Assessment of thoracoabdominal bands to detect respiratory effort-related arousal.

It would be helpful to be able to identify respiratory effort-related arousal (RERA) without needing to measure oesophageal pressure. Thoracoabdominal movements yield an indirect flow measurement from which reduction of amplitude and alteration of the inspiratory flow curve can be detected. The aim of this study was to evaluate the accuracy of using the shape and amplitude of signals from thoracoabdominal bands (inductance plethysmography) to detect RERAs. Altogether, 94 subjects suspected of having sleep apnoea but with an apnoea/hypopnoea index < or = 10 in full polysomnography with oesophageal pressure were studied. A routine polysomnographical analysis was carried out. The polysomnographies were then reanalysed at random to determine which of the identified arousals were due to RERA, as determined either by oesophageal pressure or by induction bands without an oesophageal pressure signal. Altogether, 14,617 arousals were analysed. The sensitivity and specificity to find RERA (arousal by arousal) from bands versus oesophageal pressure were both 94%. The average difference of RERA index between oesophageal pressure and bands was -0.6. The correlation between RERA index determined by oesophageal pressure and bands was 0.98. To evaluate the intra and interobserver agreement, 1183 arousals were additionally analysed. The intraobserver agreement was 91% for RERAs by oesophageal pressure and 80% by bands. The interobserver agreement was 89% by oesophageal pressure and 85% by bands. The thoracoabdominal bands can be used to identify respiratory effort-related arousal (obstructive events not detected by thermistor) with similar efficacy to oesophageal pressure measurement. Since bands are routinely used in most polysomnographies, they can be used as the usual method to detect respiratory effort-related arousal, using a thermistor to evaluate apnoeas and hypopnoeas or as a complement to other methods, such as nasal cannula, which can detect apnoeas, hypopnoeas and respiratory effort-related arousal.

Afectación perianal grave en niños con enfermedad de Crohn / Severe perianal involvement in children with Crohn's disease

El compromiso perianal es una complicación común en niños y adolescentes con enfermedad de Crohn (EC). Se caracteriza por un grupo complejo de lesiones que pueden confundirse con otras entidades, sobre todo cuando no se acompañan de otros síntomas. La enfermedad perianal grave ha sido escasamente referida en la edad pediátrica. Muestra, por lo general, una evolución tórpida, con escasa respuesta a todo tipo de terapéutica, por lo que produce importante morbilidad y es, frecuentemente, la principal causa de estrés piscológico en adolescentes y adultos jóvenes, en quienes parece ser más fecuente. El objetivo del presente trabajo es presentar 4 casos de enfermedad de Crohn con afectación perianal grave y su evolucón a largo plazo (AU)

Perianal compromise is a common complication in children and adolescents with Crohn’s disease. It is characterised by a complex group of lesions that may be confused with other diseases, especially in the absence of other symptoms. The literature regarding highly destructive perianal disease makes little reference to paediatric cases but generally shows a poor clinical course and limited response to all types of therapy. Consequently, it is a major cause of morbidity and a frequent cause of psychological distress in adolescents and young adults. The aim of this study is to present 4 cases of Crohn’s disease with destructive perianal disease, focussing on the long-term clinical course of the disease and the devastating effects that this type of presentation can produce (AU)

Antibodies to gliadin, endomysium, and tissue transglutaminase for the diagnosis of celiac disease.

BACKGROUND: Tissue transglutaminase has recently been identified as the main autoantigen recognized by antiendomysial antibodies in celiac disease. Serum immunoglobulin (Ig)A antibodies to tissue transglutaminase (tTG-ab) determined by an enzyme-linked immunosorbent assay (ELISA) technique have been reported to correlate closely with IgA antiendomysial antibodies (EMA). The purpose of this study was to assess the sensitivity, specificity, and predictive value of tTG-ab measured by a commercially available ELISA technique, compared with those of EMA and IgA antigliadin antibodies (AGA) for the diagnosis of celiac disease. METHODS: Twenty-seven serum samples were obtained from patients with untreated celiac disease, 37 from patients who had had gluten withdrawn from their diets for varying time spans, and 34 from control subjects without celiac disease. All were younger than 14 years. Presence of tTG-ab and AGA was determined by ELISA and of EMA by indirect immunofluorescence. RESULTS: Twenty-six of 27 serum samples obtained from patients at the time of diagnosis of celiac disease were AGA positive. All 27 (concordance rate 100%) were positive for EMA and tTG-ab. Of the 34 control subjects, 1 was for AGA and 2 for tTG-ab. All 34 were negative for EMA. Sensitivity, specificity, positive predictive value, and negative predictive value within this group were, for tTG-ab: 100%, 94%, 93%, and 100%, respectively; for EMA: all four indexes were 100%; and for AGA: 96%, 97%, 96%, and 97%, respectively. Of the 37 with treated celiac disease, 2 were AGA positive, 9 were EMA positive, and 6 were tTG-ab positive. The concordance rate between EMA and tTG-ab was 100% in the group with untreated celiac disease, 94% in the control subjects, and 76% in the group with treated celiac disease. CONCLUSIONS: Immunoglobulin A antibodies to tissue transglutaminase are new, highly sensitive, and specific markers of celiac disease. They can be determined easily by an accurate, comparatively cheap technique and thereby may advantageously replace the EMA marker traditionally used.

Noninvasive positive pressure ventilation and not oxygen may prevent overt ventilatory failure in patients with chest wall diseases.

Some patients with chest wall diseases (CWD) without respiratory failure manifest important alterations in nocturnal gas exchange, as a previous stage to the future development of daytime respiratory failure. The purpose of this study was to evaluate the efficacy of nasal intermittent positive pressure ventilation (NIPPV) during sleep in a group of obese patients and in another group with restrictive thoracic diseases (RTD), comparing the results with those obtained from conventional nocturnal oxygen therapy. From a total of 42 patients with CWD free of daytime respiratory failure, 27 (64%) were considered nocturnal oxygen desaturators without sleep apnea and were included in the study. The study protocol was completed by 21 of these patients. After 2 weeks of treatment, symptoms of dyspnea, morning headaches, and morning obnubilation improved significantly (p<0.05) in both groups of patients after NIPPV but not with oxygen. Baseline daytime PaO2 was 68+/-7 mm Hg in the obese group of patients and 73+/-11 mm Hg in the RTD group. It improved significantly with NIPPV to 73+/-5 mm Hg in obese patients (p<0.05) and to 77+/-12 mm Hg in the RTD group (p<0.05) but did not change with oxygen (68+/-8 mm Hg in the obese group and 73+/-12 mm Hg in the RTD group). Both treatments improved oxygen saturation during sleep, but oxygenation tends to be higher with oxygen than with NIPPV. Only NIPPV was able to normalize the baseline nocturnal alveolar hypoventilation. From the 21 patients treated, 19 decided to continue with long-term NIPPV, one with oxygen, and one refused treatment. We conclude that in patients with CWD who manifest nighttime oxygen desaturation and hypoventilation, early initiation of NIPPV is preferable to supplemental oxygen. Our results also suggest that NIPPV initiated before overt ventilatory failure could prevent its onset.

Chloride deficiency as a presentation or complication of cystic fibrosis.

Thirteen children with cystic fibrosis (CF), aged 1.5 months-15 years, had 18 episodes of hypochloraemia and metabolic alkalosis over the period 1983-1991. Five patients were not known to have CF prior to developing these electrolyte disturbances. There were two distinct clinical presentations: 5 patients had an acute isolated picture of heat exhaustion while 8 patients (all infants) had a more chronic course associated with failure to thrive. Many episodes were not associated with particularly high environmental temperatures, although most occurred during the summer and early autumn months. Serum electrolytes should be assessed regularly in children with CF, and this diagnosis should be considered in any infant presenting with unexplained hypochloraemic metabolic alkalosis.

[The singularity of population policies in Latin America and the Caribbean in the late 20th century]. / La singularidad de las politicas de poblacion en America Latina y el Caribe en las postrimerias del siglo XX.

PIP: This work questions the assumption that population policies in Latin America and the Caribbean are closely related to population growth, identifies common obstacles to population policies, and recommends actions to increase the efficacy of population policies. The demographic transition has occurred in Latin American countries with widely varying levels of economic development, cultural traditions, and family planning programs. The governments of the region that regard their rates of population growth and fertility as satisfactory seldom intervene to modify them. The demographic transition is well underway in all these countries except Guatemala and Paraguay. A diverse array of strategies has been used by the countries that have achieved significant fertility reductions, ranging from family planning services provided through the national health system in Mexico to key roles by the private and commercial sectors and intensive use of the mass media in Brazil. Governments adopting population policies defined various institutional forms for them, ranging from small technical units at a high level to interministerial councils. Institutionalization of population policies created high hopes for integration of population concerns into development strategies, but performance has largely failed to meet expectations, both because of the fragility and inferior status in the government bureaucracy of policy structures, and because of their inability to develop effective programs integrating population and development. The economic crisis of the 1980s lowered the priority of population themes. Political instability, lack of adequate human resources and financing, limited decision making capacity, and failure to establish strong interinstitutional ties have all been factors in the disappointing results of population policies. The difficulty of pinpointing exactly what constitutes the population policy and the tendency to equate population policy and family planning have been other factors hindering their full implementation. The effectiveness of population policies appears to have been compromised by their lack of specificity among government policies. To increase their efficacy it will be necessary to define their uniqueness with respect to other social policies. Population policies, their institutional framework, and the actors called upon to support then must be redefined. A national population policy should orient interventions in three areas: establishment of consensus regarding population goals, channeling funds to the implementing agencies, and providing follow-up and evaluation of demographic effects. Implementation of population policies and programs should be decentralized and should be achieved through insertion of population parameters in the activities of the health, education, and other social sectors.^ieng

[The value of pulse oximetry during the performance of a forced spirometry maneuver]. / Valor de la pulsioximetría durante la realización de la maniobra de espirometría forzada.

Given that forced spirometry is the main routine exploration in any laboratory of pulmonary functional assessment, we have analyzed the behaviour of O2 arterial saturation (SaO2) during such maneuver in patients with airflow chronic obstruction (AFCO), in order to verify any potential alterations. We have studied three groups of patients: Group A, control, 17 healthy subjects; group B, 18 patients with AFCO and initial saturation higher than 90%; group C, 15 patients with AFCO and saturation equal to or lower than 90%. Total duration of the maneuver was significantly higher in groups B and C compared with the control group (p < 0.001). In groups A and B, we did not observed any significant reductions in SaO2 with respect to the initial value, although we did observed such differences in group C (p < 0.001). None of the patients presented a subjective clinical disorder, although the absence of both complexity and risk suggest the convenience of including the oximetry as an additional parameter when conducting a forced spirometry in patients with AFCO and respiratory failure.

[Cholelithiasis in childhood. Proposals based on a multicentric study]. / Colelitiasis en la infancia. Propuestas de un estudio multicéntrico.

Fifty six cases of cholelithiasis in patients aged two months to 15 years (mean age 7.65 years) concerning to 11 hospitals are reviewed. The study protocol followed was the same in all medical records, although own criterions were considered on management performed in each center. From the cases, it follows: 1. Male/female rate is 1/1.5. 2. Symptomatology in infancy is relatively poor and pain localization is not orientative. 3. It was an incidentally finding in 41 per 100 of the cases. 4. Ultrasonography is the best examination procedure rendering diagnosis in the 51 cases it was underwent. 5. Hematologic study was abnormal in six of 46 cases. 6. Medical treatment was not performed in any hospital. 7. Existence of "lithogenic families" seems to be demonstrated. 8. The presence of four patients with Down syndrome in this series must be pointed out. 9. Among total 56 cases, 21 underwent surgical treatment, 29 were conservatively treated, two have died and four patients had spontaneous stone resolution. 10. In the face of these, we propose: A) Surgical treatment in symptomatic cases, porcelain gallbladder and nonfunctionating gallbladder. B) Expectant management and sonographic monitoring in asymptomatic cases. C) Carefully evaluation in patients with predisposing factors and patients with recurrent abdominal pain.

[Regional factors and decentralization in planning equitable changes in productivity]. / El territorio y la descentralizacion en la agenda de la transformacion productiva con equidad.

PIP: This work constitutes a critique of traditional population redistribution policies and a reflection on the relationship between economic development, productivity, and regional factors, with particular reference to Latin America and the Caribbean. The article is organized around 3 main points: an analysis of the sources of competitiveness and productive efficiency, a discussion of the relationship between spatial aspects and productivity and competitiveness, and an assessment of the implications of these factors for regional policies and decentralization. Latin America and the Caribbean suffer from a shrinking importance in the world economy and from technological backwardness. To increase the well being of their populations systematically and deliberately foster technical progress. Authentic competitiveness, sustained over time, should not be confused with the spurious competitiveness resulting from low wage levels of nonsustainable exploitation of natural resources. The new technological model requires constant learning and improvement to adapt products to changing needs. Active participation is required from all workers; the continuous improvement is based on human capital. The technological changes and transformations in the productive structure that will be required to improve productivity in Latin America and the Caribbean can significantly alter comparative regional advantages, the patterns of territorial use, and the spatial division of labor. The role of technological changes and of the organization of production must thus be considered in analyses of regional dynamics. Regional development strategies must be reexamined in light of the obsolescence of some traditional elements of regional policy. The factors influencing the location of productive activities in the context of technological development also affect population distribution and can be used to understand trends in population distribution through effects on employment.^ieng

[Territory and decentralization in the agenda for productive transformation with equity]. / El territorio y la descentralizacion en la agenda de la transformacion productiva con equidad.

PIP: The regional perspective and the decentralization in Latin American and Caribbean countries was examined in light of technological changes and transformation of economic production to boost productivity. National population policies were not the major cause of redistribution of the population, rather such transformation significantly changed the comparative regional and urban advantages in the use of territory affecting the spatial distribution of the population. Hypotheses were advanced using the transformation of production, regional development, and decentralization on the retention, attraction, and migration of population in different areas with varying economic conditions. Spurious competitiveness means global strategies of enterprises that establish foreign operations by means of factor sourcing. Flexible specialization is a company strategy of permanent innovation based on flexible equipment and a qualified work force. The increasing transnationalization of capital is the source of skills and technology that sustain competitive advantages. Decentralization can resolve local demand, facilitate access to information, mobilize resources, and exercise control over local operations. In Japan, Germany, and Italy vs. the US and France there is a social contract among companies, trade unions, universities, and regional administrations in the interest of capital and the work force. There is no direct relationship between technology and region, the industrial cluster exhibits systemic competitiveness in developed countries (the Emilian model in Italy affirms the ability of small enterprises to develop new products), the regional impact is diverse relative to new technologies (some deprived rural economic areas have potential as in central and northern Italy), and population and region are linked (regional and rural-urban differences in the growth of population and migratory flows account for spatial distribution of the population). Decentralization and systemic competitiveness concern productivity and regional policies (spatial diversity for increased productivity) and technology and human resources are interdependent (technical progress is determined by the level of qualification of the population).^ieng

[Intolerance to cow's milk proteins. An epidemiologic study]. / Intolerancia a proteínas de leche de vaca. Estudio epidemiológico.

The incidence of cow's milk protein intolerance (CMPI) varies depending on the series. The aim of the present investigation was to determine the incidence of this disease in our population and its change over the past the years. Over the period January 1977 to December 1986, 217 patients suspected to have the disease were submitted to a cow's milk challenge test. Diagnosis was confirmed clinically and/or pathologically in 121 patients and was ruled out in 96 patients. The incidence for the whole period was 0.78 cases/1,000 alive newborn infants. However, it fell significantly over the ten years, with a maximum of 1.36/1,000 alive newborn infants in 1979 and a minimum of 0.17/1,000 alive newborn infants in 1986 (r = 0.76, p less than 0.001). We conclude that, similarly to the observation in other diseases of nutritional origin, the incidence in our population of CMPI has clearly decreased, probably as a consequence of changes in the dietary habits.

[Results of the sweat test, carried out by 2 methods, for the diagnosis of cystic fibrosis]. / Resultados de la prueba del sudor, efectuada por dos métodos, para el diagnóstico de la fibrosis quística.

Un review the results of the sweat test for the diagnosis of cystic fibrosis performed by 2 methods: Electric conductivity of the sweat (2,517 test in non-cystic fibrosis and 114 in 37 cystic fibrosis children) and skin chloride electrode (121 test in non-cystic fibrosis and 20 in cystic fibrosis children). A 1% rate of false positive results was obtained with the former along with 6,1% falsely negative results in cystic fibrosis patients. The skin chloride electrode method was much less specific and sensitive. The diagnosis of cystic fibrosis should only be made once repeatedly altered sweat chloride concentrations are obtained together with careful correlation with the clinical findings. We think that both the implications of the diagnosis and the thoroughness needed in the proper performance of the sweat test warrant that the diagnosis should always be confirmed in a centre with experience in the disease.

[Incidence of hypernatremic dehydration in acute infantile gastroenteritis]. / Incidencia de la deshidratación hipernatrémica en la gastroenteritis aguda infantil.

A retrospective study on the incidence in our hospital of hypernatremic dehydration was performed. Authors observed a linear decrease both in the frequency of hypernatremic dehydration and in the incidence of hypernatremias above 160 mmol/l, during the 8-year period included in the study. For the past few years a tendency to see affected babies of older age was also observed. We believe that the reasons for these facts are the new dietary habits in infancy feeding and specially the greater use of formulas with low solute and protein content.

[Gastroenteritis caused by Campylobacter jejuni in childhood]. / Gastroenteritis por "Campylobacter jejuni" en la infancia.

Fifteen patients with stool growth of "Campylobacter jejuni" are presented. In one case it was associated with growth of "Salmonella typhimurium". Fourteen cases presented as an acute gastroenteritis whereas the remainder case was considered to be an asymptomatic carrier. The incidence was 5.8%. The disease was more frequent in infancy (13 cases occurred in ages below one year). Diarrhea was the most frequent symptom (93.3%), with presence of macroscopic blood in the stool in 78.5% of these cases. In three cases the process was associated to cow's milk protein-sensitive enteropathy. Four patients were treated with erythromycin and the stool culture become negative at the end of therapy. In the untreated cases the stool culture become negative within a period from five to 15 days. In the asymptomatic carrier the stool culture become negative after a period of two months.