Association Between Ventilation Index And Time On Mechanical Ventilation In Infants With Acute Viral Bronchiolitis

Objective: To evaluate the association between time on mechanical ventilation and anthropometric, clinical and pulmonary function variables, measured early, in infants on invasive mechanical ventilation with acute respiratory failure due to viral bronchiolitis, and the temporal progression of variables with significant correlations. Methods: Twenty-nine infants admitted to the pediatric intensive care unit of UNICAMP university hospital were studied. Acute viral bronchiolitis was defined according to clinical and radiological criteria. Children with chronic diseases and those that were hemodynamically unstable were excluded. All measurements were taken after 24 to 72 hours' mechanical ventilation, using volumetric capnography and blood gas analysis. Mechanical ventilation time was divided into: ≤ 7 days and > 7 days. Association between time on mechanical ventilation and the variables analyzed was determined by Spearman's Correlation Coefficient (r s). Results: Time on mechanical ventilation showed a significant positive correlation with PaCO 2 (r s = 0.45, p = 0.01) and ventilation index (r s = 0.51, p = 0.005), and a negative correlation with pH (r s = -0.40, p = 0.03). Ventilation indices of 37, measured between day one and day five, was associated with a progressively increased risk of more than 7 days on mechanical ventilation (OR = 4.2 on the first day to 15.71 on the fourth day). Conclusions: Ventilation index, PaCO 2 and pH, measured early, were associated with prolonged mechanical ventilation, reflecting the severity of ventilatory disturbance and the need for support. Copyright © 2005 by Sociedade Brasileira de Pediatria.816466470Shay, D.K., Holman, R.C., Newman, R.D., Liu, L.L., Stout, J.W., Anderson, L.J., Bronchiolitis-associated hospitalizations among US children, 1980-1996 (1999) JAMA, 282, pp. 1440-1446Torres, A., Gatell, J.M., Aznar, E., El-Ebiary, M., Puig De La Bellacasa, J., Gonzalez, J., Re-intubation increases the risk for nosocomial pneumonia in patients needing mechanical ventilation (1995) Am J Respir Crit Care Med, 152, pp. 137-141Esteban, A., Alia, I., Gordo, F., Fernandez, R., Solsona, J.F., Vallverdu, I., Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation (1997) Am J Respir Crit Care Med, 156, pp. 459-465. , The Spanish Lung Failure Collaborative GroupBont, L., Kavelaars, A., Heijnen, C.J., Van Vught, A.J., Kimpen, J.L., Monocyte interleukin-12 production is inversely related to duration of respiratory failure in respiratory syncytial virus bronchiolitis (2000) J Infect Dis, 181, pp. 1772-1775Tasker, R.C., Gordon, I., Kiff, K., Time course of severe respiratory syncytial virus infection in mechanically ventilated infants (2000) Acta Paediatr, 89, pp. 938-941Arnold, J.H., Thompson, J.E., Arnold, L.W., Single breath CO 2 analysis: Description and validation of a method (1996) Crit Care Med, 24, pp. 96-102Riou, Y., Leclerc, F., Neve, V., Dupuy, L., Noizet, O., Leteurtre, S., Reproducibility of the respiratory dead space measurements in mechanically ventilated children using the CO 2SMO monitor (2004) Intensive Care Med, 30, pp. 1461-1467Hubble, C.L., Gentile, M.A., Tripp, D.S., Craig, D.M., Meliones, J.N., Cheifetz, I.M., Deadspace to tidal volume ratio predicts successful extubation in infants and children (2000) Crit Care Med, 28, pp. 2034-2040Main, E., Stocks, J., The influence of physiotherapy and suction on respiratory deadspace in ventilated children (2004) Intensive Care Med, 30, pp. 1152-1159Law, B.J., Carbonell-Estrany, X., Simoes, E.A., An update on respiratory syncytial virus epidemiology: A developed country perspective (2002) Respir Med, 96 (SUPPL. B), pp. S1-7Davison, C., Ventre, K.M., Luchetti, M., Randolph, A.G., Efficacy of interventions for bronchiolitis in critically ill infants: A systematic review and meta-analysis (2004) Pediatr Crit Care Med, 5, pp. 482-489Frankel, L.R., Lewiston, N.J., Smith, D.W., Stevenson, D.K., Clinical observations on mechanical ventilation for respiratory failure in bronchiolitis (1986) Pediatr Pulmonol, 2, pp. 307-311Wang, E.E., Law, B.J., Boucher, F.D., Stephens, D., Robinson, J.L., Dobson, S., Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study of admission and management variation in patients hospitalized with respiratory syncytial viral lower respiratory tract infection (1996) J Pediatr, 129, pp. 390-395Paret, G., Ziv, T., Barzilai, A., Bem-Abraham, R., Vardi, A., Manisterski, Y., Ventilation index and outcome in children with acute respiratory distress syndrome (1998) Pediatr Pulmonol, 26, pp. 125-12

Quality Of Sleep And Quality Of Life In Adolescents Infected With Human Immunodeficiency Virus [qualidade Do Sono E Qualidade De Vida Em Adolescentes Infectados Pelo Vírus Da Imunodeficiência Humana]

Objectives: To assess sleep characteristics of adolescents infected by HIV, and to ascertain whether psychosocial aspects are associated to the quality of sleep. Methods: A cross-sectional study assessing 102 HIV-infected adolescents of both genders, aged between 10 and 20 years-old and 120 Controls. Data collection was performed by applying the Sleep Disturbance Scale for Children, the Epworth Sleepiness Scale, and the Pediatric Quality of Life Inventory. Results: A sleep disturbance prevalence of 77.4% was found in patients, and a 75% prevalence in controls, and there was correlation between quality of sleep and of life. HIV-infected adolescents scored higher for sleep breathing disorders and had higher prevalence of excessive daytime sleepiness. Conclusions: HIV-infected adolescents had similar quality of sleep compared to healthy adolescents. This may be explained by the steady improvements in daily living as a result of successful anti-retroviral therapy, and by the vulnerability that affects Brazilian adolescents living in major urban centers.706422427Carskadon, M.A., Sleep in adolescents: The perfect storm (2011) Pediatr Clin North Am, 58, pp. 637-647Owens, J.A., Belon, K., Moss, P., Impact of delaying school start time on adolescent sleep, mood, and behavior (2010) Arch Pediatr Adolesc Med, 164, pp. 608-614de-la-Llata-Romero, M., Castorena-Maldonado, A., Corsi-Cabrera, M., Sleep medicine: Development, contributions and perspectives Report of the work group on sleep medicine (2011) Rev Invest Clin, 63, pp. 90-99Mindell, J.A., Owens, J., Alves, R., Give children and adolescents the gift of a good night's sleep: A call to action (2011) Sleep Med, 12, pp. 203-204Moore, M., Meltzer, L.J., The sleepy adolescent: Causes and consequences of sleepiness in teens (2008) Paediatr Respir Rev, 9, pp. 114-120(2010) Global report: UNAIDS report on the global AIDS epidemic, , http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf, Joint United Nations Programme on HIV/AIDS (UNAIDS), [cited 16 May 2011]. Available at(2011) Ministério da Saúde 2010, , http://www.aids.gov.br/publicacao/boletim-epidemiologico-2010, Brasil, Departamento de DST, Aids e Hepatites Virais. Boletim Epidemiológico AIDS 2010 (versão preliminar). [cited 21 March]. Available atHazra, R., Siberry, G.K., Mofenson, L.M., Growing up with HIV: Children, adolescents, and young adults with perinatally acquired HIV infection (2010) Ann Rev Med, 61, pp. 169-185Ramos, A.N., Matida, L.H., Hearst, N., Heukelbach, J., AIDS in Brazilian children: History, surveillance, antiretroviral therapy, and epidemiologic transition, 1984-2008 (2011) AIDS Patient Care STDS, 25, pp. 245-255Franck, L.S., Johnson, L.M., Lee, K., Sleep disturbances in children with human immunodeficiency virus infection (1999) Pediatrics, 104, pp. 1-5Reid, S., Dwyer, J., Insomnia in HIV Infection: A systematic review of prevalence, correlates and management (2005) Psychosomatic Med, 67, pp. 260-269Rocha, C.R.S., Rossini, S., Reimão, R., Sleep disorders in high school and pre-university students (2010) Arq Neuropsiquiatr, 68, pp. 903-907Mesquita, G., Reimão, R., Nightly use of computer by adolescents: Its effect on quality of sleep (2007) Arq Neuropsiquiatr, 65, pp. 428-432Varni, J.W., Seid, M., Rode, C.A., The PedsQL: Measurement model for the pediatric quality of life inventory (1999) Med Care, 37, pp. 126-139(2009) Ministério da Saúde, , Brasil, Secretaria de Vigilância em Saúde. Programa Nacional de DST e Aids. Recomendações para Terapia Antirretroviral em Crianças e Adolescentes Infectados polo HIV. Manual de bolso. Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Brasília: Ministério da SaúdeBruni, O., Salvatori, O., Guidetti, V., The sleep disturbance scale for children (SDSC) Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence (1996) J Sleep Res, 5, pp. 251-261Johns, M.W., A new method for measuring daytime sleepiness: The Epworth sleepiness scale (1991) Sleep, 14, pp. 540-545Ferreira, V.R., Carvalho, L.B.C., Ruotolo, F., Morais, J.F., Prado, L.B.F., Prado, G.F., Sleep disturbance scale for children: Translation, cultural adaptation and validation (2009) Sleep Med, 10, pp. 457-463Bertolazi, N.A., Fagondes, S.C., Hoff, L.S., Pedro, V.D., Barreto, S.S.M., Johns, M.W., Validação da escala de sonolência de Epworth em português para uso no Brasil (2009) J Bras Pneumol, 35, pp. 877-883Klatchoian, D.A., Len, C.A., Terreri, M.T., Quality of life of children and adolescents from São Paulo: Reliability and validity of the Brazilian version of the Pediatric Quality of Life Inventory TM version 4.0 Generic Core Scales (2008) J Pediatr (Rio J), 84, pp. 308-315Potasz, C., Juliano, M.L., Varela, M.J., Prevalence of sleep disorders in children of a public hospital in São Paulo (2010) Arq Neuropsiquiatr, 68, pp. 235-241Carotenuto, M., Bruni, O., Santoro, N., Giudice, E.M., Perrone, L., Pascotto, A., Waist circumference predicts the occurrence of sleep-disordered breathing in obese children and adolescents: A questionnaire-based study (2006) Sleep Med, 7, pp. 357-361Ramalho, L.C.B., Gonçalves, E.M., Carvalho, W.R.G., Abnormalities in body composition and nutritional status in HIV-infected children and adolescents on antiretroviral therapy (2011) Int J STD AIDS, 22, pp. 453-456Chan, E.Y., Ng, D.K., Chan, C.H., Modified Epworth Sleepiness Scale in Chinese children with obstructive sleep apnea: A retrospective study (2009) Sleep Breath, 13, pp. 59-63Melendres, M.C., Lutz, J.M., Rubin, E.D., Marcus, C.L., Daytime sleepiness and hyperactivity in children with suspected sleep-disordered breathing (2004) Pediatrics, 114, pp. 768-775van Litsenburg, R.R., Huisman, J., Hoogerbrugge, P.M., Egeler, R.M., Kaspers, G.J., Gemke, R.J., Impaired sleep affects quality of life in children during maintenance treatment for acute lymphoblastic leukemia: An exploratory study (2011) Health Qual Life Outcomes, 18, pp. 9-25Erickson, J.M., Beck, S.L., Christian, B.R., Fatigue, sleep-wake disturbances, and quality of life in adolescents receiving chemotherapy (2011) J Pediatr Hematol Oncol, 33, pp. 17-25Mitchell, R.B., Boss, E.F., Pediatric obstructive sleep apnea in obese and normal-weight children: Impact of adenotonsillectomy on quality-of-life and behavior (2009) Dev Neuropsychol, 34, pp. 650-661Crabtree, V.M., Varni, J.W., Gozal, D., Health-related quality of life and depressive symptoms in children with suspected sleep-disordered breathing (2004) Sleep, 27, pp. 1131-1138Ong, L.C., Yang, W.W., Wong, S.W., Alsissiq, F., Khu, Y.S., Sleep habits and disturbances in Malaysian children with epilepsy (2010) J Paediatr Child Health, 46, pp. 80-8

Endocarditis By Kocuria Rosea In An Immunocompetent Child

Kocuria rosea belongs to genus Kocuria (Micrococcaceae family, suborder Micrococcineae, order Actinomycetales) that includes about 11 species of bacteria. Usually, Kocuria sp are commensal organisms that colonize oropharynx, skin and mucous membrane Kocuria sp infections have been described in the last decade commonly affecting immunocompromised patients, using intravenous catheter or peritoneal dialysis. These patients had mainly bacteremia/recurrent sepsis. We hereby describe the case of a 10-year-old girl, immunocompetent, who had endocarditis/sepsis by K. rosea which was identified in five different blood cultures by Vitek 2 ID-GPC card (BioMérieux, France). Negative HIV serology, blood count within normal range of leukocytes/neutrophils and lymphocytes, normal fractions of the complement, normal level of immunoglobulins for the age lymphocyte immunophenotyping was also within the expected values. Thymus image was normal at chest MRI. No catheters were required. Identification of K. rosea was essential to this case, allowing the differentiation of coagulase-negative staphylococci and use of an effective antibiotic treatment. Careful laboratory analysis of Gram-positive blood-born infections may reveal more cases of Kocuria sp infections in immunocompetent patients, which may collaborate for a better understanding, prevention and early treatment of these infections in pediatrics.1918284Savini, V., Catavitello, C., Masciarelli, G., Drug sensitivity and clinical impact of members of the genus Kocuria (2010) J Med Microbiol, 59, pp. 1395-1402Becker, K., Rutsch, F., Uekötter, A., Kocuria rhizophila adds to the emerging spectrum of micrococcal species involved in human infections (2008) J Clin Microbiol, 46, pp. 3537-3539Dotis, J., Printza, N., Papachristou, F., Peritonitis attributable to Kocuria rosea in a pediatric peritoneal dialysis patient (2012) Perit Dial Int, 32, pp. 577-578Moissenet, D., Becker, K., Mérens, A., Persistent bloodstream infection with Kocuria rhizophila related to a damaged central catheter (2012) J Clin Microbiol, 50, pp. 1495-1498Chen, H.M., Chi, H., Chiu, N.C., Kocuria kristinae: a true pathogen in pediatric patients (2013) J Microbiol Immunol InfectKaradag Oncel, E., Boyraz, M.S., Kara, A., Black tongue associated with Kocuria (Micrococcus) kristinae bacteremia in a 4-month-old infant (2012) Eur J Pediatr, 171, p. 593Lai, C.C., Wang, J.Y., Lin, S.H., Catheter-related bacteraemia and infective endocarditis caused by Kocuria species (2011) Clin Microbiol Infect, 17, pp. 190-192Rushani, D., Kaufman, J.S., Ionescu-Ittu, R., Infective endocarditis in children with congenital heart disease: cumulative incidence and predictors (2013) Circulation, 128, pp. 1412-1419Srinivasa, K.H., Agrawal, N., Agarwal, A., Dancing vegetations: Kocuria rosea endocarditis (2013) BMJ Case Rep, 28Kumar, C.G., Sujitha, P., Kocuran an exopolysaccharide isolated from Kocuria rosea strain BS-1 and evaluation of its in vitro immunosuppression activities (2014) Enzyme Microb Technol, 55, pp. 113-120Ben-Ami, R., Navon-Venezia, S., Schwartz, D., Erroneous reporting of coagulase-negative staphylococci as Kocuria spp. by the Vitek 2 system (2005) J Clin Microbiol, 43, pp. 1448-1450Boudewijns, M., Vandeven, J., Verhaegen, J., Vitek 2 automated identification system and Kocuria kristinae (2005) J Clin Microbiol, 43, p. 583

Prognostic Factors For Mechanical Ventilation In Infants With Acute Lower Respiratory Disease [fatores Prognósticos Para Ventilação Mecânica Em Lactentes Com Doença Respiratória Aguda Baixa]

OBJECTIVE. Acute lower respiratory tract infections are the most common cause of hospital admission in pediatrics. A number of admitted patients need invasive mechanical pulmonary ventilation (IMPV). This study aimed to evaluate prognostic factors for IMPV in infants admitted due to acute lower respiratory infection. METHODS. A prospective cohort study was conducted from April to September, 2004, in two university hospitals of the Campinas metropolitan area, São Paulo, Brazil. One hundred, fifty-two infants were enrolled. Epidemiological and clinical data were recorded at admission and follow-up. Two groups were analyzed, according to the need of IMPV, with a comparison of prognostic factors. Association between risk factors and the outcome were studied and assessed by Relative Risk (RR), with confidence intervals of (95%CI). RESULTS. Twenty-one patients (13.81%) needed IMPV. Factors significantly associated with IMPV on admission were: age 10 days (RR=13.69, 95%CI:4.92-38.09), oxygen therapy > 10 days (RR=13.57, 95%CI:5.41-34.03), antibiotic usage (RR=3.03, 95%CI:1.34-6.89) and readmission (RR=5.23, 95%CI:2.12-12.91) were observed. CONCLUSION. The associations between need of IMPV and early age, reduced breast feeding and cyanosis demonstrate diminished physiological reserves in the young infant with lower respiratory infection. These patients require prolonged and intensive hospital support and readmission.525342346Denny Jr., F.W., The impact of respiratory virus infections on the world's children (2001) Asthma and Respiratory Infections, pp. 1-22. , Skoner DP, editor. New York: Marcel DekerAntuñano, F.J.L., Epidemiologia de lãs infecciones respiratórias agudas em niños: Panorama regional (1997) Infecciones Respiratórias Em Niños, pp. 3-23. , Benguigui Y, Antuaño FJL, Schmunis G, Yunes J, editores. New York: Organización Panamericana de la SaludInitiative for Vaccine Research (IVR). Acute Respiratory Infections, , http://www.who.int/vaccine_research/diseases/ari/en, World Health Organization. [cited 2004 aug 23]. Avaliable fromDenny, F.W., Acute respiratory infections in children: Etiology and epidemiology (1987) Pediatr Rev, 9, pp. 135-146. , (review)Júven, T., Mertsola, J., Waris, M., Leinonen, M., Meurman, O., Roivanen, M., Etiology of community-acquired pneumonia in 254 hospitalized children (2000) Pediatr Infect Dis J, 19, pp. 293-298Meissner, H.C., Uncertainty in the management of viral lower respiratory tract disease (2001) Pediatr, 108, pp. 1000-1004Wennergren, G., Kristjansson, S., Wheezing in infancy and its long-term consequences (2002) Eur Resp Mon, 19, pp. 116-130Gold, D.R., Burge, H.Á., Carey, V., Milton, D.K., Platts-Milss, T., Weiss, S.T., Predictors of repeated wheeze in the first year of life (1999) Am J Resp Crit Care Med, 160, pp. 227-236Millán, T., Serani, F., Vargas, N.A., Valenzuela, M.S., Características biológicas y sociales de los menores de un año muertos por neumonía en la región metropolitana de Chile, 1995 (1999) Rev Panam Salud Públ, 6, pp. 333-341Post, C.L.A., Victora, C.G., Valente, J.G., Leal, M.C., Niobey, F.M.L., Sabroza, P.C., Fatores prognósticos de letalidade hospitalar por diarréia ou pneumonia em menores de um ano de idade (1992) Estudo de Caso e Controle. Rev Saúde Pública, 26, pp. 369-378Sehgal, V., Sethi, G.R., Sachved, H.P.S., Satyanarayana, L., Predictors of mortality in subjects hospitalized with acute lower respiratory tract infections (1997) Indian Pediatr, 34, pp. 213-219Willson, D.F., Landrigan, C.P., Horn, S.D., Smout, R.J., Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia (2003) J Pediatr, 143, pp. S142-S149Fundação Sistema Estadual de Análise de Dados. População/Estatísticas Vitais/SP Demográfico/ Estatísticas Vitais Do Estado de São Paulo, , http://www.seade.gov.br, [citado 2004]. Disponível emJorden, R.C., Typical vital signs in the pediatric population (1982) Multiple Trauma in Emergency Medicine: Concepts and Clinical Practice. 3 rd Ed., pp. 281-282. , Rosen P, Barkin R, et al., editors. St Louis: Mosby-Year Book, IncRosenthal, M., Bush, A., The growing lung: Normal development, and the long-term effects of pre and postnatal insults (2002) Eur Respir Mon, 19, pp. 1-24Pettigrew, M.M., Klodaee, M., Gillespie, B., Schwartz, K., Bobo, J.K., Foxman, B., Duration of breastfeeding, daycare and physician visits among infants 6 months and younger (2003) Ann Epidemiol, 13, pp. 431-435Albernazi, E.P., Menezes, A.N.G., César, J.Á., Victora, C.G., Barros, F.C., Helpern, R., Risk factors associated with hospitalization for bronchiolitis in the post-neonatal period (2003) Rev Saúde Pública, 37, pp. 485-493Duarte, D.M.G., Perfil clínico de crianças menores de cinco anos com infecção respiratória aguda (2000) J Pediatr, 76, pp. 207-212. , (Rio de J)Wang, E.E.L., Law, B.J., Stephens, D., Langley, J.M., MacDonald, N.E., Robinson, J.L., Study of interobserver reliability in clinical assesment of RSV lower respiratory illness: A pediatric investigators collaborative network for infections in Canada (PICNIC) study (1996) Pediatr Pulmonol, 22, pp. 23-27Shann, F., Fracp, J.B., Poore, P., Clinical signs that predict death in children with severe pneumonia (1999) Pediatr Infect Dis J, 8, pp. 852-855Kneyber, M.C.J., Moons, K.G.M., De Groot, R., Moll, H.A., Prediction of duration of hospitalization in respiratory syncytial virus infection (2002) Pediatr Pulmonol, 33, pp. 453-457Farias, J.A., Frutos, F., Esteban, A., Casado Flores, J., Retta, A., Baltodano, A., What is the daily practice of mechanical ventilation in pediatric intensive care units? A multicenter study (2004) Intensive Care Med, 30, pp. 918-925Roe, M., O'Donnell, D.R., Tasker, R.C., Respiratory viruses in the intensive care unit (2003) Paediat Respir Rev, 4, pp. 166-171Panitch, H.B., Respiratory syncytial virus bronchiolitis: Supportive care and therapies designed to overcome airway obstrution (2003) Pediatr Infect Dis J, 22, pp. S83-8Sigurs, N., Bjarnason, R., Sigurbergsson, F., Kjellman, B., Björkstén, B., Asthma and immunoglobulin e antibodies after respiratory syncytial virus bronchiolitis: A prospective cohort study with matched controls (1995) Pediatrics, 95, pp. 500-505Martinez, F.D., All, W., Taussig, L.M., Holberg, C.J., Halonen, M., Morgan, W.J., Asthma and wheezing in the first six years of life (1995) N Engl J Med, 332, pp. 133-138Stein, R.T., Sherrill, D., Morgan, W.J., Holberg, C.J., Halonen, M., Taussig, L.M., Respiratory syncytial virus in early life and risk of wheeze and allergy by age 13 years (1999) Lancet, 154, pp. 541-54

Initial Experience At A University Teaching Hospital From Using Telemedicine To Promote Education Through Video Conferencing [experiência Inicial De Um Hospital Universitário Utilizando A Telemedicina Na Promoção De Educação Através De Vídeo-conferências]

CONTEXT AND OBJECTIVE: Telehealth and telemedicine services are advancing rapidly, with an increasing spectrum of information and communication technologies that can be applied broadly to the population's health, and to medical education. The aim here was to report our institution's experience from 100 videoconferencing meetings between five different countries in the Americas over a one-year period. DESIGN AND SETTING: Retrospective study at Universidade Estadual de Campinas. METHODS: Through a Microsoft Excel database, all conferences in all specialties held at our institution from September 2009 to August 2010 were analyzed retrospectively. RESULTS: A total of 647 students, physicians and professors participated in telemedicine meetings. A monthly mean of 8.3 (± 4.3) teleconferences were held over the analysis period. Excluding holidays and the month of inaugurating the telemedicine theatre, our teleconference rate reached a mean of 10.3 (± 2.7), or two teleconferences a week, on average. Trauma surgery and meetings on patient safety were by far the most common subjects discussed in our teleconference meetings, accounting for 22% and 21% of the total calls. CONCLUSION: Our experience with telemedicine meetings has increased students' interest; helped our institution to follow and discuss protocols that are already accepted worldwide; and stimulated professors to promote telemedicine-related research in their own specialties and keep up-to-date. These high-technology meetings have shortened distances in our vast country, and to other reference centers abroad. This virtual proximity has enabled discussion of international training with students and residents, to increase their overall knowledge and improve their education within this institution.13013236Bashshur, R.L., On the definition and evaluation of telemedicine (1995) Telemed J, 1 (1), pp. 19-30Alverson, D.C., Edison, K., Flournoy, L., Telehealth tools for public health, emergency, or disaster preparedness and response: A summary report (2010) Telemed J E Health, 16 (1), pp. 112-114Ereso, A.Q., Garcia, P., Tseng, E., Live transference of surgical subspecialty skills using telerobotic proctoring to remote general surgeons (2010) J Am Coll Surg, 211 (3), pp. 400-411Mauer, U.M., Kunz, U., Management of neurotrauma by surgeons and orthopedists in a military operational setting (2010) Neurosurg Focus, 28 (5), pp. E10Huang, C.M., Chan, E., Hyder, A.A., Web 2.0 and internet social networking: A new tool for disaster management? --lessons from Taiwan (2010) BMC Med Inform Decis Mak, 10, p. 57Blanche, P.A., Bablumian, A., Voorakaranam, R., Holographic three-dimensional telepresence using large-area photorefractive polymer (2010) Nature, 468 (7320), pp. 80-83Jabbour, P., Gonzalez, L.F., Tjoumakaris, S., Randazzo, C., Rosenwasser, R., Stroke in the robotic era (2010) World Neurosurg, 73 (6), pp. 603-604Latifi, R., Stanonik, M.L., Merrell, R.C., Weinstein, R.S., Telemedicine in extreme conditions: Supporting the Martin Strel Amazon Swim Expedition (2009) Telemed J E Health, 15 (1), pp. 93-100Landers, S.H., Why health care is going home (2010) N Engl J Med, 363 (18), pp. 1690-1691Hede, K., Teleoncology gaining acceptance with physicians, patients (2010) J Natl Cancer Inst, 102 (20), pp. 1531-1533García jordá, E., Telemedicine: Shortening distances (2010) Clin Transl Oncol, 12 (10), pp. 650-651Latifi, R., Telepresence and telemedicine in trauma and emergency (2008) Stud Health Technol Inform, 131, pp. 275-280Hays, R.B., Peterson, L., Options in education for advanced trainees in isolated general practice (1996) Aust Fam Physician, 25 (3), pp. 362-366Ekeland, A.G., Bowes, A., Flottorp, S., Effectiveness of telemedicine: A systematic review of reviews (2010) Int J Med Inform, 79 (11), pp. 736-771Scuffham, P., Systematic review of cost effectiveness in telemedicine. Quality of cost effectiveness studies in systematic reviews is problematic (2002) BMJ, 325 (7364), p. 598. , author reply 598Rezende, E.J.C., Melo, M.C.B., Tavares, E.C., Santos, A.F., Souza, C., Ethics and eHealth: Reflections for a safe practice (2010) Rev Panam Salud Pública = Pan Am J Public Health, 28 (1), pp. 58-65Motoi, K., Ogawa, M., Ueno, H., A fully automated health-care monitoring at home without attachment of any biological sensors and its clinical evaluation (2009) Conf Proc IEEE Eng Med Biol Soc, 2009, pp. 4323-4326Azpiroz-Leehan, J., Martínez, L.F., Cadena, M.M., Imaging Facilities for Basic Medical Units: A Case in the State of Guerrero, Mexico (2010) J Digit Imaging, , Epub ahead of printKailas, A., Chong, C.C., Watanabe, F., From mobile phones to personal wellness dashboards (2010) IEEE Pulse, 1 (1), pp. 57-63Eron, L., Telemedicine: The future of outpatient therapy? (2010) Clin Infect Dis, 51 (SUPPL. 2), pp. S224-S230Nakajima, I., Japanese telemedical concept of ambulatory application (2011) J Med Syst, 35 (2), pp. 215-220Haidegger, T., Sándor, J., Benyó, Z., Surgery in space: The future of robotic telesurgery (2011) Surg Endosc, 25 (3), pp. 681-690Machado, F.S.N., Carvalho, M.A.P., Mataresi, A., Use of telemedicine technology as a strategy to promote health care of riverside communities in the Amazon: Experience with interdisciplinary work, integrating NHS guidelines (2010) Ciên Saúde Coletiva, 15 (1), pp. 247-254Latifi, R., Hadeed, G.J., Rhee, P., Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients (2009) Am J Surg, 198 (6), pp. 905-910Bulik, R.J., Shokar, G.S., Integrating telemedicine instruction into the curriculum: Expanding student perspectives of the scope of clinical practice (2010) J Telemed Telecare, 16 (7), pp. 355-35

The Use Of Growth Hormone To Treat Endocrine-metabolic Disturbances In Acquired Immunodeficiency Syndrome (aids) Patients [o Papel Do Hormônio De Crescimento No Tratamento Dos Distúrbios Endócrino-metabólicos Do Paciente Com A Síndrome Da Imunodeficiência Adquirida (aids)]

Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART ) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions. copyright© ABE&M todos os direitos reservados.525818832(2007) Unaids. Aids Epidemic Update, , http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf, December. Disponível emSecretaria de Vigilância em Saúde. 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Effects of growth hormone on visceral adipose tissue and dyslipidemia in HIV, an erratum. J Acquir Immune Defic Syndr. 2006;43:378-80Falutz, J., Therapy insight: Body-shape changes and metabolic complications associated with HIV and highly active antiretroviral therapy (2007) Nat Clin Pract Endocrinol Metab, 3, pp. 651-661Tesselaar, K., Miedema, F., Growth hormone resurrects adult human thymus during HIV-1 infection (2008) J Clin Invest, 3, pp. 844-847Lo, J.C., Mulligan, K., Noor, M.A., Schwarz, J.M., Halvorsen, R.A., Grunfeld, C., The effects of recombinant human growth hormone on body composition and glucose metabolism in HIV-infected patients with fat accumulation (2001) J Clin Endocrinol Metab, 86, pp. 3480-3487Antiretroviral therapy, fat redistribution and hyperlipidaemia in HIV-infected children in Europe (2004) Aids, 18, pp. 1443-1451. , European Paediatric Lipodystrophy GroupMinistério da Saúde. Brasil 2004. Secretaria de Vigilância em Saúde. 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Long-term effectiveness of potent antiretroviral therapy in preventing Aids and death: A prospective cohort study (2005) Lancet, 366, pp. 378-384Patel, K., Hernán, M.A., Williams, P.L., Seeger, J.D., McIntosh, K., Van Dyke, R.B., Pediatric Aids Clinical Trials Group 219/219C Study Team. 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Recommendations from SPNS/GEAM/SENBA/SENPE/AEDN/SEDCA/GESIDA on nutrition in the HIV-infected patient (2007) Nutr Hosp, 22, pp. 229-243Chantry, C.J., Frederick, M.M., Meyer 3rd, W.A., Handelsman, E., Rich, K., Paul, M.E., Endocrine abnormalities and impaired growth in human immunodeficiency virus-infected children (2007) Pediatr Infect Dis J, 26, pp. 53-60Valente, A.M.M., Reis, A.F., Machado, D.M., Succi, R.C.M., Chacra, A.R., Alterações metabólicas da síndrome lipodistrófica do HIV. (2005) Arq Bras Endocrinol Metab, 49, pp. 871-881Saint-Marc, T., Partisani, M., Poizot-Martin, I., Bruno, F., Rouviere, O., Lang, J.M., A syndrome of peripheral fat wasting (lipodystrophy) in patients receiving long-term nucleoside analogue therapy (1999) Aids, 13, pp. 1659-1667Lundgren, J.D., Battegay, M., Behrens, G., De Wit, S., Guaraldi, G., Katlama, C., EACS Executive Committee. European Aids Clinical Society (EACS) guidelines on the prevention and management of metabolic diseases in HIV (2008) HIV Medicine, 9, pp. 72-81Laue, L., Pizzo, P.A., Butler, K., Cutler Jr., G.B., Growth and neuroendocrine dysfunction in children with acquired immunodeficiency syndrome (1990) J Pediatr, 117, pp. 541-545Matarazzo, P., Palomba, E., Lala, R., Ciuti, E., Altare, F., de Sanctis, L., Growth impairment, IGF I hyposecretion and thyroid dysfunction in children with perinatal HIV-1 infection (1994) Acta Paediatr, 83, pp. 1029-1034Panamonta, O., Kosalaraksa, P., Thinkhamrop, B., Kirdpon, W., Ingchanin, C., Lumbiganon, P., Endocrine function in Thai children infected with human immunodeficiency virus (2004) J Pediatr Endocrinol Metab, 17, pp. 33-40Rondanelli, M., Caselli, D., Aricò, M., Maccabruni, A., Magnani, B., Bacchella, L., Insulin-like growth factor I (IG F-I) and IG F-binding protein 3 response to growth hormone is impaired in HIV-infected children (2002) Aids Res Hum Retroviruses, 18, pp. 331-339Fliers, E., Unmehopa, U.A., Manniesing, S., Vuijst, C.L., Wiersinga, W.M., Swaab, D.F., Decreased neuropeptide Y (NPY) expression in the infundibular nucleus of patients with nonthyroidal illness (2001) Peptides, 22, pp. 459-465Eledrisi, M.S., Verghese, A.C., Adrenal insufficiency in HIV infection: A review and recommendations (2001) Am J Med Sci, 321, pp. 137-144Tovo, P.A., de Martino, M., Gabiano, C., Cappello, N., D'Elia, R., Loy, A., Prognostic factors and survival in children with perinatal HIV infection (1992) Lancet, 339, pp. 1249-1253Nachman, S.A., Lindsey, J.C., Pelton, S., Mofenson, L., McIntosh, K., Wiznia, A., Growth in human immunodeficiency virus-infected children receiving ritonavir-containing antiretroviral therapy (2002) Arch Pediatr Adolesc Med, 156, pp. 497-503Congote, L.F., Monitoring insulin-like growth factors in HIV infection and aids (2005) Clin Chim Acta, 361, pp. 30-53Meininger, G., Grinspoon, S., Regulation of the growth hormone/ insulin-like growth factor-I axis in HIV disease (2001) Endocrinologist, 11, pp. 188-195Frost, R.A., Fuhrer, J., Steigbigel, R., Mariuz, P., Lang, C.H., Gelato, M.C., Wasting in the acquired immune deficiency syndrome is associated with multiple defects in the serum insulin-like growth factor system (1996) Clin Endocrinol (Oxf), 44, pp. 501-514Heijligenberg, R., Sauerwein, H.P., Brabant, G., Endert, E., Hommes, M.J., Romijn, J.A., Circadian growth hormone secretion in asymptomatic human immune deficiency virus infection and acquired immunodeficiency syndrome (1996) J Clin Endocrinol Metab, 81, pp. 4028-4032Rondanelli, M., Solerte, S.B., Fioravanti, M., Scevola, D., Locatelli, M., Minoli, L., Circadian secretory pattern of growth hormone, insulin-like growth factor type I, cortisol, adrenocorticotropic hormone, thyroid-stimulating hormone and prolactin during HIV infection (1997) Aids, 13, pp. 1243-1249Stanley TL, Grinspoon SK. GH/GHRH axis in HIV lipodystrophy. Pituitary. 2008 Feb 13 [Epub ahead of print]Viganò, A., Mora, S., Brambilla, P., Schneider, L., Merlo, M., Monti, L.D., Impaired growth hormone secretion correlates with visceral adiposity in highly active antiretroviral treated HIV- infected adolescents (2003) Aids, 17, pp. 1435-1441Van Rossum, A.M.C., Gaaker, M.I., Verweel, G., Hartwig, N.G., Wolfs, T.F., Geelen, S.P., Endocrinology and immunologic factors associated with recovery of growth in children with human immunodeficiency virus type 1 infection treated with protease inhibitors (2003) Pediatric Infect Dis J, 22, pp. 70-76Schambelan, M., Mulligan, K., Grunfeld, C., Daar, E.S., LaMarca, A., Kotler, D.P., Recombinant human growth hormone in patients with HIV-associated wasting. A randomized, placebo-controlled trial. Serostim Study Group (1996) Ann Intern Med, 125, pp. 873-882Krentz, A.J., Koster, F.T., Crist, D.M., Finn, K., Johnson, L.Z., Boyle, P.J., Anthropometric, metabolic, and immunological effects of recombinant human growth hormone in Aids and Aids-related complex (1993) J Acquir Immune Defic Syndr, 6, pp. 245-251McNurlan, M.A., Garlick, P.J., Steigbigel, R.T., DeCristofaro, K.A., Frost, R.A., Lang, C.H., Responsiveness of muscle protein synthesis to growth hormone administration in HIV-infected individuals declines with severity of disease (1997) J Clin Invest, 100, pp. 2125-2132Waters, D., Danska, J., Hardy, K., Koster, F., Qualls, C., Nickell, D., Recombinant human growth hormone, insulin-like growth factor 1, and combination therapy in Aids-associated wasting: A randomized, double-blind, placebocontrolled trial (1996) Ann Intern Med, 125, pp. 865-872Esposito, J.G., Thomas, S.G., Kingdon, L., Ezzat, S., Growth hormone treatment improves peripheral muscle oxygen extraction-utilization during exercise in patients with human immunodeficiency virus-associated wasting: A randomized controlled trial (2004) J Clin Endocrinol Metab, 89, pp. 5124-5131Moyle, G.J., Daar, E.S., Gertner, J.M., Kotler, D.P., Melchior, J.C., O'Brien, F., Serono 9037 Study Team. 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Respiratory Syncytial Virus (rsv) In Infants Hospitalized For Acute Lower Respiratory Tract Disease: Incidence And Associated Risks

Respiratory syncytial virus (RSV) is one of the main causes of acute lower respiratory tract infections worldwide. We examined the incidence and associated risks for RSV infection in infants hospitalized in two university hospitals in the state of São Paulo. We made a prospective cohort study involving 152 infants hospitalized for acute lower respiratory tract infections (ALRTI) in two university hospitals in Campinas, São Paulo, Brazil, between April and September 2004. Clinical and epidemiological data were obtained at admission. RSV was detected by direct immunofluorescence of nasopharyngeal secretions. Factors associated with RSV infection were assessed by calculating the relative risk (RR). The incidence of RSV infection was 17.5%. Risk factors associated with infection were: gestational age less than 35 weeks (RR: 4.17; 95% confidence interval (CI) 2.21-7.87); birth weight less than or equal to 2,500 grams (RR: 2.69; 95% CI 1.34-5.37); mother's educational level less than five years of schooling (RR: 2.28; 95% CI 1.13-4.59) and pulse oximetry at admission to hospital lower than 90% (RR: 2.19; 95% CI 1.10-4.37). Low birth weight and prematurity are factors associated with respiratory disease due to RSV in infants. Low educational level of the mother and poor socioeconomic conditions also constitute risk factors. Hypoxemia in RSV infections at admission indicates potential severity and a need for early oxygen therapy. © 2006 by The Brazilian Journal of Infectious Diseases and Contexto Publishing. All rights reserved.105357361Shay, D.K., Holman, R.C., Newman, D., Bronchiolitis-associated hospitalizations among US children, 1980-19996 (1999) JAMA, 282, pp. 1440-1446Brandenburg, A.H., Jeannet, P.Y., Steensel-Moll, H.A., Local Variability in respiratory syncytial virus disease severity (1997) Arch Dis Child, 77, pp. 410-414Fletcher, J.N., Smyth, R.L., Thomas, H.M., Respiratory syncytial virus genotypes and disease severity among children in hospital (1997) Arch Dis Child, 77, pp. 508-511Loscertales, M.P., Roca, A., Ventura, P.J., Epidemiology and clinical presentation of respiratory syncytial virus infection in a rural area of southern Mozambique (2002) Pediatr Infect Dis J, 21, pp. 148-155Mcnamara, P.S., Smyth, R.L., The pathogenesis of respiratory syncytial virus disease in childhood (2002) Br Med Bull, 61, pp. 13-28Cintra, O.A.L., Owa, M.A., Machado, A.A., Occurence and severity of infections caused by subgroup A and B respiratory syncytial virus in children in southeast Brazil (2001) J Med Virol, 65, pp. 408-412Vieira, S.E., Gilio, A.E., Miyao, C.R., Sazonalidade do vírus respiratório sincicial na cidade de São Paulo, SP (2002) Pediatria (São Paulo), 24 (1-2), pp. 73-74Welliver, R.C., Review of epidemiology and clinical risk factors for severe respiratory syncytial virus (RSV) infection (2003) J Pediatr, 143, pp. S112-S117Weisman, L., Populations at risk for developing respiratory syncytial virus and risk factors for respiratory syncytial virus severity: Infants with predisposing conditions (2003) Pediatr Infect Dis J, 22, pp. S33-S39Meisner, H.C., Selected populations at increased risk from respiratory syncytial virus infection (2003) Pediatr Infect Dis J, 22 (2), pp. S40-S45Simoes, E.A.F., Environmental and demographic risk factors for respiratory syncytial virus lower respiratory tract disease (2003) J Pediatr, 143, pp. S118-S26Sant'Anna, C.C., D'Elia, C., Bronquiolitis (1997) Infecciones Respiratorias En Niños, pp. 261-280. , In: Benguigui Y, Antuñano FJL, Schmunis G, Yunes J, eds. Organización Panamericana. de la salud, WashingtonDenny, J.R.F.W., The impact of respiratory virus infections on the world's children (2001) Asthma and Respiratory Infections, pp. 1-22. , In: Skoner DP (ed). Marcel Deker, NYLannari, M., Giovannini, M., Giuffré, L., Prevalence of respiratory syncytial virus infection in italian infants hospitalized for acute lower respiratory tract infections, and association between respiratory syncytial virus infection risk factors and disease severity (2002) Pediatr Pulmonol, 33, pp. 458-465Jorden, R.C., (1982) "Multiple Trauma" in Emergency Medicine - Concepts and Clinical Practice, pp. 281-282. , 3rd ed.Rosen P, Barkin R. (eds). Mosby-Year Book, IncStenballe, L.G., Devasundaram, J.K., Simoes, E.A.F., Respiratory syncytial virus epidemics: The ups and downs of a seasonal virus (2003) Pediatr Infect Dis J, 22, pp. S21-S32Purcell, K., Fergie, J., Driscoll Children's Hospital Respiratory Syncytial Database. Risk factors treatment and hospital course in 3308 infnts and young children, 1991 to 2002 (2004) Pediatr Infect Dis J, 23, pp. 418-423Kneyber, M.C.J., Moons, K.G.M., De Groot, R., Moll, H.Á., Prediction of duration of hospitalization in respiratory syncytial virus infection (2002) Pediatric Pulmonology, 33, pp. 453-457Willson, D.F., Landrigan, C.P., Horn, S.D., Smout, R.J., Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia (2003) J Pediatr, 143, pp. S142-S149Bello Pedrosa, O., Langenhin, M., Pujadas Ferrer, M.A., Severe infections due to respiratory syncytial virus in infants under three months of age. Incidence in patients without common risk factors (2001) Arch Pediatr Urug, 72 (SUPPL.), pp. 20-25Semple, M.G., Cowell, A., Dove, W., Dual infections of infants by human metapneumovirus and human respiratory syncytial virus is strongly associated with severe bronchiolitis (2005) J Infect Dis, 191 (3), pp. 382-386Garofalo, R.P., Hintz, K.H., Hill, V., A comparison of epidemiologic and immunologic features of bronchiolitis caused by influenza virus and respiratory syncytial virus (2005) J Med Virol, 75 (2), pp. 282-289Arostegi Kareaga, N., Montes, M., Perez-Yarza, E.G., Clinical Characteristics of children hospitalized for influenza virus infection (2005) An Pediatr (Barc.), 62 (1), pp. 5-12Bosis, S., Esposito, S., Niesters, H.G., Impact of human metapneumovirus in childhood: Comparison with respiratory syncytial virus and influenza viruses (2005) J Med Virol, 75 (1), pp. 101-104Leader, S., Kohlhase, K., Recent trends in severe respiratory syncytial virus (RSV) among US infants, 1997-2000 (2003) J Pediatr, 143, pp. S127-S32Weber, M.W., Usen, S., Jaffar, S., Mulholland, E.K., Predictors of hypoxaemia in hospital admissions with acute lower respiratory tract infection in developing country (1997) Arch Dis Child, 76, pp. 310-314Brooks, A.M., McBride, J.T., McConnochie, K.M., Predicting deterioration in previously healthy infants hospitalized with respiratory syncytial virus infection (1999) Pediatrics, 104 (3), pp. 463-467Opavsky, M.A., Stephens, D., Wang, E.E.L., Testing models predicting severity of respiratory syncytial virus infection on the PICNIC RSV database (1995) Arch Pediatr Adolesc Med, 149, pp. 1217-1220Richardson, J.Y., Ottolini, M.G., Pletneva, L., Respiratory Syncytial Virus (RSV) infection induces cyclooxygenase 2: A potential target for RSV therapy (2005) J Immunol, 174 (7), pp. 4356-4364Stark, J.M., Khan, A.M., Chiappetta, C.L., GN.Inimune and functional role of nitric oxide in a mouse model of respiratory syncytial virus infection (2005) J Infect Dis, 191 (3), pp. 387-395Vieira, S.E., Gilio, A.E., Miyao, C.R., Infecção nosocomial pelo vírus respiratório sincicial em enfermaria de pediatria (2002) Pediatria (São Paulo), 24 (1-2), pp. 17-24Diniz, E.M., Veira, R.A., Ceccon, M.E., Incidence of respiratory viruses in preterm infants submitted to mechanical ventilation (2005) Rev Inst Med Trop Sao Paulo, 47 (1), pp. 37-44MaCartney, K.K., Gorelick, M.H., Manning, M.L., Nosocomial respiratory syncytial virus infections: The cost effectiveness and cost-benefit of infection control (2000) Pediatrics, 106, pp. 520-52

Impaired Bacillus Calmette-guérin Cellular Immune Response In Hiv-exposed, Uninfected Infants

OBJECTIVE:: To evaluate cell-mediated immune response to Bacillus Calmette-Guérin (BCG) vaccination in uninfected, HIV-1-exposed infants, comparing it with unexposed children. DESIGN:: It is designed as a cross-sectional study. METHODS:: BCG-specific lymphoproliferation and T-cell subsets (CD4, CD8 and TCR γδ) by flow cytometry and interleukin-10, interferon-γ (IFN-γ) and tumor necrosis factor-α (TNF-α) concentration by ELISA were analyzed in HIV-exposed and unexposed infants. Whole blood lymphocyte immunophenotyping and blood counts were performed in exposed children. Nonparametric tests were used (P < 0.05). RESULTS:: Given the ontogeny of the immune system, exposed infants were separated into three groups according to age: exposed 1 (E1, aged 6.1-8.8 months), E2 (aged 9.1-17.1 months) and E3 (aged 18.1-26.3 months). Unexposed infants (UE group) and E1 were matched for age. Cell proliferation was not different among the three exposed groups, neither for BCG nor for phytohemagglutinin (PHA)-stimulated cultures. Furthermore, BCG-stimulated lymphoproliferation was reduced in the E1 group in comparison with the UE group. T-lymphocyte subpopulations also showed differences, with the youngest HIV-exposed groups (E1 and E2) showing a predominant proliferation of CD4 T cells in cultures with BCG, whereas E3 and UE groups had a robust γδ T-cell expansion. There was lower IFN-γ concentration in the samples from E1 group in comparison with all of the other groups. The unexposed infants showed higher TNF-α concentration in cultures with BCG and PHA in comparison with E1 group. CONCLUSION:: BCG-specific T-cell proliferation was reduced in HIV-exposed uninfected infants and IFN-γ concentration was lower in younger exposed infants, showing a delay in immune system maturation of HIV-exposed infants. © 2011 Wolters Kluwer Health Lippincott Williams & Wilkins.251720792087Thorne, C., Newell, M.-L., Epidemiology of HIV infection in the newborn (2000) Early Human Development, 58 (1), pp. 1-16. , DOI 10.1016/S0378-3782(00)00049-9, PII S0378378200000499Hawkins, D., Blott, M., Clayden, P., De Ruiter, A., Foster, G., Gilling-Smith, C., Gosrani, B., Taylor, G., Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission of HIV (2005) HIV Medicine, 6 (SUPPL. 2), pp. 107-148Amaral, E., Assis-Gomes, F., Milanez, H., Cecatti, J.G., Vilela, M.M., Pinto E Silva, J.L., Timely implementation of interventions to reduce vertical HIV transmission: A successful experience in Brazil (2007) Revista Panamericana de Salud 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