Identifying biologically implausible values in big longitudinal data: an example applied to child growth data from the Brazilian food and nutrition surveillance system.

BACKGROUND: Several strategies for identifying biologically implausible values in longitudinal anthropometric data have recently been proposed, but the suitability of these strategies for large population datasets needs to be better understood. This study evaluated the impact of removing population outliers and the additional value of identifying and removing longitudinal outliers on the trajectories of length/height and weight and on the prevalence of child growth indicators in a large longitudinal dataset of child growth data. METHODS: Length/height and weight measurements of children aged 0 to 59 months from the Brazilian Food and Nutrition Surveillance System were analyzed. Population outliers were identified using z-scores from the World Health Organization (WHO) growth charts. After identifying and removing population outliers, residuals from linear mixed-effects models were used to flag longitudinal outliers. The following cutoffs for residuals were tested to flag those: -3/+3, -4/+4, -5/+5, -6/+6. The selected child growth indicators included length/height-for-age z-scores and weight-for-age z-scores, classified according to the WHO charts. RESULTS: The dataset included 50,154,738 records from 10,775,496 children. Boys and girls had 5.74% and 5.31% of length/height and 5.19% and 4.74% of weight values flagged as population outliers, respectively. After removing those, the percentage of longitudinal outliers varied from 0.02% (<-6/>+6) to 1.47% (<-3/>+3) for length/height and from 0.07 to 1.44% for weight in boys. In girls, the percentage of longitudinal outliers varied from 0.01 to 1.50% for length/height and from 0.08 to 1.45% for weight. The initial removal of population outliers played the most substantial role in the growth trajectories as it was the first step in the cleaning process, while the additional removal of longitudinal outliers had lower influence on those, regardless of the cutoff adopted. The prevalence of the selected indicators were also affected by both population and longitudinal (to a lesser extent) outliers. CONCLUSIONS: Although both population and longitudinal outliers can detect biologically implausible values in child growth data, removing population outliers seemed more relevant in this large administrative dataset, especially in calculating summary statistics. However, both types of outliers need to be identified and removed for the proper evaluation of trajectories.

Quality of child anthropometric data from SISVAN, Brazil, 2008-2017.

OBJECTIVE: To evaluate the quality of anthropometric data of children recorded in the Food and Nutrition Surveillance System (SISVAN) from 2008 to 2017. METHOD: Descriptive study on the quality of anthropometric data of children under five years of age admitted in primary care services of the Unified Health System, from the individual databases of SISVAN. Data quality was annually assessed using the indicators: coverage, completeness, sex ratio, age distribution, weight and height digit preference, implausible z-score values, standard deviation, and normality of z-scores. RESULTS: In total, 73,745,023 records and 29,852,480 children were identified. Coverage increased from 17.7% in 2008 to 45.4% in 2017. Completeness of birth date, weight, and height corresponded to almost 100% in all years. The sex ratio was balanced and approximately similar to the expected ratio, ranging from 0.8 to 1. The age distribution revealed higher percentages of registrations from the ages of two to four years until mid-2015. A preference for terminal digits "zero" and "five" was identified among weight and height records. The percentages of implausible z-scores exceeded 1% for all anthropometric indices, with values decreasing from 2014 onwards. A high dispersion of z-scores, including standard deviations between 1.2 and 1.6, was identified mainly in the indices including height and in the records of children under two years of age and residents in the North, Northeast, and Midwest regions. The distribution of z-scores was symmetric for all indices and platykurtic for height/age and weight/age. CONCLUSIONS: The quality of SISVAN anthropometric data for children under five years of age has improved substantially between 2008 and 2017. Some indicators require attention, particularly for height measurements, whose quality was lower especially among groups more vulnerable to nutritional problems.

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.

Quality of child anthropometric data from SISVAN, Brazil, 2008-2017 / Qualidade dos dados antropométricos infantis do Sisvan, Brasil, 2008-2017

ABSTRACT OBJECTIVE To evaluate the quality of anthropometric data of children recorded in the Food and Nutrition Surveillance System (SISVAN) from 2008 to 2017. METHOD Descriptive study on the quality of anthropometric data of children under five years of age admitted in primary care services of the Unified Health System, from the individual databases of SISVAN. Data quality was annually assessed using the indicators: coverage, completeness, sex ratio, age distribution, weight and height digit preference, implausible z-score values, standard deviation, and normality of z-scores. RESULTS In total, 73,745,023 records and 29,852,480 children were identified. Coverage increased from 17.7% in 2008 to 45.4% in 2017. Completeness of birth date, weight, and height corresponded to almost 100% in all years. The sex ratio was balanced and approximately similar to the expected ratio, ranging from 0.8 to 1. The age distribution revealed higher percentages of registrations from the ages of two to four years until mid-2015. A preference for terminal digits "zero" and "five" was identified among weight and height records. The percentages of implausible z-scores exceeded 1% for all anthropometric indices, with values decreasing from 2014 onwards. A high dispersion of z-scores, including standard deviations between 1.2 and 1.6, was identified mainly in the indices including height and in the records of children under two years of age and residents in the North, Northeast, and Midwest regions. The distribution of z-scores was symmetric for all indices and platykurtic for height/age and weight/age. CONCLUSIONS The quality of SISVAN anthropometric data for children under five years of age has improved substantially between 2008 and 2017. Some indicators require attention, particularly for height measurements, whose quality was lower especially among groups more vulnerable to nutritional problems.

RESUMO OBJETIVOS Avaliar a qualidade dos dados antropométricos de crianças registradas no Sistema de Vigilância Alimentar e Nutricional (Sisvan) no período 2008-2017. MÉTODOS Estudo descritivo sobre a qualidade dos dados antropométricos de crianças menores de 5 anos atendidas nos serviços de atenção primária do Sistema Único de Saúde, a partir das bases de dados individuais do Sisvan. A qualidade dos dados foi avaliada anualmente por meio dos indicadores: cobertura, completude, razão entre sexos, distribuição da idade, preferência por dígitos de peso e estatura, valores de escore-z implausíveis, desvio-padrão e normalidade dos escores-z. RESULTADOS No total, 73.745.023 registros e 29.852.480 crianças foram identificados. A cobertura aumentou de 17,7% em 2008 para 45,4% em 2017. A completude da data de nascimento, peso e estatura correspondeu a quase 100% para todos os anos. A razão entre sexos foi equilibrada e aproximadamente similar a razão esperada, variando entre 0,8 e 1. A distribuição da idade revelou maiores percentuais de registros entre as idades de 2 a 4 anos até meados de 2015. Uma preferência pelos dígitos terminais "zero" e "cinco" foi identificada entre os registros de peso e estatura. As porcentagens de escores-z implausíveis excederam 1% para todos os índices antropométricos, com redução dos valores a partir de 2014. Uma alta dispersão dos escores-z, incluindo desvios-padrão entre 1,2 e 1,6, foi identificada principalmente nos índices incluindo estatura e nos registros de crianças menores de 2 anos e residentes das regiões Norte, Nordeste e Centro-Oeste. A distribuição dos escores-z foi simétrica para todos os índices e platicúrtica para estatura/idade e peso/idade. CONCLUSÕES A qualidade dos dados antropométricos do Sisvan para crianças menores de 5 anos melhorou substancialmente entre 2008 e 2017. Alguns indicadores requerem atenção, sobretudo para medidas de estatura, cuja qualidade foi principalmente inferior entre os grupos mais vulneráveis a agravos nutricionais.

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.

Effects of photobiomodulation in salivary glands of chronic kidney disease patients on hemodialysis.

This randomized placebo-controlled trial evaluates the impact of photobiomodulation (PBMT) on the salivary flow and biochemistry of patients with chronic kidney disease (CKD) on hemodialysis. Forty-four patients on hemodialysis self-responded two questionnaires for oral health and salivary gland function perception. The subjects were evaluated for function of salivary glands and randomly allocated to two groups: PBMT group (three irradiations at 808 nm, 100 mW, 142 J/cm2, and 4 J per site); and placebo group. Patients were submitted to non-stimulated and stimulated sialometry and after the treatment at baseline and 14 days. Salivary volume and biochemical of the saliva were analyzed. At baseline, most subjects had self-perception of poor oral health (52.6%) and salivary dysfunction (63.1%). Clinical exam revealed that 47.3% of subjects presented dry mucosa. PBMT promoted increase of the non-stimulated (p = 0.027) and stimulated saliva (p = 0.014) and decrease of urea levels in both non-stimulated (p = 0.0001) and stimulated saliva (p = 0.0001). No alteration was detected in total proteins and calcium analysis. Patients with kidney disease can present alteration in flow, concentrations, and composition of saliva, affecting oral health, but our findings suggest that PBMT is effective to improve hyposalivation and urea levels in saliva of patients with CKD.

Histopathological study of canine sebaceous tumors and their association with PCNA expression by immunohistochemistry / Estudo histopatológico de tumores sebáceos caninos e sua associação com a expressão de PCNA por imuno-histoquímica

Sebaceous tumors are common in dogs. These tumors include both benign and malignant lesions. Immunohistochemical evaluation of these tumors can aggregate information regarding the origin and degree of malignancy of the lesions. Focusing on this matter, sixty-one samples including normal skin and sebaceous tumors were selected from dogs of various breeds and ages, with no predilection for sex, from the archive of Veterinary Pathology Service of Federal Fluminense University, Niterói/RJ, Brazil. The samples underwent to histological processing, routine staining and immunohistochemistry with anti-PCNA (proliferating cell nuclear antigen). Descriptive statistical analysis was performed, the Wilcoxon-Mann-Whitney test was used to compare the distribution of anti-PCNA labelling in different groups of variables. In case there were more than two groups, the Analysis of Variance (ANOVA) test was performed. The mean age of the affected animals was 10.56 years. The most affected breeds were Caniches and Cocker Spaniels, as well as mixed breed animals. There was immunostaining of PCNA in both benign and malignant tumors, as well as in hyperplasic lesions with varying intensity. Most of the tumors were neoplasms which represented 67.27% of the total sample; within these, 75.00% were benign. The most frequent neoplasm was sebaceous adenoma (37.74%). Results indicated no statistical difference in the distribution of anti-PCNA labelling between the groups of sex, age, reproductive status, localization, size of tumor, and histopathological diagnosis. Although there are not many studies analyzing anti-PCNA labelling in sebaceous tumors, several of them pointed out to the predictive value in other neoplasms. With this matter in mind, we intended to evaluate the expression of anti-PCNA in canine sebaceous tumor and a possible association with the malignancy of the lesions.

Tumores sebáceos são comuns em cães. Tais tumores incluem lesões benignas e malignas. A avaliação imunohistoquímica desses tumores pode agregar informações sobre a origem e o grau de malignidade das lesões. Para este fim, sessenta e uma amostras, incluindo pele normal e tumores sebáceos foram selecionadas de cães de várias raças e idades, sem predileção por sexo, do arquivo do Serviço de Patologia Veterinária da Universidade Federal Fluminense, Niterói/RJ, Brasil. As amostras passaram por processamento histológico, coloração de rotina e imuno-histoquímica com anti-PCNA (proliferating cell nuclear antigen). Foram realizadas análises estatísticas descritivas além dos testes de Wilcoxon-Mann-Whitney para comparar a distribuição da marcação de anti-PCNA entre grupos de variáveis. Para variáveis com mais de dois grupos, aplicou-se a Análise de Variância (ANOVA). A idade média dos animais afetados foi de 10.56 anos. As raças mais afetadas foram Caniches e Cocker Spaniel, e ainda animais sem raça definida. Houve imunomarcação de PCNA em tumores benignos, malignos, e ainda em lesões hiperplásicas com intensidade variada. A maioria dos tumores eram neoplásicos representando 67.92% do total; destes, 75.00% eram benignos. O adenoma sebáceo foi a neoplasia mais frequente (37.74%). Não foram encontradas diferenças significativas nas distribuições de anti-PCNA entre os grupos das variáveis sexo, idade, status reprodutivo, localização e tamanho do tumor e diagnóstico histopatológico. Embora não haja estudos com anti-PCNA em tumores sebáceos caninos, numerosas publicações apontam seu valor preditivo em outras neoplasias. Com isso, a finalidade deste estudo foi avaliar a expressão de anti-PCNA em tumores sebáceos caninos e sua possível associação com a malignidade das lesões.

Hantavirus cardiopulmonary syndrome: a report of two cases / Síndrome cardiopulmonar por hantavírus: relato de dois casos

Infection with hantavirus, from the family Bunyaviridae, causes hantavirus cardiopulmonary syndrome (HCPS) in the Americas. This highly lethal anthropozoonosis afflicts preferentially individuals in rural areas and is transmitted by aerosol of excreta from infected wild rodents. The aim of this study is to report the almost simultaneous occurrence of two cases of HCPS in the municipality of Jataí, state of Goiás, Brazil.

A infecção por hantavírus, família Bunyaviridae, provoca a síndrome cardiopulmonar por hantavírus (SCPH) nos países da América. Ela é uma antropozoonose, de elevada letalidade, que tem acometido preferencialmente indivíduos em contato com o meio rural, sendo transmitida por aerossóis a partir das excretas dos roedores silvestres infectados. O objetivo deste estudo foi relatar a ocorrência, quase que simultânea, de dois casos de SCPH ocorridos no município de Jataí, Estado de Goiás, Brasil.