Daño hepático inducido por fármacos antituberculosos. ¿Qué debemos hacer en un caso pediátrico? / Antituberculous drug-induced liver injury. What we have to do with pediatric patients?

El daño hepático inducido por fármacos antituberculosos (DHIFAT) es el efecto secundario potencialmente grave más frecuentemente asociado a la toma de estos medicamentos. Los niños más pequeños, los que padecen formas extrapulmonares y los que reciben dosis altas de pirazinamida son los que presentan mayor riesgo de sufrir hepatotoxicidad con el tratamiento antituberculoso. En pediatría no existen consensos ni recomendaciones específicas de cómo manejar el DHIFAT. Presentamos el caso de una niña de 3 años diagnosticada de meningitis tuberculosa que sufrió DHIFAT y detallamos cómo se realizó el manejo de la situación, sin detrimento de completar la pauta terapéutica antituberculosa, tal como recomiendan los estándares de tratamiento. Tras una búsqueda y lectura de la literatura científica relacionada, hemos realizado la síntesis de los aspectos prácticos más relevantes para el manejo de estas situaciones inusuales para el pediatra general

Antituberculous drug-induced liver injury (ATDILI) is the most common and potentially serious adverse effect reported. Younger children, patients with extrapulmonary tuberculosis and children who are treated with high dosis of pyrazinamide are on serious risk for hepatotoxicity. There aren’t either consensus or specific recommendations about ATDILI in children. We report a case of tuberculous meningitis in a three year old girl who developed hepatotoxicity and provide some insight into its management. We performed a review of the published literature and made an update about management of ATDILI in paediatric patients

Sublingual immunotherapy in children

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A comparison of two clinical scores for bronchiolitis. A multicentre and prospective study conducted in hospitalised infants

Background: There are a number of clinical scores for bronchiolitis but none of them are firmly recommended in the guidelines. Method: We designed a study to compare two scales of bronchiolitis (ESBA and Wood Downes Ferres) and determine which of them better predicts the severity. A multicentre prospective study with patients <12 months with acute bronchiolitis was conducted. Each patient was assessed with the two scales when admission was decided. We created a new variable "severe condition" to determine whether one scale afforded better discrimination of severity. A diagnostic test analysis of sensitivity and specificity was made, with a comparison of the AUC. Based on the optimum cut-off points of the ROC curves for classifying bronchiolitis as severe we calculated new Se, Sp, LR+ and LR- for each scale in our sample. Results: 201 patients were included, 66.7% males and median age 2.3 months (IQR = 1.3-4.4). Thirteen patients suffered bronchiolitis considered to be severe, according to the variable severe condition. ESBA showed a Se = 3.6%, Sp = 98.1%, and WDF showed Se = 46.2% and Sp = 91.5%. The difference between the two AUC for each scale was 0.02 (95%CI: 0.01-0.15), p = 0.72. With new cut-off points we could increase Se and Sp for ESBA: Se=84.6%, Sp = 78.7%, and WDF showed Se = 92.3% and Sp = 54.8%; with higher LR. Conclusions: None of the scales studied was considered optimum for assessing our patients. With new cut-off points, the scales increased the ability to classify severe infants. New validation studies are needed to prove these new cut-off points (AU)

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A comparison of two clinical scores for bronchiolitis. A multicentre and prospective study conducted in hospitalised infants.

BACKGROUND: There are a number of clinical scores for bronchiolitis but none of them are firmly recommended in the guidelines. METHOD: We designed a study to compare two scales of bronchiolitis (ESBA and Wood Downes Ferres) and determine which of them better predicts the severity. A multicentre prospective study with patients <12 months with acute bronchiolitis was conducted. Each patient was assessed with the two scales when admission was decided. We created a new variable "severe condition" to determine whether one scale afforded better discrimination of severity. A diagnostic test analysis of sensitivity and specificity was made, with a comparison of the AUC. Based on the optimum cut-off points of the ROC curves for classifying bronchiolitis as severe we calculated new Se, Sp, LR+ and LR- for each scale in our sample. RESULTS: 201 patients were included, 66.7% males and median age 2.3 months (IQR=1.3-4.4). Thirteen patients suffered bronchiolitis considered to be severe, according to the variable severe condition. ESBA showed a Se=3.6%, Sp=98.1%, and WDF showed Se=46.2% and Sp=91.5%. The difference between the two AUC for each scale was 0.02 (95%CI: 0.01-0.15), p=0.72. With new cut-off points we could increase Se and Sp for ESBA: Se=84.6%, Sp=78.7%, and WDF showed Se=92.3% and Sp=54.8%; with higher LR. CONCLUSIONS: None of the scales studied was considered optimum for assessing our patients. With new cut-off points, the scales increased the ability to classify severe infants. New validation studies are needed to prove these new cut-off points.

Análisis de los factores ligados al diagnóstico del trastorno por déficit de atención e hiperactividad en la infancia / Analysis of the factors linked to a diagnosis of attention deficit hyperactivity disorder in children

Introducción: El trastorno por déficit de atención e hiperactividad (TDAH) es un trastorno neuropsiquiátrico de origen multifactorial. El objetivo de este estudio es determinar el porcentaje de pacientes que presentan TDAH del global de los enviados a la consulta por este motivo, y explorar los factores epidemiológicos y clínicos asociados al diagnóstico. Pacientes y métodos: Estudio retrospectivo analítico de una muestra de pacientes derivados a la consulta de neuropediatría por sospecha de TDAH, a la que se le aplican los criterios diagnósticos del DSM-IV. Se realiza un análisis de regresión logística para explorar los factores asociados al diagnóstico. Resultados: De los 280 pacientes, 224 eran varones (relación niños/niñas 4/1) con una edad media ± desviación estándar de 8,4±3,08 años. El 49% fue remitido desde el ámbito escolar. El 64,9% de ellos nacieron en el segundo semestre del año, fenómeno que es más acusado en las mujeres. Tras la evaluación de los sujetos, un total de 139 casos fueron diagnosticados (49,7%). Los factores asociados a un incremento de diagnósticos de TDAH fueron: el sexo varón, el TDAH parental, trastornos del sueño asociados, la presencia de tics y la ausencia de retraso del desarrollo psicomotor. Conclusiones: Solo la mitad de los niños enviados con sospecha de TDAH fueron diagnosticados del trastorno. La mayoría se encuentra entre los más jóvenes del curso escolar, sugiriendo una sobreestimación de la sospecha. Una entrevista clínica donde se explore la psicopatología parental, los trastornos del sueño y los tics parece necesaria para mejorar el proceso diagnóstico (AU)

Introduction: Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric disorder originating from multiple factors. The aim of this study is to determine the percentage of patients with ADHD out of all patients referred to our clinic for assessment, and to explore the epidemiological and clinical factors linked to this diagnosis. Patients and methods: retrospective analytical study of a sample of patients under 15 years old sent to the paediatric neurology clinic for suspected ADHD. DSM-IV criteria were used for diagnosis. We completed a binary logistic regression analysis to determine which risk factors were associated with the diagnosis. Results: Of the 280 selected patients, 224 were male (male/female ratio 4:1); mean age (SD) was 8.4 (3.08) years. Almost half (49%) of the patients were referred by their schools and 64.9% were born in the second half of the year, but this tendency was more marked in girls than in boys. Assessment according to DSM-IV criteria resulted in diagnosis of 139 subjects (49.7%). The risk factors linked to diagnosis were male sex, parents with ADHD, associated sleep disorders, tics, and absence of neurodevelopmental delay. Conclusion: Only half of the children referred for suspected ADHD were diagnosed with that condition, and most were among the youngest in their classes, which suggests that suspected ADHD is overestimated. An exhaustive clinical interview investigating the family's psychological disorders and the patient's sleep disorders and tics is needed to improve the diagnostic process (AU)

Analysis of the factors linked to a diagnosis of attention deficit hyperactivity disorder in children. / Análisis de los factores ligados al diagnóstico del trastorno por déficit de atención e hiperactividad en la infancia.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric disorder originating from multiple factors. The aim of this study is to determine the percentage of patients with ADHD out of all patients referred to our clinic for assessment, and to explore the epidemiological and clinical factors linked to this diagnosis. PATIENTS AND METHODS: retrospective analytical study of a sample of patients under 15 years old sent to the paediatric neurology clinic for suspected ADHD. DSM-IV criteria were used for diagnosis. We completed a binary logistic regression analysis to determine which risk factors were associated with the diagnosis. RESULTS: Of the 280 selected patients, 224 were male (male/female ratio 4:1); mean age (SD) was 8.4 (3.08) years. Almost half (49%) of the patients were referred by their schools and 64.9% were born in the second half of the year, but this tendency was more marked in girls than in boys. Assessment according to DSM-IV criteria resulted in diagnosis of 139 subjects (49.7%). The risk factors linked to diagnosis were male sex, parents with ADHD, associated sleep disorders, tics, and absence of neurodevelopmental delay. CONCLUSION: Only half of the children referred for suspected ADHD were diagnosed with that condition, and most were among the youngest in their classes, which suggests that suspected ADHD is overestimated. An exhaustive clinical interview investigating the family's psychological disorders and the patient's sleep disorders and tics is needed to improve the diagnostic process.

La variabilidad en el manejo de la bronquiolitis. ¿Por qué no hacemos lo que leemos? / The variability in the management of bronchiolitis. Why don’t we do what we read?

Introducción: Pese a que el tratamiento de la bronquiolitis continúa siendo un tratamiento de soporte, se ha documentado una extensa utilización de fármacos en todos los ámbitos. Los objetivos de este estudio eran conocer el manejo de la bronquiolitis en los diferentes niveles asistenciales y analizar si alguno de los factores profesionales influye en las posibles diferencias encontradas. Material y métodos: Estudio observacional de corte transversal mediante la realización de una encuesta orientada a conocer los procedimientos terapéuticos de los profesionales que atienden a los pacientes con bronquiolitis en España. Resultados: De los 402 encuestados, un 89,1% eran pediatras y el 10,9% médicos de familia. El 68,8% afirmaba utilizar el salbutamol en ocasiones, y el 57,2% lo usaba cuando la prueba broncodilatadora era positiva. El 43% no utilizaba el suero salino hipertónico y un 25,7% del total comentaba no disponer del mismo. El 56,2% refería utilizar corticoides sistémicos, y un tercio de los encuestados reconocía emplear en ocasiones la fisioterapia respiratoria. El 87% consideraba que la enfermedad no se maneja de acuerdo con las mejores pruebas disponibles. Existían diferencias según la especialidad: los médicos de familia eran quienes prescribían más salbutamol y fisioterapia respiratoria. En cuanto al ámbito asistencial, los pediatras hospitalarios administraban más suero salino hipertónico, y los de atención primaria más salbutamol y mucolíticos/antitusivos. Conclusiones: El uso de fármacos sin eficacia contrastada continúa siendo una práctica extendida en nuestro país para el tratamiento de la bronquiolitis, con diferencias entre los ámbitos asistenciales y la especialidad de los profesionales (AU)

Introduction: Despite the fact that the treatment of bronchiolitis remains a support therapy, a big use of drugs has been documented. The aims of this study were to know the management of bronchiolitis in the different settings and to assess if there was a professional factor linked to the possible differences found. Material and methods: Observational and cross-sectional study consisting in a national survey pointed to identify the treatment proceedings of the doctors who attend patients with bronchiolitis in Spain. Results: A total of 402 doctors were asked, 89.1% were pediatricians and 10.9% general practitioners. Sixty eight percent of them said they prescribe salbutamol sometimes, and 57.2 % tend to use it when the bronchodilator test is positive. Saline hypertonic was not used by the 43% of practitioners, 25,7% of them commented not to get it available. Fifty six percent declared to use systemic steroids and a third of them prescribe physiotherapy occasionally. Eighty percent of doctors considered that bronchiolitis is not managed according the best evidence available. There were differences between the specialists, being general practitioners those who prescribe more salbutamol and respiratory physiotherapy. Regarding pediatricians, those who work in hospitals tend to use more saline hypertonic, and those who attend patients in the primary setting more salbutamol and mucolytics/ antitussive. Conclusions: The use of drugs without proved efficacy for bronchiolitis is a common practice in Spain, with differences between the health settings and the specialist who manage the patient (AU)

La importancia de conocer y reconocer el espectro del síndrome alcohólico fetal / The importance of knowing and recognizing the fetal alcohol syndrome spectrum

Artículo valorado críticamente: Elliott EJ, Payne J, Morris A, Haan E, Bower C, Paediatrician contributing to the Australian Paediatric Surveillance Unit. Fetal alcohol syndrome: a prospective national surveillance study. Arch Dis Child. 2008;93;732-7. Conclusiones de los autores del estudio: este estudio epidemiológico prospectivo nacional (el primero conocido en el mundo) pone de manifiesto la gravedad, complejidad e impacto en el desarrollo de esta enfermedad. Es necesario un diagnóstico precoz y estrategias preventivas concretas. Comentario de los revisores: el síndrome alcohólico fetal es una enfermedad prevenible. Necesitamos formación para sospechar esta entidad y para realizar un diagnóstico precoz, con capacidad para reconocer todo el espectro de esta entidad (AU)

Critically appraised article: Elliott EJ, Payne J, Morris A, Haan E, Bower C, Paediatrician contributing to the Australian Paediatric Surveillance Unit. Fetal alcohol syndrome: a prospective national surveillance study. Arch Dis Child. 2008;93;732-7. Authors' conclusions: this epidemiologic prospective study, the first national data in the world, shows the complexity, severity and developmental impact of fetal alcohol syndrome. We need preventive approaches and early diagnosis. Reviewers' commentary: fetal alcohol syndrome is a predictable disease. We need the to have the knowledge to suspect it and also to make an early diagnosis and be able to recognize the broad spectrum of presentations of this disorder (AU)

Poligrafía respiratoria límites y aplicaciones / No disponible

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