Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study / Reabilitação física em unidades de terapia intensiva pediátrica brasileiras: um estudo multicêntrico de prevalência pontual

ABSTRACT Objective: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. Methods: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. Results: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. Conclusion: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

RESUMO Objetivo: Determinar a prevalência e os fatores associados à reabilitação física de crianças em estado grave em unidades de terapia intensiva pediátrica brasileiras. Métodos: Realizou-se um estudo de prevalência pontual multicêntrico, transversal, de 2 dias, abrangendo 27 unidades de terapia intensiva pediátrica (do total de 738) no Brasil em abril e junho de 2019. Este estudo brasileiro fez parte de um grande estudo multinacional chamado Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). O desfecho primário foi a prevalência de mobilidade proporcionada pela fisioterapia ou pela terapia ocupacional. Foram coletados prospectivamente dados clínicos sobre a mobilidade do paciente, possíveis eventos de segurança de mobilidade e barreiras de mobilização em pacientes admitidos por ≥ 72 horas. Resultados: As crianças com idade inferior a 3 anos eram 68% da população de pacientes. A prevalência de mobilidade fornecida pelo terapeuta foi de 74%, ou 277 dos 375 pacientes-dia. A mobilidade para fora do leito foi mais positivamente associada à presença de familiares (razão de chance ajustada de 3,31; IC95% 1,70 - 6,43) e mais negativamente associada às linhas arteriais (razão de chance ajustada de 0,16; IC95% 0,05 - 0,57). Foram relatadas barreiras à mobilização em 27% dos pacientes-dia, sendo a mais comum a falta de prescrição médica (n = 18). Registaram-se eventuais eventos de segurança em 3% de todos os eventos de mobilização. Conclusão: A mobilidade proporcionada pelo terapeuta nas unidades de terapia intensiva pediátrica brasileiras é frequente. A presença de familiares foi alta e positivamente associada à mobilidade para fora do leito. A presença de fisioterapeutas 24 horas por dia nas unidades de terapia intensiva pediátrica brasileiras pode exercer papel importante na mobilização de crianças em estado grave.

Epidemiology and treatment of sepsis at a public pediatric emergency department

ABSTRACT Objective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Vomiting in newborns as a result of a duodenal membrane: two case reports / Episódios de vômitos em recém-nascidos como consequência de membrana duodenal: relatos de dois casos

ABSTRACT Vomiting episodes in newborns are extremely common and often attributed to gastroesophageal reflux. The symptoms of vomiting, however, may be caused by other complications. In this report, we present two cases of a 1-month-old male and a 2-month-old female, both presenting vomiting episodes that led to malnutrition. Some pediatricians often attribute the diagnosis of gastroesophageal reflux to newborns that are vomiting; however, there is a portion of the population that has other causes that lead to similar symptoms. The pediatrician should be alert to the clinical signs of weight loss, dehydration and malnutrition to investigate other causes of vomiting.

RESUMO Episódios de vômito em recém-nascidos são extremamente comuns e frequentemente atribuídos a refluxo gastresofágico. Os sintomas de vômito, no entanto, podem ser causados por outras complicações. Neste relato, apresentamos dois casos: um lactente masculino, com 1 mês de idade, e um feminino, com 2 meses, ambos apresentando episódios de vômitos que levaram à desnutrição. Alguns pediatras costumam atribuir o diagnóstico de refluxo gastresofágico a recém-nascidos que estão vomitando; mas parcela da população tem outras causas que levam a sintomas semelhantes. O pediatra deve estar atento aos sinais clínicos de perda de peso, desidratação e desnutrição, para investigar outras causas de vômitos.

Morpho-anatomical characters of Limonium brasiliense leaves

Abstract Limonium brasiliense (Boiss.) Kuntze, Plumbaginaceae, is a coastal herb of the Southern Brazilian states and Rio de Janeiro State. In folk medicine, it is used in the treatment of female genitourinary tract infections and menstrual cycle irregularities. The aim of this study was to describe morpho-anatomical characters with details on venation pattern of L. brasiliense leaves, collected on the coast of Rio Grande do Sul State, in Southern Brazil. Leaf samples fixed in FAA50 (5% formaldehyde, 5% acetic acid and 90% ethanol: water mixture 50:50 v/v) and 1% glutaraldehyde and preserved in 70% ethanol, were histologically sectioned and analyzed by light and scanning electron microscopy. The L. brasiliense leaves were simple, entire, incomplete, oboval-lanceolate, venation penninervous and showed rosulated phyllotaxy, entire and revolute margin, with apex rounded to slightly retuse, base attenuate and venation pattern brochidodromous. On microscopic analysis, these leaves showed a thick and striated cuticle, salt glands, isobilateral mesophyll thicker in the apical region of the leaf blade, abundant aerenchyma in the petiole and main vein, collateral vascular bundles surrounded by fiber-sclereids, lipid substances in the cuticle and polyphenols in phloem cells.

Accident involving a 2-year-old child and Lonomia obliqua venom: clinical and coagulation abnormalities

Poisons of caterpillars have different effects on inflammatory and coagulation systems. This is a case report of a 2-year-old child that accidentally came in contact with several caterpillars of the species Lonomia obliqua. At first, the patient's exams presented abnormal coagulation and decreased fibrinogen, but the patient did not evolve to active bleeding or acute renal failure. The patient received antilonomic serum 15 h after the accident and the treatment was repeated after another 12 h due to persistent alterations shown by the coagulation exams. The venom of L. obliqua has several substances that act on the coagulation and inflammatory systems. The event is characterized by a hemorrhagic syndrome with decreases in fibrinogen. L. obliqua Stuart-factor activator (Losac) and L. obliqua prothrombin activator protease (Lopap) are components that act with procoagulatory effects. The pro-inflammatory action occurs due to metalloproteases, hyaluronidases and other substances with inflammatory activity. Studies on caterpillar venom can give new perspectives on the treatment of cancer and other diseases that cause dysfunction of the extra-cellular matrix...

The importance of coating standardization in gastro-resistant capsules produced in magistral pharmacy / Importância da padronização dos revestimentos utilizados em cápsulas gastrorresistentes produzidas em farmácia magistral

Gastro-resistant capsules are often used for several purposes, such as protection of unstable drugs in acid medium to the action of gastric fluids or protection of the gastric mucosa to irritants drugs. The aim of this study was to verify the variation of preparations of capsules coating with cellulose acetate phthalate and methacrylic acid copolymer, without drug addition, in 7-10% coating concentrations, prepared manually with four or five immersions in tested coating solution. Results were analyzed considering the formulation's disintegration test. Within the context of formulations under analysis, it was observed that the capsules coated with cellulose acetate phthalate 10% complied with the pharmacopeia's disintegration specifications. However, capsules coated with methacrylic acid copolymer did not show accordance with the pharmacopeia's specifications. The results emphasize the need for the standardization of coating methodology.

Cápsulas gastrorresistentes são frequentemente utilizadas com diversos propósitos, como a proteção de fármacos instáveis em meio ácido à ação dos fluidos gástricos ou proteção da mucosa gástrica à fármacos irritantes. O objetivo deste trabalho foi verificar a variação da preparação de revestimento de cápsulas com acetoftalato de celulose e copolímero do ácido metacrílico, sem adição de fármaco, em concentrações que variam de 7 a 10% de revestimento, preparadas manualmente com quatro a cinco camadas da solução dos revestimentos testados. Os resultados foram analisados considerando o teste de desintegração das formulações. Das formulações testadas, foi observado que as cápsulas revestidas com acetoftalato de celulose a 10% cumpriram com as especificações farmacopeicas quanto à desintegração. No entanto, cápsulas revestidas com copolímero de ácido metacrílico não mostraram conformidade com as especificações farmacopeicas. Os resultados obtidos enfatizam a necessidade de padronização da metodologia de revestimento.

Estudo de formulação de microesferas de acetobutirato de celulose com diferentes concentrações de Poloxamer 188 / Formulation study of cellulose acetate butyrate microspheres withdifferent concentrations of Poloxamer 188

Microesferas de liberação prolongada de diclofenaco de sódio (DFS) foram preparadas empregando o acetobutirato de celulose (ABC) para obtenção da matriz polimérica. Buscando modular a velocidade de liberação do fármaco, a adição de Poloxamer 188 na formulação foi testada, com diferentes proporções de ABC: Pluronic F68 (1:0; 9:1; 3:1 e 1:1). Com exceção da formulação contendo ABC e Pluronic F68 na proporção de 1:1, as outras formulações testadas conduziram à formação de partículas esféricas de tamanho micrométrico. Quando a misturaA BC: Pluronic F68 (1:1) foi empregada, ocorreu à precipitação de uma massa polimérica, sendo este efeito relacionado à elevada concentração do polímero hidrofílico na preparação. Quando comparado com as microesferas preparadas unicamente com ABC, o teor e a eficiência de encapsulação aumentaram com o acréscimo de Poloxamer 188 às formulações. Efeito semelhante foi observado na avaliação da velocidade de liberação do fármaco em meio tampão fosfato pH 7,5. Enquanto as microesferas preparadas apenas com ABC conduziram à liberação de 25% do fármaco encapsulado após 12 horas de ensaio, as microesferas preparadas com relação ABC:Pluronic 9:1 e 3:1 conduziram à liberação de 30% e 70% do fármaco, respectivamente.

Extended-release microspheres containing sodium diclofenac were prepared using the cellulose acetate butyrate (CAB) to obtain the polymer matrix. Looking modulate the rate of drug release, the addition of Poloxamer 188 at different concentrations into formulations was tested in order to obtain CAB to Poloxamer ratio of 1:0, 9:1, 3:1 and 1:1. Excepting for the formulation containing CAB and Poloxamer 1:1, the other formulations resulted in formation of spherical particles of micrometer size range. When the mixture CAB:Poloxamer (1:1) was employed, the precipitation of a polymeric mass occorred, and this effect was related to the high concentration of the hydrophilic polymer in the preparation. When compared to the microspheres prepared only with CAB, the drug content and the encapsulation efficiency increased with the addition of Poloxamer 188 in the formulations. A similar effect was observed in the evaluation of the rate of drug release in pH 7.5 phosphate buffer. While the microspheres prepared with CAB led to release of 25% of the encapsulated drug after 12 hours of testing, the microspheres prepared with CAB: Poloxamer 9:1 and 3:1 resulted in release of 30% and 70% of the drug, respectively.

Antiretroviral resistance in individuals presenting therapeutic failure and subtypes of the human immunodeficiency virus type 1 in the Northeast Region of Brazil

This study aimed to analyze human immunodeficiency virus (HIV) mutation profiles related to antiretroviral resistance following therapeutic failure, and the distribution of hiv subtypes in the Northeast Region of Brazil. A total of 576 blood samples from AIDS patients presenting therapeutic failure between 2002 and 2004 were analyzed. The genotyping kit viroSeq® was used to perform viral amplification in order to identify mutations related to hiv pol gene resistance. An index of 91.1 percent of the patients presented mutations for nucleoside reverse transcriptase inhibitors (nrti), 58.7 percent for non-nucleoside reverse transcriptase inhibitors (nnrti), and 94.8 percent for protease inhibitors (pi). The most prevalent mutations were 184V and 215E for nrti, 103N and 190A for nnrti. Most mutations associated with PIs were secondary, but significant frequencies were observed in codons 90 (25.2 percent), 82 (21.1 percent), and 30 (16.2 percent). The resistance index to one class of antiretrovirals was 14 percent, to two classes of antiretrovirals 61 percent, and to three classes 18.9 percent. Subtype B was the most prevalent (82.4 percent) followed by subtype F (11.8 percent). The prevalence of mutations related to nrti and nnrti was the same in the two subtypes, but codon analysis related to PI showed a higher frequency of mutations in codon 63 in subtype B and in codon 36 in subtype F. The present study showed that there was a high frequency of primary mutations, which offered resistance to nrti and nnrti. Monitoring patients with treatment failure is an important tool for aiding physicians in rescue therapy.