Consenso sobre el manejo de eventos de aparente amenaza a la vida del lactante (ALTE): comisión de sueño, sociedad chilena de neumología pediátrica 2013 / Consensus on evaluation and management of apparent life-threatening events in infancy (ALTE)

Un Evento de Aparente Amenaza de la Vida o ALTE (del inglés: Apparent Life Threatening Event) corresponde a un episodio agudo que ante los ojos del observador pone en riesgo la vida de un lactante menor de 1 año. Debe presentar la combinación de 2 o más de los criterios siguientes: apnea / cambio de color / alteración del tono / atoro e implicar la necesidad de algún tipo de maniobras para reanimar. En el presente consenso sobre el manejo de un ALTE se revisaron la evidencia internacional y nacional respecto al enfoque diagnóstico, estudio etiológico, criterios y duración de hospitalización y las indicaciones de monitorización domiciliaria.

Apparent life threatening events are defined as an acute episode in which the observer fears an infant < 1 year may die. ALTE is characterized by some combination of apnea, color or muscle tone change, chocking and has to be followed by cardiorespiratory reanimation. The present consensus paper reviews international and national evidence concerning diagnosis, etiologies, hospitalization criteria and indications for home monitoring.

[Consensus on evaluation and management of apparent life-threatening events in infancy (ALTE)]. / Consenso sobre el manejo de eventos de aparente amenaza a la vida del lactante (ALTE). Comisión de Sueño, Sociedad Chilena de Neumología Pediátrica 2013.

Apparent life threatening events are defined as an acute episode in which the observer fears an infant < 1 year may die. ALTE is characterized by some combination of apnea, color or muscle tone change, chocking and has to be followed by cardiorespiratory reanimation. The present consensus paper reviews international and national evidence concerning diagnosis, etiologies, hospitalization criteria and indications for home monitoring.

Prevalencia disímil de trastornos respiratorios del sueño en escolares / Prevalence of sleep-disordered breathing among schoolchildren in two communes of Santiago

Objetivo: Comparar la prevalencia de ronquido habitual como síntoma cardinal de los trastornos respiratorios del sueño (TRS) en población escolar de dos comunas de Santiago, de diferente nivel socioeconómico y exposición a contaminación ambiental. Métodos: Estudio transversal, de tipo ecológico. Se aplicó un cuestionario de sueño a los padres de escolares de 1° básico a 3°medio matriculados en dos colegios ubicados en las comunas de Puente Alto (zona sur oriente, colegio subvencionado) y Providencia (zona oriente, colegio particular). Los datos de contaminación ambiental se obtuvieron a partir del registro de estaciones de monitoreo. La caracterización socioeconómica comunal se realizó en base a fuentes ministeriales. Resultados: Los niveles de contaminación ambiental fueron mayores en el sector sur-oriente, comparado con el sector oriente de Santiago. Los indicadores comunales de nivel socioeconómico fueron superiores en la comuna de Providencia. La prevalencia de ronquido en escolares fue superior en el colegio ubicado en Puente Alto (18,2 por ciento; IC95 por ciento 14,0-21,6) en comparación al colegio ubicado en Providencia (0,7 por ciento; IC95 por ciento 0,1-2,4). Conclusión: La prevalencia de TRS fue diferente en las comunas estudiadas y podría estar atribuida a factores medioambientales y socioeconómicos. El presente estudio constituye un punto de partida para la realización de estudios de base individual.

Objective: To compare the prevalence of habitual snoring as cardinal symptom of sleep-disordered breathing (SDB) in schoolchildren from two communes of Santiago, presenting different levels of socioeconomic status and exposure to environmental pollution. Methods: Cross-sectional ecological study. A sleep questionnaire was administered to parents of primary school kids from 1st through 3rd grade, from two schools, one located in the district of Puente Alto (south-east, subsidized school) and the other in Providencia (east area, private school). Pollution data were obtained from monitoring stations. Socioeconomic characterization was performed based on government sources. Results: The levels of air pollution were higher in the south-east area, compared to the eastern sector of Santiago. Indicators of socioeconomic level were higher in the Providencia commune. The prevalence of snoring in students was higher in the school located in Puente Ailto (18.2 percent, 95 percent CI 14.0 to 21.6) compared to the school located in Providencia (0.7 percent, 95 percent CI 0.1 - 2.4). Conclusion: The prevalence of SDB was different in the communities studied and could be attributed to environmental and socioeconomic factors. This study is a starting point for further studies on individual basis.

Utilidad de un cuestionario clínico para el diagnóstico de trastornos respiratorios del sueño en niños con enfermedades neuromusculares / Usefulness of a clinical questionnaire for diagnosis of respiratory disorders of sleep in children with neuromuscular diseases

Objectives: To analyze the usefulness of a clinical questionnaire for the diagnosis of sleep disordered breathing in children with neuromuscular diseases. Patients and Methods: A sleep questionnaire and a polysom-nography were performed in a cohort of 21 children (14 boys) with neuromuscular diseases. ROC analysis was used to assess the diagnostic accuracy of the questionnaire for diagnosing sleep disordered breathing compared with polysomnography. Results: Median age was 10.7 years (2-17). According to polysomnography, 8 patients were classified as normal, 3 had primary snoring, 5 had central sleep apnea syndrome and 5 an obstructive sleep apnea syndrome. Eleven questionnaire's scores suggested sleep disordered breathing. The questionnaire's score showed a sensitivity of 75 percent, specificity of 60 percent, positive predictive value of 33 percent and negative predictive value of 90 percent for the diagnosis of an obstructive sleep apnea syndrome. The same figure for the diagnosis of a central sleep apnea syndrome was 80 percent, 64 percent, 44 percent and 90 percent. Conclusions: The questionnaire showed a moderate sensitivity and specificity. Nevertheless, the high negative predictive value of the questionnaire may support its use for screening of sleep disordered breathing. A follow-up of questionnaire's scores may identify patients, who would benefit from performance of polysomnography.

Objetivos: Analizar la utilidad de un cuestionario clínico para el diagnóstico de los trastornos respiratorios del sueño (TRS) en niños con enfermedades neuromusculares (ENM). Pacientes y Métodos: Se realizó un cuestionario de sueño junto con una polisomnografía (PSG) en un grupo de 21 niños (14 varones) con ENM. Se realizó un análisis de validez diagnóstica de los resultados del cuestionario comparados con los de la PSG. Resultados: La mediana de edad fue de 10,7 años (2-17). De acuerdo a la PSG, se clasificó a 8 pacientes como normales, 3 roncadores primarios, 5 con síndrome de apneas centrales y 5 con síndrome de apneas obstructivas (SAOS). Once cuestionarios presentaron un puntaje sugerente de TRS. El puntaje del cuestionario presentó: sensibilidad 75 por ciento, especificidad 60 por ciento, valor predictivo positivo 33 por ciento y negativo 90 por ciento para el diagnóstico de SAOS. Respecto al diagnóstico de síndrome de apneas centrales del sueño, éste valores fueron: 80 por ciento, 64 por ciento, 44 por ciento y 90 por ciento. Conclusiones: El cuestionario clínico presentó una sensibilidad y especificidad moderada. Sin embargo, el alto valor predictivo negativo del cuestionario apoyaría su uso como tamizaje de los TRS. El seguimiento del puntaje de este cuestionario permitiría identificar aquellos pacientes que se beneficiarían de la realización de una PSG.

Tropical forests were the primary sources of new agricultural land in the 1980s and 1990s.

Global demand for agricultural products such as food, feed, and fuel is now a major driver of cropland and pasture expansion across much of the developing world. Whether these new agricultural lands replace forests, degraded forests, or grasslands greatly influences the environmental consequences of expansion. Although the general pattern is known, there still is no definitive quantification of these land-cover changes. Here we analyze the rich, pan-tropical database of classified Landsat scenes created by the Food and Agricultural Organization of the United Nations to examine pathways of agricultural expansion across the major tropical forest regions in the 1980s and 1990s and use this information to highlight the future land conversions that probably will be needed to meet mounting demand for agricultural products. Across the tropics, we find that between 1980 and 2000 more than 55% of new agricultural land came at the expense of intact forests, and another 28% came from disturbed forests. This study underscores the potential consequences of unabated agricultural expansion for forest conservation and carbon emissions.

Clinical spectrum of early-onset epileptic encephalopathies associated with STXBP1 mutations.

OBJECTIVES: Heterozygous mutations in STXBP1, encoding the syntaxin binding protein 1, have recently been identified in Ohtahara syndrome, an epileptic encephalopathy with very early onset. In order to explore the phenotypic spectrum associated with STXBP1 mutations, we analyzed a cohort of patients with unexplained early-onset epileptic encephalopathies. METHODS: We collected and clinically characterized 106 patients with early-onset epileptic encephalopathies. Mutation analysis of the STXBP1 gene was done using sequence analysis of the exon and intron-exon boundaries and multiplex amplification quantification to detect copy number variations. RESULTS: We identified 4 truncating mutations and 2 microdeletions partially affecting STXBP1 in 6 of the 106 patients. All mutations are predicted to abolish STXBP1 function and 5 mutations were proven to occur de novo. None of the mutation-carrying patients had Ohtahara syndrome. One patient was diagnosed with West syndrome at disease onset, while the initial phenotype of 5 further patients did not fit into a specific recognized epilepsy syndrome. Three of these patients later evolved to West syndrome. All patients had severe to profound mental retardation, and ataxia or dyskinetic movements were present in 5 patients. CONCLUSION: This study shows that mutations in STXBP1 are not limited to patients with Ohtahara syndrome, but are also present in 10% (5/49) of patients with an early-onset epileptic encephalopathy that does not fit into either Ohtahara or West syndrome and rarely in typical West syndrome. STXBP1 mutational analysis should be considered in the diagnostic evaluation of this challenging group of patients.

[Clinical characteristics of respiratory infection due to Mycoplasma pneumoniae in hospitalized children]. / Características clínicas de la enfermedad respiratoria causada por Mycoplasma pneumoniae en niños hospitalizados.

INTRODUCTION: Studies on Mycoplasma pneumoniae infection are scarce in Chile. OBJECTIVE: To describe clinical characteristics associated with M. pneumoniae in children requiring hospitalization. MATERIAL AND METHODS: All children with a respiratory infection requiring hospitalizations between 2000-2005, whom had a M. pneumoniae specific IgM > or = 1:32, were analyzed. RESULTS: Fifty children meeting study criteria were identified with an average length of hospitalization of 4 days (range: 1-10); mean age was 5.4 years (46% were younger than 5 years). Common clinical features were cough (92%), fever (82%), malaise (74%) and respiratory distress (72%). At admission 40/45 children had hypoxemia. Chest-X ray showed interstitial pattern (69.3%), consolidation (51%) and hyperinsuflation (28.5%). Six patients had pleural effusion. Eighty four percent of patients had a favorable clinical outcome; eight children required admission to the PICU all of whom recovered. CONCLUSION: Respiratory infections associated with M. pneumoniae in our series of children had a highly variable and non-specific clinical spectrum. Chest-X rays showed different pattern in concordance with previous publications.

Características clínicas de la enfermedad respiratoria causada por Mycoplasma pneumoniae en niños hospitalizados / Clinical characterizes of respiratory infection due to Mycoplasma pneumoniae in hospitalized children

Introduction: Studies onMycoplasmapneumoniae infection are scarce in Chile. Objective: To describe clinical characteristics associated withM. pneumoniae in children requiring hospitalization. Material and Methods: All children with a respiratory infection requiring hospitalizations between 2000-2005, whom had aM. pneumoniae specific IgM ≥ 1:32, were analyzed. Results: Fifty children meeting study criteria were identified with an ave-rage length of hospitalization of 4 days (range: 1-10); mean age was 5.4 years (46 percent were younger than 5 years). Common clinical features were cough (92 percent), fever (82 percent), malaise (74 percent) and respiratory distress (72 percent). At admission 40/45 children had hypoxemia. Chest-X ray showed interstitial pattern (69.3 percent), consolidation (51 percent) and hyperinsuflation (28.5 percent). Six patients had pleural effusion. Eighty four percent of patients had a favorable clinical outcome; eight children required admission to the PICU all of whom recovered. Conclusión: Respiratory infections associated withM. pneumoniae in our series of children had a highly variable and non-specific clinical spectrum. Chest-X rays showed different pattern in concordance with previous publications.

Introducción: La infección por Mycoplasma pneumoniae es una condición respiratoria poco estudiada en nuestro medio. Objetivo: Describir las características clínicas de los niños hospitalizados porM. pneumoniae. Materiales y Métodos: Se analizaron todos los pacientes hospitalizados por infecciones respiratorias durante el 2000-2005, con IgM específica; se utilizó como diagnóstico de enfermedad por M. pneumoniae la presencia de fluorescencia verde manzana 2 a 3 positivo en títulos ≥ 1:32 diluciones. Resultados: Se analizaron 50 hospitalizaciones, con estadía promedio de 4 días (rango: 1-10); la edad promedio fue 5,4 años (46 por ciento bajo 5 años). Los síntomas más frecuentes fueron tos (92 por ciento), fiebre (82 por ciento), compromiso del estado general (74 por ciento) y dificultad respiratoria (72 por ciento). Al momento del ingreso 40/45 presentaron hipoxemia. La radiografía de tórax (RT) reveló infiltrado intersticial (69,3 por ciento), foco de consolidación (51 por ciento) e hi-perinsuflación (28,5 por ciento). Seis presentaron efusión pleural asociada. En 84 por ciento la evolución fue favorable; sin embargo, 8 niños ingresaron a la Unidad de Paciente Critico para monitorización. No hubo decesos Conclusiones: La infección respiratoria asociada aM. pneumoniae en niños produjo manifestaciones inespecíficas y variables de un caso a otro. La RT reveló una variedad de presentaciones similar a lo mostrado en la literatura médica.

Neumonía complicada con neumatocele en un lactante, caso clínico / Complicated pneumonía with pneumatocele in a infant: case-report

Introduction: Pneumatocele is an uncommon complication of pneumonia, most often asymptomatic with spontaneous resolution. Case-report: Female infant with an history of right upper lobe pneumonia, an air filled structure was noted in the chest X-ray. Asymptomatic until admitted for a wheezing episode, where an increase in the size of the structure was evidenced. She had clinical and radiological follow-up as recommended in a recent study, observing that 5 months later the cystic image was completely resolved. Discussion: According to criteria from published studies, this case is a non complicated pneumatocele because it was asymptomatic, compromised less than 50 percent of the hemithorax and no atelectasia, bronchopleural fistula or signs of infection were observed. Non complicated pneumatoceles can be followed up, and complicated can be treated by image guided catheter drainage or surgical resection. In this case, we confirmed spontaneous resolution after clinical and radiological follow-up.

Introducción: El neumatocele es una complicación poco frecuente de la neumonía, generalmente asintomático que se resuelve espontáneamente. Objetivo: Describir la presentación clínica e imageneológica de un neumatocele en un paciente pediátrico. Caso Clínico: Lactante mayor, género femenino, con antecedente de neumonía del lóbulo superior derecho a los 16 meses de vida. En controles radiográficos posteriores se evidenció una imagen aérea de paredes finas en ápex derecho en progresivo aumento. Asintomática hasta los 20 meses cuando fue hospitalizada por cuadro bronquial obstructivo por virus respiratorio sincicial y se constató crecimiento de la imagen. Se tomó conducta expectante manteniendo seguimiento clínico y radiológico. A la edad de 21 meses se evidenció resolución casi completa de imagen radiográfica. Conclusión: Este caso corresponde a un neumatocele simple, donde se recomienda mantener bajo observación. Los complicados pueden ser drenados por punción bajo imagen radiológica o resecados quirúrgicamente. En este caso se optó por seguimiento clínico y radiológico, pudiendo confirmar su resolución espontánea en el estudio posterior.

Empiema y efusión pleural en niños / Empyema and pleural efussion in children

Introducción: El empiema pleural (EP) es una complicación grave de la neumonía adquirida en la comunidad (NAC). Objetivos: Describir las características de los pacientes hospitalizados por EP en el Servicio de Pediatría del Hospital de la Universidad Católica durante el período 2000-2005. Se identificaron 86 hospitalizaciones por NAC con efusión pleural, practicándose en 59 (70 por ciento), al menos una toracocentesis. Se consideró EP a la presencia de pus, tinción de Gram con bacterias, cultivo positivo o pH < 7,10 en el líquido pleural, siendo las efusiones para-neumónicas los controles. Resultados: Se analizaron 24 EP y 25 controles [promedio 2,9 años (rango: 8 meses - 14,3 años)], 78 por ciento de edad inferior a 5 años con diferencia entre los grupos EP y controles [1,6 vs 3,3 años, respectivamente (p = 0,01)]. El promedio global (días) de síntomas previo al ingreso en los EP fue 7 (rango: 2-21), siendo los más frecuentes fiebre (100 por ciento) y tos (96 por ciento). Se identificó algún microorganismo en 15/24 EP, Streptococcus pneumoniae fue el más frecuente (n: 9). En 48 niños, el manejo inicial fue conservador, requiriéndose cuatro rescates quirúrgicos luego del cuarto día. El promedio (días) de hospitalización fue significativamente superior en el grupo EP vs controles [15 (rango: 5-38) vs 9 (rango: 3-16) (p < 0,01)]. Requirieron drenaje pleural 83 por ciento del grupo EP y 36 por ciento de los controles (p = 0,002). No hubo diferencia en el número de días de empleo de oxígeno [6 vs 4,5 (p = 0,36)] o drenaje pleural [3 vs 2,5 (p = 0,29)]. No se registraron fallecidos. Conclusión: El EP en niños fue una condición respiratoria aguda que se asoció a estadías hospitalarias prolongadas, especialmente en los de menor edad, no requiriéndose, en la mayoría, una intervención quirúrgica de rescate.

Introduction: Pleural empyema (PE) is a serious complication of community-acquired pneumonia (CAP). Objectives: To describe the clinical profile of hospitalized patients with PE in the pediatric ward of the Catholic University Hospital between 2000-2005. Patients y methods: Retrospectively, all pediatric admission due to CAP and pleural effusion (86 children) were identified. In 59 (70 percent) children > 1 thoracocentesis were performed. We considered PE as the presence in the pleural effusion of pus, and/or a positive gram strain and/ or positive culture, and/or a pH < 7.10. Children with effusions not meeting any criteria were used as controls. Results: Twenty four PE and 25 controls were identified, with a global mean age of 2.9 years (range: 8 months to 14.3 years); 78 percent were < 5 years, with a significant difference between PE and controls [1.6 vs 3.3 years (p = 0.01)]. The mean duration of symptoms in PE patients before admission was 7 days (range: 2-21), and the most frequent symptoms were fever (100 percent) and cough (96 percent). In 15/24 cases a microorganism was identified being Streptococcus pneumoniae (n = 9) the most common. In 48 patients management was conservative and in 4 surgical procedures were required. The mean duration of hospitalization was significantly higher in the PE group vs controls group: 15 (range: 5-38) vs 9 days (range 3-16) (p < 0.01). A chest tube was inserted in 83 percent of children with EP compared with 36 percent in the control group (p = 0.002). There were no difference in number of days of oxygen use [6 vs 4.5 (p = 0.36)] or number of chest tubes per child [3 vs 2.5 (p = 0.29)]. No deaths were reported. Conclusion: PE in children represented an acute respiratory event associated with more prolonged hospitalization especially at younger ages; the majority of cases did not require surgical intervention.

Actividad física y obesidad en niños con asma / Physical activity and obesity in asthmatic children

Exercise- induced asthma is frequent among children. Objective: To compare physical activity (PA) and nutritional status in asthmatic (A) versus healthy (H) children. Methods: 81 school children were enrolled (40 A and 41 H). A validated interview with opinions and attitude towards PA was performed to parents in both groups. Nutritional status was classified according to body mass index. Answers were associated with percent² test. Results: 44 percent girls, average age 9 years-old. Average hours per week of PA = 2.4 in H and 1.9 in A (p=NS); 88 percent) of A versus 56 percent of H performed < 2 hours per week of PA (p < 0.05). 85 percent of A reported frequent symptoms associated to PA. Overweight and obesity were diagnosed in 15/40 A and 11/41 H (p < 0.05). Parents of A thought that PA was "dangerous" more frequently than parents of H (p < 0.05). Conclusions: Asthmatic children practice less PA than recommendations. There is an association between asthma, obesity and less PA level. Parents of asthmatic children have a negative opinion about PA, explaining the diminished PA performed by this group.

El asma inducida por ejercicio es una enfermedad crónica frecuente en niños. El objetivo de este estudio fue comparar actividad física (AF) y estado nutricional en niños con asma (A) y sanos (S). Pacientes y Método: Participaron 81 niños, 40 A y 41 S. Se realizó un cuestionario a los padres, validado previamente, referente a opiniones y actitudes acerca de la AF. El estado nutricional se clasificó de acuerdo a índice de masa corporal. Se asociaron las respuestas entre los grupos con por ciento². Resultados: Edad promedio 9 años, 44 por ciento niñas. Promedio de horas de AF semanales fue 2,4 S y 1,9 A (p = NS). El 88 por ciento de A vs 56 por ciento de S realizaba < de 2 horas de AF semanales (p < 0,05). El 85 por ciento de A presentaba síntomas frecuentes asociados al ejercicio. En 15/40Avs 11/41 S se diagnosticó obesidad y sobrepeso (p < 0,05). Los padres de A percibían la AF como "peligrosa" más frecuentemente que S (p < 0,05). Conclusiones: Los niños con asma realizan menos AF que las recomendaciones, existiendo una asociación entre bajos niveles de AF, obesidad y asma. Los padres de niños con asma tienen una opinión negativa sobre la AF que podría explicar la escasa AF realizada por sus hijos.

Infant mortality of very preterm infants by mode of delivery, institutional policies and maternal diagnosis.

OBJECTIVE: The aim of this study was to analyse infant mortality among infants born extremely preterm in relation to mode of delivery, maternal diagnosis, and different institutional policies. METHODS: We conducted a national tertiary health care center study using Swedish Medical Birth Register (MBR) data from 1990 to 2002, to examine the 2,094 live births of infants at 23+0 to 27+6 weeks gestation. We assessed the association between mode of delivery, gestational age (GA), calendar year, maternal condition, and institutional policies on infant mortality outcome. RESULTS: At 23-25 weeks, 38% of infants (range: 34-69%) were delivered by cesarean section (CS), while at 26-27 weeks, 66% (59-80%) were delivered by CS. The CS rate for fetal or maternal indications was 98% in cases of pre-eclampsia/eclampsia, 42% for premature rupture of membranes (PROM), 68% for hemorrhage, 76% for PROM+hemorrhage, 56% for breech presentation, and 30% for preterm vertex with no other complications. After cases of pre-eclampsia/eclampsia were excluded, vaginal delivery was associated with a small increase of risk for infant death. Vaginal delivery was associated with a significantly increased risk for infant death in breech presentations and multiple births, while vaginal delivery posed a non-significant risk increase for PROM and hemorrhage. For preterm vertex without any other complications, 4 out of 5 infants were delivered vaginally without any risk increase. CONCLUSION: This study reports high CS rates for very preterm births at Swedish hospitals. In performing CS for very preterm infants, this study suggests a survival advantage for certain maternal conditions, but not for preterm labor with a vertex presentation without other obstetrical complications.

Evolución clínica y de laboratorio en lactantes con inmadurez del centro respiratorio que presentan episodios de apnea

Resumen Los episodios de pausas respiratorias y de respiración periódica son normales en los lactantes, conformando un patrón de sueño normal con el crecimiento. El objetivo de este trabajo fue evaluar un grupo de lactantes con sospecha de apnea, en quienes se encontraron, mediante polisomnografía (PSG1), evidencias de inmadurez del centro respiratorio, indicándose educación en reanimación cardiopulmonar, monitor cardiorrespiratorio (MCRP) y control de polisomnografía (PSG2). Pacientes y método: se incluyeron 34 lactantes entre mayo 1997 y mayo 2001. Apnea fue definida como la ausencia de respiración por 20 segundos (central) y 10 segundos (obstructiva y mixta); pausas respiratorias como ausencia de respiración > 6 < 20 seg (central) y > 6 < 10 seg (obstructiva). Resultados: en todos se incluyó MCRP y se realizó un estudio inicial (PSG1) y final (PSG2); se evaluó las características de la PSG1 y se compara la evolución entre los 2 estudios. La muestra incluyó 22 hombres (65%), la edad promedio de la serie fue de 2,7 ± 2,3 meses ( ± DS), rango 0,3-9 meses. Los diagnósticos de referencia fueron apnea: (n = 27), RGE (n = 2) y cianosis (n = 4). Los eventos respiratorios promedio mostraron un índice total de pausas respiratorias de 14,1/hora, con predominio de centrales, y un porcentaje de respiración periódica de 4,5%. El examen fue anormal en 32 casos por presentar desaturación arterial (n = 23), apneas (n = 8), pausas centrales (n = 19), obstructivas (n = 9) y RGE patológico (n = 5). En relación al segundo examen (PSG2), la edad fue de 11,5 ± 4,5 (rango 6-24 meses). Al comparar PSG1 vs PSG2, hubo diferencias significativas en índice total de pausas (p < 0,01), pausas centrales (p < 0,05) y respiración periódica (p < 0,05). Se concluye que la mayoría de los pacientes con inmadurez del centro respiratorio normalizan sus parámetros al año de vida, y que en éstos es de utilidad un adecuado uso del monitor cardiorrespiratorio.

Summary Introduction: episodes of central pauses and periodic breathing are normal in infants and decrease with age and growth. Objective: to evaluate a group of infants that had a polysomnography (PSG) performed due to an episode of apnea, with elevated immature sleep characteristics and who required home cardiorespiratory monitoring (HCRM) and further control PSGs. Methods: 34 patients, 22 (65%) were male, mean age 27 ± 2 months (PSG1), range 0,3-9 years, were studied between May 1997 and May 2001. Along with the first PSG (PSG1) a second was performed (PSG2) prior to the suspension of HCRM. Apnea was defined as the absence of respiration for more than 20 sec (central) or more than 10 sec (obstructive and mixed); respiratory pauses as the absence of respiration for more than 6 sec and less than 20 sec (central) or more than 6 sec and less than 10 sec (obstructive). Results: the main indications for PSG were apnea (27 pts), cyanosis (4 pts) and gastro-oesophageal reflux (GER) in 2. Respiratory events showed mean respiratory pauses of 14.1/hr, mostly central and periodic breathing during 4,5% of the total sleep time (TST). PSG1 was abnormal in 32 cases, with desaturation in 23, apnea in 8, central pauses in 19, obstructive pauses in 9 and GER in 5. PSG2 was performed at a mean age of 11,5 ± 4 months, range 6-24 months. The comparision of PSG1 vs PSG2 showed significant differences in the total respiratory index (p < 0,01), central pauses (p < 0,05) and periodic breathing (p < 0,05), being always lower in the PSG2. We conclude that the majority of patients with episodes of apnea and immature sleep patterns normalized their sleep pattern in the first year of life. In this group the correct use of HCRM is indicated.

Perfil clínico de lactantes hospitalizados por un episodio de ALTE (Apparent Life Threatening Event) / The clinical profile of infantile apparent life-threatening event (ALTE)

La definición de ALTE (Apparent Life Threatening Event) corresponde a un evento que pone en riesgo la vida de un lactante, caracterizado por cianosis, hipotonía o apnea, y que requiere de maniobras para su recuperación. Objetivo: Evaluar las causas de ALTE en nuestro centro, para estandarizar el enfrentamiento diagnóstico y de tratamiento en nuestros pacientes. Pacientes y Método: Estudio retrospectivo que enroló a 71 pacientes hospitalizados con diagnóstico de ALTE. Resultados: Las causas principales de ALTE fueron idiopático (36%), infección respiratoria viral (29%), síndrome convulsivo (12%), mala técnica de alimentación (14%). Los exámenes que con mayor frecuencia contribuyeron al diagnóstico fueron: inmunofluorescencia (IFD) viral, electroencefalograma (EEG), polisomnograma. Un 49% repitió un ALTE durante su hospitalización. Se realizó educación en reanimación a 71,4% de los padres. Al 42% se les indicó monitor cardiorrespiratorio al alta. Conclusiones: Las causas de ALTE encontradas son similares a lo publicado, destacando la alta frecuencia de ALTE idiopático. Basados en nuestros datos se propone un algoritmo de estudio, tratamiento e indicaciones de monitor cardiorrespiratorio para lactantes con diagnóstico de ALTE. Es necesario realizar un estudio controlado, prospectivo de estudio y tratamiento de esta entidad para poder afirmar y soportar adecuadamente este algoritmo.

ALTE is a life-threatening event characterized by cyanosis, hypotonia or apnea that requires life-support maneuvers for recuperation. Objective: To determine the etiology of ALTE in our center, in order to standardize an approach to the diagnosis and treatment of this entity. Method: Retrospective study of 71 infants younger than 1 year, hospitalized by ALTE. Results: The most common causes of ALTE were idiopathic (36%), viral respiratory infections (29%), feeding technique problems (14%) and seizures (12%), Important diagnostic tests include direct virus inmunofluorescence (IFD), electroencephalography and polisomnography. 49% of patients repeated an ALTE event during hospitalization. 71% of parents received basic life-support education. 42% of patients were sent home with a cardio-respiratory monitor. Conclusions: The causes of ALTE found in our investigation are similar to the ones published on previous studies, standing out the high frequency of idiopathic ALTE. Based on our data, we propose an algorithm for the diagnosis and treatment of infants with ALTE. Prospective-controlled studies related to clinical evaluation and therapy of ALTE are necessary in order to validate this algorithsm.

Quiste laríngeo congénito: una rara causa de estridor en niños / Congenital laryngeal cyst: a rare cause of stridor in children

Introducción: Los quistes laríngeos congénitos (QLC) son una causa rara de estridor en niños. Objetivo: Describir las características clínicas del QLC como responsable de estridor atípico. Caso clínico: Una lactante sana fue evaluada por cuadro agudo de disfonía y estridor asociado a dificultad respiratoria progresiva en ausencia de pródromo respiratorio viral. La nasofibrolaríngoscopía demostró una masa en el ventrículo laríngeo y pliegue aritenoepiglótico izquierdo de 1 cm. La tomografía computada sugirió un QLC único, por lo que se procedió a marsupialización con resección de sus paredes. La evolución fue favorable, con controles posteriores hasta por 3 meses, observando una progresiva disminución del proceso inflamatorio. Conclusiones: Los QLC son una causa de estridor atípico que requieren alta sospecha. Se resalta la necesidad de considerar el estudio anatómico de la vía aérea en todo niño con estridor de curso infrecuente.

Utilidad de la espirometría en preescolares de 4 y 5 años / Utility of spirometry in 4 to 5 -years old preschool patients

Background; Spirometry is the most frequently used pulmonary function test. Previous studies have demonstrated the feasibility of carrying out spirometry in preschool patients. Aim: To describe spirometric values obtained in preschool patients studied in a pediatric pulmonary function laboratory. Patients and methods: We reviewed the spirometries performed -from 1996 to 2004- in 180 preschool patients (4- to 6- years old). Records of volume/time and flow/volume curves of spirometries were obtained with a Schiller SP100 spirometer. Variability of baseline measurements of forced vital capacity (CVF) and forced expiratory volume in one second (FEV1) was analyzed. Results: The average age of the 180 school patients was 5.4 (SD:+/- 0.39) years and 53 percent were male. Either diagnosis or suspicious of asthma was the indication for performing spirometry in 172 (90 percent) of these children. One, two and three acceptable spirometric maneuvers were registered in 18 (10 percent), 99 (55 percent) and 63 (35 percent) patients respectively. Expiratory time was < 3 s in 24.4 percent (n=43), 3 to 6 s in 66 percent (n=116), and > 6 s in 9.6 percent (n=17) of patients. Expiratory time was larger in children >5- compared to <5- years old (4.1 +/- 1.3 s versus 3.1 +/- 0.49 s; p < 0.018). VEF1 variability in 162 children having 2 or 3 acceptable maneuvers was < 0.1 L in 67 percent, < 5 percent in 50 percent and < 10 percent in 80 percent. Spirometry was normal in 80.5 percent, obstructive in 19 percent and restrictive in one patient. Conclusions:We confirmed that most of the preschool patients are able to perform an adequate spirometric test in terms of acceptability and reproducibility. We suggest to study a normal population of preshool children in order to have normal local data available.

Introducción: La espirometría es el método más utilizado para evaluar la función pulmonar. Estudios previos han demostrado la factibilidad de realizar estas pruebas en la edad pre-escolar. Objetivos: Describir los valores espirométricos obtenidos en preescolares derivados al laboratorio de función pulmonar. Material y Métodos: Se analizaron en forma retrospectiva las curvas de volumen/tiempo, flujo/volumen, tiempo espiratorio, CVF y VEF1, de las espirometrías realizadas entre 1996-2004 en 180 preescolares. Se utilizó un espirómetro Schiller SP100. Se analizó el coeficiente de variación para CVF y VEF1. Resultados: Se realizaron espirometrías en 180 menores de 6 años, con edad promedio de 5,4 +/ - 0,39 años, 53 por ciento hombres. La principal indicación de la espirometría fue asma 172/180 (90 por ciento). 10 por ciento de los pacientes realizaron 1 maniobra aceptable, 55 por ciento 2 maniobras y 35 por ciento 3 maniobras reproducibles y aceptables. Considerando el tiempo espiratorio, hubo 43 curvas de < 3 s (24,4 por ciento), 116 de 3 a 6 s (66 por ciento) y 17 sobre 6 s (9,6 por ciento). Comparando los grupos menores y mayores de 5 años, se encontró una diferencia significativa solo en el tiempo espiratorio: 3,1 +/ - 0,49 s en el primer grupo y 4,1 +/ - 0,13 en el segundo (p < 0,018). Al evaluar variabilidad de VEF1 en 162 pacientes que realizaron 2 ó 3 maniobras aceptables se encontró que un 67 por ciento mostraba variabilidad <0,1 L, 50 por ciento < 5 por ciento y 80 por ciento < 10 por ciento. Las espirometrías fueron normales en 145 (80,5 por ciento) preescolares, con alteración obstructiva en 34 (19 por ciento) y con alteración restrictiva en uno (0,5 por ciento). Conclusiones: La mayoría de los preescolares cumplieron con los criterios de aceptabilidad y reproducibilidad. Se sugiere realizar valores normales en población preescolar sana de nuestro país, con el objeto de poder comparar los datos de pacientes con sospecha de patología respiratoria.

Fatal poisoning in Nordic drug addicts in 2002.

The present study from 2002 includes medicolegally examined fatal poisonings among drug addicts in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden. A common definition "drug addict" is applied by the participating countries. The number of deaths, age, sex, place of death, main intoxicant and other drugs present in the blood are recorded in order to obtain national data, as well as comparable Nordic data and data comparable to earlier studies from 1997 and 1991. The Icelandic results are commented on separately due to the low number of cases. The most fatal overdoses are seen in Norway, in both the death rate (number per 100,000 inhabitants=8.44) and in absolute number (n=232). The comparable figures for the other four countries are Denmark 5.43 (n=175), Iceland 3.6 (n=6), Finland 2.93 (n=94) and Sweden 2.56 (n=136). In earlier studies from 1991 and 1997, the highest death rate is seen in Denmark, with Norway as number two. Denmark is the only country where the death rate decreases from 1997 to 2002. A relatively large increase in deaths in the younger age groups (<30 years) is noted from 1997 to 2002, except in Denmark, where only a small increase in overdose deaths in very young people (15-19 years) is observed. Females account for 12-20% of the overdoses (three out of six deaths in Iceland). Relatively fewer deaths are recorded in the capital areas in 2002 than in 1997 and 1991, suggesting more geographically widespread drug use in the Nordic countries. Heroin/morphine is the single most frequently encountered main intoxicant, varying from 10% of the cases in Finland to 72% of the cases in Norway. Finland differs from the other countries in that a high percentage of the fatal overdoses in Finland are not caused by an illicit drug; buprenorphine overdoses are seen, and relatively few deaths resulting from heroin are seen. Methadone is the main intoxicant in 41% of the Danish overdose cases, 15% of the Norwegian cases, 4% of the Swedish cases and none of the Finnish overdose cases, an observation probably linked to different national prescription rules for methadone. The analytical screening reveals extended polydrug use. Frequently seen substances, in addition to the main intoxicant are amphetamine, tetrahydrocannabinol (THC), benzodiazepines and ethanol.

Extremely preterm cesarean delivery: a clinical study.

OBJECTIVES: To describe indications for cesarean section for extremely preterm delivery, peri- and postoperative complications and perinatal outcome. DESIGN: A case-referent study with clinical follow-up. SETTING: A tertiary perinatal center. POPULATION: All deliveries at gestational age <28 weeks at Umeå University Hospital in 1997-2003. For preterm cesarean section referents were women with elective first-time term cesarean section. METHODS: Indications for cesarean section delivery were assessed. Peri- and postoperative complications, asphyxia, and infant survival at discharge were described. RESULTS: The cesarean section rate was 75%, in one third the operation was considered as difficult. Indications for extremely preterm abdominal delivery were severe disease during pregnancy and delivery complications. Six out of ten cesarean sections were performed on fetal indication. Nonisthmic incision was performed in 20% of cases. No major postoperative complications and few minor postoperative complications were noted. Irrespective of mode of delivery, few of the infants had severe asphyxia. CONCLUSION: In balancing the risks of complications related to the surgical procedure against the purported benefits of the infant, this study adds support to the argument to deliver even extremely preterm infants by cesarean section.

Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides.

OBJECTIVE: To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents. METHOD: Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000. RESULTS: There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs. CONCLUSION: The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.

High concentrations of diazepam and nordiazepam in blood of impaired drivers: association with age, gender and spectrum of other drugs present.

A zero-concentration limit for controlled scheduled drugs in the blood of motorists was introduced in Sweden in 1999 and the annual number of arrests for driving under the influence of drugs (DUID) has since increased eight-fold. However, for prescription drugs that might cause impairment (e.g. benzodiazepines) additional proof is needed to justify prosecution, such as whether the medication was being misused. Over a 2-year period, we found 94 cases of DUID in which the concentrations of diazepam in blood was 1.1 microg/g or more. Diazepam (D) and nordiazepam (ND) were determined in whole blood by capillary gas chromatography with a limit of quantitation of 0.05 microg/g for each compound. The mean (median) and maximum concentrations of D were 2.0 microg/g (1.7 microg/g) and 7.8 microg/g and the corresponding ND concentrations were 1.5 microg/g (1.0 microg/g) and 7.6 microg/g, respectively. The concentration of D in blood exceeded 2 microg/g in 21% of cases and was over 3.0 microg/g in 11% of cases. D and ND were the only drugs present in eight cases (seven men and one women) and in another five cases ethanol was present at concentrations ranging from 0.81 to 1.98 mg/g. Polydrug use was very common in these DUID suspects and D and ND coexisted with amphetamine in 20% of cases, tetrahydrocannabinol in 18% of cases and with both these illicit drugs in 12% of cases. The next most prevalent drug combination was D, ND and morphine (mostly derived from heroin), seen in 13% of cases. Other psychoactive prescription drugs were identified in blood including alprazolam, flunitrazepam, oxazepam, zolpidem and zopiclone. This case series of DUID suspects demonstrate the high frequency of polydrug use showing preference for illicit drugs like amphetamine, cannabis and heroin, in that order. Furthermore, Swedish traffic delinquents frequently overdose with prescription drugs as exemplified here by unusually high concentrations of D and its active metabolite ND.