Fluid overload: clinical outcomes in pediatric intensive care unit

Abstract Objective The aim of this study was to analyze the effects of fluid overload related to mechanical ventilation, renal replacement therapy, and evolution to discharge or death in critically ill children. Methods A retrospective study in a Pediatric Intensive Care Unit for two years. Patients who required invasive ventilatory support and vasopressor and/or inotropic medications were considered critically ill. Results 70 patients were included. The mean age was 6.8 ± 6 years. There was a tolerable increase in fluid overload during hospitalization, with a median of 2.45% on the first day, 5.10% on the third day, and 8.39% on the tenth day. The median fluid overload on the third day among those patients in pressure support ventilation mode was 4.80% while the median of those who remained on controlled ventilation was 8.45% (p = 0.039). Statistical significance was observed in the correlations between fluid overload measurements on the first, third, and tenth days of hospitalization and the beginning of renal replacement therapy (p = 0.049) and between renal replacement therapy and death (p = 0.01). The median fluid overload was 7.50% in patients who died versus 4.90% in those who did not die on the third day of hospitalization (p = 0.064). There was no statistically significant association between death and the variables sex or age. Conclusions The fluid overload on the third day of hospitalization proved to be a determinant for the clinical outcomes of weaning from mechanical ventilation, initiation of renal replacement therapy, discharge from the intensive care unit, or death among these children.

Bloodstream infection in pediatric patients with febrile neutropenia induced by chemotherapy

Abstract Introduction Febrile neutropenia (FN) is a serious complication of cancer chemotherapy. The present study aimed to identify risk factors for documented infection in pediatric patients with FN and cancer. Methods This prospective cohort study included patients under 18 years from 2016 to 2018. Infection was defined according to the Centers for Disease Control and Prevention criteria. Results A total of 172 febrile neutropenic episodes were evaluated. From univariate analysis, the risk factors were: female gender; monocyte count < 100 cell/mm³, platelets < 50,000, C-reactive protein (CRP) > 90 mg/dl and hemoglobin < 7mg/dl at the onset of an episode; two or more episodes of FN, and; fever onset; positive blood culture at the fever onset. Independent risk factors according to the multivariate analysis were: CRP at the onset of a febrile episode > 90mg/dl, fever onset and first blood culture with a positive result. The lowest probability of infection was related to first episode and to platelets > 50,000 at the onset of fever. Conclusion A CRP > 90 at the onset of a febrile episode, platelets < 50,000, second episode or more, first fever episode during hospitalization and positive first blood culture were found to be associated with a higher risk of infection and they could be useful for the establishment of risk scores for infection in neutropenic children.

Acute invasive fungal rhinosinusitis in pediatric patients with oncohematological diseases

Abstract Introduction Invasive fungal diseases represent important causes of morbidity and mortality among pediatric oncohematological patients. Acute invasive fungal rhinosinusitis is a rare and aggressive disease that occurs mainly in immunocompromised patients. The mortality rate is high and therefore, accurate and early diagnosis is essential. Objectives The aim of this study was to describe the frequency of acute invasive fungal rhinosinusitis among pediatric oncohematological patients and characterize them with confirmed diagnoses. Methods This was a retrospective study that analyzed the medical records of pediatric patients diagnosed with oncohematological diseases and suspected fungal infections, who were included after obtaining informed consent, from January to December 2017, in the pediatric unit of a tertiary university hospital. Data collected from medical record analysis included the following: underlying diagnosis, absolute neutrophil count, clinical presentation, culture and biopsy results, surgical procedures performed, survival and mortality. Results A total of 27 patients were evaluated, with three suspected cases of acute invasive fungal rhinosinusitis. Histopathological and microbiological analyses confirmed two cases. In both cases, the pathogen isolated in the culture was Fusarium sp. The two confirmed cases were female, aged 12 and 14 years, both with an absolute neutrophil count of 10 cells/μL. The underlying disease of the first patient was acute myeloid leukemia (subtype M5), whereas the second patient presented idiopathic bone marrow aplasia. Conclusion Both confirmed cases of acute invasive fungal rhinosinusitis presented with constitutional symptoms and signs of nasal and sinusital inflammation. This demonstrates the importance of fever as a symptom in immunocompromised patients and it should prompt otorhinolaryngological investigation.

Intra-tumor genetic heterogeneity in Wilms tumor samples

SUMMARY Childhood renal tumors account for ~7% of all childhood cancers, and most cases are embryonic Wilms' tumors (WT). Children with WT are usually treated by either COG or SIOP. The later treats the children using preoperative chemotherapy, but both have around 90% of overall survival in five years. WT is a genetically heterogeneous group with a low prevalence of known somatic alterations. Only around 30% of the cases present mutation in known genes, and there is a relatively high degree of intra-tumor genetic heterogeneity (ITGH). Besides potentially having an impact on the clinical outcome of patients, ITGH may interfere with the search for molecular markers that are prospectively being tested by COG and SIOP. In this review, we present the proposal of the current UMBRELLA SIOP Study 2017/Brazilian Renal Tumor Group that requires the multi-sampling collection of each tumor to better evaluate possible molecular markers, as well as to understand WT biology

RESUMO Os tumores renais pediátricos correspondem a aproximadamente 7% de todos os tumores infantis, sendo o mais frequente o tumor de Wilms (TW). Crianças com TW são geralmente tratadas seguindo dois distintos protocolos terapêuticos (COG ou SIOP), sendo que no último, os pacientes recebem tratamento quimioterápico pré-operatório. Ambos apresentam sobrevida global em cinco anos em torno de 90%. TW é geneticamente heterogêneo, apresentando baixa prevalência de alterações somáticas conhecidas, com cerca de 30% dos casos apresentando mutações em genes conhecidos e um alto grau de heterogeneidade genética intratumoral (HGIT). Além de potencialmente ter um impacto sobre o desfecho clínico dos pacientes, a HGIT pode interferir na busca de marcadores moleculares que estão sendo testados prospectivamente pelos grupos COG e Siop. Nesta revisão, apresentamos a proposta do atual estudo Umbrella Siop 2017/Grupo de Tumores Renais Brasileiros (GTRB), que orienta a coleta de três diferentes regiões do tumor para melhor avaliar possíveis marcadores moleculares, bem como para compreender a biologia do TW.

Carcinoma adrenal em crianças: estudo longitudinal em minas gerais, brasil / Adrenal carcinoma in children: longitudinal study in minas gerais, brazil

RESUMO Objetivo: Analisar as características clínicas, laboratoriais e histopatológicas e o percurso até o estabelecimento do diagnóstico e do tratamento de pacientes com carcinoma de suprarrenal (CSR). Métodos: Estudo retrospectivo com 13 pacientes tratados no serviço de oncologia pediátrica do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG) entre 2004 e 2015. Resultados: A idade ao diagnóstico variou de 1,0 a 14,8 anos (mediana: 2,0 anos). As manifestações de hipercortisolismo foram identificadas em todos os casos, e as de virilização, em todas as meninas. Todos os pacientes preencheram os critérios de Weiss para diagnóstico histopatológico de CSR. A imuno-histoquímica foi realizada em 61,5% dos casos. A maioria dos pacientes apresentou doença em estádio I (76,9%). Todos foram submetidos à ressecção tumoral total. Dois pacientes (estádios III e IV) receberam quimioterapia associada ao mitotano. O único óbito observado foi do paciente com doença em estádio IV. A probabilidade de sobrevida global para todo o grupo aos 5,0 anos foi de 92,3±7,4%. A mediana de tempo entre o início dos sintomas e o diagnóstico foi de 9,5 meses, e de 6,0 meses entre a primeira consulta e o início do tratamento. Conclusões: A baixa idade ao diagnóstico, o predomínio de casos com doença localizada e a ressecção tumoral completa - com apenas um caso de ruptura de cápsula tumoral - são possivelmente a explicação para a evolução favorável da população estudada. O longo percurso entre o início dos sintomas e o diagnóstico sugere a importância da capacitação dos pediatras para o reconhecimento precoce dos sinais e dos sintomas do CSR.

ABSTRACT Objective: To analyze clinical, laboratory and histopathological features and the path to diagnosis establishment and treatment of patients with adrenal carcinoma (AC). Methods: Retrospective study with 13 patients assisted at the pediatric oncology service of Hospital das Clínicas, Universidade Federal de Minas Gerais, Brazil, between 2004 and 2015. Results: Age at diagnosis ranged from 1.0 to 14.8 years (median: 2.0 years). Manifestations of hypercortisolism were identified in all cases and virilization in all girls. All patients met the Weiss criteria to AC histopathological diagnosis. Immunohistochemistry was performed in 61.5% of the cases. Most patients had stage I disease (76.9%). All subjects were submitted to total tumor resection. Two patients (stages III and IV disease) received chemotherapy associated to mitotane. The only death case was that of a patient with stage IV disease. The probability of overall survival for the entire group up to 5.0 years was 92.3±7.4%. The median time between the onset of symptoms and diagnosis was 9.5 months, and 6.0 months between first visit and start of treatment. Conclusions: Low age at diagnosis, predominance of cases with localized disease and complete tumor resection - with only one case of tumor capsule rupture - can possibly explain the favorable evolution of the studied population. The long period between onset of symptoms and diagnosis highlights the importance of training pediatricians for early recognition of AC signs and symptoms.

Metástases pulmonares em crianças: estamos operando desnecessariamente? / Pulmonary metastases in children: are we operating unnecessarily?

RESUMO Objetivo: determinar, em pacientes pediátricos portadores de neoplasias malignas, as características de nódulos pulmonares identificados à tomografia computadorizada, capazes de diferenciar nódulos benignos de metástases. Métodos: estudo retrospectivo de pacientes submetidos a ressecções pulmonares de nódulos diagnosticados como metástases em um período de sete anos. Achados de tomografia e da cirurgia, assim como resultados dos exames anatomopatológicos foram comparados. Resultados: nove pacientes, submetidos a 11 intervenções cirúrgicas, foram estudados. Entre as variáveis estudadas, apenas o tamanho do nódulo, maior do que 12,5mm provou ser estatisticamente significante para predizer malignidade. Conclusão: esse estudo sugere que, entre as características tomográficas de nódulos pulmonares de crianças portadoras de neoplasias malignas, apenas o tamanho da lesão foi preditor de malignidade.

ABSTRACT Objective: to determine, in pediatric patients with malignant neoplasms, the characteristics of pulmonary nodules identified on computed tomography, as well as the possibility of differentiating benign lesions from metastases. Methods: we conducted a retrospective study of patients submitted to pulmonary resections of nodules diagnosed as metastases in a period of seven years. We compared computed tomography and surgery findings, as well as results of anatomopathological examinations. Results: we studied nine patients submitted to 11 surgical interventions. Among the studied variables, only nodule size greater than 12.5mm proved to be statistically significant to predict malignancy. Conclusion: among the tomographic characteristics of pulmonary nodules in children with malignant neoplasms, only the size of the lesion was a predictor of malignancy.

Caso 14 / Case 14

Criança do sexo masculino, dois anos de idade, natural de Parauapebas (PA), apresentava reflexo branco em olho esquerdo em fotografias desde os primeiros meses de vida. Evoluiu com diminuição progressiva da acuidade visual, cefaleia e as alterações do globo ocular evidenciadas pela fotografia e pela tomografia computadorizada.

Aspectos da qualidade de vida relacionada à saúde em oncologia pediátrica / Issues of health related quality of life in pediatric oncology

Nas últimas décadas, houve aumento significativo nos índices de sobrevida das crianças e adolescentes com diagnóstico de neoplasias malignas. Essa acentuada melhora levanta questionamentos não só em relação à quantidade ou duração da sobrevida, mas também quanto à qualidade de vida. A mortalidade não é mais o ponto final apropriado quando se está considerando a eficácia de uma intervenção médica. As crianças e seus cuidadores experimentam significativo comprometimento da qualidade de vida nos meses que se seguem ao diagnóstico do câncer. Dessa forma, tanto as decisões clínicas quanto a condução de pesquisas só deveriam ser realizadas juntamente com o desenvolvimento de boas medidas de avaliação da qualidade de vida. Objetivo: alertar o pediatra a respeito da importância da avaliação da qualidade de vida relacionada à saúde de crianças e adolescentes com câncer.Métodos: foram selecionadas 39 referências em pesquisa realizada nas bases de dados Medline e no LILACS, utilizando-se as palavras-chave qualidade de vida, sobrevida, neoplasia. (AU)

There has been in the last decades a significant increase in the survival rate of children and adolescents with cancer diagnosis. This impressive improvement raises issues related not only to the amount of gained survival years but also to the quality of such survival. Mortality is no longer the more the appropriate end point to evaluate the efficacy of a medical intervention. Children and their parents suffer a remarkable decline in their quality of life during several months after the cancer diagnosis. Thus it would be highly appropriate that the evaluation of the quality of life was also an integral part of the clinical decisions and research in this area. Objective: to alert pediatricians to the importance of evaluating health related quality of life in children and adolescents with cancer. Methods: 39 references were selected from Medline and LILACS databases using the key words quality of life, survival and neoplasm. (AU)

Apresentação clínica dos tumores sólidos mais comuns na infância e adolescência / Clinical presentation of the most common solid tumors in childhood and adolescent

O câncer infanto-juvenil é uma doença relativamente rara, sendo responsável por 0,5-3% do total de casos de câncer. Entretanto, ainda é causa de grande morbimortalidade em pacientes nessa faixa etária em nosso meio. Diagnóstico precoce e tratamento em centros especializados são essenciais para aumento da sobrevida em longo prazo. Objetivo: alertar o pediatra a respeito da importância do reconhecimento precoce das principais neoplasias malignas da infância e adolescência, dando ênfance à epedemiologia e apresentação clínica dos tumores sólidos. Métodos: foram selecionados 26 referências bibliográficas em pesquisa realizada nas base de dados Medline e no LILACS, em português, espanhol e inglês, utilizando-se as palavras-chave câncer infanto-juvenil, apresentação clínica, sobrevida.

Diagnóstico precoce do câncer infantil: responsabilidade de todos / Early diagnosis of childhood cancer: a team responsibility

OBJETIVO: Alertar para a necessidade do conhecimento e investigaçäo dos sinais e sintomas iniciais do câncer infantil, bem como para a responsabilidade de todos envolvidos no processo do seu diagnóstico precoce a fim de melhorar os nossos índices de cura. MÉTODOS: Revisäo da literatura através de consulta ao Medline. RESULTADOS: O diagnóstico do câncer infantil é um processo complexo e muitas säo as variáveis que parecem influenciá-lo. A detecçäo precoce e o pronto início do tratamento têm importante papel na reduçäo da mortalidade e morbidade do tratamento. O melhor entendimento da relaçäo entre estes fatores é de fundamental importância para o desenvolvimento de estratégias de saúde pública para detecçäo precoce do câncer infantil. CONCLUSÄO: Muitos fatores parecem estar associados ao atraso do diagnóstico do câncer infantil. O tempo que decorre entre o primeiro sintoma e o diagnóstico depende da idade da criança e do tipo do tumor, principalmente. Determinar os sinais e sintomas que devem alertar para a possibilidade de doenças malignas ainda é um desafio