Paracoccidioidomicose em crianças, com comprometimento ósseo distinto

The rarity of paracoccidioidomycosis in childhood prompted us to report two cases with different clinical and radiological skeletal involvement. The number of osteolytic lesions, the presence of periosteal reaction and the finding of Paracoccidioides brasiliensis in biopsy specimens, were distinctive features in both cases.São apresentados dois casos de paracoccidioidomicose óssea, cujas diferenças eram em relação ao número das lesões, ao aspecto radiológico e à presença do fungo em biópsia das lesões. O relato se deve à raridade desta doença em crianças

Chest diameter ratios for detecting static hyperinflation in children using photogrammetry

OBJECTIVES: To develop a photogrammetric method capable of identifying increases in anteroposterior chest diameters suggestive of pulmonary hyperinflation, and to test it with both asthmatic and asthma-free children. METHODS: Two distinct study designs were used to achieve these two objectives. The first was a descriptive analysis of diameters measured at the height of the axilla and of the xiphoid on digital images of 56 children aged 8 to 12 years photographed in the orthostatic position. The second was a case-control study of (a) 19 asthmatic children in treatment for at least 12 months; and (b) 37 children free from asthma with no prior history of complaints of respiratory/allergic disease. Diameters were measured on images of the front and left side views using CorelDRAW®, and the ratio between the front and side diameters was calculated for the axillary and xiphoid measurements, providing the diameter ratios. Diameter ratios close to or greater than 1 represent geometry tending towards a cylindrical shape, typical of hyperinflation on radiographs. RESULTS: Analysis with the t test for independent samples revealed a mean diameter ratio at the sternum that was significantly greater in the group of asthmatic children (p < 0.01) than the mean for the whole sample and also than the mean for the children without asthma. CONCLUSIONS: Despite the existence of disagreement on the best instruments, methods and times for identifying hyperinflation, results indicate that a system using diameter ratios obtained by photogrammetry is a promising tool for the identification of a kinesiopathological manifestation that is known to determine air entrapment in asthma patients. Research that combines clinical data with longitudinal intrapatient follow-up will be necessary to establish the strength of the evidence found in this study.OBJETIVOS: Desenvolver um método fotogramétrico capaz de identificar aumento do diâmetro torácico anteroposterior sugestivo de hiperinsuflação pulmonar e testá-lo em crianças asmáticas e não asmáticas. MÉTODOS: Foram conduzidos dois perfis de estudos, sendo um deles a análise descritiva dos diâmetros medidos no nível axilar e xifóideo em imagens fotográficas digitais de 56 crianças, com idade entre 8 e 12 anos, na posição ortostática, e o outro, um estudo caso-controle entre: (a) 19 crianças asmáticas em tratamento há mais de 12 meses; (b) 37 crianças não asmáticas, sem histórico pregresso ou queixas de doenças respiratórias/alérgicas. Os diâmetros foram medidos nas imagens da vista anterior e lateral esquerda pelo uso do programa CorelDraw®, e a esses diâmetros aplicou-se a razão matemática de vista anterior por lateral esquerda para cada nível, gerando o índice denominado razão diametral. A razão diametral próxima ou superior à unidade expressou uma configuração geométrica tendendo ao formato cilíndrico, típico de hiperinsuflação nas imagens radiológicas. RESULTADOS: A análise pelo teste t para amostras independentes mostrou uma média significativamente maior para razão diametral do osso esterno no grupo de crianças asmáticas (p < 0,01) que no grupo como um todo e no grupo de crianças não asmáticas. CONCLUSÕES: Apesar das controvérsias sobre instrumentos, formas e momentos de identificação da presença de hiperinsuflação, os resultados são favoráveis ao sistema de razão diametral pela biofotogrametria como ferramenta promissora na identificação de uma expressão cinesiopatológica conhecida como determinante da retenção aérea na asma. Pesquisas que agreguem informações clínicas e acompanhamento longitudinal intrapacientes serão necessárias antes de estabelecer a força das evidências encontradas neste estudo.Grupo de Apoio ao Programa de Educacao Respiratoria (GAPER)Universidade Federal do Paraná Departamento de PediatriaUFPR Departamento de Pediatria Programa de Pós-Graduação em Saúde da Criança e do AdolescenteUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de OtorrinolaringologiaUNIFESP, EPM, Depto. de OtorrinolaringologiaSciEL

Prevalence of recurrent wheezing in infants

OBJECTIVE: To identify the prevalence of recurrent wheezing in infants in the city of Curitiba, PR, Brazil. METHODS: A cross-sectional study carried out by means of administering questionnaires to the parents of infants aged 12 to 15 months attending health centers for immunization during the period between August 2005 and December 2006. This is a standardized and validated instrument consisting of questions on demographic characteristics, wheezing, respiratory infections and risk factors. At the time of the study the City Health Department had 107 health centers, 35 of which were selected by lots and distributed homogeneously across the municipal territory. RESULTS: A total of 1,364 infants (45.4%) had episodes of wheezing during their first 12 months of life, with onset at 5.5±3.1 months (mean ± standard deviation), and 678 (22.6%) had had three or more episodes. In 84.6% of the wheezing children treatment was with β2-agonists, with inhaled corticosteroids in 18.5%, oral corticosteroids in 24.3% and leukotriene receptor antagonists were used with 5.4%. The wheezing children exhibited nocturnal symptoms, intense difficulty breathing and visits to emergency services in the proportions of 58.9, 46.2 and 57.6%, respectively; 12.7% were admitted to hospital for asthma and 10.9% had had a medical diagnosis of asthma. Nocturnal symptoms, visits to emergency, severity of symptoms, hospital admissions for asthma and medical diagnoses of asthma were all more common among those who had suffered three or more crises (p < 0.001). CONCLUSIONS: There is an elevated prevalence of wheezing among the infants of Curitiba, with early onset and elevated morbidity. It is possible that these infants represent a large contingent of asthmatics.OBJETIVO: Verificar a prevalência da sibilância recorrente em lactentes na cidade de Curitiba (PR). MÉTODOS: Estudo transversal pela aplicação de questionários aos pais de lactentes, idade entre 12 e 15 meses, que procuraram unidades de saúde para imunização no período entre agosto de 2005 e dezembro de 2006. Este instrumento padronizado e validado consiste de perguntas sobre características demográficas, sibilância, infecções respiratórias e fatores de risco. Durante o período de estudo, a Secretaria Municipal de Saúde possuía 107 unidades de saúde, das quais 35 foram selecionadas por sorteio e distribuídas homogeneamente no território municipal. RESULTADOS: Um total de 1.364 lactentes (45,4%) apresentou um ou mais episódios de sibilância nos primeiros 12 meses de vida, com início aos 5,5±3,1 meses (média ± desvio padrão), e 678 (22,6%) tiveram três ou mais episódios. Utilizaram β2-agonistas, corticóides inalatórios, corticóides orais e antagonistas do receptor de leucotrienos 84,6, 18,5, 24,3 e 5,4% dos sibilantes, respectivamente. Sintomas noturnos, dificuldade intensa para respirar e visitas a emergência estiveram presente em 58,9, 46,2 e 57,6% dos lactentes que sibilaram; destes, 12,7% foram hospitalizados por asma e 10,9% tiveram diagnóstico médico de asma. Sintomas noturnos, visitas à emergência, gravidade dos sintomas, hospitalização por asma e diagnóstico médico de asma foram mais freqüentes entre os que apresentaram três ou mais crises (p < 0,001). CONCLUSÃO: A prevalência de lactentes sibilantes em Curitiba é elevada, com início precoce e alta morbidade. Possivelmente, esses lactentes representam um contingente expressivo de asmáticos.Universidade Federal do Paraná Hospital de ClínicasUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade de Santiago do ChileUNIFESP, EPMSciEL

Anafilaxia associada à vacina contra sarampo, caxumba e rubéola

A case-control study was carried out aiming to describe the cases and causes of anaphylaxis associated with the vaccine against measles, mumps and rubella. A total of 22 reported cases in children who showed mucocutaneous manifestations, during the Campanha Nacional de Vacinação (Brazilian Vaccination Campaign), conducted in the city of Curitiba, Southern Brazil, in 2004, were studied. In addition, 66 children, who were next to these cases and did not show a symptomatology after the vaccine was applied, were selected. Serum measurements of antibodies for vaccine antigens and total IgE, specific IgE antibody measurements for several allergens, and skin tests were performed. Vaccine response was adequate, specific IgE measurement and skin tests showed that potential allergens in vaccines and atopy were not associated with anaphylactic reactions. Skin tests with the vaccine and dextran were positive in the cases exclusively, suggesting sensitization to certain residual components of the vaccine and possible cross-reaction with dextran.Estudio del tipo caso-control cuyo objetivo fue describir los casos y las causas de anafilaxia asociada a la vacuna contra sarampión, varicela y rubéola. Fueron estudiados 22 casos notificados en niños de Curitiba, Sureste de Brasil, durante Campaña Nacional de Vacunación de 2004, que presentaron manifestaciones mococutáneas. Para el control, fueron seleccionados 66 niños vecinos de los casos, que no presentaron sintomatología posterior a la aplicación vacunal. Fueron realizadas dosificaciones séricas de anticuerpos para los antígenos vacunales, IgE total y específicas para diversos alérgenos, y pruebas cutáneas. La respuesta vacunal fue adecuada, la dosificación de IgE específica y las pruebas cutáneas mostraron que los alérgenos potenciales constituyentes de la vacuna y la atopia no fueron relacionados a las reacciones anafilácticas. Las pruebas cutáneas con la vacuna y el dextrano fueron positivas solamente en los casos, sugiriendo sensibilización por algún componente residual de la vacuna y posible reacción cruzada con el dextrano.Estudo do tipo caso-controle cujo objetivo foi descrever os casos e as causas de anafilaxia associada à vacina contra sarampo, caxumba e rubéola. Foram estudados 22 casos notificados em crianças de Curitiba, PR, durante Campanha Nacional de Vacinação de 2004, que apresentaram manifestações mucocutâneas. Para o controle, foram selecionadas 66 crianças vizinhas dos casos, que não apresentaram sintomatologia após a aplicação vacinal. Foram realizadas dosagens séricas de anticorpos para os antígenos vacinais, IgE total e específicas para diversos alérgenos, e testes cutâneos. A resposta vacinal foi adequada, a dosagem de IgE específica e os testes cutâneos mostraram que os alérgenos potenciais constituintes da vacina e a atopia não foram relacionados às reações anafiláticas. Os testes cutâneos com a vacina e o dextrano foram positivos somente nos casos, sugerindo sensibilização por algum componente residual da vacina e possível reação cruzada com o dextrano

Latin American anaphylaxis registry

Anaphylaxis; Food hypersensitivity; Latin AmericaAnafilaxi; Hipersensibilitat alimentària; Amèrica LlatinaAnafilaxia; Hipersensibilidad alimentaria; América LatinaBackground Recent data about clinical features, triggers and management of anaphylaxis in Latin America is lacking. Objective To provide updated and extended data on anaphylaxis in this region. Method An online questionnaire was used, with 67 allergy units involved from 12 Latin-American countries and Spain. Among data recorded, demographic information, clinical features, severity, triggering agents, and treatment were received. Results Eight hundred and seventeen anaphylactic reactions were recorded. No difference in severity, regardless of pre-existing allergy or asthma history was found. Drug induced anaphylaxis (DIA) was most frequent (40.6%), followed by food induced anaphylaxis (FIA) (32.9%) and venom induced anaphylaxis (VIA) (12%). FIA and VIA were more common in children-adolescents. Non-steroidal anti-inflammatory drugs (NSAIDs) and beta-lactam antibiotics (BLA) were the most frequent drugs involved. Milk (61.1% of FIA) and egg (15.4% of FIA) in children, and shellfish (25.5% of FIA), fresh fruits (14.2% of FIA), and fish (11.3% of FIA) in adults were the most common FIA triggers. Fire ants were the most frequent insect triggers, and they induced more severe reactions than triggers of FIA and DIA (p < 0.0001). Epinephrine was used in 43.8% of anaphylaxis episodes. After Emergency Department treatment, epinephrine was prescribed to 13% of patients. Conclusions Drugs (NSAIDs and BLA), foods (milk and egg in children and shellfish, fruits and fish in adults) and fire ants were the most common inducers of anaphylaxis. Epinephrine was used in less than half of the episodes emphasizing the urgent need to improve dissemination and implementation of anaphylaxis guidelines

Analysis of Respiratory Behavior and Clinical Parameters for Successful Extubation in Premature Infants

Background The weaning process is complex and needs to be done carefully. The success of extubation in premature babies is associated with brain maturity and adequate function of the lungs. We aimed to identify the ventilator parameters and clinical conditions related to extubation success and failure in premature infants. Materials and Methods This is anobservational study, analytical and non-comparative cohort. We selected all premature infants, into inclusion criterion, admitted to the Neonatal Intensive Care Unit (NICU) of Hospital de Clínicas, Curitiba, Brazil in Invasive mechanical ventilation (IMV). The fifty-one premature infants were evaluated every day until tracheal extubation and the data of the day of extubation were used. Results Thirty-nine premature infants had extubation success and the majority of them 32(82.05%) were appropriated for gestational age (AGA). The parameters that showed a statistical difference between success and failure group were Positive end-expiratory pressure (p = 0.03), plate pressure (p = 0.03), Partial pressure oxygen (p = 0.04), pH (p = 0.04), end-tidal CO2 (p = 0.01) and heart rate (p = 0.04). The use of caffeine periextubation and the permanence in Continuous positive airway pressure (CPAP) during the post-extubation period was higher in the success group (46.15% and 87.18%, respectively). The presence of piratory distress syndrome (RDS) was high in both groups, success group, 82.05% and failure group 100%. Conclusion The pressure values, the arterial blood gas analyses, and capnometry are important parameters to evaluate in the weaning process, checking these values closer to reference values. Supports before and after endotracheal extubation, such as the use of caffeine and CPAP, are important to avoid the need for reintubation

Dietary factors and oral cancer: a case-control study in Greater Metropolitan São Paulo, Brazil

Dietary factors associated with oral cancer were investigated in a case-control hospital-based study in the city of São Paulo, Brazil, from 1998 to 2002. A total of 835 subjects, 366 with histologically confirmed incident cases of oral-cavity or pharyngeal cancer and 469 controls participated in the study. Dietary data were collected with a food frequency questionnaire (FFQ). Odds ratios (OR) and 95% confidence intervals (95%CI) were obtained from unconditional logistic regression, adjusted for potential confounders. Inverse associations with risk of oral cancer were found for the highest intake of beans, OR = 0.37 (95%CI: 0.22-0.64), raw vegetables, OR = 0.51 (95%CI: 0.29-0.93) and the intermediate tertile of rice and pasta intake, OR = 0.56 (95%CI: 0.38-0.83). Positive associations were observed for the highest intake of eggs, OR = 1.84 (95%CI: 1.23-2.75), potatoes, OR = 2.22 (95%CI: 1.53-3.25), and milk, OR= 1.80 (95%CI: 1.09-2.98). Some traditional Brazilian foods like rice and beans emerged as protective factors against oral cancer, independently of other risk factors.Neste estudo, investigou-se os fatores dietéticos associados com o câncer oral, em um estudo tipo caso-controle de base hospitalar no Município de São Paulo, Brasil, entre 1998 e 2002. Participaram 835 indivíduos, sendo 366 casos incidentes de câncer de cavidade oral ou faringe e 469 controles. Os dados de consumo alimentar foram obtidos por um Questionário de Freqüência Alimentar (QFA). Os valores de odds ratio (OR) e intervalos com 95% de confiança (IC95%) foram estimados por regressão logística não condicional, ajustada por potenciais fatores de confusão. Verificaram-se associações inversas entre o câncer oral e o consumo mais elevado de feijão, OR = 0,37 (IC95%: 0,22-0,64), vegetais crus, OR = 0,51 (IC95%: 0,29-0,93) e para o tercil intermediário de arroz e massas, OR = 0,56 (IC95%: 0,38-0,83). Associações diretas foram observadas para o mais elevado consumo de ovos, OR = 1,84 (IC95%: 1,23-2,75), batata, OR = 2,22 (IC95%: 1,53-3,25) e leite, OR= 1,80 (IC95%: 1,09-2,98). Alimentos básicos da dieta do brasileiro, como arroz e feijão, emergiram como fatores de proteção para o câncer oral, independente de outros fatores de risco.Universidade de São Paulo Faculdade de Saúde PúblicaInstituto do Câncer Arnaldo Vieira de Carvalho Departamento de Cabeça e PescoçoHospital Heliópolis Departamento de Cabeça e PescoçoUniversidade Federal de São Paulo (UNIFESP) Hospital São PauloUNIFESP, Hospital São PauloSciEL

Delivering Value for Money to Government through Efficient and Effective Public Transit Service Continuity: Some Thoughts

This paper documents some thoughts on the reform agenda in public transit that is occurring throughout the world. The specific focus is on a growing commitment to competitive regulation through competitive tendering, and the efforts by a few governments (notably in Australia) to take control of the tangible assets used by private operators as a mechanism to exercise the opportunity, if so taken, to put services out to competitive tender. We review the theoretical arguments and the empirical evidence on contracting regimes and asset ownership, and the role that government and operator might play in a setting in which building trusting and collaborative partnerships has merit in delivering services that are in the main funded from the public purse