Factors associated with perinatal and neonatal deaths in Sao Tome & Principe: a prospective cohort study.

Background: Neonatal mortality reduction is a global goal, but its factors are seldom studied in most resource-constrained settings. This is the first study conducted to identify the factors affecting perinatal and neonatal deaths in Sao Tome & Principe (STP), the smallest Central Africa country. Methods: Institution-based prospective cohort study conducted at Hospital Dr. Ayres Menezes. Maternal-neonate dyads enrolled were followed up after the 28th day of life (n = 194) for identification of neonatal death-outcome (n = 22) and alive-outcome groups (n = 172). Data were collected from pregnancy cards, hospital records and face-to-face interviews. After the 28th day of birth, a phone call was made to evaluate the newborn's health status. Crude odds ratios and corresponding 95% confidence intervals were obtained. A p value <0.05 was considered statistically significant. Results: The mean gestational age of the death-outcome and alive-outcome groups was 36 (SD = 4.8) and 39 (SD = 1.4) weeks, respectively. Death-outcome group (n = 22) included sixteen stillbirths, four early and two late neonatal deaths. High-risk pregnancy score [cOR 2.91, 95% CI: 1.18-7.22], meconium-stained fluid [cOR 4.38, 95% CI: 1.74-10.98], prolonged rupture of membranes [cOR 4.84, 95% CI: 1.47-15.93], transfer from another unit [cOR 6.08, 95% CI:1.95-18.90], and instrumental vaginal delivery [cOR 8.90, 95% CI: 1.68-47.21], were factors significantly associated with deaths. The odds of experiencing death were higher for newborns with infectious risk, IUGR, resuscitation maneuvers, fetal distress at birth, birth asphyxia, and unit care admission. Female newborn [cOR 0.37, 95% CI: 0.14-1.00] and birth weight of more than 2,500 g [cOR 0.017, 95% CI: 0.002-0.162] were found to be protective factors. Conclusion: Factors such as having a high-risk pregnancy score, meconium-stained amniotic fluid, prolonged rupture of membranes, being transferred from another unit, and an instrumental-assisted vaginal delivery increased 4- to 9-fold the risk of stillbirth and neonatal deaths. Thus, avoiding delays in prompt intrapartum care is a key strategy to implement in Sao Tome & Principe.

Adverse birth outcomes and associated factors among newborns delivered in Sao Tome & Principe: A case‒control study.

BACKGROUND: Newborns with one-or-more adverse birth outcomes (ABOs) are at greater risk of mortality or long-term morbidity with health impacts into adulthood. Hence, identifying ABO-associated factors is crucial for devising relevant interventions. For this study, ABOs were defined as prematurity (PTB) for gestational age <37 weeks, low birth weight (LBW) <2.5 kg, macrosomia >4 kg, asphyxia for a 5-minute Apgar score <7, congenital anomalies, and neonatal sepsis. This study aimed to assess factors associated with ABOs among babies delivered at the only hospital of Sao Tome & Principe (STP), a resource-constrained sub-Saharan-Central African country. METHODS: A hospital-based unmatched case‒control study was conducted among newborns from randomly selected mothers. Newborns with one-or-more ABO were the cases (ABO group), while healthy newborns were the controls (no-ABO group). Data were collected by a face-to-face interview and abstracted from antenatal care (ANC) pregnancy cards and medical records. Multivariable logistic regression analysis was performed to identify ABO-associated factors considering a level of significance of α = 0.05. RESULTS: A total of 519 newborns (176 with ABO and 343 no-ABO) were enrolled. The mean gestational age and birthweight of cases and controls were 36 (SD = 3.7) weeks with 2659 (SD = 881.44) g and 39.6 (SD = 1.0) weeks with 3256 (SD = 345.83) g, respectively. In the multivariable analysis, twin pregnancy [aOR 4.92, 95% CI 2.25-10.74], prolonged rupture of membranes [aOR 3.43, 95% CI 1.69-6.95], and meconium- fluid [aOR 1.59, 95% CI 0.97-2.62] were significantly associated with ABOs. Eight or more ANC contacts were found to be protective [aOR 0.33, 95% CI 0.18-0.60, p<0.001]. CONCLUSION: Modifiable factors were associated with ABOs in this study and should be considered in cost-effective interventions. The provision of high-quality ANC should be a priority. Twin pregnancies and intrapartum factors such as prolonged rupture of membranes and meconium-stained amniotic fluid are red flags for ABOs that should receive prompt intervention and follow-up.

Determinants of antenatal care utilization - contacts and screenings - in Sao Tome & Principe: a hospital-based cross-sectional study.

BACKGROUND: Sao Tome & Principe (STP) has a high peri-neonatal mortality rate and access to high-quality care before childbirth has been described as one of the most effective means of reducing it. The country has a gap in the coverage-content of antenatal care (ANC) services that must be addressed to better allocate resources to ultimately improve maternal and neonatal health. Therefore, this study aimed to identify the determinants for adequate ANC utilization considering the number and timing of ANC contacts and screening completion. METHODS: A hospital based cross-sectional study was undertaken among women admitted for delivery at Hospital Dr. Ayres de Menezes (HAM). Data were abstracted from ANC pregnancy cards and from a structured face-to-face interviewer-administered questionnaire. ANC utilization was classified as partial vs adequate. Adequate ANC utilization was defined as having ANC 4 or more contacts, first trimester enrolment plus one or more hemoglobin tests, urine, and ultrasound. The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Multivariable logistic regression was used to identify determinants of adequate ANC utilization at P-value < 0.05. RESULTS: A total of 445 mothers were included with a mean age of 26.6 ± 7.1, an adequate ANC utilization was identified in 213 (47.9%; 95% CI: 43.3-52.5) and a partial ANC utilization in 232 (52.1%; 95% CI: 47.5-56.7). Age 20-34 [AOR 2.27 (95% CI: 1.28-4.04), p = 0.005] and age above 35 [AOR 2.5 (95% CI: 1.21-5.20), p = 0.013] when comparing with women aged 14-19 years, urban residence [AOR 1.98 (95% CI: 1.28-3.06), p < 0.002], and planned pregnancy [AOR 2.67 (95% CI: 1.6-4.2), p < 0.001] were the determinants of adequate ANC utilization. CONCLUSION: Less than half of the pregnant women had adequate ANC utilization. Maternal age, residence and type of pregnancy planning were the determinants for adequate ANC utilization. Stakeholders should focus on raising awareness of the importance of ANC screening and engaging more vulnerable women in earlier utilization of family planning services and choosing a pregnancy plan, as a key strategy to improve neonatal health outcomes in STP.

Intestinal Parasitic Infections, Treatment and Associated Factors among Pregnant Women in Sao Tome and Principe: A Cross-Sectional Study.

Background: Intestinal parasitic infections (IPIs) are a public health problem in developing countries such as Sao Tome and Principe (STP) although the pregnancy burden of IPIs is unknown in this endemic country. Thus, the aim of this study was to determine the prevalence of IPIs, prescribed anthelmintics, and associated factors among pregnant women admitted to Hospital Dr. Ayres de Menezes (HAM). Methods: A hospital-based cross-sectional study was conducted among pregnant women admitted to the HAM who had undergone antenatal copro-parasitological screening. Data were abstracted from antenatal care (ANC) cards regarding parasitological results and anthelmintic prescriptions. A structured questionnaire face-to-face interview was also applied. Pregnant women with an IPI (210) were compared to noninfected women (151). Data analysis was performed using SPSS version 25.0. Odds ratios (ORs) with 95% confidence intervals (CIs) for factors associated with IPIs were estimated using multiple logistic regression models. A p value <0.05 was considered statistically significant. Results: A total of 361 participants (210 IPI and 151 no-IPI) with a mean age of 26.96 (SD: 7.00) were included. The overall prevalence of IPI was 58.2% (95% CI 52.9 to 63.3), mainly due to helminthiasis, with a 55.9% (95% CI 50.7-61.2%) rate. Ascaris lumbricoides (90.9%) was the most predominant parasite species identified followed by Trichuris trichiura (13.8%). Polyparasitism was observed in 25 cases (11.9%). Anthelmintics were prescribed to 23% of pregnant women. S intercalatum (11) and E histolytica (7) infections were not adequately treated. IPI was significantly associated with primary education (AOR 1.73 (95% CI: 1.10-2.71)), unemployment (AOR 1.94 (95% CI: 1.20-3.13)), and parity of five or above (AOR 3.82 (95% CI: 1.32-11.08)). Conclusion: This study highlights the IPI burden, associated factors, and missing treatment opportunities among pregnant women with STP. This study is a useful tool for policymakers in STP to enhance the health of women and their unborn babies.

Adolescent pregnancy in Sao Tome and Principe: are there different obstetric and perinatal outcomes?

BACKGROUND: Adolescent childbirth is a major public health problem in Sao Tome and Principe (STP). Adolescent pregnancy and childbirth can carry a risk of morbidity associated with the physiological and sociological characteristics of teenage girls. This study aims to identify the main adverse obstetric and perinatal outcomes for adolescent pregnancies in the Hospital Dr. Ayres de Menezes (HAM), the only hospital in STP. METHODS: An institution-based cross-sectional study. Pregnant women ≤ 19 years of age (n = 104) were compared to non-adolescent women (n = 414). The obstetric and perinatal outcomes were compared between groups using the t test. Odds ratio (OR) were calculated through Cochran's and Mantel-Haenszel statistics test for odds ratio equal to 1, 95% confidence intervals (CI) and p values (p < 0.05) were considered significant. RESULTS: The adverse perinatal outcomes imputable to adolescent births were foetal distress with low first minute Apgar score < 7 (OR 1.94, 95% CI 1.18-3.18, p = 0.009) and performance of neonatal resuscitation manoeuvres (OR 2.4, 95% CI 1.07-5.38, p = 0.032). Compared to older mothers, teenage girls were likely to have a non-statistically significant threefold higher risk of having an obstructed labour (OR 3.40, 95% CI 0.89-12.94, p = 0.07). Other perinatal outcomes as neonatal asphyxia, risk for cerebral palsy, premature birth, early neonatal infection, and neonatal death were identical between groups as well as maternal anaemia, mode of delivery or other obstetrical outcomes. CONCLUSION: Adolescent pregnancies were associated with worse perinatal outcomes as foetal distress and higher need for neonatal resuscitation manoeuvres. This study may support STP health authorities in their efforts to make Sustainable Development Goals 3 (good health and wellbeing), 4 (quality education) and 5 (gender equality) a reality by 2030, since it identifies specific problems that need to be addressed to improve maternal adolescent health.

Health-Related Quality of Life Assessments by Children and Adolescents with Sickle Cell Disease and Their Parents in Portugal.

Health-Related Quality of Life (HRQL) can be used to measure the impact of Sickle Cell Disease (SCD) on the child and their family and is generally reduced. No research has yet measured HRQL in Portuguese pediatric SCD patients. OBJECTIVES: (1) Describe and compare HRQL of children with SCD reported by them and their parents; (2) Compare with a pediatric population with no SCD; (3) Find predictive factors of HRQL in SCD children. METHODS: Descriptive, case-control study that included sixty-eight children and adolescents with SCD (aged 3 to 18 years) and their parents. Control group-children with no SCD, matched by age, gender and ethnic background. HRQL was assessed using the multidimensional self-report PedsQL® 4.0 Generic Scales. Summary scores for overall HRQL and subscale scores for physical, emotional, social and school functioning were compared within groups (children-parents) and with the control group. Clinical and socio-demographic variables were analyzed to find predictive factors of HRQL in pediatric SCD patients. RESULTS: Children with SCD and their parents had significantly lower overall and all subdomains of HRQL, compared with the control group. Children with SCD also rated lower when compared with their parents (only significant for social functioning), with low to moderate correlations. Children and parent reports declined with increasing age. Higher pain frequency was associated with worse total and psychosocial domains of HRQL. The number of hospitalizations was a predictor of worse school score, and female gender was a predictor of worse emotional score. CONCLUSIONS: SCD significantly affects children's HRQL. Parents can provide a good proxy report, although both evaluations are beneficial. Disease status, like number of hospitalizations and frequency of pain, influences HRQL. Interventions in SCD should consider improvements in HRQL as an important outcome.

Antenatal screenings and maternal diagnosis among pregnant women in Sao Tome & Principe-Missed opportunities to improve neonatal health: A hospital-based study.

Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1-3 (inadequate), 4-7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers' mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1-3 ANC contacts, 46.4% (237) had 4-7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.

Pain in Children and Adolescents With Sickle Cell Disease: Multidimensional Assessment.

BACKGROUND: Patients with sickle cell disease (SCD) suffer from recurrent painful vaso-occlusive episodes with a significant impact on their quality of life. The aim of this study was to perform a multidimensional assessment of pain in Portuguese children and adolescents with SCD. METHODS: Subjects were children and adolescents and their parents recruited from the outpatient pediatric hematology clinic in a Portuguese Hospital. Pain frequency and a broader multidimensional evaluation was performed using the Pediatric Pain Questionnaire (PedsQL) (that includes Visual Analog Scales, color indicators, qualitative descriptors of pain [open question] and body diagram) and a structured questionnaire (PQ2), that included a term list of the Adolescent Pediatric Pain Tool, among other questions. RESULTS: Included 60 children and adolescents (36 boys and 24 girls) with a mean age of 11±4.0 years (range, 5 to 18). The majority of children (83.1%) reported no present pain and 57.6% reported pain last month, with several degrees of pain intensity. Abdomen, thorax, and limbs were the most frequent localizations. Red was the color most chosen to describe "severe pain," whereas blue and green were more used to describe "no pain." The number of pain descriptors is different using an open-ended question (2.1±1.5) than a given list of terms (15.3±8.1). The most frequent terms used in the open question were "strong/very strong," "hurts a lot," "makes cry," and "horrible." Parents used similar pain descriptors. "Makes cry," "horrible," "tiring," "unbearable," and "uncomfortable" were the most frequent terms chosen in the PQ2. Pain interfered variably with daily activities for most of the patients. CONCLUSION: Pain experienced in SCD has a broad range of intensity levels, localization, and frequency. There are a number of pain descriptors and socio-emotional factors related to the pain experience. A comprehensive multidimensional assessment that includes both child's and parents' perspective seem to be the most adequate strategy to assess pain.

[Very Low Birth Weight Infants in a Portuguese Intensive Care Unit and the Vermont Oxford Network: 15 Years of Registry Data]. / Recém-Nascido de Muito Baixo Peso numa Unidade de Cuidados Intensivos Portuguesa Comparativamente ao Vermont Oxford Network: 15 Anos de Registo.

INTRODUCTION: Our neonatal service is part of a differentiated perinatal hospital and has contributed to the Vermont Oxford Network for more than 15 years. This data base includes data on the morbidity and mortality of newborns born in the member hospitals with birth weight between 401 and 1500 g and/ or from 22 to 29 weeks and six days of gestation, or those admitted to these hospitals with up to 28 days of age. It thus allows the analysis of clinical practice and its comparison with similar units. The goal of the present paper is to disclose some of our data from the past 15 years and to compare it with the Vermont Oxford Network data trying to identify areas of possible improvement and permitting other neonatal units to compare their data with our in a benchmarking process. MATERIAL AND METHODS: Observational, retrospective study. It included newborns with birth weight ≤ 1500 g (very low birth weight newborns) born and treated at our hospital from 2001 to 2015. Descriptive data analysis, chi-square test and ANOVA, significance when p < 0.05. RESULTS: A total of 869 very low birth weight newborns were studied, median weight 1100 g and gestational age 29 weeks. Twinning was found in 37.6%. In the delivery room, 23% did not require any resuscitation, 52.2% of the newborns required invasive intubation, 78.3% had surfactant, and, since 2011, 29.7% have started noninvasive ventilation. Of the total very low birth weight newborns, 12.9% had oxygen therapy at 36 weeks of corrected age, 23% patent ductus arteriosus and late sepsis in 17.1%. There was higher neurological morbidity compared to the Vermont Oxford Network except in the case of retinopathy of prematurity. Overall mortality was 14% (122 newborns). The time of hospitalization was on average 52.7 ± 34.4 days. The 629 newborns that were discharged home had equivalent length of stay and head circumference measure but a lower weight than those in the Vermont Oxford Network, and 14.3% went home with exclusive breastfeeding. DISCUSSION: This work allowed us to study our very low birth weight newborns data and compare it with one of the largest neonatal world networks. Our population is similar from the point of view of gestational age, somatometric data, pregnancy surveillance rates and cesarean section with the most noticeable difference being the percentage of low birthweight for gestational age babies, twin pregnancies and antenatal corticosteroid treatment, superior in our center. Cardio-pulmonary and gastrointestinal disorders were overlapping. It is urgent to improve our rate of sepsis, neurologic sequelae, post-partum hypothermia control and neuroprotection with magnesium sulphate. The mortality rate and the length of stay at discharge was similar. CONCLUSION: This study allowed us to compare our population of very low birth weight newborns with those registered in the network. We have verified that we have been accompanying the evolution of Neonatology over the past years and we have identified areas for improvement.

Introdução: O nosso serviço de Neonatologia está integrado num hospital perinatal diferenciado e pertence à rede de registo Vermont Oxford Network desde há mais de 15 anos. Este registo inclui dados da morbi-mortalidade de recém-nascidos com peso de nascimento entre 401 e 1500 g e/ou das 22 às 29 semanas e seis dias de gestação, nascidos nos hospitais membros ou admitidos até aos 28 dias de vida. Permite a análise da prática clínica e comparação com unidades semelhantes. Foi nosso objetivo divulgar alguns dos nossos dados dos últimos 15 anos fazer a sua reflexão, o estudo dos resultados e evolução das práticas assistenciais neonatais ao longo dos anos, e compará-los com os dados de um grupo com o mesmo nível de cuidados da rede Vermont Oxford Network. Dado considerarmos ser fundamental o estudo dos dados de morbimortalidade das unidades de neonatologia e sua comparação com unidades congéneres no sentido de identificação de áreas suscetíveis de intervenção, consideramos a pertinência da divulgação dos nossos dados.Material e Métodos: Estudo observacional, retrospetivo. Incluídos recém-nascidos com peso de nascimento ≤ 1500 g (recém-nascido de muito baixo peso) nascidos e tratados no nosso Hospital de 2001 a 2015 e comparados em dois subgrupos temporais com os dados da rede Vermont Oxford Network. Análise dos dados descritiva, teste de qui-quadrado e ANOVA, significância quando p < 0,05.Resultados: Estudaram-se 869 recém-nascidos de muito baixo peso com uma mediana de peso 1100 g e idade gestacional 29 semanas. Eram gémeos 37,6%. Na sala de partos 23% não necessitaram de qualquer reanimação, precisaram de entubação endotraqueal 52,2% dos recém-nascidos, em 78,3% foi administrado surfactante e desde que tal começou a ser registado em 2011, 29,7% iniciaram de imediato ventilação não invasiva. Em relação às principais morbilidades estudadas do ponto de vista respiratório do total de recém-nascidos de muito baixo peso 12,9% tinham oxigenoterapia às 36 semanas de idade corrigida, em relação à persistência do canal arterial hemodinamicamente significativo esta verificou-se em 23% e do ponto de vista infecioso verificou-se sépsis tardia em 17,1%. Registámos maior morbilidade neurológica comparativamente à Vermont Oxford Network exceto na retinopatia da prematuridade. A mortalidade global foi de 14% (122 recém-nascidos). O tempo de internamento foi em média de 52,7 ± 34,4 dias. Os 629 recém-­nascidos que tiveram alta para o domicílio estiveram internados sensivelmente os mesmos dias e apresentavam valores semelhantes de perímetro cefálico, mas menor peso no dia da alta que os da rede Vermont Oxford Network, tendo tido alta da nossa unidade com aleitamento materno exclusivo 14,3% dos recém-nascidos de muito baixo peso.Discussão: Este trabalho permitiu fazer a reflexão sobre os dados do nosso serviço de Neonatologia e compará-los com os de um dos maiores registos neonatais mundiais. Verificámos que a nossa população de recém-nascidos de muito baixo peso é muito sobreponível do ponto de vista da idade gestacional e somatométrico, taxas de vigilância da gravidez e de cesarianas, sendo a diferença mais notória a percentagem de leves para a idade gestacional, de gestações gemelares e de realização de indução maturativa que foram superiores no nosso centro. As patologias do foro cardiorrespiratório e gastrointestinais foram sobreponíveis. Verificámos que é urgente melhorar a taxa de infeção associada aos cuidados de saúde, das sequelas neurológicas, do controle da hipotermia após o nascimento e da neuroprotecção com sulfato de magnésio. A taxa de mortalidade foi sobreponível assim como o tempo de internamento.Conclusão: Este trabalho permitiu-nos comparar a nossa população de recém-nascidos de muito baixo peso com os registados na rede. Verificámos que acompanhámos a evolução que a Neonatologia foi tendo ao longo dos anos e identificámos áreas suscetíveis de melhoria.

[Informed Consent - Vision and Perspectives of Adolescents, Parents and Professionals: Multicentric Study in Six Hospitals].

INTRODUCTION: According to the Convention on the Rights of Children and the national standards of the Portuguese Directorate-General for Health, adolescents have the right to make decisions about their own health. The aim of this study was to identify the dynamics of the implementation of assent and informed consent in hospital settings. MATERIAL AND METHODS: Cross-sectional and multicentre study based on surveys, which included adolescents from 14 to 18 years and their parents. Heads of departments of Pediatrics and attending physicians were also interviewed. RESULTS: 194 responses from adolescents and parents were collected, and 46 interviews were conducted with physicians and heads of department. Adolescents and parents consider participation in decision making important, but parents value their own participation significantly higher (91.7% vs 47.8%, p < 0.001 in the 14 - 15 year group, 91.8% vs 53, (89.6% vs 69.6%, p = 0.016 in the 14 - 15 year group, 91.8% vs 69.4%, p = 0.005 in the 16 - 17 years group). Information leaflets are difficult to understand by teenagers. The eight heads of department felt that doctors have awareness towards communication with teenagers but have little time available. Of the 38 attending physicians, 36 said they had learned from their older colleagues and confirmed gaps in postgraduate training. DISCUSSION: This pioneering study in Portugal enabled the identification of areas that can be optimized, through health education programs for parents and adolescents, written information that is adequate to the different age groups, training in undergraduate education for medical students and also education in health institutions for professionals. CONCLUSION: Adolescents and parents, are unaware of legal and ethical standards for consent and assent. The implementation of the adolescents' right to informed assent / informed consent was not observed. Our proposal is to implement local programs for adolescents and parents.

Introdução: A Convenção sobre os Direitos das Crianças e normas nacionais da Direção Geral da Saúde conferem aos adolescentes o direito às decisões sobre a sua saúde. O objectivo deste estudo foi identificar as dinâmicas de implementação do assentimento e do consentimento informado, em ambiente hospitalar. Material e Métodos: Estudo transversal e multicêntrico realizado a partir de inquéritos. Incluídos adolescentes dos 14 aos 18 anos e pais respectivos. Foram ainda entrevistados os diretores de serviço e assistentes hospitalares. Resultados: Obtiveram-se 194 respostas de adolescentes e pais e efetuaram-se 46 entrevistas a médicos e diretores dos serviços. Adolescentes e pais consideram importante a participação no processo de decisão mas os pais valorizam de forma significativamente superior a sua participação (91,7% vs 47,8%, p < 0,001 no grupo 14 - 15 anos; 91,8% vs 53,1%, p = 0,001, no grupo 16 - 17 anos), bem como a do médico (89,6% vs 69,6%, p = 0,016 no grupo 14 - 15 anos; 91,8% vs 69,4%, p = 0,005 no grupo 16 - 17 anos). Os folhetos informativos são pouco perceptíveis pelos adolescentes. Os oito diretores consideraram que os médicos estão sensibilizados para comunicar com os adolescentes mas têm pouco tempo disponível. Dos 38 assistentes, 36 afirma ter aprendido com os colegas mais velhos e confirmam lacunas na formação pós graduada. Discussão: Este estudo pioneiro em Portugal permitiu a identificação de áreas passíveis de otimização, através de programas da educação para a saúde para pais e adolescentes, informação escrita adequada à idade e formação no ensino pré graduado para estudantes de Medicina e educação nas instituições de saúde para os profissionais. Conclusão: Os adolescentes e pais desconhecem as normas legais e éticas quanto ao consentimento e assentimento. Não fica demonstrada a implementação do direito dos adolescentes ao assentimento informado / consentimento informado. Propõem-se programas locais de sensibilização para adolescentes e pais.

Cross-national comparison of paediatric antibiotic use in Norway, Portugal and Hungary.

A cross-national comparison was performed on paediatric (0-19 years) antibiotic use in Hungary, Norway and Portugal to explore and compare the scale and pattern of paediatric antibiotic use in these three European countries. Ambulatory care systemic antibiotic use (ATC: J01) was retrieved from national databases for year 2014. The main outcome measure was number of antibacterial packages per child inhabitant per year (packages/child/year) and was further stratified by age groups. Paediatric antibiotic use peaked in Hungary with 1.3 packages/child/year, followed by Portugal (0.8) and Norway (0.3). This ranking was retained and was most prominent in the 5- to 9-year and 10- to 14-year age groups. The pattern of antibiotic use in different paediatric age groups varied also substantially between countries. Narrow-spectrum penicillins were much commonly used in Norway in all paediatric age subgroups in comparison with Hungary and Portugal. Newer, broad-spectrum cephalosporins and macrolides were widely prescribed for Hungarian and Portuguese children in all paediatric subgroups in contrast to Norway, while tetracyclines were commonly prescribed for Norwegian adolescents. The scale and pattern of paediatric antibiotic use in Hungary and Portugal were very different compared with Norway. The high antibiotic exposure and the high consumption of broad-spectrum penicillins begin in childhood in Hungary and Portugal which underpins the responsibility of paediatric GPs.

The effect of NaCl 0.9% and NaCl 0.45% on sodium, chloride, and acid-base balance in a PICU population / Efeito do NaCl a 0,9% e do NaCl a 0,45% sobre o sódio, cloreto e equilíbrio ácido-base em uma população de UTIP

ABSTRACT OBJECTIVES: To study the effect of two intravenous maintenance fluids on plasma sodium (Na), and acid-base balance in pediatric intensive care patients during the first 24 h of hospitalization. METHODS: A prospective randomized controlled study was performed, which allocated 233 patients to groups: (A) NaCl 0.9% or (B) NaCl 0.45%. Patients were aged 1 day to 18 years, had normal electrolyte concentrations, and suffered an acute insult (medical/surgical). Main outcome measured: change in plasma sodium. Parametric tests: t-tests, ANOVA, X 2 statistical significance level was set at a = 0.05. RESULTS: Group A (n = 130): serum Na increased by 2.91 (±3.9) mmol/L at 24 h (p < 0.01); 2% patients had Na higher than 150 mmol/L. Mean urinary Na: 106.6 (±56.8) mmol/L. No change in pH at 0 and 24 h. Group B (n = 103): serum Na did not display statistically significant changes. Fifteen percent of the patients had Na < 135 mmol/L at 24 h. The two fluids had different effects on respiratory and post-operative situations. CONCLUSIONS: The use of saline 0.9% was associated with a lower incidence of electrolyte disturbances.

RESUMO OBJETIVO: Estudar o efeito de dois fluidos de manutenção intravenosos sobre o sódio (Na) plasmático e o equilíbrio ácido-base em pacientes de terapia intensiva pediátrica durante as primeiras 24 horas de internação. MÉTODOS: Foi feito um estudo controlado randomizado prospectivo. Alocamos aleatoriamente 233 pacientes para os grupos: (A) NaCl a 0,9% e (B) NaCl a 0,45%. Os pacientes com um dia a 18 anos apresentavam concentrações normais de eletrólitos e sofriam de insulto agudo (médico/cirúrgico). Principal resultado: variação no sódio plasmático. Testes paramétricos: teste t, Anova, qui-quadrado. O nível de relevância estatística foi estabelecido em a = 0,05. RESULTADOS: Grupo A (n = 130): o Na sérico aumentou 2,91 (± 3,9) mmol L-1 em 24 h (p < 0,01); 2% dos pacientes apresentaram Na acima de 150 mmol L-1. Concentração média de Na na urina: 106,6 (± 56,8) mmol L-1. Sem alteração no pH em 0 e 24 horas. Grupo B (n = 103): o Na sérico não apresentou alterações estatisticamente significativas; 15% dos pacientes apresentaram Na < 135 mmol L-1 em 24 h. Os dois fluidos tiveram efeitos diferentes sobre as situações respiratória e pós-operatória. CONCLUSÃO: O uso de solução fisiológica a 0,9% foi associado à menor incidência de distúrbios eletrolíticos.

The effect of NaCl 0.9% and NaCl 0.45% on sodium, chloride, and acid-base balance in a PICU population.

OBJECTIVES: To study the effect of two intravenous maintenance fluids on plasma sodium (Na), and acid-base balance in pediatric intensive care patients during the first 24h of hospitalization. METHODS: A prospective randomized controlled study was performed, which allocated 233 patients to groups: (A) NaCl 0.9% or (B) NaCl 0.45%. Patients were aged 1 day to 18 years, had normal electrolyte concentrations, and suffered an acute insult (medical/surgical). MAIN OUTCOME MEASURED: change in plasma sodium. Parametric tests: t-tests, ANOVA, X(2) statistical significance level was set at α=0.05. RESULTS: Group A (n=130): serum Na increased by 2.91 (±3.9)mmol/L at 24h (p<0.01); 2% patients had Na higher than 150 mmol/L. Mean urinary Na: 106.6 (±56.8)mmol/L. No change in pH at 0 and 24h. Group B (n=103): serum Na did not display statistically significant changes. Fifteen percent of the patients had Na<135 mmol/L at 24h. The two fluids had different effects on respiratory and post-operative situations. CONCLUSIONS: The use of saline 0.9% was associated with a lower incidence of electrolyte disturbances.

Chronic condition and risk behaviours in Portuguese adolescents.

Living with a chronic condition (CC) in adolescence has been historically considered protective for risk behaviours. However, research from the last decade suggest that when compared with healthy peers, adolescents living with a chronic condition can engage in risky behaviours in a similar if not higher rate than their counterparts living with out a CC. This study aims to characterize and evaluate the impact of 1) living with a chronic condition (CC), and 2) how the perception of living with a CC affects school participation, and its association with risk/protective behaviours (drunkenness, physical fight, sadness and self-harm). For this purpose 4 groups were identified: adolescents with mostly healthy behaviours, adolescents with mostly risk behaviours, adolescents with mostly risk-internalizing behaviours and adolescents with mostly risk-externalizing behaviours. A large sample was included in this study, composed by 3494 Portuguese adolescents with an average age of 15 years, who participated in the Portuguese Survey of Health Behaviour in School-aged Children/WHO (HBSC). Main results show that adolescents living with a CC have more risk-internalizing behaviours when compared to adolescents without CC, who present more healthy behaviors. Furthermore, adolescents that report that having a CC affects school participation show more risky behaviours than those not affected by a CC who present more healthy behaviours. Boys with a CC show more healthy behaviours, and those who feel that the CC affects school participation present more risky behaviours. On the other hand, girls with a CC have more risk-internalizing behaviours and less healthy behaviours It is important to point out that adolescents living with a CC represent a vulnerable group, and may engage in experimental/risky behaviours as likely as their non CC peers. Thus, potential benefits can arise from reinforcing interventions within protective contexts (family/peers/school setting). Health/education professionals, more than considering risk behaviours as dangerous in themselves, should offer adolescents with a CC an opportunity to reflect on their own decisions. Educational programs would benefit from looking at risk behaviors more from an experimentation perspective, focusing on constructive ways to help adolescents with CC to proceed into adulthood in a more appropriate developmental way.

Neonatal morbidity and outcome of live born premature babies after attempted illegal abortion with misoprostol.

UNLABELLED: Misoprostol is a synthetic prostaglandin currently employed to induce labor. Association with illegal abortion has been reported; however, neonatal outcome and morbidity after a failed attempt of abortion has not been described. OBJECTIVES: To report the association between misoprostol self-medication and preterm labor and to assess perinatal risk factors, morbidity and early outcomes. METHODS: We conducted a prospective study of all very low birth weight (VLBW) infants delivered in Hospital Fernando Fonseca, during a 5-year period. VLBW infants were assigned to misoprostol group (MG) when preterm delivery was attributed to misoprostol and matched with newborns with similar gestational age, birth- weight, and gender. RESULTS: During the study period 311 VLBW infants were born. Nineteen belonged to misoprostol group (MG) and 58 were selected for controls. Mothers from MG were significantly younger (21.5 vs 27.5, p = 0.001) and from African origin (74 vs 31%, p = 0.006), had significantly less prenatal care (21 vs 67%, p = 0.000), less antenatal steroids (5 vs 50%, p = 0.001), and were delivered less often by C-section (11 vs 60%, p = 0.000). MG infants had significantly higher rates of patent ductus arteriosus (58 vs 29%, p = 0.031) and chronic lung disease (47 vs 14%, p = 0.026). Mortality rate at 3 months was similar in both groups, but the incidence of abnormal neurodevelopment at 1 year of age was significantly higher in the MG (50 vs 16%, p= 0.02). COMMENTS: The worse outcome of MG infants seems to be determined by prenatal, natal, and postnatal factors and we believe that misoprostol is probably a significant adjuvant cofactor.

[Microlithiasis and testicular tumour]. / Microlitíase e tumor testicular.

Testicular microlithiasis is a rare entity, usually asymptomatic and bilateral. There are however reports that until 40% of the cases may be related with testicular tumours. We report an 11-year-old boy, with a four-month history of left testicular mass. Sonography showed increased volume of left testis and bilateral microlithiasis. Testicular biopsy revealed Sertoli cell tumour and he was submitted to left radical orquidectomy. Testicular cancer is often curable, especially if diagnosed and treated early. The association of malignancy justifies long term clinical and ultrasound follow-up of testicular microlithiasis.

[Echovirus type 13 meningitis: admissions to a paediatric ward at a Lisbon hospital]. / Meningite por echovirus tipo 13.

Infections by echovirus 13 are rare. In our country, it had not been previously reported any infection of this sort until 2000, when eleven echovirus 13 meningitis were observed in the Department of Pediatrics of the Hospital Fernando Fonseca. In England and Spain outbreaks of echovirus 13 meningitis during 2000 was also reported. Based on these facts the authors make an epidemiological analyses of their series.