Echocardiography Learning by Pediatricians While Screening Congenital Heart Disease with the Aid of Telemedicine.

Background: Congenital heart disease (CHD) affects 1% of all newborns and is a major public health problem. Most children with CHD benefit from early diagnosis to optimize management. However, in many places there are no specialized professionals to do so. Introduction: A screening method for CHD was developed between two states in Northeast Brazil. It was based upon the performance of an echocardiogram by local pediatricians with support of pediatric cardiologists through telemedicine. Objective: To determine if the continuous performance of examinations together with online supervision increased the level of understanding of the pediatricians about the echocardiograms. Methods: Pediatricians received online support to perform echocardiograms for 7 years (2012-2018). Although the project aimed to teach them to acquire images and send to the cardiologists for analysis and interpretation, they were encouraged to describe their own diagnostic impressions. The level of agreement between pediatricians and cardiologists was calculated. Results: A large number (n = 3,951) echocardiograms was analyzed. From them, 2,818 were classified as abnormal, inconclusive, or normal by both the pediatricians and the cardiologists. The 7-year analysis demonstrated an overall agreement of 63.7%. As for the final diagnosis, it was possible to compare 1,457 echocardiograms. The combined analysis of the 7 years demonstrated agreement in 62.2%. Discussion: The screening of CHD under online support led to more in-depth learning of echocardiography by the pediatricians. This approach potentialized the accuracy of the screening through the years. Conclusion: By enrolling in a telemedicine-based screening program, the pediatricians' degree of understanding of echocardiography increased considerably.

A telemedicine network for remote paediatric cardiology services in north-east Brazil.

PROBLEM: Providing health care for children with congenital heart diseases remains a major challenge in low- and middle-income countries. APPROACH: In October 2011, the Government of Paraíba, Brazil, established a paediatric cardiology network in partnership with the nongovernmental organization Círculo do Coração. A cardiology team supervised all network activities, using the Internet to keep in contact with remote health facilities. The network developed protocols for screening heart defects. Echocardiograms were performed by physicians under direct online supervision of a cardiologist; alternatively, a video recording of the examination was subsequently reviewed by a cardiologist. Cardiovascular surgeons came to a paediatric hospital in the state capital once a week to perform heart surgeries. LOCAL SETTING: Until 2011, the State of Paraíba had no structured programme to care for children with heart disease. This often resulted in missed or late diagnosis, with adverse health consequences for the children. RELEVANT CHANGES: From 2012 to 2014, 73,751 babies were screened for heart defects and 857 abnormalities were identified. Detection of congenital heart diseases increased from 4.09 to 11.62 per 1000 live births (P < 0.001). Over 6000 consultations and echocardiograms were supervised via the Internet. Time to diagnosis, transfers and hospital stays were greatly reduced. A total of 330 operations were carried out with 6.7% (22/330) mortality. LESSONS LEARNT: Access to an echocardiography machine with remote supervision by a cardiologist improves the detection of congenital heart disease by neonatologists; virtual outpatient clinics facilitate clinical management; the use of Internet technology with simple screening techniques allows resources to be allocated more efficiently.

Impact of a Virtual Clinic in a Paediatric Cardiology Network on Northeast Brazil.

Introduction. Congenital heart diseases (CHD) affect approximately 1% of live births and is an important cause of neonatal morbidity and mortality. Despite that, there is a shortage of paediatric cardiologists in Brazil, mainly in the northern and northeastern regions. In this context, the implementation of virtual outpatient clinics with the aid of different telemedicine resources may help in the care of children with heart defects. Methods. Patients under 18 years of age treated in virtual outpatient clinics between January 2013 and May 2014 were selected. They were divided into 2 groups: those who had and those who had not undergone a screening process for CHD in the neonatal period. Clinical and demographic characteristics were collected for further statistical analysis. Results. A total of 653 children and teenagers were treated in the virtual outpatient clinics. From these, 229 had undergone a neonatal screening process. Fewer abnormalities were observed on the physical examination of the screened patients. Conclusion. The implementation of pediatric cardiology virtual outpatient clinics can have a positive impact in the care provided to people in areas with lack of skilled professionals.

Exame físico e oximetria de pulso para detectar cardiopatias congênitas / Clinical examination and pulse oximetry to detect congenital heart defects

Fundamentos: Muitos estudos têm mostrado que a oximetria de pulso arterial é uma ferramenta eficaz para triagem de cardiopatia congênita (CC), e a maioria desses estudos foi conduzida em países desenvolvidos. Objetivo: Analisar os dados iniciais da triagem de CC realizada pelo exame físico e pela oximetria de pulso arterial em maternidade do nordeste brasileiro. Métodos: Crianças nascidas além da 34ª semana de gestação e bem clinicamente foram triadas para CC através do exame físico (EF) e pela oximetria de pulso arterial (OPA) após 24 horas de vida e antes da alta hospitalar. Resultados: As técnicas de rastreio aumentaram a detecção de CC na maternidade. No entanto, a maioria dos casos foi detectada por meio do exame físico. A oximetria de pulso arterial apresentou desempenho inferior. Conclusão: A associação de exame físico e oximetria de pulso arterial é importante na detecção de cardiopatias congênitas. A oximetria de pulso isolada, embora útil para detectar casos críticos, apresentou desempenho inferior ao exame físico.

Background: Many studies have shown that arterial-pulse oximetry is an effective tool for screening congenital heart defects (CHD), and most of these studies have been carried out in developed countries. Objective: Analyze primary data from the CHD screening performed through clinical examination and arterialpulse oximetry in a maternity hospital, in the Brazilian Northeast.Methods: Neonates born after 34 weeks of pregnancy and in good clinical conditions were screened for CHD through clinical examination (CE) and arterial-pulse oximetry (APO) after 24 hours of life and before hospital discharge. Results: Screening techniques increased the detection of CHD at the maternity hospital. However, most cases were detected through clinical examination. Underperformance of arterial-pulse oximetry. Conclusion: The combination of arterial-pulse oximetry and clinical examination is crucial in the detection of congenital heart defects. Arterial-pulse oximetry alone, although useful to detect critical cases, has underperformed against clinical examination. n

Sonolência diurna excessiva e fatores de risco cardiometabólicos em crianças e adolescentes com excesso de peso / Excessive daytime sleepnessand cardiometabolic risk factors in children and teenagers with overweight

Introdução: atualmente, é observada tendência exacerbada para sonolência diurna excessiva em crianças e adolescentes com excesso de peso. A obesidade e os distúrbios do sono, têm efeito conjunto nas doenças cardiovasculares e no diabetes mellitus. Objetivo: avaliar a prevalência de sonolência diurna excessiva e sua associação com fatores de risco cardiometabólicos. Método: estudo de corte transversal realizado em serviço público, referência em atendimento a crianças e adolescentes com excesso de peso no período de junho de 2011 a março de 2013, em Campina Grande/PB. A amostra foi composta por 140 crianças e adolescentes de cinco a 18 anos. Foi realizada antropometria, aferida a pressão arterial, aplicado questionário sobre hábitos do sono, Escala de Sonolência de Epworth e realizados exames laboratoriais (perfil lipídico, glicemia, insulina, HOMA-RI, hemoglobia glicada, proteína C-reativa ultrassensível e leptina). Os dados foram analisados pelo SPSS (v.17), através dos testes do Qui-quadrado, de variância e da correlação de Pearson, com nível de significância de 5 por cento. Resultados: A prevalência de sonolência diurna excessiva foi de 19,3 por cento e foi maior nas meninas. Naqueles com SDE foi observado maior percentual de alteração nos níveis de LDL, HbA1c e PCR-u, porém sem significância estatística. Conclusões: a presença de sonolência na amostra estudada foi prevalente e a aqueles com esta condição apresentaram resultados metabólicos menos favoráveis.(AU)

Excessive daytime sleepnessand cardiometabolic risk factors in children and teenagers with overweight / Sonolência diurna excessiva e fatores de risco cardiometabólicos em crianças e adolescentes com excesso de peso

INTRODUCTION: Currently, an exacerbated trend for excessive daytime sleepiness in overweight children and adolescents has been observed. Obesity and sleep disorders have a combined effect on cardiovascular diseases and diabetes mellitus. The aim of the study was to evaluate the prevalence of excessive daytime sleepiness and its association with cardiometabolic risk factors. METHOD: Cross-sectional study carried out in a public service, which is reference service for overweight children and adolescents in the period from June 2011 to March 2013 in Campina Grande / PB. The sample consisted of 140 children and adolescents aged from five to 18 years. Anthropometry and blood pressure measures were performed and a questionnaire on sleep habits and Epworth Sleepiness Scale were applied. Laboratory tests were also conducted (lipid profile, blood glucose levels, insulin, HOMA-IR, glycated hemoglobin, ultrasensitive C-reactive protein and leptin). Data were analyzed using SPSS software (v.17), through the chi-square test, ANOVA and Pearson's correlation, with significance level of 5 percent. RESULTS: the prevalence of excessive daytime sleepiness was 19.3 percent and it was higher among girls. In those with excessive daytime sleepiness was observed the highest percentage change in LDL levels, HbA1c and CRP-u, but without statistical significance. CONCLUSIONS: the presence of sleepiness were prevalent in this sample, and those with this condition showed less favorable metabolic results.(AU)

INTRODUÇÃO: atualmente, é observada tendência exacerbada para sonolência diurna excessiva em crianças e adolescentes com excesso de peso. A obesidade e os distúrbios do sono, têm efeito conjunto nas doenças cardiovasculares e no diabetes mellitus. OBJETIVO: avaliar a prevalência de sonolência diurna excessiva e sua associação com fatores de risco cardiometabólicos. MÉTODO: estudo de corte transversal realizado em serviço público, referência em atendimento a crianças e adolescentes com excesso de peso no período de junho de 2011 a março de 2013, em Campina Grande/PB. A amostra foi composta por 140 crianças e adolescentes de cinco a 18 anos. Foi realizada antropometria, aferida a pressão arterial, aplicado questionário sobre hábitos do sono, Escala de Sonolência de Epworth e realizados exames laboratoriais (perfil lipídico, glicemia, insulina, HOMA-RI, hemoglobia glicada, proteína C-reativa ultrassensível e leptina). Os dados foram analisados pelo SPSS (v.17), através dos testes do Qui-quadrado, de variância e da correlação de Pearson, com nível de significância de 5 por cento. RESULTADOS: A prevalência de sonolência diurna excessiva foi de 19,3 por cento e foi maior nas meninas. naqueles com SDE foi observado maior percentual de alteração nos níveis de LDL, HbA1c e PCR-u, porém sem significância estatística. CONCLUSÕES: a presença de sonolência na amostra estudada foi prevalente e a aqueles com esta condição apresentaram resultados metabólicos menos favoráveis.(AU)

Sonolência diurna excessiva e fatores de risco cardiometabólicos em crianças e adolescentes com excesso de peso / Excessive daytime sleepnessand cardiometabolic risk factors in children and teenagers with overweight

Introdução: atualmente, é observada tendência exacerbada para sonolência diurna excessiva em crianças e adolescentes com excesso de peso. A obesidade e os distúrbios do sono, têm efeito conjunto nas doenças cardiovasculares e no diabetes mellitus. Objetivo: avaliar a prevalência de sonolência diurna excessiva e sua associação com fatores de risco cardiometabólicos. Método: estudo de corte transversal realizado em serviço público, referência em atendimento a crianças e adolescentes com excesso de peso no período de junho de 2011 a março de 2013, em Campina Grande/PB. A amostra foi composta por 140 crianças e adolescentes de cinco a 18 anos. Foi realizada antropometria, aferida a pressão arterial, aplicado questionário sobre hábitos do sono, Escala de Sonolência de Epworth e realizados exames laboratoriais (perfil lipídico, glicemia, insulina, HOMA-RI, hemoglobia glicada, proteína C-reativa ultrassensível e leptina). Os dados foram analisados pelo SPSS (v.17), através dos testes do Qui-quadrado, de variância e da correlação de Pearson, com nível de significância de 5 por cento. Resultados: A prevalência de sonolência diurna excessiva foi de 19,3 por cento e foi maior nas meninas. Naqueles com SDE foi observado maior percentual de alteração nos níveis de LDL, HbA1c e PCR-u, porém sem significância estatística. Conclusões: a presença de sonolência na amostra estudada foi prevalente e a aqueles com esta condição apresentaram resultados metabólicos menos favoráveis.

Acanthosis nigricans and insulin resistance in overweight children and adolescents.

BACKGROUND: Studies have suggested an association between the presence of acanthosis nigricans (AN) and the development of diabetes. OBJECTIVE: To investigate the association between AN and insulin resistance (IR) in overweight children and adolescents receiving care at the Center for Childhood Obesity, Campina Grande, PB. METHODS: This cross-sectional study was conducted between April 2009 and April 2010 including 194 individuals of 2 to 18 years of age receiving care within the Brazilian national health network. The presence of acanthosis nigricans was verified and anthropometric measurements were taken. The following tests were performed: insulin, triglycerides, HDL-cholesterol, glucose and homeostasis model of assessment - insulin resistance (HOMA-IR). Statistical analyses were performed using the SPSS software program, version 17.0. RESULTS: There was a greater prevalence of females (66%), brown-skinned individuals (63.4%), adolescents (61.3%) and severely obese individuals (66.5%). Acanthosis nigricans was identified in 58.2% and IR in 42.7% of the participants. Acanthosis nigricans was associated with being non-white (p = 0.003), with being an adolescent (p = 0.003) and with IR (p = 0.001). Non-white individuals, adolescents and those with insulin resistance were 5.4, 2.47 and 2.66 times more likely to have acanthosis nigricans, respectively. CONCLUSION: The results of this study indicate a need to train healthcare professionals to identify acanthosis nigricans, since this condition is associated with IR. Identifying acanthosis nigricans in childhood permits the safe and timely treatment of cardiometabolic disorders through careful monitoring and appropriate treatment.

Acanthosis nigricans and insulin resistance in overweight children and adolescents / Acantose nigricans e resistência insulínica em crianças e adolescentes com excesso de peso

BACKGROUND: Studies have suggested an association between the presence of acanthosis nigricans (AN) and the development of diabetes. OBJECTIVE: To investigate the association between AN and insulin resistance (IR) in overweight children and adolescents receiving care at the Center for Childhood Obesity, Campina Grande, PB. METHODS: This cross-sectional study was conducted between April 2009 and April 2010 including 194 individuals of 2 to 18 years of age receiving care within the Brazilian national health network. The presence of acanthosis nigricans was verified and anthropometric measurements were taken. The following tests were performed: insulin, triglycerides, HDL-cholesterol, glucose and homeostasis model of assessment - insulin resistance (HOMA-IR). Statistical analyses were performed using the SPSS software program, version 17.0. RESULTS: There was a greater prevalence of females (66%), brown-skinned individuals (63.4%), adolescents (61.3%) and severely obese individuals (66.5%). Acanthosis nigricans was identified in 58.2% and IR in 42.7% of the participants. Acanthosis nigricans was associated with being non-white (p = 0.003), with being an adolescent (p = 0.003) and with IR (p = 0.001). Non-white individuals, adolescents and those with insulin resistance were 5.4, 2.47 and 2.66 times more likely to have acanthosis nigricans, respectively. CONCLUSION: The results of this study indicate a need to train healthcare professionals to identify acanthosis nigricans, since this condition is associated with IR. Identifying acanthosis nigricans in childhood permits the safe and timely treatment of cardiometabolic disorders through careful monitoring and appropriate treatment.

FUNDAMENTOS: Estudos sugerem haver associação entre a presença de Acantose Nigricans e o desenvolvimento do diabetes. OBJETIVO: Verificar a associação entre Acantose Nigricans e Resistência Insulínica (RI) em crianças e adolescentes com excesso de peso, atendidos no Centro de Obesidade Infantil, Campina Grande-PB. MÉTODOS: Estudo transversal realizado entre abril/2009 a abril/2010, com amostra de 194 pessoas entre 2 e 18 anos, usuários do Sistema Único de Saúde. Na avaliação, foi observada a presença de AN e verificadas as medidas antropométricas. Foram realizados os exames: insulina, triglicerídeos, HDL-colesterol, glicose e HOMA-IR. As análises estatísticas foram realizadas no SPSS, 17.0. RESULTADOS: Houve maior prevalência do sexo feminino (66%), pardos (63,4%), adolescentes (61,3%) e obesos graves (66,5%). Foi identificada AN em 58,2% e RI em 42,7%. A Acantose Nigricans esteve associada à cor não-branca (p=0,003), adolescentes (p=0,003) e RI (p=0,001). Os não-brancos apresentaram chance de 5,4 vezes maior de terem Acantose Nigricans, os adolescentes, de 2,47 e os com Resistência Insulínica, de 2,66. CONCLUSÃO: Os resultados na população em estudo indicam a necessidade de treinamento voltado à identificação da Acantose Nigricans para profissionais de saúde, pois este sinal esteve associado à Resistência Insulínica. Identificar a Acantose Nigricans desde a infância permite prevenir e tratar precocemente distúrbios cardiometabólicos, através de acompanhamento criterioso e tratamento adequado.