Miguel Angel Rosas-Vargas

Co-administration of salbutamol and fluticasone for emergency treatment of children with moderate acute asthma*

This study aimed to compare the efficacy of nebulized therapy with salbutamol alone or in combination with fluticasone. In a randomized, double‐blind clinical trial, 150 children with moderate acute asthma were randomly assigned to receive by nebulizations either (i) three doses of salbutamol 30 μl/kg per dose, each dose administered every 15 min, (ii) three doses of salbutamol plus two doses of fluticasone 500 μg/dose at 15 and 30 min after first dose of salbutamol, or (iii) three doses of salbutamol/fluticasone 500 μg/dose, each combined dose administered every 15 min. Pulse oxymetry (SaO2), peak expiratory flow (PEF) and Wood et al. (Am J Dis Child, 123, 1972, 123) clinical scale were evaluated at baseline, 15, 30, 45, 60, 90 and 120 min after the first nebulization. Patients in the three groups significantly improved since 15 min after the first nebulization. We did not observe differences in the recovery of SaO2 and PEF among the three groups of treatment (p > 0.10). In group 3, children showed better clinical response at 120 min than the other two groups (p < 0.05). No significant adverse effects were observed with any treatment. To summarize, in children with acute moderate asthma, nebulized salbutamol at an accumulated dose of 90 μl/kg plus fluticasone at an accumulated dose of 1500 μg produced better clinical relief after 2 h. However, similar PEF and SaO2 responses were observed with salbutamol alone or in combination with different doses of fluticasone.

A comparative study of bronchodilator reversibility with albuterol, between asthma symptomatic and asymptomatic children according to ISAAC Questionnaire in Mexico City

BACKGROUND Asthma is an important childhood disease. Recent surveys of the International Study of Asthma and Allergies in Childhood (ISAAC) suggest that the prevalence of asthma is increasing but these surveys do not include any pulmonary tests to confirm the possible diagnosis of asthma. OBJECTIVE To compare bronchodilator reversibility with the albuterol test in symptomatic and asymptomatic 6-7-year-old children with asthma participating in the ISAAC survey and living in Mexico City. PATIENTS AND METHODS We performed an observational, descriptive, comparative, cross sectional study in children participating in phase 3b of the ISAAC study. According to the ISAAC questionnaire children were classified as asthma symptomatic or asymptomatic. Both groups had bronchodilator reversibility with the albuterol test, using the guidelines of the American Thoracic Society to confirm or rule out the diagnosis of asthma. RESULTS The asymptomatic group had a baseline FEV1 of 1.70 +/- 0.34 l/sec (mean +/- SD) and an endpoint FEV1 of 1.76 +/- 0.42 l/sec; in the symptomatic group the respective values were 1.51 +/- 0.41 l/sec and 1.57 +/- 0.44 l/sec (p < 0.05). A positive reversibility test was found in 13/136 (9.6 %) children in the asymptomatic group and in 22/112 (19.6 %) children in the symptomatic group (p < 0.05). CONCLUSION Because of its low sensitivity, bronchodilator reversibility cannot be considered a diagnostic tool to confirm diagnosis of asthma.

Carboplatin hypersensitivity and desensitization in an infant.

Although the reported incidence of carboplatin hypersensitivity is low, it is important to describe it because of its potentially fatal consequences. A 1-year-old Mexican girl weighing 10 kg who had optic nerve glioma was initially scheduled to receive 12 cycles of 600 mg/m2 carboplatin (CBP) as two 300-mg/m2 intravenous infusions administered over 1 hour on 2 different days and a 1-hour intravenous infusion of 1.5 mg/m2 vincristine every 4 weeks. The patient had no history of drug allergies or any type of adverse drug reaction, but she developed itchiness, maculopapular rash, sweating, respiratory distress, and anxiety during the seventh cycle of CBP. According to the algorithm developed by Naranjo et al, the adverse drug reaction was classified as definite secondary to CBP and confirmed by positive skin tests indicating hypersensitivity to the drug. After evaluating the clinical course of the adverse drug reaction and considering the need to continue cancer treatment, a decision was made to desensitize the patient to CBP. The desensitization procedure took 8 hours and was performed during each new chemotherapy cycle until the 12 cycles of chemotherapy were successfully completed. In summary, a case of CBP hypersensitivity in a 1-year-old girl who was successfully desensitized to CBP is reported.

249 Risk Factors Associated to Mortality in Pediatric Patients with Hemophagocytic Lymphohistiocytosis.

Objective Identify risk factors associated to mortality in pediatric patients with hemophagocytic lymphohistiocytosis. Methods Retrospective cross-sectional study of medical records with discharge diagnosis of Hemophagocytic syndrome/Hemophagocytic lymphohistiocytosis (ICD-10; D76.1/D76.2) from Jan2004-May2011 in a pediatric-tertiary-care-center. Descriptive and risk analysis were made on SPSS Statistics V17.0. Results Thirty medical records were analyzed. Median-for-age: 2 years 8 months, (range: 2 months-to-15 years). Sex distribution: 14 girls (47%), 16 boys (53%). Median of symptoms duration: 1 month (range: 3 days-to-7 years). Reported symptoms and physical signs at hospital admission: fever n = 28 (93%), asthenia/adynamia n = 11 (37%), skin findings n = 10 (33%), epistaxis n = 5 (17%), gastrointestinal bleeding n = 4 (13%), hepatomegaly n = 27 (90%), splenomegaly n = 21 (70%), lymphadenopathies n = 14 (47%), paleness n = 14 (47%), purpura n = 5 (17%). Laboratory findings: anemia n = 29 (97%), LDH elevation n = 28 (93%), hypoalbuminemia n = 27 (90%), thrombocytopenia n = 26 (87%), hypertransaminasemia n = 25 (83%), haemophagocytosis n = 22 (73%), hypertrigliceridemia n = 21 (70%), hypofibrinogenemia n = 20 (67%), leucopenia n = 19 (63%), hyperferritinemia n = 15(50%). In 18 patients (60%) active infection was evident at hospital admission: pneumonia n = 9(50%), gastroenteritis n = 2 (11%), meningitis n = 1 (5%), others n = 6 (33%). Epstein-Barr virus infection was diagnosed in 7 patients (23%). All patients were treated according to HLH-2004 guidelines. Overall mortality 63% (n = 19), 9(47%) died from septic-shock, 7 (36%) haemorraghic-shock, and 1(5%) with acute liver failure. Differences between non-survivours and survivours by (x2): hypofibrinogenemia (53%versus 13%; P = 0.039), epistaxis (17% versus 0%; P = 0.023), evident clinical infection (47%versus 13%; P = 0.044), elevated LDH levels (63% versus 30%; P = 0.039), hemophagocytosis (57% versus 17%; P = 0.024). Risk factors associated to mortality: history of epistaxis (OR = 1.78, 95% CI, 1.26-2.52; P = 0.023), evident clinical infection at hospital admission (OR = 2.41, 95% CI, 1.08-5.8; P = 0.044). Normal levels of LDH showed diminished mortality risk (OR = 0.32, 95%, CI, 0.18-0.55; P = 0.039). Conclusions The present study describes the most common clinical, physical and laboratory findings in patients with haemophagocytic lymphohistiocytosis attended in our hospital. We were able to identify risk factors associated to mortality, and 1 protective factor.

396 Risk Factors Associated to Mortality in Mmexican Children with Stevens-Johnson Sndrome/Toxic Epidermal Necrolysis.

Background and Objective Identify risk factors associated to mortality in Mexican children with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Methods Cross-sectional analytical study. We reviewed the medical records of patients with hospitalization and primary diagnosis of Stevens-Johnson syndrome (SJS) or Toxic Epidermal Necrolysis (TEN) from January 1995 to May 2011. Our study variables have been previously described. We describe median (interquartilar range: IR) and percentage. Exact Fisher test, Mann Withney U and binary logistic regression were used. Results We obtained 51 medical records: 24 male (47.1%), 27 female (53%). Median age was 5 years (IR 2–8). Thirty eight (76%) corresponded to SJS, four (7.8%) to SJS-TEN overposition and nine (15.7%) to TEN. Mortality was seen in 9 patients (17.6%, 6 male [66.8%] and 3 female [33.3%], P > 0.05). Twenty two cases (43%) were attributed to anticonvulsive drugs, twenty (39%) to antibiotics, two (4%) to non-steroid anti-inflammatory drugs, two (4%) to infection, one (2%) to chemotherapeutic drugs, and in two (4%) no trigger factor was identified. Risk factors associated to mortality were: denudation of >30% Body Surface Area (BSA) (7.1% vs 55.6% P < 0.001), concomitant malignancy (0% vs 22.2% P < 0.028), moderate leucopenia (<1,000 cells/mL) (0% vs 33.3%, P < 0.001), leucocytosis (>20,000 cells/mL) (7.3% vs 22.2%, P < 0.001), hypokalemia (<3.5 mEq/L) (5.6% vs 33.3%, P < 0.011), hyperkalemia (>5.0 mEq/L) (5.6% vs 22.2%, P < 0.011). Total bilirrubin concentration >3.6 mg/dL has tendency to associate with mortality, P = 0.08. Six patients (11.7%) were treated with steroids, fifteen (29.4%) with IV human immunoglobulin and one (1.9%) with both drugs, no statistical difference was observed, though the steroid-treated group showed a tendency towards mortality increase. Some variables were not able to analyze due incomplete medical records. Conclusions Risk factors associated to mortality in patients with SSJ/TEN identified in this study are: skin denudation >30% BSA, concomitant malignancy, leucopenia, leukocytosis, hypokalemia and hyperkalemia. Total bilirrubin concentration >3.6 mg/dL has tendency to associate with mortality, although not statistically significant.

179 Evaluation and Comparison of Lung Function by Plethysmography in Adolescents with Morbid Obesity, not Morbid Obesity and Healthy Eutrophic Children.

Background The objective was to measure and compare lung function by plethysmography in young healthy children, obese and morbidly obese. Methods Cross-sectional, prospective study in 150 adolescents from 11 to 17 years old, grouped according to their body mass index (BMI): group 1 (G1) healthy eutrophic (BMI percentile 10–84 of the boards of the CDC) Group 2 (G2) not morbidly obese (BMI 85–98) and group 3 (G3), morbidly obese (BMI> 99). Anthropometry was performed and plethysmography. Statistics: mean, standard deviation (SD), confidence interval 95%, CI 95%. ANOVA post hoc analysis. Results The mean age was 13.7 years, 46.7% women and 53.3% men. G1 had 40 children, G2 had 67 and G3 had 43. Mean values and CI 95% of vital capacity (VC) of G1 was 104.97% (100.12–109.82), G2 114.65% (111.36–117.94), G3 118.09% (112.71–123.47) [G1 with significant difference compared the G2 and G3 P <0.05]. The total lung capacity (TLC) was 124.67% G1 (105.94–143.40), G2 145.61% (114.77–176.45), G3 132.27% (125.14–139.41) [no intergroup difference]. Functional residual capacity (FRC) of G1 was 145.95% (133.75–158.14), G2 122.41% (110.23–134.59), G3 115.74% (103.05–128.43) [G1 with significant difference compared with the G2 and G3 P <0.05]. The expiratory reserve volume (ERV) of G1 was 113.15% (90.57 – 135.72), G2 68.64% (60.34 – 76.93), G3 67.33% (52.40 – 82.26) [In contrast to the G1 compared to G2 and G3 P <0.05]. Inspiratory capacity (IC) in G1 was 76.90% (66.94–86.85), G2 102.04% (94.94–109 145), G3 115.72% (105.61–125.82) [G1 with significant difference compared with the G2 and G3 P < 0.05]. Conclusions The morbidly obese have a lower FRC and ERV and increased IC and CV.

46 prevalence and Associated Risk Factors for Atopic Dermatitis Symptoms in Mexican Children

Background Describe AD prevalence and identify associated risk factors in Mexican children. Methods Multi-centric, cross-sectional ambiental survey. We applied the standardized Spanish-version ISAAC questionnaire to childrens tutors aged 6 to 7 years in 8 Mexican cities. Sampling units randomly selected from local schools with advisable sample size of 3000 questionnaires per centre. Questions to evaluate actual AD: Has your child had itchy rash at any time in the past 12-months? Has this itchy rash at any time affected any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks or around the neck, ears or eyes? A risk analysis was made through multivariate logistical regression, central tendency and dispersion measures were obtained with respective 95% confidence intervals. Results A total of 25,809 questionnaires were applied at 274 schools. For current AD symptoms 18,095 questionnaires were analyzed and for severe current AD symptoms 19,173. Current AD symptoms mean global prevalence was 6.1% (95% CI, 5.7-6.4%). Mean prevalence and 95% CI per center: Monterrey 4.2% (3.5-4.9%), Mexicalli 6.3% (5.3-4.9%), Ciudad Victoria 2.3% (1.8-2.9%), Tijuana 4.9%(4.1-5.7%); North DF 8.5% (7.6-9.4%), Southeasat DF 9.4% (8.0-10.7%), Toluca 5.4% (4.6-6.2%); Veracruz 5.3% (4.3-6.2%); Villahermosa 8.6% (7.3-9.8%). Severe current AD symptoms mean global prevalence was 0.7% (95% CI, 0.6-0.9). Mean prevalence and 95% CI per center: Monterrey 0.6% (0.3-0.9%), Mexicalli 0.8% (0.5-1.2%), Ciudad Victoria 0.3% (0.1-0.6%), Tijuana 0.9% (0.5-1.2%); North DF 1.1% (0.7-1.5%), DF Southeast 1% (0.5-1.4%), Toluca 0.3% (0.1-0.5%); Veracruz 0.7% (0.4-1.1%); Villahermosa 1.2% (0.8-1.7%). Identified risk factors for current AD symptoms: presence of allergic rhinitis symptoms OR 1.94 (95% CI, 1.53-2.14; P ⩽ 0.005); conjunctivitis symptoms OR 1.81 (95% CI, 1.53-2.14; P ⩽ 0.005); accumulated asthma symptoms OR 1.51 (95% CI, 1.3-1.76; P ⩽ 0.03). Identified risk factors for severe current AD symptoms: presence of conjunctivitis symptoms OR 2.20 (95% CI, 1.42-3.4; P ⩽ 0.005); accumulated asthma symptoms OR 2.16 (95% CI, 1.38-3.39; P ⩽ 0.005); use of acetaminophen in the first year of life OR 1.80 (95% CI, 1.21-2.69; P ⩽ 0.005). Conclusions Current AD symptoms prevalence was higher at north DF, followed by Toluca and southeast DF; current severe AD symptoms were higher at Villahermosa, followed by north DF and Tijuana. The presence of rhinoconjuntivitis and accumulated asthma symptoms doubles the risk for current AD and current severe symptoms in Mexican children and Acetaminophen use in the first year of life was associated with severe current AD symptoms.