IAEA survey of paediatric computed tomography practice in 40 countries in Asia, Europe, Latin America and Africa: procedures and protocols.

OBJECTIVE: To survey procedures and protocols in paediatric computed tomography (CT) in 40 less resourced countries. METHODS: Under a project of the International Atomic Energy Agency, 146 CT facilities in 40 countries of Africa, Asia, Europe and Latin America responded to an electronic survey of CT technology, exposure parameters, CT protocols and doses. RESULTS: Modern MDCT systems are available in 77 % of the facilities surveyed with dedicated paediatric CT protocols available in 94 %. However, protocols for some age groups were unavailable in around 50 % of the facilities surveyed. Indication-based protocols were used in 57 % of facilities. Estimates of radiation dose using CTDI or DLP from standard CT protocols demonstrated wide variation up to a factor of 100. CTDI(vol) values for the head and chest were between two and five times those for an adult at some sites. Sedation and use of shielding were frequently reported; immobilisation was not. Records of exposure factors were kept at 49 % of sites. CONCLUSION: There is significant potential for improvement in CT practice and protocol use for children in less resourced countries. Dose estimates for young children varied widely. This survey provides critical baseline data for ongoing quality improvement efforts by the IAEA.

IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America, and Africa: Part 1, frequency and appropriateness.

OBJECTIVE: The purpose of this study was to assess the frequency of pediatric CT in 40 less-resourced countries and to determine the level of appropriateness in CT use. MATERIALS AND METHODS: Data on the increase in the number of CT examinations during 2007 and 2009 and appropriate use of CT examinations were collected, using standard forms, from 146 CT facilities at 126 hospitals. RESULTS: The lowest frequency of pediatric CT examinations in 2009 was in European facilities (4.3%), and frequencies in Asia (12.2%) and Africa (7.8%) were twice as high. Head CT is the most common CT examination in children, amounting to nearly 75% of all pediatric CT examinations. Although regulations in many countries assign radiologists with the main responsibility of deciding whether a radiologic examination should be performed, in fact, radiologists alone were responsible for only 6.3% of situations. Written referral guidelines for imaging were not available in almost one half of the CT facilities. Appropriateness criteria for CT examinations in children did not always follow guidelines set by agencies, in particular, for patients with accidental head trauma, infants with congenital torticollis, children with possible ventriculoperitoneal shunt malfunction, and young children (< 5 years old) with acute sinusitis. In about one third of situations, nonavailability of previous images and records on previously received patient doses have the potential to lead to unnecessary examinations and radiation doses. CONCLUSION: With increasing use of CT in children and a lack of use of appropriateness criteria, there is a strong need to implement guidelines to avoid unnecessary radiation doses to children.

Oncology practice during COVID-19 pandemic: a fast response is the best response.

The first confirmed case of coronavirus disease 2019 (COVID-19) in Brasil was reported on February 25th, 2020, and by April 3rd, 8076 were confirmed in the country. As COVID-19 disease incidence escalates in Brasil, management of cancer patients requires immediate action and oncology clinics are urged to establish a contingency plan. We have installed a COVID-19 Management Committee to elaborate and implement best practices to assist cancer outpatients as well as to provide a safe environment for clinical staff and other employees at the outpatient clinics. The challenges of cancer treatment in the midst of COVID-19 global pandemic highlight the importance of a rapid response by institutions, where organizational structure, strategic planning, agility in guidelines implementation and alternative ways to protect and support clinical staff, employees and patients may be the key to mitigate pandemic effects.

Oncology practice during COVID-19 pandemic: a fast response is the best response

SUMMARY The first confirmed case of coronavirus disease 2019 (COVID-19) in Brasil was reported on February 25th, 2020, and by April 3rd, 8076 were confirmed in the country. As COVID-19 disease incidence escalates in Brasil, management of cancer patients requires immediate action and oncology clinics are urged to establish a contingency plan. We have installed a COVID-19 Management Committee to elaborate and implement best practices to assist cancer outpatients as well as to provide a safe environment for clinical staff and other employees at the outpatient clinics. The challenges of cancer treatment in the midst of COVID-19 global pandemic highlight the importance of a rapid response by institutions, where organizational structure, strategic planning, agility in guidelines implementation and alternative ways to protect and support clinical staff, employees and patients may be the key to mitigate pandemic effects.

RESUMO O primeiro caso confirmado de Doença Associada ao Coronavírus 2019 (COVID-19) no Brasil foi confirmado em 25 de fevereiro de 2020 e em 3 de abril já haviam 8076 casos confirmados no país. A medida que a incidência de COVID-19 aumenta no Brasil, o tratamento de pacientes com câncer exige ação imediata e as clínicas oncológicas são instadas a estabelecer um plano de contingência. Instalamos um Comitê de Manejo de COVID-19 para elaborar e implementar as melhores práticas para ajudar pacientes ambulatoriais com câncer, bem como proporcionar um ambiente seguro para a equipe clínica e outros funcionários das clínicas ambulatoriais. Os desafios do tratamento do câncer em meio à pandemia global do COVID-19 destacam a importância de uma resposta rápida das instituições, onde a estrutura organizacional, o planejamento estratégico, a agilidade na implementação de diretrizes e formas alternativas de proteger e apoiar a equipe clínica, funcionários e pacientes podem ser a chave para mitigar os efeitos da pandemia.

Volume computed tomography air kerma index and image quality evaluation in Brazil.

The aim of this study was to evaluate the image quality of 29 computed tomography (CT) scanners in Brazil and to perform estimations of patient dose and image quality of common CT examinations at these equipment. The volume CT air kerma indexes (C(VOL)) were estimated, using normalised weighted air kerma indexes, supplied by the ImPACT group. The image quality tests were performed using the phantom and accreditation protocol from the American College of Radiology (ACR). The C(VOL) values for head scans varied between 8.7 and 108 mGy. The Hi-res chest examinations presented C(VOL) values varying from 0.4 to 32 mGy. For abdominal scans, the estimated C(VOL) values varied between 4.1 and 94 mGy. This wide variation of air kerma between different centres is related to the scanner type and also to the scanning parameters. The results also showed that the image quality did not attend all ACR CT accreditation requirements.

"Só sabe mesmo quanto é difícil, quem passa... ": as experiências de familiares nos cuidados de crianças e adolescentes em tratamento oncológico / "Only those who go through it really know how difficult it is... ": the experiences of family members caring for children and adolescents undergoing cancer treatment

O câncer infantojuvenil, segundo o Instituto Nacional de Câncer (INCA), constitui-se como a primeira causa de óbitos por doença entre crianças e adolescentes até 19 anos. Essa dissertação teve como objetivo compreender as experiências de familiares nos cuidados de crianças e adolescentes em tratamento oncológico à luz de um referencial teórico que agrega as questões de cuidado e do care com uma interseção entre família, gênero e classe. A pesquisa na modalidade temática foi realizada no setor de Oncologia Pediátrica do INCA, no período de novembro de 2017 a junho de 2018. Tratou-se de pesquisa qualitativa, realizada por meio de trabalho de campo, contendo a observação participante, com registro de notas em diário de campo, e entrevistas. A análise para interpretação dos dados foi inspirada pelo método de interpretação de sentidos proposta por Gomes (2008) utilizado em consonância aos referenciais teóricos supracitados que serviram de base para a pesquisa. Desta forma, os dados foram analisados segundo o contexto, o pertencimento social dos participantes e sua relação com a instituição. Diante de um cenário ambíguo de expectativas, medos e incertezas diante da doença, os relatos dos familiares evidenciaram dificuldades experimentadas com seus entes que se encontram em acompanhamento na instituição, desde o momento inicial do diagnóstico, com a assimilação e aceitação da doença, até o tratamento, em que a dinâmica casa-hospital se apresenta com muitos e variados contornos e arranjos familiares. Por um lado, são frequentes problemas com o deslocamento (longas distâncias dos domicílios à instituição, alto custo para o transporte, longo tempo de espera para acessar transportes municipais etc), que se acirram com as frequentes idas à Instituição. Nesse contexto das dinâmicas familiares, o cuidado às crianças e adolescentes é regulado de forma diferente segundo a divisão sexual do trabalho. Por outro lado, se somam a essas questões outras relativas aos baixos capitais sociais dos sujeitos, com um quadro cada vez mais acirrado de vulnerabilidade que revela precários vínculos trabalhistas, ocupações informais, baixa escolaridade e renda familiar. Diante dessa configuração, muitas das respostas às demandas dos usuários são dadas pelas suas próprias redes de apoio e familiar, pois não há políticas públicas que deem suporte efetivo às necessidades durante o tratamento. Os relatos sobre o cuidado apontam ainda para a forma como o mesmo está inserido em uma perspectiva de gênero. A pesquisa aponta para a necessidade do reconhecimento pela sociedade e pelo Estado do cuidado como um trabalho e como possibilidade da reprodução social que necessita de tempo, gastos financeiros e políticas efetivas de suporte.

According to the National Cancer Institute (INCA), childhood and juvenile cancer is the leading cause of death due to illness among children and adolescents up to 19 years of age. This dissertation aimed to understand the experiences of family members in the care of children and adolescents on cancer treatment based on a theoretical framework that aggregates the issues of care with an intersection between family, gender and class. The qualitative research in the thematic modality was carried out in the Pediatric Oncology sector of INCA, from November 2017 to June 2018. It was a qualitative research, carried out through fieldwork, containing participant observation, with registration of notes in field diary, and interviews. The analysis for interpretation of the data was inspired by the method of interpretation of meanings proposed by Gomes (2008) used in consonance with the aforementioned theoretical references that served as basis for the research. In this way, the data were analyzed according to the context, the social belonging of the participants and their relationship with the institution. In the face of an ambiguous scenario of expectations, fears and uncertainties regarding the disease, the relatives' reports showed difficulties experienced with their kindred that are being monitored in the institution, from the initial diagnosis, with the assimilation and acceptance of the disease, until the treatment, in which the dynamic home-hospital presents itself by many and varied ways and family arrangements. On one hand, there are frequent problems with the displacement (long distances from the households to the institution, high cost for transportation, long waiting time to access municipal transport, etc.), which are aggravated by frequent visits to the Institution. In this context of family dynamics, care for children and adolescents is regulated differently according to the sexual division of labor. On the other hand, there are also other issues related to low social capital of the subjects, with an increasingly intense vulnerability that reveals precarious labor relations, informal occupations, low scholarity and family income. Given this configuration, many of the responses to users' demands are given by their own support and family networks, as there are no public policies that effectively support the needs during treatment. The reports on care also point to the way it is inserted in a gender perspective. The research points to the need for recognition by society and the State of care as a job and as a possibility of social reproduction that requires time, financial expenses and effective support policies. And that the same can not be the responsibility only of the family, and especially of the women who historically assume this work and all the burden that it represents.

Neuropharmacological and genotoxic evaluation of ethanol extract from Erythrina falcata leaves, a plant used in Brazilian folk medicine

The aim of the present study was to determine neurobehavioral and genotoxic activities of ethanol extract of Erythrina falcata Benth., Fabaceae, leaves on rats. Animals were treated with ethanol extract of E. falcata (100, 300 or 500 mg/kg; i.p.) and the open field and elevated plus-maze tasks were used as behavioral models to investigate a possible effect on the locomotor and exploratory activity and anxiety, respectively. Genotoxic effect was investigated using the Comet assay. Ethanol extract of E. falcata leaves decreased the number of crossings and rearings in the open field task and increased the latency to start locomotion, though it was not able to affect habituation to apparatus measured 24h after the first session. Behavioral parameters in the plus-maze test were not affected by E. falcata. Ethanol extract did not increase damage index and damage frequency in blood or brain, indicating no genotoxic effect. The results suggest that ethanol extract of E. falcata leaves was able to affect locomotion, exploration, and motivation of animals without anxiolytic/anxiogenic effect, indicating a possible depressant action on the central nervous system. Furthermore, the lack of DNA damage in brain is an indicative that ethanol extract of E. falcata leaves may not induce neurotoxic effects.

Avaliação do kerma no ar na superfície de entrada e da qualidade da imagem em radiografias de tórax / Evaluation of entrance surface air kerma rate and clinical images quality in chest radiography

OBJETIVO: Avaliar os fatores de técnica utilizados durante exames de tórax póstero-anterior em pacientes-padrão e correlacioná-los aos valores de kerma no ar na superfície de entrada e à qualidade das imagens clínicas. MATERIAIS E MÉTODOS: O estudo foi realizado em três hospitais do Rio de Janeiro, num total de cinco salas de raios X, com dez pacientes por sala. As imagens foram avaliadas pelos radiologistas dos serviços segundo o protocolo europeu. O kerma no ar na superfície de entrada foi estimado a partir da curva de rendimento do equipamento de raios X, que foi obtida utilizando câmara de ionização acoplada a um eletrômetro. Análise de variância foi realizada para verificar se a diferença entre os valores de kerma no ar na superfície de entrada é significativa. RESULTADOS: Os valores de kerma no ar na superfície de entrada variaram entre 0,05 e 0,26 mGy, com média 60 por cento inferior ao nível de referência publicado na Portaria 453. Das imagens avaliadas, 98 por cento atenderam acima de 65 por cento dos critérios de qualidade. CONCLUSÃO: Para um padrão de qualidade da imagem, aceitável para o diagnóstico, verificou-se ampla variação do kerma no ar na superfície de entrada para pacientes-padrão. Isto demonstra a falta de padronização dos fatores de técnica e a existência de um potencial de redução do valor do kerma no ar na superfície de entrada.

OBJECTIVE: To evaluate technical factors involved in posteroanterior chest radiography in standard patients, and correlating them with entrance surface air kerma rate and with the clinical images quality. MATERIALS AND METHODS: The present study was developed at three hospitals in Rio de Janeiro, Brazil, involving a total of five x-ray rooms, with ten patients per room. The images were evaluated by the radiologists of the institutions, in accordance with the European protocol. The estimation of surface entrance air kerma rate was based on the x-ray equipment output curve obtained with an ionization chamber coupled with an electrometer. Variance analysis was performed to evaluate the significance of the difference between entrance surface air kerma rates. RESULTS: Entrance surface air kerma rates ranged between 0.05 and 0.26 mGy, with a mean value 60 percent lower than the reference level established by the Order (Portaria) 453. Among the images evaluated, 98 percent fulfilled > 65 percent of the images quality criteria. CONCLUSION: For a standard image quality that is acceptable for diagnosis purposes, a significant variation was observed in the entrance surface air kerma rate for standard patients, demonstrating the lack of technical factors standardization and a potential for decreasing the entrance surface air kerma rate.

[Anesthetic management for neonatal conjoined twins separation: case report.]. / Anestesia para separação de gêmeos isquiópagos no período neonatal: relato de caso.

BACKGROUND AND OBJECTIVES: The separation of conjoined twins has always raised considerable interest because of surgical and anesthetic complexity, pathology rarity and few survival chances. The goal of this description was to contribute to existing literature by reporting the challenges faced by our team during an anesthetic-surgical procedure for ischiopagus twins separation. CASE REPORT: Term conjoined twins, born from Cesarean section, weighing together 5100 g, who were classified as ischiopagus tetrapus. Two anesthetic-surgical teams were present and the anesthetic procedure was programmed using two units of each device: anesthesia machine, cardioscope, capnograph, pulse oximetry, electric thermometer and esophageal stethoscope. Halothane and fentanyl were used for anesthesia induction, with the twins in the lateral position and 45 masculine head rotation to allow tracheal intubation. Ventilation was manually controlled using Rees-Baraka systems. Anesthesia was also maintained with halothane, fentanyl and oxygen. Double abdominal organs were found during surgery, except for the single colon. Bladders and ischia were joined. At surgery completion, twins had stable vital signs. They remained in Neonatal Intensive Care Unit for four weeks and were discharged in good general conditions. CONCLUSIONS: The importance of the teams 'meshing of gears', multidisciplinary retrospective studies, adequate and careful monitoring and good clinical observation is emphasized. All those factors contributed for twins good evolution.

Anestesia para separaçäo de gêmeos isquiópagos no período neonatal: relato de caso / Anesthetic management for neonatal conjoined twins separation: case report

Justificativa e objetivos - A separaçäo de gêmeos unidos causa grande interesse devido à complexidade da anestesia e cirurgia, à raridade da patologia e às poucas chances de sobrevida. O objetivo desta descriçäo é o de contribuir para a literatura existente, relatando os desafios encontrados por nossa equipe no atendimento à cirurgiaðanestesia de separaçäo de gêmeos isquiópagos. Relato de caso - Pacientes gêmeos, nascidos a termo, de parto cesariano, pesando juntos 5.100 g. classificados como isquiópagus tetrapus. Duas equipes anestésico-cirúrgicas estavam presentes, sendo o procedimento anestésico esquematizado com aparelho de anestesia, cardioscópio, capnógrafo, oxímetro de pulso, termômetro elétrico, estetoscópio esofágico, todos em dobro. Realizou-se induçäo anestésica com halotano e fentanil, com os gêmeos em posiçäo lateral e com rotaçäo da cabeça em 45º para facilitar a intubaçäo traqueal. Os recém-nascidos foram mantidos em ventilaçäo controlada manualmente, utilizando o sistema de Rees-Baraka. A anestesia foi mantida com halotano, oxigênio e fentanil. Durante o per-operatório, foram encontrados órgäos abdominais duplos, com exceçäo do cólon, que era único. As bexigas e os isquios estavam ligados. Ao final da cirurgia as duas crianças apresentavam-se com sinais vitais estáveis. Os gêmeos permaneceram na Unidade de Terapia Intensiva (UTI) Neonatal por quatro semanas e receberam alta em bom estado geral. Conclusões - Ressalta-se a importância do entrosamento da equipe, do estudo retrospectivo multidisciplinar, da monitorizaçäo adequada e acurada observaçäo clínica; todos esses fatos contribuíram para a boa evoluçäo e alta dos gêmeos

Doença de Legg-Calvé-Perthes em gêmeos heterozigóticos / Legg-Calvé-Perthes disease in heterozygotic twins

A ocorrência familiar da doença de Legg-Calvé-Perthes foi descrita por alguns autores, existendo controvérsia sobre a hereditáriedade como agente etiológico desta patologia. Os autores relatam o caso de aparecimento da doença de Legg-Calvé-Perthes em gêmeos heterozigóticos; o diagnóstico em um deles foi obtido após a realização de cintilografia óssea.

Determinaçäo das taxas de dose absorvida de aplicadores de 90Sr+90Y / Determination of absorbed dose rates from applicators of 90Sr+90Y

As taxas de dose superficial de dois aplicadores dermatológicos foram determinadas utilizando uma câmara de extrapolação projetada e construída no Laboratório de Calibração do IPEN. Apresenta-se neste trabalho a comparação entre as calibrações realizadas no IPEN e pelo fabricante.