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Documento conjunto de Sociedad Chilena de Infectologia, Sociedad Chilena de Medicina Intensiva y Sociedad Chilena de Enfermedades Respiratorias

The urinary tract infection (UTI) is one of the most common bacterial infections in childhood. An adequate diagnosis is essential to be able to carry out a rational, efficient and effective treatment, however, there is great heterogeneity in diagnostic methods, specifically in the study of antimicrobial susceptibility. The aim of these recommendations is to provide tools to homogenize the diagnosis criteria, susceptibility study and antimicrobial treatment of urinary tract infection in the pediatric population, with a rational use of antibiotics approach. In the first part, the recommendations regarding diagnosis were presented, such as sampling and cut-off points, as well as microbiological considerations for susceptibility study and management of UTI in pediatrics. This second part details the management of complications, UTI in special situations, and pharmacokinetic and pharmacodynamic considerations of antimicrobials to be prescribed in UTI.

The urinary tract infection (UTI) is one of the most common bacterial infections in childhood. An adequate diagnosis is essential to be able to carry out a rational, efficient and effective treatment, however, there great heterogeneity in diagnostic methods, specifically in the study of antimicrobial susceptibility. The aim of these recommendations is to provide tools to homogenize the diagnosis criteria, susceptibility study and antimicrobial treatment of urinary tract infection in the pediatric population, with a rational use of antibiotics approach. In the first part, the recommendations regarding diagnosis are presented, such as sampling and cut-off points, as well as microbiological considerations for susceptibility study and management of UTI in pediatrics. The second part details the management of complications, UTI in special situations, and pharmacokinetic and pharmacodynamic considerations of antimicrobials to be prescribed in UTI.

Orientador: Maria Luiza Moretti Branchini Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: No Brasil, a carência de leitos hospitalares públicos especializados acarreta super lotação dos pronto-socorros e permanência de pacientes em observação por longos períodos, resultando em complicações como colonização por bactérias multi droga resistentes (MDR) e aquisição de infecções hospitalares. METODOLOGIA: No período de março de 1996 a junho de 1998 foi realizado um estudo tipo caso-controle nos pacientes assistidos na unidade de observação do pronto-socorro (UOPS) do Hospital das Clínicas (HC) - UNICAMP, para determinação de fatores de risco associados à colonização por bactérias MDR e pelo Acinetobacter baumannii MDR As cepas de A.baumannii MDR foram ana1iAAnas por dos métodos de tipagem molecular do DNA plasmidial e do DNA genômico por eletroforese em campo pulsátil (pFGE). Para o estudo da colonização por bactérias MDR foram realizadas coletas semanais de secreções de orofaringe, nasofaringe e endotraqueal dos pacientes assistidos na UOPS. O teste de Qui-quadrado, ou teste Exato de Fisher foram aplicados para a comparação entre proporções. Para variáveis contínuas ou ordenáveis entre três ou mais grupos, utilizou-se o teste de Kruskal-Wallis e o teste de Pearson para correlação linear. O critério de seleção de variáveis adotado foi o "stepwise" e o nível de significância adotado em todos os testes foi de 5%. RESULTADOS: Foram coletadas 481 amostras de secreções respiratórias em 232 pacientes e a taxa de colonização por MDR Joi de 25,43% (59 casos e 173 controles). Foram isolados 179 microrganismos e destes, 78 (16,21%) eram bactérias MDR Os isolados MDR foram o Acinetobacter baumannií (n=55), Staphylococcus aureus (n=21) e Pseudomonas aeruginosa (n=2). O tempo de permanência no PS foi de 13,9 dias para os casos e 9,8 dias para os controles (p=0,998). O tempo médio para diagnóstico da colonização foi de 9,9 dias (variação 3 a 25 dias). A doença neurológica representou 68% dos casos e 51 % dos controles (p=0,024). Na análise multivariada dos fatores de risco para colonização foram significativos a idade (p=0,05), uso de ventilação mecânica (p=0,0001) Abstract: The absence of adequate number of beds in public hospitals for severely ill patients in Brazil leads to an excessive number of patients housing in the emergency rooms (ER). The prolonged permanence in these units resulting in patients colonization and hospital infections due to multi drug resistant (MDR) bacteria. Between March 1996 to June 1998 a case-control study was performed in patients housing in the ER of Hospital das Clínicas (HC)-UNICAMP. We studied the risk factors associated with colonization of nasal, oropharyngeal and tracheal secretions by MDR bacteria and MDR Acinetobacter baumannii. A molecular typing ana1ysis using plasmid DNA and pulsed-field electrophoresis (PFGE) were performed in MDR A. baumannii strains. For statistic ana1ysis, the Chi-square and Fisher tests was applied in the comparison of proportions, for continuous variables the Kruskal- Wallis test and for linear correlation the Pearson. The level of 5% was adopted in all tests. In our study 481 samples of respiratory secretions from 232 patients were collected. The colonization by MDR bacteria was 25,4% (59 cases and 173 controls). 179 microorganisms were isolated and 78 (16.2%) were MDR bacteria, inc1uding A. baumannii (55 isolates), Staphylococcus aureus (21 isolates) and Pseudomonas aeruginosa (2 isolates). The time of stay in the ER was 13.9 days for cases and 9.8 days for controls (p=0.998). The median length of stay prior the MDR isolation was 9.9 days (range 3 to 25 days). Neurological disorders represented 68% of cases and 51% of controls patients housing in the ER (p=O.024). Multivariated ana1ysisshowed as significant risk factors for 11DR colonization: age, use of mechanical ventilation, use of nasal gastric tubes and length of thorax drains. Mortality rates were significant1y higher in cases (27.1 %) than controls (12.75). Thirty strains of MDR A. baumannii isolated from patients in the ER were typed and 13 plasmid profiles were present among the isolates. Profile A was present in 9 strains and the other profiles were distributed in two or in individual strains. Genomic DNA typing revealed two endemic patterns (profile A-16 strains; profile B-13 strains) and one strain had its individual profile. Twenty MDR A. baumannii isolates from patients housing in different wards of the hospital were also typed by PFGE, as control strains. Among the controls strains, 8 profiles were identified inc1uding the two endemic profiles from ER. The hospital infections (lU) rate was 27.26 infections/1,000 patient-days and 59.3% were case patients (p=0.001). Pneumonia related to mechanical ventilation was 64.2 pneumonia / 1,000 ventilator-days, urinary tract infection was 8.4 UTI/1,000 indwelling urinary catheter-days and blood stream infections related to central venous catheter was 8.2 infections/1,0000 catheter-days. In conclusion, the lack of specialized beds in HC-UNICAMP for severely ill patients assisted in the ER resulted in prolonged permanence of these patients in the ER. In our study, 66% of the patients with prolonged permanence in the ER were patients with neurological disorders. Elderly, use of mechanical ventilation, nasal gastric tubes and thorax drains were independent1y variables for MDR colonization. Interestingly, the patients with RI resulted in significant1y higher rate of RI than patients hospitalized in the intensive care units of our hospital. The general conditions of the ER certainly contributed to the high prevalence of A baumannii MDR colonization and the predominance of only two MDR c10nes in this unit is still a subject of investigation. The detection of isolates with identical PFGE patterns in different units of the hospital suggests intra-hospital spread of MDR A. baumannii Mestrado Ciências Básicas Mestre em Clínica Médica

El progreso socio-economico de la poblacion chilena se ha traducido tambien en la evolucion epidemiologica de las neumonias en pediatria. De ser una primordial causa de mortalidad, junto con la diarrea aguda, hoy, la neumonia continua siendo una importante causa de hospitalizacion, pero su letalidad se ha reducido considerablemente. Factores determinantes en este progreso han sido: mejores condiciones nutricionales de los pacientes, mejor y pronto acceso a la salud, optimizacion de los servicios de urgencia perifericos y aquellos adosados a los hospitales con servicios pediatricos, avances en los cuidados intensivos de pacientes criticos e, indudablemente, cambios etiologicos, a saber, bacterias por virus como primerisima etiologia de las IRAS bajas. Este ultimo componente- la evolucion etiologica de la neumonia adquirida en la comunidad por ninos-es abordado en esta guia, cuyo objeto es racionalizar el uso prudente y adecuado de antimicrobianos en la neumonia de causa bacteriana en Pediatria Esta guia excluye aquellas neumonias que afectan a pacientes con afecciones cronicas (que mantienen contacto estrecho con recintos hospitalarios y/o con internaciones periodicas), pacientes inmunocomprometidos y lactantes bajo 3 meses de edad. Diversos factores (ambientales, comorbilidades, inmunitarios, etc.), nos llevan a no incluir a estos pacientes en una recomendacion general.

La otitis media aguda (OMA), una de las infecciones mas comunes de la infancia, es la causa mas frecuente de visitas al medico, de consumo de antimicrobianos y de indicacion quirurgica en ninos. En los ultimos anos se han realizado grandes esfuerzos en la prevencion de la OMA, como la implementacion de vacuna conjugada de Streptococcus pneumoniae, el fomento de prolongar la lactancia materna y las campanas para disminuir el consumo de tabaco, factores que han tenido impacto en su epidemiologia, con reduccion en la incidencia y cambios en su perfil microbiologico. El diagnostico es basicamente clinico y, dado los cambios epidemiologicos antes descritos, se hace de vital importancia su correcto reconocimiento y el uso adecuado de antimicrobianos.

Los hermanos Moreno Galván suponen uno de los ejemplos más sólidos de compromiso político y estético durante el franquismo. Mientras Francisco Moreno Galván componía letras flamencas que criticaban, de un modo metafórico y soterrado, la falta de libertades e injusticias sociales que se vivían en España, su hermano José María elaboraba una teoría del arte en la que sostenía que el flamenco es una construcción popular, vinculada al concepto unamuniano de “intrahistoria”, y que, al igual que otras manifestaciones plásticas, experimenta una renovación estética. Las Reuniones de Cante Jondo de La Puebla de Cazalla (Sevilla), de las que Francisco es padre, acabarían convirtiéndose en mítines políticos “cantados” o interpretados que encontrarían eco en la teoría estética y el periodismo de su hermano José María. The Moreno Galván brothers are one of the strongest examples of political and aesthetics commitment during the Franco regime. While Francisco Moreno Galván composed flamenco lyrics that criticized, in a metaphorical and underground way, the lack of freedoms and social injustices that were experienced in Spain, his brother José María elaborated a theory of art in which he argued that flamenco is a popular construction, linked to the unamunian concept of “Intrahistory”, and which, like other artistic manifestations, undergoes an aesthetic renovation. The Cante Jondo Meetings in La Puebla de Cazalla (Seville), of which Francisco is the father, would end up becoming “sung” or interpreted political rallies that would find an echo in the aesthetic theory and journalism of his brother José María.

Objectives: to build and validate three clinical simulation scenarios and report the application with candidates for the specialist’s degree in stomatherapy. Methods: methodological study, building three scenarios and evaluation checklists; content validation with judges, using content validity index and Modified Kappa Coefficient; pre-test and application. Results: scenarios built based on nursing care for: 1. insufficiency and venous ulcer; 2. demarcation of intestinal stomia; and 3. Clean intermittent catheterization. In the content validation of the 24 items appreciated, 83%, 80%, and 92% were validated without change. In the pre-test, the objectives and checklists were adjusted. In the application, to standardize the evaluation, actors and evaluators were trained previously, and each candidate passed the three stations. Conclusions: scenarios built and with validated content, based on evidence and covering the three areas of stomatherapy. The pre-test allowed for adjustments in the scenarios, and the candidates achieved the expected objectives. RESUMEN Objetivos: construir y validar tres escenarios de simulación clínica y relatar aplicación con candidatos al título de experto en estomaterapia. Métodos: estudio metodológico, con construcción de tres escenarios y checklists de evaluación; validez de contenido con jueces, usando índice de validez de contenido y Índice de Kappa; pretest y aplicación. Resultados: escenarios construidos basado en los cuidados de enfermería para: 1. Insuficiencia y úlcera venosa; 2. Demarcación de estoma intestinal; y 3. Cateterismo intermitente limpio. La validez de contenido, de los 24 ítems apreciados, 83%, 80% y 92% validaron inalterados, respectivamente. El pretest, se ajustaron los objetivos y checklists. La aplicación, para uniformización de la evaluación, actores y evaluadores entrenaron previamente, y cada candidato pasó en las tres estaciones. Conclusiones: escenarios construidos y con contenido validado, basados en evidencias y abarcando todas áreas de la estomaterapia. El pretest permitió ajustes en los escenarios, y los candidatos alcanzaron los objetivos esperados. RESUMO Objetivos: construir e validar três cenários de simulação clínica e relatar a aplicação com candidatos ao título de especialista em estomaterapia. Métodos: estudo metodológico, com construção de três cenários e checklists de avaliação; validação de conteúdo com juízes, usando índice de validade de conteúdo e Coeficiente de Kappa Modificado; pré-teste e aplicação. Resultados: cenários construídos com base nos cuidados de enfermagem para: 1. Insuficiência e úlcera venosa; 2. Demarcação de estomia intestinal; e 3. Cateterismo intermitente limpo. Na validação de conteúdo, dos 24 itens apreciados, 83%, 80% e 92% foram validados sem alteração, respectivamente. No pré-teste, ajustaram-se os objetivos e checklists. Na aplicação, para uniformização da avaliação, atores e avaliadores foram treinados previamente, e cada candidato passou nas três estações. Conclusões: cenários construídos e com conteúdo validado, baseados em evidências e abrangendo as três áreas da estomaterapia. O pré-teste permitiu ajustes nos cenários, e os candidatos alcançaram os objetivos esperados.

Until the end of the 1970s, enterostomal therapy could be practiced by other health professionals and even lay people. But soon after the creation of the World Council of Enterostomal Therapists (WCETTM) in 1978, this became an exclusive specialty of nurses (from 1980 onwards).

Até o final da década de 1970, a estomaterapia podia ser exercida por outros profissionais da saúde e até por leigos. Mas logo após a criação do World Council of Enterostomal Therapists (WCETTM) em 1978, passou a ser uma especialidade exclusiva do enfermeiro (a partir de 1980).

Multiplex polymerase chain reaction (PCR) allows simultaneous detection of respiratory viruses, raising questions about their relevance in the clinical feature.To evaluate the contribution of clinical, epidemiological, and virological factors in the clinical course of children hospitalized due to ARI with viral co-detection.Pediatric patients ≤ 15 years old, hospitalized due to ARI at the UC-CHRISTUS Health Network Clinical Hospital between June and October 2014, and who presented a positive respiratory molecular panel test, were included. Respiratory samples (nasopharyngeal swab, tracheal aspiration, or bronchoalveolar lavage) with positive panel tests by Seeplex® RV15 OneStep ACE Detection Seegene® technique, were analyzed with a second technique (xTAG-RVP-FASTv2 Luminex®, USA), which allows simultaneous and semi-quantitative detection of 17 respiratory viruses. Clinical and epidemiological records were collected.One virus was identified in 42/57 children (74%) and two or more in 15/57 (26%). Intensive care unit (ICU) hospi talization was significantly more frequent in patients with viral co-detection (OR = 5,5; IC 95%: 1,5 19,6). The most frequently detected viruses were rhinovirus/enterovirus (HRV/EV) (29%) and res piratory syncytial virus (RSV) (25%), and the most common co-detection was HRV/EV-RSV (33%). In x-rays, patients with HRV/EV infection presented interstitial images more frequently, while RSV was associated with condensations (p = 0.002). For HRV/EV, median fluorescence intensity (MFI, semi-quantification) were 1788 and 2456 in co-detection and single agent, respectively (p = 0.022). Children with HRV/EV co-detection had a longer hospital stay compared to isolated identification (5 versus 3 days, p = 0,028).In children hospitalized due to ARI, viral co-detection is frequent and associated with more ICU hospitalizations. Our study highlights the presence of HRV/ EV in viral co-detection and longer length of stay. More studies are needed to define the relevance of viral co-detection in hospitalized pediatric patients.

La playa constituye uno de los atractivos más importantes de los destinos turísticos mundiales donde se encuentran diversos negocios que son la base de la actividad económica ofreciendo desarrollo en la comunidad donde se encuentren. El artículo compara el modelo del ciclo de vida de los destinos turísticos con el inventario de los negocios turísticos en las playas de Cancún, San Juan y Punta Cana, con la finalidad de conocer la actividad comercial que se ofrece a los visitantes en las zonas de estudio. Se reflexiona respecto a las diferencias y similitudes entre playas turísticas de 3 destinos internacionales en diferentes etapas, reflexión que permite proyectar un escenario futuro de desarrollo económico y el establecimiento de estrategias de negocios en el segmento de sol y playa. The beach is a destination of the most important attractions of tourist destinations where there are several businesses that are the basis of economic activity offered by the development in the community where they are located. The article compares the model of the life cycle of tourist destinations with the inventory of tourist businesses on the beaches of Cancun, San Juan and Punta Cana, with the purpose of knowing the commercial activity that is offered to visitors in the zones of study. It was reflected on the differences and similarities between the tourist beaches of the three international destinations in different stages, the reflection that allows to project a future scenario of economic development and the establishment of business strategies in the segment of sun and beach.

Eating disorders (ED) are psychiatric diseases characterized by the alteration of the caloric intake. Besides, ED have a high comorbidity with depression and anxiety. In Mexico, the Hospital Anxiety and Depression Scale (HADS) has shown to be a valid and reliable instrument in patients with HIV, cancer, and obesity but its psychometric properties have not been assessed in patients with ED, being the latter the aim of this research. A total of 325 patients (Mage = 22.0, SD = 9.7), completed the HADS. Based on principal axis factoring and oblimin rotation the scale yielded 12 items divided into two subscales: Depression (with nine items) and Anxiety (with three items). With this structure was confirmed the internal consistency of the scale (α = 0.88) and the two subscales (α > 0.80), however the items did not group in the same order than they did in the original scale, for this reason the new configuration of the HADS was analyzed in detail based on the features of the population where the scale was examined, this means, in patients with ED.

Bartonella henselae is cat scratch disease's etiological agent, which is considered an endemic infection in Chile. It typically presents as a self-limited regional lymphadenopathy and less frequently with systemic involvement and extranodal or atypical manifestations: hepatosplenic, ocular or musculoskeletal involvement, among others. We present three cases of atypical cat scratch disease with ocular compromise, as neurorretinitis. This review highlights the importance of the active search for ocular complications in patients with disseminated cat scratch disease, leading to possible change in treatment and prognosis of the disease.

Objetivo: Este estudo teve como objetivo identificar, na literatura, as medidas não invasivas de prevenção da recidiva de úlceras venosas (UVs). Método: Realizou-se revisão integrativa nas bases de dados da Biblioteca Virtual em Saúde (BVS), Public Medline (PubMed), Cumulative Index of Nursing and Allied Health Literature (CINAHL) e Excerpta Medica dataBASE (Embase) no período de 2015 a 2017. A busca bibliográfica foi realizada utilizando-se os descritores controlados “varicose ulcer” e “recurrence” e o operador booleano AND entre eles em todas as bases de dados descritas, em português, inglês e espanhol. Após as buscas, dois revisores realizaram a pré-seleção por títulos e resumo dos artigos seguida da leitura na íntegra dos estudos pré-selecionados. Resultado: Identificaram-se 210 estudos, sendo que 188 foram excluídos por não atenderem à questão norteadora. Dois revisores leram na íntegra os 22 artigos pré-selecionados e incluíram nesta revisão nove que fizeram parte da discussão deste trabalho. Conclusão: Os estudos desta revisão sugerem que a adesão e o uso correto da terapia compressiva com meias associados a medidas de educação e autocuidado são efetivos para prevenção de recidiva da UV. A associação de ácido acetilsalicílico com as medidas padrão de tratamento ainda carece de resultados conclusivos e sugerem-se novos estudos para comprovação da eficácia.

Objective: This study aimed to identify, in the literature, noninvasive measures for prevention of venous ulcer recurrence (VUs). Methods: An integrative review was carried out in the databases of the Biblioteca Virtual em Saúde (BVS), Public Medline (PubMed), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Excerpta Medica Database (Embase) in the period from 2015 to 2017. the search was performed using the controlled descriptors «varicose ulcer» and «recurrence» and the Boolean operator AND between them in all databases described, in Portuguese, English, and Spanish. After the searches, two reviewers carried out the pre-selection by titles and summary of the articles followed by the full reading of the pre-selected studies. Results: 210 studies were identified, of which 188 were excluded because they did not attend to the guiding question. Two reviewers read in full the 22 pre-selected articles and included in this review nine that were part of the discussion of this paper. Conclusion: Studies in this review suggest that adherence and correct use of compressive therapy with socks associated with education and self-care measures are effective in preventing recurrence of VU. The association of acetylsalicylic acid with standard measures of treatment still lacks conclusive results and new studies to prove efficacy are suggested.

Objetivo: Analisar os tipos de pessários, as indicações e o impacto no tratamento da incontinência urinária (IU). Métodos: Trata-se de revisão integrativa com publicações de 2007 a 2017 indexadas nas bases de dados Biblioteca Virtual em Saúde, Medical Literature Analysis and Retrieval System Online, Scopus Info Site, Cumulative Index to Nursing and Allied Health Literature e Web of Science. Resultados: Selecionaram-se oito artigos. Os pessários indicados foram prato, anel, Uresta® e Contiform®. A redução ou resolução da IU de esforço (IUE) em mulheres foi observada por análise de parâmetros objetivos, como avaliação urodinâmica e questionários de qualidade de vida. Destacou-se viabilidade econômica. Evidenciaram-se desajuste, dificuldades no uso, incômodo e manutenção de perdas urinárias entre os motivos de não adesão. Prolapso avançado e comprimento vaginal curto foram preditivos de insucesso. Identificaram-se eventos adversos em baixa incidência: retenção urinária e leucorreia. Conclusão: A terapia pessária é eficaz no tratamento da IUE quando acompanhada por profissionais capacitados. Características individuais e percepções sobre o dispositivo são determinantes no sucesso terapêutico. Estudos de maior amostragem, tempo de seguimento e qualidade, bem como estimulo a publicações nacionais, são necessários para investigação de medidas objetivas de IU, fatores clínicos e demográficos em relação ao sucesso do pessário.

Temperature increase can affect germination in a positive or negative way. A temperature increment of 0.6 °C occurred during the last decades, and by 2099 an increment of 1.5 to 4.7 °C is expected. The aim in this study was to evaluate seed germination from certain provenances of Acacia farnesiana and A. schaffneri at different temperatures. The information generated thereby will make it possible to determine the ability of these two species to adapt to global warming. Fruits were collected from at least 10 mother plants per provenance per species; seeds were scarified and sown in soil in plastic trays, placed inside an incubator at actual soil temperature (Control (T0)), and subjected to 5 treatments with increased temperature: Control temperature +2 °C (T1), +5 °C (T2), +7 °C (T3), +10 °C (T4) and +15 °C (T5) for 15 days. A. farnesiana showed higher germination at T2 and T3, while A. schaffneri presented its higher germination at T2; there were not significant differences between the two species. A. farnesiana seeds had the fastest germination (t50) at T3, with significant differences between provenances (the fastest germination occurred at the School of Forest Sciences, UANL), and A. schaffneri seeds germinated fastest at T1, without significant differences between provenances. The results suggest that both species and their provenances can germinate if temperatures increase according to the current predictions.

Nutritional problems are frequent among patients with neuromuscular diseases, who consequently need an adequate evaluation.to describe nutritional assessment and to estimate and measure body composition and energy requirement in children with neuromuscular diseases.We performed anthropometry, skinfold measurement and bioelectric impedance analysis (BIA) for estimate and measure, respectively, fat mass (FM). Resting energy expenditure (REE) was estimated by Schofield equations and measured by indirect calorimetry (IC). We compared actual energy intake with post-assessment recommendations.We studied 40 patients, 13.6 ± 3.3 years old (Range: 5.8-19.3), 80% boys, diagnosed with Duchenne Muscular Dystrophy (n = 21), other dystrophies (7), Muscular Spinal Atrophy (7), myopathies (3) and others (2). According to body mass index (BMI) 22.5% were well nourished (zBMI -1 to +1), 17.5% overweight (zBMI +1 to +2), 17.5% obese (zBMI ≥ +2), and 42.5% undernourished (zBMI -1). Estimated FM was 20.2% (3.6-46.3), lower than BIA measurement: 34.2% (9.6-60.5) p 0.001. Estimated REE was higher than measured REE: 1325 (813-2244) vs. 1202 (900-2100) kcal/day, p = 0.002. Actual energy intake: 1452 (1033-2476) was higher than recommended: 1300 (900-1900) kcal/day, p 0.001.Undernutrition and overweight are prevalent in this group of children with neuromuscular diseases. Clinical assessment underestimates FM and overestimates REE.

La consideración de la familia como célula fundamental de la sociedad, le merece una protección especial de parte de la legislación, que parte de la Constitución Política hasta contar con un cuerpo normativo propio como es el Derecho de Familia, sobre todo por la función socializadora y educadora de los nuevos ciudadanos/as. Nadie puede negar la importancia de la familia, aunque hoy en día padezca una crisis de valores y de identidad. Por el contrario, la sociedad y el Estado necesitan de la familia para tener el relevo generacional necesario y contar con ciudadanos que aporten al desarrollo del país. El recién aprobado Código de la Familia de Nicaragua establece que la protección a la familia es obligación de la sociedad, el Estado y sus propios integrantes. Esta protección consiste principalmente en establecer un vínculo donde existan valores como el amor, el respeto, la solidaridad y ayuda mutua, pero especialmente donde se respeten y cumplan –con responsabilidad– los derechos y deberes de cada uno de los miembros de la familia. Entre los derechos y deberes uno que tiene gran importancia es el relacionado con la educación de los hijos e hijas, un deber que el padre y la madre no pueden delegar en ninguna otra persona o institución. Con los lazos de afecto y con el cumplimiento de las obligaciones de cada uno, se podrán evitar muchas crisis familiares, contado con familias más fuertes y estables para el bien de la sociedad en general.