[Respiratory emergencies]

Respiratory emergencies in a patient with cancer can have their origin in pathologies of the airway, of the pulmonary parenchyma or the large vessels. The cause can be the tumour itself or concomitant complications. Obstruction of the airway should be initially evaluated with endoscopic procedures. Surgery is rarely possible in serious situations. The endobronchial placement of stents or radioactive isotopes (brachytherapy), tumoural ablation by laser or photodynamic therapy can quickly alleviate the symptoms and re-establish the air flow. Treatment of haemoptysis depends on the cause that is provoking it and on its quantity. Bronchoscopy continues to be the front line procedure in the majority of cases; it provides diagnostic information and can interrupt bleeding through washes with ice-cold serum, endobronchial plugging or topical injections of adrenaline or thrombin. External radiotherapy continues to be an extraordinarily useful procedure in treating haemoptysis caused by tumours and in carefully selected situations of endobronchial therapy with laser or brachytherapy, and bronchial arterial embolisation can provide a great palliative effect. Respiratory emergencies due to pulmonary parenchyma disease in the oncology patient can have a tumoural, iatrogenic or infectious cause. Early recognition of each of these will determine the administration of a specific treatment and the possibilities of success.

[Medullar compression]

Medullar compression is an oncological and neurological emergency, whose diagnosis and early treatment are key factors for avoiding severe and irreversible neurological damage. Paralysis, loss of consciousness and alteration in control of the sphincters are the final consequence of the process, and represent an important source of morbidity of the oncology patient, besides being related to a shorter time of survival. The invasion of the vertebral body by haematogenous dissemination is the most frequent cause of medullar compression. On occasions it can create mechanical vertebral instability which represents a real orthopaedic emergency. Pain is the earliest and most frequent symptom. The signs and symptoms appear to the degree that the process advances, passing through motor weakness, alterations in consciousness until paralysis and incontinence of the sphincters are reached, as a result of complete neurological damage. Clinical history and physical exploration should lead to suspicion about the level at which medullar compression is developing, and the most important complementary exploration is MR of the entire spine, which should be requested immediately in order to decide on starting treatment. Treatment is individualised and must be started early. In general, corticoids in combination with radiotherapeutic oncological treatment and/or surgery are the therapeutic weapons to employ.

[Acute dysphagia of oncological origin. Therapeutic management]

Dysphagia is one of the most frequent syndromes in patients with tumours of the head and neck, and the oesophagus. This can be the initial symptom or, more frequently, related to the oncological treatment. We review the most important therapeutic and physio-pathological aspects of acute dysphagia of oncological origin. Deglutition is a complex process in which numerous muscular-skeletal structures intervene under the neurological control of different cranial nerves. The complex neuro-muscular coordination needed for a correct deglutition can be affected by numerous situations, both from the effect of the tumours and from their treatment, basically surgery or radiotherapy. In conclusion, it can be affirmed that for a suitable treatment of oncological dysphagia, a correct initial evaluation and an active treatment are required, since not only the patient's quality of life but, on numerous occasions, the possibility of continuing the treatment and thus maintaining the possibilities of a cure depend on control of the dysphagia.

[Malign obstruction of the superior vena cava]

The present paper offers a review of the malign syndromes of the superior vena cava, their clinical expressions related to the anatomical characteristics of the compartment where the superior vena cava runs, the diagnostic requirements for realising treatment under the best conditions and the ensemble of measures that must be adopted in dealing with this.

[Metastatic bone disease. Diagnosis and treatment]

The high incidence of bone metastasis secondary to carcinomas and its serious functional repercussion are motives for constant study and advance in the methods of evaluation, diagnosis and treatment. Pain is the most frequently shown symptom, although at times the start is a pathological fracture. The classic tests of detection and evaluation of the spread of the metastatic disease, simple radiology and gammagraphy, are today complemented by others such as computerised tomography (CT) and magnetic resonance (MR), improving the information on the characteristics of the lesion both inside and outside the bone. On the other hand, positron emission tomography (PET) is showing a far higher sensitivity than gammagraphy and will probably be the test of the future for the early detection of metastasis and of silent primary tumours. The possibilities of treatment of bone metastasis are based on the use of bone regenerators, radiotherapy and surgery. The former two are indicated in lesions already detected in radiography, whether symptomatic or not, if there is no foreseeable risk of fracture. Surgery is indicated in situations of poor or null response to those treatments, when the risk of fracture is high or a pathological fracture has been produced. Before any therapeutic planning, a detailed evaluation of the patient must be carried out, both at a local level (size, site, extension of the metastasis) and general (type of primary tumour, phase of treatment and response, estimated survival).

[Neutropenia and fever in the patient with cancer]

Infection in the immunocompromised host is a serious clinical situation due to its high morbi-mortality and is one of the most frequent complications in the patient with cancer. In patients treated with chemotherapy, the risk of infection basically depends on the duration and intensity of the neutropenia. It is essential to evaluate, the most probable pathogen involved to initiate, a priori, the most suitable treatment, and also to evaluate the general clinical situation of the patient, because from the very beginning the treatment is quite aggressive. Outpatient care is possible for patients at "low risk" of complications. By evaluating the antecedents and clinical history of the patient, through physical exploration and from the data of laboratory and radiological explorations these points can be acknowledged. The early start of broad spectrum antibiotherapy is crucial, and in this chapter we review the most recent therapeutical recommendations.

Hepatitis A in Latin America: a changing epidemiologic pattern

In a multicenter study, hepatitis A virus (HAV) seroprevalence was surveyed in six countries in Latin America in which in 12,000 subjects were stratified for age. The highest rates of seroprevalence were recorded in the Dominican Republic (89.0%) and Mexico (81.0%), with lower rates in Brazil (64.7%), Chile (58.1%), Venezuela (55.7%), and Argentina (55.0%). The seroprevalence of HAV in children between 1 and 5 years of age was less than 50%, except in the Dominican Republic. In the 5-10-year-old age group, seroprevalence rates have also decreased compared with previous reports. This suggests that the epidemiology is shifting from high to intermediate endemicity, with the population susceptible to HAV infection shifting from children to adolescents and adults. Furthermore, data from Brazil, Argentina, and Mexico show that HAV seroprevalence is significantly lower in people living in medium and high socioeconomic conditions. This study suggests the need for appropriate vaccination programs to be implemented targeting children, adolescents, and adults, particularly in higher socioeconomic groups.

Epidemiology of cystic fibrosis in Latin America: preliminary communication

We conducted a retrospective study of 743 patients with cystic fibrosis (CF), covering the 1979-89 period in 4 Latin American (LA) institutions to evaluate the clinical features of the disease. The review, although dealing only with patients referred to, or diagnosed at these institutions may be considered to comprise the majority of patients living in these areas. Diagnosis was confirmed by the sweat test in all cases. There was a slight predominance of males, (61.0%) mainly in the Brazilian group. The mean age at diagnosis was over 3 years. This was similar to the mean age at admission. Almost half of the patients were still alive at follow-up, but their mean age was low (6.4 years in Brazil, 7.4 in Chile, 9.6 in Mexico, and 11.3 in Argentina). Mean age at death ranged from 3.1 years (Chile) to 8.7 years (Argentina). The highest proportion of living patients was in Chile (71.4%) and the lowest in Argentina (33.8%). Survival curve comprised 15 years after diagnosis for the Argentinian group, compared to 6 years for the remaining groups. Fifty percent of the patients lived 6-7 years after diagnosis in Argentina, 4-5 years in Mexico and Chile, and 3 years in Brazil. Among Argentine patients 39.2% survived to 10 years of age, and 18% to 15 years. These findings suggest that CF is not rare in LA but extensive epidemiological studies are needed to obtain accurate figures on the magnitude of the problem.

[School achievement and neurologic examination: a 7-years' correlation study]

Neurological examination and school performance were analyzed in 146 children from a longitudinal follow up on growth and development at northern metropolitan Santiago, Chile. Their reading and writing abilities and their performance on neuro-maturational tests at the third elementary grade, were compared with academic achievements seven years later and highly significant correspondence was found among these terms. Reading comprehension and simple arithmetic problem solving abilities were the most affected aspects in children that exhibited multiple subtle neurological abnormal signs. Writing and design abilities were also involved up to a certain degree. Intellectual endowment was a determinant factor in this relationship since children above average. I.Q. showed less neurological involvement and better academic qualifications and vice versa. Subjects with many subnormal neuro-maturational signs had relative under-ratings at school examinations, whichsoever their mental level was. Thirty percent of the initial 208 study case were missed in the 7 year time span: Most of them were unable to read and write properly at third elementary school grade, showed evidence of several minor neurological failures and abandoned school in the mean time. By contrast, 96% of the index group could be reexamined. This bias implies that between early learning plus neurological status, at age 9 years and the later academic performance should have been an extremely positive interrelationship for the whole series.

Electrolyte levels in the CSF of children with nontumoral hydrocephalus. Relation to clinical parameters

The levels of calcium and magnesium (by atomic absorption spectrophotometry), sodium and potassium (by flame photometry), inorganic phosphate and proteins (by spectrophotometry) were measured in the CSF of 27 children with hydrocephalus and compared with the CSF data on 10 controls, so as to study the effect of the blood-brain and blood-CSF barrier alterations observed in hydrocephalus, on the CSF electrolytes. Ca (P less than 0.001), Mg (P less than 0.01) and phosphate (P less than 0.05) were found to be increased, K (P less than 0.01) decreased, and Na levels not significantly altered. Linear regression analysis of hydrocephalic patients showed a linear correlation (r = +0.62) between phosphate and proteins (P less than 0.01) and (r = +0.66) between phosphate and Ca (P less than 0.001). Comparison of control CSF electrolyte levels with those found in the CSF of hydrocephalic patients were grouped according to clinical variables: sex (F, M), age (less than or equal to 1.5 months, greater than 1.5 months), etiological variants (congenital, acquired), treated infection (no, yes), surgical treatment (no, yes), time of onset (less than or equal to 1 month, greater than 1 month), ventricular dilation (mild, severe) and intracranial hypertension (mild or severe). These comparisons showed specific increases of Mg for males (P less than 0.05), acquired hydrocephalus (P less than 0.05) and severe intracranial hypertension (ICH) (P less than 0.001), moderate decrease in the Na levels in acquired hydrocephalus (P less than 0.05) and mild ICH (P less than 0.05), specific increases of phosphate in females (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)