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Abstract Objective: To assess the predictive value of selected growth phenotypes for neonatal morbidity and mortality in preterm infants < 30 weeks and to compare them with INTERGROWTH-21st (IG21). Methods: Retrospective analysis of data from the Brazilian Neonatal Research Network (BNRN) database for very low birth weight (VLBW) at 20 public tertiary-care university hospitals. Outcome: the composite neonatal morbidity and mortality (CNMM) consisted of in-hospital death, oxygen use at 36 weeks, intraventricular hemorrhage grade 3 or 4, and Bell stage 2 or 3 necrotizing enterocolitis. Selected growth phenotypes: small-for-gestational-age (SGA) defined as being < 3rd (SGA3) or 10th (SGA10) percentiles of BW, and large-for-gestational-age (LGA) as being > 97th percentile of BW. Stunting as being < 3rd percentile of the length and wasting as being < 3rd percentile of BMI. Single and multiple log-binomial regression models were fitted to estimate the relative risks of CNMM, comparing them to IG21. Results: 4,072 infants were included. The adjusted relative risks of CNMM associated with selected growth phenotypes were (BNRN/IG21): 1.45 (0.92–2.31)/1.60 (1.27–2.02) for SGA; 0.90 (0.55–1.47)/1.05 (0.55–1.99) for LGA; 1.65 (1.08–2.51)/1.58 (1.28–1.96) for stunting; and 1.48 (1.02–2.17) for wasting. Agreement between the two references was variable. The growth phenotypes had good specificity (>95%) and positive predictive value (70-90%), with poor sensitivity and low negative predictive value. Conclusion: The BNRN phenotypes at birth differed markedly from the IG21 standard and showed poor accuracy in predicting adverse neonatal outcomes.

https://doi.org/10.1016/j.jped.2022.07.007

Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital
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Soares, Deydson Rennan Alves

; Rodrigues, Dalma

; Carmona, Fabio

Revista Paulista de Pediatria

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2023, Volume 41 elocation e2022123

Abstract: En Pt | Text: En Pt | PDF: En | PDF: Pt

Abstract Objective: The handoff is the act of transferring information and responsibility among healthcare providers, and it is critical for the patient safety and the quality of service. The aim of this study was to evaluate the implementation of a standardized medical handoff system [I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver)] and assess the effect on the amount and quality of the information transmitted during medical handoffs in a pediatric ward. Methods: In a prospective intervention study, physicians (staff and residents) who work in 12- or 24-h shifts in the pediatric ward of a single tertiary care Brazilian hospital were eligible. Those who agreed to participate were trained in an online session (lecture plus simulation). Medical handoffs were recorded pre- and post-intervention (training) to compare the amount and quality of information transmitted in handoffs. Results: The handoff standardization significantly increased the number of relevant information delivered for 12 out of the 16 items assessed without increasing, in seconds, the handoff duration (45.9 vs. 48.0; p=0.349). The protocol training and the following discussion about communication resulted in greater focus and attention among participants during transfers, decreasing time spent with interruptions and communication unrelated to the patient (18 vs. 2.7%). Regarding the I-PASS elements, there was an increase in the number of action lists and contingency plans reported (31 vs. 81% and 16 vs. 73%, respectively; p<0.001 for both). Conclusion: Standardization brought greater efficiency and objectivity to handoffs. It increased the quantity and quality of the information transmitted while successfully drawing attention to the most important points.

RESUMO Objetivo: A passagem de plantão, ato de transferir informações e responsabilidade entre os médicos, é um dos elementos-chave para a qualidade do serviço prestado e a segurança do paciente. Este estudo objetivou avaliar a implantação de um sistema padronizado de passagem de plantão (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver — I-PASS) e avaliar o efeito sobre a quantidade de informações transmitidas em passagens de plantão de uma enfermaria pediátrica. Métodos: Estudo prospectivo de intervenção da implementação de um sistema padronizado de passagem de plantão (I-PASS). Foram realizadas gravações das passagens de plantão em período pré- e pós-intervenção. O treinamento dos médicos que participam das escalas de plantão foi feito em módulo teórico-prático, com o auxílio de plataformas digitais. Resultados: A padronização da passagem de plantão resultou em aumento do número de informações relevantes, entregues em 12 dos 16 itens pesquisados, sem aumentar a duração em segundos da transferência (45,9 vs. 48,0; p=0,349). O treinamento do protocolo aliado à discussão sobre estratégias de comunicação implicou maior foco e atenção durante as passagens, reduzindo o tempo gasto com interrupções e comunicações que não se referiam ao paciente (18 vs. 2,7%). No que se refere aos elementos do I-PASS, houve acréscimo na citação de pendências (31 vs. 81%, p < 0,001) e plano de contingenciamento (16 vs. 73%, p < 0,001). Conclusão: A padronização da passagem de plantão trouxe maior eficiência ao processo no que se refere a número de informações transmitidas, objetividade na transferência e atenção aos pontos importantes.

https://doi.org/10.1590/1984-0462/2023/41/2022123

Sanitary measures to contain COVID-19 spread decreased pediatric hospitalizations due to other respiratory infections in São Paulo, Brazil
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Altizani, Gabriela Marengone

; Balbão, Viviane da Mata Pasti

; Gaspar, Gilberto Gambero

; Aragon, Davi Casale

; Carmona, Fabio

Jornal de Pediatria

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sep 2022, Volume 98 N. 5 Pages 533 - 539

Abstract: En | Text: En | PDF: En

Abstract Objective After the Covid-19 pandemics hit Brazil and sanitary measures were adopted to contain its dissemination, pediatric hospital admissions were apparently fewer than usual. The authors aimed to describe the time trends of public hospital admissions of children and adolescents due to respiratory infections (RIs) in São Paulo State, Brazil, before and after the adoption of sanitary measures to contain the dissemination of Covid-19. Methods Ecological, time-series study on the monthly average number of admissions per day of children and adolescents (< 16 years) admitted to public hospitals of São Paulo due to acute RIs between January 2008 and March 2021. Data from 2008 to 2019 were used to adjust the statistical model, while data from 2020 and 2021 were compared to the values predicted by the model. Results In 2020 and 2021, the number of hospital admissions was significantly lower than predicted by the time series. However, lethality was three times higher in these years, compared to the previous, and six times higher in patients with Covid-19, compared to those without the disease. Hospitalization costs in 2020 and 2021 were lower than in previous years. Conclusions These findings suggest that the sanitary measures adopted to contain the dissemination of Covid-19 also effectively reduce the transmission of other respiratory viruses. Policymakers and administrators can use this knowledge as a guide to planning preventative interventions that could decrease the number and severity of RIs and related hospital admissions in children and adolescents, decreasing the burden on the public health system.

https://doi.org/10.1016/j.jped.2022.01.005

Evaluation of renal replacement therapy in children and adolescents in the state of Amazonas, Brazil
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Schramm, Ana Matilde Menezes Melik

; Facincani, Inalda

; Carmona, Fabio

Revista Paulista de Pediatria

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2022, Volume 40 elocation e2021057

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

Resumo Objetivo Descrever as características de crianças e adolescentes com doença renal crônica (DRC) dialítica no estágio 5 submetidos à terapia renal substitutiva no Amazonas, Brasil, estimando a frequência de casos atuais e novos, e discorrer sobre a presença de anemia e distúrbios do metabolismo ósseo. Métodos Foram estudados 35 pacientes de 7 a 19 anos em hemodiálise ou diálise peritoneal (DP) de junho de 2018 a abril de 2019. As frequências de casos atuais e novos foram estimadas com base na população do Amazonas de 0 a 19 anos no mesmo período. Foram coletados dados sobre a doença de base da DRC, seu diagnóstico, a diálise e a análise bioquímica. Resultados As frequências de casos atuais e novos foram 24 e 15 pacientes por milhão de pessoas em idade compatível (pmpic), respectivamente. As causas da DRC foram síndrome nefrótica (22,8%), síndrome nefrítica (14,3%) e bexiga neurogênica (14,3%), com 48,6% de causa ignorada. Dez pacientes fizeram biópsia renal, sendo sete com glomeruloesclerose segmentar e focal. A maioria (80%) fazia hemodiálise, com Kt/V médio de 1,4, sendo o cateter venoso central de duplo lúmen o acesso vascular em 51,4% dos casos. Observou-se hipocalcemia em 82,8% dos pacientes, hiperfosfatemia em 57,2%, insuficiência ou deficiência de vitamina D em 60% e valores do paratormônio alterados em 48,6%. A hemoglobina encontrava-se baixa em 80%, com deficiência absoluta ou funcional de ferro em 28,6%. Conclusões Em crianças e adolescentes do Amazonas, Brasil, encontramos uma frequência de 24 pacientes com DRC dialítica e 16.3 pmpic por ano de novos casos. Os pacientes são, principalmente, adolescentes em hemodiálise, metade sem diagnóstico causal da DRC, com alta frequência de anemia e distúrbio do metabolismo ósseo.

Abstract Objective: To describe the characteristics of stage-5 chronic kidney disease (CKD) children and adolescents undergoing renal replacement therapy (RRT) in Amazonas, Brazil, estimating the frequencies of current and new cases, describing the presence of anemia and bone metabolism disorders. Methods: Thirty-five patients aged 7 to 19 years-old on hemodialysis (HD) or peritoneal dialysis (PD) were studied between June 2018 and April 2019. The frequencies of current and new cases were estimated based on the 0 to 19 years-old population of Amazonas, in the same period. Data were collected about the underlying cause and diagnosis of CKD, dialysis, and biochemical analysis. Results: The frequencies of current and new cases were 24 and 15 patients per million people of compatible age (pmpca), respectively. The causes of CKD were nephrotic syndrome (22.8%), nephritic syndrome (14.3%), and neurogenic bladder (14.3%); in 48.6%, the cause was unknown/not investigated. Ten patients underwent renal biopsy, seven with segmental and focal glomerulosclerosis. The majority (80%) were on HD, with an average kt/V of 1.4, and in 51.4% the vascular access was the double lumen catheter. Hypocalcemia was found in 82.8% of patients, hyperphosphatemia in 57.2%, vitamin D insufficiency or deficiency in 60%, and altered parathyroid hormone values in 48.6%. Hemoglobin was low in 80%, with absolute/functional iron deficiency in 28.6%. Conclusions: In children and adolescents of Amazonas, Brazil, we found 24 pmpca with stage-5 CKU currently in RRT and 16.3 pmpca per year of new cases requiring RRT. Most patients were adolescents on HD, half without a causal diagnosis of CKD, with a high frequency of anemia and bone metabolism disorder.

https://doi.org/10.1590/1984-0462/2022/40/2021057

Weight/length ratio references and newborn body composition estimation at birth from a Brazilian cohort
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Grandi, Carlos

; Rodrigues, Livia dos S.

; Aragon, Davi C.

; Carmona, Fabio

; Cardoso, Viviane C.

Jornal de Pediatria

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dec 2021, Volume 97 N. 6 Pages 610 - 616

Abstract: En | Text: En | PDF: En

Abstract Objectives: The objective was to calculate weight/length (W/L) ratio values and percentiles by sex and gestational age (GA) to estimate fat mass (FM), fat-free mass (FFM) and body fat percentage (BF%) as well as to compare these indices in preterm, small (SGA), and large (LGA) for GA, stunted and wasted infants from a Brazilian cohort of newborns, comparing with the INTERGROWTH-21st. Methods: Secondary, cross-sectional analysis of data obtained of 7427 live-born infants from the BRISA Cohort Study in the city of Ribeirão Preto, SP, Brazil in 2010. For body composition estimation, W/L ratio was used in multiple regression models. The 3rd, 50th, and 97th percentiles for W/L ratio and body composition measures (FM, FFM, and BF%) were calculated using fractional polynomial regression models. Results: Average W/L ratio was 6.50 kg/m (SD 0.87), while for FM, BF%, and FFM the corresponding values were 359.64 g (145.76), 10.90% (3.05) and 2798.84 g (414.84), respectively. SGA (< 3rd percentile), and wasted infants showed the lowest W/L ratios and measures of body composition. The 3rd, 50th, and 97th percentiles charts of W/L, FM, BF%, and FFM by GA and sex are presented. Conclusions: W/L ratio values of the RP-BRISA Cohort are higher than IG-21st. SGA (< 3rd) and wasted infants showed the lowest W/L ratio and measures of body composition. The body composition references presented here could be used to refine the nutritional assessment of Brazilian newborns and to facilitate comparisons across populations.

https://doi.org/10.1016/j.jped.2020.12.004 1 downloads

Central Venous Oxygen Saturation/Lactate Ratio and Prediction of Major Adverse Events After Pediatric Heart Surgery
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Rocha, Victória Helena Stelzer

; Manso, Paulo Henrique

; Carmona, Fabio

Brazilian Journal of Cardiovascular Surgery

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dec 2021, Volume 36 N. 6 Pages 736 - 742

Abstract: En | Text: En | PDF: En

Abstract Introduction: Major adverse events (MAE) are unexpected but undesirably frequent after pediatric congenital heart surgery and contribute to poorer outcomes. The aim of this study was to test the predictive value of a ratio between central venous oxygen saturation and arterial lactate (ScvO2/lactate) for MAE after pediatric congenital heart surgery in a Brazilian university hospital. Methods: We conducted a retrospective observational study in a tertiary care university hospital, including 194 infants and children submitted to surgery for congenital heart disease. The predictive value of ScvO2, lactate, and ScvO2/lactate ratio were assessed by the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: The incidence of MAE was 16% — cardiac arrest/death, unplanned reoperation, and low cardiac output syndrome were the most common events. Overall, ScvO2/lactate ratio discriminated patients with and without MAE very well (AUC 0.842), performing better than either variable alone, with sensitivity of 48%, specificity of 94%, PPV of 60%, and NPV of 91%. Conclusion: A ScvO2/lactate ratio > 5 can accurately identify patients at low risk of MAE after pediatric congenital heart surgery, with very good specificity and NPV, but poor sensitivity and PPV.

https://doi.org/10.21470/1678-9741-2020-0521

Disseminating health evidence summaries to increase evidence use in health care
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Galvao, Maria Cristiane Barbosa

; Carmona, Fabio

; Grand, Roland

; Pluye, Pierre

; Ricarte, Ivan Luiz Marques

Revista de Saúde Pública

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2018, Volume 52 elocation 57

Abstract: En | Text: En | PDF: En

ABSTRACT OBJECTIVE: To verify whether an intervention based on disseminating health evidence summaries by e-mail to health professionals increases access to health evidence databases, and whether health professionals intend to apply the evidence received by e-mail in their clinical practice. METHODS: This quantitative study started with a survey to collect demographic data and patterns of access to health evidence databases. It was followed by a longitudinal intervention, over 48 weeks, that disseminated 143 health evidence summaries to 339 health professionals with higher education degree who work in the Brazilian Unified Health System. In the longitudinal intervention phase, health professionals voluntarily assessed the received health evidence summaries using the information assessment method. Finally, the study concluded with a survey to identify changes in accessing health evidence databases. RESULTS: Of the 339 Brazilian health professionals participating in this research, 90 (26.5%) answered the initial and final surveys. After 48 weeks, there was an increase in the use of health evidence databases; 186 (54.9%) participants submitted 7,942 assessments of health evidence summaries, which were relevant for patient care in 5,409 (68%) assessments. CONCLUSIONS: The dissemination of health evidence summaries by e-mail to health professionals in Brazil increases the reported use of evidence in clinical practice.

https://doi.org/10.11606/s1518-8787.2018052000418 1103 downloads

Disseminating health evidence summaries to increase evidence use in health care
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Galvao, Maria Cristiane Barbosa

; Carmona, Fabio

; Grand, Roland

; Pluye, Pierre

; Ricarte, Ivan Luiz Marques

Revista de Saúde Pública

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2018, Volume 52 elocation 57

Abstract: En | Text: En | PDF: En

https://doi.org/10.11606/s1518-8787.2018052000418 77 downloads

Neuroprotective Anesthesia Regimen and Intensive Management for Pediatric Cardiac Surgery with Cardiopulmonary Bypass: a Review and Initial Experience
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Klamt, Jyrson Guilherme

; Vicente, Walter Villela de Andrade

; Garcia, Luis Vicente

; Carmona, Fabio

; Abrão, João

; Menardi, Antônio Carlos

; Manso, Paulo Henrique

Brazilian Journal of Cardiovascular Surgery

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dec 2017, Volume 32 N. 6 Pages 523 - 529

Abstract: En | Text: En | PDF: En

Abstract This article describes our proposal for routine anesthesia, intraoperative medical management, cerebral and physiological monitoring during pediatric cardiac surgery with cardiopulmonary bypass that intend to provide appropriate anesthesia (analgesia, hypnosis), neuroprotection, adequate cerebral and systemic oxygen supply, and preventing against drugs neurotoxicity. A concise retrospective data is presented.

https://doi.org/10.21470/1678-9741-2016-0064 1285 downloads

10.

Collaborative Quality Improvement in the Congenital Heart Defects: Development of the ASSIST Consortium and a Preliminary Surgical Outcomes Report
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Carmona, Fabio

; Manso, Paulo Henrique

; Ferreira, Mariana Nicoletti

; Ikari, Nana Miura

; Jatene, Marcelo Biscegli

; Amato, Luciana

; Turquetto, Aida Luiza

; Caneo, Luiz Fernando

Brazilian Journal of Cardiovascular Surgery

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aug 2017, Volume 32 N. 4 Pages 260 - 269

Abstract: En | Text: En | PDF: En

Abstract Objective: ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. Methods: A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. Results: Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). Conclusion: The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.

https://doi.org/10.21470/1678-9741-2016-0074 827 downloads

11.

Herbal medicines: old and new concepts, truths and misunderstandings
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Carmona, Fabio

; Pereira, Ana Maria Soares

Revista Brasileira de Farmacognosia

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apr 2013, Volume 23 N. 2 Pages 379 - 385

Abstract: En | Text: En | PDF: En

Men have been using herbal medicines for thousands of years. The advantages of this type of therapeutics include good availability, local cultural aspects, individual preferences, the increasing demand for natural and organic products, and the already validated synergistic effects of herbal medicines. However, ethically, the scope and limits of these drugs need to be established not only by ethnopharmacological evidences but also by scientific investigations, which confirm the therapeutic effects. With this study, we propose to discuss the possible advantages of using herbal medicines instead of purified compounds, the truth and myths about herbal medicines, drug discovery, and the implications for medical education and health care.

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