Abstract Neuromuscular electrical stimulation (NMES) can be an alternative to conventional exercising. This randomized clinical trial evaluated the effect of NMES in type 2 diabetes patients. Twenty-eight individuals with type 2 diabetes were assigned to NMES (n=14) or NMES-placebo (n=14) applied to knee extensor muscles for 60 minutes. Glucose variability, microvascular function and endothelial function were evaluated through continuous glucose monitoring system, near infrared spectroscopy and flow-mediated dilatation, respectively. Glucose levels (mg/dl) decreased 2h (184 ± 11 vs 223 ±15), 3h (179 ± 12 vs 219 ±14) and 4h (177 ± 12 vs 212 ±12) after NMES, in comparison to NMES-placebo. No differences in glucose variability were found: coefficient of variation (%) at 0-6h (11.4±1.3 vs 11.4±1.2), 6-12h (9.8±1.0 vs 11.6±1.6), 12-18h (15.5±2.0 vs 11.4±2.1), 18-24h (12.8±2.3 vs 10.0±1.6); standard deviation (mg/dl) at 0-6h (21.6±2 vs 24.6±3.5), 6-12h (19.5±1.8 vs 20.3±2.8), 12-18h (29.9±3.5 vs 21.3±2.8),18-24h (22.8±4.1 vs 16.6±2.0) and mean amplitude of glycemic excursions (mg/dl) 54.9±25.0 vs 70.3±35.7. Endothelial and microvascular functions did not change. In conclusion, one acute NMES session was strong enough to trigger glucose reduction in individuals with type 2 DM, but it failed to induce any significant change in glucose variability, endothelial and microvascular functions. (NMES exercising patients Twentyeight Twenty eight n=14 n14 n 14 (n=14 NMESplacebo placebo 6 minutes system flowmediated flow mediated dilatation respectively mg/dl mgdl mg dl (mg/dl h 184 (18 1 22 ±15, 15 ±15 , ±15) 179 (17 21 ±14 177 ±12 NMESplacebo. placebo. found % (% 06h 0 6h 11.4±1.3 11413 4 3 (11.4±1. 11.4±1.2, 11412 11.4±1.2 11.4±1.2) 612h 12h 9.8±1.0 9810 9 8 (9.8±1. 11.6±1.6, 11616 11.6±1.6 11.6±1.6) 1218h 18h 15.5±2.0 15520 5 (15.5±2. 11.4±2.1, 11421 11.4±2.1 11.4±2.1) 1824h 18 24h 12.8±2.3 12823 (12.8±2. 10.0±1.6 10016 10 10.0±1.6) 21.6±2 2162 (21.6± 24.6±3.5, 24635 24.6±3.5 24 24.6±3.5) 19.5±1.8 19518 19 (19.5±1. 20.3±2.8, 20328 20.3±2.8 20 20.3±2.8) 29.9±3.5 29935 29 (29.9±3. 21.3±2.8,1824h 213281824h 21.3±2.8 ,18 22.8±4.1 22841 (22.8±4. 16.6±2.0 16620 16 549250 54 25 54.9±25. 703357 70 35 7 70.3±35.7 conclusion DM n=1 n1 (n=1 (1 ±1 17 ( 11.4±1. 1141 (11.4±1 9.8±1. 981 (9.8±1 1161 11.6±1. 15.5±2. 1552 (15.5±2 1142 11.4±2. 12.8±2. 1282 (12.8±2 10.0±1. 1001 21.6± 216 (21.6 2463 24.6±3. 19.5±1. 1951 (19.5±1 2032 20.3±2. 29.9±3. 2993 (29.9±3 21328 21.3±2. ,1 22.8±4. 2284 (22.8±4 16.6±2. 1662 54925 54.9±25 70335 70.3±35. n= (n= 11.4±1 114 (11.4± 9.8±1 98 (9.8± 116 11.6±1 15.5±2 155 (15.5± 11.4±2 12.8±2 128 (12.8± 10.0±1 100 21.6 (21. 246 24.6±3 19.5±1 195 (19.5± 203 20.3±2 29.9±3 299 (29.9± 2132 21.3±2 22.8±4 228 (22.8± 16.6±2 166 5492 54.9±2 7033 70.3±35 (n 11.4± (11.4 9.8± (9.8 11.6± 15.5± (15.5 12.8± (12.8 10.0± 21. (21 24.6± 19.5± (19.5 20.3± 29.9± (29.9 213 21.3± 22.8± (22.8 16.6± 549 54.9± 703 70.3±3 11.4 (11. 9.8 (9. 11.6 15.5 (15. 12.8 (12. 10.0 (2 24.6 19.5 (19. 20.3 29.9 (29. 21.3 22.8 (22. 16.6 54.9 70.3± 11. (11 9. (9 15. (15 12. (12 10. 24. 19. (19 20. 29. (29 22. (22 16. 54. 70.3 70.

RESUMO Objetivo: Avaliar a capacidade do Teste de Caminhada de 6 Minutos para predizer a melhora do estado funcional físico em longo prazo de pacientes sobreviventes à unidade de terapia intensiva. Métodos: Foram avaliados, de forma prospectiva, entre fevereiro de 2017 e agosto de 2018, em um ambulatório pós-unidade de terapia intensiva, 32 sobreviventes à unidade de terapia intensiva. Foram inscritos consecutivamente os pacientes com permanência na unidade de terapia intensiva acima de 72 horas (para admissões emergenciais) ou acima de 120 horas (para admissões eletivas) que compareceram ao ambulatório pós-unidade de terapia intensiva 4 meses após receberem alta da unidade de terapia intensiva. A associação entre a distância percorrida no Teste de Caminhada de 6 Minutos realizado na avaliação inicial e a evolução do estado funcional físico foi avaliada durante 8 meses, com utilização do Índice de Barthel. Resultados: A distância média percorrida no Teste de Caminhada de 6 Minutos foi significantemente mais baixa nos sobreviventes à unidade de terapia intensiva do que na população geral (405m versus 557m; p < 0,001). A idade (β = -4,0; p < 0,001) e a fraqueza muscular (β = -99,7; p = 0,02) se associaram com a distância percorrida no Teste de Caminhada de 6 Minutos. A distância percorrida no Teste de Caminhada de 6 Minutos se associou com melhora do estado funcional físico no período de 8 meses de acompanhamento desses pacientes (razão de chance para cada 10m: 1,07; IC95% 1,01 - 1,16; p = 0,03). A área sob a curva Característica de Operação do Receptor para predição da melhora funcional física pelo Teste de Caminhada de 6 Minutos foi de 0,72 (IC95% 0,53 - 0,88). Conclusão: O Teste de Caminhada de 6 Minutos, realizado 4 meses após a alta da unidade de terapia intensiva, predisse com precisão moderada a melhora do estado funcional físico de sobreviventes à unidade de terapia intensiva.

ABSTRACT Objective: To evaluate the ability of the 6-Minute Walk Test to predict long-term physical functional status improvement among intensive care unit survivors. Methods: Thirty-two intensive care unit survivors were prospectively evaluated from February 2017 to August 2018 in a post-intensive care unit outpatient clinic in Brazil. Individuals with intensive care unit stays > 72 hours (emergency admissions) or > 120 hours (elective admissions) attending the post-intensive care unit clinic four months after intensive care unit discharge were consecutively enrolled. The association between the 6-Minute Walk Test distance at baseline and physical functional status was assessed over 8 months using the Barthel Index. Results: The mean 6-Minute Walk Test distance was significantly lower in intensive care unit survivors than in the general population (405m versus 557m; p < 0.001). Age (β = -4.0; p < 0.001) and muscle weakness (β = -99.7; p = 0.02) were associated with the 6-Minute Walk Test distance. A 6-Minute Walk Test distance was associated with improvement in physical functional status over the 8-month follow-up (odds ratio for each 10m of 1.07; 95%CI 1.01 - 1.16; p = 0.03). The area under the Receiver Operating Characteristic curve for the 6-Minute Walk Test prediction of physical functional status improvement was 0.72 (95%CI 0.53 - 0.88). Conclusion: The 6-Minute Walk Test performed 4 months after intensive care unit discharge predicted long-term physical functional status among intensive care unit survivors with moderate accuracy.

Although the genus Duguetia is well known for producing alkaloids as chemical constituents, there are no reports of alkaloids identified in the species D. lanceolata. Thus, aiming to identify the chemical composition of this species, the dereplication of alkaloidic phase was performed by use of ultra-high performance liquid chromatography high resolution electrospray ionization tandem mass spectrometry (UHPLC-HR-ESI-MS/MS) and 1H nuclear magnetic resonance (NMR). The chromatographic fractionation of the alkaloid extract from Duguetia lanceolata (Annonaceae) leaves afforded four fractions (I-IV) that were shown to be composed of aporphine alkaloids. 1H NMR analysis and UHPLC-HR-ESI-MS/MS based dereplication allowed the identification of eight alkaloids: glaucine (1), norglaucine (2), isocorydine (3), N-methyllaurotetanine (4), oxoglaucine (5), liriodenine (6), lanuginosine (7), dehydroglaucine (8). Compounds 2,3, 4,6 and 7 were described for the first time in this species, while alkaloids 1,5 and 8 are newly discovered in the genus Duguetia. Additionally, the antiparasitic activity of the four fractions was evaluated in vitro against Leishmania infantum and Trypanosoma cruzi. Fraction I, composed exclusively by 1, displayed activity against Leishmania infantum and Trypanosoma cruzi intracellular amastigotes, with half maximal inhibitory concentration (IC50) values of 7.5 and 28.6 µg mL-1, respectively. Fraction IV (constituted by 2,3 and 4) showed activity against promastigotes of Leishmania infantum with IC50 value of 50.0 µg mL-1, while fraction II (constituted by 5 and 6) showed activity against trypomastigotes of Trypanosoma cruzi, with IC50 values of 83.0 µg mL-1. This work showed that fragmentation in UHPLC-HR-ESI-MS/MS combined with 1H NMR analysis of fractions is useful for identifying alkaloids in mixtures. Additionally, it was also demonstrated the potential of aporphine alkaloids from Duguetia lanceolata St. -Hil (Annonaceae) in the search for new drug candidates for neglected diseases.

In the present work, leaves of Pentacalia desiderabilis (Asteraceae) were subjected to extraction using aqueous 1-butyl-3-methylimidazolium bromide (BMImBr) in the microwave assisted extraction (MAE). The obtained extract was partitioned using CH2Cl2 and antifungal activity against Cladosporium cladosporioides and C. sphaerospermum of the organic phase was evaluated. Sequentially, this material was subjected to several chromatographic procedures to afford four quinoid derivatives identified as jacaranone (1), methyl-jacaranone (2), quinolacetic acid (3), and methyl 1-hydroxy-4-oxo-cyclohexaneacetate (4), being the first occurrence of compounds 2 - 4 in P. desiderabilis. Isolated quinoid derivatives were submitted to bioautography assay and the obtained results indicated that compounds 1 - 3 are active against Cladosporium cladosporioides (0.78, 12.5 and 12.5 µg, respectively) and C. sphaerospermum (3.13, 12.5 and 12.5 µg, respectively).

RESUMO: Com o objetivo de estudar parâmetros indicativos de bem-estar, 30 equinos de corrida foram avaliados quanto ao temperamento, comportamento, parâmetros clínicos (condição geral, escoriações, escore corporal, cólicas no último ano, frequências cardíaca e respiratória) e níveis de cortisol plasmático (matutino, vespertino e ritmo circadiano). Todos os animais apresentaram boas condições físicas gerais, parâmetros clínicos normais para a espécie e não tiveram cólica no ano anterior ao estudo, demonstrando a preocupação dos tratadores com a saúde física dos animais. Contudo, 36,7% dos animais estudados apresentavam estereotipias. Apesar da alta incidência de indivíduos com ritmo circadiano do cortisol (RCC) alterado dentro do grupo de animais com comportamentos anormais (63,64%), não foi encontrada diferença estatística (P>0,05) quando comparado com a incidência do grupo de animais sem estereotipia (31,58%). Quatro animais com estereotipia portavam dispositivos para restringir a expressão de anomalias. Desses, todos apresentaram RCC alterado, permitindo demonstrar que equinos restringidos fisicamente de realizar sua estereotipia apresentam 18 vezes mais chances de ter alteração no RCC do que um animal de comportamento normal. Conclui-se que os equinos do Jockey Club do Paraná, apesar de apresentarem condições físicas satisfatórias comparados a estudos nacionais anteriores, possuíam alterações comportamentais e de função adrenocortical compatíveis com estresse crônico. Os achados também corroboram noções prévias de que a estereotipia é uma forma de tentar aliviar o estresse crônico em equinos, e que o uso de meios físicos para restringir sua manifestação aumenta a chance de distúrbios no metabolismo do cortisol.

ABSTRACT: The objective was to study indicative parameters of welfare in 30 race horses evaluated for temperament, behavior, clinical parameters (general condition, abrasions, body score, colic in the last year, heart and respiratory rates) and plasma cortisol levels (morning, afternoon and circadian rhythm). All animals presented good general physical condition, normal clinical parameters for the species and no colic episodes in the year preceding the study. However, 36.7% of animals had stereotypies. Despite the high incidence of altered circadian cortisol rhythmicity (CCR) within the group of animals with abnormal behavior (63.64%), there was no statistical difference (P>0.05) when compared with the incidence in the group animals without stereotyping (31.58%). Four animals with stereotypic behavior carried devices to restrict the expression of anomalies. All these four individuals had altered CCR, showing that restricting the stereotypic behavior of a horse increases 18 times the chances of altered CCR when compared to an individual with normal behavior. The horses of the Jockey Club of Paraná, despite having good physical condition compared to previous national studies, had behavioral and adrenocortical function consonant with chronic stress changes. The results also corroborate previous concepts of stereotyping as stress relieving in horses, and that the use of its physical restriction increases the chances of disturbances in cortisol metabolism.

ABSTRACT Background A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.

In this work, it is proposed a new strategy to improve the dispersion of inorganic fillers in polymeric matrices by producing surface carbon nanostructures. Clay/carbon nanofibers particles were prepared and used as fillers to improve the mechanical and thermal properties of ultra-high molecular weight polyethylene (UHMWPE). Thermogravimetry (TG), differential scanning calorimetry (DSC), elemental analyses, Raman, X-ray diffraction (XRD) and scanning electron microscopy (SEM) showed that chemical vapor deposition (CVD) with ethanol at different temperatures, i.e. 700, 800 and 900 °C with and without Fe catalyst, can be used to produce carbon (0.5-3.6 wt.%), mainly as nanofibers, on the clay surface. The use of these clay/carbon particles as fillers in UHMWPE at 1 and 3 wt.% produced an increase in the yield stress from 16 to ca. 20 MPa and Young modulus from 314 MPa for pure UHMWPE to values near 395-408 MPa. Moreover, the presence of the carbon/clay composites led to a strong improvement of the thermal properties of the UHMWPE increasing the decomposition Tonset (degradation start temperature) from 445 up to 472 °C. It was also observed by the crystallization enthalpies that the UHMWPE increased the crystallinity from 55 to 80-85% in the presence of the carbon composites. These results are discussed in terms of the strong interactions of the hydrophobic carbon nanostructures on the clay surface with the polymer hydrophobic chains.

RESUMEN Introduction: Mycobacterium tuberculosis Beijing lineage isolates are considered to be especially virulent, transmissible and prone to acquire resistances. Beijing strains have been reported worldwide, but studies in Latin America are still scarce. The only multinational study performed in the region indicated a heterogeneous distribution for this lineage, which was absent in Chile, Colombia and Ecuador, although further studies found the lineage in Chile and Colombia. Objective: To search for the presence of the Beijing lineage in Ecuador, the only country in the region where it remains unreported. Materials and methods: We obtained a convenience sample (2006-2012) from two hospitals covering different populations. The isolates were genotyped using 24-MIRU-VNTR. Lineages were assigned by comparing their patterns to those in the MIRU-VNTRplus platform. Isolates belonging to the Beijing lineage were confirmed by allele-specific PCR. Results: We identified the first Beijing isolate in Ecuador in an unexpected epidemiological scenario: A patient was infected in the Andean region, in a population with low mobility and far from the borders of the neighboring countries where Beijing strains had been previously reported. Conclusion: This is the first report of the presence of the Beijing lineage in Ecuador in an unusual epidemiological context that deserves special attention.

ABSTRACT Introducción. Los aislamientos de Mycobacterium tuberculosis pertenecientes al linaje Beijing se consideran especialmente virulentos y transmisibles, y con mayor tendencia a la adquisición de resistencia. El linaje Beijing se ha reportado en todo el mundo; sin embargo, en Latinoamérica los estudios al respecto son más escasos. En el único estudio multinacional llevado a cabo en la región, se detectó una distribución heterogénea del linaje, y no se le encontró en Chile, Colombia y Ecuador, aunque en estudios nacionales posteriores se identificaron aislamientos en Chile y Colombia. Objetivo. Rastrear la presencia del linaje Beijing de M. tuberculosis en Ecuador, único país en la región en el que aún no se reporta. Materiales y métodos. Se analizó una muestra de conveniencia (2006-2012) en dos hospitales que atendían poblaciones diferentes. La genotipificación de los aislamientos de M. tuberculosis se hizo mediante la plataforma 24-MIRU-VNTR. La asignación de linajes se hizo mediante la comparación de los patrones genotípicos con los incluidos en la plataforma MIRU-VNTRplus, y aquellos pertenecientes al linaje Beijing fueron confirmados mediante reacción en cadena de la polimerasa específica de alelo. Resultados. Se detectó el primer aislamiento Beijing en Ecuador, en una circunstancia epidemiológica inesperada: un paciente de la región andina, proveniente de una comunidad con escasa movilidad y alejada de las fronteras con los países limítrofes, Perú y Colombia, en los que ya se han identificado aislamientos de M. tuberculosis pertenecientes al linaje Beijing. Conclusiones. En este trabajo se reporta por primera vez la presencia del linaje Beijing de M. tuberculosis en Ecuador en un contexto epidemiológico inusual que merece especial atención.

Resumo Objetivo: Apresentar uma revisão sobre a evolução, o desenvolvimento e a consolidação da emergência pediátrica no exterior e no Brasil, assim como discutir o programa de residência nessa importante área de atuação para o pediatra. Fontes dos dados: Revisão do tipo narrativa, em que os autores usaram documentos pré-selecionados empregados nos requisitos mínimos para o programa em Residência de Medicina de Emergência Pediátrica e para artigos selecionados por interesse para desenvolvimento do tema usaram as bases de dados SciELO e Medline entre 2000 e 2017. Síntese dos dados: Foram descritos os antecedentes históricos e a evolução inicial da emergência pediátrica no Brasil e diversos desafios, na organização, no dimensionamento, na formação de profissionais e, também, na regulamentação do exercício profissional dessa nova especialidade. Também se descreve um novo programa de residência em emergência pediátrica a ser implantado no Brasil Conclusões: A formação em emergência pediátrica será um poderoso estímulo para atrair indivíduos talentosos, fixá-los nessa importante área da medicina, na qual poderão exercer sua liderança e promover qualificação na assistência, na pesquisa e no ensino, assim como atuar decisivamente no seu gerenciamento.

Abstract Objective: The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians. Data sources: This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017. Data synthesis: The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described. Conclusions: Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.

Essential oils of ripe fruits from Schinus terebinthifolius (Anacardiaceae), obtained using a pilot extractor and a Clevenger apparatus were chemically characterized. Due the high amount of (-)- α-pinene in both oils, this monoterpene was tested against the protozoan parasite Trypanosoma cruzi, showing a moderate potential (IC50 63.56 µg/mL) when compared to benznidazole (IC50 43.14 µg/mL). Otherwise, (-)- α-pinene oxide did not showed anti-trypanosomal activity (IC50 > 400 µg/mL) while (-)-pinane showed an IC50 of 56.50 µg/mL. The obtained results indicated that the epoxydation of α-pinene results to the loss of the anti-parasitic activity while its hydrogenation product, contributed slightly to the increased activity.

OBJETIVO: Analisar as práticas médicas e os cuidados de final de vida oferecidos a crianças internadas em unidades de tratamento intensivo pediátrico em diferentes regiões do planeta. FONTES DOS DADOS: Foram selecionados artigos sobre cuidados de final de vida publicados nos últimos 20 anos nas bases de dados PubMed, MEDLINE e LILACS, com ênfase nos estudos sobre morte em unidades de tratamento intensivo pediátrico no Brasil, América Latina, Europa e América do Norte, usando as seguintes palavras-chave: morte, bioética, tratamento intensivo pediátrico, reanimação cardiopulmonar e limitação de suporte de vida. SÍNTESE DOS DADOS: Observa-se uma concentração de publicações sobre limitação de suporte de vida (LSV) na América do Norte e Europa. Nas unidades de tratamento intensivo pediátrico norte-americanas, observa-se uma maior incidência de LSV (~ 60%) do que na Europa e América Latina (30-40%). Essas diferenças parecem estar relacionadas a fatores culturais, religiosos, legais e econômicos. Na última década, a LSV em unidades de tratamento intensivo pediátrico brasileiras aumentou de 6 para 40%, sendo a ordem de não reanimar a forma mais freqüente. Destaca-se, ainda, a pequena participação da família no processo decisório. Recente resolução do Conselho Federal de Medicina normatiza a LSV em nosso meio, desmistificando alguns receios de ordem legal. Os autores apresentam uma proposta de protocolo a ser seguido nesta eventualidade. CONCLUSÕES: Adoção de LSV em crianças em fase final de doença irreversível tem amparo ético, moral e legal. No Brasil, essas medidas são ainda adotadas de forma tímida, exigindo uma mudança de comportamento, especialmente no envolvimento da família no processo decisório.

OBJECTIVE: To analyze the medical practices and the end-of-life care provided to children admitted to pediatric intensive care units in different parts of the globe. SOURCES: Articles on end-of-life care published during the last 20 years were selected from the PubMed, MEDLINE and LILACS databases, with emphasis on studies of death in pediatric intensive care units in Brazil, Latin America, Europe and North America, using the following keywords: death, bioethics, pediatric intensive care, cardiopulmonary resuscitation and life support limitation. SUMMARY OF THE FINDINGS: Publications on life support limitation (LSL) are concentrated in North America and Europe. In North American pediatric intensive care units there is a greater incidence of LSL (~ 60%) than in Europe or Latin America (30-40%). These differences appear to be related to cultural, religious, legal and economic factors. Over the last decade, LSL in Brazilian pediatric intensive care units has increased from 6 to 40%, with do not resuscitate orders as the most common method. Also of note is the low level of family participation in the decision-making process. A recent resolution adopted by the Federal Medical Council (Conselho Federal de Medicina) regulated LSL in our country, demystifying a certain apprehension of a legal nature. The authors present a proposal for a protocol to be followed in these cases. CONCLUSIONS: The adoption of LSL with children in the final phases of irreversible diseases has ethical, moral and legal support. In Brazil, these measures are still being adopted in a timid manner, demanding a change in behavior, especially in the involvement of families in the decision-making process.

OBJETIVO: Avaliar a incidência de morte encefálica (ME), bem como as condutas e protocolos adotados após confirmação diagnóstica em sete unidades de tratamento intensivo pediátrico (UTIP) localizadas em três regiões brasileiras. MÉTODOS: Estudo transversal e multicêntrico baseado na revisão e análise retrospectiva de prontuários de todos os óbitos ocorridos entre janeiro de 2003 e dezembro de 2004 em sete UTIP localizadas em Porto Alegre (duas), São Paulo (duas) e Salvador (três). Dois residentes de cada serviço previamente treinados preencheram protocolo padronizado avaliando dados demográficos, causa do óbito, critérios para diagnóstico de ME e conduta médica adotada. RESULTADOS: Identificamos 525 óbitos, sendo 61 (11,6%) com diagnóstico de ME. A incidência de ME diferiu entre as sete UTIP (24,2 a 4,5%; p = 0,015), porém sem diferença nas três regiões (12, 15 e 7%; p = 0,052). A causa mais freqüente foi hemorragia intracraniana (31,1%). Em 80% dos casos, o diagnóstico clínico de ME foi confirmado por exame complementar (100% na Região Sul, 68% na Sudeste e 72% na Nordeste, p = 0,02). A retirada de suporte vital após diagnóstico de ME diferiu nas três regiões, sendo mais rápida (p = 0,04) no Sul (1,8±1,9 h) que no Sudeste (28,6±43,2 h) e Nordeste (15,5±17,1 h). Apenas seis (9,8%) crianças com ME foram doadoras de órgãos. CONCLUSÃO: Apesar da lei que define critérios para ME existir no Brasil desde 1997, verificamos que ela não é obedecida uniformemente. Conseqüentemente, suporte vital desnecessário é ofertado a indivíduos já mortos, existindo ainda um modesto envolvimento das UTIP com doações de órgãos.

OBJECTIVE: To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS: A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS: A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8±1.9 h) than in the southeast (28.6±43.2 h) and than in the northeast (15.5±17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION: Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

OBJETIVO: Avaliar os modos de morte e fatores associados à limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil. MÉTODO: Estudo transversal e retrospectivo em que foram revisados todos os óbitos ocorridos em 2002 em três unidades de terapia intensiva pediátrica de referência de Porto Alegre por uma equipe de pesquisadores treinados para esse fim. Foram avaliadas as características gerais, o modo de morte (ressuscitação cardiopulmonar, morte encefálica, ordem de não reanimar, não oferta e retirada de suporte vital - esses três últimos agrupados em limitação de suporte de vida), o tempo de internação - hospitalar e na unidade de terapia intensiva pediátrica -, o plano de final de vida e a participação da família nessa decisão. Para as comparações, foram utilizados o teste t de Student, Mann Whitney, qui-quadrado, odds ratio e análise multivariada. RESULTADOS: Aproximadamente 53,3% dos óbitos receberam ressuscitação cardiopulmonar. A incidência de limitação de suporte de vida foi de 36,1%, havendo diferença significativa (p = 0,014) entre os hospitais (25 versus 54,3 e 45,5%). A forma de limitação de suporte de vida mais freqüente foi "ordem de não reanimar" (70%). Observou-se associação entre limitação de suporte de vida com presença de doença crônica (odds ratio = 8,2; IC95% = 3,2-21,3) e tempo de internação na unidade de terapia intensiva pediátrica > 24h (odds ratio = 4,4; IC95% = 1,6-11,8). A participação da família e dos comitês de ética no plano de final de vida foi inferior a 10%. CONCLUSÕES: A ressuscitação cardiopulmonar ainda é oferecida em uma freqüência maior do que a descrita nos países do hemisfério norte, enquanto que a limitação de suporte vital é realizada preferentemente através da ordem de não reanimar. Esses achados e a pequena participação da família refletem dificuldades em relação às decisões de final de vida enfrentadas por intensivistas do sul do Brasil.

OBJECTIVES: To describe causes of death and factors involved in the decision-making process related to life support limitation at three university-affiliated pediatric intensive care units in the south of Brazil. METHODS: A retrospective study was conducted, based on a review of the medical records of all deaths occurring during 2002 at three pediatric intensive care units in Porto Alegre. Three previously trained pediatric fellows from each service performed the study. Data were assessed relating to general case characteristics, causes of death (failed cardiopulmonary resuscitation, brain death, do-not-resuscitate orders, withholding or withdrawing life-sustaining treatment - the last three modes were classified as the life support limitation group), length of stay in hospital, end-of-life plans and the participation of patients' families and Ethics Committees. The Student t test, Mann Whitney, chi-square, odds ratio and multivariate analyses were used for comparisons. RESULTS: Close to 53.3% of fatal cases had received full cardiopulmonary resuscitation. The incidence of life support limitation was 36%, with statistical differences (p = 0.014) between the three hospitals (25 versus 54.3 and 45.5%, respectively). The most frequent form of life support limitation was a do-not-resuscitate order (70%). Life support limitation was associated with the presence of chronic disease (odds ratio = 8.2; 95%CI 3.2-21.3) and length stay in the pediatric intensive care unit (odds ratio = 4.4; 95%CI 1.6-11.8). The rate of involvement of families and Ethics Committees in the decision-making process was lesser than 10%. CONCLUSIONS: Cardiopulmonary resuscitation is offered more frequently than is observed in northern countries. In contrast, life support limitation is offered through do-not-resuscitate orders. These findings and the low participation of the families in the decision-making process reflect the difficulties to be overcome by those professionals who are responsible for handling critically ill children in southern Brazil.

OBJETIVO: Revisar as atuais estratégias de uso de analgésicos e sedativos em salas de emergência e em unidades de tratamento intensivo pediátrico. FONTES DOS DADOS: Revisão de bibliografia realizada na base de dados da Medline, além de capítulos de livros de terapia intensiva pediátrica e da experiência dos serviços dos autores. SÍNTESE DOS DADOS: Apesar de todos os avanços e pesquisas no campo da dor, o uso de sedativos e analgésicos em unidades intensivas pediátricas continua deficitário. A dor e o desconforto associados a situações de urgência, procedimentos invasivos e internações prolongadas ainda resultam em significativa morbidade aos pacientes pediátricos criticamente enfermos. A dificuldade de comunicação do paciente pediátrico com a equipe médica, a grande quantidade de procedimentos invasivos necessários à manutenção da vida, aliados à antiga premissa de que os mecanismos de dor não estão bem desenvolvidos nas crianças, fazem desse tema um desafio nas unidades de terapia intensiva pediátrica. Neste estudo, revisamos as drogas mais utilizadas no manejo da dor e sedação, apresentando novas opções terapêuticas mais largamente estudadas recentemente. CONCLUSÕES: Nos últimos dez anos, desenvolveu-se uma consciência mais crítica em relação à necessidade de promover um adequado alívio da dor e da ansiedade inerentes aos ambientes de emergência e de UTI, devendo ser esta uma prioridade no planejamento terapêutico de crianças extremamente doentes.

OBJECTIVE: To review the current strategies for use of sedatives and analgesics in emergency rooms and intensive care units. SOURCES OF DATA: Original data from our emergency rooms and intensive care units; Medline literature review focused on sedatives and analgesic drugs; textbooks. SUMMARY OF THE FINDINGS: Despite the advances in understanding pain in children, in many critical care units the misguided treatment of pain and anxiety still results in significant morbidity. Difficulties in communication, invasive procedures and the belief that children do not have sufficient neurologic development to process noxious sensations are still a challenge in intensive care units CONCLUSIONS: The last decade was marked by significant advances in understanding pediatric pain. Treating intensive care unit-related pain and anxiety has clear benefits which may influence the course of disease.