Pediatric palliative care and end-of-life: a systematic review of economic health analyses.

OBJECTIVE: To perform a systematic review of the health economic evidence on the care of children and adolescents with complex clinical conditions, comparing groups included and not included (control group) in palliative care at the end of life. DATA SOURCE: The seven databases searched were PubMed, Embase, Web of Science, Cochrane Library, Virtual Health Library-Latin American and Caribbean Health Sciences Literature (VHL-LILACS), EBSCOhost, and Paediatric Economic Database Evaluation, following recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, from January 1979 to November 2020. The review included studies of patients under 18 years of age with complex clinical conditions that compared a palliative care group with a control group. The economic outcomes analyzed were length and place of stay at the end of life (home, hospice, ward, intensive care unit, emergency room), diagnostic and therapeutic procedures performed, and health-related costs. The exclusion criteria were: studies without a matched control group, conference/congress abstracts, letters to the editor, editorials, comments, qualitative studies, narrative reviews, studies with ten or fewer participants in each group, articles published in languages other than English, Portuguese, or Spanish. DATA SYNTHESIS: Out of the 518 articles identified, 4 met the inclusion criteria. We found evidence of direct economic benefits, such as reduced health costs, indirect savings, and protection of patients from undergoing invasive procedures, surgeries, and costly therapies, which cause greater suffering at the end of life. Therefore, participating in a palliative care program saved financial and technological resources, besides increasing the frequency of deaths at home and improving the quality of life. CONCLUSIONS: Public and private policies to promote palliative care represent better efficiency when allocating available health care resources.

Pediatric palliative care and end-of-life: a systematic review of economic health analyses / Cuidados paliativos pediátricos e no fim de vida: uma revisão sistemática da avaliação econômica em saúde

Abstract Objective: To perform a systematic review of the health economic evidence on the care of children and adolescents with complex clinical conditions, comparing groups included and not included (control group) in palliative care at the end of life. Data source: The seven databases searched were PubMed, Embase, Web of Science, Cochrane Library, Virtual Health Library-Latin American and Caribbean Health Sciences Literature (VHL-LILACS), EBSCOhost, and Paediatric Economic Database Evaluation, following recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, from January 1979 to November 2020. The review included studies of patients under 18 years of age with complex clinical conditions that compared a palliative care group with a control group. The economic outcomes analyzed were length and place of stay at the end of life (home, hospice, ward, intensive care unit, emergency room), diagnostic and therapeutic procedures performed, and health-related costs. The exclusion criteria were: studies without a matched control group, conference/congress abstracts, letters to the editor, editorials, comments, qualitative studies, narrative reviews, studies with ten or fewer participants in each group, articles published in languages other than English, Portuguese, or Spanish. Data synthesis: Out of the 518 articles identified, 4 met the inclusion criteria. We found evidence of direct economic benefits, such as reduced health costs, indirect savings, and protection of patients from undergoing invasive procedures, surgeries, and costly therapies, which cause greater suffering at the end of life. Therefore, participating in a palliative care program saved financial and technological resources, besides increasing the frequency of deaths at home and improving the quality of life. Conclusions: Public and private policies to promote palliative care represent better efficiency when allocating available health care resources.

Resumo Objetivo: Realizar revisão sistemática das evidências de economia da saúde no cuidado de crianças e adolescentes com condições clínicas complexas, comparando no fim de vida o grupo inserido em cuidados paliativos com o grupo não inserido (grupo controle). Fontes de dados: As sete bases de dados pesquisadas foram PubMed, Embase, Web of Science, Cochrane Library, Biblioteca Virtual da Saúde-Literatura Latino-Americana e do Caribe em Ciências da Saúde (BVS-LILACS), EBSCOhost e Paediatric Economic Database Evaluation, seguindo as recomendações do Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, de janeiro/1979 a novembro/2020. A revisão incluiu estudos com pacientes com condições clínicas complexas, idade inferior a 18 anos, comparativos de um grupo inserido em cuidados paliativos com um grupo controle não inserido em cuidados paliativos. Os desfechos econômicos analisados foram tempo e local de permanência no fim de vida (casa, hospice, enfermaria, unidade de terapia intensiva, pronto-socorro), procedimentos diagnósticos e terapêuticos realizados e custos relacionados aos cuidados de saúde. Os critérios de exclusão foram: estudos sem grupo controle pareados, resumos de conferências/congressos, cartas ao editor, editoriais, comentários, estudos qualitativos, revisões narrativas, estudos com dez ou menos participantes, artigos publicados em outras línguas além de inglês, português e espanhol. Síntese dos dados: Do total de 518 artigos identificados, quatro preencheram os critérios de inclusão. Houve evidências de benefícios econômicos diretos de redução de custos monetários relacionados à saúde e também indiretos, de economia e proteção ao paciente de procedimentos invasivos, cirurgias e terapias onerosas, que geram maior sofrimento no fim de vida. Portanto, estar inserido em um programa de cuidados paliativos promoveu economia de recursos financeiros e tecnológicos, além de ter possibilitado maior frequência de óbitos no domicílio e maior qualidade de vida. Conclusões: Políticas públicas e privadas para promover cuidados paliativos representam melhor eficiência na alocação dos recursos disponíveis para cuidados em saúde.

Frequency of Community-acquired Methicillin-resistant Staphylococcus aureus in Pediatric Population in a General Hospital in São Paulo, Brazil, Over 5 Years.

We retrospectively evaluated the frequency of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in children at a general hospital in São Paulo, Brazil, from 2011 to 2015. Of 64 patients with confirmed S. aureus infection, 11 (17.2%) had CA-MRSA. CA-MRSA infections in Brazil, and in particular those with a severe presentation, should not be overlooked.

Dengue fever as a cause of hemophagocytic lymphohistiocytosis.

Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropod-borne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome.

Acute Hemorrhagic Edema of Infancy: an unusual diagnosis for the general pediatrician.

Acute Hemorrhagic Edema of Infancy (AHEI) is a rare leukocytoclastic vasculitis, clinically characterized by the classical triad: palpable purpuric skin lesions, edema and fever, and is commonly misdiagnosed as Henoch-Schönlein purpura. In addition to its sudden onset, AHEI is also characterized by its self-limited course with complete and spontaneous recovery occurring between 1 and 3 weeks. Because of the scarcity of studies on therapy with corticosteroids, the conservative approach is usually recommended. The authors report an unusual case of an one-year-old boy who presented with typical cutaneous rash of AHEI and orchitis, the latter showing complete resolution after less than 24 hours of prednisolone therapy. The authors call attention to this entity mainly as a differential diagnosis of Henoch-Schönlein purpura and to the importance of new studies to establish the benefits of corticosteroid therapy for AHEI.

Otomastoiditis caused by Sphingomonas paucimobilis: case report and literature review.

Sphingomonas paucimobilis is an aerobic Gram-negative bacillus that, although rare in humans, most commonly infects immunocompromised and hospitalized patients. Among the 59 pediatric cases of S. paucimobilis infection reported in the literature, the most common diagnosis involves isolated bacteremia. These cases are related to sporadic or epidemic infections. Death related to this infection occurred in only one case. The authors report a case of an 11-year-old boy with the diagnosis of Sphingomonas paucimobilis otomastoiditis and a thorough review of the literature on this infection in pediatrics. The patient presented a 20-day history of fever, otalgia, otorrhea, and progressive retroauricular swelling with protrusion of the left ear; despite 15 days of amoxicillin regimen. His past medical history included chronic bilateral otitis media, but no cause of immunosuppression was found. A brain computed tomography scan showed left otomastoiditis associated with a large circumscribed fluid collection with deep involvement of the soft tissues of the temporal region, including the subperiosteal space. Blood tests showed neutrophilia and elevated C-reactive protein. Surgical manipulation of the cited collection drained a large amount of a fetid purulent secretion. Ceftazidime and clindamycin were empirically initiated. The outcome was favorable, with fever defervescence and resolution of the scalp deformation. Culture of the drained secretion was positive for S. paucimobilis. Ciprofloxacin was scheduled for a further 10 days after discharge. The follow-up showed complete recovery. As far as we know, this is the first case of S. paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. The authors call attention to the increasing number of reports on S. paucimobilis infection over the years, and therefore to the importance of this pathogen, which was previously underestimated.

Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review.

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses.

Molecular epidemiology of human adenovirus isolated from children hospitalized with acute respiratory infection in São Paulo, Brazil.

In a study of acute respiratory disease, two collections of nasopharyngeal aspirates (NPA) were obtained from children hospitalized at the Pediatric Clinic of the University Hospital, São Paulo, in 1995 and 2000. Adenovirus was detected in 33 (8.2%) of 401 children followed. These viruses were isolated in HEp-2, HEK-293, or NCI-H292 cells and serotyped by neutralization. The genome types were determined after restriction analyses of the genomic DNA extracted from infected cells. Nineteen isolates were characterized as Human adenovirus B, genome types HAdV-3a, HAdV-7h, and HAdV-7h1; 11 as Human adenovirus C, genome types HAdV-1D10, HAdV-2D25, HAdV-5D2, and HAdV-6D3. Our findings show that species C adenoviruses present an endemic infection pattern, with co-circulation of different serotypes and genome types; no new genomic variant was observed. Species B adenoviruses showed epidemic infection patterns, with shifts in the predominant genome type. The isolates from 1995 belong to genome type 7h, or the variant 7h1, with a clear substitution of the type 7b, prevalent in São Paulo for more then 10 years. In 2000, the variant 7h1 predominated and the emergence of the type 3a was observed. Almost 10 years passed between the identification of HAdV-7h in Argentina and its detection in São Paulo. The geographic isolation of these two countries was reduced by the increase in population mobility due to growing commercial relationships.

Purpura trombocitopenica imunologica associada a hepatite A: relato de caso / Immune thrombocytopenic purpura associated to hepatitis A: a case report

Relatar um caso grave de purpura trombocitopenica imunologica apos infeccoes pelo virus da hepatite A...

A coleta simultanea de swab nasal e do aspirado de nasofaringe para pesquisa de virus respiratorios em criancas hospitalizadas / Combined nasal swab and nosopharinx aspirate collection for respiratory virus search in hospitalized children

Avaliar a sensibilidade do swab nasal e do aspirado de nasofaringe, em coleta sumultanea com unificacao da amostra, para a pesquisa de virus em criancas com doenca do trato respiratorio...

Infeccao nosocomial pelo virus respiratorio sincicial em enfermaria de pediatria / Nosocomial respiratory syncytial virus infection at pediatric ward

Objetivo : avaliar a taxa de infeccao nosocomial causada por virus no trato respiratorio inferior de criancas internadas em uma enfermaria geral de pediatria durante a epidemia...

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in Säo Paulo, Brazil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations....

Infecçöes virais em crianças internadas por doença aguda no trato respiratório inferior / Viral infections in hospitalized children affected by acute lower respiratory tract disease

Objetivo: Avaliar a freqüência dos principais vírus respiratórios em crianças internadas por doença do trato respiratório inferior em hospital universitário. Métodos: Foi realizado estudo prospectivo que incluiu duas coortes de crianças internadas no período de abril a julho de 1996. Os grupos selecionados segundo a presença de patologia deo trato respiratório inferior: Grupo A - com doença aguda (tempo de história inferior a sete dias), e B-sem patologia respiratória presente ou recente. Os parâmetros para definiçäo de doença do trato respiratório inferior incluíram alteraçöes na propedêutica pulmonar e/ou às radiografias simples do tórax. Foram pré-definidos critérios clínicos e radiológicos para classificaçäo das doenças do trato respiratório inferior no grupo A. Foi coletado, à internaçäo, material da nasofaringe de todas as crianças para detecçäo de vírus, através de cultura em meio celular e por imunofluorescência direta. Resultados: Foram selecionados 201 casos, 126 no grupo A e 75 no grupo B. Foram identificados vírus em 71 crianças do grupo A (56,4 por cento), enquanto eram somente 3 no grupo B (4,0 por cento). Nas crianças do grupo A foi predominante o vírus respiratório sincicial, detectado em 66 casos, sendo também identificados adenovírus (4) e influenza (1) em outros pacientes. No grupo B foram identificados dois pacientes com vírus respiratório sincicial e um com adenovírus. Os pacientes do grupo A que apresentavam vírus respiratório sincicial tinham mediana de idade (3 meses) menor do que os outros casos deste grupo (13 meses) e apresentavam mais sibilância ao exame físico (78,7 por cento versus 33,3 por cento). Este vírus esteve associado à maior parte dos casos de broquiolite (84 por cento) e à metade das pneumonias (46,4 por cento). Conclusöes: Os autores constataram uma significativa presença de vírus na maior parte dos casos de crianças internadas com patologia aguda do trato respitatório inferior...

Sorotipos de pneumococos isolados de criancas com pneumonia: implicacao com a imunizacao especifica anti-pneumococica / Streptococcus pneumoniaie serotypes in children with pneumonia: vaccine especific for pneumococcal disease

Os autores identificaram q22 cepas de pneumococos isolados de 124 criancas internadas com pneumonia aguda durante um periodo de 15 anos. Estas pertenciam a 19 sorotipos (16 sorogrupos). A vacina anti-pneumococica com 23 antigenos permitiria potencial cobertura a 89,3 por cento dos casos de pneumonia, observando-se apenas os sorotipos envolvidos. Porem, e constatada eficacia reduzida desta vacina em criancas menores de dois anos, faixa etaria que abrange a maior parte dos casos estudados (mediana=1 ano). Outras vacinas anti-pneumococicas que contem um maximo de antigenos pertencentes a oito sorogrupos tem sido testadas. Nesta circunstancias os dados coletados no presente estudo sugerem a inclusao dos sorogrupos 1, 4, 5, 6, 7, 14, 19 e 23 que abrangem 89,3 por cento das cepas analisadas. O estudo constata variacao regional da frequencia dos sorogrupos de pneumococo implicados com patologias pediatricas.