Role of soluble triggering receptor expressed on myeloid cells-1 for diagnosing ventilator-associated pneumonia after cardiac surgery: an observational study

Abstract\ud \ud \ud \ud Background\ud The diagnosis of ventilator-associated pneumonia (VAP) is a challenge, particularly after cardiac surgery. The use of biological markers of infection has been suggested to improve the accuracy of VAP diagnosis. We aimed to evaluate the usefulness of soluble triggering receptor expressed on myeloid cells (sTREM)-1 in the diagnosis of VAP following cardiac surgery.\ud \ud \ud \ud Methods\ud This was a prospective observational cohort study of children with congenital heart disease admitted to the pediatric intensive care unit (PICU) after surgery and who remained intubated and mechanically ventilated for at least 24 hours postoperatively. VAP was defined by the 2007 Centers for Disease Control and Prevention criteria. Blood, modified bronchoalveolar lavage (mBAL) fluid and exhaled ventilator condensate (EVC) were collected daily, starting immediately after surgery until the fifth postoperative day or until extubation for measurement of sTREM-1.\ud \ud \ud \ud Results\ud Thirty patients were included, 16 with VAP. Demographic variables, Pediatric Risk of Mortality (PRISM) and Risk Adjustment for Congenital Heart Surgery (RACHS)-1 scores, duration of surgery and length of cardiopulmonary bypass were not significantly diferent in patients with and without VAP. However, time on mechanical ventilation and length of stay in the PICU and in the hospital were significantly longer in the VAP group. Serum and mBAL fluid sTREM-1 concentrations were similar in both groups. In the VAP group, 12 of 16 patients had sTREM-1 detected in EVC, whereas it was undetectable in all but two patients in the non-VAP group over the study period (p = 0.0013) (sensitivity 0.75, specificity 0.86, positive predictive value 0.86, negative predictive value 0.75, positive likelihood ratio (LR) 5.25, negative LR 0.29).\ud \ud \ud \ud Conclusion\ud Measurement of sTREM-1 in EVC may be useful for the diagnosis of VAP after cardiac surgery.We thank Ms. Flavia P. Escremim for performing real time-PCR analysis for virus detection and Mr. Davi Casale Aragon for his help with statistical analysis. This study was supported by FAEPA (Fundação de Apoio ao Ensino, Pesquisa e Assistência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo)

Implantação e desenvolvimento do Laboratório de Simulação (LabSim) da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP)

Introduction: simulation is a technique that has gained great acceptance for teaching skills and professional behavior in several areas. To overcome the limitations imposed by the high cost of the materials involved and the need for specific training, higher education institutions have implemented dedicated laboratories. Ribeirao Preto Medical School of University of Sao Paulo (RPMS-USP) has recently installed its Simulation Lab (LabSim) with the following goals: 1) To centralize, facilitate, train and coordinate didactic activities involving Simulation; 2) To promote self-directed learning among undergraduate students; 3) To develop research in Simulation in Healthcare. Objectives: to describe the process of LabSim implementation to preserve the RPMS-USP history; to analyze this process to outline new goals for its continued development. This is a descriptive study, based on revised historical documents. Methodology: the process of LabSim development is described in chronological order, highlighting the motivations for the decisions made. Results: 1) Simulation is a teaching methodology and not the simple use of technology, being necessary the training of personnel besides the incorporation of technology. 2) The physical structure is an important component to explore the methodology in its entirety. One should consider the principles of Flexibility, Space Utilization, Flow Management, Connectivity and Immersion. Consider Benchmarking to evaluate the solutions of other laboratories so you can contextualize them into your reality. 3) Individualize the addition of new simulator according to the disciplines that already use the methodology and link this acquisition with personnel training. 4) The self-learning potential of new simulators can maximize the exposure time and individualize the feedback. Conclusions: the RPMS-USP’s LabSim future goals include teacher training, strengthening the inclusion of disciplines, seeking multidisciplinary action in accordance with the standards of the Undergraduate Committee, the development of research in the field of Simulation and the national and international projection of the laboratory through accreditation processes. Nevertheless, based on the evidence provided, the implementation of the LabSim is a very successful and evolving experience.Introdução: a Simulação é uma técnica de ensino que vem ganhando grande aceitação para o ensino de habilidades e comportamento profissional em diversas áreas. Para contornar as limitações impostas pelo elevado custo dos materiais envolvidos e da necessidade de capacitação específica, as instituições de ensino superior (IES) têm implantado laboratórios específicos. A FMRP-USP completou recentemente a instalação de seu Laboratório de Simulação (LabSim) com os objetivos de: 1) Centralizar, facilitar, capacitar e coordenar as atividades didáticas que envolvam Simulação para os cursos oferecidos pela FMRP-USP; 2) Promover autoaprendizado entre alunos de graduação para consolidação e complementação do conteúdo fornecido em cursos regulares; 3) Desenvolver iniciativas inovadoras de capacitação e pesquisa em Simulação em Saúde. Objetivos: descrever o processo de implantação do LabSim para preservar a história da FMRP-USP; analisar este processo para traçar novas metas para seu desenvolvimento contínuo. Metodologia: o processo de desenvolvimento e fomento do LabSim é descrito em função cronológica, destacando-se as motivações para as decisões tomadas. Trata-se de estudo descritivo, embasado no resgate documental pertinente da FMRP-USP. Resultados: 1) A simulação é uma metodologia de ensino e não o simples uso de tecnologia, sendo necessário o investimento em capacitação de pessoal além da incorporação de tecnologia. 2) A estrutura física é um componente importante para explorar a metodologia em sua totalidade. Deve-se considerar os princípios de Flexibilidade, Aproveitamento de Espaço, Gerenciamento de fluxo, Conectividade e Imersão. Também deve ser considerada a realização de “benchmarking”, avaliando as soluções de outros laboratórios para que possam ser contextualizadas à realidade da IES. 3) Deve-se individualizar a aquisição de novos equipamentos com base nas disciplinas que já utilizam a metodologia e a aquisição deve estar vinculada com capacitação. 4) Um dos potenciais dos simuladores atuais é o autoaprendizado, que pode maximizar o tempo de exposição e individualizar o “feedback”. Conclusões: o LabSim da FMRP-USP deve ainda concretizar algumas de suas metas como a capacitação docente, o fortalecimento da inclusão de disciplinas da FMRP-USP buscando atuação multidisciplinar de acordo com as normas da Comissão de Graduação, o desenvolvimento de pesquisas na área de simulação e a projeção nacional e internacional do laboratório através de processos de acreditação. No entanto, frente às conquistas expostas, a implantação do LabSim é uma experiência exitosa e se encontra em franca evolução

COVID-19 Diagnostic and Management Protocol for Pediatric Patients

This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19

Impact of children with complex chronic conditions on costs in a tertiary referral hospital

OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients’ complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed

Do our newly graduated medical doctors have adequate knowledge about neonatal resuscitation?

CONTEXT AND OBJECTIVE: Neonatal resuscitation should be part of medical school curriculums. We aimed to evaluate medical school graduates' knowledge of neonatal resuscitation. DESIGN AND SETTING: Cross-sectional study on the performance of candidates sitting a medical residency exam at Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, in 2004. METHODS: There were two questions on neonatal resuscitation. One question in the theory test aimed at evaluating basic knowledge on the initial approach towards newly born infants. The question in the practical exam was designed to evaluate the candidate's ability to perform the initial steps of resuscitation and to establish bag-mask ventilation. RESULTS: Out of 642 candidates from 74 medical schools, 151 (23.5%) answered the theory question correctly. Significantly more physicians from public medical schools in the State of São Paulo answered correctly than did those from other schools in Brazil (52.5% versus 9.2%; p < 0.05). A total of 436 candidates did the practical exam. The grades among graduates from medical schools belonging to the State of São Paulo were significantly higher than among those from other schools (5.9 ± 2.6 versus 4.1 ± 2.1; p < 0.001). The grades for the practical question among candidates who had answered the theory question correctly were significantly higher than those obtained by candidates who had given wrong answers (p < 0.05). CONCLUSION: Medical school graduates' knowledge of neonate resuscitation in the delivery room is quite precarious. Emphasis on neonatal resuscitation training is urgently needed in medical schools

Monitoring of protein catabolism in neonates and young infants post-cardiac surgery

Aims: To evaluate cell catabolism by balance of nitrogen and phosphate, and creatinine excretion in children post-cardiac surgery; to establish protein and energy requirements to minimize catabolism; and to assess nutritional therapy by following these parameters and serial anthropometric measurements. Methods: A prospective observational study of children with congenital heart disease undergoing cardiac surgery. Blood samples and 24-h urine collections were obtained postoperatively for creatinine measurement and nitrogen and phosphate balance. Anthropometric measurements (weight, mid-arm muscle circumference and triceps skinfold thickness) were obtained preoperatively and at paediatric intensive care unit and hospital discharge. Results: Eleven children were studied for 3-10 postoperative days. Anabolism was associated with higher protein and energy intakes compared to catabolism (1.1 vs. 0.1 g/kg/day and 54 vs. 17 kcal/kg/day, respectively). On days with anabolism, phosphate balance was greater compared with that on days with catabolism. Daily creatinine excretion did not correlate with protein balance. Anthropometric measurements did not change significantly over time. Conclusions: Children with congenital heart disease undergoing cardiac surgery achieved anabolism with > 55 kcal/kg/day and > 1 g/kg/day of protein. Balance of phosphate was useful to monitor cell breakdown. Anthropometric measurements were not valuable to evaluate nutritional therapy in this population.CAPES (Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior[1309/06-4]FAEPA (Fundacao de Apoio ao Ensino, Pesquisa e Assistencia do Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo

Aprotinina não influencia troponina I, NTproBNP e função renal em crianças operadas com circulação extracorpórea High-dose aprotinin does not affect troponin I, N-Terminal pro-B-type natriuretic peptid and renal function in children submitted to surgical correction with extracorporeal circulation

OBJETIVO: Avaliar se o uso de aprotinina em altas doses hemostáticas pode influenciar as funções miocárdicas, renais e metabólicas em crianças operadas com circulação extracorpórea (CEC). MÉTODOS: Estudo prospectivo randomizado em crianças de 30 dias a 4 anos de idade, submetidas à correção de cardiopatia congênita acianogênica, com CEC e divididas em dois grupos, um denominado Controle (n=9) e o outro, Aprotinina (n=10). Neste, a droga foi administrada antes e durante a CEC. As disfunções miocárdicas e multiorgânicas foram analisadas por marcadores clínicos e bioquímicos. Foram consideradas significantes as diferenças com P<0,05. RESULTADOS: Os grupos foram semelhantes quanto às variáveis demográficas e intra-operatórias, exceto por maior hemodiluição no Grupo Aprotinina. Não houve benefício quanto aos tempos de ventilação pulmonar mecânica, permanência no Centro de Terapia Intensiva Pediátrica (CTIP) e hospitalar, nem quanto ao uso de inotrópicos e função renal. A relação PaO2/FiO2 (pressão parcial de oxigênio arterial/fração inspirada de oxigênio) apresentou queda significativa com 24h PO, no Grupo Controle. As perdas sanguíneas foram semelhantes nos dois grupos. Os marcadores troponina I cardíaca (cTnI), fração MB da creatinofosfoquinase (CKMB), transaminase glutâmico-oxalacética (TGO) e fração amino-terminal do peptídio natriurético tipo B (NT-proBNP) não apresentaram diferenças marcantes inter-grupos. A lactatemia e acidose metabólica pós-CEC foi maior no Grupo Aprotinina. Não houve complicações tromboembólicas, neurológicas ou de hipersensibilidade com o uso da aprotinina. CONCLUSÃO: A aprotinina em altas doses não influenciou significativamente nos marcadores séricos troponina I e NTproBNP e de função renal, porém foi associado com maior hemodiluição, lactatemia e acidose metabólica.<br>OBJECTIVE: To evaluate if the use of hemostatic high-dose aprotinin seems influence to myocardial, renal and metabolic functions in children submitted to surgical correction with extracorporeal circulation (ECC). Material and Methods A prospective randomized study was conducted on children aged 30 days to 4 years submitted to correction of acyanogenic congenital heart disease with ECC and divided into two groups: Control (n=9) and Aprotinin (n=10). In the Aprotinin Group the drug was administered before and during ECC and the myocardial and multiorgan dysfunctions were analyzed on the basis of clinical and biochemical markers. Differences were considered to be significant when P<0.05. RESULTS: The groups were similar regarding demographic and intraoperative variables, except for a greater hemodilution in the Aprotinin Group. The drug had no benefit regarding time of mechanical pulmonary ventilation, permanence in the pediatric postoperative intensive care unit (ICU) and length of hospitalization, or regarding the use of inotropic drugs and renal function. The partial arterial oxygen pressure/inspired oxygen fraction ratio (PaO2/FiO2) was significantly reduced 24h after surgery in the Control Group. Blood loss was similar for both groups. Cardiac troponin I (cTnI), creatine kinase MB fraction (CKMB), serum glutamic-oxaloacetic transaminase (SGOT) and the aminoterminal fraction of natriuretic peptide type B (NT-proBNP) did not differ significantly between groups. Post-ECC blood lactate concentration and metabolic acidosis was more intense in the Aprotinin Group. There were no complications with the use of aprotinin. CONCLUSION: High-dose aprotinin did not significant influence in serum markers troponin I, NT-proBNP and renal function, but did associated with hemodilution, blood lactate concentration and metabolic acidosis more intense

Design and Implementation of a Professional Master’s Program linked to the Medical Residency: the experience of the Ribeirão Preto Medical School, University of São Paulo

A prática assistencial em saúde apresenta desafios crescentes, exigindo do médico o desenvolvimento de habilidades e competências diversificadas que facilitem a sua atuação qualificada. A reflexão crítica e a autonomia no gerenciamento da prática profissional exigem do médico domínio de fundamentos de metodologia científica, o que nem sempre é contemplado nas matrizes curriculares dos programas de residência médica, por seu caráter de treinamento em serviço. Visando suprir essa lacuna na formação médica, foi instituído, na Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), um programa de pós-graduação stricto senso (mestrado profissional) vinculado a programas de pós-graduação lato sensu (residência médica e estágios de complementação especializada) do Hospital das Clínicas da FMRP-USP. Este relato de experiência destina-se à apresentação do racional e dos processos para a implantação do Programa de Pós-Graduação “Mestrado Profissional em Medicina” da FMRP-USP, bem como seus objetivos, público-alvo e perfil do egresso. Espera-se que este relato contribua para a reflexão a respeito dos diferentes componentes e da complexidade da formação médica.The health care practice presents growing challenges, requiring physicians to develop various skills and competencies that facilitate their qualified performance. Critical reflection and autonomy in the management of professional practice require the physician to master the fundamentals of scientific methodology, which is not always included in the curriculum of medical residency programs due to its in-service training nature. Aiming to fill this gap in medical education, a graduate program (professional master’s degree) was established at the Ribeirão Preto Medical School at the University of São Paulo (FMRP-USP). This experience report is intended to present the rationale and processes for implementing the Graduate Program “Professional Master in Medicine” at the FMRP-USP, in additionto its objectives, target audience, and graduate profile. It is expected that this report will contribute to a reflection on the different components and complexity of medical training