Incidence and risk factors of abdominal compartment syndrome in pediatric oncology patients: a prospective cohort study.

Abdominal compartment syndrome (ACS) has been the subject of increasing research over the past decade owing to its effects on morbidity and mortality in critically ill patients. This study aimed to determine the incidence and risk factors of ACS in patients in an onco-hematological pediatric intensive care unit in a middle-income country and to analyze patient outcomes. This prospective cohort study was conducted between May 2015 and October 2017. Altogether, 253 patients were admitted to the PICU, and 54 fulfilled the inclusion criteria for intra-abdominal pressure (IAP) measurements. IAP was measured using the intra-bladder indirect technique with a closed system (AbViser AutoValve®, Wolfle Tory Medical Inc., USA) in patients with clinical indications for indwelling bladder catheterization. Definitions from the World Society for ACS were used. The data were entered into a database and analyzed. The median age was 5.79 years, and the median pediatric risk of mortality score was 7.1. The incidence of ACS was 27.7%. Fluid resuscitation was a significant risk factor for ACS in the univariate analysis. The mortality rates in the ACS and non-ACS groups were 46.6% and 17.9%, respectively (P < 0.05). This is the first study of ACS in critically ill children with cancer.   Conclusion: The incidence and mortality rates were high, justifying IAP measurement in children with ACS risk factors.

First experience with multiple mini interview for medical school admission in Brazil: Does it work in a different cultural scenario?

PURPOSE: Evaluation of non-cognitive skills never has been used in Brazil. This study aims to evaluate Multiple Mini Interviews (MMI) in the admission process of a School of Medicine in São Paulo, Brazil. METHODS: The population of the study comprised 240 applicants summoned for the interviews, and 96 raters. MMI contributed to 25% of the applicants' final grade. Eight scenarios were created with the aim of evaluating different non-cognitive skills, each one had two raters. At the end of the interviews, the applicants and raters described their impressions about MMI. The reliability of the MMI was analyzed using the Theory of Generalization and Many-Facet Rasch Model (MFRM). RESULTS: The G-study showed that the general reliability of the process was satisfactory (coefficient G = 0.743). The MMI grades were not affected by the raters' profile, time of interview (p = 0.715), and randomization group (p = 0.353). The Rasch analysis showed that there was no misfitting effects or inconsistent stations or raters. A significant majority of the applicants (98%) and all the raters believed MMIs were important in selecting students with a more adequate profile to study medicine. CONCLUSIONS: The general reliability of the selection process was excellent, and it was fully accepted by the applicants and raters.

Epidemiology of Sepsis in Children Admitted to PICUs in South America.

OBJECTIVES: To report the prevalence of sepsis within the first 24 hours at admission and the PICU sepsis-related mortality among critically ill children admitted to PICU in South America. DESIGN: A prospective multicenter cohort study. SETTING: Twenty-one PICU, located in five South America countries. PATIENTS: All children from 29 days to 17 years old admitted to the participating PICU between June 2011 and September 2011. Clinical, demographic, and laboratory data were registered within the first 24 hours at admission. Outcomes were registered upon PICU discharge or death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 1,090 patients included in this study, 464 had sepsis. The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively. The median age of sepsis patients was 11.6 months (interquartile range, 3.2-48.7) and 43% had one or more prior chronic condition. The prevalence of sepsis was higher in infants (50.4%) and lower in adolescents (1.9%). Sepsis-related mortality was 14.2% and was consistently higher with increased disease severity: 4.4% for sepsis, 12.3% for severe sepsis, and 23.1% for septic shock. Twenty-five percent of deaths occurred within the first 24 hours at PICU admission. Multivariate analysis showed that higher Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, the presence of two or more chronic conditions, and admission from pediatric wards were independently associated with death. CONCLUSIONS: We observed high prevalence of sepsis and sepsis-related mortality among this sample of children admitted to PICU in South America. Mortality was associated with greater severity of illness at admission and potentially associated with late PICU referral.

Validation of tool to assess pediatric residents' knowledge of development and behavior.

OBJECTIVE: This study aimed to create and validate an instrument to measure pediatric residents' knowledge about development and behavior. METHODS: This was a longitudinal study with the consecutive application of questionnaires to validate an instrument of analysis. The modified Delphi technique was used for validation, which involved judges who were selected based on their expertise. Judges, who were renowned for their knowledge of the subject and willing to participate, were chosen from different states of Brazil. A convenience sample was obtained. The original questionnaire included 45 open questions divided into 13 relevant thematic axes on development and behavior. RESULTS: After the third round using the Delphi technique, the whole questionnaire had a validity index of more than 80% on scope and relevance as well as all thematic axes, and the 44 final questions. CONCLUSIONS: The whole questionnaire was considered validated by the 14 expert judges who participated in the study.

Content validation of a questionnaire to assess the knowledge of pediatricians, family, and community physicians on obesity.

OBJECTIVE: The aim of this study was to validate the content of a questionnaire in order to assess the attitudes and practices in childcare consultations, knowledge on overweight and obesity, their risk factors, and barriers in addressing the issue by pediatricians and family physicians. METHODS: The Delphi technique was used, with the objective of reaching a consensus on a certain subject, through experts' opinions. The content validity index (CVI) of each item, axis, and questionnaire was calculated. The inter-rater reliability was calculated using an agreement coefficient suitable for the answer distribution such as Gwet's AC2 with ordinal weight. RESULTS: A total of 63 experts were invited to assess and give their opinion on the questionnaire. In all, 52 accepted the invitation and analyzed the instrument. After two rounds, the questionnaire reached the proper CVI for the study and was considered complete, with its final version having 40 questions, a final index of 95%, and an inter-rate reliability of 0.905. CONCLUSIONS: This instrument, developed to assess attitudes and practices, knowledge, and barriers found in addressing the obesity by primary care physicians, obtained a CVI greater than 0.8 and an excellent agreement coefficient of the 52 judges. Therefore, its content can be considered validated.

Knowledge of gynecologists in the public health system care of women victims of violence.

OBJECTIVE: This study aimed to evaluate the knowledge of the obstetricians and gynecologists in the care of women victims of violence in the public health system and the existence of institutional mechanisms to support them. METHODS: A cross-sectional and observational study was conducted with an electronic questionnaire by physicians who provided care in the obstetrics and gynecology emergency unit of the public health system. This study aimed to identify the care for victims of violence who received the institutional mechanisms of support, the difficulties encountered in determining the appropriate care, and estimates of the prevalence of violence against women. RESULTS: Notably, 92 physicians responded to the questionnaire. Of these, 85% had already provided care in one or more cases of violence, and 60% believed that <20% of the women received adequate care in these cases, mainly due to the short-time frame of the consultation, lack of team preparation, and lack of institutional resources. A total of 61% of the participants believed that they were not prepared to provide adequate care in those cases. CONCLUSIONS: Most of the physicians interviewed, although reported to have sufficient knowledge to adequately treat victims of violence, did not provide such care due to lack of institutional support.

Factors associated with multidrug-resistant bacteria in healthcare-associated infections: a pediatric intensive care unit case-control study.

OBJECTIVE: To investigate the prevalence of factors related to healthcare-associated infections, caused by multidrug-resistant bacteria, in a pediatric intensive care unit. METHODS: A retrospective case-control study conducted from January 1, 2007 to December 31, 2018, in São Paulo (SP), Brazil. The study was carried out at the pediatric intensive care unit of a high-complexity, tertiary care general hospital. The study included patients aged 1 month to 19 years, admitted to the pediatric intensive care unit, diagnosed as healthcare-associated infections. RESULTS: There was significant evidence of infection by multidrug-resistant bacteria associated with immunosuppressed patients (p<0.001), in whom the likelihood of multidrug-resistant bacteria infection was estimated to be nine-fold higher than among non-immunosuppressed patients (OR 8.97; 95%CI 2.69-29.94). In the analysis of multiple logistic regression model, we observed that immunosuppressed patients had an 8.5-fold higher chance of multidrug-resistant bacteria infection when compared to non-immunosuppressed patients (OR 8.48; 95%CI 2.54-28.35; p=0.001). There is evidence of association between the Case Group and presence of Gram-positive (p=0.007), coagulase-negative Staphylococcus (p<0.001), and Gram-negative (p=0.041) microorganisms. CONCLUSION: The immunocompromised-state variable is a factor related to healthcare-associated infections caused by multidrug-resistant bacteria, and the Case Group presented higher proportions of Gram-positive microorganisms and coagulase-negative Staphylococcus.

The impact of monitoring software on antimicrobial management in a pediatric intensive care unit.

INTRODUCTION: Antimicrobial stewardship programs are necessary practices to combat resistance in hospital infections. However, studies frequently cite the scarcity of technological resources as an obstacle to the comprehensive development of ASPs. OBJECTIVES: The aim of the study was to assess the impact of monitoring software on reducing antibiotic consumption and reducing resistance in a pediatric intensive care unit. METHODS: We conducted an analytical longitudinal study during the period January 1, 2007, to December 31, 2018, in the pediatric intensive care unit of a high-complexity tertiary general hospital in Brazil. RESULTS: In the period after the implementation of software, we observed decreases in total antimicrobial consumption (P = .037). Regarding Enterobacterales, we observed a decrease in the proportion of antimicrobial resistance of first and second-generation cephalosporin classes (P = .041) and third and fourth-generation cephalosporins (P = .028). There was a decrease in the proportion of resistance of nonfermenting gram-negative bacilli to aminoglycoside scans (P = .016). We also observed evidence of a decrease in the proportion of resistance of Staphylococcus aureus agents to oxacillin (P < .001). CONCLUSIONS: The monitoring software reduced the total consumption of antimicrobials and decreased the proportion of resistance, therefore demonstrating its importance in controlling the development of multidrug-resistant bacteria.

Epidemiology and treatment of sepsis at a public pediatric emergency department.

OBJECTIVE: To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. METHODS: A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. RESULTS: A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. CONCLUSION: Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

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

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

Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study. / Prevalência e desfechos da sepse em crianças internadas em hospitais públicos e privados na América Latina: um estudo observacional multicêntrico.

OBJECTIVE: To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals. METHODS: Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries. RESULTS: Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals. CONCLUSION: In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

OBJETIVO: Relatar a prevalência e os desfechos da sepse em crianças admitidas em hospitais públicos e privados na América Latina. MÉTODOS: Análise post-hoc dos dados do Latin American Pediatric Sepsis Study (LAPSES), um estudo de coorte que avaliou a prevalência e os desfechos da sepse em crianças admitidas em 21 unidades de terapia intensiva pediátricas de cinco países latino-americanos. RESULTADOS: Dentre os 464 pacientes com sepse, 369 (79,5%) foram admitidos em hospitais públicos e 95 (20,5%) em privados. Em comparação com os admitidos em hospitais privados, os pacientes com sepse admitidos em hospitais públicos não diferiram em termos de idade, sexo, condição de imunização, tempo de permanência no hospital ou tipo de admissão, porém tiveram incidência mais alta de choque séptico, escores Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2) e Pediatric Logistic Organ Dysfunction (PELOD) mais altos e taxas mais elevadas de doenças de base e analfabetismo materno. A proporção entre pacientes admitidos a partir de enfermarias pediátricas e mortalidade relacionada à sepse foi mais alta nos hospitais públicos. A análise multivariada não mostrou qualquer correlação entre mortalidade e tipo de hospital, porém, nos hospitais públicos, a mortalidade se associou com níveis mais altos de gravidade no momento da admissão à unidade de terapia intensiva. CONCLUSÃO: Nesta amostra de crianças admitidas em condições críticas em cinco países latino-americanos, a prevalência de choque séptico nas primeiras 24 horas da admissão e a mortalidade relacionada à sepse foram mais elevadas em hospitais públicos do que nos privados. A mortalidade relacionada à sepse mais elevada em crianças admitidas em unidades de terapia intensiva pediátrica de hospitais públicos se associou com maior gravidade por ocasião da admissão à unidade de terapia intensiva, porém não com o tipo de hospital. São necessários novos estudos para elucidar as causas da maior prevalência e mortalidade de sepse pediátrica em hospitais públicos.

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

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

Length of stay in pediatric intensive care unit: prediction model.

OBJECTIVE: To propose a predictive model for the length of stay risk among children admitted to a pediatric intensive care unit based on demographic and clinical characteristics upon admission. METHODS: This was a retrospective cohort study conducted at a private and general hospital located in the municipality of Sao Paulo, Brazil. We used internal validation procedures and obtained an area under ROC curve for the to build of the predictive model. RESULTS: The mean hospital stay was 2 days. Predictive model resulted in a score that enabled the segmentation of hospital stay from 1 to 2 days, 3 to 4 days, and more than 4 days. The accuracy model from 3 to 4 days was 0.71 and model greater than 4 days was 0.69. The accuracy found for 3 to 4 days (65%) and greater than 4 days (66%) of hospital stay showed a chance of correctness, which was considering modest. Conclusion: Our results showed that low accuracy found in the predictive model did not enable the model to be exclusively adopted for decision-making or discharge planning. Predictive models of length of stay risk that consider variables of patients obtained only upon admission are limit, because they do not consider other characteristics present during hospitalization such as possible complications and adverse events, features that could impact negatively the accuracy of the proposed model.

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

Vomiting episodes in newborns are extremely common and often attributed to gastroesophageal reflux. The symptoms of vomiting, however, may be caused by other complications. In this report, we present two cases of a 1-month-old male and a 2-month-old female, both presenting vomiting episodes that led to malnutrition. Some pediatricians often attribute the diagnosis of gastroesophageal reflux to newborns that are vomiting; however, there is a portion of the population that has other causes that lead to similar symptoms. The pediatrician should be alert to the clinical signs of weight loss, dehydration and malnutrition to investigate other causes of vomiting.

Is procalcitonin useful to differentiate rejection from bacterial infection in the early post-operative period of liver transplantation in children?

PCT is a protein that is recognized as an acute marker of inflammation. Previous studies performed in adults who underwent liver or heart transplantation indicated that PCT plasmatic levels help to differentiate between rejection and infection. The objective of this study was to evaluate whether PCT has the same role in liver-transplanted children. Thirty-six patients were studied between the first and the thirtieth post-operative days, and PCT determinations were prospectively performed according to the clinical status of the patient. In the non-complicated patients, PCT measurements performed on the first and second post-operative days revealed a median value of 1.60 ng/mL (mean 5.68 +/- 7.05; range 0.69-18.30). After the fourth day of transplantation, PCT plasma concentrations decreased to a median value of 0.21 ng/mL (mean 0.47 +/- 0.59; range 0.05-2.00; normal values are less than 0.5 ng/mL). In infected patients, PCT plasma levels demonstrated a significant increase, differing from the patients with acute liver rejection whose levels were similar to those of non-complicated patients. In conclusion, we could demonstrate that in the early post-operative period of liver transplantation in children, measuring PCT plasmatic levels might be a useful tool for differentiation between bacterial infection and acute liver rejection.

[Hyperglycemia, morbidity and mortality in critically ill children: critical analysis based on a systematic review]. / Hiperglicemia e morbimortalidade em crianças graves: análise crítica baseada em revisão sistemática.

OBJECTIVE: This article focused on verifying if hyperglycemia in critically ill pediatric patients is a risk factor for increased morbidity and mortality and carried out a critical analysis of the articles in pediatrics and neonatology. METHODS: A systematic review of literature was performed using Medline, Cochrane, Lilacs and Embase databases and references of articles. Articles written in Portuguese, English and Spanish were selected and the terms used in the search were hyperglycemia, intensive care units (pediatrics), hospitals, pediatrics and pediatric intensive care. Cohort studies, retrospective and prospective, were selected for analysis. The outcomes evaluated were mortality during pediatric intensive care unit (PICU) stay, mortality during hospital stay, length-of-stay in the PICU, mortality due to specific diseases, and risk of infection and time of mechanical ventilation. RESULTS: During the study period 79 articles related to hyperglycemia in critically ill pediatric patients were selected; 15 (19%) were cohort studies (2 prospective and 13 retrospective) that were analyzed separately. CONCLUSION: Analysis of these cohort studies supported the conclusion that hyperglycemia, isolated or persistent during stay in PICU, increases morbidity, mortality and length-of-stay in PICU of critically ill children. However, these studies disclosed methodological issues such as lack of protocols for glucose measurement, design (most of them retrospective cohorts) and many articles did not confirm hyperglycemia as a single predictor of morbidity and mortality in pediatrics; therefore further prospective studies are necessary.

Validation of tool to assess pediatric residents' knowledge of development and behavior / Validação de instrumento para avaliar conhecimento acerca de desenvolvimento e comportamento entre residentes de pediatria

ABSTRACT Objective: This study aimed to create and validate an instrument to measure pediatric residents' knowledge about development and behavior. Methods: This was a longitudinal study with the consecutive application of questionnaires to validate an instrument of analysis. The modified Delphi technique was used for validation, which involved judges who were selected based on their expertise. Judges, who were renowned for their knowledge of the subject and willing to participate, were chosen from different states of Brazil. A convenience sample was obtained. The original questionnaire included 45 open questions divided into 13 relevant thematic axes on development and behavior. Results: After the third round using the Delphi technique, the whole questionnaire had a validity index of more than 80% on scope and relevance as well as all thematic axes, and the 44 final questions. Conclusions: The whole questionnaire was considered validated by the 14 expert judges who participated in the study.

RESUMO Objetivo: Construir e validar o conteúdo de um instrumento de análise do conhecimento acerca do diagnóstico de transtornos de desenvolvimento e comportamento entre residentes de pediatria. Métodos: Foi realizada uma aplicação consecutiva de questionários, visando à validação de um instrumento de análise. A metodologia utilizada para a validação foi a técnica Delphi modificada. Juízes especialistas procedentes de diferentes Estados do Brasil foram selecionados com base em sua expertise no tema, por meio de uma amostra de conveniência. O primeiro questionário submetido continha originalmente 45 questões de múltipla escolha, divididas em 13 eixos temáticos relevantes, sobre desenvolvimento e comportamento. Resultados: Após a terceira rodada da metodologia, o questionário como um todo obteve mais de 80% de índice de validade de conteúdo sobre abrangência e relevância, assim como todos os eixos temáticos e as 44 questões finais. Conclusões: O questionário como um todo foi considerado validado pelos 14 juízes especialistas que participaram do estudo.