Maximal static respiratory pressures in children and adolescents.

This study was designed to establish reference values of maximal static respiratory pressures in children and adolescents in our community, and compare them with previous studies. Participants were recruited from three schools (randomly chosen from those located in the metropolitan area of the city of Valencia) after appropriate consent. None of the participants had a previous history of pulmonary, cardiac, and/or skeletal abnormalities, and all of them had normal spirometry. Forced spirometry (Spirotrac III, Vitalograph) and maximal inspiratory (P(ImaxRV)) and expiratory (P(EmaxTLC)) pressure values (Sibelmed 163) were obtained by the same investigator, following national guidelines (SEPAR 1990).We studied 392 subjects (185 males, 207 females) whose ages ranged from 8-17 years. The reproducibility of measurements was investigated in a subgroup of 88 participants (randomly selected from the total sample, and stratified for age and gender) by means of the intraclass correlation coefficient (P(EmaxTLC), 0.98; P(ImaxRV), 0.95). P(EmaxTLC) and P(ImaxRV) values were significantly different between males and females (P < 0.0001) and were normally distributed. A stepwise, linear multiple regression model was built in each gender group (male/female) for the prediction of P(ImaxRV) and P(EmaxTLC) values. Independent variables (weight, height, and age) and their potential interactions were forced to enter the model in order to maximize the square of the multiple correlation coefficient of the resultant equation. This model turned out to be applicable (homoscedasticity, independence, and normality requirements) for P(ImaxRV) (in males and females) and for P(EmaxTLC) (in males but not in females). Variables included in the model were age and the product of weight and height. Their predictive power ranged between 0.21-0.51. In conclusion, P(ImaxRV) and P(EmaxTLC) values increase with age from 8 until 17 years. In all age groups, values were higher in males than in females. Weight, height, and age are included in the predictive equations for P(ImaxRV) (in males and females) and P(EmaxTLC) (in males). Their predictive value is similar to that reported by other authors and ranges between 0.21-0.51. This model is not suitable for the prediction of P(EmaxTLC) in females; the observed mean and range should be used instead.

[Distribution of pulmonologists and chest surgeons in Spain]. / Distribución de neumólogos y cirujanos torácicos en España.

OBJECTIVE: To study the real situation of respiratory medicine specialists and chest surgeons in the Spanish health service. SUBJECTS AND METHOD: Using the database of the secretary of the Spanish Society of Respiratory Medicine and Chest Surgery (SEPAR) for 1999, we gathered data on 326 Spanish hospitals. We were thus able to ascertain the level of staffing of respiratory medicine and chest surgery departments. The results were expressed as simple percentages showing distribution by age, duties and geographic area. The number of specialists per 100,000 inhabitants in each community was also calculated based on population data provided by the National Statistics Institute for 1997. RESULTS: We studied 1,786 physicians or surgeons (1,245 pneumologists, 185 surgeons and 356 from other specialties). The mean age was 41 9 years for pneumologists, 44 10 years for surgeons and 51 8 years for the others. We observed unequal distribution by geographic area, with a high of 6.66 pneumologists and 0.9 surgeons per 100,000 inhabitants in Asturias and Madrid, respectively and a low of 1.4 pneumologists per 100,000 inhabitants in Murcia and 0 surgeons in Extremadura. CONCLUSIONS: Specialist coverage by pneumologists and chest surgeons is inadequate in many provinces and communities in Spain. The professional market is not saturated, indicating that future specialists can look forward to market demand.

Distribución de neumólogos y cirujanos torácicos en España / Distribution of pulmonologists and chest surgeons in Spain

OBJETIVOS: Conocer la situación real de los especialistas en neumología y cirugía torácica en el marco de la red sanitaria pública española. SUJETOS Y MÉTODO: Teniendo en cuenta la base de datos de la Secretaría de la SEPAR del año 1999, se recopiló información de 326 hospitales españoles. Se pudo obtener, así, la composición de las plantillas de las secciones o servicios de neumología y cirugía torácica de los mismos. Los resultados se expresaron como proporciones simples en lo referente a su distribución por edades, cargos y autonomías. Además, se calcularon las tasas por 100.000 habitantes en cada comunidad (datos de población según el Instituto Nacional de Estadística del año 1997). RESULTADOS: Se evaluó un total de 1.786 médicos (1.245 neumólogos, 185 cirujanos y 356 pertenecientes a otras especialidades). La edad media fue de 41 ñ 9 años para los neumólogos, 44 ñ 10 años en el grupo de cirujanos y 51 ñ 8 años en el resto. La distribución por comunidades autónomas fue desigual, encontrándose un máximo de 6,66 neumólogos y 0,9 cirujanos/100.000 habitantes en Asturias y Madrid, respectivamente, y un mínimo de neumólogos en Murcia y de cirujanos torácicos en Extremadura (1,4 y 0/100.000 habitantes, respectivamente). CONCLUSIONES: La situación de las especialidades de neumología y cirugía torácica es deficitaria en muchas provincias y comunidades autónomas de nuestra geografía. En este sentido, el mercado profesional no está saturado, por lo que parece haber unas buenas perspectivas laborales para los futuros especialistas. (AU)

[Cough-inducing capsaicin challenge test in a healthy population]. / Test de provocación tusígena con capsaicina: resultados en una población sana.

OBJECTIVE: Cough-inducing agents are used to study the cough reflex in both pharmacological and physiological research. Clinical use of cough challenge testing as a tool in diagnostic algorithms has been limited by the lack of either uniform methodology or reference values for healthy subjects. The objective of this study was to determine the cough threshold for capsaicin in a sample of healthy subjects, while also evaluating the influence of age, sex and smoking. We also assessed the reliability and repeatability of the test. MATERIAL AND METHODS: Ninety-two healthy subjects were enrolled and given a capsaicin challenge test using concentrations from 0.49 to 500mg. The concentrations of capsaicin that triggered two and five coughs, C2 and C5 respectively, were recorded. The test was repeated three days later in a sub-sample of 30 subjects. RESULTS: No subject showed clinical or functional signs of bronchoconstriction. The mean values obtained for the study population were log C2:1.5 +/- 0.69 mM. and log C5: 2.1 +/- 0.4 microM. The geometric means were 31.6 and 134.8 microM for C2 and C5, respectively. No significant differences were found for sex or smoking; however age was significantly related to log C5 (r: -0.27, p < 0.05). Repeatability of the capsaicin test was high, with intra-class correlation coefficients and 95% confidence intervals of 0.75 (0.53-0.87) and 0.88 (0.76-0.97)for C2 and C5, respectively. CONCLUSION: The capsaicin challenge test was safe and easy to administer,gave reproducible results and allowed us to obtain reference values for a healthy population in our community.

Test de provocación tusígena con capsaicina: resultados en una población sana / Cough-inducing capsaicin challenge test in a healthy population

OBJETIVOS: Es conocido el uso de agentes tusígenos en el estudio del reflejo de la tos, tanto en el campo de la investigación farmacológica como de la fisiología de dicho reflejo. Su aplicación clínica como una herramienta más en los algoritmos diagnósticos se ve limitada por la falta de uniformidad metodológica y de valores de referencia en sujetos sanos. El objetivo del presente estudio ha sido determinar el umbral tusígeno a la capsaicina en una muestra de sujetos sanos, evaluando la influencia de la edad, el sexo y el tabaquismo, así como analizando la fiabilidad y repetibilidad del test. MATERIAL Y MÉTODOS: Se incluyeron en el estudio 92 sujetos sanos a los que se les aplicó el test de provocación con capsaicina, cuyas concentraciones iban desde 0,49 a 500 µM. Se determinaron los valores de C2 y C5, siendo éstas las concentraciones de capsaicina que provocan al menos dos y 5 toses, respectivamente. La prueba se repitió a los 3 días en una submuestra de 30 sujetos. RESULTADOS: Ningún paciente presentó evidencia clínica ni funcional de broncoconstricción. Los valores medios obtenidos en la población de estudio fueron log C2: 1,5 ñ 0,69 µM y log C5: 2,1 ñ 0,4 µM. La media geométrica para ambos valores fue: C2: 31,6 y C5: 134,8 µM. No se hallaron diferencias significativas para el sexo ni el tabaquismo. Sin embargo, la edad guardó una asociación significativa con el log C5. La repetibilidad del test de la capsaicina fue alta, con un coeficiente de correlación intraclase y un intervalo de confianza del 95 por ciento de 0,75 (0,53-0,87) y 0,88 (0,76-0,94) para C2 y C5, respectivamente. CONCLUSIÓN: El test de provocación con capsaicina ha resultado seguro, fácil de aplicar, con unos resultados reproducibles y nos ha permitido obtener unos valores de referencia en una población sana de nuestra área (AU)

[Outpatient ENT surgery in a district hospital]. / Cirugía ambulatoria en ORL en un hospital de distrito.

Our experience in out-patient surgery from October 1994 to July 1996 is reported. Patients were selected using anesthesiology criteria (anesthetic risk I or II, psychosocial criteria, operation time less that 1 h 30 min, age > 6 years). One hundred seventy-eight patients underwent surgery: 61 direct suspension laryngoscopy, 50 adenoidectomy, 48 septoplasty, 10 functional endoscopic sinus surgery, 8 myringotomy, and 1 nasal decortication. Fourteen patients (7.86%) required hospital admission. No patients required ENT care in the first 24 hours after release from the Ambulatory Surgery Unit.

[Toxic habits in relation to cancer of the larynx]. / Hábitos tóxicos en relación con el cáncer de laringe.

Various modifiable toxic risk factors for cancer of the larynx were evaluated in our geographic area in a retrospective epidemiological study of a sample of 373 patients diagnosed as cancer of the larynx chosen randomly at the La Fe Hospital of Valencia Spain over a 5-year period. A "z" test of the contrast of proportions of the laryngeal cancer series studied and the results of a National Health Survey showed significant differences between the two study populations (p < 0.05). Compared with the National Health Survey, smoking had an odds ratio (OR) of 72.21 (33.10 < OR < 166.31) (p < 0.05, Mantel-Haenszel test). The association between smoking and cancer of the larynx increased with the dose. Alcohol consumption had an OR: 1.52 (1.09 < OR < 2.11) (p < 0.05, Mantel-Haenszel test). Smoking carried a risk of 71.21 and had an etiological fraction of 98.61% (IC 95%: 65.17-100%), thus representing 98.61% of all etiological factors. Control of smoking could have prevented 65.17-100% of cases of cancer of the larynx (243 cases in our series). Alcohol consumption had a risk of 0.52 and etiological fraction of 34.21% (IC 95%: 2.38-100%). Control of alcohol use could have prevented cancer of the larynx in 2.38-100% of cases (9 cases in our series).

[Adverse effects on the respiratory system in textile printing sprayers]. / Efectos adversos sobre el tracto respiratorio en trabajadores de aerografía textil.

OBJECTIVE: To study the initial respiratory effects and those observed 18 months later after the inhalation of toxic and irritant substances in textile aerography workers. SUBJECTS: Seventeen patients (14 women and 3 men), with a mean age of 21 years (range: 18-38). METHODS: Initially, pulmonary effects were assessed by pathological (transbronchial biopsy and/or video-thoracoscopy) and functional findings [spirometry with lung volumes and study of diffusion capacity of CO (DLCO)]. Eighteen months later a challenge bronchial test with histamine was performed. RESULTS: Forty-one per cent of patients had pathologic lesions with intraalveolar fibrin, 35% had minimal non-specific lesions, 18% bronchiolitis obliterans with organized pneumonia (BOOP) and 6% pulmonary fibrosis and BOOP. Functional respiratory test showed two patients with a slight restrictive pattern, one patient with very severe restriction and six patients with low DLCO. The challenge tests was positive for 59% of patients. CONCLUSION: After the massive inhalation of irritant and/or toxic substances, patients presented different types of pathological response at pulmonary level. In our workers histological repairing lesions--of high or low degree--were found, BOOP being the lesions observed most frequently, and different patterns of functional involvement. Fifty-nine per cent of cases developed non-specific bronchial hyperreactivity consistent with a reactive airways dysfunction syndrome.

[Contribution of the bronchodilator test in the study of bronchial reversibility]. / Aportación del test broncodilatador al estudio de la reversibilidad bronquial.

This study sought to determine the optimum dose of salbutamol and the most useful method for calculating bronchodilator response. Changes in FEV1 after inhalation of 3 doses of salbutamol 200 micrograms were measured in 150 adults (64 healthy individuals, 18 with rhinitis, 53 with asthma and 15 with bronchitis). Bronchodilator response was calculated by 4 different methods: absolute value, percent change form baseline FEV1, from theoretical value and from weighted value. Significant differences in response were observed among the various methods of assessment. Patients with asthma and bronchitis showed the greatest response to salbutamol and their results were used to analyze the usefulness of the reversibility indices. The index that discriminated best was percent of theoretical reference value, although the sensitivity of this index was low and specificity varied from 0.73 to 1 depending on the cut-off point used. This index of reversibility along with absolute value proved to be the least dependent on baseline FEV1. We conclude that bronchodilator response is best assessed by calculating changes in FEV1 in relation to a theoretical reference value. This bronchomotor test, however, does not adequately assess patients with asthma and bronchitis.

Survival after emergency department versus operating room thoracotomy for penetrating cardiac injuries.

The authors undertook a 6-year retrospective review to assess their experience with penetrating cardiac injuries. Special emphasis was placed on identifying patients with and without tamponade and those requiring emergency department (ED) thoracotomy. Forty-eight patients were identified. Overall survival was 64.6 per cent. Thirty-three patients had tamponade, with 20 requiring ED thoracotomy. Fifteen patients did not have tamponade and two of these needed ED thoracotomy. Five patients who had ED thoracotomy were long-term survivors (22.7%). The remaining 26 patients, 13 with tamponade and 13 without, received operating room (OR) thoracotomy and all survived. The data shows that excellent results are possible with OR thoracotomy for penetrating cardiac injuries, with or without tamponade. However, results are not as good when ED thoracotomy is necessary. This may relate to the severity of the injury, the duration of tamponade, or the inability to control cardiac bleeding during thoracotomy in the ED setting. Even though survival is low with ED thoracotomy, it is high enough to continue to support its use in the deteriorating patient with a penetrating cardiac wound.

Combined orthopedic and vascular injury in the lower extremities: indications for amputation.

A retrospective review was undertaken to determine risk factors associated with amputation after open fractures of the lower extremity that were complicated by vascular injury. During an 11-year period ending in December 1987, we observed open fractures in 31 patients and injuries to the popliteal artery in 16 patients, to the tibial arteries in eight patients, to the femoral artery in five patients, and to the dorsal artery of the foot in two patients. Vascular repair was accomplished in 25 patients; 12 patients had primary end-to-end anastomosis, 12 patients had reverse saphenous vein grafts, and one patient had a bovine graft. Of these 25 patients, five patients required amputation because of infection and three patients required amputation because of continued ischemia. Three patients with irreparable damage had immediate amputation, and three patients without distal ischemia had vessel ligation only. The risk factors associated with amputation were shock on admission (10 of 19 patients [p less than 0.02]) and a crushed extremity (10 of 18 patients [p less than 0.01]). The overall amputation rate, which included three immediate amputations and eight late amputations, was 35.2%. The data suggest that limb salvage is possible in two thirds of patients with combined orthopedic and vascular injuries of the lower extremity, but a history of shock or crush injury with vascular compromise is an unfavorable prognostic sign.

Incidence and diagnosis of C7-T1 fractures and subluxations in multiple-trauma patients: evaluation of the advanced trauma life support guidelines.

A 5-year retrospective review was done to evaluate C-7 and C7-T1 cervical spine injuries and to assess the advanced trauma life support guidelines for cervical spine evaluation. Eighteen fractures of C-7 and four fracture-dislocation at C7-T1 were identified. Nineteen of the patients had neck pain, tenderness, or neurologic findings on initial examination. Three patients were awake and asymptomatic. The initial diagnosis could be made from lateral cervical spine x-ray film in only three of the 22 patients. In the remaining patients, the diagnosis was made by either swimmer's view (7 of 8 positive), oblique views (1 of 1 positive), flexion-extension views (2 of 3 positive), or computed tomography (CT) scan (7 of 7 positive). In two patients, the diagnosis was not made in the first 24 hours. Follow-up x-ray films were positive in 3 of 22 lateral cervical spine films, 10 of 14 swimmer's views, 2 of 3 oblique views, 2 of 3 flexion-extension views, and 14 of 20 CT scans. The data support the advanced trauma life support recommendation for liberal use of cervical spine radiologic screening. We recommend that the screening examination consist of a lateral cervical spine film, and a swimmer's view, if necessary, to visualize C-7 and the C7-T1 interspace. We further recommend that strong consideration be given to the use of a five-view trauma series. CT scan should be viewed as complementary to conventional film techniques.