Manifestaciones mucocutáneas y su relación con el recuento de linfocitos T CD4 en pacientes infectados con el virus de inmunodeficiencia humana hospitalizados en Medellín, Colombia / Mucocutaneous manifestations and their relationship with CD4 T-lymphocyte count in hospitalized patients infected with the human immunodeficiency virus (HIV) in Medellín, Colombia

Introducción. Entre el 80 y el 95 % de los pacientes infectados por el virus de inmunodeficiencia humana (HIV) desarrollan manifestaciones en la piel que sirven como marcadores de su estado inmunológico. Objetivos. Describir las manifestaciones dermatológicas y los factores clínicos y sociodemográficos de los pacientes hospitalizados con diagnóstico de HIV y su correlación con el recuento de linfocitos T CD4. Materiales y métodos. Se hizo un estudio observacional de corte transversal y retrospectivo a partir del registro de las historias clínicas de 227 pacientes mayores de edad con diagnóstico de HIV, evaluados por dermatología en un hospital de Medellín, Colombia. Resultados. Los 227 registros daban cuenta de 433 manifestaciones dermatológicas, el 64,4 % de ellas infecciosas. Las tres manifestaciones más frecuentes fueron candidiasis oral, condilomas acuminados y reacciones a medicamentos. Se encontró una relación estadísticamente significativa entre el virus del herpes zóster (HZ) diseminado y la sífilis secundaria, con un recuento de CD4 entre 200 y 499 células/mm3 (p=0,04 y 0,028, respectivamente), y entre la candidiasis oral y un recuento de CD4 menor de 100 células/ mm3 (p=0,008). Conclusiones. La relación entre el herpes zóster diseminado y un recuento de CD4 entre 200 y 499 células/mm3 sugiere que, a pesar de los recuentos altos, se pueden presentar formas graves de la enfermedad debido a una posible disfunción de las células T y el agotamiento del sistema inmunológico. La relación entre la candidiasis oral y un recuento de CD4 menor de 100 células/mm3 plantea la posibilidad de considerar esta infección micótica como un marcador importante de debilitamiento inmunológico de los pacientes con HIV.

Introduction. About 80-95% of patients infected with the human immunodeficiency virus (HIV) develop skin manifestations, which are markers of the patients' immune status. Objective. To describe the dermatologic manifestations and the clinical and sociodemographic factors of hospitalized patients diagnosed with HIV and their correlation with CD4 T-lymphocyte count. Materials and methods. We conducted an observational, cross-sectional, and retrospective study of the medical records of 227 adult patients with HIV diagnosis evaluated by dermatology in a hospital in Medellín, Colombia. Results. We included 227 patient records with 433 dermatologic manifestations, 64.4% of them infectious. The most frequent manifestations were oral candidiasis, condylomata acuminata, and drug reactions. Moreover, a statistically significant relationship was found between disseminated herpes zoster virus and secondary syphilis with a CD4 count between 200-499 cells/mm3 (p=0.04 and 0.028, respectively). There was also a statistically significant relationship between oral candidiasis and a CD4 count of less than 100 cells/ mm3 (p=0.008). Conclusions. The relationship between disseminated herpes zoster with CD4 between 200-499 cells/mm3 suggests that, despite having high CD4 counts, severe forms of the disease may occur due to possible T-cell dysfunction and depletion of the immune system. Additionally, the relationship between oral candidiasis and CD4 less than 100 cells/mm3 indicates the potential role of oral candidiasis as an essential marker of weakened immune status in HIV patients.

Clinical management of fever in children in Brazil: practical recommendations from an expert panel

ABSTRACT The objective of this study was to answer several questions related to the assessment and treatment of fever, as well as other controversies that exist during its management in pediatric patients. First, an advisory board with medical experts was conducted to discuss the clinical journey of these patients, considering the main challenges and possible solutions. After this discussion, a non-systematic literature review was performed, between November 2019 and January 2020, to collect the most relevant evidence available in the scientific databases MEDLINE, Lilacs, and SciELO. A narrative review was carried out based on scientific evidence and on extensive experience of experts in clinical practice. The experts developed a set of recommendations and clarifications about the assessment of the severity of fever in pediatrics, the need for treatment and the choice of the most appropriate antipyretic. The most common controversies in the management of fever in pediatric patients were also addressed, such as alternating antipyretics, persistent fever, and dose equivalence. In primary management of pediatric patients, fever should be seen as a relevant symptom that requires treatment with antipyretics in potentially more complex or severe cases, when it causes discomfort to children or is associated with infectious diseases.

Diseño y validación de un Protocolo de Atención Psicológica para la ideación suicida / Design and validation of a psychological attention protocol for suicidal ideation

Resumen La cifra de personas que presentan o han presentado alguna conducta suicida ha aumentado significativamente en Colombia desde el año 2014 al 2019, convirtiendo la conducta suicida en una problemática de salud pública; sin embargo, es un concepto amplio, que abarca diferentes tipos de conductas, por esto es necesario establecer un protocolo de atención para estandarizar las acciones del terapeuta o personas que se desempeñan en los servicios prestadores de salud. El presente artículo tiene como objetivo describir cómo se realizó el diseño y la validación de un protocolo de atención psicológica para atención en ideación suicida de los consultantes que asisten a un centro de atención psicológica de una institución universitaria de la ciudad de Bogotá. Se realizó un estudio cuantitativo, de tipo instrumental, el cual implicó: a) el diseño de la ruta de atención, situaciones que activan el protocolo y el módulo de atención en crisis; b) la participación de 10 jueces expertos con el fin de realizar la validación por contenido de todos los componentes del protocolo de atención psicológica. Los resultados arrojaron que el diseño es pertinente, suficiente y relevante para la problemática que se buscó abordar.

Abstract Currently, the number of people who present or have presented some suicidal behavior has increased significantly in Colombia from 2014 to 2019, making suicidal behavior a public health problem. However, it is abroad concept that covers different types of behavior, so it is necessary to establish a protocol of care to standardize the actions of the therapist and/or people who work in health care services. The present article aims to describe how a psychological care protocol was designed and validated for the care of suicidal ideation of consultants who attend a psychological care center at a university institution in the city of Bogotá. A quantitative, instrumental study was carried out, which involved: a) designing the care route, situations that activate the protocol and the crisis care module; b) the participation of 10 expert judges to carry out the validation of the content of all the components of the psychological care protocol. The results showed that the design of the care protocol is pertinent, sufficient, and relevant to the problem to be addressed.

Measuring early childhood development in Brazil: validation of the Caregiver Reported Early Development Instruments (CREDI) / Medição do desenvolvimento na primeira infância no Brasil: validação dosInstrumentos sobre o Desenvolvimento na Primeira Infância Relatado por Cuidadores(CREDI)

Abstract Objective The present study aims to analyze the psychometric properties and general validity of the Caregiver Reported Early Development Instruments (CREDI) short form for the population-level assessment of early childhood development for Brazilian children under age 3. Method The study analyzed the acceptability, test-retest reliability, internal consistency and discriminant validity of the CREDI short-form tool. The study also analyzed the concurrent validity of the CREDI with a direct observational measure (Inter-American Development Bank's Regional Project on Child Development Indicators; PRIDI). The full sample includes 1,265 Brazilian caregivers of children from 0 to 35 months (678 of which comprising an in-person sample and 587 an online sample). Results Results from qualitative interviews suggest overall high rates of acceptability. Most of the items showed adequate test-retest reliability, with an average agreement of 84%. Cronbach's alpha suggested adequate internal consistency/inter-item reliability (α > 0.80) for the CREDI within each of the six age groups (0-5, 6-11, 12-17, 18-23, 24-29 and 30-35 months of age). Multivariate analyses of construct validity showed that a significant proportion of the variance in CREDI scores could be explained by child gender and family characteristics, most importantly caregiver-reported cognitive stimulation in the home (p < 0.0001). Regarding concurrent validity, scores on the CREDI were significantly correlated with overall PRIDI scores within the in-person sample at r = 0.46 (p < 0.001). Conclusions The results suggested that the CREDI short form is a valid, reliable, and acceptable measure of early childhood development for children under the age of 3 years in Brazil.

Resumo Objetivo O presente estudo visa analisar as propriedades psicométricas e a validade geral do formulário curto dos Instrumentos sobre o Desenvolvimento na Primeira Infância Relatado por Cuidados (CREDI) para avaliação em nível populacional do desenvolvimento na primeira infância de crianças brasileiras com menos de três anos. Método O estudo analisou a aceitabilidade, a confiabilidade teste-reteste, a consistência interna e a validade discriminante da ferramenta CREDI. O estudo também analisou a validade concorrente do CREDI com uma medida observacional direta (Projeto Regional sobre os Indicadores de Desenvolvimento na Infância do Banco Interamericano de Desenvolvimento; PRIDI). A amostra total inclui 1.265 cuidadores brasileiros de crianças de 0 a 35 meses (678 em uma amostra presencial e 587 em uma amostra on-line). Resultados Os resultados das entrevistas qualitativas sugerem altas taxas gerais de aceitabilidade. A maior parte dos itens mostrou confiabilidade teste-reteste adequada, com concordância média de 84%. O coeficiente alfa de Cronbach sugeriu consistência interna/confiabilidade entre itens (α > 0,80) para o CREDI em cada uma das seis faixas etárias (0-5 α = 6-11, 12-17, 18-23, 24-29 e 30-35 meses de idade). As análises multivariadas da validade do constructo mostraram que uma proporção significativa da variação nas pontuações do CREDI pode ser explicada pelo sexo da criança e pelas características familiares, mais importante o estímulo cognitivo em casa relatado pelo cuidador (p < 0,0001). Com relação à validade concorrente, as pontuações do CREDI foram significativamente correlacionadas às pontuações gerais do PRIDI na amostra presencial em r = 0,46 (p < 0,001). Conclusões Os resultados sugerem que o formulário curto CREDI é uma medida válida, confiável e aceitável de desenvolvimento na primeira infância para crianças com menos de três anos no Brasil.

Associação entre sinais de sofrimento psíquico até dezoito meses e rebaixamento da qualidade de vida aos seis anos de idade / Association between signs of psychological distress up to 18 months and decrease in quality of life at six years of age / Association entre des signaux de détresse psychologique jusqu'à dix-huit mois et qualité de vie inférieure à six ans / Asociación entre las señales del sufrimiento psíquico hasta los dieciocho meses y la disminución de la calidad de vida en los seis años de edad

A pedido do Ministério da Saúde foi desenvolvido e validado um protocolo de Indicadores clínicos de Risco para o Desenvolvimento Infantil (IRDI) para detectar riscos para transtornos psíquicos de desenvolvimento em bebês de 0 a 18 meses. Este trabalho teve como objetivo verificar a validade preditiva do IRDI, a partir de sua relação com dois instrumentos: o Autoquestionnaire Qualité de Vie Enfant Imagé (AUQUEI) e o Child Health Questionnaire (CHQ), ambos já validados no Brasil e aplicados aos seis anos de vida. A amostra foi composta por 46 crianças de três centros de saúde de São Paulo. Os resultados indicaram que o IRDI não se mostrou sensível à avaliação de qualidade de vida obtida com o uso do AUQUEI. No entanto, a associação estatisticamente significante encontrada entre resultados obtidos no IRDI e no CHQ mostrou maior capacidade do IRDI para predizer qualidade de vida relacionada ao índice psicossocial do que ao índice físico do mesmo instrumento.

At the request of the Ministry of Health, a protocol of Clinical Risk Indicators for Child Development (IRDI) capable of detecting risk for psychic development disorders in infants aged between 0 and 18 months was developed and validated. This study aimed to verify the degree of association between IRDI and two other instruments for assessing quality of life: Autoquestionnaire Qualité de Vie Enfant Image - AUQUEI and Child Health Questionnaire - CHQ, both already validated in Brazil and applied at the age of six years. The sample comprised 46 children from three health centers in São Paulo, Brazil. The results indicated that IRDI was not sensitive to the assessment of quality of life achieved by using AUQUEI. However, a statistically significant association found between the results of IRDI and CHQ showed higher capacity of IRDI to predict quality of life related to psychosocial index than the physical index of the same instrument.

À la demande du Ministère de la Santé, un groupe de psychanalystes a développé et validé un protocole d'Indicateurs de Risque Cliniques pour le Développement de l'Enfant (IRDI), capable de détecter les risques de troubles dans le développement mentaux chez bébés d'âge entre 0 et 18 mois. Cette étude visait à déterminer le degré d'association entre l'IRDI et des deux autres instruments qui évaluent la qualité de vie : l'Autoquestionnaire Qualité de Vie Enfant Imagé (AUQUEI) et le Child Health Qtuestionnaire (CHQ). Les deux ont été validés au Brésil et on été appliqués aux enfants à l'áge de six ans. L'échantillon comprenait 46 enfants hospitalisés dans trois centres de santé à São Paulo, au Brésil. Les résultats indiquent que l'IRDI n'est pas sensible à l'évaluation de la qualité de vie obtenue par l'AUQUEI. Cependant, l'association statistiquement significatif trouvée dans les résultats a montrée une capacité du IRDI de prédire la qualité de vie liée à l'index psychosocial plus grande que de laquelle liée à l'index physique du même instrument.

Un protocolo de Indicadores clínicos de Riesgo para el Desarrollo Infantil (IRDI) fue desarrollado y validado a demanda del Ministerio de Salud para detectar los riesgos de trastornos psíquicos de desarrollo en los niños de 0 a 18 meses. Este estudio tuvo como objetivo determinar el grado de asociación entre el IRDI y otros dos instrumentos que evalúan la calidad de vida: el Autoquestionnaire Qualité de Vie Enfant Imagen (AUQUEI) y el Child Health Questionnaire (CHQ), ambos ya validados en Brasil y aplicados a los seis años de edad. La muestra consta de 46 niños de tres centros de salud de São Paulo. Los resultados indicaron que el IRDI no se mostró sensible a la evaluación de la calidad de vida obtenida mediante el uso del AUQUEI. Sin embargo, la asociación estadísticamente significativa encontrada entre los resultados obtenidos en el IRDI y CHQ mostró una mayor capacidad del IRDI para predecir la calidad de vida relacionada al índice psicosocial que al físico del mismo instrumento.

Guía para el diagnóstico, seguimiento y tratamiento de la enfermedad de Fabry / Guidelines for diagnosis, monitoring and treatment of Fabry disease

La enfermedad de Fabry es un trastorno de almacenamiento lisosomal hereditario ligado al cromosoma X, ocasionado por el déficit de la enzima alfa galactosidasa A. El conocimiento sobre esta patología, y en particular su manejo médico, ha progresado notablemente en la última década, incluyendo el desarrollo de su tratamiento específico. La presente guía fue desarrollada por profesionales médicos de diversas especialidades involucrados en la atención de pacientes con enfermedad de Fabry. La discusión y análisis de las evidencias científicas disponibles, sumado a la experiencia de cada uno de los participantes, ha permitido desarrollar los conceptos vertidos en esta guía con el objetivo de brindar una herramienta útil para todos los profesionales que asisten a pacientes con enfermedad de Fabry.

Fabry disease is an X-linked hereditary lysosomal storage disorder caused by deficiency of the enzyme alpha-galactosidase A. Knowledge about this disease, and its medical management, has made remarkable progress in the last decade, including the development of its specific treatment. This guide was developed by medical professionals from various specialties involved in the care of patients with Fabry disease. The discussion and analysis of the available scientific evidence, coupled with the experience of each of the participants, has allowed us to develop the concepts included in this guide in order to provide a useful tool for all professionals who care for patients with Fabry disease.

Custos hospitalares da meningite causada por Streptococcus pneumoniae na cidade de São José dos Campos, São Paulo, Brasil / Hospital costs related to streptococcal meningitis among children in São José dos Campos, São Paulo State, Brazil

O conhecimento dos custos hospitalares é de grande importância para os processos de tomada de decisão em saúde pública. O objetivo deste estudo foi estimar os custos hospitalares diretos relacionados à meningite pneumocócica em crianças com até 13 anos (inclusive), na cidade de São José dos Campos, São Paulo, Brasil, de janeiro de 1999 a dezembro de 2008. Foram obtidos dados de prontuários médicos. O cálculo foi realizado pelo método misto de mensuração das quantidades dos itens de custos e atribuição de valor aos itens consumidos (micro-costing e gross-costing). Os valores monetários referem-se a novembro de 2009, sendo expressos em reais. A análise das frequências e médias foi realizada pelo programa Epi Info versão 3.5.1. Foram notificados 41 casos. Os custos hospitalares diretos variaram de R$ 1.277,90 a R$ 19.887,56 (média = R$ 5.666,43), ou seja, 10 a 20 vezes maiores que o custo médio de internações pago pelo SUS. Os custos dos honorários profissionais foram os mais relevantes, seguidos pelos custos dos medicamentos, procedimentos, materiais e exames laboratoriais.

Knowledge of hospital costs is highly important for public health decision-making. This study aimed to estimate direct hospital costs related to pneumococcal meningitis in children 13 years or younger in the city of São José dos Campos, São Paulo State, Brazil, from January 1999 to December 2008. Data were obtained from medical records. Hospital costs were calculated according to the mixed method for measurement of quantities of items with identified costs and value attribution to items consumed (micro-costing and gross-costing). All costs were calculated according to monetary values for November 2009 and in Brazilian currency (Real). Epi Info 3.5.1 was used for frequencies and means analysis. Forty-one cases were reported. Direct hospital costs varied from R$ 1,277.90 to R$ 19,887.56 (mean = R$ 5,666.43), or 10 to 20 times the mean cost of hospitalization for other diseases. Hospital staff labor was the highest cost, followed by medication, procedures, supplies, and lab tests.

Relação da doença respiratória declarada pelos pais e fatores socioeconômicos e culturais / Relationship between respiratory tract diseases declared by parents and socioeconomic and cultural factors

OBJETIVO: Verificar a relação entre a doença respiratória das crianças declarada pelos pais e os seguintes aspectos: instituição de ensino da criança, grau de instrução dos pais, renda per capita, classe de consumo e grupo étnico da família. MÉTODOS: Estudo descritivo com enfoque retrospectivo, por meio da análise de dados coletados de pais de uma amostra de 959 escolares entre cinco e nove anos, que residiam no distrito estudado, em São Paulo, em 2004. O levantamento das informações foi realizado por meio de instrumento de coleta de dados. As doenças respiratórias pesquisadas no conjunto foram: rinite, rinossinusite, otite, laringite, faringoamigdalite, pneumonia e asma. A associação entre doença respiratória declarada e aspectos socioeconômicos foi avaliada pelo teste do qui-quadrado. RESULTADOS: Os pais de crianças que frequentavam escolas privadas declararam significativamente mais doenças respiratórias em seus filhos, em comparação aos pais de crianças que estudavam em escolas públicas. Os pais com grau de instrução superior ou ensino médio completo declararam significativamente mais doença respiratória em seus filhos. Não houve associação entre a doença respiratória com renda per capita, classe de consumo e etnia. CONCLUSÕES: A percepção mais apurada sobre a saúde dos filhos geralmente associa-se à maior escolaridade dos pais, o que também determina melhores condições de vida. Provavelmente, por isso, os pais cujos filhos frequentavam escolas privadas e com melhor nível de escolaridade referiram mais doenças respiratórias nas crianças. Infere-se, portanto, que conquistas na percepção de saúde e, consequentemente, nas condições de saúde associam-se à melhora do nível educacional.

OBJECTIVE: To determine the association between children's respiratory diseases reported by parents and the following criteria: attendance at private or public school, parents' educational level; family per capita income; household socioeconomic class, and family ethnicity. METHODS: This retrospective descriptive study analyzed data collected from questionnaires responded by the parents of 959 schoolchildren between five to nine years old, living in the district selected for the study, in São Paulo, Brazil, over 2004. Respiratory diseases reported by parents were rhinitis, rhinosinusitis, ear infections, laryngitis, pharyngitis, pneumonia, asthma and asthma-like diseases. A chi-square test was used to evaluate the association between respiratory diseases reported by parents and family socioeconomic factors. RESULTS: Parents of children in private schools reported significantly more respiratory diseases in their children than those whose children attended public schools. More respiratory diseases were reported for children whose parents finished high school or college. There were no significant differences between respiratory diseases and per capita income, socioeconomic class or ethnicity. CONCLUSIONS: A more accurate perception about the health of children is generally associated with parents' higher education, which is also expected to ensure better living conditions. This may explain why parents with a higher level of education and whose children attended private schools reported more respiratory diseases in their children. Our findings suggest that improvement of educational level is associated with more accurate health perceptions and, consequently, better health conditions.

Criptococosis diseminada en anciano con VIH / Disseminated cryptococcosis in an elderly patient with HIV

Se presenta un paciente masculino de 79 años con un cuadro clínico de síntomas constitucionales, asociado a pleuresía linfocítica, meningitis e hidrocefalia, confirmándose posteriormente criptococosis diseminada y VIH-SIDA, con complicaciones asociadas a la terapia con anfotericina B y desenlace fatal. La criptococosis es una de las infecciones más frecuentes del SNC en pacientes con VIH y se han identificado varios factores que confieren mal pronóstico. En infección por VIH, se considera paciente "anciano" a aquellos mayores de 50 años. En general las características clínicas son similares a los pacientes más jóvenes, pero los adultos mayores, especialmente después de 65 años de edad, tienen más probabilidad de desarrollar SIDA en uno a tres años, mayor riesgo de diseminación de infecciones oportunistas y mayor mortalidad. En Colombia para el año 2007, según registros del Ministerio de Protección Social, había 5283 personas con SIDA mayores de 45 años (Acta Med Colomb 2011; 36: 85-89).

We report the case of a 79-year-old male patient with a clinical picture of constitutional symptoms associated with lymphocytic pleurisy, meningitis, and hydrocephalus. Disseminated cryptococcosis and HIV/AIDS were later confirmed. Complications of therapy with amphotericin B arose and the patient died. Cryptococcosis is one of the most common CNS infections in patients with HIV. Several factors that indicate a poor prognosis have been identified. In HIV infection, the patient is considered "old" above 50 years of age. The clinical features of these patients are generally similar to those found in younger patients; however, especially after the age of 65 years, these patients are more prone to developing AIDS over a period of 1-3 years, and their risk of acquiring disseminated opportunistic infections is increased. Their mortality rates are also higher. In Colombia, during 2007, according to the records of the Ministry of Social Protection, there were 5283 people older than 45 years with AIDS (Acta Med Colomb 2011; 36: 85-89).

A inclusão da perspectiva do paciente na consulta médica: um desafio na formação do médico / Inclusion of the patient's perspective in medical consultations: a challenge for medical education

A insuficiência do modelo biomédico para a resolução da maioria dos problemas de saúde da população vem sendo discutida. Diversos autores referem que a realização da consulta médica se associa a melhores resultados quando apoiada nos pressupostos do modelo centrado no paciente, dentre os quais se destaca a inclusão da perspectiva do paciente. Para que isso ocorra, é necessário conhecer as dimensões físicas, psicossociais e culturais que a compõem e incluí-las na realização de entrevistas médicas. Como a formação do médico na graduação ainda é apoiada no modelo biomédico, a mudança de paradigma para a realização de consultas médicas suscita mudanças curriculares significantes.

Growing discussion has focused on the failure of the biomedical model to solve most of the population's health problems. According to various authors, medical consultations lead to better outcomes when they are backed by the principles of the patient-centered model, including the patient's perspective. This requires knowing the physical, psychosocial, and cultural dimensions comprising the patient's perspective and including them in the patient interview. Since undergraduate medical training is still based on the biomedical model, the paradigm shift for medical consultations involves significant curriculum changes.

Aspectos diagnósticos da otite média com derrame na faixa etária pediátrica: [revisão] / Diagnostic aspects of otitis media with effusion in children: [review]

OBJETIVOS: apresentar e discutir aspectos diagnósticos da otite média com derrame (OMD) na prática clínica da atenção primária à saúde. MÉTODOS: foram pesquisadas as bases de dados Medline, Lilacs e SciELO (1994-2004). Identificados 523 artigos, dos quais 30 foram considerados para o presente trabalho. RESULTADOS: os estudos revelaram disparidade entre as definições, inconsistência no quadro clínico e falta de padronização dos critérios diagnósticos. Isto contribuiu para a inadequação diagnóstica da OMD. As evidências que levaram ao diagnóstico de efusão foram: a) pelo menos duas anormalidades do tímpano relacionadas à coloração, opacificação e mobilidade; e/ou b) membrana timpânica (MT) tipicamente retraída, côncava, e com alteração da coloração; e/ou c) mobilidade reduzida ou ausente na otoscopia pneumática (OP). A OP mostrou ser mais acurada que a otoscopia simples (OS), sendo considerada como método de escolha para o diagnóstico clínico da OMD. Quando houver dúvida na otoscopia pneumática, pode-se indicar a timpanometria, que aumenta a acurácia deste diagnóstico. CONCLUSÕES: na prática clínica, o diagnóstico da OMD deve ser realizado, primariamente pela otoscopia pneumática, em toda criança com suspeita de OMD. Em caso de dúvida deve-se indicar a timpanometria.

OBJECTIVES: to present and discuss diagnostic aspects of middle ear infection with effusion at a primary health care clinic. METHODS: research was carried out using the Medline, Lilacs and SciELO databases (1994-2004). Five hundred and twenty-three articles were found, of which 30 were considered for this review. RESULTS: the study revealed considerable disparity with regard to definitions, inconsistency in terms of clinical profile and a lack of standardization of diagnostic criteria. This has contributed to inadequate diagnosis of otitis media with effusion (OME). Evidence leading to a diagnosis of effusion were: a) at least two eardrum abnormalities relating to discoloration, darkening and mobility; and/or b) tympanic membrane (MT) typically retracted, concave, and with altered coloration; and/or c) reduced mobility or absence of mobility on pneumatic otoscopy (PO). The PO was shown to be more accurate than simple otoscopy (SO), which is considered the method of choice for diagnosis of OME. When the pneumatic otoscopy is inconclusive, tympanometry may recommended, as this increases the accuracy of the diagnosis. CONCLUSIONS: in clinical practice, diagnosis of OME should be carried out principally by way of pneumatic otoscopy, to which all children suspected of having OME should be submitted. Where there is doubt, tympanometry is recommended.

Febre sem sinais localizatórios: avaliação de um protocolo de atendimento / Fever without source: evaluation of a guideline

OBJETIVO: Avaliar a aplicabilidade de um protocolo de atendimento padronizado para crianças de até 36 meses de idade com febre sem sinais localizatórios (FSSL). MÉTODOS: Estudo de coorte prospectivo em crianças com FSSL atendidas no Pronto-Socorro do Hospital Universitário da Universidade de São Paulo, São Paulo (SP), de junho de 2006 a maio de 2007. O protocolo estratifica o risco de infecção bacteriana grave (IBG) de acordo com a presença ou não de toxemia, idade e valor da temperatura. Conforme avaliação de risco, indicava-se triagem laboratorial: hemograma, hemocultura, sedimento urinário, urocultura e, se necessário, radiografia torácica, liquor e coprocultura. RESULTADOS: Foram estudadas 251 crianças das quais 215 foram acompanhadas até o diagnóstico final. Vinte crianças apresentavam toxemia, e 195 estavam em bom estado geral (30 com idade de até 3 meses, e 165, de 3 a 36 meses). Nas crianças de 3 a 36 meses não toxêmicas, 95 tinham temperatura axilar > 39 ºC. Em 107 crianças (49,8 por cento), houve melhora espontânea do quadro febril; em 88 (40,9 por cento), foi identificada doença benigna autolimitada; e em 20 (9,3 por cento), IBG. Dentre as IBG, identificamos 16 infecções urinárias, três pneumonias e uma bacteremia oculta. Das 215, 129 (60 por cento) não receberam qualquer antibioticoterapia, e 86 receberam antibiótico em algum momento (45, empiricamente). O antibiótico empírico foi mantido por, em média, 72 horas. CONCLUSÃO: O protocolo aplicado mostrou-se adequado para o seguimento destas crianças que fizeram coleta de exames simples e passíveis de serem realizados na maioria dos serviços. A infecção urinária foi a IBG mais frequente nas crianças com FSSL.

OBJECTIVE: To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS: Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS: We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 ºC. In 107 (49.8 percent) children, there was spontaneous resolution of fever; in 88 (40.9 percent), benign self-limited disease was identified; and in 20 (9.3 percent), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60 percent) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION: The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Micetoma: [revisión] / Mycetoma: [review]

El micetoma es una enfermedad crónica, inflamatoria, subcutánea y granulomatosa, causada por diferentes especies de hongos (eumicetoma), actinomicetos (actinomicetoma) o bacterias como Staphylococcus aureus, Pseudomonas aeruginosa (Botriomicosis). Esta patología ocurre entre latitudes15 al sur y 30 Norte y es endémica en áreas relativamente áridas. Los microorganismos causales están presentes en el suelo y pueden entrar al tejido subcutáneo por inoculación traumática. El micetoma comúnmente afecta adultos entre 20 y 40 años, predominantemente hombres. El pie es el sitio más comúnmente afectado. El micetoma se presenta como una inflamación subcutánea progresiva. Se desarrollan múltiples nódulos, los cuales supuran y drenan a través de senos, descargando granos durante la fase activa de la enfermedad. El diagnóstico se basa en radiología, imágenes ultrasónicas, citología, cultivo e inmunodiagnóstico. El actinomicetoma es susceptible a tratamiento antibiótico prolongado, preferiblemente con varias medicaciones. El Eumicetoma se trata con excisión quirúrgica agresiva combinada con tratamiento médico y la botriomicosis se trata con antibióticos una vez establecido el diagnóstico, ojalá con aislamiento del agente causal.

Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by different fangal species (Eumycetoma), actinomycetes (Actimonycetoma), or bacteria Staphylococcus aureus, Pseudomonas aeruginosa, (Botryomycosis). It occurs between the latitudes of 15 South and 30. North and is endemic in relatively arid areas. The organisms are present in the soil and may enter the subcutaneous tissue by traumatic inoculation. Mycetoma commonly affects adults aged 20 to 40 years, predominantly males. The foot is most commonly affected. Mycetoma presents itself as progressive, subcutaneous swelling. Multiple nodules develop which may supúrate and drain through sinuses, discharging grains during the active phase of the disease. Diagnosis may involve radiology, ultrasonic imaging, cytology, culture, histology, or immunodiagnosis. Actinomycetoma is amenable to prolonged treatment by antibiotics, preferably by combining several medications. Eumycetoma is usually treated by aggressive surgical excision combined with medical treatment and Botryomycosis is treated with antibiotics upon establushment of the diagnosis preferably after isolation of the causal agent.

Clinical indicators of child development in the capitals of nine Brazilian states: the influence of regional cultural factors

OBJECTIVE: Evaluating the interaction between mother or caregiver and infant through the Clinical Indicators of Risks in Infant Development and investigating whether local and cultural influences during infant development affect these clinical indicators. INTRODUCTION: The Clinical Indicators of Risks in Infant Development was created in order to fully assess infants' development and the subjective relationship between the babies and their caregivers. The absence of two or more Clinical Indicators of Risks in Infant Developments suggests a possibly inadequate mental development. Given the continental size of Brazil and its accentuated cultural differences, one might question how trustworthy these indicators can be when applied to each of the geographical regions of the country. METHODS: This was a cross-sectional study with 737 infants from the capitals of 9 Brazilian states. The size of the initial sample population was based on a pilot study carried out in the cities of São Paulo and Brasília. The ages of children were grouped: 0-3 months, 4-7 months, 8-11 months and 12-18 months. The chi-square test was used together with analyses by the statistical software SPSS 13.0. RESULTS: Statistical analysis of results from the different municipalities against the total sample did not reveal any statistically significant differences. Municipalities represented were Belém (p=0.486), Brasília (p=0.371), Porto Alegre (p=0.987), Fortaleza (p=0.259), Recife (p=0.630), Salvador (0.370), São Paulo (p=0.238), Curitiba (p=0.870), and Rio de Janeiro (p= 0.06). DISCUSSION: Care for mental development should be considered a public health issue. Its evaluation and follow-up should be part of the already available mother-child assistance programs, which would then be considered to provide "full" care to children. CONCLUSIONS: Local habits and culture did not affect the results of the Clinical Indicators of Risks in Infant Development indicators. Clinical...

Láseres en dermatología / Lasers in dermatology

Los avances en la tecnología del láser han progresado tan rápidamente durante la década pasada, que se ha logrado el tratamiento exitoso de muchas enfermedades cutáneas y defectos congénitos, incluyendo lesiones vasculares y pigmentadas, tatuajes y cicatrices y pelo no deseado. La demanda de la cirugía láser se ha incrementado sustancialmente tanto para los pacientes como para los dermatólogos, debido a la facilidad que tiene para remover muchas lesiones, combinada con una baja incidencia de secuelas postoperatorias adversas.En esta revisión se muestran los Láseres que hay disponibles y sus aplicaciones cutáneas, haciendo énfasis en los recientes avances y modificaciones en la tecnología láser, que han incrementado el arsenal quirúrgico y mejorado la eficacia y seguridad de los tratamientos...

Tratamento nao intervencionista da diarreia persistente / Non interventionist treatment on persistent diarrhea

Avaliar uma terapeutica nao intervencionista, sem emprego de medicacao e, preferencialmente, com manutencao da alimentacao para o tratamento da diarreia persistente...