Fatores associados ao óbito em casos confirmados de COVID-19 no estado do Rio de Janeiro.

BACKGROUND: COVID-19 can occur asymptomatically, as influenza-like illness, or as more severe forms, which characterize severe acute respiratory syndrome (SARS). Its mortality rate is higher in individuals over 80 years of age and in people with comorbidities, so these constitute the risk group for severe forms of the disease. We analyzed the factors associated with death in confirmed cases of COVID-19 in the state of Rio de Janeiro. This cross-sectional study evaluated the association between individual demographic, clinical, and epidemiological variables and the outcome (death) using data from the Unified Health System information systems. METHODS: We used the extreme boosting gradient (XGBoost) model to analyze the data, which uses decision trees weighted by the estimation difficulty. To evaluate the relevance of each independent variable, we used the SHapley Additive exPlanations (SHAP) metric. From the probabilities generated by the XGBoost model, we transformed the data to the logarithm of odds to estimate the odds ratio for each independent variable. RESULTS: This study showed that older individuals of black race/skin color with heart disease or diabetes who had dyspnea or fever were more likely to die. CONCLUSIONS: The early identification of patients who may progress to a more severe form of the disease can help improve the clinical management of patients with COVID-19 and is thus essential to reduce the lethality of the disease.

Association between socio-environmental factors, coverage by family health teams, and rainfall in the spatial distribution of Zika virus infection in the city of Rio de Janeiro, Brazil, in 2015 and 2016.

BACKGROUND: Zika virus (ZIKV) infection caused outbreak in Brazil, in 2015 and 2016. Disorganized urban growth, facilitates the concentration of numerous susceptible and infected individuals. It is useful to understand the mechanisms that can favor the increase in ZIKV incidence, such as areas with wide socioeconomic and environmental diversity. Therefore, the study analyzed the spatial distribution of ZIKV in the city of Rio de Janeiro, Brazil, in 2015 and 2016, and associations between the incidence per 1000 inhabitants and socio-environmental factors. METHODS: The census tracts were used as the analytical units reported ZIKV cases among the city's inhabitants. Local Empirical Bayesian method was used to control the incidence rates' instability effect. The spatial autocorrelation was verified with Moran's Index and local indicators of spatial association (LISA). Spearman correlation matrix was used to indicate possible collinearity. The Ordinary Least Squares (OLS), Spatial Lag Model (SAR), and Spatial Error Model (CAR) were used to analyze the relationship between ZIKV and socio-environmental factors. RESULTS: The SAR model exhibited the best parameters: R2 = 0.44, Log-likelihood = - 7482, Akaike Information Criterion (AIC) = 14,980. In this model, mean income between 1 and 2 minimum wages was possible risk factors for Zika occurrence in the localities. Household conditions related to adequate water supply and the existence of public sewage disposal were associated with lower ZIKV cumulative incidence, suggesting possible protective factors against the occurrence of ZIKV in the localities. The presence of the Family Health Strategy in the census tracts was positively associated with the ZIKV cumulative incidence. However, the results show that mean income less than 1 minimum wage were negatively associated with higher ZIKV cumulative incidence. CONCLUSION: The results demonstrate the importance of socio-environmental variables in the dynamics of ZIKV transmission and the relevance for the development of control strategies.

Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care.

OBJECTIVE: To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. METHODS: Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0-18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates. RESULTS: The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23-2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17-79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70-0.98); specificity, 0.76 (95%CI: 0.75-0.76); NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 23.0%, and undertriage, 11.5%. CONCLUSION: This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.

Spatial-temporal distribution of incidence, mortality, and case-fatality ratios of coronavirus disease 2019 and its social determinants in Brazilian municipalities.

The COVID-19 pandemic caused impact on public health worldwide. Brazil gained prominence during the pandemic due to the magnitude of disease. This study aimed to evaluate the spatial-temporal dynamics of incidence, mortality, and case fatality of COVID-19 and its associations with social determinants in Brazilian municipalities and epidemiological week. We modeled incidence, mortality, and case fatality rates using spatial-temporal Bayesian model. "Bolsa Família Programme" (BOLSAFAM) and "proportional mortality ratio" (PMR) were inversely associated with the standardized incidence ratio (SIR), while "health insurance coverage" (HEALTHINSUR) and "Gini index" were directly associated with the SIR. BOLSAFAM and PMR were inversely associated with the standardized mortality ratio (SMR) and standardized case fatality ratio (SCFR). The highest proportion of excess risk for SIR and the SMR started in the North, expanding to the Midwest, Southeast, and South regions. The highest proportion of excess risk for the SCFR outcome was observed in some municipalities in the North region and in the other Brazilian regions. The COVID-19 incidence and mortality in municipalities that most benefited from the cash transfer programme and with better social development decreased. The municipalities with a higher proportion of non-whites had a higher risk of becoming ill and dying from the disease.

Association of development quotient with nutritional status of vitamins B6, B12, and folate in 6-59-month-old children: Results from the Brazilian National Survey on Child Nutrition (ENANI-2019).

BACKGROUND: Vitamins B6, B12, and folate are essential for the formation and maintenance of the human brain, but studies evaluating these vitamins with early childhood development (ECD) in children under 5 y are limited and controversial. OBJECTIVES: To evaluate the association between vitamins B6, B12, and folate concentrations/status and ECD. METHODS: Data regarding 6520 children aged 6-59 mo from the ENANI-2019 (the Brazilian National Survey on Child Nutrition) were analyzed. ECD was assessed using the Survey of Well-being of Young Children's milestones questionnaire. Vitamin B6 concentration (nmol/L) was classified according to the tertile of the distribution and with the cutoff <20 nmol/L. Folate concentrations >45.3 nmol/L were classified as high, and vitamin B12 <150 pmol/L was deficient. The graded response model was used to estimate developmental age, and the developmental quotient (DQ) was calculated as the developmental age divided by chronological age. Multiple linear regression models were adjusted for confounders. RESULTS: The DQ mean (95% confidence interval) for Brazilian children was 0.99 (0.97-1.01). Children aged 6-23 mo [1.13 (1.10-1.16)] had a higher DQ mean than those aged 24-35 [0.99 (0.95-1.03)] and 36-59 mo [0.89 (0.86-0.92)]. Child age was inversely associated with DQ (ß = -0.007; P < 0.001). An interaction between child age and vitamin B12 deficiency in the DQ (ß = -0.005; P < 0.001) indicated that, in children aged 36-59 mo, the DQ was markedly lower in children with vitamin B12 deficiency than in those without vitamin B12 deficiency. Vitamin B6 concentrations were directly associated with the DQ (ß = 0.0004; P = 0.031) among children aged 24-59 mo in the adjusted model. No association was observed between folate status and DQ. CONCLUSIONS: In Brazil, the DQ is lower among older children and those with vitamin B12 deficiency. Vitamin B6 status was directly associated with the DQ in children aged 24-59 mo.

Malnutrition in mother-child dyads in the Brazilian National Survey on Child Nutrition (ENANI-2019).

Malnutrition affects billions of individuals worldwide and represents a global health challenge. This study aimed to determine the prevalence of malnutrition (undernutrition or overweight) among mother-child dyads in children under 5 years old in Brazil in 2019 and to estimate changes in this prevalence from 2006 to 2019. Individual-level data from the Brazilian National Survey on Child Nutrition (ENANI-2019) and the Brazilian National Survey of Demography and Health of Women and Children carried out in 2006 (PNDS 2006) were analyzed. Malnutrition outcomes in mother-child dyads included overweight mother and child, undernourished mother and child, and the double burden of malnutrition, i.e., overweight mother and child having any form of undernourishment (stunting, wasting, or underweight). Prevalence and 95% confidence intervals (95%CI) were estimated. Most women (58.2%) and 9.7% of the children were overweight, 6.9% were stunted, and 3.1% of mothers and 2.9% of the children were underweight. The prevalence of overweight in the mother-child dyad was 7.8% and was statistically higher in Southern Brazil (9.7%; 95%CI: 7.5; 11.9) than in the Central-West (5.4%; 95%CI: 4.3; 6.6). The prevalence of overweight mother and stunted child was 3.5%, with statistically significant difference between the extremes of the mother's education [0-7 vs. ≥ 12 years, 4.8% (95%CI: 3.2; 6.5) and 2.1%, (95%CI: 1.2; 3.0), respectively]. Overweight in the dyad increased from 5.2% to 7.8%, and the double burden of malnutrition increased from 2.7% to 5.2% since 2006. Malnutrition in Brazilian mother-child dyads seems to be a growing problem, and dyads with lower formal education, higher maternal age, and from the South Region of Brazil were more vulnerable.

Validity of the computerized version of the pediatric triage system CLARIPED for emergency care.

OBJECTIVE: To evaluate the validity of the computerized version of the pediatric triage system CLARIPED. METHODS: Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed. RESULTS: 19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. CONCLUSION: The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.

SARS due to COVID-19: Predictors of death and profile of adult patients in the state of Rio de Janeiro, 2020.

INTRODUCTION: We aimed to describe the profile of adult patients and analyze the predictors of death from severe acute respiratory syndrome (SARS) due to coronavirus disease 2019 (COVID-19) in the state of Rio de Janeiro. Knowledge of the predictors of death by COVID-19 in Rio de Janeiro, a state with one of the highest mortality rates in Brazil, is essential to improve health care for these patients. METHODS: Data from the Information System for Epidemiological Surveillance of Influenza and the Mortality Information System were used. A binary logistic regression model evaluated the outcome of death, sociodemographic data, and clinical-epidemiological and health care covariates. Univariate, bivariate, and multivariate statistics were performed with the R program, version 4.0.0. RESULTS: Overall, 51,383 cases of SARS due to COVID-19 among adults were reported in the state between March 5 and December 2, 2020. Mortality was high (40.5%). The adjusted final model presented the following predictors of death in SARS patients due to COVID-19: male sex (odds ratio [OR] = 1.10, 95% confidence interval [CI], 1.04-1.17); age (OR = 5.35, 95%CI, 4.88-5.88; ≥75 years); oxygen saturation <95% (OR = 1.48, 95%CI, 1.37-1.59), respiratory distress (OR = 1.31, 95%CI, 1.21-1.41) and dyspnoea (OR = 1.25, 95%CI, 1.15-1.36), the presence of at least one risk factor/comorbidity (OR = 1.32, 95%CI, 1.23-1.42), chronic kidney disease (OR = 1.94, 95%CI, 1.69-2.23), immunosuppression (OR = 1.51, 95%CI, 1.26-1.81) or chronic neurological disease (OR = 1.36, 95%CI, 1.18-1.58), and ventilatory support, invasive (OR = 8.89, 95%CI, 8.08-9.79) or non-invasive (OR = 1.25, 95%CI, 1.15-1.35). CONCLUSIONS: Factors associated with death were male sex, old age, oxygen saturation <95%, respiratory distress, dyspnoea, chronic kidney and neurological diseases, immunosuppression, and use of invasive or noninvasive ventilatory support. Identifying factors associated with disease progression can help the clinical management of patients with COVID-19 and improve outcomes.

Diabetes and hypertension are associated with lowered cognitive performance among middle-aged Brazilian adults: cross-sectional analyses nested in the longitudinal Pró-Saúde study.

BACKGROUND: Cardiovascular risk factors are frequently associated with lowered cognitive performance among elderly people, but rarely among middle-aged adults. OBJECTIVES: To investigate associations between cardiovascular risk factors (age, physical inactivity, smoking, alcohol use, hypertension and diabetes) and lower cognitive performance among middle-aged (45-64 years) Brazilian adults. DESIGN AND SETTING: Cross-sectional study nested within the Pró-Saúde cohort. From 2,876 baseline study participants (1999), we randomly selected 488 participants and gave them validated and standardized cognitive tests (2012). METHODS: We used multiple linear and logistic regression analyses to detect associations of cardiovascular risk factors with crude scores in cognitive tests on memory (word test) and executive function (verbal fluency tests), and with overall cognitive performance scores, respectively. RESULTS: All cognitive test scores presented statistically significant inverse associations with age and direct associations with education. There was no association between lower cognitive performance and smoking or alcohol use. In both 1999 and 2012, after adjusting for sex, age and schooling, being physically active was inversely associated with lower performance regarding late memory. For individuals with diabetes in 1999, there was an association with lower performance regarding executive function, while there was a borderline association for those reporting it only in 2012. Having a diagnosis of hypertension since 1999 was associated with lower performance regarding both memory and executive functions, while reporting hypertension in 2012 was associated with lower performance regarding executive function. CONCLUSIONS: Aging, low schooling and cardiovascular risk factors may represent life course disadvantages associated with cognitive decline even among middle-aged Brazilian adults.

Fetal, neonatal, and infant outcomes associated with maternal Zika virus infection during pregnancy: A systematic review and meta-analysis.

The occurrence of fetal and neonatal disorders in pregnant women with Zika virus infection in the literature is not consistent. This study aims to estimate the prevalence rate of these disorders in fetuses/neonates of pregnant women with confirmed or probable infection by Zika virus. A systematic review with meta-analysis was conducted in November 2020. Cohort studies that contained primary data on the prevalence of unfavorable outcomes in fetuses or neonates of women with confirmed or probable Zika virus infection during pregnancy were included. A total of 21 cohort studies were included, with a total of 35,568 pregnant women. The meta-analysis showed that central nervous system abnormalities had the highest prevalence ratio of 0.06 (95% CI 0.03-0.09). Intracranial calcifications had a prevalence ratio of 0.01 (95% CI 0.01-0.02), and ventriculomegaly 0.01 (95% CI 0.01-0.02). The prevalence ratio of microcephaly was 0.03 (95% CI 0.02-0.05), fetal loss (miscarriage and stillbirth) was 0.04 (95% CI 0.02-0.06), Small for Gestational Age was 0.04 (95% CI 0.00-0,09), Low Birth Weight was 0.05 (95% CI 0.03-0.08) and Prematurity was 0.07 (95% CI 0.04-0.10). The positivity in RT-PCR for ZIKV performed in neonates born to infected mothers during pregnancy was 0.25 (95% CI 0.06-0.44). We also performed the meta-analysis of meta-analysis for microcephaly with the prevalence ratios from other two previously systematic reviews: 0.03 (95% CI 0.00-0.25). Our results contribute to measuring the impact of Zika virus infection during pregnancy on children's health. The continuous knowledge of this magnitude is essential for the implementation development of health initiatives and programs, in addition to promoting disease prevention, especially in the development of a vaccine for Zika virus. PROSPERO protocol registration: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125543.

Spatial analysis of COVID-19 incidence and the sociodemographic context in Brazil.

BACKGROUND: Identified in December 2019 in the city of Wuhan, China, the outbreak of COVID-19 spread throughout the world and its impacts affect different populations differently, where countries with high levels of social and economic inequality such as Brazil gain prominence, for understanding of the vulnerability factors associated with the disease. Given this scenario, in the absence of a vaccine or safe and effective antiviral treatment for COVID-19, nonpharmacological measures are essential for prevention and control of the disease. However, many of these measures are not feasible for millions of individuals who live in territories with increased social vulnerability. The study aims to analyze the spatial distribution of COVID-19 incidence in Brazil's municipalities (counties) and investigate its association with sociodemographic determinants to better understand the social context and the epidemic's spread in the country. METHODS: This is an analytical ecological study using data from various sources. The study period was February 25 to September 26, 2020. Data analysis used global regression models: ordinary least squares (OLS), spatial autoregressive model (SAR), and conditional autoregressive model (CAR) and the local regression model called multiscale geographically weighted regression (MGWR). FINDINGS: The higher the GINI index, the higher the incidence of the disease at the municipal level. Likewise, the higher the nurse ratio per 1,000 inhabitants in the municipalities, the higher the COVID-19 incidence. Meanwhile, the proportional mortality ratio was inversely associated with incidence of the disease. DISCUSSION: Social inequality increased the risk of COVID-19 in the municipalities. Better social development of the municipalities was associated with lower risk of the disease. Greater access to health services improved the diagnosis and notification of the disease and was associated with more cases in the municipalities. Despite universal susceptibility to COVID-19, populations with increased social vulnerability were more exposed to risk of the illness.

Improvement of 1st-hour bundle compliance and sepsis mortality in pediatrics after the implementation of the surviving sepsis campaign guidelines.

OBJECTIVES: To study the impact of the implementation of the Pediatric Surviving Sepsis Campaign protocol on early recognition of sepsis, 1-h treatment bundle and mortality. METHODS: Retrospective, single-center study, before and after the implementation of the sepsis protocol. OUTCOMES: sepsis recognition, compliance with the 1-h bundle (fluid resuscitation, blood culture, antibiotics), time interval to fluid resuscitation and antibiotics administration, and mortality. Patients with febrile neutropenia were excluded. The comparisons between the periods were performed using non-parametric tests and odds ratios or relative risk were calculated. RESULTS: We studied 84 patients before and 103 after the protocol implementation. There was an increase in sepsis recognition (OR 21.5 [95% CI: 10.1-45.7]), in the compliance with the 1-h bundle as a whole (62% x 0%), and with its three components: fluid resuscitation (OR 31.1 [95% CI: 3.9-247.2]), blood culture (OR 15.9 [95% CI: 3.9-65.2]), and antibiotics (OR 35.6 [95% CI: 8.9-143.2]). Significant reduction between sepsis recognition to fluid resuscitation (152min×12min, p<0.001) and to antibiotics administration (137min×30min) also occurred. The risk of death before protocol implementation was four times greater (RR 4.1 [95% CI: 1.2-14.4]), and the absolute death risk reduction was 9%. CONCLUSION: Even if we considered the low precision of some estimates, the lower limits of the Confidence Intervals show that the implementation of the Pediatric Surviving Sepsis Campaign guidelines alongside a qualitive assurance initiative has led to improvements in sepsis recognition, compliance with the 1-h treatment bundle, reduction in the time interval to fluid resuscitation and antibiotics, and reduction in sepsis mortality.

Pediatric patients with COVID-19 admitted to intensive care units in Brazil: a prospective multicenter study.

OBJECTIVE: To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19. METHOD: Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March-May 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity. RESULTS: Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43-21.12; p = 0.01). CONCLUSIONS: In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.

Viral detection profile in children with severe acute respiratory infection.

OBJECTIVES: The role of viral co-detection in children with severe acute respiratory infection is not clear. We described the viral detection profile and its association with clinical characteristics in children admitted to the Pediatric Intensive Care Unit (PICU) during the 2009 influenza A(H1N1) pandemic. METHOD: Longitudinal observational retrospective study, with patients aged 0-18 years, admitted to 11 PICUs in Rio de Janeiro, with suspected H1N1 infection, from June to November, 2009. The results of respiratory samples which were sent to the Laboratory of Fiocruz/RJ and clinical data extracted from specific forms were analyzed. RESULTS: Of 71 samples, 38% tested positive for H1N1 virus. Of the 63 samples tested for other viruses, 58 were positive: influenza H1N1 (43.1% of positive samples), rhinovirus/enterovirus (41.4%), respiratory syncytial vírus (12.1%), human metapneumovirus (12.1%), adenovirus (6.9%), and bocavirus (3.5%). Viral codetection occured in 22.4% of the cases. H1N1-positive patients were of a higher median age, had higher frequency of fever, cough and tachypnea, and decreased leukometry when compared to H1N1-negative patients. There was no difference in relation to severity outcomes (number of organic dysfunctions, use of mechanical ventilation or amines, hospital/PICU length of stay or death). Comparing the groups with mono-detection and co-dection of any virus, no difference was found regarding the association with any clinical variable. CONCLUSIONS: Other viruses can be implicated in SARI in children. The role of viral codetection has not yet been completely elucidated.

VALIDITY AND RELIABILITY OF A NEW TRIAGE SYSTEM FOR PEDIATRIC EMERGENCY CARE: CLARIPED. / VALIDADE E CONFIABILIDADE DE UM NOVO SISTEMA DE CLASSIFICAÇÃO DE RISCO PARA EMERGÊNCIAS PEDIÁTRICAS: CLARIPED.

OBJECTIVE: To assess the validity and reliability of a triage system for pediatric emergency care (CLARIPED) developed in Brazil. METHODS: Validity phase: prospective observational study with children aged 0 to 15 years who consecutively visited the pediatric emergency department (ED) of a tertiary hospital from July 2 to 18, 2013. We evaluated the association of urgency levels with clinical outcomes (resource utilization, ED admission rate, hospitalization rate, and ED length of stay); and compared the CLARIPED performance to a reference standard. Inter-rater reliability phase: a convenience sample of patients who visited the pediatric ED between April and July 2013 was consecutively and independently double triaged by two nurses, and the quadratic weighted kappa was estimated. RESULTS: In the validity phase, the distribution of urgency levels in 1,416 visits was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5% yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The percentage of patients who used two or more resources decreased from the orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%, respectively, p<0.0001), as did the ED admission rate, ED length of stay, and hospitalization rate. The sensitivity to identify patients with high urgency level was 0.89 (confidence interval of 95% [95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater reliability in 191patients classified by two nurses was substantial (kw2=0.75; 95%CI 0.74-0.79). CONCLUSIONS: The CLARIPED system showed good validity and substantial reliability for triage in a pediatric emergency department.

OBJETIVO: Avaliar a validade e a confiabilidade de um sistema de classificação de risco para emergências pediátricas (CLARIPED) desenvolvido no Brasil. MÉTODOS: Fase de validade: estudo observacional prospectivo em crianças de 0 a 15anos atendidas consecutivamente no serviço de emergência pediátrica (SEP) de um hospital terciário entre 2 e 18de julho de 2013. Avaliou-se a associação dos níveis de urgência com desfechos clínicos (utilização de recursos, taxa de admissão no SEP, taxa de hospitalização e tempo de permanência no SEP); e comparou-se o desempenho do CLARIPED com um padrão de referência. Fase de confiabilidade interobservadores: uma amostra de conveniência de pacientes atendidos entre abril e julho de 2013 foi submetida a duas classificações de risco consecutivas e independentes, e estimou-se o Kappa ponderado quadrático. RESULTADOS: Em 1.416 atendimentos realizados na fase de validade, a distribuição de níveis de urgência foi: 0,0% vermelho/emergência; 5,9% laranja/muito urgente; 40,5% amarelo/urgente; 50,6% verde/pouco urgente; e 3,0% azul/sem urgência. Ospercentuais de pacientes que usaram dois ou mais recursos diminuíram do nível laranja para o amarelo, verde e azul (81, 49, 22 e 2%, respectivamente, p<0,0001), assim como a taxa de admissão no SEP, o tempo de permanência no SEP e a taxa de admissão hospitalar. Asensibilidade para discriminar pacientes muito urgentes foi de 0,89 (intervalo de confiança de 95%- IC95% 0,78-0,95), e a taxa de subtriagem foi de 7,4%. Aconfiabilidade interobservadores em 191 pacientes classificados por duas enfermeiras foi substancial (kw2=0,75; IC95% 0,74-0,79). CONCLUSÕES: O sistema CLARIPED mostrou boa validade e substancial confiabilidade para classificação de risco em um serviço de emergência pediátrica.

Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care

Abstract Objective To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. Methods Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0-18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates. Results The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23-2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17-79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70-0.98); specificity, 0.76 (95%CI: 0.75-0.76); NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 23.0%, and undertriage, 11.5%. Conclusion This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.

Malnutrition in mother-child dyads in the Brazilian National Survey on Child Nutrition (ENANI-2019) / Má nutrição em díades mãe-filho no Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019) / Malnutrición en díadas madre-hijo en el Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019)

Abstract: Malnutrition affects billions of individuals worldwide and represents a global health challenge. This study aimed to determine the prevalence of malnutrition (undernutrition or overweight) among mother-child dyads in children under 5 years old in Brazil in 2019 and to estimate changes in this prevalence from 2006 to 2019. Individual-level data from the Brazilian National Survey on Child Nutrition (ENANI-2019) and the Brazilian National Survey of Demography and Health of Women and Children carried out in 2006 (PNDS 2006) were analyzed. Malnutrition outcomes in mother-child dyads included overweight mother and child, undernourished mother and child, and the double burden of malnutrition, i.e., overweight mother and child having any form of undernourishment (stunting, wasting, or underweight). Prevalence and 95% confidence intervals (95%CI) were estimated. Most women (58.2%) and 9.7% of the children were overweight, 6.9% were stunted, and 3.1% of mothers and 2.9% of the children were underweight. The prevalence of overweight in the mother-child dyad was 7.8% and was statistically higher in Southern Brazil (9.7%; 95%CI: 7.5; 11.9) than in the Central-West (5.4%; 95%CI: 4.3; 6.6). The prevalence of overweight mother and stunted child was 3.5%, with statistically significant difference between the extremes of the mother's education [0-7 vs. ≥ 12 years, 4.8% (95%CI: 3.2; 6.5) and 2.1%, (95%CI: 1.2; 3.0), respectively]. Overweight in the dyad increased from 5.2% to 7.8%, and the double burden of malnutrition increased from 2.7% to 5.2% since 2006. Malnutrition in Brazilian mother-child dyads seems to be a growing problem, and dyads with lower formal education, higher maternal age, and from the South Region of Brazil were more vulnerable.

Resumo: A má nutrição afeta bilhões de indivíduos em todo o mundo e representa um desafio de saúde global. Este estudo teve como objetivo determinar a prevalência de má nutrição (desnutrição ou excesso de peso) entre díades mãe-filho em crianças menores de cinco anos no Brasil em 2019 e estimar as mudanças nessa prevalência de 2006 a 2019. Foram analisados dados individuais do Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019) e da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher realizada em 2006 (PNDS 2006). Os desfechos de má nutrição incluíram mãe e filho com excesso de peso, mãe e filho desnutridos e a dupla carga de má nutrição, ou seja, mãe com excesso de peso e filho com qualquer forma de desnutrição (défict de crescimento, magreza ou baixo peso). Foram estimadas a prevalência e os intervalos de 95% de confiança (IC95%). A maioria das mulheres (58,2%) e 9,7% das crianças estavam acima do peso, 6,9% apresentaram déficit de crescimento e 3,1% das mães e 2,9% das crianças estavam abaixo do peso. A prevalência de excesso de peso na díade mãe-filho foi de 7,8% e foi estatisticamente maior no Sul do Brasil (9,7%; IC95%: 7,5; 11,9) do que no Centro-oeste (5,4%; IC95%: 4,3; 6,6). A prevalência de mãe com sobrepeso e filho com déficit de crescimento foi de 3,5%, com uma diferença estatisticamente significante entre os extremos de escolaridade materna [(0-7 vs. ≥ 12 anos de estudo), 4,8% (IC95%: 3,2; 6,5) and 2,1% (IC95%: 1,2; 3,0), respectivamente]. O excesso de peso na díade aumentou de 5,2% para 7,8% e a dupla carga de má nutrição aumentou de 2,7% para 5,2% desde 2006. A má nutrição nas díades mãe-filho brasileiras parece ser um problema crescente, sendo as mais vulneráveis aquelas com menor escolaridade e maior idade materna e residentes na Região Sul do Brasil.

Resumen: La malnutrición afecta a muchas personas en todo el mundo y representa un desafío para la salud mundial. Este estudio tuvo como objetivo determinar la prevalencia de malnutrición (desnutrición o sobrepeso) entre díadas madre-hijo en niños menores de cinco años en Brasil en 2019 y estimar cambios en esta prevalencia de 2006 a 2019. Se analizaron datos individuales del Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019) y de la Encuesta Nacional de Demografía y Salud del Niño y de la Mujer de 2006 (PNDS 2006). Los resultados de la malnutrición incluyeron a madre e hijo con sobrepeso, madre e hijo desnutridos y la doble carga de mala nutrición, es decir, madre con sobrepeso e hijo con cualquier forma de desnutrición (retardo en el crecimiento, emaciación o bajo peso). Se calcularon prevalencias y los intervalos de 95% de confianza (IC95%). La mayoría de las mujeres (58,2%) y el 9,7% de los niños tenían sobrepeso, el 6,9% de los niños presentaban retraso en el crecimiento, y el 3,1% de las madres y el 2,9% de los niños, bajo peso. La prevalencia de sobrepeso en la díada madre-hijo fue del 7,8%, estadísticamente mayor en el Sur de Brasil (9,7%; IC95%: 7,5; 11,9) que en el Centro-Oeste (5,4%; IC95%: 4,3; 6,6). La prevalencia de madres con sobrepeso y de niños con retraso del crecimiento fue del 3,5%, con una diferencia estadísticamente significativa entre los extremos de nivel educativo de la madre [(0-7 vs. ≥ 12 años de nivel educativo), 4,8% (IC95%: 3,2; 6,5) y 2,1% (IC95%: 1,2; 3,0), respectivamente]. El sobrepeso en la díada tuvo un aumento del 5,2% al 7,8%, y la doble carga de mala nutrición aumentó del 2,7% al 5,2% desde 2006. La malnutrición en la díada madre-hijo brasileña resulta ser un problema creciente, siendo las más vulnerables aquellas con menor escolaridad y mayor edad materna y residentes en la Región Sur de Brasil.

Uso da anatomia foliar no controle de qualidade do chá verde Camellia sinensis L. Kuntze. (Theaceae) / Use of leaf anatomy in the quality control of green tea Camellia sinensis L. Kuntze. (Theaceae)

O chá verde é considerado uma bebida funcional e, como resultado, seu consumo aumentou drasticamente ao longo dos anos. Com a alta demanda comercial, irregularidades têm sido encontradas nos produtos, dentre as quais podemos destacar a falsificação e adulteração da matéria-prima. Portanto, o objetivo deste trabalho foi avaliar a autenticidade de diferentes marcas de chá verde a partir da identificação de características anatômicas diagnósticas da espécie. Foram obtidas 57 amostras de 19 marcas diferentes, 13 delas comercializadas a granel (folhas inteiras) e seis em sachês (pulverizadas), em estabelecimentos comerciais de cidades do Sul do Espírito Santo e da Zona da Mata Mineira. Para verificar a autenticidade, as amostras foram submetidas a processos usuais em anatomia vegetal (microscopia de luz), e comparadas com a descrição da espécie na literatura científica. Seis marcas (31,57% das amostras) não apresentaram as principais características anatômicas do chá verde, como esclereídes irregulares e tricomas tectores, demonstrando a inautenticidade do produto. Os resultados apontam a ocorrência de adulterações que podem expor a saúde dos consumidores.

Prevalence of microcephaly in eight south-eastern and midwestern Brazilian neonatal intensive care units: 2011-2015.

OBJECTIVE: To describe the prevalence of microcephaly in infants admitted to the neonatal intensive care units (NICUs) in eight private hospitals in south-eastern and midwestern Brazil, from 2011 to 2015. DESIGN: Observational, cross-sectional study in a cohort of neonates. SETTING: Eight private NICUs situated in the cities of Rio de Janeiro (RJ), São Paulo (SP) and Federal District of Brasilia (FDB). PATIENTS: Neonates up to 7 days of age and >23 weeks of gestational age. MAIN OUTCOME MEASURES: Primary outcomes were the annual prevalence of microcephaly and severe microcephaly, both overall and in subgroups according to gestational age, type of microcephaly (proportional or disproportional) and the NICU's location in RJ, SP or FDB. RESULTS: In this cohort of 8275 neonates admitted to eight private NICUs, the overall prevalence of microcephaly was 5.6% (95% CI 5.1% to 6.1%) and severe microcephaly, 1.5% (95% CI 1.2% to 1.7%). There was no annual variation in these overall estimates (p=0.48 and p=0.99, respectively), nor in the studied subgroups. Microcephaly prevalence was higher in extremely premature and term newborns (7.7% and 7.2%; p<0.001, respectively). Disproportional microcephaly was much more common than proportional microcephaly (prevalence 5.0% vs 0.6%; p<0.001). CONCLUSIONS: The prevalence of microcephaly showed little variation from 2011 to 2015 in these south-eastern and midwestern Brazilian NICUs, suggesting that the impact of the Zika epidemic in neonates that occurred mainly in the north-eastern region in 2015 did not yet affect the infants of those regions during the studied period. These prevalence results can serve as a reference for comparisons with any future Zika outbreaks in the same or similar populations from these regions.