Diagnosis of Tuberculosis among Children and Adolescents

The authors discuss the challenging aspects of the diagnosis of tuberculosis in children and adolescents, since there is no gold standard for its diagnosis. The different clinical and radiological presentations and the low bacteriological positivity of tuberculosis in childhood are grounds for confrontation to the present. Immunological tests called interferon gamma release assays (IGRAs) failed to overcome the tuberculin skin test in practice. Advances with nucleic acid amplification tests, on the other hand, have contributed to the diagnosis of tuberculosis among adolescents. Standardized systems for diagnosis can be useful as tools for screening or for decision‐making in childhood tuberculosis

BRONCOSCOPIA PEDIÁTRICA: EXPERIÊNCIA DE 20 ANOS DE UM CENTRO DE REFERÊNCIA DO RIO DE JANEIR

Objective: to describe 20-year experience of a pediatric bronchoscopy service, highlighting clinical and demographic aspects, indications, endoscopic findings and the occurrence of serious complications. Methods: descriptive, retrospective study of bronchoscopy exams performed from 2000 to 2019, in a pediatric hospital in Rio de Janeiro. Results: 1,372 exams were performed, 795 (58%) of which were boys and 676 (49%) were infants. Fiberoptic bronchoscopy (FB) was the technique used in 940 exams (69%). Stridor was the indication in 315 exams (21%), followed by investigation of radiological images (17%), tracheostomy revision (11%) and tracheal intubation complications (10%). Laryngomalacia was observed in 255 (68%) cases of stridor and inflammation (65-52%) and secretion plugs (34-27%) in cases of atelectasis. Subglottic stenosis was the endoscopic diagnosis in 71 (45%) of the exams performed due to tracheal intubation complications. Granuloma and supraostial malacia were present, respectively, in 35% and 20% of tracheostomized children. The frequency of major complications was 0.22%. There were no deaths. Conclusions: Laryngomalacia was the main diagnosis in cases of stridor. Subglottic stenosis is an important diagnosis in cases with previous tracheal intubation. The high frequency of supraostial complications in tracheostomized children reinforces the need for endoscopic evaluation prior to decannulation. Bronchoscopy proved to be a safe method in the pediatric population.Objetivo: describir la experiencia de 20 años de un servicio de broncoscopia pediátrica, destacando los aspectos clínicos y demográficos, las indicaciones, los hallazgos endoscópicos y la ocurrencia de complicaciones graves. Métodos: estudio descriptivo retrospectivo de exámenes broncoscópicos realizados entre 2000 y 2019, en un hospital pediátrico de Río de Janeiro. Resultados: se realizaron 1.372 exámenes, de las cuales 795 (58%) fueron varones y 676 (49%) niños. La broncofibroscopia (BF) fue la técnica utilizada en 940 exámenes (69%). El estridor fue la indicación en 315 exámenes (21%), seguido de investigación de imágenes radiológicas (17%), revisión de traqueostomía (11%) y complicaciones de la intubación traqueal (10%). Se observó laringomalacia en 255 (68%) casos de estridor e inflamación (65-52%) y plugs de secreción (34-27%) en casos de atelectasia. La estenosis subglótica fue el diagnóstico endoscópico en 71 (45%) de los exámenes realizados por complicaciones de la intubación traqueal. El granuloma y la malacia supraostial estaban presentes, respectivamente, en el 35 % y el 20 % de los pacientes traqueostomizados. La frecuencia de complicaciones mayores fue del 0,22%. No hubo muertes. Conclusiones: La laringomalacia fue el principal diagnóstico en los casos de estridor. La estenosis subglótica es un diagnóstico importante en casos con intubación traqueal previa. La alta frecuencia de complicaciones supraostiales en pacientes traqueostomizados refuerza la necesidad de una evaluación endoscópica previa a la decanulación. La broncoscopia demostró ser un método seguro en la población pediátrica.Objetivo: descrever a experiência de 20 anos de um serviço de broncoscopia pediátrica, destacando aspectos clínicos e demográficos, indicações, achados endoscópicos e ocorrência de complicações graves. Métodos: estudo descritivo, retrospectivo, dos exames de broncoscopia realizados no período de 2000 a 2019, em um hospital pediátrico- RJ. Resultados: foram realizados 1.372 exames, sendo 795 (58%) meninos e 676 (49%) lactentes. A broncofibroscopia (BF) foi a técnica utilizada em 940 exames (69%). Estridor foi a indicação em 315 exames (21%), seguida de investigação de imagens radiológicas (17%), revisão de traqueostomia (11%) e complicações de intubação traqueal (10%). A laringomalácia foi observada em 255 (68%) dos casos de estridor e inflamação (65- 52%) e plugs de secreção (34- 27%) nos casos de atelectasia. A estenose subglótica foi o diagnóstico endoscópico em 71 (45%) dos exames realizados por complicações de intubação traqueal. Granuloma e malácia supra-ostial estavam presentes, respectivamente, em 35% e 20% das crianças traqueostomizadas. A frequência de complicações maiores foi de 0,22%. Não houve óbitos. Conclusões: A laringomalácia foi o principal diagnóstico nos casos de estridor. A estenose subglótica é um diagnóstico importante nos casos em que houve intubação traqueal prévia. A alta frequência de complicações supra-ostiais em crianças traqueostomizadas reforça a necessidade de avaliação endoscópica prévia à decanulação. A broncoscopia mostrou-se um método seguro na população pediátrica.Objetivo: descrever a experiência de 20 anos de um serviço de broncoscopia pediátrica, destacando aspectos clínicos e demográficos, indicações, achados endoscópicos e ocorrência de complicações graves. Métodos: estudo descritivo, retrospectivo, dos exames de broncoscopia realizados no período de 2000 a 2019, em um hospital pediátrico- RJ. Resultados: foram realizados 1.372 exames, sendo 795 (58%) meninos e 676 (49%) lactentes. A broncofibroscopia (BF) foi a técnica utilizada em 940 exames (69%). Estridor foi a indicação em 315 exames (21%), seguida de investigação de imagens radiológicas (17%), revisão de traqueostomia (11%) e complicações de intubação traqueal (10%). A laringomalácia foi observada em 255 (68%) dos casos de estridor e inflamação (65- 52%) e plugs de secreção (34- 27%) nos casos de atelectasia. A estenose subglótica foi o diagnóstico endoscópico em 71 (45%) dos exames realizados por complicações de intubação traqueal. Granuloma e malácia supra-ostial estavam presentes, respectivamente, em 35% e 20% das crianças traqueostomizadas. A frequência de complicações maiores foi de 0,22%. Não houve óbitos. Conclusões: A laringomalácia foi o principal diagnóstico nos casos de estridor. A estenose subglótica é um diagnóstico importante nos casos em que houve intubação traqueal prévia. A alta frequência de complicações supra-ostiais em crianças traqueostomizadas reforça a necessidade de avaliação endoscópica prévia à decanulação. A broncoscopia mostrou-se um método seguro na população pediátrica

O ESTRESSE EM CRIANÇAS E ADOLESCENTES COM ASMA

Objetivos: verificar a presença do estresse em crianças e adolescentes com asma e avaliar aassociação do estresse com variáveis clínicas e psicossociais. Método: estudo transversal com criançase adolescentes asmáticos entre 7 e 12 anos de idade, atendidos em ambulatório de pneumologiapediátrica. Utilizou-se a Escala de Estresse Infantil, o Critério de Classificação Econômica Brasil equestionário padronizado para coleta de informações. A análise estatística foi realizada através doteste qui-quadrado, curva ROC, teste exato de Fisher e Mann-Whitney, sendo utilizado o modelo deregressão logística após análise univariada. Resultados: o estresse foi detectado em 38 % (19/50)dos pacientes, com predomínio de reações psicológicas. Foram encontradas associações comsignificância estatística entre o estresse e dificuldades escolares (p = 0,026), classe sócio-econômicaC2 e D (p=0,013) e sintomas da doença há sete anos ou menos (p = 0,0037). Estas associaçõespermaneceram após a regressão logística. Não foram encontradas associações com significânciaestatística entre a gravidade da asma e o estresse. Conclusões: houve estresse em mais de umterço dos casos de crianças e adolescentes com asma. Houve maior frequência de estresse emcrianças e adolescentes de classes sócio-econômicas desfavorecidas e naqueles que apresentavamsintomas de asma em período inferior ou igual a 7 anos e com dificuldades escolares.Objective: To evaluate stress in children and adolescents with asthma and its association withclinical and psychosocial features. Methods: Cross-sectional study conducted with asthmatic childrenand adolescents between 7 and 12 years old, seen at the pediatric pulmonary outpatient clinic. TheStress Childhood Scale, the Criterion of Economic Classification Brazil and a questionnaire wereused to collect data. Statistical analysis was realized using the Chi-square Test, ROC curve, FisherTest and Mann-Whitney. A logistic regression analysis model was used after univariety analysis.Results: Stress was detected in 38 % (19/50) of the patients, with predominance of psychologicalreactions. Statistical significance associations were found between stress and scholar difficulties,socioeconomic class C2 and D (p = 0,013) and asthma symptoms in a period less than or equal to 7years (p = 0,003). These associations remained after logistic regression model. There was no statisticalsignificance association between asthma gravity and stress. Conclusions: More than one-third ofchildren and adolescents with asthma were stressed. This rate was higher in lower socioeconomicclasses and in those patients with scholar difficulties and with symptoms of asthma in a period lessthan or equal to 7 years

Lethality by pneumonia and factors associated to death

AbstractObjectiveto describe the case-fatality rate (CFR) and risk factors of death in children with community-acquired acute pneumonia (CAP) in a pediatric university hospital.Methoda longitudinal study was developed with prospective data collected from 1996 to 2011. Patients aged 1 month to 12 years were included in the study. Those who left the hospital against medical orders and those transferred to ICU or other units were excluded. Demographic and clinical-etiological characteristics and the initial treatment were studied. Variables associated to death were determined by bivariate and multivariate analysis using logistic regression.Resultsa total of 871 patients were selected, of whom 11 were excluded; thus 860 children were included in the study. There were 26 deaths, with a CFR of 3%; in 58.7% of these, penicillin G was the initial treatment. Pneumococcus was the most common pathogen (50.4%). From 1996 to 2000, there were 24 deaths (93%), with a CFR of 5.8% (24/413). From 2001 to 2011, the age group of hospitalized patients was older (p = 0.03), and the number of deaths (p = 0.02) and the percentage of disease severity were lower (p = 0.06). Only disease severity remained associated to death in the multivariate analysis (OR = 3.2; 95%CI: 1.2-8.9; p = 0.02).Conclusionwhen the 1996-2000 and 2001-2011 periods were compared, a significant reduction in CFR was observed in the latter, as well as a change in the clinical profile of the pediatric inpatients at the institute. These findings may be related to the improvement in the socio-economical status of the population. Penicillin use did not influence CFR

Gene-Xpert Ultra for the diagnosis of extrapulmonary tuberculosis in children and adolescents

This prospective study describes the use of Gene-Xpert Ultra for the diagnosis of extrapulmonary tuberculosis (EPTB) in children and adolescents, in Rio de Janeiro, Brazil. Eighteen patients were studied; the final diagnosis of EPTB was established in 13 (72%). Gene-Xpert Ultra results showed detection in 10/13 (77%) of EPTB cases (7 of these 10 with trace-positive results). Gene-Xpert Ultra proved to be a promising method for the diagnosis of childhood EPTB

Pico de fluxo de tosse em crianças e jovens com atrofia muscular espinhal tipo II e tipo III

La atrofia muscular espinal es una enfermedad neurodegenerativa, que puede presentarse con insuficiencia respiratoria progresiva. Este trabajo pretende describir el pico flujo de tos de niños y jóvenes con atrofia muscular espinal tipo II y III. Se trata de un estudio descriptivo transversal realizado en la clínica ambulatoria de neuropediatría entre marzo de 2011 y mayo de 2012, con los pacientes con más de 5 años de edad con atrofia muscular espinal tipo II y III. De los 53 pacientes elegibles, 21 participaron del estudio. La medición del pico flujo de tos se llevó a cabo a través de peak flow meter en pacientes en la posición sentada y supina. Después del registro de las tres medidas, se seleccionó la mayor. Los individuos con tipo III tuvieron valores pico flujo de tos mayores que los con tipo II. Las medidas registradas en la posición sentada (AME tipo II 159,4 l/min; AME tipo III 287,9 l/min) fueron las más altas que la de posición supina (AME tipo II 146,9 l/min; AME tipo III 257,5 l/min), con diferencias significativas (p-valor=0,008 posición sentada y p=0,033 posición supina). Se concluyó que los individuos con AME tipo III presentan mayor PFT, especialmente en la posición sentada, comparados con los de tipo II.Spinal muscular atrophy is a neurodegenerative disorder, which may be associated with progressive respiratory failure. Our aim is to describe the peak cough flow of children and young people with spinal muscular atrophy types II and III. This is a descriptive, cross-sectional study conducted at a neuropediatrics outpatient clinic between March 2011 and May 2012, with patients with spinal muscular atrophy types II and III, and aging more than 5 years. Out of the 53 eligible patients, 21 participated in the research. The measurement of peak cough flow was carried out through the peak flow meter, with patients sitting and lying down. After taking three measures, we selected the one with the highest value among them. Type-III individuals reached peak cough flow values higher than those of type-II individuals. Measures taken in the sitting position (SMA II 159.4 l/min; SMA III 287.9 l/min) were higher than those measured in the lying position (SMA II 146.9 l/min; SMA III 257.5 l/min), with significant difference (p-value=0.008 in sitting position, and p=0.033 in lying position). We concluded that individuals with SMA III manifest higher PCF, especially when sitting, in comparison with SMA II.A atrofia muscular espinhal é uma doença neurodegenerativa, que pode cursar com insuficiência respiratória progressiva. O objetivo deste trabalho é descrever o pico de fluxo de tosse de crianças e jovens com atrofia muscular espinhal dos tipos II e III. Trata-se de um estudo transversal descritivo realizado em ambulatório de neuropediatria entre março de 2011 e maio de 2012, com pacientes com atrofia muscular e espinhal dos tipos II e III com mais de 5 anos de idade. Dos 53 pacientes elegíveis, 21 participaram da pesquisa. A medição do pico de fluxo de tosse foi realizada através do peak flow meter com os pacientes sentados e deitados. Após registradas três medidas, foi selecionada a maior entre elas. Os indivíduos do tipo III alcançaram valores de pico de fluxo de tosse superiores aos dos indivíduos do tipo II. As medidas tomadas em posição sentada (AME tipo II 159,4 l/min; AME tipo III 287,9 l/min) foram superiores às medidas em posição deitada (AME tipo II 146,9 l/min; AME tipo III 257,5 l/min), com diferença significativa (p-valor=0,008 posição sentada e p=0,033 posição deitada). Concluiuse que indivíduos com AME tipo III apresentam maior PFT, principalmente quando sentados, em comparação com o tipo II

Demographic mapping and characterization of physical therapy care profile offered in Neonatal Intensive Care Units in the City of Rio de Janeiro, Brazil

Este estudio visa el mapeo y la caracterización del perfil de la asistencia fisioterapéutica ofrecida en unidades de cuidados intensivos (UCI) neonatales de los hospitales públicos y privados de Río de Janeiro (RJ), Brasil. Para eso, fueron realizadas entrevistas con los jefes a respecto de las rutinas de los servicios de fisioterapia de los hospitales de Río de Janeiro con UCI neonatales entre enero de 2013 y enero de 2015. Las preguntas abordaron a respecto de distribición de las horas de trabajo, organización y localización institucional, tiempo de experiencia en la área, tipos de técnicas fisioterapéuticas y recursos utilizados. Fueron incluidos 27 hospitales (17 públicos y 10 privados) de la seguiente forma: 6 hospitales en Zona Sul, 8 en Zona Norte, 8 en Zona Oeste y 5 en Centro y Zona Portuaria. El número total de fisioterapeutas integrantes de los equipos fue de 141, siendo que 59% de ellos eron expertos en cuidados intensivos neonatales. En lo que se refiere a los jefes entrevistados, 16 (59%) también eron expertos y 21 (79%) poseían más de cinco años de experiencia. Fueron citadas diversas técnicas fisioterapéuticas, como: fisioterapia motora, vibración torácica y reequilibrio tóraco-abdominal. A partir del exposto, se verificó que la asistencia fisioterapéutica neonatal de Río de Janeiro não está distribuída uniformemente en el territorio, estando más concentrada en las regiones Sul y Central. Además, falta padronización de las rutinas y carga horaria, siendo necesaria adecuación del perfil asistencial para atención ideal y integral del neonato.Este estudo visa ao mapeamento e a caracterização do perfil da assistência fisioterapêutica oferecida em unidades de terapia intensiva (UTI) neonatais dos hospitais públicos e privados do Rio de Janeiro (RJ). Para isso, foram realizadas entrevistas com os chefes sobre as rotinas dos serviços de fisioterapia dos hospitais do Rio de Janeiro com UTI neonatais entre janeiro de 2013 e janeiro de 2015. As perguntas abordaram distribuição das horas de trabalho, organização e localização institucional, tempo de experiência na área, tipos de técnicas fisioterapêuticas e recursos utilizados. Foram incluídos 27 hospitais (17 públicos e 10 privados) da seguinte forma: 6 hospitais na Zona Sul, 8 na Zona Norte, 8 na Zona Oeste e 5 no Centro e Zona Portuária. O número total de fisioterapeutas integrantes das equipes foi de 141, sendo que 59% deles eram especialistas em terapia intensiva neonatal. No que se refere aos chefes entrevistados, 16 (59%) também eram especialistas e 21 (79%) possuíam mais de cinco anos de experiência. Foram citadas diversas técnicas fisioterapêuticas, como: fisioterapia motora, vibração torácica e reequilíbrio tóraco-abdominal. A partir do exposto, verificou-se que a assistência fisioterapêutica neonatal do Rio de Janeiro não está distribuída uniformemente no território, estando mais concentrada nas regiões Sul e Central. Além disso, falta padronização das rotinas e carga horária, sendo necessária adequação do perfil assistencial para atenção ideal e integral do recém-nascido (RN).This study aims to map and characterize the profile of physical therapy care offered in intensive care units (ICU) of public and private hospitals in the city of Rio de Janeiro. To this end, a cross-sectional study was conducted by interviews with the heads/routine chiefs of physical therapy services of the hospitals in the city of Rio de Janeiro with neonatal ICU (NICU) from January 2013 to January 2015. The questions comprised the distribution of working hours, organization and institutional location, time of experience in the area, types of physical therapy techniques and resources used. Twenty seven hospitals (17 public and 10 private) were studied as follows: 6 hospitals in the South area of the city, 8 in the North, 8 in the West and 5 in the central area and port area. The total number of physical therapists of the teams was 141, and 59% of them were experts in neonatal intensive care. With regard to the heads/routine chiefs, 16 (59%) were specialists in neonatal intensive care and 21 (79%) had more than five years of experience. Various physical therapy techniques were cited as: motor physical therapy, chest vibration and thoracic-abdominal rebalance. According to the results, there was not a single standard regarding routines, protocols, professional organization and training, and techniques used. In addition, it was found that the physical therapy in ICUs was not held full-time, neither provided the three shifts care

String test: a potentially useful tool in the diagnosis of pulmonary tuberculosis in Brazilian children and adolescents

This study investigated the potential use of the String Test (ST) for the diagnosis of pulmonary tuberculosis (PTB) in children and adolescents. This is a case series of patients aged 4-15 years presenting with clinically presumed PTB and submitted to ST in three pediatric TB referral centers in Brazil, between November 2017 and July 2020. The ST was performed in the morning, after 4-12 h of fasting, followed by ingestion of the capsule by the patient, which was attached to the patient’s malar region. The material was collected for simultaneous smear microscopy (acid-fast bacilli - AFB), culture and the molecular investigation by the GeneXpert MTB/RIF®. Thirty-three patients with presumed PTB were included and ST was performed in 26 (78.8%) of them and 7 (21.2%) patients could not swallow the cord. The diagnosis of PTB was established in 11 (42.3%) of the 26 patients who underwent the ST. The diagnosis of PTB was confirmed (by culture or GeneXpert MTB/RIF®) in 5 patients, 4 of whom were also positive by the ST. Two of them showed positivity by the GeneXpert MTB/RIF® only in the ST sample. Two other patients had a positive ST following the induced sputum test (AFB, GeneXpert MTB/RIF®, and positive culture in both specimens). Thus, ST was positive in 36.4% of the patients in whom PTB was diagnosed. ST could be a useful test for diagnosing PTB in children and adolescents

Causes of variation in BCG vaccine efficacy: examining evidence from the BCG REVAC cluster randomized trial to explore the masking and the blocking hypotheses.

BCG protection varies and in some places (nearest the equator) is low or absent. Understanding this variation can inform the efforts to develop new vaccines against tuberculosis. Two main hypotheses are used to explain this variation: under masking, new vaccines are unlikely to increase protection; under blocking new vaccines have a greater potential to be effective when BCG is not. We conducted a cluster randomized trial to explored the masking and blocking hypotheses by studying BCG vaccine efficacy of neonatal vaccination and when administered for the first or a second (revaccination) time at school age in two sites (Manaus close and Salvador further south from the equator). Seven hundred and sixty three state schools were matched on socio economic characteristics of the neighborhood and 239,934 children were randomized to vaccine (BCG vaccination at school age) or control group. Protection by first BCG vaccination at school age was high in Salvador (34%, 95% CI 7-53%, p=0.017) but low in Manaus (8%, 95% CI t0 39-40%, p=0.686). For revaccination at school age, protection was modest in Salvador (19%, 95% CI 3-33%, p=0.022) and absent in Manaus (1%, 95% CI to 27-23%, p=0.932). Vaccine efficacy for neonatal vaccination was similar in Salvador (40%, 95% CI 22-54%, p<0.001) and Manaus (36%, 95% CI 11-53%, p=0.008). Variation in BCG efficacy was marked when vaccine was given at school age but absent at birth, which points towards blocking as the dominant mechanism. New tuberculosis vaccines that overcome or by pass this blocking effect could confer protection in situations where BCG is not protective

Diagnosis of pulmonary tuberculosis in children and adolescents: comparison of two versions of the Brazilian Ministry of Health scoring system

The aim of this study was to evaluate the concordance between two versions of the scoring system (2011 and 2019), recommended by the Brazilian Ministry of Health, for the diagnosis of pulmonary tuberculosis (PTB) in children and adolescents. A retrospective descriptive study was performed to assess the medical records of children and adolescents with PTB, in TB units from Brazilian cities located in Rio de Janeiro, Minas Gerais, and Parana States, from January 1st, 2004, to December 1st, 2018. Patients aged 0 to 18 years old with a diagnosis of PTB were included. The comparison between the two scoring systems showed a moderate concordance according to the κ coefficient value = 0.625. Fourteen patients showed a reduction in the TB score, going from 30 points in the 2011, to 25 points or less in the 2019 one. Seventy one percent of these 14 patients had radiological changes suggestive of PTB and 86% had tuberculin skin tests greater than 10 mm. The study concluded that a moderate agreement was observed between the 2011 and 2019 scoring systems, with an increase in the number of patients scoring 25 points or less in 2019, which can eventually hinder the diagnosis of PTB