An Unusual IgE-Mediated Hypersensitivity: Two Case Reports of Paracetamol Allergy.

Paracetamol is one of the most commonly used analgesic and antipyretic agents worldwide, attributed in part to its excellent safety profile when administered at recommended doses. Paracetamol allergy is not common, and the majority of the reactions are related to the pharmacological action of cyclooxygenase 1 inhibition. Selective and Immunoglobulin E (IgE)-mediated hypersensitivity reactions are rare. In this article, the authors report two cases of paracetamol allergy in which the mechanism of IgE-mediated hypersensitivity was demonstrated by positive skin tests and basophil activation tests. We highlight the relevance of identifying the mechanism underlying the reaction since patients with IgE-mediated paracetamol allergies will be able to tolerate non-steroidal anti-inflammatory drugs.

Segurança da vacinação contra a COVID-19 em doentes referenciados dos cuidados de saúde primários por alergia ao veneno de himenópteros / COVID-19 vaccination safety in patients with hymenoptera venom allergy referred by primary health care

Introdução: As reações de hipersensibilidade após vacinação contra a COVID-19 têm vindo a ser descritas, embora a anafilaxia seja rara. A hipersensibilidade ao veneno de himenópteros constitui a terceira causa mais frequente de anafilaxia em Portugal, embora não pareça aumentar o risco de anafilaxia à vacinação contra a COVID-19. Objetivos: Avaliar a segurança da vacinação contra a COVID-19 em doentes com história de alergia ao veneno de himenópteros referenciados dos Cuidados de Saúde Primários (CSP). Métodos: Estudo observacional retrospectivo com inclusão dos doentes com alergia ao veneno de himenópteros referenciados pelos CSP ao serviço de Imunoalergologia, para estratificação do risco de reações de hipersensibilidade à vacina contra o SARS-CoV-2, entre janeiro e dezembro de 2021. Resultados: No total, incluíram-se 18 doentes, 72% do sexo feminino, média de idades de 61±18 [21-89] anos. Na caracterização do tipo da reação ao veneno de himenópteros, as reações locais exuberantes corresponderam a 33% de todas as reações referidas. Quanto a sintomas sistêmicos de anafilaxia, foram referidos sintomas mucocutâneos (33%), respiratórios (28%), cardiovasculares (33%) e gastrointestinais (11%). A abelha foi o inseto mais frequentemente implicado (61%). Relativamente aos valores de triptase basal, 3 doentes apresentaram níveis acima do cut-off estabelecido de 11,4 ng/mL, tendo indicação formal para iniciar esquema de vacinação em meio hospitalar. Durante o processo vacinal registrou-se um total de 46 administrações em 18 doentes, todas sem intercorrências. Apenas 5 doentes foram vacinados em meio hospitalar, tendo sido os restantes encaminhados para os CSP. Os doentes com mastocitose confirmada ou suspeita foram submetidos à pré-medicação com anti-histamínico anti-H1 e anti- H2, bem como montelucaste, na véspera e no dia da vacinação. Conclusões: A vacinação contra a COVID-19 é segura em doentes com reação de hipersensibilidade ao veneno de himenópteros. O protocolo utilizado mostrou ser eficaz na segregação de doentes entre CSP e cuidados secundários/terciários.

Introduction: Despite numerous reports of hypersensitivity reactions to COVID-19 vaccination, anaphylaxis is rare. Although hypersensitivity reactions to hymenoptera venom are the third most common cause of anaphylaxis in Portugal, they don't appear to enhance the risk of anaphylactic reaction to COVID-19 vaccination. Objectives: To assess the safety of COVID-19 vaccination in patients with a history of hymenoptera venom allergy. Methods: This retrospective observational study included patients with hymenoptera venom allergy referred by primary health care to the Immunoallergology Outpatient Clinic of a tertiary hospital between January and December 2021 to stratify the risk of hypersensitivity reactions to the SARSCoV- 2 vaccine. Results: A total of 18 patients were included: 72% women; mean age 61 (SD, 18 [range 21-89]) years. One-third of all reported reactions to hymenoptera venom were large and local. Topical systemic symptoms of anaphylaxis were mucocutaneous (33%), respiratory (28%), cardiovascular (33%) and gastrointestinal (11%). The honeybee was the most frequently involved hymenoptera species (61%). The basal tryptase levels of 3 patients were above the established cut-off (11.4 ng/mL) and they were formally indicated for vaccination in a hospital setting. Concerning the vaccination process, 46 doses were administered to the 18 patients and no reactions were recorded. Only 5 patients were vaccinated in a hospital environment; the rest were referred to primary health care centers. Patients with confirmed or suspected mastocytosis were premedicated with anti-H1 and anti-H2 antihistamines, as well as montelukast, the day before and on the day of vaccination. Conclusions: COVID-19 vaccination is safe for patients with hypersensitivity to hymenoptera venom. The risk assessment protocol effectively designated patients to primary or secondary/tertiary health care.

Comparative analysis of pulmonary function in children born preterm and full-term at 6-9 years of age / Análise comparativa da função pulmonar em crianças de 6 a 9 anos de idade nascidas pré-termo e a termo

Abstract Objective: To compare pulmonary function parameters and the prevalence of altered pulmonary function in children born preterm and full-term, using the Global Lung Initiative reference values. Methods: This is a cross-sectional study with 6-9-year-old children submitted to measurement of airway resistance (Rint) and spirometry according to the American Thoracic Society and European Respiratory Society Technical Statement. The inclusion criteria were, among the preterm group: gestational age <37 weeks and birth weight <2000g; among the full-term group: schoolchildren born full-term with birth weight >2500g, recruited at two public schools in São Paulo, Brazil, matched by sex and age with the preterm group. As exclusion criteria, congenital malformations, cognitive deficit, and respiratory problems in the past 15 days were considered. Results: A total of 112 children were included in each group. Preterm children had gestational age of 30.8±2.8 weeks and birth weight of 1349±334g. Among them, 46.6% were boys, 46.4% presented respiratory distress syndrome, 19.6% bronchopulmonary dysplasia, and 65.2% were submitted to mechanical ventilation in the neonatal unit. At study entry, both groups were similar in age and anthropometric parameters. Parameters of pulmonary function (Z scores) in preterm and full-term groups were: Rint (0.13±2.24 vs. -1.02±1.29; p<0.001); forced vital capacity (FVC) (-0.39±1.27 vs. -0.15±1.03; p=0.106), forced expiratory volume in one second (FEV1)/FVC (-0.23±1.22 vs. 0.14±1.11; p=0.003), FEV1 (-0.48±1.29 vs. -0.04±1.08; p=0.071), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) (1.16±1.37 vs. 2.08±1.26; p=0.005), respectively. The prevalence values of altered airway resistance (16.1 vs. 1.8%; p<0.001) and spirometry (26.8 vs. 13.4%, p=0.012) were higher in preterm infants than in full-term ones. Conclusions: Preterm children had higher prevalence of altered pulmonary function, higher Z scores of airway resistance, and lower Z scores of FEV1/FVC and FEF25-75 compared with those born full-term.

RESUMO Objetivo: Comparar parâmetros de função pulmonar e a prevalência de função pulmonar alterada em crianças nascidas pré-termo e a termo, utilizando a referência Global Lung Function Initiative. Métodos: Estudo transversal com crianças de 6-9 anos submetidas à medida de resistência de vias aéreas (Rint) segundo o American Thoracic Society and the European Respiratory Society Technical Statement. Como critérios de inclusão, entre o grupo pré-termo, estavam os nascidos com idade gestacional <37 semanas e peso <2000g; e entre o grupo termo, escolares de duas escolas públicas do município de São Paulo, nascidos a termo com peso >2500g, pareados por sexo e idade com o grupo pré-termo. Excluíram-se malformações congênitas, déficit cognitivo e problemas respiratórios havia menos de 15 dias. Resultados: Incluíram-se 112 crianças em cada grupo. Os prematuros (46,4% masculinos) apresentaram idade gestacional de 30,8±2,8 semanas e peso de 1349±334g. Entre eles, 46,4% tiveram síndrome de desconforto respiratório, 19,6% displasia broncopulmonar, e 65,2% receberam ventilação mecânica na unidade neonatal. À inclusão no estudo, os dois grupos apresentaram idade e dados antropométricos semelhantes. Os valores (escores Z) em nascidos pré-termo e a termo foram, respectivamente: Rint (0,13±2,24 vs. -1,02±1,29; p<0,001), capacidade vital forçada (CVF) (-0,39±1,27 vs. -0,15±1,03; p=0,106), volume expiratório forçado no primeiro segundo (VEF1)/CVF (-0,23±1,22 vs. 0,14±1,11; p=0,003), VEF1 (-0,48±1,29 vs. -0,04±1,08; p=0,071) e fluxo expiratório forçado em 25-75% da capacidade vital (FEF25-75) (1,16±1,37 vs. 2,08±1,26; p=0,005). A prevalência de alterações na resistência de vias aéreas (16,1 vs. 1,8%, p<0,001) e na espirometria (26,8 vs. 13,4%, p=0,012) foi maior nos prematuros. Conclusões: As crianças nascidas pré-termo apresentaram maior prevalência de alteração pulmonar, maiores escores Z de resistência de vias aéreas e menores escores Z de VEF1/CVF e FEF25-75 quando comparadas às nascidas a termo.

Comparative analysis of pulmonary function in children born preterm and full-term at 6-9 years of age.

OBJECTIVE: To compare pulmonary function parameters and the prevalence of altered pulmonary function in children born preterm and full-term, using the Global Lung Initiative reference values. METHODS: This is a cross-sectional study with 6-9-year-old children submitted to measurement of airway resistance (Rint) and spirometry according to the American Thoracic Society and European Respiratory Society Technical Statement. The inclusion criteria were, among the preterm group: gestational age <37 weeks and birth weight <2000g; among the full-term group: schoolchildren born full-term with birth weight >2500g, recruited at two public schools in São Paulo, Brazil, matched by sex and age with the preterm group. As exclusion criteria, congenital malformations, cognitive deficit, and respiratory problems in the past 15 days were considered. RESULTS: A total of 112 children were included in each group. Preterm children had gestational age of 30.8±2.8 weeks and birth weight of 1349±334g. Among them, 46.6% were boys, 46.4% presented respiratory distress syndrome, 19.6% bronchopulmonary dysplasia, and 65.2% were submitted to mechanical ventilation in the neonatal unit. At study entry, both groups were similar in age and anthropometric parameters. Parameters of pulmonary function (Z scores) in preterm and full-term groups were: Rint (0.13±2.24 vs. -1.02±1.29; p<0.001); forced vital capacity (FVC) (-0.39±1.27 vs. -0.15±1.03; p=0.106), forced expiratory volume in one second (FEV1)/FVC (-0.23±1.22 vs. 0.14±1.11; p=0.003), FEV1 (-0.48±1.29 vs. -0.04±1.08; p=0.071), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) (1.16±1.37 vs. 2.08±1.26; p=0.005), respectively. The prevalence values of altered airway resistance (16.1 vs. 1.8%; p<0.001) and spirometry (26.8 vs. 13.4%, p=0.012) were higher in preterm infants than in full-term ones. CONCLUSIONS: Preterm children had higher prevalence of altered pulmonary function, higher Z scores of airway resistance, and lower Z scores of FEV1/FVC and FEF25-75 compared with those born full-term.

Factor analysis of the performance at the medical residency exam, progress test and clerkship rotations performance coefficient / Análise fatorial do desempenho no exame de residência médica, teste de progresso e coeficiente de desempenho nos estágios do internato

Abstract: Introduction: The relationships between the students' performance on medical residency exams and progress tests and medical clerkship rotations are not well established. Objective: The objective of this study was to measure the correlations between grades on progress tests and clerkship rotations assessments and the medical residency exam and determine which performance had the strongest correlation with the final medical residency exam. Methods: This was a retrospective and longitudinal study with correlation analyses of grades on progress tests from the 1st to 6th year of medical school, the clerkship rotations performance coefficient (5th and 6th years of school) and the final medical residency exam in a cohort of students enrolled in a federal public medical school using factor analysis. Students who performed the progress tests from the 1st to 6th year were included. Results: Of 123 students enrolled in the first year of medical school in 2009, 114 (92.7%) performed the progress tests during the six years and were included. The average grades on the progress tests from 1 to 10 were 2.67 (1st year), 3.01 (2nd year), 4.19 (3rd year), 4.01 (4th year), 5.19 (5th year), and 6.38 (6th year). The average grades in the clerkship rotations were 8.32 (5th year) and 8.26 (6th year). The average score on the theoretical medical residency exam was 7.53 and the final result of the medical residency exam was 8.05. Factor analysis detected three domains with greater correlation strength that accounted for 76.3% of the model variance. Component 1 was identified as the coefficient of academic performance (CAP) 5th, CAP 6th and final medical residency exam grades, whereas component 2 was constituted by the grades of the 5th and 6th years progress tests and the third component comprised the progress tests of the 2nd, 3rd and 4th years. Conclusions: Grades on the progress tests, the clerkship rotations assessments and the final medical residency exam were correlated. Moreover, the performance during the medical clerkship rotations showed the strongest correlations with medical residency exam grades.

Resumo: Introdução: As relações entre o desempenho dos alunos nos exames de residência médica e testes de progresso e os estágios no internato médico não estão bem estabelecidas. Objetivo: Este estudo teve como objetivos medir as correlações entre as notas nos testes de progresso e as notas no internato e o resultado final do exame de residência médica, e determinar qual desempenho teve a maior correlação com o exame final da residência médica. Método: Trata-se de um estudo retrospectivo e longitudinal com análises de correlação de notas em provas de progresso do primeiro ao sexto ano do curso de Medicina, coeficiente de desempenho de estágios do internato (quinto e sexto anos) e notas do exame final de residência médica em uma coorte de alunos matriculados em uma Faculdade de Medicina de uma instituição pública federal, usando análise fatorial. Foram incluídos os alunos que realizaram os testes de progresso do primeiro ao sexto ano. Resultado: Dos 123 alunos matriculados no primeiro ano do curso de Medicina em 2009, 114 (92,7%) realizaram os testes de progresso durante os seis anos letivos e foram incluídos. As notas médias nos testes de progresso de 1 a 10 foram 2,67 (primeiro ano), 3,01 (segundo ano), 4,19 (terceiro ano), 4,01 (quarto ano), 5,19 (quinto ano) e 6,38 (sexto ano). As notas médias nos estágios foram 8,32 (quinto ano) e 8,26 (sexto ano). A nota média no exame teórico da residência médica foi 7,53; e a média no exame final da residência, 8,5. A análise fatorial detectou três domínios com maior força de correlação que responderam por 76,3% da variância do modelo. O componente 1 foi identificado como coeficiente de rendimento acadêmico (CAP) 5º, CAP 6º e o resultado final do exame de residência médica, o componente 2 foi formado pelas notas das provas de progresso do quinto e sextos anos, e o terceiro componente compreendeu as notas do progresso do segundo, terceiro e quarto anos. Conclusão: As notas das provas de progresso, as avaliações do internato e o exame final de residência médica apresentaram correlações significantes. Além disso, o desempenho durante o internato apresentou maior correlação com as notas do exame final de residência médica.

Molecular diagnosis and immunotherapy selection in a Portuguese population sensitized to grass and olive pollens / Diagnóstico molecular e seleção de imunoterapia numa população portuguesa sensibilizada ao pólen de gramíneas e de oliveira

Introduction: Phleum pratense (Phl p) and Olea europaea (Ole e) are common allergenic pollen. Objectives: To describe the sensitization patterns to Phl p and Ole e allergens in a subset of allergic rhinitis patients with positive skin prick tests (SPTs) to these pollens and compare the allergen immunotherapy (AIT) choice before and after determination of molecular components. Methods: Candidates to pollen immunotherapy with positive SPTs to both Phl p and Ole e were recruited. All of them underwent an SPT with a panel of aeroallergens and measurements of serum specific IgE (sIgE) to Phl p, Ole e, Phl p1, Phl p5, Phl p7, Phl p12, Ole e1, Ole e7, and Bet v2. Results: Forty adults were included. Of these, 83% and 65% were sIgE-positive to Phl p and Ole e, using the 0.35 kUA/L and 0.70 kUA/L cut-offs, respectively. Moreover, 42.5% of patients had positive sIgE to Phl p1 and/or Phl p5, 2.5% only to Ole e1, and 47.5% to both (0.35 kUA/L cutoff). By increasing the cut-off to 0.7 kUA/L, 55% of patients were sensitized to Phl p1 and/or Phl p5, and no patient was sensitized only to Ole e1. After component-resolved diagnosis, AIT choice was changed in 15 (37.5%) patients, with a decrease in the number of prescriptions of AIT with both grass and olive pollens and with olive alone, together with an increase in the prescriptions of AIT with grass pollen alone. Conclusion: Genuine sensitization to Olea europaea was reduced, and the sensitization patterns were heterogeneous. Knowledge of pattern of sensitization to molecular components changed immunotherapy prescription in more than one third of the patients.

Introdução: Os polens de Phleum pratense (Phl p) e de Olea europaea (Ole e) são fontes alergênicas comuns. Objetivos: Descrever os padrões de sensibilização aos alergênios destes dois polens num subconjunto de pacientes com rinite alérgica polínica e comparar a escolha de imunoterapia, antes e depois da determinação de alergênios moleculares para Phl p e Ole e. Métodos: Foram recrutados candidatos para imunoterapia com polens, com testes cutâneos positivos para Phl p e Ole e. Todos realizaram um painel de testes em picada a aeroalergênios e determinação de IgE séricas específicas para Phl p, Ole e, rPhl p1, rPhl p5, rPhl p7, rPhl p 12, rOle e 1, nOle e 7, rBet v2. Resultados: Foram incluídos 40 adultos. Em relação à sIgE para Phl p e Ole e, 83% e 65% dos pacientes apresentaram positividade para ambos, usando o cut-off de 0,35 kUA/L e 0,70 kUA/L, respectivamente. A positividade para Phl p1 e/ou Phl p 5 foi encontrada em 42,5%, para Ole e 1 apenas em 2,5%, enquanto 47,5% apresentaram sIgE positivo para ambos (cut-off corte de 0,35 kUA/L). Aumentando o cut-off para 0,7 kUA/L, 55% foram sensibilizados para Phl p1 e/ou Phl p5, nenhum paciente foi sensibilizado apenas para Ole e 1. Após a determinação dos alergênios para os componentes moleculares, a escolha de imunoterapia foi alterada em 15 (37,5%) pacientes, com uma diminuição no número de vacinas para Phleum + Olea e apenas para Olea e um aumento na prescrição de vacinas para Phleum. Conclusão: A sensibilização genuína do Olea europaea foi reduzida e os padrões de sensibilização foram heterogêneos. O conhecimento da sensibilização aos componentes moleculares dos alergênios mudou a prescrição de imunoterapia em mais de um terço dos pacientes.

Serologic and molecular studies to identify neonatal alloimmune neutropenia in a cohort of 10,000 neonates.

Neonatal alloimmune neutropenia (NAIN) is caused by maternal alloimmunisation to fetal human neutrophil antigens (HNAs). This study investigated maternal HNA/HLA alloantibodies involved with NAIN and identified the frequency of NAIN in Brazilian neonates. Neonatal neutropenia (neutrophil count < 1.5 × 109 /L) was investigated in samples from 10,000 unselected neonates, resulting in 88 neutropenic newborns (NBs) and their 83 mothers. Genotyping was performed by PCR-SSP (HNA-1/-4) and PCR-RFLP (HNA-3/-5). Serologic studies were performed by GAT (granulocyte agglutination test), Flow-WIFT (white blood cells immunofluorescence test) and LABScreen-Multi-HNA-Kit (OneLambda®) (LSM). Neonatal neutropenia was identified in 88/10,000 (0·9%) NBs. Genotyping revealed 60·2% maternal-fetal HNA incompatibilities (31·8% for HNA-1; 14·8% for HNA-3; 15·9% for HNA-4; 21·6% for HNA-5). Serologic studies revealed 37·3% of mothers with positive results with at least one technique. The detected anti-HNA specificities were confirmed in eight positive cases related to HNA-1/-3 systems. In cases with maternal-fetal HNA-4/-5 incompatibility, no specific neutrophil alloantibodies were found but anti-HLA I/II were present. Anti-HNA-2 was not identified. This is a large Brazilian study which involved the investigation of antibodies against all five HNA systems in neutropenia cases and showed a frequency of NAIN in 8/10,000 neonates. Among the HNA antibodies identified, we highlight the anti-HNA-1d and anti-HNA-3b, antibodies unusual in alloimmunised women, and rarely related to NAIN cases.

INCIDENCE OF SMALL FOR GESTATIONAL AGE NEONATES, ACCORDING TO THE FENTON AND INTERGROWTH-21ST CURVES IN A LEVEL II MATERNITY.

OBJECTIVE: To compare the incidence of small for gestational age infants among late preterm and term newborns, using the Fenton and Intergrowth-21st curves. METHODS: Observational and retrospective study with newborns in a level II maternity. The study was approved by the Institution's Ethics Committee. Live births from July 2007 to February 2009 with a gestational age from 34 to 41 weeks and seven days were included. Neonates with incomplete data were excluded. Appropriate weight for gestational age was assessed by the Fenton and Intergrowth-21st intrauterine growth curves, considering birth weight <10th percentile as small for gestational age. The degree of agreement between the two curves was assessed by the Kappa coefficient. Numerical variables were compared using the Student t-test or the Mann-Whitney. Categorical variables were compared using the chi-square test. Statistical analyzes were performed using SPSS17® software, considering significant, p<0.05. RESULTS: We included 2849 newborns with a birthweight of 3210±483 g, gestational age of 38.8±1.4 weeks; 51.1% male. The incidence of small for gestational age in the full sample was 13.0 vs. 8.7% (p<0.001, Kappa=0.667) by the Fenton and Intergrowth-21st curves, respectively. Among late preterm, the incidence of small neonates was 11.3 vs. 10.9% (p<0.001; Kappa=0.793) and among full-term infants it was 13.1% vs. 8.5% (p<0.001; Kappa=0.656), respectively for the Fenton and Intergrowth-21st curves. CONCLUSIONS: The incidence of small for gestational age newborns was significantly higher using the Fenton curve, with greater agreement between the Fenton and Intergrowth-21st curves among late preterm, compared to full term neonates.

Incidence of small for gestational age neonates, according to the fenton and intergrowth-21st curves in a level ii maternity / Incidência de recém-nascidos pequenos para a idade gestacional segundo curva de fenton e intergrowth-21st em uma maternidade de nível secundário

ABSTRACT Objective: To compare the incidence of small for gestational age infants among late preterm and term newborns, using the Fenton and Intergrowth-21st curves. Methods: Observational and retrospective study with newborns in a level II maternity. The study was approved by the Institution's Ethics Committee. Live births from July 2007 to February 2009 with a gestational age from 34 to 41 weeks and seven days were included. Neonates with incomplete data were excluded. Appropriate weight for gestational age was assessed by the Fenton and Intergrowth-21st intrauterine growth curves, considering birth weight <10th percentile as small for gestational age. The degree of agreement between the two curves was assessed by the Kappa coefficient. Numerical variables were compared using the Student t-test or the Mann-Whitney. Categorical variables were compared using the chi-square test. Statistical analyzes were performed using SPSS17® software, considering significant, p<0.05. Results: We included 2849 newborns with a birthweight of 3210±483 g, gestational age of 38.8±1.4 weeks; 51.1% male. The incidence of small for gestational age in the full sample was 13.0 vs. 8.7% (p<0.001, Kappa=0.667) by the Fenton and Intergrowth-21st curves, respectively. Among late preterm, the incidence of small neonates was 11.3 vs. 10.9% (p<0.001; Kappa=0.793) and among full-term infants it was 13.1% vs. 8.5% (p<0.001; Kappa=0.656), respectively for the Fenton and Intergrowth-21st curves. Conclusions: The incidence of small for gestational age newborns was significantly higher using the Fenton curve, with greater agreement between the Fenton and Intergrowth-21st curves among late preterm, compared to full term neonates.

RESUMO Objetivo: Comparar a incidência de neonatos pequenos para idade gestacional entre nascidos vivos pré-termo tardios e a termo utilizando as curvas de Fenton e Intergrowth-21st. Métodos: Estudo observacional retrospectivo com recém-nascidos de uma maternidade pública de nível secundário. Foram incluídos nascidos vivos de julho/2007 a fevereiro/2009 com idade gestacional de 34 a 41 semanas e seis dias. O estudo foi aprovado pelo Comitê de Ética da instituição. Foram excluídos recém-nascidos com dados incompletos. Para adequação do peso/da idade gestacional, utilizaram-se as curvas de crescimento intrauterino de Fenton e Intergrowth-21st, considerando-se pequeno aquele com peso ao nascer <10º percentil. O grau de concordância entre as duas curvas foi avaliado pelo coeficiente Kappa. As variáveis numéricas foram comparadas pelo teste t de Student ou de Mann-Whitney, conforme distribuição, e as categóricas pelo teste χ2. As análises estatísticas foram realizadas no programa Statistical Package for the Social Sciences (SPSS) 17®, considerando-se significante p<0,05. Resultados: Foram incluídos 2.849 recém-nascidos com peso ao nascer de 3210±483 g, idade gestacional de 38,8±1,4 semanas, sendo 51,1% masculinos. A incidência de recém-nascidos pequenos para a idade gestacional pela curva de Fenton e Intergrowth-21st na amostra total foi, respectivamente, de 13 e 8,7% (p<0,001; Kappa=0,667). Entre os pré-termo tardios, a incidência foi de 11,3 e 10,9% (p<0,001; Kappa=0,793) e entre os nascidos a termo foi de 13,1 e 8,5%, (p<0,001; Kappa=0,656), respectivamente, para as curvas de Fenton e Intergrowth-21st. Conclusões: A incidência de recém-nascidos pequenos para idade gestacional foi significantemente maior pela curva de Fenton, com maior concordância entre as curvas de Fenton e Intergrowth-21st em recém-nascidos pré-termo tardios do que nos nascidos a termo.

Factors associated with student performance on the medical residency test.

OBJECTIVE: To determine whether the scores of the Progress test, the Skills and Attitude test, and the medical internship are correlated with the medical residency exam performance of students who started medical school at the Federal University of São Paulo in 2009. METHODS: The scores of 684 Progress tests from years 1-6 of medical school, 111 Skills and Attitude exams (5th year), 228 performance coefficients for the 5th and 6th years of internship, and 211 scores on the medical residency exam were analyzed longitudinally. Correlations between scores were assessed by Pearson's correlation. Factors associated with medical residency scores were analyzed by linear regression. RESULTS: Scores of Progress tests from years 1-6 and the Skills and Attitude test showed at least one moderate and significant correlation with each other. The theoretical exam and final exam scores in the medical residency had a moderate correlation with performance in the internship. The score of the theoretical medical residency exam was associated with performance in internship year 6 (ß=0.833; p<0.001), and the final medical residency exam score was associated with the Skills and Attitude score (ß=0.587; p<0.001), 5th-year internship score, (ß=0.060; p=0.025), and 6th-year Progress test score (ß=0.038; p=0.061). CONCLUSIONS: The scores of these tests showed significant correlations. The medical residency exam scores were positively associated with the student's performance in the internship and on the Skills test, with a tendency for the final medical residency exam score to be associated with the 6th-year Progress test.

Factors associated with student performance on the medical residency test

SUMMARY OBJECTIVE: To determine whether the scores of the Progress test, the Skills and Attitude test, and the medical internship are correlated with the medical residency exam performance of students who started medical school at the Federal University of São Paulo in 2009 METHODS: The scores of 684 Progress tests from years 1-6 of medical school, 111 Skills and Attitude exams (5th year), 228 performance coefficients for the 5th and 6th years of internship, and 211 scores on the medical residency exam were analyzed longitudinally. Correlations between scores were assessed by Pearson's correlation. Factors associated with medical residency scores were analyzed by linear regression. RESULTS: Scores of Progress tests from years 1-6 and the Skills and Attitude test showed at least one moderate and significant correlation with each other. The theoretical exam and final exam scores in the medical residency had a moderate correlation with performance in the internship. The score of the theoretical medical residency exam was associated with performance in internship year 6 (β=0.833; p<0.001), and the final medical residency exam score was associated with the Skills and Attitude score (β=0.587; p<0.001), 5th-year internship score, (β=0.060; p=0.025), and 6th-year Progress test score (β=0.038; p=0.061). CONCLUSIONS: The scores of these tests showed significant correlations. The medical residency exam scores were positively associated with the student's performance in the internship and on the Skills test, with a tendency for the final medical residency exam score to be associated with the 6th-year Progress test.

RESUMO OBJETIVO: Analisar a presença de correlação e associação entre as notas dos Testes de Progresso, provas de Habilidades e Atitudes e notas de desempenho no internato em relação às notas de Residência Médica (RM) de alunos ingressantes em 2009 no curso médico da Universidade Federal de São Paulo. MÉTODOS: análise longitudinal de 684 notas de Testes de Progresso do 1º ao 6º ano, 111 de Habilidades e Atitudes (5º ano), 228 coeficientes de rendimento do 5º e 6º anos e 211 notas da Prova de Residência Médica. Analisou-se a correlação de Pearson entre as notas e os fatores associados às notas da RM por regressão linear. RESULTADOS: Os Testes de Progresso do 1º ao 6º ano e Habilidades apresentaram pelo menos uma correlacao moderada e significante entre si. As notas da prova teorica e nota final da RM tiveram correlacao moderada com as notas de desempenho no internato. A nota teorica da Prova de RM se associou ao desempenho no internato no 6º ano (β=0,833; p<0,001) e nota final da Prova de RM se associou as notas da prova de Habilidades e Atitudes (β=0,587; p<0,001), desempenho no 5º ano (β=0,060, p=0,025) e Testes de Progresso do 6º ano (β=0,038; p=0,061). CONCLUSÕES: Houve correlacao significante entre as notas das diversas provas. A nota da prova de Residencia Medica se associou positivamente ao desempenho do aluno no internato e prova de Habilidades, com tendencia de associacao do Teste de Progresso do 6º ano com o desempenho final na prova de RM.

Pattern of respiratory muscle activity during exercise tests in children born prematurely.

INTRODUCTION: Preterm children display only slightly lower exercise capacity than term children do during their development, despite their previous cardiopulmonary impairments. This raises doubts about the role of the respiratory muscles' influence on exercise capacity. This study aimed to compare respiratory muscle activity in preterm and term children using an exercise test. METHODS: This cross-sectional study involved comparison of 35 term children and 39 matched preterm children aged 6-9 years, who were born prematurely with a birth weight <1500 g. An adapted treadmill incremental test was utilized and surface electromyography of the sternocleidomastoid (SCM), upper trapezius (UT), and rectus abdominis (RA) muscles was performed. The root mean square was calculated every minute and compared between and within groups. A Monte Carlo simulation was also applied, and the area under the curve was calculated to evaluate the differences between groups. RESULTS: During the entire exercise, the SCM muscle activity was higher in preterm children with a larger area under the curve than in the term children. There was no difference in the RA and UT muscle activity between groups throughout the test. CONCLUSION: The results suggest a greater contribution of the SCM muscle sin preterm children's performance than in term children's performance during high-intensity exercises. TRIAL REGISTRATION: Brazilian Clinical Trial Registry (ReBec) - RBR-89hr2h.

Aerobic Capacity of Preterm Children with Very Low Birth Weight at School Age and its Associated Factors / Capacidad aeróbica de niños prematuros de muy bajo peso al nacer y edad escolar y sus factores asociados

INTRODUCTION: Respiratory morbidities of preterm infants can cause significant ventilatory impairment thus compromising the aerobic capacity in childhood and adolescence. Therefore, the present study was conducted to evaluate the aerobic capacity in school age preterm children with VLBW and its associated factors. METHODS: A cross-sectional study was conducted among preterm born with VLBW and term children, both aged 6-9 years. An individualized symptom-limited treadmill testing protocol performed aerobic capacity. Measured variables: oxygen pulse (PuO2), percentage of maximum heart rate for age (%HR max), tidal volume/inspiratory capacity ratio (TV/IC), oxygen consumption (VO2) peak, and the ratio of the anaerobic threshold of gas exchange to the predicted percentage of maximum VO2 (VO2@LA/%VO2 max.pred.) were compared between groups. Univariate and multiple linear regression analyses were used to determine the factors associated with aerobic capacity. RESULTS: Thirty-four preterm and 32 term children were included. Similar VO2 peak and the other variables were observed. The development of bronchopulmonary dysplasia (BPD) and being obese/overweight was positively associated with %HR max. The Z-score for height/age and birth weight < 1000 g was positively associated with PuO2 and peak VO2, and negatively associated with overweight/obesity and female sex. CONCLUSIONS: Aerobic capacity was similar in both groups. Sex, development of BPD, birth weight < 1000 g and factors related to body growth, such as Z-score for height/age and overweight/obesity, were associated with aerobic capacity in preterm children with VLBW

INTRODUCCIÓN: Las enfermedades respiratorias de los niños prematuros pueden causar importantes impedimentos ventilatorios que comprometen la capacidad aeróbica en la infancia y en la adolescencia. El presente estudio se llevó a cabo para evaluar la capacidad aeróbica de niños prematuros en edad escolar de muy bajo peso al nacer (BPN) y los factores asociados. MÉTODOS: Se llevó a cabo un estudio transversal con niños prematuros de muy BPN y con niños a término, ambos grupos con edades comprendidas entre los 6 y 9 años. Las siguientes variables se compararon entre los 2 grupos: el pulso de oxígeno (PuO2), el porcentaje de frecuencia cardíaca máxima (%FC máx.), la relación entre el volumen corriente y la capacidad inspiratoria (TV/IC), el consumo pico de oxígeno (VO2) y la relación entre el umbral anaeróbico de intercambio de gas y el porcentaje estimado de VO2 máximo (VO2@LA/%VO2 máx. pred.). Se llevaron a cabo análisis de regresión lineal univariante y multivariante para determinar los factores asociados con la capacidad aeróbica. RESULTADOS: Se incluyeron 34 niños prematuros y 32 niños a término. Se registraron valores similares de VO2 pico y de otras variables. El desarrollo de displasia broncopulmonar (BPD) y de obesidad/sobrepeso mostró una asociación positiva con el %FC máx. El Z-score para la altura/edad y el peso al nacer < 1.000 g se asoció positivamente con la SaO2 y el VO2 y negativamente con el sobrepeso/obesidad y el sexo femenino. CONCLUSIONES: La capacidad aeróbica fue similar entre los 2 grupos. El sexo, el desarrollo de BPD, peso al nacer < 1.000 g y factores relacionados con el crecimiento corporal, tales como el Z-score para la altura/edad y para el sobrepeso/obesidad se asociaron con la capacidad aeróbica en niños prematuros de muy BPN

Aerobic Capacity of Preterm Children with Very Low Birth Weight at School Age and its Associated Factors.

INTRODUCTION: Respiratory morbidities of preterm infants can cause significant ventilatory impairment thus compromising the aerobic capacity in childhood and adolescence. Therefore, the present study was conducted to evaluate the aerobic capacity in school age preterm children with VLBW and its associated factors. METHODS: A cross-sectional study was conducted among preterm born with VLBW and term children, both aged 6-9 years. An individualized symptom-limited treadmill testing protocol performed aerobic capacity. Measured variables: oxygen pulse (PuO2), percentage of maximum heart rate for age (%HR max), tidal volume/inspiratory capacity ratio (TV/IC), oxygen consumption (VO2) peak, and the ratio of the anaerobic threshold of gas exchange to the predicted percentage of maximum VO2 (VO2@LA/%VO2 max.pred.) were compared between groups. Univariate and multiple linear regression analyses were used to determine the factors associated with aerobic capacity. RESULTS: Thirty-four preterm and 32 term children were included. Similar VO2 peak and the other variables were observed. The development of bronchopulmonary dysplasia (BPD) and being obese/overweight was positively associated with %HR max. The Z-score for height/age and birth weight <1000g was positively associated with PuO2 and peak VO2, and negatively associated with overweight/obesity and female sex. CONCLUSIONS: Aerobic capacity was similar in both groups. Sex, development of BPD, birth weight <1000g and factors related to body growth, such as Z-score for height/age and overweight/obesity, were associated with aerobic capacity in preterm children with VLBW.

Association between thoracic musculoskeletal abnormalities and lung function in preterm infants.

INTRODUCTION: In view of the difficulties and risks of performing lung function tests in infants and the hypothesis that children with abnormal pulmonary test may exhibit thoracic musculoskeletal alterations. OBJECTIVES: This study aimed to determine the frequency of abnormal lung function and their relationship. MATERIALS AND METHODS: This was a cross-sectional study with children from 6 to 12 months of corrected age, born at a gestational age of <37 weeks and with a birthweight ≤1500 g, who were subjected to a lung function test and photogrammetry--an objective and non-invasive procedure. To verify the association between the thoracic musculoskeletal abnormalities and measure changes in lung function, univariate linear regression was used. The level of statistical significance was setted at P < 0.05. RESULTS: Of the 38 infants, 12 (31.6%) exhibited abnormal lung function, including 9 (23.7%) with obstructive function and 3 (7.9%) with restrictive function. A significant association was noted between forced expiratory volume at 0.5 second <-2 z score and the acromion/xiphoid process/acromion angle (ß = 4.935); forced vital capacity <-2 z score and the angle of the manubrium/left acromion/trapezium (ß = 0.033) and forced expiratory volume at 0.5 second and forced vital capacity ratio <-2 z score and the inframammillary point/xiphoid process/inframammillary point angle (ß = 0.043). CONCLUSION: Preterm infants with very low birthweight presented a high frequency of abnormal lung function, particularly obstructive type and thoracic musculoskeletal abnormalities were associated with changes in lung function.

Comparative analysis of gross motor coordination between overweight/obese and eutrophic children / Análise comparativa da coordenação motora grossa em crianças com sobrepeso/obesidade e eutróficas / Análisis comparativo de la coordinación motora gruesa en niños con sobrepeso / obesidad y eutróficas

Abstract Introduction: Overweight and obese children may have lower motor coordination score than normal-weight children. Objective: To compare gross motor coordination between overweight/obese and normal-weight children and investigate the associated factors with the motor coordination scores. Method: This cross-sectional study involved 169 children of both genders, aged 6-9 years. Children with malformations, bone, muscle, and joint or neurological disorders, and BMI z < -2 were excluded. Gross motor coordination was assessed by the "Körperkoordinationstest für Kinder" (KTK). The associated factors with the motor coordination scores were analyzed by linear regression. Results: The mean scores for balancing backwards (84.2 ± 13.2 vs. 91.0 ± 15.0), hopping over on one foot (127.9 ± 10.1 vs. 132.3 ± 12.1), shifting platforms sidewise (123.5 ± 23.4 vs. 129.8 ± 14.9), as well as the overall motor scores (112.5 ± 14.8 vs. 118.8 ± 11.6) were significantly lower (p < 0.05) in overweight/obese children when compared to normal-weight children. The percentage of poor motor scores (< 85) in balancing backwards was higher in overweight/obese children (60.4% vs. 36.4%, p = 0.004) and was similar for jumping sideways (18.8% vs. 9.9%, p = 0.116), as well as for shifting platforms sidewise (6.3% vs. 0.8%, p = 0.070). By multiple linear regression analysis, the variables overweight/obesity and sports practice for less than 2 times/week decreased significantly (p < 0.05) the motor coordination score by -18.7 and -15.6 points, respectively. Conclusion: The overweight/obese children scored lower in the motor coordination tests compared to the normal-weight children. Overweight/obesity and low frequency of physical activity were associated with lower scores of gross motor coordination.

Resumo Introdução: Crianças com sobrepeso/obesidade podem ter menores escores de coordenação motora, comparadas às eutróficas. Objetivo: Comparar a coordenação motora grossa entre escolares com sobrepeso/obesidade e eutróficos e analisar os fatores associados aos escores de coordenação motora. Método: Este estudo transversal incluiu crianças de 6-9 anos, de ambos os sexos. Foram excluídas crianças com malformações congênitas, deformidades osteomioarticulares, distúrbios neurológicos ou IMC < -2 escore-z. Avaliou-se a coordenação motora grossa pelos testes Körperkoordinations test für Kinder (KTK). Fatores associados aos escores de coordenação motora foram analisados por regressão linear. Resultado: As médias dos escores na marcha para trás (84,2 ± 13,2 vs. 91,0 ± 15,0), saltos monopedais (127,9 ± 10,1 vs. 132,3 ± 12,1), transferência em plataformas (123,5 ± 23,4 vs. 129,8 ± 14,9) e o escore global dos testes (112,5 ± 14,8 vs. 118,8 ± 11,6) foram significantemente menores (p < 0,05) em crianças com sobrepeso/obesidade, comparadas às eutróficas. A porcentagem de alunos com escore motor deficiente (< 85) foi maior no sobrepeso/obesidade na marcha para trás (60,4% vs. 36,4%, p = 0,004) e semelhantes nos saltos laterais (18,8% vs. 9,9%, p = 0,116) e transferência lateral (6,3% vs. 0,8%, p = 0,070). Na análise de regressão linear múltipla, as variáveis sobrepeso/obesidade e prática de esporte < 2 vezes/semana reduziram significantemente (p < 0,05) o escore motor global em 18,7 e 15,6 pontos, respectivamente. Conclusões: Crianças com sobrepeso/obesidade apresentaram menores escores de coordenação motora que as eutróficas. Sobrepeso/obesidade e baixa frequência de atividade física se associaram a menores escores de coordenação motora grossa.

Resumen Introducción: Niños con sobrepeso/obesidad pueden tener menores escores de coordinación motora, comparados a las eutróficas. Objetivo: Comparar la coordinación motora gruesa entre escolares con sobrepeso/obesidad y eutróficos, y analizar factores asociados a coordinación motora. Método: Este estudio transversal incluyó niños de 6-9 años, de ambos géneros. Se excluyeron: niños con malformaciones congénitas, deformidades osteomioarticulares, trastornos neurológicos o IMC < -2 escore-z. Se evaluó la coordinación motora gruesa por las pruebas Körperkoordinations test für Kinder (KTK). Factores asociados a los escores de coordinación motora fueron analizados por regresión lineal. Resultado: Las medias de los escores en la marcha hacia atrás (84,2 ± 13,2 vs. 91,0 ± 15,0), saltos monopedales (127,9 ± 10,1 vs. 132,3 ± 12,1, transferencia en plataformas (123,5 ± 23,4 vs. 129,8 ± 14,9) y escore global (112,5 ± 14,8 vs. 118,8 ± 11,6) fueron significativamente menores (p < 0,05) en niños con sobrepeso/obesidad, comparados a las eutróficas. El porcentaje de alumnos con escore motor deficiente (< 85) fue mayor en sobrepeso/obesidad en la marcha hacia atrás (60,4% vs. 36,4%, p = 0,004) y similares en los saltos laterales (18,8% vs. 9,9%, p = 0,116) y transferencia lateral (6,3% vs. 0,8%, p = 0,070). En el análisis de regresión lineal múltiple, las variables sobrepeso/obesidad y práctica de deporte < 2 veces/semana redujeron significantemente (p < 0,05) el puntaje motor global en 18,7 y 15,6 puntos, respectivamente. Conclusiones: Niños con sobrepeso/obesidad presentaron menores escores de coordinación motora que las eutróficas. Sobrepeso/obesidad y baja frecuencia de actividad física se asociaron a menores escores de coordinación motora gruesa.

Chlorhexidine: a hidden life-threatening allergen.

Chlorhexidine is a commonly used antiseptic and disinfectant in the health-care setting. Anaphylaxis to chlorhexidine is a rare but potentially life-threatening complication. Epidemiologic data suggest that the cases of chlorhexidine allergy appears to be increasing. In this article we report a life-threatening anaphylactic shock with cardiorespiratory arrest, during urethral catheterization due to chlorhexidine. The authors also performed a literature review of PubMed library of anaphylactic cases reports due to this antiseptic between 2014 and 2018, demonstrating the increase in the number of cases occurring worldwide and the importance of detailed anamnesis and appropriate diagnostic workup of allergic reactions to disinfectants.

BLOOD CELLS PROFILE IN UMBILICAL CORD OF LATE PRETERM AND TERM NEWBORNS.

OBJECTIVE: To describe the hematological profile in cord blood of late preterm and term newborns and compare blood indices according to sex, weight for gestational age and type of delivery. METHODS: Cross-sectional study with late preterm and term newborns in a second-level maternity. Multiple gestation, chorioamnionitis, maternal or fetal hemorrhage, suspected congenital infection, 5-minute Apgar <6, congenital malformations, and Rh hemolytic disease were excluded. Percentiles 3, 5,10, 25, 50, 75, 90, 95 and 97 of blood indices were calculated for both groups. RESULTS: 2,662 newborns were included in the sample, 51.1% males, 7.3% late preterms, 7.8% small for gestational age (SGA) and 81.2% adequate for gestational age (AGA). Mean gestational age was 35.6±1.9 and 39.3±1.0 weeks, respectively, for premature and term neonates. The erythrocytes indices and white blood cells increased from 34-36.9 to 37-41.9 weeks. Basophils and platelets remained constant during gestation. Premature neonates presented lower values ​​of all blood cells, except for lymphocytes and eosinophils. SGA neonates presented higher values ​​of hemoglobin, hematocrit and lower values of leukocytes, neutrophils, bands, segmented, eosinophils, monocytes and platelets. Male neonates presented similar values ​​of erythrocytes and hemoglobin and lower leukocytes, neutrophils, segmented and platelets. Neonates delivered by C-section had lower values ​​of red blood cells and platelets. Chronic or gestational hypertension induced lower number of platelets. CONCLUSIONS: Blood cells increased during gestation, except for platelets and basophils. SGA neonates had higher hemoglobin and hematocrit values and lower leukocytes. Number of platelets was smaller in male SGAs, born by C-section and whose mothers had hypertension.

Visual scanning preferences in low birth weight preterm infants / Preferências de rastreamento visual em prematuros nascidos com baixo peso

Abstract Introduction Few studies have used eye tracking as a screening tool for autism spectrum disorder (ASD) in preterm infants. Objectives To evaluate fixation time on social and non-social figures and percentage of preterm babies who gazed at the images. Methods This was a cross-sectional study of 31 preterm infants born weighing ≤ 2,000 g in which eye gaze was evaluated at 6 months of corrected age. Six boards with social and non-social figures were projected on a computer screen, successively, evaluating time and percentage of preterm babies who gazed at each board. The Modified Checklist for Autism in Toddlers (M-CHAT) was answered at 18 months of corrected age. Results Preterm infants showed longer visual fixation time on social figures compared with non-social images, regardless of the position of the social figure on the board. Similar percentages of preterm infants gazed either at social or non-social figures, at social figures with a direct or an indirect look, and at the eyes or mouth of the social figures. No preterm infant screened positive on the M-CHAT. Conclusion At 6 months of corrected age, preterm infants show the ability to gaze in an eye-tracking test, with preference for social figures, suggesting that this tool could be useful as another screening instrument for ASD.

Resumo Introdução Poucos estudos utilizaram a varredura visual como ferramenta para rastreamento de transtorno do espectro do autismo (TEA) em bebês prematuros. Objetivos Avaliar bebês prematuros quanto ao o tempo de fixação de olhar em figuras sociais e não sociais e a porcentagem deles que olharam para as imagens. Métodos Este estudo transversal incluiu 31 bebês prematuros com ≤ 2.000 g ao nascer, cujo rastreamento visual foi avaliado aos 6 meses de idade corrigida. Seis pranchas com figuras sociais e não sociais foram projetadas em tela de computador, sucessivamente, avaliando-se o tempo e porcentagem de prematuros que olharam para cada prancha. O Modified Checklist for Autism in Toddlers (M-CHAT) foi respondido aos 18 meses de idade corrigida. Resultados Os bebês prematuros apresentaram maior tempo de fixação visual em figuras sociais do que não sociais, independentemente da posição da figura social na prancha. Porcentagens similares de prematuros olharam tanto para figuras sociais como para não sociais, para figuras sociais com olhar direto ou indireto, e para boca ou olhos das figuras sociais. Nenhum prematuro foi rastreado positivamente pelo M-CHAT. Conclusão Aos 6 meses de idade corrigida, prematuros apresentaram habilidade para varredura em teste de rastreamento visual, com preferência por figuras sociais, sugerindo que esta ferramenta pode ser útil como mais um instrumento para rastreamento de TEA.