricians in palivizumab prescription rates: the importance of parental counselling approach.

AIM: To investigate differences in palivizumab prescription rates between Dutch paediatricians, and the role of parent counselling in this practice variation. METHODS: A retrospective chart review of premature infants <32 weeks of gestation, aged less than six months at the start of the winter season, born between January 2012 and July 2014, in three secondary hospital-based paediatric practices in the Netherlands. RESULTS: We included 208 patients, 133 (64%) of whom received palivizumab. Prescription rates varied considerably between the three hospitals: 8% (6/64), 89% (32/36) and 99% (97/98). A noticeable difference in the way parents were counselled about palivizumab was the use of the number needed to treat (NNT). In the hospital with the lowest prescription rate (8%), an NNT of 20 to prevent one hospitalisation was explicitly discussed with parents. Bronchiolitis-related hospital admissions occurred in 11.3% of patients receiving palivizumab compared to 20.0% in nonimmunised infants (p = 0.086). CONCLUSION: Considerable practice variation exists among Dutch paediatricians regarding palivizumab prescription rates. The counselling method seems to play an important role. Presenting palivizumab prophylaxis as a preference-sensitive decision, combined with the explicit use and explanation of an NNT, leads many parents to refrain from respiratory syncytial virus immunisation.

Treatment, outcomes and costs of asthma exacerbations in Chilean children: a prospective multicenter observational study.

OBJECTIVE: To describe potential regional variations in therapies for severe asthma exacerbations in Chilean children and estimate the associated health expenditures. METHODS: Observational prospective cohort study in 14 hospitals over a one-year period. Children five years of age or older were eligible for inclusion. Days with oxygen supply and pharmacological treatments received were recorded from the clinical chart. A basic asthma hospitalization basket was defined in order to estimate the average hospitalization cost for a single patient. Six months after discharge, new visits to the Emergency Room (ER), use of systemic corticosteroids and adherence to the controller treatment were evaluated. RESULTS: 396 patients were enrolled. Patients from the public health system and from the north zone received significantly more days of oxygen, systemic corticosteroids and antibiotics. Great heterogeneity in antibiotic use among the participating hospitals was found, from 0 to 92.3% (ICC 0.34, 95% CI 0.16-0.52). The use of aminophylline, magnesium sulfate and ketamine varied from 0 to 36.4% between the different Pediatric Intensive Care Units (ICC 0.353, 95% CI 0.010-0.608). The average cost per inpatient was of $1910 USD. 290 patients (73.2%) completed the follow-up six months after discharge. 76 patients (26.2%) were not receiving any controller treatment and nearly a fourth had new ER visits and use of systemic corticosteroids due to new asthma exacerbations. CONCLUSIONS: Considerable practice variation in asthma exacerbations treatment was found among the participating hospitals, highlighting the poor outcome of many patients after hospital discharge, with an important health cost.

Healthcare reimbursement costs of children with type 1 diabetes in the Netherlands, a observational nationwide study (Young Dudes-4).

BACKGROUND: Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children. Studies on costs related to T1DM are scarce and focused primarily on the costs directly related to diabetes. We aimed to investigate both the overall healthcare costs and the more specific costs related to the management of diabetes. METHODS: This is a retrospective and observational, nationwide cohort study of all Dutch children (aged 0-18 years) with T1DM. Data were collected from the national registry for healthcare reimbursement, in which all Dutch insurance companies combine their reimbursement data. In the Netherlands for all Dutch citizens health care is covered by law and all children are treated by hospital-based paediatricians. RESULTS: We analysed 6710 children distributed over 81 hospitals: 475 children in 6 university hospitals and 6235 children in 75 general hospitals. Total reimbursement for all children with T1DM over the period 2009 to 2011 was € 167,494,732 corresponding to an annual mean of € 55,831,577 of total costs and € 8326 euros per child. When comparing small (between 26 and 54 patients), medium (57-84 patients) and large (88-248 patients) general hospitals, costs per patient were highest in the hospitals with the highest number of T1DM patients. The costs for devices, secondary care and pharmaceutics had most impact on total expenditures. Over the study period, there was a slight decrease in per person costs. CONCLUSION: The overall health expenditure of a child with T1DM is more than € 8000 per patient per annum. Given the move towards more device-intensive multidisciplinary care for these patients, the costs of treating T1DM in children are likely to increase further in the coming years.

Hospitalizations for asthma exacerbation in Chilean children: A multicenter observational study.

BACKGROUND: Asthma hospitalization rates in Chilean children have increased in the last 14 years, but little is known about the factors associated with this. OBJECTIVE: Describe clinical characteristics of children hospitalized for asthma exacerbation. METHODS: Observational prospective cohort study in 14 hospitals. Over a one-year period, children five years of age or older hospitalized with asthma exacerbation were eligible for inclusion. Parents completed an online questionnaire with questions on demographic information, about asthma, indoor environmental contaminant exposure, comorbidities and beliefs about disease and treatment. Disease control was assessed by the Asthma Control Test. Inhalation technique was observed using a checklist. RESULTS: 396 patients were enrolled. 168 children did not have an established diagnosis of asthma. Only 188 used at least one controller treatment at the time of hospitalization. 208 parents said they believed their child had asthma only when they had an exacerbation and 97 correctly identified inhaled corticosteroids as anti-inflammatory treatment. 342 patients used the wrong spacer and 73 correctly performed all steps of the checklist. CONCLUSIONS: Almost half of the patients were not diagnosed with asthma at the time of hospitalization despite having a medical history suggestive of the disease. In the remaining patients with an established diagnosis of asthma potentially modifiable factors like bad adherence to treatment and poor inhalation technique were found. Implementing a nationwide asthma program including continued medical education for the correct diagnosis and follow up of these patients and asthma education for patients and caregivers is needed to reduce asthma hospitalization rates in Chilean children.

Pathotyping and antibiotic resistance of porcine enterovirulent Escherichia coli strains from Switzerland (2014-2015).

INTRODUCTION: A total of 131 porcine E. coli were isolated in 2014 and 2015 from the gut of 115 pigs raised in Switzerland and suffering from diarrhea. The isolates were tested for antibiotic resistance, serotypes, virulence factors and genetic diversity. Serotypes were assigned by agglutination tests and virulence genes were identified by polymerase chain reaction (PCR). Antibiotic resistance profile was determined by the measurement of the MIC of 14 antibiotics and by the detection of the corresponding genes using microarray and PCR approaches. Genetic diversity was determined by repetitive palindromic PCR (rep- PCR) revealing a heterogenous population. Half of the E. coli isolates possessing virulence factors could not be assigned to any of the 19 serotypes tested, but contained toxins and adhesins similarly to the sero-typable E. coli isolates. The most prevalent E. coli serotypes found were K88ac (18%), O139:K82 (6%), O141:K85ac (5%), O108:K`V189` (5%), O119:K`V113` (3%) and O157:K`V17` (2%). The combination of toxins EAST-1, STb and LT-I and adhesin F4 characterizing ETEC was the most frequent. The shigatoxin Stx2e (STEC) and intimin Eae (EPEC) were also detected, but less frequently. Seventy percent of the isolates were resistant to at least one antibiotic and 29% were resistant to more than 3 antibiotics. Isolates exhibited resistance to tetracycline (50%) associated to resistance genes tet(A), tet(B) and tet(C), sulfamethoxazole (49%) [sul1, sul2 and sul3], trimethoprim (34%) [dfr], nalidixic acid (29%), ampicillin (26%) [blaTEM-1], gentamicin (17%) [aac(3) -IIc, aac(3) -IVa and aac(3) -VIa], chloramphenicol (17%) [catAI and catAIII], and ciprofloxacin (8%) [mutations in GyrA (S83L) and ParC (S80I)]. All isolates were susceptible to 3rd generation cephalosporins, carbapenems, colistin and tigecycline. Pathogenic E. coli isolates from pigs in Switzerland could frequently not be assigned to a known serotype even if they contained diarrhea-causing virulence factors. They also harbor resistance mechanisms conferring resistance to antibiotics which are commonly used in pig husbandry, except for colistin. A careful identification of the causative agent and antibiotic susceptibility testing is highly recommended for targeted therapy and prudent use of antibiotics.

INTRODUCTION: Dans la cadre de cette étude, on a isolé, durant les années 2014 et 2015, 131 souches d'E.coli provenant des intestins de porcs suisses souffrant de diarrhée. Ces souches ont été testées quant à leurs résistances aux antibiotiques; en outre on a déterminé leurs sérotypes, leurs facteurs de virulence et leur diversité génétique. L'attribution des isolats d'E.coli aux divers sérogroupes a été réalisée au moyen d'une séro-agglutination et les facteurs de virulence ont été déterminés par PCR. Les profils de résistance aux antibiotiques ont été déterminés par la mesure des concentrations inhibitrices minimales de 14 antibiotiques. Les gènes qui y étaient associés ont été identifiés par puces à ADN et PCR. La diversité génétique a été déterminée au moyen de PCR répétitives palindromiques (rep PCR). La moitié des isolats d'E.coli qui possédaient des facteurs de virulence n'ont pas pu être classés dans un des 19 sérotypes testés, bien qu'ils aient possédé les mêmes toxines et adhésines que les isolats qu'il a été possible de typiser. Les sérotypes les plus fréquemment trouvés étaient (18%), O139:K82 (6%), O141:K85ac (5%), O108:K`V189` (5%), O119:K`V113` (3%) et O157:K`V17` (2%). La combinaison des toxines EAST-1, STb et LT-I et de l'adhésine F4, qui est caractéristique pour les E.coli entérotoxiques (ETEC), a été le plus fréquemment trouvée. La shigatoxine Stx2e (STEC) et l'Intimin Eae (EPEC) étaient par contre plutôt rares. Les résultats des rep PCR montraient une population hétérogène. 70% des isolats présentaient une résistance face à au moins un antibiotique et 29% étaient résistants à plus de 3 antibiotiques. Les isolats montraient des résistances vis-à-vis de la tétracycline (50%) associée avec les gènes de résistance tet(A), tet(B) et tet(C), du sulfaméthoxazole (49%) [sul1, sul2 et sul3], du trimethoprime (34%) [dfr], de l'acide nalidixique (29%), de l'ampicilline (26%) [blaTEM-1], de la gentamicine (17%) [aac(3) -IIc, aac(3) -IVa et aac(3) -VIa], du chloramphenicol (17%) [catAI and catAIII] et de la ciprofloxacine (8%) [mutations dans GyrA (S83L) et ParC (S80I)]. Tous les isolats étaient sensibles aux céphalosporines de troisième génération, au carbapénèmes, à la colistine et à la tigecycline. Les E.coli pathogènes des porcs en Suisse n'ont souvent pas pu être attribués aux sérogroupes connus, bien qu'ils possèdent les facteurs de virulence causant la diarrhée. En outre on a découvert divers mécanismes de résistance contre des antibiotiques qui sont régulièrement utilisés dans la production porcine. En conséquence, une identification rigoureuse et soignée des germes responsables de maladie et un testage de la sensibilité avant traitement est de première importance.

Biological effects of inhaled nitrogen dioxide in healthy human subjects.

PURPOSE: Several epidemiological studies indicate that inhaled nitrogen dioxide (NO2) at low concentrations have been statistically associated with adverse health effects. However, these results are not reflected by exposure studies in humans. The aim of the study was to assess the acute functional and cellular responses to different NO2 concentrations in healthy human subjects with various techniques. METHODS: Twenty-five subjects were exposed for 3 h to NO2 concentrations 0, 0.1, 0.5, and 1.5 ppm in a randomized crossover study design during 4 consecutive weeks. In each subject, lung function, diffusion capacity and exhaled nitric oxide were measured and inflammation markers were assessed in blood, nasal secretions, induced sputum and exhaled breath condensate. RESULTS: From all lung function indices under consideration, only intrathoracic gas volume was borderline significantly increased after 0.5 ppm (p = 0.048) compared to 0.1 ppm NO2. Regarding the cellular effect parameters, the macrophage concentration in induced sputum decreased with increasing NO2 concentration, although these changes were only borderline significant (p = 0.05). CONCLUSION: These results do not suggest a considerable acute adverse response in human subjects after 3 h of exposure to NO2 in the NO2 concentration range investigated in this study.

Double-blind food challenges in children in general paediatric practice: useful and safe, but not without pitfalls.

OBJECTIVE: To describe results of double-blind placebo-controlled food challenges (DBPCFC) with cow's milk, hen's egg, soy, peanut and hazelnut in general paediatric practice. METHODS: Food challenges were performed between January 2006 and June 2011, in children 0-18 years of age, on two half-day hospital admissions with a one-week interval. Tests were performed in a double-blind fashion following a standardised protocol with validated recipes. RESULTS: Overall, 234 food challenges were performed in 209 children: 160 with cow's milk, 35 with peanut, 21 with hen's egg, 11 with hazelnuts, and 7 with soy. In two thirds of the cases, the DBPCFC was negative (cow's milk: 57.5%; peanut: 40.0%; hen's egg: 66.7%, hazelnut: 90.9%, soy: 100%). The only patient characteristic significantly associated with a positive DBPCFC was the presence of symptoms from three different organ systems (p=0.007). Serious systemic allergic reactions with wheeze or anaphylaxis occurred in only two children (0.9%). Symptoms were recorded on 29.3% of placebo days. In 30/137 children with a negative test (22%), symptoms returned when reintroducing the allergen into the diet, mostly (66.7%) transient. Of the 85 tests regarded as positive by the attending physician, 19 (22.4%) did not meet predefined criteria for a positive test. This was particularly common with non-specific symptoms. CONCLUSION: A DBPCFC can be safely performed in a general hospital for a range of food allergens. The test result is negative in most cases except for peanut. Non-specific symptoms may hamper the interpretation of the DBPCFC, increasing the risk of a false-positive result.

Exposure of healthy subjects with emissions from a gas metal arc welding process: part 1--exposure technique and external exposure.

BACKGROUND: Studies concerning welding fume-related adverse health effects in welders are hampered by the heterogeneity of workplace situations, resulting in complex and non-standardized exposure conditions. METHODS: In order to carry out welding fume exposure studies under controlled and standardized conditions, the Aachen Workplace Simulation Laboratory was developed. This laboratory consists of an emission room, in which welding fume is produced, and an exposure room in which human subjects are exposed to these fumes. Both rooms are connected by a ventilation system which allows the welding fume concentration to be regulated. Particle mass concentration was measured with a TEOM microbalance and the particle number-size distribution using a Grimm SMPS device. RESULTS: In a study, which is the subject of this paper, it has been shown that welding fume concentration can easily be regulated between 1 and about 3 mg m(-3). The chosen concentration can be kept constant for more than 8 h. However, transport of the particles from the emission room into the exposure room leads to a change in particle size distribution, which is probably due to coagulation of the fraction of smallest particles. CONCLUSION: The Aachen Workplace Simulation Laboratory is suitable for controlled exposure studies with human subjects.

Exposure of healthy subjects with emissions from a gas metal arc welding process: part 3--biological effect markers and lung function.

BACKGROUND: Metal active gas welding (MAG) is a widely-used welding technique resulting in high emissions of welding fume particles. This study investigated whether short-term exposure to these fume particles results in changes in lung function and early stages of inflammatory reactions. METHODS: Twelve healthy, young male subjects were exposed to MAG fumes for 6 h with three different exposure concentrations in a three-fold cross-over study design. Exposure was performed in the "Aachen Workplace Simulation Laboratory" under controlled conditions with constant fume concentration. Fume concentrations were 0, 1, and 2.5 mg m(-3) in randomized order. Before and after each exposure, spirometry, and impulse oscillometry were performed and breath condensate samples were collected in order to quantify inflammatory markers like Nitrate, Nitrite, Nitrotyrosine, Hydroxyprolin and Malondialdehyde. RESULTS: A significant dependency on the exposure concentration could not be established for any of the endpoint parameters. CONCLUSION: In healthy, young subjects neither changes in spirometry nor changes in inflammatory markers measured in exhaled breath condensate could be detected after short-term exposure.

Parent misperception of control in childhood/adolescent asthma: the Room to Breathe survey.

The aim of our study was to determine how often asthma control is achieved in children and adolescents, and how asthma affects parents' and children's daily lives. Interviews, including the childhood asthma control test (C-ACT), were conducted with 1,284 parents of asthmatic children (aged 4-15 yrs), as well as with the children themselves (aged 8-15 yrs; n=943), in Canada, Greece, Hungary, the Netherlands, South Africa and the UK. Parents reported mild asthma attacks at least weekly in 11% of children, and serious attacks (requiring oral corticosteroids or hospitalisation) at least annually in 35%. Although 73% of parents described their child's asthma as mild or intermittent, 40% of children/adolescents had C-ACT scores ≤ 19, indicating inadequate control, and only 14.7% achieved complete Global Initiative for Asthma (GINA)-defined control and just 9.2% achieved Scottish Intercollegiate Guidelines Network (SIGN)/British Thoracic Society (BTS)-defined control. Guideline-defined asthma control was significantly less common than well-controlled asthma using the C-ACT (p<0.001). Asthma restricted the child's activities in 39% of families and caused lifestyle changes in 70%. Complete asthma control is uncommon in children worldwide. Guideline-defined control measures appear to be more stringent than those defined by C-ACT or families. Overall, parents underestimate their child's asthma severity and overestimate asthma control. This is a major potential barrier to successful asthma treatment in children.

Facilitators and barriers to a nationwide implementation of competency-based postgraduate medical curricula: a qualitative study.

BACKGROUND: Postgraduate medical education (PGME) curricula are being redesigned across the western world. AIM: This study examined the implementation process (what works where and why) of new competency-based PGME curricula and relevant factors influencing this process. METHODS: In a nationwide project (2006-2010) in the Netherlands, competency-based PGME curricula were implemented for residents in Pediatrics and Obstetrics & Gynecology. The authors conducted 25 semi-structured interviews and used a multi-level theoretical framework to guide coding. RESULTS: The implementation process proved to be highly dynamic, non-linear, and influenced by many factors. These could be divided into attributes of the innovations/adopters, the implementation process, and the organization. The context determined the speed, quality, and direction of the process and how a factor affected the process. CONCLUSIONS: We identified specific features of PGME innovation: the challenge of implementing other competencies than that of the medical expert; the importance of regional implementation strategies and educational support; the balance between training and patient care; and the need for regional inter-organizational networks of hospitals. The authors recommend: design the curriculum with the needs of the users in mind; facilitate knowledge sharing; organize educational support; translate the national curriculum to the local workplace; and promote regional inter-organizational networks between hospitals.

[Mills' syndrome]. / Sindrom Millsa.

Mills' syndrome is an idiopathic, slowly progressive ascending spastic hemiparesis. Some authors consider it as a unilateral variant of progressive lateral sclerosis. Due to the rarity of the disease and the slow clinical course, this article presents a clinical case and discusses the diagnostic criteria for the syndrome.

Performance of biomarkers SMRP, CA125, and CYFRA 21-1 as potential tumor markers for malignant mesothelioma and lung cancer in a cohort of workers formerly exposed to asbestos.

The aim of the study is to examine the cancer-predictive values of SMRP (soluble mesothelin-related peptides), CA125, and CYFRA21-1 as potential tumor markers for lung cancer and malignant mesothelioma in a cohort of workers formerly exposed to asbestos. A voluntary surveillance program has been established for German workers with former asbestos exposure. A subgroup of 626 subjects with a mean age of 63 years (range 53-70 years) at baseline was enrolled in an extended health examination program with high-resolution computer tomography (HRCT) of the chest and blood drawing between 1993 and 1997. Serum concentrations of SMRP, CA125, and CYFRA21-1 were measured in archived serum samples in 2005 and 2006. A mortality follow-up was conducted through 2007. So far, 12 cases with lung cancer and 20 cases with malignant mesothelioma have been observed in this cohort. The average time between sample collection and diagnosis was 4.7 years. Analyzed biomarkers showed low sensitivities (5-25%) and positive predictive values (4-30%) for both cancer sites. Marker combinations resulted in sensitivities between 5 and 50% and positive predictive values ranging from 3 to 14%. Even in those cases, where biomarker concentrations were available within 36 months before diagnosis, no trend for increasing biomarker levels was observed. The analyzed tumor markers were characterized by high specificities, but low sensitivities. SMRP, CA125, and CYFRA21-1 alone or in combination were less suitable to serve as predictors for the diagnosis of lung cancer or malignant mesothelioma. However, a prospective study with annual sampling might reveal a better predictive value of these markers.

Internal exposure of hairdressers to permanent hair dyes: a biomonitoring study using urinary aromatic diamines as biomarkers of exposure.

PURPOSE: To determine whether the occupational exposure of hairdressers to permanent hair dyes can be quantified by the use of biological monitoring of urinary aromatic diamines as one of the main constituents and to compare these levels to those recently determined in persons after personal application of hair dyes. METHODS: Fifty-two hairdressers (40 female and 12 male) from 16 hairdresser salons in and around the city of Aachen took part in this field study. Subjects were asked to document all operations associated with possible exposure to permanent hair dyes like mixing colour, application of colour, washing after dyeing, and cutting of freshly coloured hair. Excretion of aromatic diamines 2,5-toluylene diamine (2,5-TDA) and p-phenylene diamine (p-PDA) as main constituents of commercially available hair dyes was measured in urine samples using a highly specific and accurate GC/MS-method. Urine samples were taken at 5 points of time during the work week: pre-shift before the start of the work week, pre- and post-shift on the third day of the work week and finally pre- and post-shift on the last day of a work week in order to meet different workloads and possible accumulative effects over the week. Nineteen persons matched for age served as a control group and gave spot urine samples. RESULTS: Although the levels were generally low, we could determine a significantly higher internal exposure to 2,5-TDA in hairdressers (medians ranged from <0.2 µg/g creatinine up to 1.7 µg/g creatinine at various sampling times, with a maximum of 155.8 µg/g creatinine) compared to the control group (median <0.2 µg/g creatinine, maximum 3.33 µg/g creatinine). At the same time, p-PDA was detectable only in selected cases in the group of hairdressers but not in the control group. Overall, there was neither an intra-shift effect seen nor an effect across the work week. There was also no significant difference in urinary excretion of participants who reported wearing protective gloves compared to those who reported not wearing protective gloves. CONCLUSION: The internal exposure to aromatic diamines in hairdressers using permanent hair dyes can be determined using biological monitoring. The extent of exposure is low compared to subjects after personal application of hair dyes, who excreted more than 200 times higher amounts of aromatic diamines. This slight work-related exposure might be reduced by the strict adherence to the use of suitable gloves as well as long-sleeved clothing.

[Lambert-Eaton myasthenic syndrome]. / Síndrome miasteniforme de Lambert-Eaton.

INTRODUCTION: Early diagnosis based on clinical findings, neurophysiological studies and serum antibody titres allows early initiation of symptomatic treatment and oncological screening. Reports of patients with LEMS in Latin America are scarce. AIM: This article aims to describe the characteristics of patients with LEMS from a private centre in Buenos Aires, Argentina, and to compare them with those of other series that have been published. PATIENTS AND METHODS: The medical records of 13 patients with LEMS with clinical findings, compatible electromyogram and/or positive antibodies were reviewed. Follow-up was performed until associated neoplasia was ruled out or confirmed according to the recommended algorithms. RESULTS: Four patients were diagnosed with T-LEMS, two of them with small-cell lung carcinoma. Of the nine patients with NT-LEMS, five had a DELTA-P score of 3 and 4. Nine patients presented with the classic clinical triad from the onset of the disease. All patients had electromyogram findings compatible with presynaptic neuromuscular plaque defect. Of the total, 70% improved symptomatically with pyridostigmine. CONCLUSIONS: The clinical findings, together with compatible neurophysiological studies, are sufficient for the diagnosis of LEMS. The relationship between the DELTA-P score and the risk of small-cell lung carcinoma could not be replicated. Symptomatic treatment with pyridostigmine represents an effective therapeutic alternative.

TITLE: Síndrome miasteniforme de Lambert-Eaton.Introducción. El síndrome miasteniforme de Lambert-Eaton (LEMS) es una patología paraneoplásica (T-LEMS) o idiopática autoinmunitaria (NT-LEMS) ocasionada por autoanticuerpos contra los canales de calcio dependientes del voltaje presinápticos de la unión neuromuscular. El 60% de los T-LEMS se asocia a carcinoma de pulmón de células pequeñas. Una puntuación Dutch-English LEMS Tumor Association Prediction (DELTA-P) mayor de 3 denota un riesgo elevado de dicha asociación. El diagnóstico precoz fundado en los hallazgos clínicos, estudios neurofisiológicos y dosificación de títulos de anticuerpos en el suero permite iniciar tempranamente el tratamiento sintomático y la búsqueda oncológica. Son escasos los informes de pacientes con LEMS en Latinoamérica. Objetivo. Describir las características de pacientes con LEMS de un centro privado de Buenos Aires, Argentina, y compararlas con las de otras series publicadas. Pacientes y métodos. Se revisaron historias clínicas de 13 pacientes con LEMS con hallazgos clínicos, electromiograma compatible y/o anticuerpos positivos. Se realizó seguimiento hasta descartar o confirmar una neoplasia asociada de acuerdo con los algoritmos recomendados. Resultados. Cuatro pacientes presentaron diagnóstico de T-LEMS, dos de ellos con carcinoma de pulmón de células pequeñas. De los nueve pacientes con NT-LEMS, cinco presentaron una puntuación DELTA-P de 3 y 4. Nueve pacientes presentaron la tríada clínica clásica desde el inicio. Todos los pacientes presentaron en el electromiograma hallazgos compatibles con defecto de placa neuromuscular presináptico. El 70% mejoró sintomáticamente con piridostigmina. Conclusiones. Los hallazgos clínicos, junto con los estudios neurofisiológicos compatibles, resultan suficientes para el diagnóstico de LEMS. No pudo replicarse la relación entre puntuación DELTA-P y riesgo de carcinoma de pulmón de células pequeñas. El tratamiento sintomático con piridostigmina representa una alternativa terapéutica eficaz.

Vasculitic Peripheral Neuropathy, Differences Between Systemic and Non-Systemic Etiologies: A Case Series and Biopsy Report.

BACKGROUND: Vasculitic peripheral neuropathy (VPN) is caused by vessel inflammation leading to peripheral nerve injury of acute-to-subacute onset. When VPN occurs in the context of systemic disease it is classified as Systemic Vasculitic Neuropathy (SVN) and as Non-Systemic Vasculitic Neuropathy (NSVN) when restricted to the nerves. OBJECTIVE: This study aimed to compare the clinical characteristics, biopsy findings and disease outcome in patients with VPN. METHODS: Clinical records of adult patients with VPN diagnosed at our institution between June-2002 and June-2019 were retrospectively reviewed. Demographic characteristics, clinical manifestations, nerve conduction studies, nerve biopsies, treatment and clinical evolution were analyzed in all patients with at least 6 months follow-up. RESULTS: Twenty-five patients with VPN were included (SVN, n = 10; NSVN, n = 15). No significant differences in demographic or clinical features were found between groups. The median delay between symptom onset and nerve biopsy was significantly longer in NSVN patients (10 vs 5.5 months, p = 0.009). Erythrocyte sedimentation rate (ESR) values over 20 mm/h were significantly more common in SVN patients (100% vs. 60%, p = 0.024). Nerve biopsies showed active lesions more frequently in treatment-naive patients compared to those who had received at least 2 weeks of corticosteroids (92% vs 38%; p = 0.03), with a higher proportion of definite VPN cases (92 vs 46%; p = 0.04). CONCLUSIONS: Although the clinical manifestations are similar, ESR is an important tool to help distinguish between both conditions. Early nerve biopsy in untreated patients increases diagnostic accuracy, avoiding misdiagnosis.

Comorbidities of asthma during childhood: possibly important, yet poorly studied.

Asthma in adults is associated with comorbidities such as obesity, gastro-oesophageal reflux, dysfunctional breathing and mental disorders. Herein, we provide an overview of the current state of evidence on these comorbidities in childhood asthma. The prevalence, known mechanisms and possible treatment options for each comorbid condition will be discussed. Obesity is an increasing health problem in children, but its relationship with asthma remains unclear. Allergic rhinitis is a very common comorbidity in asthma, both in children and in adults, but its effect on childhood asthma severity has not been studied. The prevalence and treatment options of dysfunctional breathing, a known comorbidity in adult asthma, have not yet been studied in paediatric asthma. Food allergies appear to cause more severe reactions in patients with asthma. Depressive disorders are more prevalent in childhood asthma than in healthy children, but seem to be poorly recognised and treated in children. Although gastro-oesophageal reflux is commonly thought to be a comorbid disease complicating asthma, it remains uncertain whether treatment improves asthma control. In conclusion, knowledge of asthma comorbidities in childhood is sparse. Further studies are urgently needed to identify the prevalence, and, more importantly, the effects of these comorbidities and their treatment on the degree of asthma control in children.

Paediatrics in Vienna.

The aim of this article is to describe the paediatric highlights from the 2009 European Respiratory Society Annual Congress in Vienna, Austria. The best abstracts from the seven groups of the Paediatric Assembly (asthma and allergy, respiratory epidemiology, cystic fibrosis, respiratory physiology, respiratory infections and immunology, neonatology and paediatric intensive care, and bronchology) are presented alongside findings from the current literature.

Respiratory medicines for children: current evidence, unlicensed use and research priorities.

This European Respiratory Society task force has reviewed the evidence for paediatric medicines in respiratory disease occurring in adults and children. We describe off-licence use, research priorities and ongoing studies. Off-licence and off-label prescribing in children is widespread and potentially harmful. Research areas in asthma include novel formulations and regimens, and individualised prescribing. In cystic fibrosis, future studies will focus on screened infants and robust outcome measures are needed. Other areas include new enzyme and antibiotic formulations and the basic defect. Research into pneumonia should include evaluation of new antibacterials and regimens, rapid diagnostic tests and, in pleural infection, antibiotic penetration, fibrinolytics and surveillance. In uncommon conditions, such as primary ciliary dyskinesia, congenital pulmonary abnormalities or neuromuscular disorders, drugs indicated for other conditions (e.g. dornase alfa) are commonly used and trials are needed. In neuromuscular disorders, the beta-agonists may enhance muscle strength and are in need of evaluation. Studies of antibiotic prophylaxis, immunoglobulin and antifungal drugs are needed in immune deficiency. We hope that this summary of the evidence for respiratory medicines in children, highlighting gaps and research priorities, will be useful for the pharmaceutical industry, the paediatric committee of the European Medicines Agency, academic investigators and the lay public.

Can sensitization to aeroallergens disappear over time in children with allergic disease?

BACKGROUND: Remittance of aeroallergen sensitization has been shown in population-based studies, but there is a common perception that sensitization to aeroallergens rarely if ever disappears in children with allergic disease. METHODS: We retrospectively reviewed all specific IgE tests carried out in children aged 0-18 years at our hospital laboratory over a 14-year period. Of 3115 children sensitized to one or more aeroallergens, 244 (7.8%) were retested after a mean (SD) period of 45 (28) months at their physician's discretion. RESULTS: Disappearance of sensitization to individual aeroallergens did occur, with remittance rates ranging from 3.1% for house dust mite to 17.5% for cat. However, complete remittance of aeroallergen sensitization was found in only one subject. In up to 35% of cases, remittance of sensitization was offset by the appearance of one or more new aeroallergen sensitizations. Remittance was only observed in children sensitized to multiple allergens (with a median of 3 aeroallergen sensitizations), and their median degree of sensitization was low (median 2.1 kU/L). CONCLUSION: Aeroallergen sensitization can disappear in children with allergic disease, but only in polysensitized individuals. Complete remittance of sensitization to aeroallergens is rare in symptomatic children.