Gait analysis of leprosy patients with foot drop using principal component analysis

BACKGROUND

Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis.

METHODS

Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA).

FINDINGS

Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8^o ± 8.3), terminal stance (-29.1^o ± 11.5), and swing (-12.4^o ± 6.2) in the affected limb compared to unaffected (-6.6^o ± 10.3; -14.6^o ± 11.6; 2.4^o ± 7.6) and controls (-5.4^o ± 2.5; -18.8^o ± 5.8; -1.4^o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups.

INTERPRETATION

Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.

Mental Health and Emotional Disorders During the COVID-19 Pandemics: Prevalence and Extent in PICU Staff

OBJECTIVES

To assess the prevalence of burnout, anxiety and depression symptoms, and posttraumatic stress disorder (PTSD) in PICU workers in Brazil during the first peak of the COVID-19 pandemic. To compare the results of subgroups stratified by age, gender, professional category, health system, and previous mental health disorders.

DESIGN

Multicenter, cross-sectional study using an electronic survey.

SETTING

Twenty-nine public and private Brazilian PICUs.

SUBJECTS

Multidisciplinary PICU workers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Self-reported questionnaires were used to measure burnout (Maslach Burnout Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), and PTSD (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5]) in 1,084 respondents. Subjects were mainly young (37.1 ± 8.4 yr old) and females (85%), with a median workload of 50 hours per week. The prevalence of anxiety and depression was 33% and 19%, respectively, whereas PTSD was 13%. The overall median burnout scores were high in the emotional exhaustion and personal accomplishment dimensions (16 [interquartile range (IQR), 8-24] and 40 [IQR, 33-44], respectively) whereas low in the depersonalization one (2 [IQR, 0-5]), suggesting a profile of overextended professionals, with a burnout prevalence of 24%. Professionals reporting prior mental health disorders had higher prevalence of burnout (30% vs 22%; p = 0.02), anxiety (51% vs 29%; p < 0.001), and depression symptoms (32.5% vs 15%; p < 0.001), with superior PCL-5 scores for PTSD ( p < 0.001). Public hospital workers presented more burnout (29% vs 18.6%, p < 0.001) and more PTSD levels (14.8% vs 10%, p = 0.03). Younger professionals were also more burned out ( p < 0.05 in all three dimensions).

CONCLUSIONS

The prevalence of mental health disorders in Brazilian PICU workers during the first 2020 peak of COVID-19 was as high as those described in adult ICU workers. Some subgroups, particularly those reporting previous mental disorders and younger professionals, should receive special attention to prevent future crises.

Toxic stress, epigenetics and child development

OBJECTIVES

To describe the concept of toxic stress, present the basics of epigenetics and discuss their relationship with child development.

DATA SOURCE

Narrative literature review through a search in the SciELO, Lilacs, Medline databases using the terms Adverse Childhood Experience OR Early Life Stress, Epigenomic OR Epigenetic, Child Development OR Infant Development.

DATA SYNTHESIS

Continuing stress response, known as toxic stress, can occur when a child experiences intense, frequent, and/or prolonged adversity-such as physical or emotional abuse, chronic neglect, for example-without adequate adult support. This toxic stress can have harmful effects on learning, behavior, and health throughout life. Epigenetics, an emerging scientific research area​, shows how environmental influences affect gene expressions and explains how early experiences can impact throughout life.

CONCLUSIONS

Toxic stress causes changes in the human body response systems that can be explained in part by epigenetic changes, which can be temporary or long-lasting. Pediatricians must be aware of these mechanisms and their consequences, seeking to prevent them and thus promote the health, well-being, and quality of life of children, contributing to their full development.

Multicenter validation of PIM3 and PIM2 in Brazilian pediatric intensive care units

OBJECTIVE

To validate the PIM3 score in Brazilian PICUs and compare its performance with the PIM2.

METHODS

Observational, retrospective, multicenter study, including patients younger than 16 years old admitted consecutively from October 2013 to September 2019. We assessed the Standardized Mortality Ratio (SMR), the discrimination capability (using the area under the receiver operating characteristic curve - AUROC), and the calibration. To assess the calibration, we used the calibration belt, which is a curve that represents the correlation of predicted and observed values and their 95% Confidence Interval (CI) through all the risk ranges. We also analyzed the performance of both scores in three periods: 2013-2015, 2015-2017, and 2017-2019.

RESULTS

41,541 patients from 22 PICUs were included. Most patients aged less than 24 months (58.4%) and were admitted for medical conditions (88.6%) (respiratory conditions = 53.8%). Invasive mechanical ventilation was used in 5.8%. The median PICU length of stay was three days (IQR, 2-5), and the observed mortality was 1.8% (763 deaths). The predicted mortality by PIM3 was 1.8% (SMR 1.00; 95% CI 0.94-1.08) and by PIM2 was 2.1% (SMR 0.90; 95% CI 0.83-0.96). Both scores had good discrimination (PIM3 AUROC = 0.88 and PIM2 AUROC = 0.89). In calibration analysis, both scores overestimated mortality in the 0%-3% risk range, PIM3 tended to underestimate mortality in medium-risk patients (9%-46% risk range), and PIM2 also overestimated mortality in high-risk patients (70%-100% mortality risk).

CONCLUSIONS

Both scores had a good discrimination ability but poor calibration in different ranges, which deteriorated over time in the population studied.

CORRELATION BETWEEN QUALITY OF LIFE AND THE CLINICAL RESULTS OF PATIENTS WITH LEPROSY WITH DROP FOOT AFTER TENDON TRANSFER

Objective

To evaluate the functional results of surgically correcting drop foot in patients with leprosy and compare their SALSA, Social Participation, and AOFAS score.

Methods

Overall, 22 patients were subjected to posterior tibial tendon transfer via the subcutaneous route to the foot dorsum with an average follow-up of 56 months (min 12, max 70). In our sample, 15 of the enrolled patients were men and seven, women, aged between 20 and 73 years old who were operated on from January 2014 to December 2017. The Pearson's correlation test (r) was used to measure the correlation among those scales. A p < 0.05 was considered significant between the pre- and pos-operative AOFAS scale scores.

Results

Pre-operative average AOFAS score was 59.6 (min 35, max 74) and 77.2 postoperative (min 36, max 97) (p < 0.0001), postoperative Salsa and Social Participation scale, 30.6 and 22.5, respectively. Statistical analysis suggests a strong positive correlation between AOFAS and Salsa scales (r = -0.83) and AOFAS and social participation (r = -0.78). Average dorsiflexion was 5.4 degrees.

Conclusion

The surgical correction of drop foot positively affects the quality of life and social participation of patients with leprosy. Level of Evidence III, Retrospective Study.

Case Report: SARS-CoV-2 Mother-to-Child Transmission and Fetal Death Associated With Severe Placental Thromboembolism

SARS-CoV-2 infection during pregnancy is not usually associated with significant adverse effects. However, in this study, we report a fetal death associated with mild COVID-19 in a 34-week-pregnant woman. The virus was detected in the placenta and in an unprecedented way in several fetal tissues. Placental abnormalities (MRI and anatomopathological study) were consistent with intense vascular malperfusion, probably the cause of fetal death. Lung histopathology also showed signs of inflammation, which could have been a contributory factor. Monitoring inflammatory response and coagulation in high-risk pregnant women with COVID-19 may prevent unfavorable outcomes, as shown in this case.

Fetal, neonatal, and infant outcomes associated with maternal Zika virus infection during pregnancy: A systematic review and meta-analysis

The occurrence of fetal and neonatal disorders in pregnant women with Zika virus infection in the literature is not consistent. This study aims to estimate the prevalence rate of these disorders in fetuses/neonates of pregnant women with confirmed or probable infection by Zika virus. A systematic review with meta-analysis was conducted in November 2020. Cohort studies that contained primary data on the prevalence of unfavorable outcomes in fetuses or neonates of women with confirmed or probable Zika virus infection during pregnancy were included. A total of 21 cohort studies were included, with a total of 35,568 pregnant women. The meta-analysis showed that central nervous system abnormalities had the highest prevalence ratio of 0.06 (95% CI 0.03-0.09). Intracranial calcifications had a prevalence ratio of 0.01 (95% CI 0.01-0.02), and ventriculomegaly 0.01 (95% CI 0.01-0.02). The prevalence ratio of microcephaly was 0.03 (95% CI 0.02-0.05), fetal loss (miscarriage and stillbirth) was 0.04 (95% CI 0.02-0.06), Small for Gestational Age was 0.04 (95% CI 0.00-0,09), Low Birth Weight was 0.05 (95% CI 0.03-0.08) and Prematurity was 0.07 (95% CI 0.04-0.10). The positivity in RT-PCR for ZIKV performed in neonates born to infected mothers during pregnancy was 0.25 (95% CI 0.06-0.44). We also performed the meta-analysis of meta-analysis for microcephaly with the prevalence ratios from other two previously systematic reviews: 0.03 (95% CI 0.00-0.25). Our results contribute to measuring the impact of Zika virus infection during pregnancy on children's health. The continuous knowledge of this magnitude is essential for the implementation development of health initiatives and programs, in addition to promoting disease prevention, especially in the development of a vaccine for Zika virus. PROSPERO protocol registration: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125543.

Point-of-care ultrasound by the pediatrician in the diagnosis and follow-up of community-acquired pneumonia

OBJECTIVES

To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines.

SOURCE OF DATA

A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected.

SYNTHESIS OF DATA

CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance.

CONCLUSIONS

Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

Cross-cultural adaptation of the Richmond Agitation-Sedation Scale to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care

OBJECTIVE

To perform a cross-cultural adaptation of the Richmond Agitation-Sedation Scale (RASS) to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care.

METHODS

Cross-cultural adaptation process including the conceptual, item, semantic and operational equivalence stages according to current recommendations.

RESULTS

Pretests, divided into two stages, included 30 professionals from the pediatric intensive care unit of a university hospital, who administered the translated RASS to patients aged 29 days to 18 years. The pretests showed a content validity index above 0.90 for all items: 0.97 in the first stage of pretests and 0.99 in the second.

CONCLUSION

The cross-cultural adaptation of RASS to Brazilian Portuguese resulted in a version with excellent comprehensibility and acceptability in a pediatric intensive care setting. Reliability and validity studies should be performed to evaluate the psychometric properties of the Brazilian Portuguese version of the RASS.

Screening of COVID-19 in outpatient children with cancer or solid organ transplantation: preliminary report

Clinical presentation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pediatric immunosuppressed patients is unknown. Emerging data describe a milder or asymptomatic course in children compared with adults in this scenario. We present the seroprevalence and clinical features of coronavirus disease 2019 in a prospective cohort of 114 immunosuppressed children and adolescents from three groups: kidney transplantation, liver transplantation, and cancer patients. Among the thirty-five (30.7%) patients who had a positive serological test for SARS-CoV-2, 77% did not report previous symptoms and none of them developed any complications of coronavirus disease 2019 (COVID-19) after 30 or more days of follow-up. Among those who were symptomatic, diarrhea, fever, and cough were the most common findings.Conclusion: Seroprevalence of SARS-CoV-2 infection is high among immunosuppressed children and adolescents. COVID-19 has a mild or asymptomatic course in most of these patients. What is Known: • The number of immunosuppressed patients with coronavirus disease 2019 is increasing. • Viral infections have the potential for greater severity in immunocompromised children. What is New: • Seroprevalence for severe acute respiratory syndrome coronavirus 2 in immunocompromised pediatric patients was 31%. • A quarter of the serology-positive patients reported mild symptoms and none of them developed multisystem inflammatory syndrome in children associated with coronavirus disease 2019.

CLINICAL AND LABORATORY CHARACTERISTICS OF SARS-COV-2 INFECTION IN CHILDREN AND ADOLESCENTS

OBJECTIVE

To present the current evidence on clinical and laboratory characteristics of infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during childhood and adolescence.

DATA SOURCE

This is a narrative review conducted in the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Latin American and Caribbean Health Sciences Literature in the Virtual Health Library (LILACS/VHL), Scopus, Web of Science, Cochrane Library, portal of the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES), Scientific Electronic Library Online (SciELO), ScienceDirect, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The terms used were SARS-CoV-2, COVID-19, novel coronavirus, child, newborn, and adolescent.

DATA SYNTHESIS

Unlike adults, most children infected by SARS-CoV-2 have mild or asymptomatic clinical presentations. Symptomatic children mainly have low fever and cough, with some associated gastrointestinal symptoms. Severe cases are rare and occur especially in infants under one year of age. Detection of viral particles in feces seems to be more persistent in children and can be used as a tool for diagnosis and control of the quarantine period. Different from adults, children can present distinct inflammatory responses, as has happened in new cases of Kawasaki-like syndrome associated with SARS-CoV-2 infection.

CONCLUSIONS

Most children have asymptomatic or mild presentations, with a prevalence of fever, cough, and gastrointestinal symptoms. New cases with different systemic inflammatory reactions in children have been reported, with clinical manifestations distinct from those typically found in adults.

Microcefalia e alterações do sistema nervoso central relacionadas à infecção congênita pelo vírus Zika e outras etiologias infecciosas no estado do Rio de Janeiro: estudo transversal, 2015 a 2017

Objetivo.

Descrever o perfil clínico-epidemiológico dos casos confirmados de microcefalia e/ou alterações do sistema nervoso central (SNC) relacionadas a infecção congênita pelo vírus Zika e outras etiologias infecciosas no estado do Rio de Janeiro no período de novembro de 2015 a julho de 2017.

Métodos.

Realizou-se um estudo transversal de 298 casos (conforme definição do Ministério da Saúde) notificados à Secretaria de Estado de Saúde do Rio de Janeiro no período estudado. Analisaram-se variáveis demográficas, epidemiológicas, clínicas, radiológicas e laboratoriais, com análise estatística descritiva bivariada e múltipla por regressão logística para estudo de fatores associados ao óbito.

Resultados.

A idade mediana das mães foi 24 anos; 30,9% relataram febre, e 64,8%, exantema à gestação. A mediana do perímetro cefálico ao nascer foi 29 cm e a do peso foi 2 635 g. O diagnóstico etiológico foi de Zika congênita em 46,0%; de sífilis, toxoplasmose, rubéola, citomegalovírus e vírus herpes simplex (STORCH) em 13,8%, com predomínio da sífilis; e de agente infeccioso não definido em 40,3%. Alterações do SNC diferentes de microcefalia foram descritas em 88,3%, predominando calcificações cerebrais, ventriculomegalia e atrofia cerebral. A letalidade total foi 7,0%, sendo 19,0% nos casos de Zika confirmada laboratorialmente e 22,2% nos de toxoplasmose. Na análise múltipla, o peso ao nascer foi o principal preditor de óbito.

Conclusões.

Apesar da epidemia de Zika, 13,8% dos casos foram por STORCH. A letalidade e a elevada ocorrência de malformações neurológicas além da microcefalia mostram a gravidade da infecção, com impacto nas famílias e no sistema de saúde.

Normal Hearing Function in Children Prenatally Exposed to Zika Virus

Introduction  The association between prenatal Zika virus infection and hearing alterations in offspring has been the object of some studies, although few have assessed children without microcephaly. However, a current trend to include prenatal Zika virus exposure in the group of risk indicators for hearing loss is noted. Objective  To present a series of 27 children prenatally exposed to the Zika virus submitted to multiple hearing assessments over time. Methods  A cohort of children born to symptomatic mothers with laboratorial Zika virus infection confirmation during pregnancy was submitted to an otoacoustic emission test, auditory brainstem response test (automated, neurodiagnostic and frequency-specific), audiometry, and imitanciometry over a period of 36 months since birth. The hearing assessment was performed independently of the presence of microcephaly or other apparent signs of congenital Zika syndrome. Results  The hearing tests presented predominantly normal results. Some children had signs of middle ear pathology. The only microcephalic child had normal electrophysiological tests, as well as preserved audiometric thresholds, but presented altered motor responses to sound. Conclusion  Prenatal exposure to Zika virus does not always determine hearing impairment. This risk seems to be more associated to the severity of the central nervous system damage. Hearing screening and follow-ups of the affected children are important, as well as further research in this area.

Interaction between vitamin A supplementation and chronic malnutrition on child development

Abstract 200 million pre-school age children are not developing properly. Delays in child development are associated with multiple factors. This study aims to analyze if vitamin A supplementation is associated with improved development and how this effect could be mediated by nutritional status. Population-based study surveyed a representative sample of 8000 households, 1232 children 0-35 months, in the state of Ceará, Brazil. The variables analysed included child developmental status, nutritional determinants and confounding factors. The main effects and interactions were evaluated using Cox regressive models. Vitamin A supplementation showed protective effect to delay in cognitive and motor development modified by interaction with nutritional status. While well-nourished supplemented children presented a 67% lower risk of cognitive delay (adjusted PRR = 0·33 [0·21–0·53]), stunted children had no benefit from supplementation (adjusted PRR = 0·97 [0·39–2·40]). Vitamin A supplementation has a protective effect on child development, but not in stunted children. This suggests that supplementation is effective in promoting child development, especially if associated to a joint effort to improve the nutritional status of children, given the importance of this mediator.

Auditory findings associated with Zika virus infection: an integrative review

Introduction

Possible associations between Zika virus infection and hearing loss were observed during the epidemic in the Americas.

Objective

To describe the auditory alterations, pathogenesis and recommendations for follow-up in individuals with prenatal or acquired Zika virus infection.

Methods

Bibliographic research conducted in March/2018–April/2019 at the main available databases. Article selection, data extraction and quality evaluation were carried out by two independent reviewers. Studies containing auditory evaluation of patients with congenital or acquired Zika virus infection; and/or hypotheses or evidences on the pathophysiology of auditory impairment associated with Zika virus; and/or recommendations on screening and follow-up of patients with auditory impairment by Zika virus were included.

Results

A total of 27 articles were selected. Sensorineural and transient hearing loss were reported in six adults with acquired Zika virus infection. Of the 962 studied children, 482 had microcephaly and 145 had diagnostic confirmation of Zika virus; 515 of the 624 children with auditory evaluation performed only screening tests with otoacoustic emissions testing and/or automated click-stimuli auditory brainstem response testing. Studies in prenatally exposed children were very heterogeneous and great variations in the frequency of altered otoacoustic emissions and automated click-stimuli auditory brainstem response occurred across the studies. Altered otoacoustic emissions varied from 0% to 75%, while altered automated click-stimuli auditory brainstem response varied from 0% to 29.2%. Sensorineural, retrocochlear or central origin impairment could not be ruled out. One study with infected mice found no microscopic damage to cochlear hair cells. Studies on the pathogenesis of auditory changes in humans are limited to hypotheses and recommendations still include points of controversy.

Conclusion

The available data are still insufficient to understand the full spectrum of the involvement of the auditory organs by Zika virus, the pathogenesis of this involvement or even to confirm the causal association between auditory involvement and virus infection. The screening and follow-up recommendations still present points of controversy.

Efficacy, immunogenicity and safety of a recombinant tetravalent dengue vaccine (CYD-TDV) in children aged 2-17 years: systematic review and meta-analysis

BACKGROUND

Randomised controlled trials have evaluated the recombinant tetravalent dengue vaccine (CYD-TDV). However, individual results may have little power to identify differences among the populations studied.

OBJECTIVE

To evaluate efficacy, immunogenicity and safety of CYD-TDV in the prevention of dengue in children aged 2-17 years.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (from 1950 to 5 December 2018), EMBASE (from 1947 to 5 December 2018) and Cochrane (from 1993 to 5 December 2018).

ELIGIBILITY CRITERIA OF STUDIES

Randomised trials comparing efficacy, immunogenicity and safety of CYD-TDV with placebo or other vaccines for preventing dengue cases in children aged 2-17 years.

OUTCOME MEASURES

Efficacy, immunogenicity and safety of CYD-TDV.

STUDY APPRAISAL AND METHODS

Calculations were made of relative risk (RR) and mean difference (MD) for dichotomous and continuous outcomes, respectively. All estimates were calculated considering a 95% CI estimate. A p<0.05 was considered statistically significant.

RESULTS

Nine studies involving 34 248 participants were included. The overall efficacy of CYD-TDV was 60% (RR 0.40 (0.30 to 0.54)). Serotype-specific efficacy of the vaccine was 51% for dengue virus type-1 (DENV-1) (RR 0.49 (0.39 to 0.63)); 34% for DENV-2 (RR 0.66 (0.50 to 0.86)); 75% for DENV-3 (RR 0.25 (0.18 to 0.35)) and 77% for DENV-4 (RR 0.23 (0.15 to 0.34)). Overall immunogenicity (MD) of CYD-TDV was 225.13 (190.34 to 259.93). Serotype-specific immunogenicity was: DENV-1: 176.59 (123.36 to 229.83); DENV-2: 294.21 (181.98 to 406.45); DENV-3: 258.78 (146.72 to 370.84) and DENV-4: 189.35 (141.11 to 237.59). The most common adverse events were headache and pain at the injection site.

LIMITATIONS

The main limitation of this study was unclear or incomplete data.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

CYD-TDV is considered safe and able to partially protect children and adolescents against four serotypes of DENV for a 1-year period. Despite this, research should prioritise improvements in vaccine efficacy, thus proving higher long-term protection against all virus serotypes.

PROSPERO REGISTRATION NUMBER

CRD42016043628.

VALIDADE E CONFIABILIDADE DE UM NOVO SISTEMA DE CLASSIFICAÇÃO DE RISCO PARA EMERGÊNCIAS PEDIÁTRICAS: CLARIPED

Objective:

To assess the validity and reliability of a triage system for pediatric emergency care (CLARIPED) developed in Brazil.

Methods:

Validity phase: prospective observational study with children aged 0 to 15 years who consecutively visited the pediatric emergency department (ED) of a tertiary hospital from July 2 to 18, 2013. We evaluated the association of urgency levels with clinical outcomes (resource utilization, ED admission rate, hospitalization rate, and ED length of stay); and compared the CLARIPED performance to a reference standard. Inter-rater reliability phase: a convenience sample of patients who visited the pediatric ED between April and July 2013 was consecutively and independently double triaged by two nurses, and the quadratic weighted kappa was estimated.

Results:

In the validity phase, the distribution of urgency levels in 1,416 visits was the following: 0.0% red (emergency); 5.9% orange (high urgency); 40.5% yellow (urgency); 50.6% green (low urgency); and 3.0% blue (no urgency). The percentage of patients who used two or more resources decreased from the orange level to the yellow, green, and blue levels (81%, 49%, 22%, and 2%, respectively, p<0.0001), as did the ED admission rate, ED length of stay, and hospitalization rate. The sensitivity to identify patients with high urgency level was 0.89 (confidence interval of 95% [95%CI] 0.78-0.95), and the undertriage rate was 7.4%. The inter-rater reliability in 191patients classified by two nurses was substantial (kw²=0.75; 95%CI 0.74-0.79).

Conclusions:

The CLARIPED system showed good validity and substantial reliability for triage in a pediatric emergency department.

Viral detection profile in children with severe acute respiratory infection

Objectives

The role of viral co-detection in children with severe acute respiratory infection is not clear. We described the viral detection profile and its association with clinical characteristics in children admitted to the Pediatric Intensive Care Unit (PICU) during the 2009 influenza A(H1N1) pandemic.

Method

Longitudinal observational retrospective study, with patients aged 0–18 years, admitted to 11 PICUs in Rio de Janeiro, with suspected H1N1 infection, from June to November, 2009. The results of respiratory samples which were sent to the Laboratory of Fiocruz/RJ and clinical data extracted from specific forms were analyzed.

Results

Of 71 samples, 38% tested positive for H1N1 virus. Of the 63 samples tested for other viruses, 58 were positive: influenza H1N1 (43.1% of positive samples), rhinovirus/enterovirus (41.4%), respiratory syncytial vírus (12.1%), human metapneumovirus (12.1%), adenovirus (6.9%), and bocavirus (3.5%). Viral codetection occured in 22.4% of the cases. H1N1-positive patients were of a higher median age, had higher frequency of fever, cough and tachypnea, and decreased leukometry when compared to H1N1-negative patients. There was no difference in relation to severity outcomes (number of organic dysfunctions, use of mechanical ventilation or amines, hospital/PICU length of stay or death). Comparing the groups with mono-detection and co-dection of any virus, no difference was found regarding the association with any clinical variable.

Conclusions

Other viruses can be implicated in SARI in children. The role of viral codetection has not yet been completely elucidated.

[Prevalence and associated factors of macrosomia in Peru, 2013]

Objectives

To determine the prevalence of macrosomia and factors associated with it in Peru and to describe the occurrence of complications peri- and postpartum.

Materials and Methods

Birth weights of children under the age of 5 years were analyzed using data from the 2013 Demographic and Family Health Survey (ENDES) carried out by the Instituto Nacional de Estadística e Informática. Children with a birth weight higher than 4000 g were considered macrosomic. A logistic regression analysis was used to establish the independent association of sociodemographic factors with macrosomia.

Results

The sample comprised 6121 children. The prevalence of macrosomia was 5.3% (95% interval confidence: 4.8-5.9%). Being male, a higher birth order, maternal obesity, and greater maternal height were independently linked with macrosomia. Caesarean births were more common in macrosomic children than unaffected ones (43.9% vs 26.9%). Complications during birth and postpartum were common but not statistically linked with macrosomia.

Conclusions

The prevalence of macrosomia in Peru is relatively low compared to other low-to-middle income countries. The factors associated with macrosomia were mainly unmodifiable, with the exception of maternal obesity. Macrosomic children were more frequently born by caesarean. Weight reduction and the prevention of obesity in women of childbearing age in Peru could potentially reduce macrosomia and caesarean rates.

Co-infection with Zika and Chikungunya viruses associated with fetal death-A case report

We describe a case of fetal death associated with a recent infection by Chikungunya virus (CHIKV) in a Brazilian pregnant woman (positive RT-PCR in blood and placenta). Zika virus (ZIKV) infection during pregnancy was also identified, based on a positive RT-PCR in a fetal kidney specimen. The maternal infection caused by the ZIKV was asymptomatic and the CHIKV infection had a classical clinical presentation. The fetus had no apparent anomalies, but her weight was between the 3rd and 10th percentile for the gestational age. This is the second case report of congenital arboviral co-infection and the first followed by antepartum fetal death.

The relation of cash transfer programs and food insecurity among families with preschool children living in semiarid climates in Brazil

Abstract Background Food insecurity has important effects on human health, particularly in children’s. It continues to increase, with an estimated prevalence of 14.9% in the USA and 35% in Brazil. There have been few studies on the effect of cash transfer programs (CTPs) on the prevalence of food security in Brazil. Objective Evaluate the association between cash transfer programs and reductions in inequity and food insecurity. Method Population-based cross-sectional study in the state of Ceará, Northeast Brazil, with a sample of 8.000 households. Ceará is one of the poorest states. The state population of 8.5 million inhabitants, social security benefits and government grants, “ Bolsa Família”, have become the most stable source of income. The main outcomes measures were food insecurity and CTP participation. Multivariate logistic models were constructed to assess the association between participation in CTPs and food security. Results Participation in CTPs was found to be independently related to the prevalence of food security (APR 2.29 95% CI 1.57-3.33), as are education level, residential setting, and children’s nutritional status. Conclusions CTPs and investment in education are initiatives that might be used to reduce food insecurity.

Prevalence of trachoma in school children in the Marajó Archipelago, Brazilian Amazon, and the impact of the introduction of educational and preventive measures on the disease over eight years

Trachoma is the leading infectious cause of blindness in the world and is associated with precarious living conditions in developing countries. The aim of the present study was to evaluate the prevalence of trachoma in three municipalities of the Marajó Archipelago, located in the state of Pará, Brazil. In 2008, 2,054 schoolchildren from the public primary school system of the urban area of the region and their communicants were clinically examined; in 2016, 1,502 schoolchildren were examined. The positive cases seen during the clinical evaluation were confirmed by direct immunofluorescence (DIF) laboratory tests. The presence of antibodies against the genus Chlamydia was evaluated by indirect immunofluorescence (IIF), and the serotypes were determined by microimmunofluorescence (MIF). In 2008, the prevalence of trachoma among schoolchildren was 3.4% (69 cases) and it was more frequent in children between six and nine years of age and in females; among the communicants, a prevalence of 16.5% was observed. In 2016, three cases of trachoma were diagnosed (prevalence of 0.2%), found only in the municipality of Soure. The results of the present study showed that in 2008, trachoma had a low prevalence (3.4%) among schoolchildren in the urban area of Marajó Archipelago; eight years after the first evaluation and the introduction of control and prevention measures (SAFE strategy), there was a drastic reduction in the number of cases (0.2%), demonstrating the need for constant monitoring and effective measures for the elimination of trachoma.

Trachoma is one of the main neglected infectious diseases and carry a considerable burden to human health as a consequence of the clinical severity of the disease which may evolve to blindness. The lack of hygiene, education and other indicators of low social and economic markers occurring in developing and underdeveloped countries favour the spread of Chlamydia trachomatis, the bacterium causing trachoma. Although there is an easy, cheap and available treatment, reinfections are common and transmission is a consequence of bad hygienic habits and the various serotypes of the bacterium. The Marajó territory, in the North of the Amazon region of Brazil, is a large area with an ill educated, poor population, with almost no access to health resources and with almost no chance of transportation to major urban centers. Trachoma was detected a long time ago in the island and now, for the first time, a clear effort was produced during an eight year period in order to improve health hygienic habits among children and their relatives. The number of new cases following an initial diagnosis, was significantly reduced by the application of the WHO SAFE (Surgery, Antibiotics, Facial hygiene and Education for better habits) strategy.

Trends of the microcephaly and Zika virus outbreak in Brazil, January-July 2016

In the last two months, there have been indications that the Zika virus epidemic is on the decline in Brazil. We reviewed the surveillance data published by the Brazilian Ministry of Health to assess trends of microcephaly and neurological abnormalities suggestive of congenital infection, as well as Zika virus disease in Brazil as a whole and its various regions. From November 2015 to July 2016, 8301 cases of microcephaly were reported in Brazil, mainly in the Northeast region. The number of newly reported cases is declining throughout the country, except in the Southeast region. The numbers of cases that remain under investigation still represent 37.7% of all reported cases in early July. Meanwhile, from January to June, 2016, 165,241 cases of Zika virus disease were reported in Brazil. The state of Rio de Janeiro (Southeast) experienced the third highest incidence, lagging behind only the states of Bahia (Northeast) and Mato Grosso (Midwest). In early June, the number of new Zika virus cases showed a marked decline in all of the regions, except the North. Although the Zika epidemic seems to be diminishing, continued monitoring and surveillance of reported microcephaly and neurological abnormality cases is essential, and investigation efforts need to be vastly improved, as some states still reported high incidences of Zika disease in the first half of 2016.

Preeclampsia: Prevalence and perinatal repercussions in a University Hospital in Rio de Janeiro, Brazil

Preeclampsia (PE) prevalence studies in Brazil are both scarce and not divided in accordance with gestational age at delivery. We accessed PE prevalence according to delivery before 34, 37 and 42weeks in a cross-sectional study including 4464 single deliveries. PE was diagnosed in 301 cases (6.74%); Prevalence of PE was 0.78%; 1.92% and 6.74% according to deliveries before 34, 37 and 42weeks. PE was associated with fetal death, prematurity and small for gestational age newborns.

CLARIPED: a new tool for risk classification in pediatric emergencies

OBJECTIVE

To present a new pediatric risk classification tool, CLARIPED, and describe its development steps.

METHODS

Development steps: (i) first round of discussion among experts, first prototype; (ii) pre-test of reliability, 36 hypothetical cases; (iii) second round of discussion to perform adjustments; (iv) team training; (v) pre-test with patients in real time; (vi) third round of discussion to perform new adjustments; (vii) final pre-test of validity (20% of medical treatments in five days).

RESULTS

CLARIPED features five urgency categories: Red (Emergency), Orange (very urgent), Yellow (urgent), Green (little urgent) and Blue (not urgent). The first classification step includes the measurement of four vital signs (Vipe score); the second step consists in the urgency discrimination assessment. Each step results in assigning a color, selecting the most urgent one for the final classification. Each color corresponds to a maximum waiting time for medical care and referral to the most appropriate physical area for the patient's clinical condition. The interobserver agreement was substantial (kappa=0.79) and the final pre-test, with 82 medical treatments, showed good correlation between the proportion of patients in each urgency category and the number of used resources (p<0.001).

CONCLUSIONS

CLARIPED is an objective and easy-to-use tool for simple risk classification, of which pre-tests suggest good reliability and validity. Larger-scale studies on its validity and reliability in different health contexts are ongoing and can contribute to the implementation of a nationwide pediatric risk classification system.

Neonatal near miss in the Birth in Brazil survey

This study used data from the Birth in Brazil survey, a nationwide hospital-based study of 24,197 postpartum women and their newborns, collected between February 2011 and July 2012. A three-stage cluster sampling design (hospitals, days, women) was used consisting of stratification by geographic region, type of municipality (capital or non-capital), and type of hospital financing. Logistic regression was used to identify variables that were potential predictors of neonatal mortality and neonatal near miss indicators. After testing nineteen variables, five were chosen to compose a set of neonatal near miss indicators (birth weight of less than 1,500 g, Apgar score of less than 7 in the 5th minute of life, use of mechanical ventilation, gestational age of less than 32 weeks and congenital malformations). The neonatal near miss rate in the Birth in Brazil survey was 39.2 per thousand live births, three and a half times higher than the neonatal mortality rate (11.1 per thousand). These neonatal near miss indicators were able to identify situations with a high risk of neonatal death.

Metodologia das Pesquisas Populacionais de Saúde Materno-Infantil: uma série transversal realizada no Estado do Ceará de 1987 a 2007

Objectivo: descrever os métodos utilizados nas Pesquisas de Saúde Materno-Infantil (PESMIC) no Ceará, durante 20 anos. Métodos: a série de inquéritos realizados no período de 20 anos foi analisada nos seguintes aspectos: a) Estudos transversais em série de base populacional, com amostra representativa de 8000 famílias; b) Utilizou-se questionários e medições antropométricas, estudando-se níveis e causas de mortalidade infantil, prevalência de desnutrição da mãe e da criança, duração da amamentação, cobertura vacinal, prevalência e manejo da diarreia e acesso aos serviços de saúde materno-infantil; c) Obteve-se como resultado as variáveis desfechos (principal mortalidade infantil) e diversos determinantes materno-infantis e socioeconómicos. Resultados: o índice de resposta foi de quase 100% nos cinco inquéritos realizados (1986-2007), e ocorreram importantes mudanças nos indicadores sociodemográficos e de saúde; redução de 81% da taxa de mortalidade infantil, aumento de 43% da taxa de amamentação; índice de imunização de 95%. Observou-se aumento de 243% do índice de sobrepeso. Foram entrevistados no total somado dos cinco estudos: 177.132 residentes, sendo 47.508 mulheres e 13.049 crianças. Conclusões: recomenda-se a continuidade desses estudos utilizando-se a mesma metodologia, possibilitando analises de variações temporais.

Prevalence and determinants of child undernutrition and stunting in semiarid region of Brazil

OBJECTIVE

To analyze the evolution in the prevalence and determinants of malnutrition in children in the semiarid region of Brazil.

METHODS

Data were collected from two cross-sectional population-based household surveys that used the same methodology. Clustering sampling was used to collect data from 8,000 families in Ceará, Northeastern Brazil, for the years 1987 and 2007. Acute undernutrition was calculated as weight/age < -2 standard deviation (SD); stunting as height/age < -2 SD; wasting as weight/height < -2 SD. Data on biological and sociodemographic determinants were analyzed using hierarchical multivariate analyses based on a theoretical model.

RESULTS

A sample of 4,513 and 1,533 children under three years of age, in 1987 and 2007, respectively, were included in the analyses. The prevalence of acute malnutrition was reduced by 60.0%, from 12.6% in 1987 to 4.7% in 2007, while prevalence of stunting was reduced by 50.0%, from 27.0% in 1987 to 13.0% in 2007. Prevalence of wasting changed little in the period. In 1987, socioeconomic and biological characteristics (family income, mother’s education, toilet and tap water availability, children’s medical consultation and hospitalization, age, sex and birth weight) were significantly associated with undernutrition, stunting and wasting. In 2007, the determinants of malnutrition were restricted to biological characteristics (age, sex and birth weight). Only one socioeconomic characteristic, toilet availability, remained associated with stunting.

CONCLUSIONS

Socioeconomic development, along with health interventions, may have contributed to improvements in children’s nutritional status. Birth weight, especially extremely low weight (< 1,500 g), appears as the most important risk factor for early childhood malnutrition.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliação de prontuários de 23.940 puérperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para análise dos potenciais fatores de risco para o óbito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regiões Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condições do recém-nascido foram os principais fatores associados ao óbito neonatal. A inadequação do pré-natal e da atenção ao parto indicaram qualidade não satisfatória da assistência. A peregrinação de gestantes para o parto e o nascimento de crianças com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organização da rede de saúde. Óbitos de recém-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos óbitos. A qualificação da atenção, em especial da assistência hospitalar ao parto se configura como foco prioritário para maiores avanços nas políticas públicas de redução das taxas e das desigualdades na mortalidade infantil no Brasil.

Avaliação da limitação das atividades diárias e qualidade de vida de pacientes com hanseníase submetidos à cirurgia de neurólise para tratamento das neurites

A neurólise é indicada para reduzir o sofrimento neural e impedir a instalação de sequelas e incapacidades em pacientes com hanseníase. O objetivo deste estudo foi verificar o grau de limitação das atividades e a qualidade de vida de pacientes com hanseníase submetidos a neurólise para tratamento das neurites. Participaram do estudo os pacientes submetidos à neurólise no período de 1998 a 2011. Foram coletadas informações sociodemográficas e clínicas, limitações das atividades (SALSA) e a qualidade de vida (WHOQOL-bref). As análises estatísticas incluíram a frequência, as medidas de tendência central e dispersão, os testes de Mann-Whitney e Kruskall-Wallis e o coeficiente de correlação de Spearman adotando-se p<0,05. A amostra foi composta por 36 pacientes com média de idade de 44,0 anos e 3 anos de pós-operatório. Seis pacientes apresentaram grau 0 de incapacidade; 18, grau 1 e 12, grau 2. A principal diferença da escala SALSA ocorreu entre o grau 0 (média 31,8) e o grau 1 (média 42,56). Os valores obtidos na análise do WHOQOL-bref incluíram os domínios físico (média 11,10), psicológico (média 13,41), relações sociais (média 15,15), meio ambiente (média 11,63). As facetas do WHOQOL-bref mais comprometidas foram: capacidade para o trabalho; sentimentos negativos (psicológico); atividade sexual (relações sociais); recursos financeiros (meio ambiente). Apesar da realização da neurólise, a maior parte dos integrantes apresentou limitações nas atividades, sendo maior naqueles com incapacidades físicas. A maior insatisfação na qualidade de vida foi no domínio físico, principalmente no que se refere à dor e à necessidade de cuidados de saúde.

Professional profile of pediatric intensivists in Rio de Janeiro, southeastern Brazil

OBJECTIVE

This study described the sociodemographic profile and professional qualifications of pediatric intensive care physicians in the State of Rio de Janeiro (RJ), southeastern Brazil.

METHODS

This investigation was an observational, cross-sectional and descriptive study that was conducted in neonatal, pediatric and mixed intensive care units in the State of Rio de Janeiro. Physicians working in the participating intensive care units voluntarily completed a semistructured and anonymous questionnaire. Questionnaires that were not returned within 30 days were considered lost, and questionnaires with less than 75% questions completed were excluded. The differences in neonatal and pediatric intensive care physicians' medical training were compared using the Chi-squared test with a 5% significance level.

RESULTS

A total of 410 physicians were included in this study: 84% female, 48% between 30 and 39 years old and 45% with monthly incomes between US $1,700 to 2,700. Forty percent of these physicians worked exclusively in this specialty, and 72% worked in more than one intensive care unit. Only 50% of the participants had received specific training (either medical residency or specialization) in neonatology, and only 33% were board-certified specialists in this area. Only 27% of the physicians had received specific training in pediatric intensive care medicine, and only 17% were board-certified specialists (p < 0.0005 for both comparisons). Most (87%) physicians had participated in scientific events within the past 5 years, and 55% used the internet for continued medical education. However, only 25% had participated in any research. Most (63%) physicians were dissatisfied with their professional activity; 49% were dissatisfied due to working conditions, 23% due to low incomes and 18% due to training-related issues.

CONCLUSION

These results suggested that the medical qualifications of neonatal and pediatric intensive care physicians in the State of Rio de Janeiro, Brazil are inadequate, especially in pediatric intensive care medicine. A high level of dissatisfaction was reported, which may jeopardize the quality of medical assistance that is provided by these professionals.

Condições sociodemográficas de crianças de zero a dois anos filhas de mães com HIV/Aids, Fortaleza, CE, Brasil

OBJETIVOS: identificar as condições sociodemográficas das crianças de 0 a 2 anos de idade nascidas de mães HIV + / AIDS em Fortaleza, Ceará, Nordeste do Brasil. MÉTODOS: estudo transversal utilizando um questionário semiestruturado com cuidadores (63 mães e 5 avós) de crianças no ambulatório de um hospital estadual, entre Dezembro de 2005 e Abril de 2006. RESULTADOS: a idade média das mães foi de 26 anos de idade. Aproximadamente 16% eram analfabetas, 57,3% eram casadas e 5,9% viúvas. Mais de dois terços (79,4%) das mulheres participantes do estudo tornou-se ciente de seu status de HIV + no último parto e 51,5% relataram não receber qualquer tipo de assistência social do governo. A idade média das crianças foi de 15,6 meses e 13% não tiveram um teste de HIV. A maioria delas era proveniente de áreas rurais (60,3%), com renda familiar média mensal de R$ 446,32. Verificou-se que 57,9% das crianças viviam em uma casa com cinco ou mais pessoas, e 31% relataram ter quatro ou mais crianças morando na mesma casa. CONCLUSÕES: há necessidade de estratégias de prevenção e promoção à saúde, levando em consideração o contexto social das famílias que vivem com HIV/AIDS.

Postoperative pain and associated factors in adolescent patients undergoing two-visit root canal therapy

This prospective study investigated the frequency and intensity of postoperative pain and identified associated factors in adolescents undergoing two-visit root canal therapy. Sixty-four patients aged 11 to 18 years old presenting with molars with pulp necrosis were assigned consecutively to two visits (plus an interappointment dressing using calcium-hydroxide paste). Pain intensity was recorded on a visual analogue scale (VAS) of 0-5. Data were analysed using multivariate logistic regression. The frequency of postoperative pain was 32.8% (21/64), with intensities of VAS 1 and VAS 2 in 81%, VAS 3 in 14.3% and VAS 4 in 4.7% of the 21 cases in which it was experienced. Spontaneous preoperative pain (odds ratio (OR) = 6.60; 95% confidence interval (CI) = 1.61-26.97; P = 0.009) and absence of apical perodontitis (OR = 5.65; 95% CI = 1.34-23.87; P = 0.01) were associated with postoperative pain. The frequency of postoperative pain was high, but the intensity, in general, was low, including flare-ups. The presence of spontaneous preoperative pain and absence of apical periodontitis increase the probability of suffering from postoperative pain.

Implementação da estratégia Atenção Integrada às Doenças Prevalentes na Infância no Nordeste, Brasil

OBJETIVO: A maioria das mortes em crianças é evitável. A estratégia Atenção Integrada às Doenças Prevalentes na Infância, desenvolvida pela Organização Mundial da Saúde e Fundo das Nações Unidas para a Infância, pretende reduzir a mortalidade infantil por meio de ações para melhorar o desempenho dos profissionais de saúde, a organização do sistema de saúde e as práticas da família e da comunidade. O artigo teve por objetivo descrever fatores associados à implementação dessa estratégia em três estados do Nordeste do Brasil. MÉTODOS: Estudo ecológico realizado em 443 municípios do Ceará, Paraíba e Pernambuco, em 2006. A distribuição de variáveis independentes econômicas, geográficas, ambientais, nutricionais, organização do serviço de saúde e mortalidade infantil foram comparadas entre os municípios com e sem a estratégia. Esses fatores foram avaliados por meio de modelo hierárquico utilizando regressão de Poisson para o cálculo de razões de prevalências após ajuste para fatores de confusão. RESULTADOS: Dos municípios estudados, 54% possuíam a estratégia: Ceará (65 com e 43 sem), Paraíba (27 com e 21 sem) e Pernambuco (147 com e 140 sem). Após controle para fatores de confusão, os fatores significativamente associados com a ausência da estratégia, foram: menor índice de desenvolvimento humano, menor população e maior distância da capital. CONCLUSÕES: Houve iniqüidade no desenvolvimento da estratégia, pois municípios de maior risco para a saúde infantil apresentaram menores taxas de aplicação de suas ações. São necessárias políticas de saúde que reforcem sua consolidação nos municípios de maior risco de mortalidade infantil.

[Implementation of the Integrated Management of Childhood Illnesses strategy in Northeastern Brazil]

OBJECTIVE

The majority of child deaths are avoidable. The Integrated Management of Childhood Illnesses strategy, developed by the World Health Organization and the United Nations Children's Fund, aims to reduce child mortality by means of actions to improve performance of health professionals, the health system organization, and family and community practices. The article aimed to describe factors associated with the implementation of this strategy in three states of Northeastern Brazil.

METHODS

Ecological study conducted in 443 municipalities in the states of Northeastern Brazil Ceará, Paraíba and Pernambuco, in 2006. The distribution of economic, geographic, environmental, nutritional, health service organization, and child mortality independent variables were compared between municipalities with and without the strategy. These factors were assessed by means of a hierarchical model, where Poisson regression was used to calculate the prevalence ratios, after adjustment of confounding factors.

RESULTS

A total of 54% of the municipalities studied had the strategy: in the state of Ceará, 65 had it and 43 did not have it; in the state of Paraíba, 27 had it and 21 did not have it; and in the state of Pernambuco, 147 had it and 140 did not have it. After controlling for confounding factors, the following variables were found to be significantly associated with the absence of the strategy: lower human development index, smaller population, and greater distance from the capital.

CONCLUSIONS

There was inequality in the development of the strategy, as municipalities with a higher risk to child health showed lower rates of implementation of actions. Health policies are necessary to help this strategy to be consolidated in the municipalities that are at a higher risk of child mortality.

["It takes two to tango": a study on inconsistent use of male condoms by adolescents in Rio de Janeiro, Brazil]

This study assessed gender-related aspects involved in the inconsistent use of male condoms by adolescents in Rio de Janeiro, Brazil. Four focus groups were conducted, two with each gender, two in a public school and two in a private school, totaling 34 participants, comparing gender and social status. The resulting material was analyzed using a critical interpretative approach. Among the emerging themes, "gender relations" were chosen, consisting of three dimensions: trust, submission, and initiative. So-called unequal gender power was not detected in the adolescents' discourse, which however revealed an apparent inequality in negotiation and initiative in condom use. Differences between public and private schools were subtle. Some changes may be occurring in the field of adolescent sexual behavior. The results indicate the importance of channels for dialogue, taking into account the singularity of groups in order to establish intervention strategies adapted to subjects and different historical and cultural contexts.

Prevalência dos fatores de risco para doença cardiovascular em funcionários do Centro de Pesquisas da Petrobras

OBJECTIVE

To determine the prevalence of risk factors for cardiovascular diseases in employees of the research center at Petrobras.

METHODS

In a cross-sectional study, employees of the research center at Petrobras were assessed clinically and by laboratory testing from March 2000 and February 2001. Those who did not attend the periodical annual medical examination of 2000 were excluded from the study. The percentage of risk factor occurrence and the mean standard deviation of the biochemical variables, blood pressure, and body mass index were calculated.

RESULTS

Of 1,911 employees, 970 were studied, 75.4% were men and 24.6% were women with a mean age of 42.2 years old. The risk factors were lack of exercise (67.3%), cholesterol > 200 mg/dL (56.6%), overweight (42%), obesity (17%), blood hypertension (18.2%), smoking (12.4%), and diabetes mellitus (2.5%).

CONCLUSION

The high prevalence of risk factors for cardiovascular disease in young individuals draws attention to the need for the adoption of workplace programs to encourage healthy lifestyles and to prevent diseases.

[Management of acute respiratory infections in children: evaluation in Rio de Janeiro health care facilities]

The goal of this article was to assess quality of case management for acute respiratory infection (ARI) in children and to detect barriers to proper management. A cross-sectional approach was used with a representative sample of primary and out-patient health care facilities under the Rio de Janeiro Municipal Health Department. Physicians were observed while attending children under five years of age with ARI, and the children were then evaluated according to standard criteria, and the results compared. Physicians were interviewed and health care facilities evaluated for availability of antibiotics. We studied 29 facilities (two hospitals, 20 health centers, and seven health posts), interviewed 46 physicians, and observed 267 children. Sensitivity of the classification used to detect pneumonia was 21.8 (95% CI: 9.3-40.4), specificity was 77.3 (95% CI: 70.3-82.4), and accuracy was 70.6 (95% CI: 64.7-75.5). Antibiotics were prescribed unnecessarily for 8.9% of ARI cases. Standard antibiotics were available in all the health care facilities. We conclude that quality of ARI case management in children can be improved substantially, especially with more training and supervision and better organization of services.