Análisis de atención inicial y manejo del traumatismo craneoencefálico estable en Urgencias de Pediatría. Estudio comparativo / Analysis of initial care and management of stable cranioencephalic traumatism in Pediatric Emergency Department. A comparative study

El traumatismo craneoencefálico (TCE) constituye un motivo de consulta frecuente en Urgencias de Pediatría; la mayoría de tipo leve. Tras su valoración con el triángulo de evaluación pediátrica y clasificación del nivel de urgencia, se debe aplicar un protocolo de actuación que establezca su adecuado manejo y solicitud de prueba de imagen. El objetivo del estudio es analizar las características de dos grupos de pacientes valorados con 4 años de diferencia, establecer su valoración inicial, pruebas de imagen y necesidad de observación hospitalaria. Resultados. Total 169 episodios (prevalencia 2,6%). Año 2010: 92 episodios, 90 pacientes. Año 2014: 77 episodios, 76 pacientes. En ambos años predomina el sexo masculino, el motivo de consulta más prevalente es el TCE aislado, y cuando asocia clínica predominan los vómitos, y en la exploración la existencia de herida externa. El registro de constantes de frecuencia cardiaca y presión arterial se ha incrementado significativamente. Se ha reducido el porcentaje de radiografías de cráneo simple realizadas de forma global en 1,4% y en la franja de edad entre 1 y 2 años en un 7,1%. El porcentaje de tomografía axial computarizada craneal (TAC) fue similar en ambos años. Precisó observación un 13% en 2010 y 9,1% en 2014. Discusión. Es imprescindible conseguir un equilibrio en la valoración urgente del TCE estable que permita reducir la radiación aplicada al paciente en forma de radiología convencional, mantener la adecuación de la indicación de la TAC craneal ajustada y su estancia en forma de observación hospitalaria

Cranioencephalic traumatism (CET) is a cause of frequent medical visits in the Pediatric Emergency Department, most of them being mild. After evaluation with the pediatric assessment triangle and classification on an emergency level, an action protocol should be applied that establishes its adequate management and request for imaging test. The purpose of the study is to analyze the characteristics of two groups of patients evaluated with a different of 4 years, to establish their initial evaluation, imaging tests and need for hospital observation. Results. Total 169 episodes (prevalence 2.6%). Year 2010: 92 episodes, 90 patients. Year 2014: 77 episodes, 76 patients. In both years, there was a predominance of male gender, the most prevalent reason for the visit was isolated CET, and when symptoms were associated, vomiting clinically predominated, while in the physical exam, the external wound predominated. The recording of the vital signs of heart rate and blood pressure has significantly increased. The percentage of simple brain x-rays performed globally has reduced by 1.4% and the age range between 1 and 2 years by 7.1%. The percentage of cranial computed tomography was similar in both years. A total of 13% required observation in 2010 and 9.1% in 2014. Discussion. It is essential to achieve a balance in urgent assessment of stable CET that would make it possible to reduce the radiation applied to the patient in form of conventional radiology, to maintain adaptation of the indication of the cranial CT scan indication and the patients stay in form of hospital observation

Quimioterapia en el cáncer de pulmón / Chemotherapy in lung cancer

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Valoración del fenotipo neoangiogénico y linfangiogénico en lesiones preneoplásicas y primarias de cáncer de pulmón / No disponible

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[The influence of tobacco consumption on the prevalence of symptoms related to asthma]. / Influencia del consumo de tabaco en la prevalencia de síntomas relacionados con el asma.

OBJECTIVE: To determine whether tobacco consumption affects the prevalence of asthmatic symptoms. The European Asthma Study Questionnaire was used. DESIGN: Cross-sectional descriptive study. SETTING: Guadalajara Health Area. PATIENTS: Sample of 3000 people between 20 and 44 living in Guadalajara. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measuring instrument was the European Asthma Study Questionnaire, to which two items on tobacco dependency were added. All the symptoms except asthma attack changed in function of the amount of tobacco consumed. Sibilant noises varied from 8.3% in non-smokers (NS), to 17.5% in light smokers (LS), 28.7% in moderate smokers (MS) and 42.6% in heavy smokers (HS). Night cough also increased in parallel with consumption: 14.1% in NS, 23.2% in LS, 41.2% in HS. Nocturnal thoracic pressure (14.7%), attacks of breathlessness (12.3%) and being considered to have asthma symptoms (14.2%) were more common in heavy smokers. Non-smokers had greater prevalence of sibilant noise with breathlessness (NS 57.7%, LS 39.2%, MS 30.4%, HS 34.5%) and without an associated cold (NS 45.2%, LS 20.3%, MS 23.4%, HS 29.9%), and used asthma treatments more often (NS 3.5%, LS 1.7%, MS 1.5%, HS 1%). CONCLUSIONS: The studies using this questionnaire should include additional questions on the tobacco history of the participants, since it seems that tobacco smoking and its amount may affect findings.

Utility of transfer factor to detect different bronchodilator responses in patients with chronic obstructive pulmonary disease.

Previous studies have described that there are different types of disease in patients with established chronic obstructive pulmonary disease (COPD) with different clinical course and functional responses. The aim of this study was to evaluate if the presence of low transfer factor (LTF) values can predict the effectiveness of bronchodilator therapy, and to assess whether this group has different risk factors that may be related with the responses. Eighty patients with COPD were evaluated on three occasions. Initial assessment included a standard respiratory questionnaire, blood analysis, skin prick test and baseline lung function, all performed on the first visit. Bronchodilator response was evaluated after low (0.2 mg) and high (1 mg) doses of salbutamol, and after 2 weeks of oral prednisone. In patients with normal TLCO/VA % (NTF), a higher proportion of subjects with previous history of atopy was the only statistically significant difference compared to those with LTF (odds ratio 4.33; 95% confidence interval 1.06-25.15). Although the mean response in forced expiratory volume in 1 s (FEV1) to treatment was analogous in both groups, when bronchodilation was expressed as percent of predicted, there was a clear trend to a lower response in patients with LTF (0.2 mg salbutamol: 6.99 +/- 5.64 vs. 8.94 +/- 6. 61, p = 0.15; 1 mg salbutamol: 10.18 +/- 6.37 vs. 13.45 +/- 7.90, p < 0.05; oral prednisone: 5.51 +/- 6.94 vs. 8.74 +/- 10.81, p = 0.06). The percentage of patients who had >12% improvement from that predicted in FEV1 was also lower in this group (42 vs. 72%; p < 0. 05). Moreover, TLCO/VA% was significantly lower in those subjects with a negative bronchodilator trial with salbutamol (68 +/- 25 vs. 81 +/- 26; p < 0.05) and prednisone (69 +/- 26 vs. 90 +/- 22; p < 0. 01). In patients with LTF and NTF, airway responsiveness was only significantly related with basal airflow limitation (LTF, r = 0.44; NTF, r = 0.38). All other interaction terms were not statistically significant. These results indicate that in patiens with similar serverity of COPD, the presence of LTF indicates a decreased probability of a positive bronchodilator response, probably reflecting different pathological lesions. We suggest that transfer factor should be taken into consideration when bronchial response is evaluated in large clinical trials.

[Prevalence of symptoms related to asthma in Guadalajara]. / Prevalencia de síntomas relacionados con el asma en Guadalajara.

The objective of this study was to determine the prevalence of asthma-related symptoms in the Guadalajara Health Area, using the methods prescribed by the first phase of the European Asthma Study (EAS). A transversal descriptive study by self-administered questionnaire in a population of 2,968 subjects aged 20 to 44 years old assigned to the Guadalajara Health Area was performed. The study took place between September 1995 and February 1996. We received 2,435 responses (81.2% of the sample). Each symptom was studied in relation to sex, age, domicile and smoking and the results were compared to data from other Spanish health areas participating in the EAS. Significant differences were found between our results and those of other Spanish health areas. Subjects reporting asthma symptoms accounted for 8.6% (C.I. 7.5% to 9.8%) of the sample. Presence of asthma was related to place of residence but not to age or sex.

[Non-invasive assessment of a snorer with diurnal hypersomnia without features of sleep apnea]. / Valoración no invasiva de un paciente roncador con hipersomnia diurna sin criterios de síndrome de apnea del sueño.

We report a case of increased upper airway resistance diagnosed by impedance plethysmograph. This simple non invasive technique may provide an alternative to polysomnography administered with an esophageal tube, particularly to screen patients before ordering further studies.

Utility of complete dead space washout by real-time gas analysis in the measurement of transfer factor in patients with chronic airflow limitation.

Chronic obstructive pulmonary disease (COPD) is associated with impaired gas mixing and increased dead space, but little is known about the effect of improving alveolar gas sample by complete correction of dead space in an attempt to significantly improve the final result of transfer factor compared with standard guidelines of the European Respiratory Society (ERS) and American Thoracic Society (ATS). By using a rapid infrared analyzer, TLCO was measured by the single breath method in 152 COPD patients at different stages of severity (FEV1:57% predicted; CI 95%:24-91). Standard washout volume of 0.75 liter was insufficient to clear phases I and II in 36 patients (23.7%). In 19 subjects (12.5%), a washout volume larger than 1 liter was necessary for complete dead space clearance, although in these patients, correction visually adequate to complete clear phases I and II resulted in higher TLCO values. Only in 5 patients (3.3%) did the final result change by more than 5% from the previous value. A vital capacity higher than 3 liters, rather than the degree of airflow limitation was a better predictor for larger washout volume requirements. We conclude that in the measurement of TLCO by the breathholding method, ERS and ATS recommendations for washout volume can be safely used for clinical purposes in a wide range of patients with mild to severe obstruction.

[Cholesterol in pleural fluid. Its usefulness in differentiating between exudates and transudates]. / Colesterol en líquido pleural. Utilidad en la diferenciación entre exudados y trasudados.

To analyze the usefulness of cholesterol levels in the differentiation of exudates and transudates. A 3.5-year prospective study of 170 patients with pleural discharge. Clinical microbiological and cyto-histological criteria were used for diagnosis. Exudates were classified by Light's criteria, by cholesterol > or = 45 mg/dl in pleural liquid, by a cholesterol in pleural liquid/cholesterol in serum quotient > or = 0.3 and by a finding of both LDH and cholesterol in pleural fluid. These criteria were compared with the final etiological diagnosis. Only pleural discharges with confirmed etiological diagnoses were analyzed. In the 130 pleural discharges for which certain etiological diagnoses were obtained, 33 were transudates and 97 were exudates. Light's criteria allowed accurate classification of 92 (95%) of the 97 exudates and 30 (91%) of the 33 transudates. The cholesterol in pleural liquid/cholesterol in serum quotient was the most productive and useful parameter (96% sensitivity, 97% specificity), better than pleural fluid cholesterol and the Light's criteria. The association of LDH and pleural fluid cholesterol classified 100% of the exudates, with efficacy similar to that of Light's criteria. The cholesterol in pleural fluid/serum quotient was the most useful biochemical variable. Cholesterol levels were about as useful as Light's criteria. The association of LDH and cholesterol allows us to bypass blood analyses for the diagnosis of exudates.

Safety of the transbronchial biopsy in outpatients.

The objective of our study was to determine the safety of transbronchial biopsy (TBB) in nonhospitalized patients. The design was a prospective study of the consecutive cases from July 1987 until September 1988 in the setting of a university hospital of the third level with 1,800 beds. The patients were a consecutive sample of 169 patients who had 184 procedures of fiberoptic bronchoscopy (FOB) with TBB performed. They suffered from different diseases: lung nodules or masses, diffuse interstitial disease, alveolar condensation, etc. An FOB with TBB was performed in immunocompetent outpatients, who were kept under observation for four hours and then had a chest roentgenogram taken afterwards. We contacted them again after 72 hours to rule out delayed complications. In three cases, more than 100 ml of blood were obtained during the FOB, without significant hemoptysis being recorded in those patients during the observation period; chest pain occurred in 15 patients during the TBB; pneumothorax occurred in two patients (1 percent), one of whom required admission to the hospital, without requiring chest tube drainage. Other complications are reported (bronchospasm, parenchymal hemorrhage, and pneumonia). In conclusion, we consider the TBB to be a technique with a low incidence of complications for outpatients, so therefore we do not believe that admission to the hospital is mandatory for this type of patient, although we do recommend a longer observation period.

[The treatment of pulmonary tuberculosis in a special hospital. Its evolution from 1948 to 1986]. / Tratamiento de la tuberculosis pulmonar en un hospital monográfico. Evolución desde 1948 a 1986.

Nine hundred and sixty six patients diagnosed of pulmonary and/or pleural tuberculosis and admitted to a specialized hospital from 1948 to 1986, have been retrospectively analyzed, investigating their treatment and evolution. Sixty two percent of patients did not fulfil pharmaceutical treatment as far as number and dose of drugs, evolving through the decades (50, 60, 70, and 80s) with a 100%, 82%, 37% and 3% respectively. A 13% of patients did not receive any chemotherapy, 16% underwent surgery, and 53% received a second treatment. Real or hidden monotherapy was given to 38% of patients. Isoniazide has been the most uniformly used drug. Streptomycin has been the most frequently underdosed used drug. Sputum culture turned negative in 42% and 51% of patients during the first 3 and 6 months respectively, with a 42% of positives persisting after one year and a 30% when discharged. A statistically significant difference is observed when comparing all the variables between admitted patients up to 1969 and from 69 to 86 in favor of the second period.

[Evolution of pulmonary tuberculosis at a specialized hospital from its beginning to the present time. General aspects]. / Evolución de la tuberculosis pulmonar en un hospital monográfico desde su puesta en marcha hasta el momento actual. Aspectos generales.

A retrospective analysis of pleuropulmonary tuberculosis patients admitted to a specialized hospital from the day it started functioning to 1986 is performed. The epidemiological and clinical aspects of 966 medical histories are reviewed. 32% of these patients had household contacts with patients suffering the same disease. We could also observe an increase with time in the percentage of diabetic and alcoholic patients. With respect to the bacteriological study we have to point out that in 86% of patients Koch Bacillus was detected. A decrease in length of hospital stay as well as a decrease in mortality up to 3% is observed. These variables are recorded at two time points: when the hospital first started and at the present time, analyzing any possible statistically significant differences.