Mental Health and Emotional Disorders During the COVID-19 Pandemics: Prevalence and Extent in PICU Staff.

OBJECTIVES: To assess the prevalence of burnout, anxiety and depression symptoms, and posttraumatic stress disorder (PTSD) in PICU workers in Brazil during the first peak of the COVID-19 pandemic. To compare the results of subgroups stratified by age, gender, professional category, health system, and previous mental health disorders. DESIGN: Multicenter, cross-sectional study using an electronic survey. SETTING: Twenty-nine public and private Brazilian PICUs. SUBJECTS: Multidisciplinary PICU workers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Self-reported questionnaires were used to measure burnout (Maslach Burnout Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), and PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5]) in 1,084 respondents. Subjects were mainly young (37.1 ± 8.4 yr old) and females (85%), with a median workload of 50 hours per week. The prevalence of anxiety and depression was 33% and 19%, respectively, whereas PTSD was 13%. The overall median burnout scores were high in the emotional exhaustion and personal accomplishment dimensions (16 [interquartile range (IQR), 8-24] and 40 [IQR, 33-44], respectively) whereas low in the depersonalization one (2 [IQR, 0-5]), suggesting a profile of overextended professionals, with a burnout prevalence of 24%. Professionals reporting prior mental health disorders had higher prevalence of burnout (30% vs 22%; p = 0.02), anxiety (51% vs 29%; p < 0.001), and depression symptoms (32.5% vs 15%; p < 0.001), with superior PCL-5 scores for PTSD ( p < 0.001). Public hospital workers presented more burnout (29% vs 18.6%, p < 0.001) and more PTSD levels (14.8% vs 10%, p = 0.03). Younger professionals were also more burned out ( p < 0.05 in all three dimensions). CONCLUSIONS: The prevalence of mental health disorders in Brazilian PICU workers during the first 2020 peak of COVID-19 was as high as those described in adult ICU workers. Some subgroups, particularly those reporting previous mental disorders and younger professionals, should receive special attention to prevent future crises.

Screening of COVID-19 in outpatient children with cancer or solid organ transplantation: preliminary report.

Clinical presentation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pediatric immunosuppressed patients is unknown. Emerging data describe a milder or asymptomatic course in children compared with adults in this scenario. We present the seroprevalence and clinical features of coronavirus disease 2019 in a prospective cohort of 114 immunosuppressed children and adolescents from three groups: kidney transplantation, liver transplantation, and cancer patients. Among the thirty-five (30.7%) patients who had a positive serological test for SARS-CoV-2, 77% did not report previous symptoms and none of them developed any complications of coronavirus disease 2019 (COVID-19) after 30 or more days of follow-up. Among those who were symptomatic, diarrhea, fever, and cough were the most common findings.Conclusion: Seroprevalence of SARS-CoV-2 infection is high among immunosuppressed children and adolescents. COVID-19 has a mild or asymptomatic course in most of these patients. What is Known: • The number of immunosuppressed patients with coronavirus disease 2019 is increasing. • Viral infections have the potential for greater severity in immunocompromised children. What is New: • Seroprevalence for severe acute respiratory syndrome coronavirus 2 in immunocompromised pediatric patients was 31%. • A quarter of the serology-positive patients reported mild symptoms and none of them developed multisystem inflammatory syndrome in children associated with coronavirus disease 2019.

The Impact of the Novel Coronavirus on Brazilian PICUs.

OBJECTIVES: To study the impact of the coronavirus disease 2019 pandemic, considering the physical distancing and schools closing, on the characteristics of admission and epidemiology on Brazilian PICUs. DESIGN: Observational, multicenter, time series analysis, of electronic medical records from 15 PICU in Brazil. Data consisted of all March, April, and May PICU admissions from 2017 to 2020. SETTING: Fifteen private PICUs in Brazil. PATIENTS: Pediatric patients admitted to the PICU from March to May since 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The period from March 11, 2020, to March 17, 2020, was considered the "intervention point" studied, corresponding to the suspension of school activities and the beginning of physical distancing in Brazil. During the pandemic period studied, there were 28 cases of coronavirus disease 2019 (one death). The mean age was higher (p = 0.000), the length of stay was shorter (p = 0.000), but mortality rates were similar among the periods (p = 0.36). The model estimated a reduction of 1,483 PICU admissions from March 2020 to May 2020. At the end of May, there was an estimated drop of -146.6 bronchiolitis admissions (95% CI, -242.8 to -50.3; p = 0.016); -71 asthma admissions (95% CI, -93.6 to -48.63; p = 0.000); and -59 community-acquired pneumonia admissions (95% CI, -74.7 to -43.3; p = 0.000) per period. The model showed no effect of the "intervention" (physical distancing) on hospitalization rates for epilepsy, diarrhea, sepsis, bacterial meningitis, or surgery when analyzed individually. When assessed together, the model estimated a reduction of 73.6 admissions (95% IC, -132 to -15.2; p = 0.43). CONCLUSIONS: The coronavirus disease 2019 pandemic strongly affected Brazilian PICUs, reducing admissions, length of stay, and the epidemiological profile. The measures to oppose the coronavirus disease 2019 pandemic may have prevented thousands of PICU hospitalizations across the country.

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study.

OBJECTIVE: To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students. METHODS: 33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge's g. RESULTS: Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20). CONCLUSION: HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

Impact of prematurity on LINE-1 promoter methylation.

Aim: Promoter methylation of LINE-1 may be affected by prematurity, but there is little evidence in the literature.Materials & methods: Blood from premature and full-term neonates on days 0, 5, 30 and 90 was analyzed for DNA methylation percentage in a promoter region of the LINE-1, after bisulfite conversion and pyrosequencing.Results: Premature infants, as a whole, showed significantly lower methylation percentage at birth, but this difference diminished over time. However, the subgroup of extremely premature (<28 weeks gestational age) had higher methylation percentages, similar to full-term newborns.Conclusion: This research underscores the critical role of prematurity on the methylation pattern of LINE-1. These findings underline the complexity of epigenetic regulation in prematurity and emphasize the need for further studies.

Premature birth can have significant effects on a baby's development and long-term health. This study investigates how being born prematurely affects a process called DNA methylation, which can influence how genes are turned on or off. Specifically, we examined the LINE-1 promoter, a frequently occurring region of DNA known for its role in regulating gene activity.We collected blood samples from both premature and full-term newborns at birth and at several points in the early months of life. Our findings showed that premature babies have lower levels of LINE-1 promoter methylation at birth compared with full-term babies. These differences in methylation could possibly affect the babies' development and health as they grow.Our research highlights the need for continued study in this area to explore how these epigenetic changes impact long-term health and to develop strategies to mitigate these effects.

Knowledge regarding extracorporeal membrane oxygenation management among Brazilian pediatric intensivists: a cross-sectional survey.

OBJECTIVE: To assess Brazilian pediatric intensivists' general knowledge of extracorporeal membrane oxygenation, including evidence for its use, the national funding model, indications, and complications. METHODS: This was a multicenter cross-sectional survey including 45 Brazilian pediatric intensive care units. A convenience sample of 654 intensivists was surveyed regarding their knowledge on managing patients on extracorporeal membrane oxygenation, its indications, complications, funding, and literature evidence. RESULTS: The survey addressed questions regarding the knowledge and experience of pediatric intensivists with extracorporeal membrane oxygenation, including two clinical cases and 6 optional questions about the management of patients on extracorporeal membrane oxygenation. Of the 45 invited centers, 42 (91%) participated in the study, and 412 of 654 (63%) pediatric intensivists responded to the survey. Most pediatric intensive care units were from the Southeast region of Brazil (59.5%), and private/for-profit hospitals represented 28.6% of the participating centers. The average age of respondents was 41.4 (standard deviation 9.1) years, and the majority (77%) were women. Only 12.4% of respondents had taken an extracorporeal membrane oxygenation course. Only 19% of surveyed hospitals have an extracorporeal membrane oxygenation program, and only 27% of intensivists reported having already managed patients on extracorporeal membrane oxygenation. Specific extracorporeal membrane oxygenation management questions were responded to by only 64 physicians (15.5%), who had a fair/good correct response rate (median 63.4%; range 32.8% to 91.9%). CONCLUSION: Most Brazilian pediatric intensivists demonstrated limited knowledge regarding extracorporeal membrane oxygenation, including its indications and complications. Extracorporeal membrane oxygenation is not yet widely available in Brazil, with few intensivists prepared to manage patients on extracorporeal membrane oxygenation and even fewer intensivists recognizing when to refer patients to extracorporeal membrane oxygenation centers.

Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study.

OBJECTIVE: To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units. METHODS: A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours. RESULTS: Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events. CONCLUSION: Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

Pediatric Sepsis Research: Where Are We and Where Are We Going?

Sepsis continues to be one of the leading causes of admission to the Pediatric Intensive Care Unit, representing a great challenge for researchers and healthcare staff. This mini review aims to assess research on pediatric sepsis over the years. Of the 2,698 articles retrieved from the Scopus database, the 100 most cited were selected (50 published since 2000 and 50 published since 2016). The most cited studies, published in the 21st century, are highlighted, with their main findings and perspectives.

Prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic.

OBJECTIVE: The proportion of children with complex chronic conditions is increasing in PICUs around the world. We determined the prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic. METHODS: The authors conducted a point prevalence cross-sectional study among fifteen Brazilian PICUs during the COVID-19 pandemic. The authors enrolled all children admitted to the participating PICUs with complex chronic conditions on three different days, four weeks apart, starting on April 4th, 2020. The authors recorded the patient's characteristics and functional status at admission and discharge days. RESULTS: During the 3 study days from March to June 2020, the authors enrolled 248 patients admitted to the 15 PICUs; 148 had CCC (prevalence of 59.7%). Patients had a median of 1 acute diagnosis and 2 chronic diagnoses. The use of resources/devices was extensive. The main mode of respiratory support was conventional mechanical ventilation. Most patients had a peripherally inserted central catheter (63.1%), followed by a central venous line (52.5%), and 33.3% had gastrostomy or/and tracheostomy. The functional status score was significantly better at discharge compared to admission day due to the respiratory status improvement. CONCLUSIONS: The prevalence of children with CCC admitted to the Brazilian PICUs represented 59.7% of patients during the COVID-19 pandemic. The functional status of these children improved during hospitalization, mainly due to the respiratory component.

Clinical features, electroencephalogram, and biomarkers in pediatric sepsis-associated encephalopathy.

To date, no specific diagnostic criteria for sepsis-associated encephalopathy (SAE) have been established. We studied 33 pediatric patients with sepsis prospectively and evaluated the level of consciousness, the presence of delirium, electroencephalographic (EEG) findings, and plasma levels of neuron-specific enolase and S100-calcium-binding protein-B. A presumptive diagnosis of SAE was primarily considered in the presence of a decreased level of consciousness and/or delirium (clinical criteria), but specific EEG abnormalities were also considered (EEG criteria). The time course of the biomarkers was compared between groups with and without clinical or EEG criteria. The Functional Status Scale (FSS) was assessed at admission, discharge, and 3-6 months post-discharge. Clinical criteria were identified in 75.8% of patients, EEG criteria in 26.9%, both in 23.1%, and none in 23.1%. Biomarkers did not differ between groups. Three patients had an abnormal FSS at discharge, but no one on follow-up. A definitive diagnostic pattern for SAE remained unclear. Clinical criteria should be the basis for diagnosis, but sedation may be a significant confounder, also affecting EEG interpretation. The role of biomarkers requires a better definition. The diagnosis of SAE in pediatric patients remains a major challenge. New consensual diagnostic definitions and mainly prognostic studies are needed.

NR3C1 gene methylation and cortisol levels in preterm and healthy full-term infants in the first 3 months of life.

Aim: To describe NR3C1 exon-1F methylation and cortisol levels in newborns. Materials & methods: Preterm ≤1500 g and full-term infants were included. Samples were collected at birth and at days 5, 30 and 90 (or at discharge). Results: 46 preterm and 49 full-term infants were included. Methylation was stable over time in full-term infants (p = 0.3116) but decreased in preterm infants (p = 0.0241). Preterm infants had higher cortisol levels on the fifth day, while full-term infants showed increasing levels (p = 0.0177) over time. Conclusion: Hypermethylated sites in NR3C1 at birth and higher cortisol levels on day 5 suggest that prematurity, reflecting prenatal stress, affects the epigenome. Methylation decrease over time in preterm infants suggests that postnatal factors may modify the epigenome, but their role needs to be clarified.

We investigated the methylation of a gene, NR3C1 exon-1F, and cortisol levels in newborns. DNA methylation is a biochemical process that can modify gene activity. In the case of this gene, higher methylation might be associated with higher cortisol levels. We studied 46 preterm infants (born weighing 1500 g or less) and 49 full-term infants. Our results revealed that the preterm infants had hypermethylation at birth and higher cortisol levels on day 5, but decreasing methylation and stable cortisol levels over time. Meanwhile, methylation remained stable and cortisol levels increased in full-term babies with time. These unexpected results suggest that prematurity can be associated with prenatal epigenetic changes in the NR3C1 gene, but postnatal factors may induce further modifications. More research is needed to understand these findings better.

Multicenter validation of PIM3 and PIM2 in Brazilian pediatric intensive care units.

Objective: To validate the PIM3 score in Brazilian PICUs and compare its performance with the PIM2. Methods: Observational, retrospective, multicenter study, including patients younger than 16 years old admitted consecutively from October 2013 to September 2019. We assessed the Standardized Mortality Ratio (SMR), the discrimination capability (using the area under the receiver operating characteristic curve - AUROC), and the calibration. To assess the calibration, we used the calibration belt, which is a curve that represents the correlation of predicted and observed values and their 95% Confidence Interval (CI) through all the risk ranges. We also analyzed the performance of both scores in three periods: 2013-2015, 2015-2017, and 2017-2019. Results: 41,541 patients from 22 PICUs were included. Most patients aged less than 24 months (58.4%) and were admitted for medical conditions (88.6%) (respiratory conditions = 53.8%). Invasive mechanical ventilation was used in 5.8%. The median PICU length of stay was three days (IQR, 2-5), and the observed mortality was 1.8% (763 deaths). The predicted mortality by PIM3 was 1.8% (SMR 1.00; 95% CI 0.94-1.08) and by PIM2 was 2.1% (SMR 0.90; 95% CI 0.83-0.96). Both scores had good discrimination (PIM3 AUROC = 0.88 and PIM2 AUROC = 0.89). In calibration analysis, both scores overestimated mortality in the 0%-3% risk range, PIM3 tended to underestimate mortality in medium-risk patients (9%-46% risk range), and PIM2 also overestimated mortality in high-risk patients (70%-100% mortality risk). Conclusions: Both scores had a good discrimination ability but poor calibration in different ranges, which deteriorated over time in the population studied.

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.

Cross-cultural adaptation of the Richmond Agitation-Sedation Scale to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. / Adaptação transcultural para o Brasil da Richmond Agitation-Sedation Scale para avaliação da sedação em terapia intensiva pediátrica.

OBJECTIVE: To perform a cross-cultural adaptation of the Richmond Agitation-Sedation Scale (RASS) to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. METHODS: Cross-cultural adaptation process including the conceptual, item, semantic and operational equivalence stages according to current recommendations. RESULTS: Pretests, divided into two stages, included 30 professionals from the pediatric intensive care unit of a university hospital, who administered the translated RASS to patients aged 29 days to 18 years. The pretests showed a content validity index above 0.90 for all items: 0.97 in the first stage of pretests and 0.99 in the second. CONCLUSION: The cross-cultural adaptation of RASS to Brazilian Portuguese resulted in a version with excellent comprehensibility and acceptability in a pediatric intensive care setting. Reliability and validity studies should be performed to evaluate the psychometric properties of the Brazilian Portuguese version of the RASS.

OBJETIVO: Realizar adaptação transcultural para o Brasil da Richmond Agitation-Sedation Scale (RASS) para avaliação da sedação em terapia intensiva pediátrica. MÉTODOS: Processo de adaptação transcultural incluindo as etapas de equivalência conceitual, de itens, semântica e operacional, de acordo com recomendações atuais. RESULTADOS: Pré-testes, divididos em duas etapas, incluíram 30 profissionais da unidade de terapia intensiva pediátrica de um hospital universitário, que aplicaram a RASS traduzida em pacientes de 29 dias a 18 anos. Os pré-testes mostraram Índice de Validade de Conteúdo acima de 0,90 para todos os itens: 0,97 na primeira etapa de pré-testes e 0,99 na segunda. CONCLUSÃO: A adaptação transcultural da RASS para o português do Brasil resultou em versão com excelente compreensão e aceitabilidade em cenário de terapia intensiva pediátrica. Estudos de confiabilidade e de validade devem ser realizados para avaliar as propriedades psicométricas da versão adaptada para o português do Brasil da RASS.

Children's Multisystem inflammatory syndrome with myopathy.

This report describes a case of multisystem inflammatory syndrome in a child that evolved with a pattern of toxic shock syndrome with coronary artery ectasia and neurological involvement, documented by magnetic resonance imaging, with changes in the corpus callosum and myopathy in the pelvic girdle and paravertebral musculature.

Multisystem inflammatory syndrome in children (MIS-C) during SARS-CoV-2 pandemic in Brazil: a multicenter, prospective cohort study.

OBJECTIVE: To describe the clinical, laboratory, and radiological characteristics, as well as the outcomes of children with MIS-C. METHOD: Multicenter, prospective cohort study, conducted in 17 pediatric intensive care units in five states in Brazil, from March to July 2020. Patients from 1 month to 19 years who met the MIS-C diagnostic criteria were included consecutively. RESULTS: Fifty-six patients were included, with the following conditions: Kawasaki-like disease (n = 26), incomplete Kawasaki disease (n = 16), acute cardiac dysfunction (n = 10), toxic shock syndrome (n = 3), and macrophage activation syndrome (n = 1). Median age was 6.2 years (IQR 2.4-10.3), 70% were boys, 59% were non-whites, 20% had comorbidities, 48% reported a contact with COVID-19 cases, and 55% had a recent SARS-CoV-2 infection confirmed by RT-PCR and/or serology. Gastrointestinal symptoms were present in 71%, shock symptoms in 59%, and severe respiratory symptoms in less than 20%. d-Dimer was increased in 80% and cardiac dysfunction markers in more than 75%. Treatment included immunoglobulin (89%); corticosteroids, antibiotics, and enoxaparin in about 50%; and oseltamivir and antifungal therapy in less than 10%. Only 11% needed invasive mechanical ventilation, with a median duration of five days (IQR 5-6.5). The median length of PICU stay was six days (IQR 5-11), and one death occurred (1.8%). CONCLUSIONS: Most characteristics of the present MIS-C patients were similar to that of other cohorts. The present results may contribute to a broader understanding of SARS-CoV-2 infection in children and its short-term consequences. Long-term multidisciplinary follow-up is needed, since it is not known whether these patients will have chronic cardiac impairment or other sequelae.

The importance of bioelectrical impedance in the critical pediatric patient.

BACKGROUND & AIMS: Sepsis is still a significant cause of death in the Intensive Care Unit and its early diagnosis is vital. Changes in cell permeability have been observed early in sepsis. Lower values of bioelectrical impedance (BIA) such as reactance adjusted by height (Xc/H) and phase angle (PA) have already been studied as a prognostic biomarker for many diseases and may indicate cell injury. BIA is a low cost, practical, noninvasive method that can be measured at bedside. This study investigated the utility of PA and Xc/H raw values in the pediatric critical care unit as predictors of progression to septic shock, as a clinical monitoring tool and to support the diagnosis of septic shock. METHODS: We prospectively analyzed bioelectrical impedance in 145 children aged between one month and six years who were not in septic shock on admission to the intensive care unit Serial bioelectrical impedance analysis (BIA) measures were analyzed to determine the sensitivity and specificity of accurately identifying children who subsequently developed septic shock. Kaplan-Meier septic shock-free survival curves modeled by Xc/H and PA were done. RESULTS: The free-septic shock survival curve analysis showed that patients with the lowest median values of Xc/H and PA were associated with the highest percentage of occurrence of septic shock (p = 0.0001 for Xc/H and <0.0006 for PA) and longest length of stay in the intensive care unit (p < 0.0011 for Xc/H and p < 0.004 for PA). Values of Xc/H below 48.63 Ohm/m at admission showed statistically significant odds ratio (OR) of 3.72 for developing septic shock any time during the hospitalization period, with a 87% sensitivity, 35% specificity and an area under the curve (AUC) of 0.62. The PA at admission did not show significant results. During hospitalization, patients with Xc/H below 35.72 Ohm/m were 3.38 times more likely to develop septic shock in the next day, with a sensitivity of 66.7%, a specificity of 62.3% and AUC of 0.65. PA values below 3.27 had an OR of 9.58 for a septic shock the next day with a sensitivity of 95.8%, specificity of 29.4% and AUC of 0.62. The presence of a value of Xc/H below 33 Ohm/m showed a strong association with the occurrence of septic shock on the same day of the measurement, with an OR of 11.7, as well as a value of PA below 2.64, showed an OR of 14.2. CONCLUSIONS: The bioelectrical parameters Xc/H and phase angle have limitations in predicting septic shock as isolated biomarkers, but have a potential role as a monitoring tool in the pediatric intensive care unit. The comparative value with other biomarkers remains to be elucidated.

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.

High-fidelity simulation versus case-based discussion for training undergraduate medical students in pediatric emergencies: a quasi-experimental study

Abstract Objective: To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students. Methods: 33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge'sg. Results: Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20). Conclusion: HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.