Prognostic factors for metastasis in cutaneous melanoma

Abstract: Background: Melanoma is a malignant neoplasia that shows high mortality when diagnosed in advanced stages. Early identification of high-risk patients for the development of melanoma metastases is the main strategy to reduce mortality. Objective: To assess the influence of eight epidemiological and histopathologic features on the development of metastases in patients diagnosed with primary cutaneous melanoma. Methods: Our historical cohort comprised patients with invasive primary cutaneous melanoma seen between 1995 and 2012 at a public university hospital and a private oncologic surgery institution in Southeastern Brazil. The following variables were analyzed: gender, age, family history of melanoma, site of the primary tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and the mitotic index. Kaplan-Meier univariate test and multivariate Cox proportional hazard analysis were used to assess factors associated with disease-free survival. Results: Five hundred and fourteen patients were enrolled. The univariate analysis identified the following significant risk factors: gender, age, site of the tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and mitotic index. Multivariate analysis included 244 patients and detected four significant prognostic factors: male gender, nodular clinical and histologic subtype, Breslow thickness > 4mm, and histologic ulceration. The mitotic index was not included in this analysis. Study limitations: Small number of patients in multivariate analysis. Conclusions: The following prognostic factors to the development of melanoma metastasis were identified in the study: male gender, nodular histologic subtype, Breslow thickness > 4mm and ulceration.

A prospective study of patients with large congenital melanocytic nevi and the risk of melanoma

Abstract: Background: Large congenital melanocytic nevus (LCMN) is considered a risk factor for melanoma, although the magnitude of this risk is controversial. Objective: To evaluate the risk of melanoma development in patients with LCMN seen at a dermatology referral center in Brazil during a twelve-year period. To the best of our knowledge, there are no published similar studies on large congenital melanocytic nevus in South America. Methods: Our prospective cohort included only patients with congenital nevi ≥20cm. The cumulative risk of developing melanoma and the standardized morbidity ratio were calculated for patients followed up prospectively for at least 1 month. Results: Sixty-three patients were enrolled in this study. One patient who developed melanoma prior to enrollment was excluded, and five were eliminated because of insufficient follow-up time. Mean follow-up for the remaining 57 patients was 5.5 years (median 5.2 years). Median age of entry into the study was 2.6 years. Most patients (75.4%) underwent only clinical observation. Melanomas occurred in 2 (3.5%) patients. Five-year cumulative risk for melanoma was 4.8% (95% CI: 1.9-11.5%). Standardized morbidity ratio was 1584 (95% CI: 266-5232, p<0.001). Study limitations: The small sample size reduces the accuracy of risk estimates. Conclusions: This study analyzed prospectively for the first time data from South America demonstrating that patients with LCMN have a higher risk of developing melanoma than the general population (p<0.001).

Patch-test results in children and adolescents: systematic review of a 15-year period

Abstract The number of studies on patch-test results in children and adolescents has gradually increased in recent years, thus stimulating reviews. This paper is a systematic review of a 15-year period devoted to studying the issue. Variations pertaining to the number and age groups of tested children and/or adolescents, the number of subjects with atopy/atopic dermatitis history, the quantity, type and concentrations of the tested substances, the test technique and type of data regarding clinical relevance, must all be considered in evaluating these studies, as they make it harder to formulate conclusions. The most common allergens in children were nickel, thimerosal, cobalt, fragrance, lanolin and neomycin. In adolescents, they were nickel, thimerosal, cobalt, fragrance, potassium dichromate, and Myroxylon pereirae. Knowledge of this matter aids health professionals in planning preventive programs aimed at improving children's quality of life and ensuring that their future prospects are not undermined.

Cardiovascular risk factors and increased carotid intima-media thickness in young patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency

ABSTRACT Objective Increased arterial intima-media thickness has been observed in adults with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD). CAH has also been associated with obesity, insulin resistance, and hypertension. The aim of the present study was to compare youths with CAH with healthy, normal-weight individuals, evaluating carotid intima-media thickness (CIMT) and indicative factors of cardiovascular risk to seek for abnormalities in the CAH group. Subjects and methods Clinical, biochemical, and ultrasonographic evaluations, according to published criteria, were performed in 113 subjects (5 to 20 years old): 40 patients with 21-OHD and 73 healthy individuals matched for gender, pubertal status, and age. Results Most CAH patients were female (80%), salt-losers (72.5%), and pubescent (80%); 10 (25%) patients were overweight. An increase in CIMT was observed both on the right (p = 0.0240) and left (p = 0.0003) sides in 38 CAH patients compared with the healthy individuals. The body mass index, BMI/age Z score, and systolic blood pressure (SBP) were higher in patients compared with controls (p < 0.000 and p = 0.0219, respectively). Conclusions Findings of increased CIMT, BMI, and SBP in young patients with 21-OHD indicate the need for early identification and intervention regarding cardiovascular risk. Validating these findings might result in improved therapeutic approaches for children with 21-OHD in the future. Arch Endocrinol Metab. 2015;59(6):541-7.

Patch test results in children and adolescents. Study from the Santa Casa de Belo Horizonte Dermatology Clinic, Brazil, from 2003 to 2010

AbstractBACKGROUND:Patch testing is an efficient method to identify the allergen responsible for allergic contact dermatitis.OBJECTIVE:To evaluate the results of patch tests in children and adolescents comparing these two age groups' results.METHODS:Cross-sectional study to assess patch test results of 125 children and adolescents aged 1-19 years, with suspected allergic contact dermatitis, in a dermatology clinic in Brazil. Two Brazilian standardized series were used.RESULTS:Seventy four (59.2%) patients had "at least one positive reaction" to the patch test. Among these positive tests, 77.0% were deemed relevant. The most frequent allergens were nickel (36.8%), thimerosal (18.4%), tosylamide formaldehyde resin (6.8%), neomycin (6.4%), cobalt (4.0%) and fragrance mix I (4.0%). The most frequent positive tests came from adolescents (p=0.0014) and females (p=0.0002). There was no relevant statistical difference concerning contact sensitizations among patients with or without atopic history. However, there were significant differences regarding sensitization to nickel (p=0.029) and thimerosal (p=0.042) between the two age groups under study, while adolescents were the most affected.CONCLUSION:Nickel and fragrances were the only positive (and relevant) allergens in children. Nickel and tosylamide formaldehyde resin were the most frequent and relevant allergens among adolescents.

Reflexões sobre a suplementação de ferro na população infantil / Reflections on iron supplementation in children

Este estudo tem como objetivo aprimorar conhecimentos e melhorar a prática diária na assistência à saúde da criança. Buscou-se utilizar referências a partir do ano de 1987,conseguidas em bibliotecas virtuais e acervo pessoal de Pediatria. Os textos foram submetidosà leitura exploratória, interpretativa e seletiva. Este estudo busca reflexão sobre a consciência e o comportamento de pais e cuidadores, tentando compreender os problemas advindos da não suplementação ou da suplementação inadequada de ferro, com o intuito de orientar sobre a importância da suplementação de ferro na primeira infância.Também adverte sobre a necessidade de mais estudos sobre os benefícios e malefícios pouco discutidos e difundidos advindos da suplementação de ferro na dieta na infância.

This study aims to improve the knowledge and daily practice in child health care. We attempted to use references starting in 1987, achieved in virtual libraries and personal collections in Pediatrics. The texts were submitted to an exploratory, interpretive, and selective reading. This study aims to reflect on the consciousness and behavior of parents and caregivers, trying to understand the problems resulting from no supplementation orinadequate iron supplementation in order to advise on the importance of iron supplementation in early childhood. In addition, it warns about the need for more studies on the benefits and harms arising from iron supplementation in the childhood diet, which are little discussed and disseminated.

Comorbidities and cardiovascular risk factors in patients with psoriasis

BACKGROUND: Psoriasis is a chronic inflammatory disease and its pathogenesis involves an interaction between genetic, environmental, and immunological factors. Recent studies have suggested that the chronic inflammatory nature of psoriasis may predispose to an association with other inflammatory diseases, especially cardiovascular diseases and metabolic disorders. OBJECTIVES: To describe the demographic, clinical, epidemiological, and laboratory characteristics of a sample of psoriasis patients; to assess the prevalence of cardiovascular comorbidities in this group of patients; and to identify the cardiovascular risk profile using the Framingham risk score. METHODS: We conducted a cross-sectional study involving the assessment of 190 patients. Participants underwent history and physical examination. They also completed a specific questionnaire about epidemiological data, past medical history, and comorbidities. The cardiovascular risk profile was calculated using the Framingham risk score. RESULTS: Patients' mean age was 51.5 ± 14 years, and the predominant clinical presentation was plaque psoriasis (78.4%). We found an increased prevalence of systemic hypertension, type 2 diabetes, metabolic syndrome, and obesity. Increased waist circumference was also found in addition to a considerable prevalence of depression, smoking, and regular alcohol intake. Patients' cardiovascular risk was high according to the Framingham risk score, and 47.2% of patients had moderate or high risk of fatal and non-fatal coronary events in 10 years. CONCLUSIONS: Patients had high prevalence of cardiovascular comorbidities, and high cardiovascular risk according to the Framingham risk score. Further epidemiological studies are needed in Brazil for validation of our results. .

The gap between knowledge on HIV/AIDS and sexual behavior: a study of teenagers in Vespasiano, Minas Gerais State, Brazil / A lacuna entre o conhecimento sobre HIV/AIDS e o comportamento sexual: uma investigação com adolescentes de Vespasiano, Minas Gerais, Brasil / La laguna entre el conocimiento sobre VIH/SIDA y el comportamiento sexual: una investigación con adolescentes de Vespasiano, Minas Gerais, Brasil

The aim of this study was to investigate gaps between knowledge on HIV/AIDS and sexual behavior among teenagers. The study used a cross-sectional design with a representative random sample of 1,158 teenagers (14 to 19 years of age) enrolled in nine public secondary schools and who answered validated questionnaires. Data analysis included descriptive statistics and tests of hypotheses (chi-square, Mann-Whitney and Kruskal-Wallis, Kendall, and Fisher's exact test). The vast majority of the teenagers (98.7%) expressed doubt on at least one question. Condom use during first sexual intercourse was significantly associated with condom use in sexual relations in the previous six months. There was no statistical association between knowledge on HIV/AIDS and frequency of condom use or number of sexual partners. Health actions are needed that link schools to health services, in addition to not only elaborating appropriate information but also valorizing teenagers' individuality in the development of proposals.

O objetivo foi investigar as lacunas entre o conhecimento sobre o HIV/AIDS e o comportamento sexual em adolescentes do ensino médio. Delineamento transversal com amostra representativa e aleatória de 1.158 adolescentes entre 14 a 19 anos, matriculados em nove escolas públicas que responderam a questionários validados. A análise dos dados envolveu estatística descritiva e testes de hipóteses (qui-quadrado, Mann-Whitney e Kruskal-Wallis, Kendal e teste exato de Fisher). A maioria dos adolescentes (98,7%) apresentou dúvida em alguma questão proposta. O uso do preservativo na primeira relação sexual influenciou o uso nas relações dos últimos seis meses. Não houve associação estatística entre o conhecimento sobre HIV/AIDS com a frequência do uso de preservativo e a multiplicidade de parceiros sexuais. É necessário a implementação de ações em saúde que articulem a escola aos serviços de saúde e que além de trabalhar a informação, valorizem a individualidade dos adolescentes na construção das propostas.

El objetivo fue investigar las lagunas entre el conocimiento sobre el VIH/SIDA y el comportamiento sexual en adolescentes de enseñanza media. Delineación transversal con muestra representativa y aleatoria de 1.158 adolescentes entre 14 a 19 años, matriculados en nueve escuelas públicas que respondieron a cuestionarios validados. El análisis de los datos implicó estadística descriptiva y tests de hipótesis (chi-cuadrado, Mann-Whitney y Kruskal-Wallis, Kendal y test exacto de Fisher). La mayoría de los adolescentes (98,7%) presentó dudas en alguna cuestión propuesta. El uso del preservativo en la primera relación sexual influenció el uso en las relaciones de los últimos seis meses. No hubo asociación estadística entre el conocimiento sobre VIH/SIDA con la frecuencia del uso de preservativo y la multiplicidad de compañeros sexuales. Es necesaria la implementación de acciones en salud que articulen la escuela a los servicios de salud y que además de trabajar con la información, valoren la individualidad de los adolescentes en la construcción de las propuestas.

Final height in congenital adrenal hyperplasia: the dilemma of hypercortisolism versus hyperandrogenism / Altura final na hiperplasia suprarrenal congênita: o dilema do hipercortisolismo versus hiperandrogenismo

OBJECTIVE: The purpose of this study was to identify factors that might interfere with reaching the final height in patients with 21-hydroxylase deficiency (21-OHD). SUBJECTS AND METHODS: Thirty-one patients with classical 21-OHD who reached their FH in our Institution were eva­luated in order to compare the Z score for final height (FHZ) with: (1) the target height, (2) the standard height for the population, and (3) the hydrocortisone treatment schedule. RESULTS: The FHZ of -2.13 ± 1.11 had a significant negative correlation with the hydrocortisone doses used throughout the period of study. Patients who reached FH within the normal population range were those who received lower doses of hydrocortisone, as compared to those whose FH remained below -2 SDS. CONCLUSION: We conclude that careful treatment adjustments have a major influence on growth of children with CAH, and that the dose range for hydrocortisone replacement that does not lead to side effects is relatively narrow. The better height outcome was achieved in 21-OHD patients who received lower doses of hydrocortisone.

OBJETIVO: O objetivo do estudo foi a identificação de fatores que podem interferir na aquisição de altura final de pacientes com a deficiência de 21-hidroxilase (21OHD). SUJEITOS E MÉTODOS: A altura final (escore Z: FHZ) de 31 pacientes com a forma clássica da 21OHD, acompanhados em nossa instituição, foi comparada com: (1) a altura alvo, (2) o padrão de referência para a população, e (3) a dose de hidrocortisona durante o acompanhamento. RESULTADOS: Observou-se correlação negativa significativa entre o FHZ de -2,13 ± 1,11 e as doses de hidrocortisona utilizadas durante o período de estudo. Os pacientes que atingiram altura final dentro do padrão de referência para a população usaram doses mais baixas de hidrocortisona quando comparados àqueles que permaneceram abaixo de -2 DP. CONCLUSÃO: O cuidado nos ajustes das doses durante o tratamento da 21OHD tem grande influência sobre o crescimento das crianças. A faixa de variação da dose de reposição da hidrocortisona que não causa efeitos colaterais é relativamente estreita. O melhor resultado estatural foi observado nos pacientes com 21OHD tratados com doses mais baixas de hidrocortisona.

Infecções de sítio cirúrgico na criança e no adolescente / Surgery infections in children and adolescents

Infecções de sítio cirúrgico (ISC) representam uma das principais infecções relacionadas à assistência à saúde e importante complicação na prática cirúrgica. Em Pediatria, as ISC representam 17% de todas as infecções relacionadas à assistência à saúde, mas a magnitude do problema precisa ser mais bem dimensionada. As ISC podem ser divididas em três categorias: incisional superficial, incisional profunda e órgãos ou cavidades. As ISC são diagnosticadas segundo os critérios do Centers for Disease Control and Prevention e, no Brasil, do Ministério da Saúde. A vigilância dessas infecções deve ser feita durante a internação e após a alta, pois significativo número se manifesta fora do hospital. Bactérias constituem a principal causa da infecção e são representadas principalmente pelos estafilococos. Para se estabelecer programa de prevenção e controle dessas infecções é importante conhecer os fatores de risco, tais como: idade, classificaçãoAmerican Society of Anesthesiology (ASA), tempo de internação préoperatório, uso inadequado de antibioticoprofilaxia, duração da cirurgia, potencial de contaminação da ferida cirúrgica, entre outros. As ISC podem ser passíveis de prevenção em mais de 60%, desde que medidas adequadas sejam instituídas. A adesão aos guidelines para prevenção de infecções cirúrgicas pode reduzir significativamente a sua incidência e custos relacionados...

Surgery infections constitute an important complication in the surgery practice and one of the main infections demanding health care. In Pediatrics, surgery infections represent 17 % of all infections demanding to health care, but the problem magnitude needs to be better and further assessed. Such infections can be divided in three categories: surface incisional, deep incisional, and organs or cavities. The surgery infections are diagnosed according to criteria proposed by the Centers for Diagnose Control and Prevention and, in Brazil, by the Ministry of Health. Such infections must be monitor during hospital admission and after discharge, as a significant number of occurrences take place outside the hospital. Bacteria ? mostly staphylococcus ? are usually the main cause of infection. Establishing a prevention and control program for such infections demand a deep understanding of such factors or risk as: age, American Society of Anesthesiology (ASA) classification, preoperative hospital stay, inadequate use of antibiotics, surgery duration, potential of surgery injury conamination. Surgery infections can be prevented in over 60 % of the cases, provided that adequate measures are taken. Compliance with preventive guidelines for surgery infections can significantly reduce incidence and related costs...

The impact of highly active antiretroviral therapy on the survival of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil

The use of highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV)-infected patients has reduced the number of acquired immune deficiency syndrome-related deaths worldwide. This study assessed the impact of HAART on the survival and death rates of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil. Data were obtained from a historic cohort of vertically HIV-infected children and adolescents aged zero-19 years old who were admitted from March 1989-December 2004 and were followed until June 2006. Patients who used HAART were included if they were treated for at least 12 weeks. Of 359 patients, 320 patients met the inclusion criteria. The overall mortality rate was 9.7% [31/320; 95% confidence interval (CI): 6.0-13%]. The median survival for the non-HAART and HAART groups was 31.5 and 55.9 months, respectively (log rank = 22.11, p < 0.0001). In the multivariate analysis, the statistically significant variables were HAART and the weight-for-age Z score < -2, with HAART constituting a protective factor [relative risk (RR): 0.13; CI 95%: 0.05-0.33] and malnutrition constituting a risk factor (RR: 3.44; CI 95%: 1.60-7.40) for death. The incidence of death was 5.1/100 person-years in the non-HAART group and 0.8/100 person-years in the HAART group (p < 0.0001).

Impacto da terapia antirretroviral combinada no crescimento e nas taxas de hospitalização de crianças infectadas pelo HIV / Impact of HAART on growth and hospitalization rates among HIV-infected children

OBJETIVO: Avaliar mudanças em parâmetros de crescimento e hospitalização em crianças infectadas pelo vírus da imunodeficiência humana (human immunodeficiency virus, HIV) em uso de terapia antirretroviral combinada. MÉTODOS: As crianças foram avaliadas durante os primeiros 3 anos de terapia. A resposta clínica foi avaliada a cada 24 semanas com base em escores z de peso/idade e altura/idade. Modelos de regressão linear foram utilizados para identificar preditores de resposta clínica. Dados relevantes relativos à hospitalização dos pacientes foram obtidos retrospectivamente mediante revisão dos prontuários clínicos. RESULTADOS: Um total de 196 crianças foram avaliadas. A média do escore z aumentou de -1,62 (±1,32) no início do estudo para -1,14 (±1,12) na semana 24. A média do escore z de altura/idade aumentou de -1,88 (±1,45) para -1,66 (±1,18). Foi observada associação entre maiores escores z no início do estudo e maiores aumentos nos escores z de peso/idade ao longo do tempo. Cargas virais mais baixas e escores de altura/idade mais altos também estiveram associados com maior recuperação do crescimento. Oitenta e cinco crianças (43,3 por cento) foram hospitalizadas. A maioria das internações esteve associada a causas infecciosas, sendo apenas dois casos de infecções oportunistas. CONCLUSÃO: A terapia combinada resultou em aumentos significativos nos escores z de peso/idade e altura/idade. A menor idade, o uso de inibidores de protease e a classificação clínica em estágios avançados estiveram associados a uma maior efetividade do tratamento. Além disso, o estudo demonstrou a eficácia da terapia para a redução das taxas de hospitalização, morte e incidência de infecções oportunistas entre crianças portadoras do HIV.

OBJECTIVE: To evaluate HAART-associated changes in growth and hospitalization rates over time in a cohort of HIV-infected children. METHODS: Children starting HAART were assessed during the first 3 years of therapy. Clinical response was assessed every 24 weeks by z scores of weight-for-age and height-for-age. Linear regression models were used to detect predictors of clinical response. Pertinent information on hospitalizations was obtained retrospectively through review of medical records. RESULTS: A total of 196 children were assessed. Mean weight z score increased from -1.62 (±1.32) at baseline to -1.14 (±1.12) by week 24. Mean height z score increased from -1.88 (±1.45) at baseline to -1.66 (±1.18). Better z scores at baseline were associated with greater increases in weight z scores over time. Lower viral load and higher height z scores at baseline were also associated with improved height catch-up. Eighty-five children (43.3 percent) were hospitalized. Most hospitalizations were prompted by infectious disease, with only two due to opportunistic infections. CONCLUSION: HAART was associated with significant increases in weight and height z scores. Younger age, the use of protease inhibitors and advanced clinical disease were associated with better outcomes. The present study demonstrated the effectiveness of HAART in significantly reducing hospitalization, death, and incidence of opportunistic infections among HIV-infected children.

Pulmonary paracoccidoidomycosis: radiology and clinical-epidemiological evaluation / Paracoccidioidomicose pulmonar: radiologia e avaliação clínico-epidemiológica

INTRODUCTION: The purpose of this study was to compare respiratory signs and symptoms between patients with and without chest X-ray abnormalities in order to establish the meaning of radiographic findings in pulmonary PCM diagnosis. METHODS: The epidemiological, clinical and radiological lung findings of 44 patients with paracoccidiodomycosis (PCM) were evaluated. Patients were divided into two groups of 23 and 21 individuals according to the presence (group 1) or absence (group 2) of chest X-ray abnormalities, respectively, and their clinical data was analyzed with the aid of statistical tools. RESULTS: As a general rule, patients were rural workers, young adult males and smokers - group 1 and 2, respectively: males (91.3 percent and 66.7 percent); mean age (44.4 and 27.9 year-old); smoking (34.7 percent and 71.4 percent); acute/subacute presentation (38.1 percent and 21.7 percent); chronic presentation (61.9 percent and 78.3 percent). The most frequent respiratory manifestations were - group 1 and 2, respectively: cough (25 percent and 11.4 percent) and dyspnea (22.7 percent and 6.8 percent). No statistical difference was observed in pulmonary signs and symptoms between patients with or without radiographic abnormalities. The most frequent radiological finding was nodular (23.8 percent) or nodular-fibrous (19 percent), bilateral (90.5 percent) and diffuse infiltrates (85.7 percent). CONCLUSIONS: Absence of statistical difference in pulmonary signs and symptoms between these two groups of patients with PCM indicates clinical-radiological dissociation. A simplified classification of radiological lung PCM findings is suggested, based on correlation of these data and current literature review.

INTRODUÇÃO: Comparar sinais e sintomas respiratórios entre pacientes com e sem alterações à radiografia de tórax para se estabelecer o significado dos achados radiográficos no diagnóstico da paracoccidioidomicose pulmonar. MÉTODOS: Os achados epidemiológicos, clínicos e radiológicos de 44 pacientes com paracoccidioidomicose (PCM) foram avaliados. Os pacientes foram divididos em dois grupos de 23 e 21 indivíduos de acordo com a presença (grupo 1) ou ausência (grupo 2) de anormalidades à radiografia de tórax, respectivamente, e seus dados clínicos foram analisados com auxílio de ferramentas estatísticas. RESULTADOS: Como regra geral, os pacientes eram trabalhadores rurais do sexo masculino, tabagistas e em idade adulta jovem - grupo 1 e 2, respectivamente: homens (91,3 por cento e 66,7 por cento); média de idade (44,4 e 27,9 anos); tabagismo (34,7 por cento e 71,4 por cento); forma aguda/subaguda (38,1 por cento e 21,7 por cento); forma crônica (61,9 por cento e 78,3 por cento). As manifestações respiratórias mais frequentes foram - grupo 1 e 2, respectivamente: tosse (25 por cento e 11,4 por cento) e dispnéia (22,7 por cento e 6,8 por cento). Nenhuma diferença estatística foi observada nos sinais e sintomas respiratórios entre pacientes com ou sem anormalidades radiográficas. Os achados radiológicos mais frequentes foram o padrão nodular (23,8 por cento) ou nodular-fibrótico (19 por cento), bilateral (90,5 por cento) e infiltrado difuso (85,7 por cento). CONCLUSÕES: A ausência de diferença estatística nos sinais e sintomas pulmonares entre estes dois grupos de pacientes com PCM sugere dissociação clínico-radiológica. Uma classificação simplificada dos achados radiológicos pulmonares da PCM é sugerida, com base na correlação destes dados e revisão da literatura atual.

Reflexões sobre a suplementação de ferro na população infantil / Refletions about iron supplementation in children

Este estudo tem como objetivo aprimorar conhecimentos e melhorar a prática diária na assistência à saúde da criança. Buscou-se utilizar referências a partir do ano de 1987,conseguidas em bibliotecas virtuais e acervo pessoal de Pediatria. Os textos foram submetidos à leitura exploratória, interpretativa e seletiva. O presente estudo busca a reflexão sobre a consciência e o comportamento de pais e cuidadores, tentando,assim, orientar sobre a importância da suplementação de ferro na primeira infância. As considerações finais insistem em compreender os problemas advindos da não suplementação ou da suplementação inadequada de ferro, visando a uma atitude reflexiva mais cautelosa e zelosa de pais e cuidadores sobre essa prática, também sobre a necessidade de mais estudos sobre os benefícios e malefícios pouco discutidos e difundidos advindos desta...

This study it has as objective to improve knowledge and to improve practical the daily inhealth care of the child. One searched to use references from the year of 1987, obtained invirtual libraries and personal collection of Pediatrics. The texts had been submitted to the Exploratory, interpretive and selective reading. The present study it searchs a reflectionon the conscience and the behavior of parents and caregivers, thus trying, to guide onthe importance of the suplementation of iron in first infancy. The final thoughts insist on understanding the problems resulting from or not supplementation of inadequate iron supplementation, aiming at a more cautious attitude reflective and caring for parent sand caregivers about this practice, also on the need for more studies on the benefits and disadvantages discussed and little derived from this broadcast...

Efeito na Ressuscitação Cardiopulmonar utilizando treinamento teórico versus treinamento teórico-prático / Effects of the use of theoretical versus theoretical-practical training on Cardiopulmonary Resuscitation / Efecto en la Resucitación Cardiopulmonar utilizando entrenamiento teórico versus entrenamiento teórico-prático

FUNDAMENTO: O conhecimento teórico e a habilidade de realizar ressuscitação cardiopulmonar (RCP) de qualidade são essenciais para a sobrevida do paciente vítima de morte súbita. OBJETIVO: Determinar se o ensino apenas teórico é capaz de promover o ensino da RCP de boa qualidade e conhecimento em profissionais da área da saúde comparado com curso teórico-prático de suporte básico de vida. MÉTODOS: Vinte enfermeiras voluntárias participaram do treinamento teórico de RCP e desfibrilação externa automática (DEA) utilizando aula teórica e vídeo usado nos cursos de Suporte Básico de Vida da American Heart Association (BLS-AHA; grupo A). Foram comparadas com 26 alunos profissionais da saúde que participaram de um curso regular teórico-prático de BLS-AHA (grupo B). Após os cursos, os participantes foram submetidos à avaliação teórica e prática como recomendado nos cursos do BLS-AHA. As avaliações práticas foram gravadas e posteriormente pontuadas por três instrutores experientes. A avaliação teórica foi um teste de múltipla escolha usada nos cursos regulares do BLS-AHA. RESULTADOS: Não houve diferença na avaliação teórica (p = ns), entretanto a avaliação prática foi consistentemente pior no grupo A, evidenciado pelos três examinadores (p < 0,05). CONCLUSÃO: A Utilização de vídeos de RCP e aulas teóricas não melhoraram a capacidade psicomotora em realizar RCP de boa qualidade, entretanto pode melhorar a capacidade cognitiva (conhecimento). Áreas críticas de atuação são o ABCD primário e o correto uso do DEA.

BACKGROUND: Theoretical knowledge and skill to perform good quality cardiopulmonary resuscitation (CPR) are essential for the survival of patients with sudden death. OBJECTIVE: To determine whether a theoretical course alone is sufficient to promote good quality CPR training and knowledge for health professionals in comparison to a theoretical-practical basic life support training. METHODS: Twenty volunteer nurses participated in the theoretical CPR and automated external defibrillation (AED) training by means of a theoretical class and video used in the Basic Life Support Training of the American Heart Association (BLS-AHA; group A). They were compared to other 26 health professionals who attended regular theoretical-practical BLS-AHA training (group B). After the training, the participants took theoretical and practical tests as recommended in BLS-AHA courses. The practical tests were recorded and were later scored by three experienced instructors. The theoretical test was a multiple choice test used in regular BLS-AHA courses. RESULTS: No difference was observed in the theoretical tests (p = ns). However, the practical tests were consistently worse in group A, as evaluated by the three examiners (p < 0.05). CONCLUSION: The use of CPR videos and theoretical training did not improve the individuals' psychomotor ability to perform good quality CPR; however, it may improve their cognitive ability (knowledge). Critical areas of intervention are the primary ABCD and the correct use of AED.

FUNDAMENTO: El conocimiento teórico y la habilidad de realizar resucitación cardiopulmonar (RCP) de calidad son esenciales para la sobrevida del paciente víctima de muerte súbita. OBJETIVO: Determinar si la enseñanza sólo teórica es capaz de promover la enseñanza de la RCP de buena calidad y conocimiento en profesionales del área de salud comparado con curso teórico-práctico de soporte básico de vida. MÉTODOS: Veinte enfermeras voluntarias participaron del entrenamiento teórico de RCP y desfibrilación externa automática (DEA) utilizando clase teórica y video usado en los cursos de Soporte Básico de Vida de la American Heart Association (BLS-AHA; grupo A). Fueron comparadas con 26 alumnos profesionales de la salud que participaron de un curso regular teórico-práctico de BLS-AHA (grupo B). Después de los cursos, los participantes fueron sometidos a evaluación teórica y práctica como es recomendado en los cursos del BLS-AHA. Las evaluaciones prácticas fueron grabadas y posteriormente puntuadas por tres instructores experimentados. La evaluación teórica fue un test de multiple choice usado en los cursos regulares del BLS-AHA. RESULTADOS: No hubo diferencia en la evaluación teórica (p = ns), mientras tanto la evaluación práctica fue consistentemente peor en el grupo A, evidenciado por los tres examinadores (p < 0,05). CONCLUSIÓN: La utilización de videos de RCP y aulas teóricas no mejoraron la capacidad psicomotora para realizar RCP de buena calidad, en cambio puede mejorar la capacidad cognitiva (conocimiento). Áreas críticas de actuación son el ABCD primario y el correcto uso del DEA.

Operação de Fontan: uma técnica em evolução / Fontan operation: a technique in evolution

Objetivo: Estudos recentes de fluxo com modelos experimentais de anastomoses cavopulmonares totais (ACPTs) baseados em ressonância magnética e angiografia demonstram que este é um procedimento bem estabelecido para o tratamento de várias cardiopatias, mas o melhor arranjo espacial continua controverso. Nosso intuito é apresentar os resultados imediatos com três diferentes técnicas de ACPTs. Métodos: Ensaio clínico de ACPTs realizadas no período de janeiro de 2005 a julho de 2008 com 40 pacientes, com idade média de 6,4 ± 3,2 anos, com Glenn prévio. Os pacientes foram divididos em três grupos, dependendo da técnica cirúrgica empregada: Grupo 1 (G1) - túnel lateral; Grupo 2 (G2) - conduto extracardíaco; Grupo 3 (G3) - conduto intracardíaco dirigido para o ramo esquerdo de artéria pulmonar, todos com fenestração. Foram avaliadas variáveis pré e pós-operatórias. Resultados: Foram incluídos 11 pacientes no G1, 10 no G2 e 19 no G3. As variáveis pré-operatórias foram semelhantes nos três grupos (P>0,05). A mortalidade foi maior nos Grupos 1 e 2 (9,1 por cento e 10,0 por cento, respectivamente), comparadas ao Grupo 3 (zero), porém sem significância estatística (P=0,3841). Efusão pleural foi ausente no Grupo 3, diferença significativa (P=0,0128) em relação aos outros grupos (40,0 por cento e 33,3 por cento). A mediana do tempo de hospitalização pós-operatória foi menor no Grupo 3 (8 dias), em relação aos grupos 1 e 2 (18 e 13 dias, respectivamente) (P=0,0164). Conclusão: A técnica de conduto intracardíaco foi associada a menor morbidade pós-operatória, sendo a opção atual do nosso serviço na anastomose cavopulmonar total.

Objectives: Recent experimental flow studies based on angiography and magnetic resonance have shown that total cavopulmonary anastomosis (TCPA) is a valid concept for surgical treatment of many congenital heart defects, but there is not agreement of the best surgical arrangement. Our purpose is to analyze the immediate results with three different techniques of TCPA. Methods: We sought to analyze retrospectively all TCPA realized from January 2005 to July 2008; there were 40 patients, all with previous Glenn anastomosis, with mean age of 6.4 ± 3.2 years. Three different techniques were employed: Group 1 (G1) lateral tunnel, Group 2 (G2) extracardiac conduits, Group 3 (G3) intracardiac conduit directed to the left pulmonary artery. All patients had a fenestration done. Results: G1 had 11 patients, G2 10 patients and G3 19 patients. Preoperative data were similar in the 3 groups (P>0.05). Surgical mortality was higher in Groups 1 and 2 (9.1 percent and 10 percent) compared to Group 3 (0 percent) but there was no statistical significance (P=0.3841). Pleural effusion was absent in Group 3 (0 percent), which was statistically significant in relation to the other groups (P=0.0128). The hospitalization time was also significantly lower in G3 (8 days) in relation to G1 (18 days) and G2 (13 days) (P=0.0164). Conclusion Intracardiac TCPA was associated with lower postoperative morbidity and is currently our preferred technique.

Nosocomial infections in brazilian pediatric patients: using a decision tree to identify high mortality groups

Nosocomial infections (NI) are frequent events with potentially lethal outcomes. We identified predictive factors for mortality related to NI and developed an algorithm for predicting that risk in order to improve hospital epidemiology and healthcare quality programs. We made a prospective cohort NI surveillance of all acute-care patients according to the National Nosocomial Infections Surveillance System guidelines since 1992, applying the Centers for Disease Control and Prevention 1988 definitions adapted to a Brazilian pediatric hospital. Thirty-eight deaths considered to be related to NI were analyzed as the outcome variable for 754 patients with NI, whose survival time was taken into consideration. The predictive factors for mortality related to NI (p < 0.05 in the Cox regression model) were: invasive procedures and use of two or more antibiotics. The mean survival time was significantly shorter (p < 0.05 with the Kaplan-Meier method) for patients who suffered invasive procedures and for those who received two or more antibiotics. Applying a tree-structured survival analysis (TSSA), two groups with high mortality rates were identified: one group with time from admission to the first NI less than 11 days, received two or more antibiotics and suffered invasive procedures; the other group had the first NI between 12 and 22 days after admission and was subjected to invasive procedures. The possible modifiable factors to prevent mortality involve invasive devices and antibiotics. The TSSA approach is helpful to identify combinations of predictors and to guide protective actions to be taken in continuous-quality-improvement programs.

Análise dos resultados do atendimento ao paciente com infarto agudo do miocárdio com supradesnivelamento do segmento ST nos períodos diurno e noturno / Treatment outcome of patients with acute myocardial infarction and ST segment elevation in routine duty hours and off-hours

Introdução: A angioplastia coronariana primária com implante de stents é considerada o melhor método de tratamento no infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST), com resultados mais favoráveis e menor incidência de complicações quando comparada a outras formas de tratamento. Avaliamos a eficácia do atendimento nos período diurno e noturno e a evolução hospitalar desses pacientes. Método: Analisamos, de forma retrospectiva, os dados de 274 pacientes submetidos a angioplastia primária no período compreendido entre julho de 2004 e agosto de 2008, divididos em dois grupos: os atendidos no período diurno e os atendidos no período noturno. Foram analisados as características clínicas e angiográficas, o tempo porta-balão, o sucesso angiográfico primário e a ocorrência de complicações. Resultados: Dos 274 pacientes analisados, 186 (67,8%) foram atendidos no período diurno e 88 (32,2%), no período noturno. As características clínicas e angiográficas foram semelhantes em ambos os períodos. O tempo portabalão alcançado no período noturno (64,1 minutos) foi menor que o do período diurno (72,5 minutos) (P = 0,02). O sucesso angiográfico foi semelhante (93%) em ambos os turnos. Houve maior número de complicações maiores no período noturno, à custa de acidente vascular cerebral (0% vs. 3,4%; P = 0,032), reinfarto (1% vs. 5,6%; P = 0,037) e revascularização da lesão-alvo (1% vs. 5,6%; P = 0,037)...

Background: Primary coronary angioplasty with stent implantation has been considered the treatment of choice in acute myocardial infarction with ST segment elevation, leading to more favorable outcomes and lower incidence of complications when compared to other treatments. The efficacy of patient care in routine duty hours and off-hours and the in-hospital course of these patients were analyzed. Methods: Two hundred and seventy-four patients undergoing primary angioplasty between July 2004 and August 2008 were retrospectively analyzed and divided into two groups: those treated during routine duty hours and those treated during off-hours. Clinical and angiographic characteristics, door-to-balloon time, primary angiographic success, and the occurrence of complications were analyzed. Results: Of 274 patients studied, 186 (67.8%) were treated during routine duty hours and 88 (32.2%) were treated during off-hours. Clinical and angiographic characteristics were similar in both periods. Door-to-balloon time at night (64.1 minutes) was lower than at daytime (72.5 minutes). Primary angiographic success was similar (93%) in both shifts. There was a greater number of major complications at night due to stroke (0% vs. 3.4%; P = 0.032), reinfarction (1% vs. 5.6%; P = 0.037) and target lesion revascularization (1% vs. 5.6%; P = 0.037)...