Determinació de l’hemoglobina en sang / Measurement of blood haemoglobin

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Neumonías recurrentes y persistentes. Manejo diagnóstico por el pediatra / Recurrent pneumonia and persistent pneumonia: diagnostic evaluation by the pediatrician

Se define como neumonía recurrente a aquella que presenta dos o más episodios diagnosticados en un año o un total de tres o más episodios. En cualquier paciente que cumpla estos criterios, está indicado iniciar un estudio etiológico. La elección de las pruebas complementarias se convierte en un reto para el clínico, dado que el diagnóstico diferencial es muy amplio. Se presenta un protocolo que pretende establecer una guía racional del manejo diagnóstico del paciente afectado por neumonías de repetición

Recurrent pneumonia is defined as two or more episodes in the same year or a lifelong total of three or more episodes. An investigation of the etiology should be carried out in any child that meets these criteria. The approach to this study represents a challenge for the physician given the wide differential diagnosis. We describe a protocol for the purpose of establishing guidelines for a rational diagnostic approach in the patient who presents recurrent pneumonia

Hypertransaminasemia in pediatric celiac disease patients and its prevalence as a diagnostic clue.

OBJECTIVES: The aims of this study were to evaluate the following: 1) the prevalence of hypertransaminasemia (HT) in a pediatric celiac disease (CD) and its relation with clinical parameters; 2) the frequency of HT as the only manifestation of pediatric CD; and 3) the evolution of HT after a gluten free diet. METHODS: A total of 114 consecutive pediatric CD patients were studied (60% with classical and 40% with atypical forms). Antiendomisyum antibodies and anti-tissue transglutaminase antibodies were determined in patients with a clinical suspicion of CD (including unexplained chronic HT), in patients at risk, and in patients with preoperative increased ALT activity for minor surgery. CD was confirmed by duodenal biopsy. At baseline, the relationship between clinical factors and aminotransferase status was univariately and multivariately assessed. After starting a gluten free diet, patients were followed up, until serological markers cleared and serum aminotransferase normalized. RESULTS: HT occurred in 32% of patients (37 of 114) at diagnosis. HT was the only manifestation of CD in five patients (4.3%). Patients with HT were younger (2.9 +/- 0.4 yr) than patients with normal aminotransferases (5.1 +/- 0.5 yr) (p = 0.007). A higher percentage of patients with classical CD tend to have abnormal aminotransferases (73%; 95% CI = 65-81%) than do patients with atypical CD (27%; 95% CI = 19-35%) (p = 0.068). Logistic regression analysis showed that only younger age was significantly associated with HT (p = 0.039; OR = 0.8; 95% CI = 0.71-0.99). Aminotransferases normalized with a gluten free diet in all 35 patients who were followed-up, either before (n = 18) or at the same time (n = 17) as serological markers cleared. CONCLUSIONS: HT is a frequent finding in pediatric CD patients and, in a substantial proportion, may be the only manifestation of CD. Thus, serological markers of CD should be introduced in the first step of the diagnostic workup of liver diseases in pediatric patients.

Antioxidant status in anorexia nervosa.

OBJECTIVE: The study of the antioxidant status in female adolescents (N = 82) with anorexia nervosa, by the measurement of erythrocyte tocopherol concentration, and the determination of activities of the main antioxidant enzymes: superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase. METHOD: Tocopherol was measured by high-performance liquid chromatography (HPLC) with ultraviolet (UV) detection, and antioxidant enzyme activities by spectrometric methods using a Cobas Fara automated centrifugal analyzer. RESULTS: Tocopherol was significantly decreased in the anorexic patients compared to reference values (p < .02). In 21% of patients, tocopherol levels were below the reference interval. Superoxide dismutase activity was significantly decreased (p < .0001), while catalase activity was increased (p < .0001). The activity of the glutathione system enzymes did not show significant differences between patients and controls. DISCUSSION: The deficient concentration of erythrocyte tocopherol together with the altered antioxidant enzyme activities suggest a certain degree of oxidative damage in anorexia nervosa owing to both factors deficient micronutrient intake and oxidative stress.

[Analytic preoperative control and serum alaninaminotransferase (ALT) activity]. / Actividad sérica alaninoaminotransferasa (ALT) y control analítico preoperatorio.

A standard model of analytical preoperative profile does not exist, so we decided to perform a wide profile. In this revision, we studied the utility of determining serum ALT activity in analytical preoperative controls, searching for the causes of its elevation in pediatric patients who would undergo minor surgery. Of the 3,750 patients analysed, 1.57% showed elevated serum ALT activity. Searching for the main cause, we found the following groups: I) patients with diseases unrelated to the surgical procedures that cause elevated serum activity; II) patients on pharmacological treatments which may produce transitory elevations of serum ALT activity, and III) patients with elevated serum ALT activity that has no evident clinical or pharmacological cause. The high incidence of patients with this abnormality justified the inclusion of serum ALT activity in the profile. We conclude that: a) the reasons for this elevation should be investigated, b) pediatricians should consider postponing surgery, and c) resumption of normal serum ALT activity should be monitored.

[Meningitis in pediatrics. Clinical and epidemiological study of 173 cases]. / Meningitis en pediatría. Estudio clínico y epidemiológico de 173 casos.

BACKGROUND: To know the incidence, clinical presentation, differential diagnosis and resistance level to antibiotics in pediatric meningitis. METHODS: 173 cases of meningitis (bacterial: 69, viral: 104) have been prospectively followed during 1988 according to a previously established clinical and laboratory protocol. RESULTS: Meningitis attack rate was 60 cases/100,000 children younger than 15 years per year (meningococcal: 25/100,000, Haemophilus: 2/100,000). Mortality was 1.4%. 40% of bacterial meningitis received previous antibiotic treatment. Sensitivity of culture, Gram stain, and direct antigen detection by latex and EIA was 79%, 61.7%, 20.5% and 34%, respectively. Bacterial and viral differential diagnosis, by the application of Boyer's score was 95% sensitive and 98% specific. Four out of six cases of Haemophilus meningitis were ampicillin and chloramphenicol resistant; 39% of meningococcus had their penicillin susceptibility decreased between 2 and 8 times, although no therapeutic failures were seen. CONCLUSIONS: Laboratory parameters might not separate bacterial and viral meningitis at early stages of illness. Gram stain is an excellent and sensitive method of bacterial detection in CSF. Moderate resistance to penicillin in meningococcus is very frequent but clinical failures are not yet present.

Adolescent medicine among pediatricians in Catalonia.

To ascertain if Catalan pediatricians were seeing adolescent patients, an anonymous self-administered questionnaire was mailed to 188 members of the Catalan Society of Pediatrics. The instrument included questions about training in adolescent medicine, type of practice, office and clinical practices pertinent to adolescents, and opinions and perceptions regarding adolescent care. Of 188 physicians, 69 (36.7%) responded. Respondents see an average of 12 patients (mean age of 16 years) in a 5-hr office day. The reported mean duration of a first visit for an adolescent was longer than for a child (39.7 +/- 15.4 min versus 33.5 +/- 11.3, respectively; p less than 0.001), but there were no differences in length of time spent for follow-up visits. Only 20% of the pediatricians had different schedules for adolescents than for children, and 16% provided a separate waiting room; 29% preferred dealing with infants, 4.3% with children, 4.3% with adolescents, and 52.2% had no preference. Most (74%) believe that the pediatrician is the physician of choice to treat adolescent patients. Major-perceived obstacles to providing comprehensive care to teens include not having different schedules or waiting rooms, confidentiality, and the patient's perception of them as a "children's doctor." One-third think that they have the skills needed to give medical advice, 14.5% that they can offer comprehensive care, 1.5% are not interested in treating adolescents, and 43.4% would like to improve their knowledge and skills.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular Epidemiology of multiply resistant Haemophilus influenzae type b in day care centers.

We studied the molecular epidemiology of multiply resistant Haemophilus influenzae type b in four day care centers after each had a case of invasive infection due to organisms resistant to four or more antibiotics. Colonization rates among 174 childhood contacts and 27 employees of the four separate day care centers were 28% in children (range, 13.5%-43.7%) and 22% (range, 18.7%-33.0%) in employees. All strains were type b, were biotype I, were type 12 by isoenzyme analysis, and harbored plasmids whose mass was 45 or 52 megadaltons. Restriction endonuclease analysis indicated that the plasmids were closely related to one another but that there were at least three distinct plasmids. The four index strains had two different outer membrane protein profiles and three distinct plasmid restriction patterns; an additional outer membrane protein profile and plasmid restriction pattern were found in carrier strains.

Rifampin for eradicating carriage of multiply resistant Haemophilus influenzae b.

We studied the efficacy of rifampin prophylaxis in reducing the prevalence of ampicillin- and chloramphenicol-resistant Haemophilus influenzae type b in four day care facilities after each center had individual cases of invasive infections (two meningitis, one pneumonia and one cellulitis) caused by multiply resistant organisms. Rifampin was given in a single daily dose of 20 mg/kg for 4 days. Cultures were taken pretreatment and 10 days after the last dose of rifampin. Included in the study were 174 children and 27 adults. We identified a total of 55 nasopharyngeal carriers; 45 received rifampin and 10 refused treatment. On the 10-day follow-up culture in the second sample, 95.5 and 20%, respectively, of treated and untreated children were no longer colonized with H. influenzae (P less than 0.001, Fisher's exact test). We conclude that rifampin can successfully reduce the prevalence of multiply resistant H. influenzae type b carriers attending day care centers.

Comparative susceptibilities of ampicillin and chloramphenicol resistant Haemophilus influenzae to fifteen antibiotics.

Eighty-three isolates of ampicillin and chloramphenicol resistant Haemophilus influenzae were tested for susceptibility to fifteen antibiotics by the agar dilution method. Fifty-four were from paediatric patients with H. influenzae disease and 29 from nasopharyngeal carriers (pre-school children). Twenty-five strains belonged to serotype b, one to serotype a, one to serotype c and the rest were non-typable. All strains produced beta-lactamase and inactivated chloramphenicol in a rapid bioassay, suggesting the production of chloramphenicol-acetyltransferase. The most active drugs were ceftriaxone, cefotaxime, latamoxef, aztreonam and desacetyl-cefotaxime (MIC90: 0.03, 0.06, 0.12, 0.25 and 0.25 mg/l, respectively). Cefuroxime, rifampicin and imipenem (MIC90 1 mg/l), and the combination of amoxycillin and clavulanic acid (MIC90 2:1 mg/l), also showed good activity. Cefaclor, erythromycin, tetracycline, trimethoprim, sulfamethoxazole and cotrimoxazole were the least active of the drugs studied. The excellent in-vitro activity of the new beta-lactam agents against H. influenzae resistant to ampicillin and chloramphenicol offers a therapeutic alternative in the treatment of serious infections caused by these micro-organisms.

Multiply resistant Haemophilus influenzae type b causing meningitis: comparative clinical and laboratory study.

Thirty-five patients with meningitis caused by Haemophilus influenzae type b were admitted to our hospital from January 1981 to December 1984; 60% of the strains were resistant to ampicillin, 65.7% to chloramphenicol, and 57% to both antibiotics. No significant differences in age, sex, previous treatment, clinical symptoms, outcome, and mortality were found between the 20 patients whose strains were resistant to both ampicillin and chloramphenicol and the other 15 patients whose strains were susceptible to ampicillin, chloramphenicol, or both. Alternative therapeutic agents were a combination of carbenicillin and gentamicin and new cephalosporins. At present, cefotaxime is our treatment of choice for meningitis caused by H. influenzae type b.

Susceptibility studies of multiply resistant Haemophilus influenzae isolated from pediatric patients and contacts.

From February 1981 to December 1983, 225 strains were isolated from pediatric patients infected with Haemophilus influenzae. Forty-one strains were found to be resistant to ampicillin, chloramphenicol, and other antibiotics. They were isolated from 20 patients with invasive diseases (meningitis, 16; bacteremia, 4) and 21 with noninvasive diseases (otitis media, 19; conjunctivitis, 2). During this period, 44 patients with invasive diseases were seen (meningitis, 28; bacteremia, 16). Strains resistant to both ampicillin and chloramphenicol occurred in 45.4% of cerebrospinal fluid and blood isolates and in 51% of cerebrospinal fluid isolates only. In this group, individual resistance to ampicillin was 50%; chloramphenicol, 52.2%; tetracycline, 54.5%; and sulfamethoxazole-trimethoprim, 63.6%. No epidemiological relationship could be found among the patients. The presence of asymptomatic carriers was investigated in two nurseries and in eight family groups. From a total of 125 individuals studied, 80 were found to be colonized by H. influenzae, and 36 carried multiply resistant strains. From patients and carriers, 77 strains were found to be resistant to ampicillin, chloramphenicol, and other drugs; 39 belonged to type b (cerebrospinal fluid, 16; blood, 4; ear, 7; and nasopharynx, 12), and 38 were non-type b. The most frequent pattern of resistance was ampicillin-chloramphenicol-tetracycline-sulfamethoxazole-trimethoprim (94.8%), followed by ampicillin-chloramphenicol-tetracycline (3.9%). The disk diffusion method correctly predicted multiple resistance. The mean inhibition zone diameters were: ampicillin, 12.8 mm; chloramphenicol, 15.2 mm; tetracycline, 9.9 mm; and sulfamethoxazole-trimethoprim, 10.8 mm. These resistant strains were susceptible to cefotaxime, moxalactam, cefoperazone, cefuroxime, rifampin, and gentamicin. Our data suggest that in Spain the resistance of H. influenzae to ampicillin and chloramphenicol is endemic and that other effective therapeutic modalities are needed.

[Therapeutic errors and dose measuring devices]. / Errores terapéuticos con dosificadores domésticos.

In order to investigate the possibilities of therapeutical error in syrups administration, authors have measured the capacity of 158 home spoons (x +/- SD). They classified spoons in four groups: group I (table spoons), 49 units (11.65 +/- 2.10 cc); group II (tea spoons), 41 units (4.70+/-1.04 cc); group III (coffee spoons), 41 units (2.60 +/- 0.59 cc), and group IV (miscellaneous), 27 units. They have compared the first three groups with theoreticals values of 15, 5 and 2.5 cc, respectively, ensuring, in the first group, significant statistical differences. In this way, they analyzed information that paediatricians receive from "vademecums", which they usually consult and have studied two points: If syrup has a meter or not, and if it indicates drug concentration or not. Only a 18% of the syrups have a meter and about 88% of the drugs indicate their concentration (mg/cc). They conclude that to prevent errors of dosage, the pharmacological industry must include meters in their products. If they haven't the safest thing is to use syringes.