Aprendizaje interprofesional en los internados de las carreras de la salud del Hospital Josefina Martínez / Interprofessional learning of interns at Josefina Martínez Hospital

Introducción: las dinámicas de atención en salud requieren que los profesionales que componen el equipo de salud trabajen en for-ma colaborativa. Sin embargo, durante su formación, las oportunidades de aprendizaje con otras disciplinas son escasas. Se reportan los resultados del primer proyecto para promover el aprendizaje interprofesional en los internos que rotan por el Hospital Josefina Martínez. Método: de marzo a julio 2018, se realizó un taller constituido por dos sesiones, en cada rotación de internado. Participaron internos de cinco carreras en forma conjunta (kinesiología, odontología, nutrición, fonoaudiología y terapia ocupacional). Se adaptó la encuesta de disposición al aprendizaje interprofesional, para ser aplicada antes y después de cada taller. Se calcularon las medianas, rangos intercuartílicos (Q1; Q3y se compararon los puntajes mediante test de Wilcoxon. Resultados: hubo una disposición positiva inicial al aprendizaje interprofesional, con mejoría significativa después de los talleres en todas las dimensiones de la encuesta: Trabajo en equipo y colaboración (<0,001), trabajo centrado en el paciente (<0,001), y sentido de identidad profesional (<0,05). La diferencia del puntaje global de la encuesta también fue significativa (<0,001). Conclusiones: se demostró un cambio favorable y significativo en las respuestas de los internos después de los talleres, en todas las dimensiones de la encuesta. En los comentarios, destacaron la relevancia de aprender con estudiantes de otras carreras, describiendo que aumentó su conocimiento sobre éstas y reforzando el impacto que dicha integración tiene en mejorar la atención y resolución de problemas en salud.

Background: The dynamics of health care require that the health professionals work collaboratively; however, during their training, learning opportunities with other disciplines are infrequent. The results of the first project to promote interprofessional learning in the clinical internship at Hospital Josefina Martínez are reported. Methods: From March to July 2018, two workshops for each internship rotation were carried. Students from fivecareers participated together (Kinesiology, Dentistry, Nutrition, Speech Therapy, and Occupa-tional Therapy). The readiness to interprofessional scale survey was adapted, to be applied before and after each workshop. Medians, interquartile range (Q1; Q3) were calculated, and the Wilcoxon test was used to compare the results. Results: There was an initial po-sitive readiness for interprofessional learning, with a significant improvement in all the dimensions of the survey, after the workshops: Teamwork and collaboration (<.001), patient-centered care (<.001), and sense of professional identity (<.05). The differences from the overall survey were also significant (<0.001). Conclusions: A favorable change was demonstrated in the responses of the students after the workshops, overalland in all the dimensions of the survey. In the comments, the students highlighted the relevance of learning with students from other careers, describing that it increased their knowledge about different professions and strengthening the impact that this integration has in improving attention and resolving health problems.

Calidad de vida en niños y adolescentes con Atrofia Muscular Espinal / Quality of life in children and adolescents with Spinal Muscular Atrophy

INTRODUCCIÓN: La calidad de vida (CV) es un aspecto fundamental del tratamiento en pacientes con Atrofia Muscular Espinal (AME). Existe escasa información a nivel local e internacional. OBJETIVO: Caracterizar la CV en una muestra de niños y adolescentes chilenos con AME. SUJETOS Y MÉTODO: Estudio observacional, transversal. Se aplicó un cuestionario y el módulo neuromuscular 3.0 de la encuesta PedsQLtm, a padres de niños con AME de 2-18 años. Ésta consta de 3 ámbitos: Enfermedad, Comunicación y Familia. Se consideró el puntaje >60 como CV buena, 30-60 regular y <30, deficiente. Se utilizó el programa MINITAB-17®, considerando significativo p ≤ 0,05. RESULTADOS: Se reclutaron 38 pacientes, con edad mediana 8 años (2-18), 52,7% hombres, y 17 (44,7%) AME I. Todos con confirmación genética. El puntaje total fue 51,92 ± 17, correspondiendo 31% a CV buena, 55% regular y 14% baja. En AME I fue 46,5 ± 15,2 y en AME II-III, 56,3 ± 17,4 (p = 0,071). Para el ámbito de Enfermedad fue 53,83 ± 18,1, de Familia 48,6 ± 23,14 y Comunicación 33,3 (RIC: 0,0-83,33). En este último, tuvieron mayor puntaje los pacientes con AME II o III, los mayores de 6 años, los con menor apoyo ventilatorio y los residentes en regiones. Sin embargo, en el análisis multivariado solamente el tipo de AME fue significativo, explicando 40,9% de la variación del puntaje del área de comunicación. Conclusiones: En esta muestra de pacientes con AME, la calidad de vida fue regular a buena en la mayoría. El área más baja fue la de Comunicación, con mayor puntaje en aquellos con mayor capacidad motora funcional.

INTRODUCTION: Quality of life (QoL) is a key aspect in the treatment of patients with Spinal Muscular Atrophy (SMA). International information regarding QoL in SMA is scarce, and is not available in our country. OBJECTIVE: To characterize QoL in a sample of Chilean children and adolescents with SMA. SUBJECTS AND METHOD: Observational, cross-sectional study. A general questionnaire and the PedsQLTM 3.0 Neuromuscular Module Inventory were applied to parents of children with SMA aged 2 to 18 years. It has three areas: Disease, Communication, and Family. A score >60 was considered as good QoL, 30-60 as regular, and <30 as low. MINITAB-17® software was used, considering significant a p <0.05 value. RESULTS: We recruited 38 patients, with median age 8 years (2-18), 52.63% were male, and 17 (44.7%) with SMA I. All had genetic confirmation. The total score of QoL was 51.92 ± 17, representing 31% good, 55% regular, and 14% low. Regarding SMA I, it was 46.5 ± 15.2 and SMA II-III, 56.3 ± 17.4 (p = 0.071). Concerning the area of Disease, it was 53.83 ± 18.1, Family 48.6 ± 23.14, and Communication 33.3 (IQR: 0.0; 83.33). In this last area, children with SMA II-III, older than 6 years., with non-invasive ventilatory support, or living out of the metropolitan area had hig her scores, however, in multivariate analysis, only SMA type was significant, which explained 40,9% of the variation in the communication area score. CONCLUSIONS: In this sample of SMA pediatric patients, the QoL was regular or good in most of them. The lowest area was communication, with a higher score in those children with higher motor function.

Lactancia materna, obesidad y síndrome metabólico en la edad escolar / Breastfeeding, obesity and metabolic syndrome at school age

INTRODUCCIÓN: La lactancia materna (LM) puede ser un factor protector de la obesidad y sus complicaciones metabólicas. OBJETIVO: Determinar la asociación entre el antecedente de amamantamiento y la presencia de obesidad, síndrome metabólico (SM) y resistencia insulínica (RI). PACIENTES Y MÉTODOS: Estudio transversal en 20 escuelas públicas de Santiago, Chile. Se evaluó antropometría, presión arterial, perfil lipídico, glicemia, insulinemia e índice HOMA. Los padres respondieron una encuesta sobre el antecedente de LM. Se definió SM según criterios de Cook y RI como HOMA > percentil 90. RESULTADOS: Se recibieron 3.278 encuestas válidas. La edad promedio fue de 11,4 ± 1 años, siendo 52,3% mujeres. La mayoría (98,2%) recibió LM, con una prevalencia de 15,9% de obesidad versus 18,6% en los que no la recibieron (p = 0,039). Hubo una tendencia no significativa a que SM y sus componentes, excepto RI, fueran más prevalentes en el grupo no amamantado. Los escolares que recibieron LM por 3-6 meses presentaron una menor prevalencia de obesidad y de algunos componentes de SM que los que recibieron menor tiempo o no la recibieron; el efecto fue inverso cuando la LM se prolongó por más de 9 meses. CONCLUSIONES: La prevalencia de obesidad fue mayor en los escolares que no fueron amamantados. Durante el primer semestre, la LM de mayor duración se asoció a menor prevalencia de obesidad y complicaciones metabólicas.

INTRODUCTION: Breastfeeding (BF) can be a protective factor against obesity and its associated metabolic complications. OBJECTIVE: To determine the association between breastfeeding history and present obesity, metabolic syndrome (MS) and insulin resistance (IR). PATIENTS AND METHODS: Cross-sectio nal study in 20 public schools in Santiago, Chile. Anthropometry and blood pressure were assessed. Blood lipids, glucose, insulin and HOMA index were measured in a fast blood sample. Parents answe red a survey on BF. MS was defined according to Cook's criteria and IR as HOMA > 90th percentile. Parents answered a survey about the antecedent of breastfeeding. Chi2 and Fischer tests were used (SSPS). RESULTS: 3,278 surveys were valid. Average age: 11.4 ± 1 years, 52.3% were female. Most of them (98.2%) were breasted, with a 15.9% prevalence of obesity versus 18.6% in the group that was not breastfed (p = 0.039). There was a non-significant trend of higher prevalence in MS and its components (except IR) in the non-breastfed group. The group breastfed from three to six months had a lower prevalence of obesity and MS components than the 0 to 3 months group ; the effect was the opposite when BF lsted longer than nine months. CONCLUSIONS: The prevalence of obesity was higher in children that did not received breastfeeding. A longer breastfeeding time during the first semester of life was associated with lower prevalence of obesity and metabolic complications.

La presión arterial es un importante marcador de ateroesclerosis subclínica en niños / Association of carotid intima media thickness with blood pressure and HDL cholesterol in children

Background: Cardiovascular risk factors must be controlled since childhood. Aim: To assess the association of carotid intima media thickness (CIMT) with the components of the metabolic syndrome in Children. Material and Methods: Cross sectional assessment of 299 children aged 11.5 ± 0.9years (58% women) with and without metabolic syndrome components. Anthropometric parameters and blood pressure were measured and a blood sample was obtained to measure blood glucose and lipids. CIMT was measured using high resolution ultrasound. Results: Ninety three percent of children were post puberal, 64% were overweight and 25% had metabolic syndrome. Mean and maximum CIMT correlated with systolic blood pressure (r = 0.21 and 0.21 respectively p < 0.01). Children with a CIMTover the 75th percentile had higher blood pressure and lower HDL cholesterol. A stepwise logistic regression accepted both variables as predictors of CIMT with odds ratios for mean CIMT of 1.46 (1.19-1-79) and 0.81 (0.7-0.94) perfive units of change, respectively. Conclusions: In this group of children systolic blood pressure and HDL cholesterol are associated to CIMT.

Insulinemia e índice HOMA en niños y adolescentes chilenos / Normal plasma insulin and HOMA values among chilean children and adolescents

Background: Plasma insulin and HOMA (homeostasis model assessment) index, used to determine insulin resistance, do not have local standard values for children and adolescents in Chile. Aim: To establish the normal reference intervals for insulin and HOMA in children and adolescents aged 10-15 years, according to sex and puberal maturation. Material and Methods: A cross-sectional study of 2,153 children and adolescents from Puente Alto County was performed, during 2009 and 2010. Anthropometry and self-report of puberal maturation were assessed. Fasting glucose (hexoquinase) and insulin blood levels (chemiluminiscence), were determined and HOMA index was calculated. Percentile distributions of these variables were calculated. Results: The reference group included only subjects with normal body mass index and fasting blood glucose (n = 1,192). Girls had higher insulin and HOMA values than boys (12.5 ± 6.0 and 9.1 ± 4.9 μϋ/mL (p < 0.01) and 2.7 ± 1.4 and 2.1 ± 1,1 (p < 0.01), respectively). Subjects with Tanner I and IIpuberal stages had lower insulin and HOMA mean values than subjects with Tanner III and IV (9.0 ± 4.3 and 12.5 ± 6.2μϋ/ml (p < 0.01) and2.0 ± 1 and2.8 ± 1.4 (p < 0.01), respectively). Conclusions: The 90th percentile of insulin and HOMA distributions according to sex and maturation, was selected as the upper cut-off point to identify individuals with insulin resistance. HOMA cutoff point for Tanner I and II boys was 3.2, for Tanner I and II girls was 4.1, for Tanner III and IV boys was 4.2 and for Tanner III and IV girls was 5.0.

Evolución nutricional y función pulmonar en niños y adolescentes chilenos con fibrosis quística / Growth and pulmonary function in Chilean children and adolescents with cystic fibrosis

Background: Nutrition influences morbidity and mortality in patients with cystic fibrosis (CF), affecting their lung function. Aim: To characterize the nutritional status of a group of CF patients and to analyze its evolution and relationship to lung function. Patients and Methods: A retrospective cohort of CF children and adolescents attemded in our institution for 15 years, was analyzed. Age and form of presentation, mutation, weight and stature (measured annually at least), microbial colonization and forced expiratory volume in the first second (FEV1) were registered. Results: We gathered information about 33 patients, 64 percent males, diagnosed at 23.8 ± 45.6 months old (range 1-216), 85 percent had a genetic study (10 children had one or more Df508 alleles) and 94 percent had pancreatic insufficiency. In their last visit they were 13.0 ± 5.8 years old, their body mass index z-score (BMIz) was -0.25 ± 1.2 and their FEV1 was 80.4 ± 28.6 percent. According to BMI: 73 percent were eutrophic, 18 percent undernourished and 9 percent were overweight. According to weight/ for height index (WH), the figures for eutrophy, undernutrition and overweight were 70, 6 and 24 percent, respectively. Only 12 percent had short stature. Those with P. aeruginosa infection had lower BMI. There was a positive correlation between FEV1 and BMIz (+0.46, p = 0.02), but not with WH. During follow-up, there was a gradual deterioration of weight, height, and BMIz after 10-12 years of age and an overall gradual FEV1 decrease. Conclusions: The prevalence of malnutrition in these patients with CF is high; undernutrition is higher if defined by BMIz and unlike WH, correlates to lung function. Nutritional deterioration starts before adolescence.

Strain y strain rate auricular izquierdo evaluado por speckle tracking está relacionado a PCR ultrasensible en adolescentes obesos / Speckle tracking derived left atrial strain and strain rate are related to high sensitive C reactive protein in obese adolescents

Introducción: La obesidad y el síndrome metabólico están asociados a un tamaño auricular izquierdo (AI) aumentado y mayor riesgo cardiovascular. El strain y strain rate longitudinal determinado por speckle tracking son herramientas novedosas en la evaluación de la función AI. Objetivo: evaluar el strain y strain rate AI en adolescentes obesos y su relación con biomarcadores de riesgo cardiovascular. Métodos: se incluyeron adolescentes consecutivos con un z-índice de masa corporal (z-IMC) > 1 en ritmo sinusal sin otra comorbilidad y un grupo control pareado por edad y sexo. Se registraron las características clínicas y ecocardiográficas con evaluación del strain AI: onda s (LASs), onda a (LASa) y strain rate AI: onda s (LASRs), onda a (LASRa) por speckle tracking. Se midió adiponectina y PCR ultrasensible. Se utilizó t-Student, chi-cuadrado y correlación de Pearson. Resultados: Se incluyeron 15 sujetos por grupo de edad promedio de 13 años, 47 por ciento hombres sin diferencia entre ambos grupos. Los pacientes con sobrepeso presentaron significativamente mayores niveles de PCR us respecto del grupo control, 0,5 +/- 0,1 mg/L vs 1,4 +/- 0,3, p = 0,04 y menores de LASs (44 +/- 1,8 vs 32 +/-1,1 por ciento;p<0,01), LASa ( -1,7 +/- 0,3 vs -0,7 +/- 0,3 1/s; p<0,01), LASRs ( 1,7 +/- 0,07 vs 1,3 +/- 0,03 por ciento; p<0,01), LASRa (-1,8 +/- 0,1 vs -1,2 +/-0,08 1/s;p<0,01). En el grupo con sobrepeso se encontró una correlación negativa significativa entre LASs, LASRs y PCR ultrasensible (R: -0,62; p < 0,01 y R: -0,58: p = 0,02 respectivamente). Conclusiones: El strain y strain rate AI se encuentran reducidos en adolescentes obesos y estos parámetros de función AI se correlacionan con un estado inflamatorio aumentado. La importancia clínica de estos hallazgos requieren mayor investigación.

Background: Obesity is an emerging problem in children worldwide and a well-known risk factor for atrial fibrillation (AF) in adulthood. There is some evidence that functional and structural changes responsible for the development of AF may arise early in life. Left atrial (LA) strain and strain rate, assessed by speckle tracking, are indices of LA function and correlate with the development of AF. Objective: To evaluate LA strain and strain rate in obese adolescents and their correlation with plasma levels of high sensitive C reactive protein (hs-CRP) and adiponec-tin, two markers of cardiovascular risk. Methods: Fifteen obese adolescents, age 13 +/- 0.2 yr, body mass index (BMI)-z-score 1.9 +/- 0.16 and 15 lean controls were recruited. All patients underwent transtho-racic echocardiography with evaluation of LA strain and strain rate: a wave (LASa and LASRa) and s wave (LASs and LASRs). Plasma levels of hs-CRP was determined. Student's t test, chi-square and Pearson correlation were used for statistical analysis. Results: Obese patients had a lower LASs (44 +/- 1.8 vs 32 +/- 1.1 percent, p < 0.01), LASa (- 1.7 ± 0.3 vs - 0.7 +/- 0.1, p < 0.01), LASRs (1.7 +/- 0.07 vs 1.3 +/- 0.03, p < 0.01) and LASRa (- 1.8 +/- 0.1 vs - 1.2 +/- 0.08, p < 0.01). Plasma hs-CRP levels were significantly higher in the obese group and displayed a significant inverse correlation with LASs (r: - 0.62, p < 0.01) and LASRs (r: - 0.58, p = 0.02). Conclusion: Obese adolescents had an impaired LA function compared to age-matched lean subjects, which correlated with an increased inflammatory state. It is likely that LA dysfunction may predispose to AF later in life.

Enfermedades neurológicas en niños: un adecuado apoyo nutricional / Children with neurological diseases: An adequate nutritional support

Nutritional support plays an important role in multidisciplinary treatment of children with neurological diseases. It influences their morbi-mortality and the principal objective is to attain the growth that allows them to express their full functional potential ensuring a better quality of life. An adequate nutritional support is individualized, secure, as physiological as possible, adapted to the co-morbidity of the patient, complete in all nutrients contribution, monitorized and dynamic; it is modified according to the general condition and disease evolution.

El cuidado nutricional forma parte del manejo integral y multidisciplinario de los niños con enfermedades neurológicas. Influye en la morbimortalidad de estos pacientes y persigue alcanzar un crecimiento que permita expresar sus capacidades, mejorando su calidad de vida. un adecuado apoyo nutricional es individualizado, seguro, lo más fisiológico posible, adaptado a la co-morbilidad del paciente, integral en su aporte de nutrientes, es monitorizado y por último, dinámico, es decir, modificado según la condición general y evolución de la enfermedad neurológica de base.

Índice cintura estatura y agregación de componentes cardiometabólicos en niños y adolescentes de Santiago / Waist height ratio, ultrasensitive c reactive protein and metabolic syndrome in children

Background: Waist to height ratio and ultrasensitive C-reactive protein are predictors of the presence of the metabolic syndrome in children. Aim: To determine the proportional risk of metabolic syndrome component clustering in children, using waist to height ratio and ultrasensitive C-reactive protein. Material and Methods: Anthropometric measures, blood pressure, fasting serum lipid profle, blood glucose and ultrasensitive C-reactive protein were determined in 209 children aged 11.5 ± 2 years (50 percent females). The presence of the metabolic syndrome as a function of waist to height ratio and C-reactive protein was modeled using logistic regression equations. The risk of clustering one, two or more components of the metabolic syndrome was calculated. Results: Metabolic syndrome was present in 5 percent of all children and 18 percent of those that were obese. The cut off points for waist to hip ratio and ultrasensitive C-reactive protein were 0.55 and 0.61 mg/L, respectively. For each 0.01 increment in waist to height ratio, the odds ratio of increasing one component of the metabolic syndrome was 1.2 (1.15-1.25) or 15 to 25 percent. The odds ratio for log-transformed ultrasensitive C-reactive protein was 1.62 (1.26-2.09). Excluding waist circumference, the odds ratio of adding one or more components of the metabolic syndrome was 1.05 (1.01-1.09) per 0.01 increment in waist to height ratio, but the odds ratio for C-reactive protein was no longer significant. Conclusions: Waist to height ratio and ultrasensitive C-reactive protein predict the risk of clustering components of the metabolic syndrome in these children.

Validación de un puntaje de riesgo cardiovascular en niños españoles aplicado a una población de escolares de Santiago de Chile / Association between a cardiovascular risk score and early markers of atherosclerotic disease in Chilean children

Background: A cardiovascular risk score for children, that includes traditional risk factors, obesity, sedentary habits and a family history of cardiovascular disease, has been recently proposed by Spanish researchers. Aim: To apply this score in school age children in Santiago de Chile and correlate its results with markers of subclinical atherosclerotic disease. Material and Methods: Retrospective analysis of data obtained from 209 children, aged 11.5 ± 2 years, studied between 2005 and 2006. Weight, height, blood pressure, ultrasound measurement of carotid intimamedia thickness and fow mediated dilatation of brachial artery and ultrasensible C reactive protein (us PCR) were measured. The Spanish cardiovascular risk score was calculated and correlated with ultrasound parameters and C reactive protein. Results: According to the score, 173 children (83 percent) had a low cardiovascular risk, 28 (13 percent) an intermediate risk and 8 (4 percent) a high risk. There was no association between the cardiovascular risk score and carotid intima-media thickness, fow mediated arterial dilatation and us PCR. Conclusions: No significant association was observed between the proposed cardiovascular risk score and early markers of atherosclerotic disease in this group of children.

Razón cintura estatura como predictor de riesgo cardiometabólico en niños y adolescentes / Waist-Height ratio as a predictor if cardio-metabolic risk in children

En niños, la obesidad general y visceral se asocian con mayor riesgo cardiometabólico. El aumento en la prevalencia del síndrome metabólico (SM) en niños y adolescentes empeora el riesgo cardiovascular. Necesitamos contar con nuevos marcadores que permitan predecir el SM en niños. Objetivo: Comparar índice de masa corporal (zIMC) con razón cintura estatura (RCE) como predictores de SM en niños chilenos. Método: Estudio transversal en 618 escolares, edad 10.8 +/- 1.9 años, 51.6 por ciento mujeres, 190 eutróficos, 174 sobrepeso, 254 obesos, estrato socioeconómico medio y medio bajo, área urbana de Santiago. Determinamos peso, talla, circunferencia de cintura, presión arterial, perfil lipídico y glicemia. Diagnóstico de SM basado en la presencia de > 3 criterios de Cook. El SM se modeló en función de RCE y z score IMC , con modelos de regresión logística. Se usaron curvas ROC para comparar RCE y zIMC como predictores de SM. Punto de corte según índice de YOUDEN. Resultados: La prevalencia de SM fue 15.37 por ciento. Promedio de z IMC + 1.22 +/- 0.90 y de RCE 0.52 +/-0.07. Punto de corte óptimo para SM: RCE 0.55 (sensibilidad 72 por ciento, especificidad 70 por ciento) yzIMC: 1.76 (sensibilidad 71 por ciento, especificidad 74 por ciento). Conclusión: RCE y zIMC predicen igualmente el riesgo cardiometabólico en niños y adolescentes. Dada la mayor facilidad de calcular RCE, la transforma en mejor herramienta definiendo riesgo en este grupo. El punto de corte > 0.55 sería buen predictor de SM en niños y adolescentes.

Among children both general and visceral obesity are associated with increased cardio-metabolic risk. The increasing prevalence of the metabolic syndrome (MS) in children and adolescents increases cardiovascular risk. Studies of new clinical markers which can easily and accurately predict MS in children and adolescents are needed. Aim: To compare zBMI and waist to height ratio (WHR) as predictors of MS in Chilean children. Method: We performed a crossectional study of 618 schoolchildren, age 11 +/- 2 years, 52 percent females, 190 eutrophic, 174 overweight, 254 obese, from middle and low social economic strata from the Santiago urban area. We determined weight, height, waist circumference, blood pressure and fasting lipids and glycemia. MS diagnosis was based on the presence of > 3 Cook criteria. MS was modeled in function of WHR and z score BMI, through logistic regression models. ROC curves were used to compare zBMI and WHR as predictors of MS. The cut off point by YOUDEN index was used. Results: The prevalence of MS was 15 percent. Mean zBMI was +1.22 +/- 0.90 and WHR 0.52 +/- 0.07. Cut off point for MS were: WHR 0,55 (sensitivity 72 percent, specificity 70 percent)and zBMI: 1.76 (sensitivity 71 percent, specificity 74 percent). Conclusions: Both WHR and zBMI similarly predicted cardio metabolic risk in children and adolescents. The greater feasibility of calculating WHR makes it a good tool for defining risk in this group. A cut off point >0.55 might be a good predictor of MS in children and adolescents.

Marcadores de aterosclerosis temprana y síndrome metabólico en niños / Early markers for atherosclerosis and metabolic syndrome in children

Background: The high prevalence of obesity in children favors the appearance of metabolic syndrome (MS), increasing their cardiovascular risk. Aim: To evaluate components of MS in children and to correlate them with surrogate markers of atherosclerosis andsubclinical inflammation. Material and methods: We studied 209 children aged 11.5 ± 2 years (50% girls, 30% prepuberal). Fifty percent had normal weight, 18% were overweight, 29% were obese and 3% were undernourished. A fasting blood sample was obtained to measure lipid levels,glucose, insulin, adiponectin and ultrasensitive C-reactive protein (usCRP). Subclinical atherosclerosis was evaluated using flow mediated dilatation of brachial artery (FMD) andcarotid intima-media thicknes (IMT). For diagnosis of MS we adapted Cook’s criteria. Results: Five percent of all children and 18% of those with overweight had MS. Children with more components had significantly higher fasting insulin and Homeostasis Model Assessment (HOMA) values. Clustering of MS components was also associated to higher values of usCRP and non significantly to lower adiponectin levels. We did not find differences in FMD. In obese children there was a tendency towards a higher IMT with clustering of MS components, although not significant. Conclusions: Children with overweight presented a higher risk of a clustering ofMS components, which was also associated with insulin resistance and increase in ultrasensitive C reactive protein.

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.

Proteína C-reactiva y su relación con adiposidad, factores de riesgo cardiovascular y aterosclerosis subclínica en niños sanos de la Región Metropolitana / C-reactive protein in relation to adiposity, cardiovascular risk factor and subclinical atherosclerosis in healthy children from Santiago, Chile

Introducción: La proteína C-reactiva ultrasensible (PCRus) es un marcador de riesgo (FR) emergente. En adultos, se asocia a la mayoría de los FR metabólicos, al desarrollo de diabetes y predice eventos cardiovasculares futuros. Dado que la aterosclerosis puede comenzar en la niñez, es importante conocer los niveles de este marcador y sus relaciones con los FR clásicos en la población pediátrica. Objetivo: Determinar los niveles de PCRus y establecer su relación con medidas antropométricas de adiposidad, FR tradicionales y medidas de aterosclerosis subclínica en niños de Santiago. Método: Estudio prospectivo en hijos de sujetos sanos de la zona urbana de Santiago. En todos los niños se realizó una encuesta sobre FR clásicos, se evaluó antropometría, maduración puberal y perfil lipídico, glicemia y PCR ultrasensible (Dade Behring) en muestra de sangre en ayunas. En todos se realizó además estudio de función endotelial por dilatación mediada por flujo en arteria braquial (DMF) y del grosor íntima-media carotídeo (IMT). Resultados: Se incluyeron en este análisis 88 niños (51 por ciento hombres), edad 10 +/- 2 (promedio DS) años. La PCRus del grupo fue 0.88 +/- 1.47 mg/L (mediana = 0.38 mg/L). En ambos sexos, la PCRus se correlacionó en forma directa a índice de masa corporal (IMC, expresado en puntaje z), a estimación clínica de grasa corporal: masa grasa total (MGT), grasa troncal, perímetro de cintura (PC) y a colesterol LDL (p<0.04). Los niños en el tercil superior de PCR presentaron mayor: zIMC, MGT, PC y LDL que los niños en los terciles inferiores (ver tabla). Los factores de riesgo para determinar una PCR elevada, en forma aislada, fueron: zIMC (OR=2.25 {1.25-4.04}), MGT (OR=1.09 {1.03-1.15}) y PC (OR=1.06 {1.01-1.11}). No se demostró asociación entre PCRus y DMF o IMT. Conclusión: La PCRus se asocia en forma directa a índices de adiposidad y a colesterol LDL en niños...

Background: Ultrasensitive C-reactive protein (USCRP) is an emergent cardiovascular risk factor (RF). In adults, USCRP is associated to most metabolic RF, to diabetes and future cardiovascular events. Since atherosclerosis may develop in childhood, the relation of USCRP to classic RF in children deserves attention. Aim: To correlate USCRP levels with adiposity, traditional RF and subclinical atherosclerosis in children from Santiago Methods: Children from healthy parents living in urban areas of Santiago were prospectively studied. A survey of traditional RF, anthropometric measurements, pubertal maturation, serum lipid profile, serum blood sugar level and USCRP (Dade Behring) were determined in all children in a fasting sample. Endothelial function was assessed by flow mediated vasodilation of the brachial artery (FMD) and intimal media thickness (IMT) Results: 88 children (51 percent males) aged 10 +/-2 years were studied. Mean USCRP was 0.88 mg/L(SD 1.47, median 0.38). In both gender groups USCRP was directly correlated to body mass index (BMI, z score), total body fat (TBF) , central adiposity measured by skin folds, waist circumference (WC) and LDL cholesterol (p<0.04). Children at top tercile USCRP level exhibited greater BMI, total body fat, central adiposity, WC and LDL level as compared to those in the lower USCRP tercile (Table). Independent predictors of high CRP levels were BMI (OR 2.55, 95 percent CI1.25-4.04), MGT (OR 1.09 (1.03-1.15)) and WC (OR 1.06 (1.01-1.11)). There was no association between USPCR and FMV or IMT. Conclusion: USCRP is directly associated to adiposity indices and serum LDL level in children. This study showed no association of USCRP and indices of subclinical atherosclerosis. Follow up of these children will help determine whether subclinical inflammation will predict the appearance of atherosclerosis when they reach adult age.