Abstract Objective To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. Methods Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0-18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates. Results The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23-2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17-79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70-0.98); specificity, 0.76 (95%CI: 0.75-0.76); NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 23.0%, and undertriage, 11.5%. Conclusion This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service. Paulo Brazil Prospective secondarylevel secondary Sep2018 Sep 2018 Sep-201 Ago2019. Ago2019 Ago 2019. 2019 Ago-2019 018 0 18 0-1 selected Sensitivity specificity PPV NPV estimated under over rates 24338 24 338 24,33 002 02 0.02% 09 9 0.9% 235 23 5 23.5% 479 47 47.9% 277 27 7 27.7 highest urgency. . urgency) 0.0%, 00 (0.0% 01 1 0.1% 71 7.1 20% 20 20%) 1.9%, 19 (1.9% 4 2,4% 48 8 4.8% 241 24.1% 60% 60 60%) diagnostictherapeutic diagnostic therapeutic 2.3%, 3 (2.3% 30 3.0% 59 5.9% 288 28 28.8% 40% 40 40%) 12 (12 15 995 99 99.5 36 min. min min) RED, (RED OR 2.55 255 55 95%CI 95CI CI 95 2.232.92 223292 2.23 2.92 92 2.23-2.92 23.9 239 7.1779.62, 7177962 7.17 79.62 , 17 79 62 7.17-79.62) BLUE. BLUE) 088 88 0.8 (95%CI 0.700.98 070098 0.70 0.98 70 98 0.70-0.98) 076 76 0.7 0.750.76 075076 0.75 75 0.75-0.76) 099 0.9 0.991.00 099100 1.00 0.99-1.00) 230 23.0% 115 11 11.5% Sep201 201 Sep-20 Ago201 Ago-201 0- 2433 33 24,3 0.02 23.5 47.9 27. 0.0% (0.0 0.1 7. 1.9% (1.9 2,4 4.8 24.1 6 2.3% (2.3 3.0 5.9 28.8 (1 99. 2.5 25 232 2.232.9 22329 223 2.2 292 2.9 2.23-2.9 23. 1779 7.1779.62 717796 717 7962 79.6 7.17-79.62 08 0. 700 0.700.9 07009 070 098 0.70-0.98 07 750 0.750.7 07507 075 0.75-0.76 991 0.991.0 09910 100 1.0 0.99-1.00 23.0 11.5 Sep20 Sep-2 Ago20 Ago-20 243 24, 0.0 47. (0. 1.9 (1. 2, 4. 24. 2.3 (2. 3. 5. 28. ( 2. 2.232. 2232 22 29 2.23-2. 177 7.1779.6 71779 796 79. 7.17-79.6 0.700. 0700 0.70-0.9 0.750. 0750 0.75-0.7 0.991. 0991 10 1. 0.99-1.0 11. Sep2 Sep- Ago2 Ago-2 (0 (2 2.232 2.23-2 7.1779. 7177 7.17-79. 0.700 0.70-0. 0.750 0.75-0. 0.991 0.99-1. Ago- 2.23- 7.1779 7.17-79 0.70-0 0.75-0 0.99-1 7.177 7.17-7 0.70- 0.75- 0.99- 7.17-

Resumo: A má nutrição afeta bilhões de indivíduos em todo o mundo e representa um desafio de saúde global. Este estudo teve como objetivo determinar a prevalência de má nutrição (desnutrição ou excesso de peso) entre díades mãe-filho em crianças menores de cinco anos no Brasil em 2019 e estimar as mudanças nessa prevalência de 2006 a 2019. Foram analisados dados individuais do Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019) e da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher realizada em 2006 (PNDS 2006). Os desfechos de má nutrição incluíram mãe e filho com excesso de peso, mãe e filho desnutridos e a dupla carga de má nutrição, ou seja, mãe com excesso de peso e filho com qualquer forma de desnutrição (défict de crescimento, magreza ou baixo peso). Foram estimadas a prevalência e os intervalos de 95% de confiança (IC95%). A maioria das mulheres (58,2%) e 9,7% das crianças estavam acima do peso, 6,9% apresentaram déficit de crescimento e 3,1% das mães e 2,9% das crianças estavam abaixo do peso. A prevalência de excesso de peso na díade mãe-filho foi de 7,8% e foi estatisticamente maior no Sul do Brasil (9,7%; IC95%: 7,5; 11,9) do que no Centro-oeste (5,4%; IC95%: 4,3; 6,6). A prevalência de mãe com sobrepeso e filho com déficit de crescimento foi de 3,5%, com uma diferença estatisticamente significante entre os extremos de escolaridade materna [(0-7 vs. ≥ 12 anos de estudo), 4,8% (IC95%: 3,2; 6,5) and 2,1% (IC95%: 1,2; 3,0), respectivamente]. O excesso de peso na díade aumentou de 5,2% para 7,8% e a dupla carga de má nutrição aumentou de 2,7% para 5,2% desde 2006. A má nutrição nas díades mãe-filho brasileiras parece ser um problema crescente, sendo as mais vulneráveis aquelas com menor escolaridade e maior idade materna e residentes na Região Sul do Brasil.

Resumen: La malnutrición afecta a muchas personas en todo el mundo y representa un desafío para la salud mundial. Este estudio tuvo como objetivo determinar la prevalencia de malnutrición (desnutrición o sobrepeso) entre díadas madre-hijo en niños menores de cinco años en Brasil en 2019 y estimar cambios en esta prevalencia de 2006 a 2019. Se analizaron datos individuales del Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019) y de la Encuesta Nacional de Demografía y Salud del Niño y de la Mujer de 2006 (PNDS 2006). Los resultados de la malnutrición incluyeron a madre e hijo con sobrepeso, madre e hijo desnutridos y la doble carga de mala nutrición, es decir, madre con sobrepeso e hijo con cualquier forma de desnutrición (retardo en el crecimiento, emaciación o bajo peso). Se calcularon prevalencias y los intervalos de 95% de confianza (IC95%). La mayoría de las mujeres (58,2%) y el 9,7% de los niños tenían sobrepeso, el 6,9% de los niños presentaban retraso en el crecimiento, y el 3,1% de las madres y el 2,9% de los niños, bajo peso. La prevalencia de sobrepeso en la díada madre-hijo fue del 7,8%, estadísticamente mayor en el Sur de Brasil (9,7%; IC95%: 7,5; 11,9) que en el Centro-Oeste (5,4%; IC95%: 4,3; 6,6). La prevalencia de madres con sobrepeso y de niños con retraso del crecimiento fue del 3,5%, con una diferencia estadísticamente significativa entre los extremos de nivel educativo de la madre [(0-7 vs. ≥ 12 años de nivel educativo), 4,8% (IC95%: 3,2; 6,5) y 2,1% (IC95%: 1,2; 3,0), respectivamente]. El sobrepeso en la díada tuvo un aumento del 5,2% al 7,8%, y la doble carga de mala nutrición aumentó del 2,7% al 5,2% desde 2006. La malnutrición en la díada madre-hijo brasileña resulta ser un problema creciente, siendo las más vulnerables aquellas con menor escolaridad y mayor edad materna y residentes en la Región Sur de Brasil.

Abstract: Malnutrition affects billions of individuals worldwide and represents a global health challenge. This study aimed to determine the prevalence of malnutrition (undernutrition or overweight) among mother-child dyads in children under 5 years old in Brazil in 2019 and to estimate changes in this prevalence from 2006 to 2019. Individual-level data from the Brazilian National Survey on Child Nutrition (ENANI-2019) and the Brazilian National Survey of Demography and Health of Women and Children carried out in 2006 (PNDS 2006) were analyzed. Malnutrition outcomes in mother-child dyads included overweight mother and child, undernourished mother and child, and the double burden of malnutrition, i.e., overweight mother and child having any form of undernourishment (stunting, wasting, or underweight). Prevalence and 95% confidence intervals (95%CI) were estimated. Most women (58.2%) and 9.7% of the children were overweight, 6.9% were stunted, and 3.1% of mothers and 2.9% of the children were underweight. The prevalence of overweight in the mother-child dyad was 7.8% and was statistically higher in Southern Brazil (9.7%; 95%CI: 7.5; 11.9) than in the Central-West (5.4%; 95%CI: 4.3; 6.6). The prevalence of overweight mother and stunted child was 3.5%, with statistically significant difference between the extremes of the mother’s education [0-7 vs. ≥ 12 years, 4.8% (95%CI: 3.2; 6.5) and 2.1%, (95%CI: 1.2; 3.0), respectively]. Overweight in the dyad increased from 5.2% to 7.8%, and the double burden of malnutrition increased from 2.7% to 5.2% since 2006. Malnutrition in Brazilian mother-child dyads seems to be a growing problem, and dyads with lower formal education, higher maternal age, and from the South Region of Brazil were more vulnerable.

Abstract Leaf anatomical features are widely used to better understand angiosperm taxonomy. However, such information is scarce for the family Myrtaceae. Aiming to fill this knowledge gap, we studied anatomical and micromorphological leaf characters of ten species of Psidium: P. cattleyanum, P. cauliflorum, P. corynanthum, P. guajava, P. guineense, P. macahense, P. myrtoides, P. oligospermum, P. ovale and P. sartorianum. Uniseriate epidermis, paracytic stomata, secretory cavities, and adaxial hypodermis are common among the studied species and are typical characteristics of Myrtaceae. The presence of three or more layers of palisade parenchyma and the absence of sclerenchyma are diagnostic characters of P. guajava. The abaxial epidermis of Psidium cattleyanum and P. macahense possess curved walls. Psidium corynanthum and P. macahense are the only species with sinuous anticlinal walls on both sides of the epidermis, with all other species having straight or curved walls. Open bicollateral vascular bundles are present in all the studied species except P. guineense. With the exception of P. cauliflorum, all the studied species possess druses. The absence of collenchyma in the adaxial face is exclusive to P. ovale. The leaf anatomy of P. macahense, P. corynanthum, P. oligospermum and P. ovale are described for the first time here. taxonomy However Myrtaceae gap P cauliflorum guajava guineense myrtoides sartorianum stomata cavities druses here

Resumo As características anatômicas foliares são amplamente utilizadas para melhor compreender a taxonomia entre as angiospermas. No entanto, tais informação são escassas para a família Myrtaceae. Com o objetivo de preencher esta lacuna de conhecimento, estudamos a anatomia foliar de dez espécies do gênero Psidium: P. cattleyanum, P. cauliflorum, P. corynanthum, P. guajava, P. guineense, P. macahense, P. myrtoides, P. oligospermum, P. ovale e P. sartorianum. A epiderme unisseriada, os estômatos paracíticos, as cavidades secretoras e a hipoderme adaxial são comuns entre as espécies estudadas e são características típicas de Myrtaceae. A presença de três ou mais camadas de parênquima paliçádico e a ausência de esclerênquima são caracteres diagnósticos de P. guajava. A epiderme abaxial de Psidium cattleyanum e P. macahense possuem paredes curvas. Psidium corynanthum e P. macahense são as únicas espécies com paredes anticlinais sinuosas em ambos os lados da epiderme, sendo que todas as outras espécies têm paredes retas ou curvas. Os feixes vasculares bicolaterais abertos estão presentes em todas as espécies estudadas, exceto em P. guineense. Com exceção de P. cauliflorum, todas as espécies estudadas possuem drusas. A ausência de colênquima na face adaxial é exclusiva de P. ovale. A anatomia foliar de P. macahense, P. corynanthum, P. oligospermum e P. ovale é descrita pela primeira vez neste trabalho. angiospermas entanto Myrtaceae conhecimento P cauliflorum guajava guineense myrtoides sartorianum unisseriada paracíticos curvas drusas trabalho

Resumen: La malnutrición afecta a muchas personas en todo el mundo y representa un desafío para la salud mundial. Este estudio tuvo como objetivo determinar la prevalencia de malnutrición (desnutrición o sobrepeso) entre díadas madre-hijo en niños menores de cinco años en Brasil en 2019 y estimar cambios en esta prevalencia de 2006 a 2019. Se analizaron datos individuales del Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019) y de la Encuesta Nacional de Demografía y Salud del Niño y de la Mujer de 2006 (PNDS 2006). Los resultados de la malnutrición incluyeron a madre e hijo con sobrepeso, madre e hijo desnutridos y la doble carga de mala nutrición, es decir, madre con sobrepeso e hijo con cualquier forma de desnutrición (retardo en el crecimiento, emaciación o bajo peso). Se calcularon prevalencias y los intervalos de 95% de confianza (IC95%). La mayoría de las mujeres (58,2%) y el 9,7% de los niños tenían sobrepeso, el 6,9% de los niños presentaban retraso en el crecimiento, y el 3,1% de las madres y el 2,9% de los niños, bajo peso. La prevalencia de sobrepeso en la díada madre-hijo fue del 7,8%, estadísticamente mayor en el Sur de Brasil (9,7%; IC95%: 7,5; 11,9) que en el Centro-Oeste (5,4%; IC95%: 4,3; 6,6). La prevalencia de madres con sobrepeso y de niños con retraso del crecimiento fue del 3,5%, con una diferencia estadísticamente significativa entre los extremos de nivel educativo de la madre [(0-7 vs. ≥ 12 años de nivel educativo), 4,8% (IC95%: 3,2; 6,5) y 2,1% (IC95%: 1,2; 3,0), respectivamente]. El sobrepeso en la díada tuvo un aumento del 5,2% al 7,8%, y la doble carga de mala nutrición aumentó del 2,7% al 5,2% desde 2006. La malnutrición en la díada madre-hijo brasileña resulta ser un problema creciente, siendo las más vulnerables aquellas con menor escolaridad y mayor edad materna y residentes en la Región Sur de Brasil. Resumen mundial madrehijo 201 200 ENANI2019 ENANI (ENANI-2019 PNDS . 2006) decir retardo peso peso) 95 IC95%. IC95 IC IC95% (IC95%) 58,2% 582 58 2 (58,2% 97 9 7 9,7 69 6 6,9 31 3 1 3,1 29 2,9 78 8 7,8% (9,7% 7,5 75 5 11,9 119 11 CentroOeste Centro Oeste 5,4% 54 4 (5,4% 4,3 43 6,6. 66 6,6 6,6) 35 3,5% 07 0 [(0- vs educativo, , educativo) 48 4,8 (IC95% 3,2 32 6,5 65 21 2,1 1,2 3,0, 30 3,0 3,0) respectivamente. respectivamente respectivamente] 52 5,2 27 2,7 creciente 20 ENANI201 (ENANI-201 IC9 58,2 (58,2 9, 6, 3, 2, 7,8 (9,7 7, 11, 5,4 (5,4 4, 3,5 [(0 (IC95 1, 5, ENANI20 (ENANI-20 58, (58, (9, (5, [( (IC9 ENANI2 (ENANI-2 (58 (9 (5 [ (IC (ENANI- ( (ENANI

Abstract: Malnutrition affects billions of individuals worldwide and represents a global health challenge. This study aimed to determine the prevalence of malnutrition (undernutrition or overweight) among mother-child dyads in children under 5 years old in Brazil in 2019 and to estimate changes in this prevalence from 2006 to 2019. Individual-level data from the Brazilian National Survey on Child Nutrition (ENANI-2019) and the Brazilian National Survey of Demography and Health of Women and Children carried out in 2006 (PNDS 2006) were analyzed. Malnutrition outcomes in mother-child dyads included overweight mother and child, undernourished mother and child, and the double burden of malnutrition, i.e., overweight mother and child having any form of undernourishment (stunting, wasting, or underweight). Prevalence and 95% confidence intervals (95%CI) were estimated. Most women (58.2%) and 9.7% of the children were overweight, 6.9% were stunted, and 3.1% of mothers and 2.9% of the children were underweight. The prevalence of overweight in the mother-child dyad was 7.8% and was statistically higher in Southern Brazil (9.7%; 95%CI: 7.5; 11.9) than in the Central-West (5.4%; 95%CI: 4.3; 6.6). The prevalence of overweight mother and stunted child was 3.5%, with statistically significant difference between the extremes of the mother’s education [0-7 vs. ≥ 12 years, 4.8% (95%CI: 3.2; 6.5) and 2.1%, (95%CI: 1.2; 3.0), respectively]. Overweight in the dyad increased from 5.2% to 7.8%, and the double burden of malnutrition increased from 2.7% to 5.2% since 2006. Malnutrition in Brazilian mother-child dyads seems to be a growing problem, and dyads with lower formal education, higher maternal age, and from the South Region of Brazil were more vulnerable. Abstract challenge undernutrition motherchild 201 200 Individuallevel Individual level ENANI2019 ENANI (ENANI-2019 PNDS analyzed ie i e i.e. stunting, stunting (stunting wasting underweight . underweight) 95 95%CI 95CI CI (95%CI estimated 58.2% 582 58 2 (58.2% 97 9 7 9.7 69 6 6.9 31 3 1 3.1 29 2.9 78 8 7.8 (9.7% 7.5 75 11.9 119 11 CentralWest Central West 5.4% 54 4 (5.4% 4.3 43 6.6. 66 6.6 6.6) 35 3.5% s 07 0 [0- vs 48 4.8 3.2 32 6.5 65 21 2.1% 1.2 3.0, 30 3.0 , 3.0) respectively. respectively respectively] 52 5.2 27 2.7 problem age vulnerable 20 ENANI201 (ENANI-201 i.e 58.2 (58.2 9. 6. 3. 2. 7. (9.7 11. 5.4 (5.4 4. 3.5 [0 2.1 1. 5. ENANI20 (ENANI-20 58. (58. (9. (5. [ ENANI2 (ENANI-2 (58 (9 (5 (ENANI- ( (ENANI

Resumo: A má nutrição afeta bilhões de indivíduos em todo o mundo e representa um desafio de saúde global. Este estudo teve como objetivo determinar a prevalência de má nutrição (desnutrição ou excesso de peso) entre díades mãe-filho em crianças menores de cinco anos no Brasil em 2019 e estimar as mudanças nessa prevalência de 2006 a 2019. Foram analisados dados individuais do Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019) e da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher realizada em 2006 (PNDS 2006). Os desfechos de má nutrição incluíram mãe e filho com excesso de peso, mãe e filho desnutridos e a dupla carga de má nutrição, ou seja, mãe com excesso de peso e filho com qualquer forma de desnutrição (défict de crescimento, magreza ou baixo peso). Foram estimadas a prevalência e os intervalos de 95% de confiança (IC95%). A maioria das mulheres (58,2%) e 9,7% das crianças estavam acima do peso, 6,9% apresentaram déficit de crescimento e 3,1% das mães e 2,9% das crianças estavam abaixo do peso. A prevalência de excesso de peso na díade mãe-filho foi de 7,8% e foi estatisticamente maior no Sul do Brasil (9,7%; IC95%: 7,5; 11,9) do que no Centro-oeste (5,4%; IC95%: 4,3; 6,6). A prevalência de mãe com sobrepeso e filho com déficit de crescimento foi de 3,5%, com uma diferença estatisticamente significante entre os extremos de escolaridade materna [(0-7 vs. ≥ 12 anos de estudo), 4,8% (IC95%: 3,2; 6,5) and 2,1% (IC95%: 1,2; 3,0), respectivamente]. O excesso de peso na díade aumentou de 5,2% para 7,8% e a dupla carga de má nutrição aumentou de 2,7% para 5,2% desde 2006. A má nutrição nas díades mãe-filho brasileiras parece ser um problema crescente, sendo as mais vulneráveis aquelas com menor escolaridade e maior idade materna e residentes na Região Sul do Brasil. Resumo global mãefilho 201 200 ENANI2019 ENANI (ENANI-2019 PNDS . 2006) seja défict 95 IC95%. IC95 IC IC95% (IC95%) 58,2% 582 58 2 (58,2% 97 9 7 9,7 69 6 6,9 31 3 1 3,1 29 2,9 78 8 7,8 (9,7% 7,5 75 5 11,9 119 11 Centrooeste Centro oeste 5,4% 54 4 (5,4% 4,3 43 6,6. 66 6,6 6,6) 35 3,5% 07 0 [(0- vs estudo, , estudo) 48 4,8 (IC95% 3,2 32 6,5 65 21 2,1 1,2 3,0, 30 3,0 3,0) respectivamente. respectivamente respectivamente] 52 5,2 27 2,7 crescente 20 ENANI201 (ENANI-201 IC9 58,2 (58,2 9, 6, 3, 2, 7, (9,7 11, 5,4 (5,4 4, 3,5 [(0 (IC95 1, 5, ENANI20 (ENANI-20 58, (58, (9, (5, [( (IC9 ENANI2 (ENANI-2 (58 (9 (5 [ (IC (ENANI- ( (ENANI

Abstract Objective: To evaluate the validity of the computerized version of the pediatric triage system CLARIPED. Methods: Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPVand NPV), undertriage, and overtriage rates were assessed. Results: 19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67,120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. Conclusion: The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.

Abstract Objectives To study the impact of the implementation of the Pediatric Surviving Sepsis Campaign protocol on early recognition of sepsis, 1 -h treatment bundle and mortality. Methods Retrospective, single-center study, before and after the implementation of the sepsis protocol. Outcomes: sepsis recognition, compliance with the 1 -h bundle (fluid resuscitation, blood culture, antibiotics), time interval to fluid resuscitation and antibiotics administration, and mortality. Patients with febrile neutropenia were excluded. The comparisons between the periods were performed using non-parametric tests and odds ratios or relative risk were calculated. Results We studied 84 patients before and 103 after the protocol implementation. There was an increase in sepsis recognition (OR 21.5 [95% CI: 10.1-45.7]), in the compliance with the 1 -h bundle as a whole (62% x 0%), and with its three components: fluid resuscitation (OR 31.1 [95% CI: 3.9−247.2]), blood culture (OR 15.9 [95% CI: 3.9−65.2]), and antibiotics (OR 35.6 [95% CI: 8.9−143.2]). Significant reduction between sepsis recognition to fluid resuscitation (152min × 12min, p < 0.001) and to antibiotics administration (137min × 30min) also occurred. The risk of death before protocol implementation was four times greater (RR 4.1 [95% CI: 1.2-14.4]), and the absolute death risk reduction was 9%. Conclusion Even if we considered the low precision of some estimates, the lower limits of the Confidence Intervals show that the implementation of the Pediatric Surviving Sepsis Campaign guidelines alongside a qualitive assurance initiative has led to improvements in sepsis recognition, compliance with the 1 -h treatment bundle, reduction in the time interval to fluid resuscitation and antibiotics, and reduction in sepsis mortality.

ABSTRACT BACKGROUND: Cardiovascular risk factors are frequently associated with lowered cognitive performance among elderly people, but rarely among middle-aged adults. OBJECTIVES: To investigate associations between cardiovascular risk factors (age, physical inactivity, smoking, alcohol use, hypertension and diabetes) and lower cognitive performance among middle-aged (45-64 years) Brazilian adults. DESIGN AND SETTING: Cross-sectional study nested within the Pró-Saúde cohort. From 2,876 baseline study participants (1999), we randomly selected 488 participants and gave them validated and standardized cognitive tests (2012). METHODS: We used multiple linear and logistic regression analyses to detect associations of cardiovascular risk factors with crude scores in cognitive tests on memory (word test) and executive function (verbal fluency tests), and with overall cognitive performance scores, respectively. RESULTS: All cognitive test scores presented statistically significant inverse associations with age and direct associations with education. There was no association between lower cognitive performance and smoking or alcohol use. In both 1999 and 2012, after adjusting for sex, age and schooling, being physically active was inversely associated with lower performance regarding late memory. For individuals with diabetes in 1999, there was an association with lower performance regarding executive function, while there was a borderline association for those reporting it only in 2012. Having a diagnosis of hypertension since 1999 was associated with lower performance regarding both memory and executive functions, while reporting hypertension in 2012 was associated with lower performance regarding executive function. CONCLUSIONS: Aging, low schooling and cardiovascular risk factors may represent life course disadvantages associated with cognitive decline even among middle-aged Brazilian adults.

Resumo Objetivo: Descrever as características clínicas de crianças e adolescentes internados em unidade de terapia intensiva com COVID-19 confirmada. Método: Estudo prospectivo, multicêntrico, observacional, em 19 unidades de terapia intensiva pediátrica. Foram incluídos pacientes entre um mês e 19 anos, admitidos consecutivamente (março a maio de 2020). As características demográficas, clínico-epidemiológicas, o tratamento e os resultados foram coletados. Os subgrupos foram comparados de acordo com as comorbidades, idade < 1 ano e necessidade de ventilação mecânica invasiva. Um modelo de regressão logística multivariável foi utilizado para preditores de gravidade. Resultados: Setenta e nove pacientes foram incluídos (10 com síndrome inflamatória multi-ssistêmica). Mediana de idade, quatro anos; 54% eram do sexo masculino (síndrome inflamatória multissistêmica, 80%); 41% tinham comorbidades (síndrome inflamatória multissistêmica, 20%). Febre (76%), tosse (51%) e taquipneia (50%) foram comuns nos dois grupos. Sintomas graves egastrointestinais e marcadores inflamatórios mais elevados foram mais frequentes na presença de síndrome inflamatória multissistêmica. Infiltrados intersticiais pulmonares foram comuns em ambos os grupos, mas o derrame pleural foi mais prevalente no grupo com síndrome inflamatória multissistêmica (43% vs. 14%). A ventilação mecânica invasiva foi utilizada em 18% (mediana 7,5 dias); antibióticos, oseltamivir e corticosteroides foram utilizados em 76%, 43% e 23%, respectivamente, mas não a hidroxicloroquina. A mediana do tempo de permanência na unidade de terapia intensiva pediátrica foi de 5 dias; duas mortes ocorreram (3%) no grupo não- síndrome inflamatória multissistêmica. Os pacientes com comorbidades eram mais velhos, e as comorbidades foram independentemente associadas à necessidade de ventilação mecânica invasiva(OR 5,5; IC95%, 1,43-21,12; P 0,01). Conclusões: Nas unidades de terapia intensiva pediátrica brasileiras, a COVID-19 apresentou baixa mortalidade, a idade inferior a um ano não foi associada a um pior prognóstico, os pacientes com síndrome inflamatória multissistêmica apresentaram sintomas mais graves, biomarcadores inflamatórios mais elevados e uma grande predominância no sexo masculino, mas apenas a presença de comorbidades e doenças crônicas foi um preditor independente de gravidade.

Abstract Objective: To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19. Method: Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March-May 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity. Results: Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43-21.12; p = 0.01). Conclusions: In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.

RESUMO Objetivo: Avaliar a validade e a confiabilidade de um sistema de classificação de risco para emergências pediátricas (CLARIPED) desenvolvido no Brasil. Métodos: Fase de validade: estudo observacional prospectivo em crianças de 0 a 15anos atendidas consecutivamente no serviço de emergência pediátrica (SEP) de um hospital terciário entre 2 e 18de julho de 2013. Avaliou-se a associação dos níveis de urgência com desfechos clínicos (utilização de recursos, taxa de admissão no SEP, taxa de hospitalização e tempo de permanência no SEP); e comparou-se o desempenho do CLARIPED com um padrão de referência. Fase de confiabilidade interobservadores: uma amostra de conveniência de pacientes atendidos entre abril e julho de 2013 foi submetida a duas classificações de risco consecutivas e independentes, e estimou-se o Kappa ponderado quadrático. Resultados: Em 1.416 atendimentos realizados na fase de validade, a distribuição de níveis de urgência foi: 0,0% vermelho/emergência; 5,9% laranja/muito urgente; 40,5% amarelo/urgente; 50,6% verde/pouco urgente; e 3,0% azul/sem urgência. Ospercentuais de pacientes que usaram dois ou mais recursos diminuíram do nível laranja para o amarelo, verde e azul (81, 49, 22 e 2%, respectivamente, p<0,0001), assim como a taxa de admissão no SEP, o tempo de permanência no SEP e a taxa de admissão hospitalar. Asensibilidade para discriminar pacientes muito urgentes foi de 0,89 (intervalo de confiança de 95%- IC95% 0,78-0,95), e a taxa de subtriagem foi de 7,4%. Aconfiabilidade interobservadores em 191 pacientes classificados por duas enfermeiras foi substancial (kw2=0,75; IC95% 0,74-0,79). Conclusões: O sistema CLARIPED mostrou boa validade e substancial confiabilidade para classificação de risco em um serviço de emergência pediátrica.

ABSTRACT 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.

ABSTRACT 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.

OBJETIVOS: identificar os códigos de procedimentos constantes no Sistema de Informação Hospitalar - Sistema Único de Saúde (SIH-SUS) considerados como Morbidade Materna Extremamente Grave (MMEG) e construir um algoritmo para o manejo/preparação da base de dados de Autorização de Internação Hospitalar visando a captura dos casos de MMEG neste banco de dados. MÉTODOS: utilizaram-se os dados do SIH-SUS fornecidos pela Secretaria de Saúde de Juiz de Fora e referem se as internações ocorridas no SUS no período de 2006-2007. Foram selecionadas todas as internações cujo diagnóstico principal compreendia todo o capítulo XV da Classificação Internacional de Doenças (CID10) - Complicações da gravidez, aborto, parto e puerpério e/ou internações em que procedimentos obstétricos foram realizados. Para identificação dos procedimentos no SIH-SUS, considerados como MMEG, adotaram-se os critérios propostos pela Organização Mundial da Saúde. O algoritmo foi desenvolvido no software Microsoft Access. RESULTADOS: foram capturados 326 casos de MMEG entre as 8620 mulheres selecionadas, perfazendo uma taxa de 37,8/1000 mulheres. Os procedimentos mais frequentes foram transfusão de hemoderivados, "permanência a maior" e pré-eclampsia grave/eclâmpsia, com prevalências de 15,7/1000, 9,5/1000 e 8,2/1000, respectivamente. CONCLUSÕES: o algoritmo utilizado pode otimizar o uso do SIH-SUS para a captação dos casos de MMEG e gerar informações para os serviços de vigilância da morbimortalidade materna e avaliação de cuidados obstétricos.

OBJECTIVES: to identify codes for constant procedures in the Brazilian National Health System's Hospital Information System (SIH-SUS) deemed to be cases of Extremely Severe Maternal Morbidity (MMEG) and to develop an algorithm to manage/prepare an AIH database, with a view to identifying cases of MMEG in this database. METHODS: the data used were from the SIH-SUS supplied by the Juiz de Fora Health Secretary and refer to admissions to SUS hospitals between 2006 and 2007. The study covered all admissions where the principal diagnosis involved all of Chapter XV of CID10 - complications of pregnancy, miscarriage, delivery and puerperium and/or admissions to hospital involving obstetric procedures. For identification of SIH-SUS procedures deemed to be MMEG, the criteria proposed by the WHO were used. The algorithm was developed using Microsoft Access. RESULTS: 326 cases of MMEG were found among the 8620 women selected, constituting a rate of 37. 8/1000 women. The most frequent procedures were transfusion of blood products, "a longer stay" and severe pre-eclampsia/eclampsia, with a prevalence of 15. 7/1000, 9. 5/1000 and 8. 2/1000, respectively. CONCLUSIONS: the algorithm used may optimize the use of the SIH-SUS for identifying cases of MMEG and generating information for maternal morbidity and mortality surveillance services and the evaluation of obstetric care.