Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study.

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.

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.

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.

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.

A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital.

Introduction: Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high. Methods: This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10-20 ml/kg saline solution within the first hour of diagnosis. Results: A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days; p < 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2, p < 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27); p < 0.001)]. Conclusions: A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.

Barriers and Proposed Solutions to a Successful Implementation of Pediatric Sepsis Protocols.

The implementation of managed protocols contributes to a systematized approach to the patient and continuous evaluation of results, focusing on improving clinical practice, early diagnosis, treatment, and outcomes. Advantages to the adoption of a pediatric sepsis recognition and treatment protocol include: a reduction in time to start fluid and antibiotic administration, decreased kidney dysfunction and organ dysfunction, reduction in length of stay, and even a decrease on mortality. Barriers are: absence of a written protocol, parental knowledge, early diagnosis by healthcare professionals, venous access, availability of antimicrobials and vasoactive drugs, conditions of work, engagement of healthcare professionals. There are challenges in low-middle-income countries (LMIC). The causes of sepsis and resources differ from high-income countries. Viral agent such as dengue, malaria are common in LMIC and initial approach differ from bacterial infections. Some authors found increased or no impact in mortality or increased length of stay associated with the implementation of the SCC sepsis bundle which reinforces the importance of adapting it to most frequent diseases, disposable resources, and characteristics of healthcare professionals. Conclusions: (1) be simple; (2) be precise; (3) education; (5) improve communication; (5) work as a team; (6) share and celebrate results.

Hydrogel containing (1 → 6)-ß-D-glucan (lasiodiplodan) effectively promotes dermal wound healing.

A hydrogel containing exocellular (1 → 6)-ß-D-glucan (lasiodiplodan, LAS) was developed and its wound healing potential was evaluated. ß-Glucans have attracted much interest by the cosmetic industry sector because of their bioactive and functional properties and in promoting skin health. In the present work an ß-glucan was studied as a healing biomaterial that has not hitherto been reported in the scientific literature. LAS produced by the ascomycete Lasiodiplodia theobromae MMPI was used in the formulation of a healing hydrogel. Physicochemical and microbiological quality parameters, antioxidant potential and stability of the formulation was evaluated. FTIR, thermal analysis and SEM techniques were also employed in the characterization. Wistar rats were used as a biological model to investigate the wound healing potential. Histological analyses of cutaneous tissue from the dorsal region were conducted after 4, 7, 10 and 14 days of treatment, and evaluated re-epithelialization, cell proliferation and collagen production. Physicochemical stability, microbiological quality and antioxidant potential, especially in relation to its ability to scavenge hydroxyl radicals were found. The hydrogel stimulated cell re-epithelialization and proliferation during all days of the treatment, and stimulated an increase of collagen fibers. Lasiodiplodan showed immunomodulatory activity in wound healing and this biomacromolecule could be an alternative compound in wound care.

A topical formulation containing quercetin-loaded microcapsules protects against oxidative and inflammatory skin alterations triggered by UVB irradiation: enhancement of activity by microencapsulation.

Ultraviolet B (UVB) irradiation causes free radical production, increase inflammation and oxidative stress, thus, supporting the use of antioxidants by topical administration as therapeutic approaches. Quercetin (QC) is a flavonoid with antioxidant activity, however, high liposolubility makes it difficult to remain in the viable skin layer. Thus, this study evaluated whether microencapsulation of QC would enhance its activity in comparison with the same dose of free QC (non-active dose) and unloaded-microcapsules added in formulation for topical administration in a mouse model of UVB irradiation targeting the skin. Topical formulation containing Quercetin-loaded microcapsules (TFcQCMC) presents physico-chemical (colour, consistence, phase separation and pH) and functional antioxidant stability at 4 °C, room temperature and 40 °C for 6 months. TFcQCMC inhibited the UVB-triggered depletion of antioxidants observed by GSH (reduced glutathione), ability to reduce iron, ability to scavenge 2,2'-azinobis radical and catalase activity. TFcQCMC also inhibited markers of oxidation (lipid hydroperoxides and superoxide anion production). Concerning inflammation, TFcQCMC reduced the production of inflammatory cytokines, matrix metalloproteinase-9 activity, skin edoema, collagen fibre damage, myeloperoxidase activity/neutrophil recruitment, mast cell and sunburn cell counts. The pharmacological activity of TFcQCMC was not shared by the same pharmaceutical form containing the same dose of free QC or unloaded control microcapsules.

Dimeric glycosylated flavan-3-ol and antimicrobial in vitro evaluation of Trichilia catigua extracts.

Trichilia catigua is a tree known as "catuaba", widely distributed in Brazil. Studies carried out with T. catigua barks suggest that plant has antidepressant, antidiabetic, antimicrobial, antioxidant, antiviral, and preventive against brain damage. The aim of this work was to isolate and characterise compounds from the semipurified fraction of T. catigua barks, and to conduct microbiological screening against bacteria and fungi. The crude extract (CE) of "catuaba" was produced by turbo extraction with acetone-water, and later, partitioned to yield ethyl-acetate (EAF) and aqueous (AqF) fractions. From AqF the new catechin-3-O-α-L-rhamnoside-(4α→8)-epicatechin was isolated, identified, and described here for the first time. Regarding antimicrobial activity, the extracts presented impressive results, mainly for Vancomycin Resistant Enterococcus faecium (VREfm) with MIC of 156.5 µg/mL. The results suggest that extract of T. catigua could potentially be used as an adjuvant to treatment and is a promising candidate for the development of new antimicrobial drugs.

Vomiting in newborns as a result of a duodenal membrane: two case reports.

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.

Stem bark extract of Poincianella pluviosa incorporated in polymer film: Evaluation of wound healing and anti-staphylococcal activities.

Poincianella pluviosa has already been described as capable of healing skin wounds. In an attempt to prolong contact of the drug with the wound, it was proposed in this study to evaluate wound healing using a crude extract (CE) of P. pluviosa incorporated in carboxymethylcellulose polymer films. The chromatographic profile of the semipurified fraction of P. pluviosa was evaluated by ultra-high performance liquid chromatography (UHPLC), confirming the compounds gallic acid, geraniin, and ellagic acid. The films were evaluated for their physical and mechanical properties, water vapor permeability, moisture absorption capacity, and FTIR spectroscopy. For in vivo experiments, wounds were made on the back of rats and treated daily for 4, 7, 10, or 14 days with film containing CE or control film. At the end of each period, skin permeation analysis and histological analysis were made using re-epithelialisation, cell proliferation, and collagen formation. Statistical significance was determined by GraphPad Prism using t test and Mann-Whitney test. Anti-staphylococcal activity was evaluated with standard strains of Staphylococcus aureus, methicillin-resistant, and coagulase negative. It was demonstrated that the presence of CE in the films increased the capacity to absorb water and decreased resistance and permeability. The CE of the film permeated the skin, reaching the dermis and was able to influence re-epithelisation, cell proliferation, and collagen formation. Satisfactory results were observed against S. aureus strains, particularly coagulase negative. Films with CE of P. pluviosa can be an alternative in the wound healing, protecting against opportunistic infections and giving comfort to the patient.

Chemical analysis of the semipurified extract of Paullinia cupana and evaluation of in vitro inhibitory effects against Helicobacter pylori.

Paullinia cupana Kunth, commonly known as guarana, is a native Brazilian plant species from the Amazon area that presents various biological effects, including antimicrobial action. The aim of this study was to chemically analyse the semipurified aqueous extract (AqF) of the plant and to evaluate the activity of crude (CE), ethyl-acetate (EAF), and AqF extracts against Helicobacter pylori. The chemical profile of AqF was determined based on solid analysis 13C-NMR, direct infusion mass spectrometry (ESI-MS), and MALDI-TOF. The 13C-NMR spectrum showed characteristics of flavan-3-ol and oligomeric proanthocyanidins. ESI-MS revealed the presence of procyanidin, caffeic acid and its derivatives. MALDI-TOF analysis detected procyanidins of up to 6 units and profisetinidins of up to 5 units. Whereas CE and EAF showed inhibitory activity against H. pylori, CE, EAF, and AqF presented not high inhibitory activity against urease. The results demonstrate the potential of P. cupana to control and prevent H. pylori infection.

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.

In vitro evaluation of the protective effects of plant extracts against amyloid-beta peptide-induced toxicity in human neuroblastoma SH-SY5Y cells.

Alzheimer's disease (AD) is the most common form of dementia and has no cure. Therapeutic strategies focusing on the reduction of oxidative stress, modulation of amyloid-beta (Aß) toxicity and inhibition of tau protein hyperphosphorylation are warranted to avoid the development and progression of AD. The aim of this study was to screen the crude extracts (CEs) and ethyl-acetate fractions (EAFs) of Guazuma ulmifolia, Limonium brasiliense, Paullinia cupana, Poincianella pluviosa, Stryphnodendron adstringens and Trichilia catigua using preliminary in vitro bioassays (acetylcholinesterase inhibition, antioxidant activity and total polyphenol content) to select extracts/fractions and assess their protective effects against Aß25-35 toxicity in SH-SY5Y cells. The effect of the EAF of S. adstringens on mitochondrial membrane potential, lipid peroxidation, superoxide production and mRNA expression of 10 genes related to AD was also evaluated and the electropherogram fingerprints of EAFs were established by capillary electrophoresis. Chemometric tools were used to correlate the in vitro activities of the samples with their potential to be evaluated against AD and to divide extracts/fractions into four clusters. Pretreatment with the EAFs grouped in cluster 1 (S. adstringens, P. pluviosa and L. brasiliense) protected SH-SY5Y cells from Aß25-35-induced toxicity. The EAF of S. adstringens at 15.62 µg/mL was able completely to inhibit the mitochondrial depolarization (69%), superoxide production (49%) and Aß25-35-induced lipid peroxidation (35%). With respect to mRNA expression, the EAF of S. adstringens also prevented the MAPT mRNA overexpression (expression ratio of 2.387x) induced by Aß25-35, which may be related to tau protein hyperphosphorylation. This is the first time that the neuroprotective effects of these fractions have been demonstrated and that the electropherogram fingerprints for the EAFs of G. ulmifolia, L. brasiliense, P. cupana, P. pluviosa and S. adstringens have been established. The study expands knowledge of the in vitro protective effects and quality control of the evaluated fractions.

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.