Urinary sepsis in children: a systematic review of diagnostic and therapeutic aspects

During the last decade, new imaging techniques and biological probesprovided further insight into the pathogenesis and natural history ofurinary tract infection (UTI) in children. Especially in newborns, UTIis a common cause of fever and probably the most common causeof renal parenchymal loss. In children aged equal or less than 2years, the symptoms of UTI are vague and non-specific - fever,irritability, poor feeding, vomiting, diarrhea and ill appearance. Inneonates, clinical symptoms or laboratory tests could not be usedto predict UTI episodes or eliminate the likelihood of a UTI even ifother sites of infections are clinically suggested. For this reason, thegoal of managing UTI in children is based on identifying and modifyingfactors that may increase the risk of renal parenchymal and functionalloss as from the onset of infection. Moreover, selective antimicrobialpressure is a major concern when treating children with UTI, asrenal parenchymal loss may occur within a short period of time, ifinadequate antimicrobial agents are utilized. OBJECTIVES: Thissystematic review assessed recent diagnostic and therapeuticaspects of severe UTI in children. We also summarized wellconductedstudies and the most important publications regardingdiagnosis and treatment of urinary sepsis in the pediatric population.SEARCH STRATEGY: Trials and reviews were searched in generaland specialized databases (MEDLINE, Cochrane Library) andreferences were reviewed. SELECTION CRITERIA: All publishedtrials and reviews were eligible for inclusion provided they reportedresults for the pediatric population, included clinically significantevents resulting from urinary tract infection, and included specificaspects of diagnosis and therapy. DATA COLLECTION: One reviewerextracted Information. Diagnostic and therapeutic aspects of urinarysepsis in the pediatric age group were assessed

Acometimento concomitante do intestino delgado e esôfago distal em criança com enterite necrosante maciça

Necrotizing enterocolitis is a disease of the newborn that may involve the small intestine and/or the colon, and the stomach. To our knowledge, massive necrosis of the small intestine with concomitant involvement of the esophagus has never been reported. A case of a 6-month-old boy with necrotizing enterocolitis and pan-necrosis of the small intestine, cecum, and the lower third of the esophagus is presented. After 70 days of treatment, intestinal transit was established by an anastomosis between the first centimeter of jejunum and the ascending colon. Finally, esophageal transit was established by a total gastric transposition with cervical esophagogastric anastomosis. The patient was maintained under total parenteral nutrition, and after 19 months he developed fulminant hepatic failure due to parenteral nutrition; he then underwent combined liver and small bowel transplantation. After 2 months, the patient died due to undefined neurologic complications, probably related to infection or immunosuppressive therapy.A enterite necrosante é uma doença típica do período neo-natal que pode acometer o intestino delgado, colo e/ou estômago. Até o presente, a necrose maciça do intestino delgado com o acometimento concomitante do esôfago nunca foi relatada. É apresentado o caso de um lactente com 6 meses de idade com enterite necrosante e acometimento de todo intestino delgado, ceco e terço inferior do esôfago. Após setenta dias de tratamento, o trânsito intestinal foi re-estabelecido por anastomose entre o primeiro centímetro do jejuno e o colo ascendente. Finalmente, o trânsito esofagiano foi refeito pela transposição gástrica total e anastomose esôfago-gástrica cervical. O paciente foi mantido em nutrição parenteral durante 19 meses e ao fim deste período desenvolveu falência hepática aguda, tendo sido submetido a transplante duplo de fígado e intestino delgado. Dois meses após, faleceu em decorrência de complicações neurológicas, provavelmente relacionadas à infecção ou ao tratamento imunossupressor

Burnout prevalence in medical students attending a team-based learning school

IntroductionWorldwide burnout prevalence among medical students is high. It has a negative impact on students’ personal and professional lives as well as on their psychosocial wellbeing and academic performance. It can result in physicians with emotional distancing and indifference to work, and it compromises the quality of healthcare offered to society. This study evaluates burnout in medical students selected by mini-multiple interviews (MMIs) who were being taught by the team-based learning (TBL) method. MMIs are often used to select students with soft skills for medicine, and TBL is related to greater academic achievement, which would allow students to have greater resilience to stress. Information on burnout occurrence is lacking for this type of student.MethodsStudents (N = 143) attending the first three semesters at a private medical school were evaluated. The Copenhagen Burnout Inventory—Student Version (CBI-SV) questionnaire was applied on three occasions (applications = Apps one, two, and three) in each semester. Scores ≥ 50 were considered to indicate burnout. Data were analyzed by statistics programs.ResultsPersonal-related and study-related burnout frequencies for 1st semester students were, respectively, 24.4 and 22% in App one and rose to 51 and 48.5% at the semester’s end. Second- and third-semester students’ frequencies reached 80.4 and 78.8%, respectively. Around 40% of 1st semester students having burnout at App one maintained the burnout score. Peer- and teacher-related burnout frequencies are low (4.9 and 2.4%) at the 1st semester App one and rose to the highest (24–30%) by the end of the 2nd semester. Woman students had significantly higher burnout frequencies in the personal- (p < 0.001) and study-related burnout subscales (p = 0.003). Students living with friends had lower study-related burnout scores than those living with family or alone (p = 0.024). There were no significant correlations between the burnout scores and tuition funding (partial or total) or having or not having religious faith.DiscussionThe prevalence of personal- and study-related burnout among medical students of the Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), perceived via mini-multiple interviews (MMI)—selected and team-based learning (TBL)—taught, was similar to those internationally reported. The college semester and the gender of woman were associated with worse burnout levels. Additional studies are needed to support more effective actions to reduce the impact of stress on students

Acidose metabólica na infância: por que, quando e como tratá-la?

Objectives: To critically discuss the treatment of metabolic acidosis and the main mechanisms of disease associated with this disorder; and to describe controversial aspects related to the risks and benefits of using sodium bicarbonate and other therapies.Sources: Review of PubMed/MEDLINE, LILACS and Cochrane Library databases for articles published between 1996 and 2006 using the following keywords: metabolic acidosis, lactic acidosis, ketoacidosis, diabetic ketoacidosis, cardiopulmonary resuscitation, sodium bicarbonate, treatment. Classical publications concerning the topic were also reviewed. the most recent and representative were selected, with emphasis on consensus statements and guidelines.Summary of the findings: There is no evidence of benefits resulting from the use of sodium bicarbonate for the hemodynamic status, clinical outcome, morbidity and mortality in high anion gap metabolic acidosis associated with lactic acidosis, diabetic ketoacidosis and cardiopulmonary resuscitation. Therefore, the routine use of sodium bicarbonate is not indicated. Potential side effects must be taken into consideration. Treating the underlying disease is essential to reverse the process. the efficacy of other alternative therapies has not been demonstrated in large-scale studies.Conclusions: Despite the known effects of acidemia on the organism in critical situations, a protective role of acidemia in hypoxic cells and the risk of alkalemia secondary to drug interventions are being considered. There is consensus regarding the advantages of alkali and sodium bicarbonate therapy in cases with normal anion gap; however, in the presence of high anion gap acidosis, especially lactic acidosis, diabetic acidosis and cardiopulmonary resuscitation, the use of sodium bicarbonate is not beneficial and has potential adverse effects, limiting its indication. the only points of agreement in the literature refer to the early treatment of the underlying disease and the mechanisms generating metabolic acidemia. Other promising treatment alternatives have been proposed; however, the side effects and absence of controlled studies with pediatric populations translate into lack of evidence to support the routine use of such treatments.Irmandade Santa Casa Miserlcordia São Paulo, Fac Ciencias Med, São Paulo, SP, BrazilUniversidade Federal de São Paulo, São Paulo, SP, BrazilHosp Israelita Albert Einstein, Ctr Terapia Intens Pediat, São Paulo, SP, BrazilUniv São Paulo, Fac Med, Dept Pediat, São Paulo, SP, BrazilUniv São Paulo, Hosp Clin, Inst Crianca,CTI Pediat, Fac Med, São Paulo, SP, BrazilUniversidade Federal de São Paulo, São Paulo, SP, BrazilWeb of Scienc

Choque séptico por Pseudomonas aeruginosa associado a éctima gangrenosa em criança com agamaglobulinemia

Ecthyma gangrenosum (EG) due to Pseudomonas aeruginosa is a rare and invasive infection that can be associated with agammaglobulinemia. The cornerstone of the treatment is based on prompt recognition with appropriate antibiotic coverage and intravenous immunoglobulin. The authors report a case of EG emphasizing the clinical and therapeutic aspects of this condition.Éctima Gangrenosa (EG) por Pseudomonas aeruginosa é uma infecção rara e invasiva que pode ser associada com agamaglobulinemia. O tratamento fundamental é baseado no pronto reconhecimento com cobertura de antibiótico apropriada e imunoglobulina intravenosa. Os autores relatam caso de EG dando ênfase aos aspectos clínicos e terapêuticos desta condição

How is Mechanical Ventilation Employed in a Pediatric Intensive Care Unit in Brazil?

OBJECTIVE: to investigate the relationship between mechanical ventilation and mortality and the practice of mechanical ventilation applied in children admitted to a high-complexity pediatric intensive care unit in the city of São Paulo, Brazil. DESIGN: Prospective cohort study of all consecutive patients admitted to a Brazilian high-complexity PICU who were placed on mechanical ventilation for 24 hours or more, between October 1st, 2005 and March 31st, 2006. RESULTS: Of the 241 patients admitted, 86 (35.7%) received mechanical ventilation for 24 hours or more. Of these, 49 met inclusion criteria and were thus eligible to participate in the study. Of the 49 patients studied, 45 had chronic functional status. The median age of participants was 32 months and the median length of mechanical ventilation use was 6.5 days. The major indication for mechanical ventilation was acute respiratory failure, usually associated with severe sepsis / septic shock. Pressure ventilation modes were the standard ones. An overall 10.37% incidence of Acute Respiratory Distress Syndrome was found, in addition to tidal volumes > 8 ml/kg, as well as normo- or hypocapnia. A total of 17 children died. Risk factors for mortality within 28 days of admission were initial inspiratory pressure, pH, PaO2/FiO2 ratio, oxygenation index and also oxygenation index at 48 hours of mechanical ventilation. Initial inspiratory pressure was also a predictor of mechanical ventilation for periods longer than 7 days. CONCLUSION: Of the admitted children, 35.7% received mechanical ventilation for 24 h or more. Pressure ventilation modes were standard. Of the children studied, 91% had chronic functional status. There was a high incidence of Acute Respiratory Distress Syndrome, but a lung-protective strategy was not fully implemented. Inspiratory pressure at the beginning of mechanical ventilation was a predictor of mortality within 28 days and of a longer course of mechanical ventilation

Complicações de aspiração de corpo estranho traqueobrônquico em crianças: relato de 5 casos e revisão da literatura

Aspiração de corpo estranho em via áerea é uma das principais causas de morte em crianças, especialmente nas menores que 3 anos de idade. A aspiração do corpo estranho pode causar um amplo espectro de sintomas, e o diagnóstico precoce é altamente associado com o sucesso da retirada do material inalado. Apesar dos grandes avanços nos procedimentos endoscópicos e anestésicos, um grande número de dificuldades e complicações ainda estão presentes nesta situação clínica. Neste estudo, descrevemos 5 casos de sérias complicações agudas, incluindo pneumomediatismo, pneumotórax, atelectasia total, migração do corpo estranho e necessidade de toracotomia, em crianças admitidas em nosso Centro de Terapia Intensiva em 1999 e 2000, situações essas que poderiam ser prevenidas com reconhecimento precoce e rápida intervenção terapêutica.Foreign body aspiration (FBA) is one of leading causes of death in children, especially among those younger than 3 years of age. The inhalation of a foreign body may cause a wide variety of symptoms, and early diagnosis is highly associated with the successful removal of the inhaled foreign material. Despite the great advances in endoscopic procedures and anesthesia, a large number of difficulties and complications still result from foreign body aspiration. We describe 5 cases of serious acute complications following aspiration of foreign bodies that became lodged in the tracheobronchial tree, including pneumomediastinum, pneumothorax, total atelectasis, foreign body dislodgment, and need for thoracotomy in children admitted into our intensive care unit in 1999 and 2000; these were all situations that could have been prevented with early recognition and prompt therapeutic intervention

Availability of pediatric and neonatal intensive care units in the city of São Paulo

OBJECTIVE: To describe the health care service provided in pediatric intensive care units in the city of São Paulo, by identifying and describing the units and analyzing their geographic distribution. METHODS: A descriptive cross-sectional study was carried out during a two-year period (August 2000 to July 2002). Data were collected through questionnaires answered by medical directors of each pediatric and neonatal intensive care unit. RESULTS: São Paulo is served by 107 pediatric and neonatal intensive care units, of which 85 (79.4%) completed and returned the questionnaire. We found a very unequal distribution of units as there were more units in places with the least pediatric population. Regarding to pediatric intensive care units specialization, 7% were pediatric, 41.2% were neonatal and 51.7% were mixed (pediatric and neonatal). Regarding hospital funds, 15.3% were associated with philanthropic institutions, 37.6% were private and 47% were public. A total of 1,067 beds were identified, of which 969 were active. The ratio bed/patient aged 0-14 was 1/2,728, varying from 1/604 at health districts - I to 1/6,812 at health districts - III. The units reported an average of 11.7 beds (2 to 60). The neonatal intensive care unit had a median of 16.9 beds per unit and pediatric intensive care units a median of 8.5 beds/unit. CONCLUSION: In São Paulo, we found an uneven distribution of pediatric and neonatal intensive care units among the health districts. There was also an uneven distribution between public and private units, and neonatal and pediatric ones. The current report is the first step in the effort to improve the quality of medical assistance in pediatric and neonatal intensive care units in São Paulo.OBJETIVO: Caracterizar a assistência de saúde prestada em tratamento intensivo pediátrico e neonatal no município de São Paulo através da identificação, descrição e distribuição geográfica das unidades. MÉTODOS: Estudo descritivo, tipo transversal, onde foram estudadas as unidades de terapia intensiva pediátrica e neonatal do município de São Paulo, no período de agosto de 2000 a julho de 2002. A coleta dos dados foi realizada por meio de questionário preenchido pelo coordenador médico de cada unidade. RESULTADOS: Foram listadas 107 unidades de terapia intensiva pediátricas e neonatais no município de São Paulo. Oitenta e cinco (79,4%) unidades forneceram os dados, constituindo a população de estudo. Observou-se maior número de unidades de terapia intensiva em Núcleos Regionais de Saúde com menor população pediátrica. Quanto à faixa etária, 7% eram exclusivamente pediátricas, 41,2% neonatais, e 51,7% mistas. Em relação ao mantenedor: 47% eram públicas, 37,6% privadas, e 15,3% filantrópicas. Identificamos 1.067 leitos, estando 969 em atividade. A razão leito/paciente de 0 a 14 anos foi de 1:2.728, variando de 1:604 (Núcleo Regional de Saúde - I) a 1:6.812 (Núcleo Regional de Saúde - III). O número de leitos por unidade variou de 2 a 60, com média de 11,7 (unidades de terapia intensiva neonatais: 16,9; mistas: 8,5). CONCLUSÃO: No município de São Paulo, observou-se uma distribuição desproporcional das unidades de terapia intensiva pediátrica e neonatal entre os cinco Núcleos Regionais de Saúde. Houve também uma distribuição desproporcional entre unidades de terapia intensiva públicas e privadas e entre neonatais e pediátricas. Esse estudo foi o primeiro esforço na busca por melhor qualidade na assistência intensiva pediátrica e neonatal no município de São Paulo.Universidade de São Paulo Faculdade de MedicinaUniversidade Federal de São Paulo (UNIFESP) Departamento de PediatriaUniversidade de São Paulo Hospital Universitário Unidade de Terapia Intensiva PediátricaUNIFESP, Depto. de PediatriaSciEL

Meningoencefalite associada ao Mycoplasma pneumoniae

We report a case of a child with meningoencephalitis of atypical etiology. The patient developed the disease after an infection in the upper airways with unfavorable evolution. The clinical recovery was only possible after the administration of adequate antibiotic therapy for the etiological agent. This case report describes a child with meningoencephalitis of atypical etiology. The patient developed the disease after an infection in the superior airways with negative evolution. The clinical recovery was possible only after the introduction of adequate antibiotic therapy for the etiological agent.Este relato de caso descreve uma criança com menignoencefalite de etiologia atípica. A paciente desenvolveu a doença após infecção de vias aéreas superiores, com evolução desfavorável. Houve recuperação clínica somente após introdução de antibioticoterapia adequada para o agente etiológico.Universidade de São Paulo Faculdade de Medicina Instituto da CriançaHospital Israelita Albert EinsteinUniversidade Federal de São Paulo (UNIFESP) Laboratory of Pediatric Gastroenterology Experimental SurgeryHospital Israelita Albert Einstein Pediatric DepartmentUNIFESP, Laboratory of Pediatric Gastroenterology Experimental SurgerySciEL

Estudo prospectivo comparativo de sistema especialista de prescrição médica na redução de erro e sobrecarga de trabalho médico

Erros médicos preveníveis(EMP) em hospitais excedem às mortes causadas por acidentes \ud automobilísticos, câncer de mama e AIDS. O Institute of Medicine estima até 98.000 mortes \ud causadas por EMP. O risco é aumentado quando os EMPs ocorrem em pacientes criticamente \ud enfermos ou com medicações que variam com o peso do paciente. A demora da primeira \ud prescrição é uma preocupação em UTI. Fadiga e sobrecarga podem comprometer a segurança \ud numa UTI pediátrica. Objetivos: Comparar a funcionalidade de um Sistema Especialista(SE) \ud experimental com a prescrição médica convencional Materiais/Métodos: Após termo de \ud consentimento, pediatras de um hospital universitário são convidados a fazer a prescrição de 10 \ud itens medicamentosos completos(soro de manutenção, adenosina, adrenalina, atropina, \ud difenilhidantoína, vancomicina , ceftadizima, anfotericina_B, dobutamina, fentanil) para uma \ud criança hipotética. Comparou-se a prescrição convencional com a prescrição feita no SE, após \ud um treinamento prévio de 2 minutos. Uma equipe(médicos, enfermeiras e farmacêuticas) \ud avaliaram os EMPs. Comparações feitas pelo X2, teste exato de fisher, teste t-student pareado ou \ud Wilconson, quando aplicáveis. Significância considerada: p<0.05. Resultados:13 médicos \ud residentes e 7 assistentes participaram do estudo com tempo médio de formação de 10,1+/-9 anos \ud . Constatados 57 casos de EMP (9 ilegibilidades, 23 omissões, 6 erros de dose, 14 erros de \ud diluição e 5 erros de velocidade de infusão) pela prescrição convencional comparado com 1 \ud duplicação de medicação na prescrição por SE(p<0,001). O tempo médio de prescrição dos 10 \ud medicamentos utilizando a abordagem ONE TOUCH do SE foi de 22,4 +/- 5,6 segundos_[13-36 \ud segundos] e estava significantemente abaixo do tempo de prescrição convencional (média:557 +/- \ud 164 segundos; p=0,00088). O tempo médio de prescrição com SE foi 27 vezes(IC95% 21,5-\ud 32,5)) mais rápido que a convencional com economia de 89,1 minutos em uma UTI de 10 leitos. \ud Conclusão:Embora não infalível, o uso de SE requer pouco tempo de treinamento e resulta em \ud significante diminuição de erros e sobrecarga de trabalho