Predictors of a positive oral food challenge to cow's milk in children sensitized to cow's milk

INTRODUCTION AND OBJECTIVES: The diagnosis of IgE-mediated cow's milk allergy (CMA) is often based on clinical history and on specific IgE levels and/or skin-prick tests (SPT), both of which are sensitive but not specific. The gold standard, oral food challenge (OFC), is expensive and time-consuming and involves a risk of severe allergic reactions. This study aimed to determine the value of specific IgEs, ratios of specific IgEs for cow's milk and its components to total IgE, and wheal size on SPT for predicting a positive OFC for CMA. MATERIAL AND METHODS: We retrospectively studied 72 patients [median age, four years; age range 0.75-15 years] sensitized to cow's milk who underwent OFCs to milk. predictive variables between patients with positive and negative OFCs were compared. Receiver operator characteristic (ROC) curves were uses to assess variables' discriminatory capacity and Youden's index to determine the best cut-offs for predicting CMA. RESULTS: The OFC was positive in 39 (54%) patients. Wheal size on SPT and all specific IgEs and specific-to-total IgE ratios were significantly different between patients with positive OFCs and those with negative OFCs (p < 0.001). The variable with the greatest area under the ROC curve was casein-specific IgE (0.98), followed by β-lactoglobulin-specific IgE (0.923), casein-specific-to-total-IgE ratio (0.919), and α-lactalbumin-specific IgE (0.908). Casein-specific IgE ≥ 0.95kU/L yielded 88.9% sensitivity and 90.9% specificity. CONCLUSIONS: In our center, casein-specific IgE > 0.95kU/L can obviate an OFC to cow's milk for the diagnosis of CMA in patients sensitized to cow's milk with a compatible history

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Predictors of a positive oral food challenge to cow's milk in children sensitized to cow's milk.

INTRODUCTION AND OBJECTIVES: The diagnosis of IgE-mediated cow's milk allergy (CMA) is often based on clinical history and on specific IgE levels and/or skin-prick tests (SPT), both of which are sensitive but not specific. The gold standard, oral food challenge (OFC), is expensive and time-consuming and involves a risk of severe allergic reactions. This study aimed to determine the value of specific IgEs, ratios of specific IgEs for cow's milk and its components to total IgE, and wheal size on SPT for predicting a positive OFC for CMA. MATERIAL AND METHODS: We retrospectively studied 72 patients [median age, four years; age range 0.75-15 years] sensitized to cow's milk who underwent OFCs to milk. predictive variables between patients with positive and negative OFCs were compared. Receiver operator characteristic (ROC) curves were uses to assess variables' discriminatory capacity and Youden's index to determine the best cut-offs for predicting CMA. RESULTS: The OFC was positive in 39 (54%) patients. Wheal size on SPT and all specific IgEs and specific-to-total IgE ratios were significantly different between patients with positive OFCs and those with negative OFCs (p<0.001). The variable with the greatest area under the ROC curve was casein-specific IgE (0.98), followed by ß-lactoglobulin-specific IgE (0.923), casein-specific-to-total-IgE ratio (0.919), and α-lactalbumin-specific IgE (0.908). Casein-specific IgE ≥0.95kU/L yielded 88.9% sensitivity and 90.9% specificity. CONCLUSIONS: In our center, casein-specific IgE >0.95kU/L can obviate an OFC to cow's milk for the diagnosis of CMA in patients sensitized to cow's milk with a compatible history.

Lactante con distrés respiratorio en invierno. Más allá de las bronquiolitis / Infant with respiratory disters in winter. Beyond bronchiolitis

La dificultad respiratoria en el lactante engloba varias entidades clínicas. Aunque en invierno la más frecuente es la bronquiolitis, no debemos olvidar, entre ellas, las malformaciones pulmonares congénitas (MPC). Se presenta el caso de un lactante de 6 semanas de vida que acudió a Urgencias en invierno por un cuadro de dificultad respiratoria en contexto catarral. Se realizó un diagnóstico inicial de bronquiolitis, pero posteriormente se alcanzó el diagnóstico correcto de enfisema lobar congénito (ELC). Se publica este caso para hacer hincapié en la importancia de revisar un diagnóstico con enfoque analítico, especialmente cuando el curso clínico no es típico. También nos debe servir para recordar que, a pesar de la mejora del diagnóstico prenatal, el diagnóstico de una MPC puede ser en el periodo neonatal o incluso más tardío. Por lo tanto, las MPC deben considerarse en el diagnóstico diferencial de síntomas respiratorios en un niño

Respiratory distress in the infant encompasses several clinical entities. Although bronchiolitis is the most frequent in winter, we should not forget congenital pulmonary malformations (CPMs). We are reporting a case of 6-week-old male presented to pediatric emergency ward during the winter period with respiratory distress in context of a cold. An initial diagnosis of bronchiolitis was made. The authors explore how the correct diagnosis of congenital lobar emphysema (CLE) was reached. This case emphasizes the importance of reviewing a diagnosis through an analytical approach, particularly in non-typical clinical courses. It should also help us to remember that despite the improvement of prenatal diagnosis, we also have CPMs diagnosis in the neonatal period or even later. Therefore, CPMs need to be considered in the differential diagnosis of respiratory symptoms in a child

Measurement of percentage dose at the surface for a 6 MV photon beam.

AIM: To evaluate if a radiochromic film (RF) Gafchromic EBT3 is suitable for surface dose measurements of radiotherapy treatments performed with a 6 MV linear accelerator. Two aspects of RF were analyzed, beam energy dependence and surface dose determination. BACKGROUND: The measurements done at the surface or near the radiation source are done without charged electronic equilibrium and also have contribution of electron contamination. The detectors used for these measurements should not alter the dose to the target. To counteract these dosimetric problems it is proposed to do the measurements with radiochromic films which are thin detectors and have tissue equivalent properties. MATERIALS AND METHODS: The measurements were done using a Novalis linear accelerator (LINAC) with nominal energy of 6 MV. To determine the surface dose, the total scatter factors (TSF) of three different field sizes were measured in a water phantom at 5 cm depth. Energy dependence of EBT3 was studied at three different depths, using a solid water phantom. The surface measurements were done with the RF for the same field sizes of the TSF measurements. The value of the percentage depth dose was calculated normalizing the doses measured in the RF with the LINAC output, at 5 cm depth, and the TSF. RESULTS: The radiochromic films showed almost energy independence, the differences between the curves are 1.7% and 1.8% for the 1.5 cm and 10 cm depth, respectively. The percentage depth doses values at the surface measured for the 10 cm × 10 cm, 5 cm × 5 cm and 1 cm × 1 cm were 26.1 ± 1.3%, 21.3 ± 2.4% and 20.2 ± 2.6%, respectively. CONCLUSIONS: The RF-EBT3 seems to be a detector suitable for measurements of the dose at the surface. This suggests that RF-EBT3 films might be good candidates as detectors for in vivo dosimetry.

Bronchoalveolar lavage to evaluate new pulmonary infiltrates in allogeneic hematopoietic stem cell transplant recipients: impact on antimicrobial optimization.

BACKGROUND: Pulmonary complications cause significant morbidity and mortality after allogeneic hematopoietic stem cell transplant (AHSCT). Bronchoscopy with targeted bronchoalveolar lavage (BAL) is often used in AHSCT patients with suspected lower respiratory tract infection (LRTI) to help guide management. AIM: To evaluate how positive BAL results change antimicrobial management of AHSCT recipients with suspected LRTI. METHODS: We performed a retrospective review of BAL results from January 2014 to July 2016 for 54 AHSCT recipients. A positive BAL was determined by culture, multiplex polymerase chain reaction (PCR), Aspergillus galactomannan antigen (AGA), and cytology. FINDINGS: BAL was positive for infectious etiologies in 63%, and antimicrobials were adjusted in 48/54 (89%) of patients. Antibacterial escalation was predicted by a positive BAL bacterial culture (OR 7.61, P=0.017). Antibiotic de-escalation was more likely with an elevated AGA (OR 3.86, P=0.035). Antiviral initiation was more likely with positive BAL multiplex PCR (OR 17.33, P=0.010). Antifungals were more likely to be escalated or changed with an elevated AGA (OR 4.33, P=0.020). The patients with a negative BAL were more likely to be started on steroids (OR 0.19, P= 0.043). CONCLUSIONS: BAL was helpful to determine the etiology of pulmonary complications and optimize antimicrobials. The addition of AGA and multiplex PCR to standard BAL significantly impacted de-escalating antibiotics and adjusting antifungals to provide adequate coverage. The association with an elevated AGA with antibacterial de-escalation highlights a new role for BAL in antimicrobial optimization.

Assessment of an image-guided neurosurgery system using a head phantom.

OBJECTIVE: To acknowledge the challenges and limitations of image-guided neurosurgery systems, we compared the application accuracy of two different image registration methods for one commercial system. (VectorVision, BrainLab, Germany). METHODS: We used an anthropomorphic head phantom for radiosurgery and a custom built add-on to simulate surgical targets inside the brain during an image-guided neurosurgery. We used two image registration methods, fiducial registration using attachable surface markers for computed tomography (CT) and surface registration using infrared laser face scanning. After simulation, we calculated the three-dimensional (3D) distance between the predicted position of a target, and its actual position using a registered pointer and an infrared camera. Deviations were measured for both superficial fiducial markers and internal surgical targets by five different users. RESULTS: Deviations from the location of fiducial markers after each registration method were 2.15 ± 0.93 mm after CT surface marker registration and 1.25 ± 0.64 mm after infrared face scanner registration. The mean target registration errors were 2.95 ± 1.4 mm using fiducial registration and 2.90 ± 1.3 mm using surface registration. The largest deviations (6.2 mm) were found for the targets in the skull base and posterior cranial fossa. Fiducial deviations and target registration errors were statistically uncorrelated. The total application accuracy was 4.87 ± 0.97 mm after CT surface marker registration and 4.14 ± 0.64 mm after infrared face scanner registration. CONCLUSIONS: Despite others have reported differences, we did not find significant variations between both registration methods for the target registration error, although application accuracy was slightly better after surface face registration. Superficial registration errors, but not the target registration error, can be routinely evaluated in the operating room. Since both errors were uncorrelated, surgeons may neglect the achievable accuracy of the procedure. The described method is recommended to assess application accuracy in the operating room.

Stereotactic radiosurgery for pediatric patients with intracranial arteriovenous malformations: variables that may affect obliteration time and probability.

INTRODUCTION: It is debatable whether pediatric patients diagnosed with arteriovenous malformations (AVMs) should be treated as adults. Several indexes to classify AVMs have been proposed in the literature, and most try to predict the outcome for each specific treatment. The indexes differ in the variables considered, but they are all based in adult populations. In this study, we analyzed the variables that influence the obliteration time and probability of occurrence in a Mexican pediatric population diagnosed with an AVM and treated with stereotactic radiosurgery (SRS). METHODS: We analyzed 45 pediatric patients (<18 years) with a minimum follow-up of 10 months and a maximum of 112 months. We used logistic regression analysis and Kaplan-Meier curves to evaluate the influence of age, AVM volume, prescribed dose, minimum dose, maximum dose, time of follow-up, sex, previous hemorrhage, venous drainage, treatment technique, previous treatment and location. We also evaluated the predictive power of the following indexes: Spetzler-Martin, RBAS, or K index dose deviation. RESULTS: We found that the radiation technique used may influence the obliteration occurrence (p=0.057). The data suggests that circular arcs are a more efficient treatment technique than dynamic arcs. However, no relationship of dose or volume with treatment technique could be found. Obliteration was also dependent on follow-up time and after three years of follow-up, the obliteration probability decreases (p=0.024). According to Kaplan-Meier analysis, the nidus obliteration time was related with the location according to the Spetzler-Martin index. If the nidus was located in a non-eloquent region, there was a tendency of a shorter obliteration time (p=0.071). CONCLUSION: None of the previously proposed indexes for adults predict obliteration in this pediatric population. Treatment technique, eloquence and follow up time were the only variables that showed influence in obliteration. Since the highest probability of obliteration occurs during the first three years, if the nidus has not been obliterated after this time then another treatment option could be considered.

Tratamientos respiratorios en la enfermedad neuromuscular / Respiratory treatments in neuromuscular disease

Revisadas en un artículo anterior la fisiopatología respiratoria del enfermo neuromuscular (ENM), así como su evaluación clínica y las principales complicaciones causantes de su deterioro pulmonar, en el presente artículo se describen los tratamientos respiratorios necesarios para preservar la función pulmonar del ENM durante el mayor tiempo posible, así como en situaciones especiales (infecciones respiratorias, cirugía de escoliosis, etc.). Se hace especial hincapié en la utilidad de la ventilación no invasiva cuyo uso está cambiando la historia natural de muchas de estas enfermedades. La prolongación de la vida en estos niños permite que lleguen a las unidades de neumología de adultos para proseguir su atención. La transición desde la pediatría debe ser un proceso activo, progresivo en el tiempo y poco estresante para el paciente ante la adaptación a ese nuevo entorno, manteniendo siempre una atención multidisciplinar

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained

Effect of dosimeter type for commissioning small photon beams on calculated dose distribution in stereotactic radiosurgery.

PURPOSE: To assess the impact of the detector used to commission small photon beams on the calculated dose distribution in stereotactic radiosurgery (SRS). METHODS: In this study, six types of detectors were used to characterize small photon beams: three diodes [a silicon stereotactic field diode SFD, a silicon diode SRS, and a silicon diode E], an ionization chamber CC01, and two types of radiochromic film models EBT and EBT2. These detectors were used to characterize circular collimated beams that were generated by a Novalis linear accelerator. This study was conducted in two parts. First, the following dosimetric data, which are of particular interest in SRS, were compared for the different detectors: the total scatter factor (TSF), the tissue phantom ratios (TPRs), and the off-axis ratios (OARs). Second, the commissioned data sets were incorporated into the treatment planning system (TPS) to compare the calculated dose distributions and the dose volume histograms (DVHs) that were obtained using the different detectors. RESULTS: The TSFs data measured by all of the detectors were in good agreement with each other within the respective statistical uncertainties: two exceptions, where the data were systematically below those obtained for the other detectors, were the CC01 results for all of the circular collimators and the EBT2 film results for circular collimators with diameters below 10.0 mm. The OAR results obtained for all of the detectors were in excellent agreement for all of the circular collimators. This observation was supported by the gamma-index test. The largest difference in the TPR data was found for the 4.0 mm circular collimator, followed by the 10.0 and 20.0 mm circular collimators. The results for the calculated dose distributions showed that all of the detectors passed the gamma-index test at 100% for the 3 mm/3% criteria. The aforementioned observation was true regardless of the size of the calculation grid for all of the circular collimators. Finally, the dose volume histogram results were independent of the size of the calculation grid used. CONCLUSIONS: The results of this study showed that all of the studied detectors produced similar commissioned data sets for the TPS dose calculations. However, this result only validated the dose distribution calculation in the TPS and could not be used to assess the dose delivery to the target in which the TFS data were used to calculate the monitor units (the TFS data were not used in the TPS dose distribution calculation). Therefore, this study could not be used to determine the most accurate detector commissioning data set; however, all of the detectors exhibited superior performance for the relative dosimetry of small photon beams.

[Respiratory treatments in neuromuscular disease]. / Tratamientos respiratorios en la enfermedad neuromuscular.

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained.

Comparative analysis of several detectors for the measurement of radiation transmission and leakage from a multileaf collimator.

The multileaf collimator (MLC) is the standard device used to shape radiation beams for 3-d conformal and intensity-modulated radiation therapy (IMRT). Due to the inherent properties of MLC, there is a small amount of radiation transmitted through the leaves, called radiation transmission (RT). Accurate measurements of this radiation are required to commission and validate IMRT-capable treatment planning systems because this radiation may impact the dosimetry of IMRT-calculated dose distributions. This work compares several detectors in the measurement of RT for a micro-multileaf collimation system. The results show that there are statistically significant differences in the measured RT values between detectors from 3.5 to 12.5% for the same MLC model and less than 0.2% relative to the isocentre dose for an open reference field. However, although small in magnitude, these differences may impact the dosimetry of IMRT treatment planning by up to 1.78 Gy to the healthy tissue surrounding the target for a treatment of 60 Gy in 30 fractions. By the later, these differences must be included as a source of uncertainty in IMRT dose delivery. Also, it must be established which detector offers the most reliable results in the measurement of the RT by using Monte Carlo simulation methods.

Derrame pleural paraneumónico / Parapneumonic pleural effusion

La neumonía es la causa más frecuente de derrame pleural en niños. En los últimos años se han observado cambios epidemiológicos con un aumento de la prevalencia de complicaciones y de ingresos por derrame pleural, así como cambios en la etiología (gérmenes y serotipos), pudiendo estar relacionados con el uso más racional de antibióticos y los cambios en la estrategia vacuna. No hay evidencias en Pediatría para algunas de las recomendaciones sobre manejo del derrame pelural paraneumónico. Es por ello que realizamos esta revisión, basándose en las recomendaciones de la Sociedad Española de Neumología Pediátrica y la evidencia científica actual. El tratamiento deberá basarse en el empleo adecuado y precoz de antibioterapia endovenosa. El uso de técnicas complementarias, como la colocación de drenaje pleural (con o sin fibrinolíticos), la realización de toracoscopia y toracotomía, dependerá de la presencia de complicaciones y del estadio evolutivo del derrame (AU)

Pneumonia is the most frequent cause of pleural effusion in children. In recent years, changes in the epidemiological pattern have been observed, with an increase of complications and rate of admissions. Microbiological changes have been also described, such as types of bacteria and serotypes implicated, which can be related to different antibiotic policy and immunization schedule. No conclusive guidelines have been published for pediatric population regarding the management of parapneumonic pleural effusion. Therefore, we reviewed this topic based on Sociedad Española de Neumología Pediátrica (Spanish Society of Pediatric Pulmonology) recommendations and a review of the existing literature. Treatment should be based on early diagnosis and proper intravenous antibiotic use. Pleural effusion management includes different procedures such as pleural drainage (with or without fibirnolytics), thoracoscopy and thoracotomy, depending on the presence of complications and the evolutive stage (AU)

Recomendaciones previas al vuelo y a viajes con exposición a altitud en pacientes con patología respiratoria / Recommendations for management of patients with lung disease planning a flight or high altitude travel

Cada año un gran número de niños viajan en avión y se desplazan a lugares con altitud significativa. La mayoría de estos viajes se producen sin incidentes reseñables. Debido a los numerosos cambios socioeconómicos recientes, también ha aumentado la cantidad de pacientes con patología cardiopulmonar previa que realizan este tipo de desplazamientos. Los cambios ambientales en estos entornos, en especial la hipoxia, puede conllevar un riesgo de sucesos adversos importantes. El pediatra debe de conocer las patologías susceptibles de complicaciones en altitud, así como los estudios previos necesarios y las recomendaciones de prevención y tratamiento de las complicaciones en estas circunstancias. El Grupo de Trabajo de Técnicas de la Sociedad Española de Neumología Pediátrica se propuso la elaboración de un documento que revisara la literatura publicada sobre el tema, estableciendo unas recomendaciones de utilidad en el manejo de estos pacientes (AU)

Every year a large number of children travel by plane and/or to places with high altitudes. Most of these journeys occur without incident. Immigration and recent socioeconomic changes have also increased the number of patients with cardiopulmonary disease who travel. Environmental changes in these places, especially lower oxygen, can lead to a risk of significant adverse events. The paediatrician must be aware of the diseases that are susceptible to complications, as well as the necessary preliminary studies and recommendations for treatment in these circumstances. The Techniques Group of the Spanish Society of Paediatric Chest Diseases undertook to design a document reviewing the literature on the subject, providing some useful recommendations in the management of these patients (AU)

[Recommendations for management of patients with lung disease planning a flight or high altitude travel]. / Recomendaciones previas al vuelo y a viajes con exposición a altitud en pacientes con patología respiratoria.

Every year a large number of children travel by plane and/or to places with high altitudes. Most of these journeys occur without incident. Immigration and recent socioeconomic changes have also increased the number of patients with cardiopulmonary disease who travel. Environmental changes in these places, especially lower oxygen, can lead to a risk of significant adverse events. The paediatrician must be aware of the diseases that are susceptible to complications, as well as the necessary preliminary studies and recommendations for treatment in these circumstances. The Techniques Group of the Spanish Society of Paediatric Chest Diseases undertook to design a document reviewing the literature on the subject, providing some useful recommendations in the management of these patients.

Pulmón y altitud. Recomendaciones para el viaje en altitud / No disponible

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Guía de diagnóstico y tratamiento del asma de control difícil en el niño / Diagnosis and treatment guidelines for difficult-to-control asthma in children

Los niños con asma de control difícil (ACD) requieren frecuentes consultas, reciben complejos regímenes de tratamiento y, a menudo, requieren ingresos en el hospital. Su frecuencia es escasa, y abarca no más del 5% de la población asmática. El ACD requiere un diagnóstico de certeza, por lo que se tendrán que descartar causas de falso ACD, y es necesario hacer un diagnóstico diferencial con factores de enfermedad sobreañadida, medioambientales, psicológicos, y analizar causas que determinen una baja adherencia al tratamiento. Ante un verdadero ACD, el estudio de la inflamación (óxido nítrico exhalado, esputo inducido, lavado broncoalveolar y biopsia bronquial), la función pulmonar y la clínica nos pueden permitir clasificar el ACD en diversos fenotipos que nos facilitarán la toma de decisiones terapéuticas (AU)

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier (AU)

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]. / Guía de diagnóstico y tratamiento del asma de control difícil en el niño.

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

Hipertensión pulmonar asociada al VIH en una adolescente con infección de transmisión vertical / Pulmonary hypertension associated with vertically transmitted HIV infection in an adolescent girl

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