César A. Araújo-Neto

The role of respiratory viral infections among children hospitalized for community-acquired pneumonia in a developing country.

We report an investigation for 16 bacteria and viruses among 184 children hospitalized with pneumonia in Salvador, Brazil. Etiology was established in 144 (78%) cases. Viral, bacterial, and mixed infections were found in 110 (60%), 77 (42%), and 52 (28%) patients, respectively. Rhinovirus (21%) and Streptococcus pneumoniae (21%) were the most common pathogens. Our results demonstrate the importance of viral and pneumococcal infections among those patients.

Procalcitonin is useful in identifying bacteraemia among children with pneumonia.

Abstract Empirical antibiotic use is prescribed in managing children with pneumonia worldwide. We assessed the usefulness of procalcitonin (PCT) and interferon-alpha (IFN-α) in differentiating viral from bacterial pneumonia. Among 159 hospitalized children, pneumonia was diagnosed based on clinical complaints plus pulmonary infiltrate. Aetiology was investigated for 9 viruses and 4 atypical and 3 typical bacteria. PCT and IFN-α were measured in the serum sample collected on admission. Eight patients had bacteraemic infections, 38 had non-bacteraemic typical infections, and 19 patients had atypical bacterial infections. Viral and unknown aetiology was established in 57 (36%) and 34 (21%) cases, respectively. Three patients with bacterial infection without collected blood culture were excluded. IFN-α (IU/ml) was detectable in 20 (13%) cases. The difference among median PCT values of the bacteraemic (4.22; 1.56–7.56), non-bacteraemic typical bacterial (1.47; 0.24–4.07), atypical bacterial (0.18; 0.06–1.03) and only viral (0.65; 0.11–2.22) subgroups was significant (p = 0.02). PCT was ≥2 ng/ml in 52 (33%) cases. The presence of IFN-α was associated with PCT <2 ng/ml (90% vs. 64%, p = 0.02). The negative predictive value (95% confidence interval) of PCT ≥2 ng/ml was 95% (89–100%), 89% (78–100%), 93% (85–100%) for differentiation of bacteraemic from viral, atypical bacterial and non-bacteraemic typical bacterial infection, respectively, and 58% (49–68%) for differentiation between bacterial and viral infection. PCT may be useful in identifying bacteraemia among children hospitalized with community-acquired pneumonia. IFN-α was uncommonly detected.

Seasonal patterns of viral and bacterial infections among children hospitalized with community-acquired pneumonia in a tropical region

Abstract Community-acquired pneumonia (CAP) is a common cause of morbidity among children. Evidence on seasonality, especially on the frequency of viral and bacterial causative agents is scarce; such information may be useful in an era of changing climate conditions worldwide. To analyze the frequency of distinct infections, meteorological indicators and seasons in children hospitalized for CAP in Salvador, Brazil, nasopharyngeal aspirate and blood were collected from 184 patients aged <5 y over a 21-month period. Fourteen microbes were investigated and 144 (78%) cases had the aetiology established. Significant differences were found in air temperature between spring and summer (p = 0.02) or winter (p < 0.001), summer and fall (p = 0.007) or winter (p < 0.001), fall and winter (p = 0.002), and on precipitation between spring and fall (p = 0.01). Correlations were found between: overall viral infections and relative humidity (p = 0.006; r = 0.6) or precipitation (p = 0.03; r = 0.5), parainfluenza and precipitation (p = 0.02; r = −0.5), respiratory syncytial virus (RSV) and air temperature (p = 0.048; r = −0.4) or precipitation (p = 0.045; r = 0.4), adenovirus and precipitation (p = 0.02; r = 0.5), pneumococcus and air temperature (p = 0.04; r = −0.4), and Chlamydia trachomatis and relative humidity (p = 0.02; r = −0.5). The frequency of parainfluenza infection was highest during spring (32.1%; p = 0.005) and that of RSV infection was highest in the fall (36.4%; p < 0.001). Correlations at regular strength were found between several microbes and meteorological indicators. Parainfluenza and RSV presented marked seasonal patterns.

Reduced posterior corpus callosum area in suicidal and non-suicidal patients with bipolar disorder

BACKGROUND Impulsivity is a characteristic of bipolar disorder (BD) that can contribute to the risk for suicidal behavior. Evidence suggests that gray and white matter abnormalities are linked with impulsivity, but little is known about the association between corpus callosum (CC) and impulsivity in BD. We examined the CC area and impulsivity in euthymic bipolar I patients, with and without lifetime history of suicide attempts, and in healthy controls. METHODS Nineteen bipolar patients with a suicide attempt history (BP-S), 21 bipolar patients without suicide attempt history (BP-NS), and 22 healthy controls (HC) underwent clinical assessment by the Structured Clinical Interview with the DSM-IV axis I (SCID-I), the Barratt Impulsiveness Scale (BIS-11), and MRI scan. RESULTS No differences were observed for any CC subregion between BP-S and BP-NS groups. There was a significant reduction in the genu (p=0.04) and isthmus areas (p=0.01), in bipolar patients compared with HC. In the BP-S group, the BIS-11 total (p=0.01), attention (p=0.001) and non-planning (p=0.02) impulsivity scores were significantly higher than in the BP-NS and HC groups. LIMITATIONS These results cannot establish causality because of the cross-sectional nature of the study. CONCLUSION This report potentially provides evidence that a reduction in the CC area is present even in non-symptomatic bipolar patients, which may be evidence of a biological trait marker for BD. Furthermore, the study demonstrated that BP-S group had higher impulsivity even during euthymia, which points to a sustained association between lifetime history of suicide attempts and impulsivity in BD.

Severity of childhood community-acquired pneumonia and chest radiographic findings.

To assess if chest radiographic findings present on admission are associated with severity of childhood community‐acquired pneumonia (CAP), a total of 161 children hospitalized with pulmonary infiltrate were enrolled in the study; 48 (30%) patients were excluded because of presence of bilateral chest radiographic alterations (33; 20%) and presence of underlying diseases (15; 9%). According to WHO and BTS criteria, severe CAP was present in 57 (50%) and in 96 (85%) cases, respectively; 29 (26%) were aged less than 1 year. The median age (months) was 22 (mean 24 ± 14, range 2–58). Overall, radiographic finding was right‐sided in 77 (68%) cases and the upper lobe was compromised in 36 (32%) cases. By analyzing data stratified to age, the frequency of upper lobe involvement was significantly higher among severe cases (WHO criteria) only for those patients aged ≥1 year (13/35 [37%] vs. 7/45 [16%], P = 0.03, OR [95% CI] 3.2 [1.1–9.2]). The specificity and positive predictive value of upper lobe involvement for severity among the latter group of patients were 84% (95% CI 70–93%) and 65% (95% CI 41–84%), respectively. No association was found by using the BTS criteria. The admission chest radiography was useful to predict severity of children aged ≥1 year hospitalized with CAP. Pediatr Pulmonol. 2009; 44:249–252.

Simkania negevensis infection among Brazilian children hospitalized with community-acquired pneumonia

a convenient and usefully intermittent therapy, which the majority of individuals find acceptable. In our study we were concerned to identify a relatively large minority of individuals in whom the justification for pentamidine prophylaxis was not adequately documented or substantiated and this has led to a review of our procedures and a formalisation of our criteria for admission to the pentamidine clinic. The default rate on attendance for the clinic was worst in the HIV positive population and reflected the rather haphazard and chaotic lifestyles of some of these patients rather than any apparent difficulty in accessing the service for other reasons. The minimum cost of a single monthly appointment at the pentamidine clinic was £47.00, which compares with £2.81 for a one-month course of cotrimaxazole, 960 mg taken three times weekly. Thus pentamidine is an expensive alternative to the gold standard therapy. Highlighting this has been a trigger to initiating a review of reasons why patients are on pentamidine rather than alternative drugs. The identification of the proportions of patients coming from different disciplines has been of value in establishing payment pathways to support the service.

Amygdalar volume in borderline personality disorder with and without comorbid post-traumatic stress disorder: a meta-analysis.

INTRODUCTION Four studies have found a smaller amygdalar volume in patients with borderline personality disorder (BPD) relative to controls, whereas four other studies have found similar amygdalar volume in BPD patients relative to controls. This study aims to compare amygdalar volumes of BPD patients with controls, and also to compare BPD patients with and without post-traumatic stress disorder (PTSD) with controls in order to determine whether PTSD can explain the heterogeneity of findings. METHOD Systematic review and meta-analysis of magnetic resonance imaging studies that measured amygdalar volumes in BPD patients and healthy controls. FINDINGS A significant reduction of amygdalar volumes in BPD patients was confirmed (p < .001). However, data from the studies that discriminated BPD patients with and without PTSD indicated that amygdalar volumes were significantly smaller in BPD patients without PTSD relative to controls (left: p = .02; right: p = .05), but not in BPD patients with PTSD relative to controls (left: p = .08; right: p = .20). CONCLUSION This meta-analysis suggests that amygdalar volumes are reduced in patients with BPD. This pattern is confirmed in BPD patients without PTSD, but not in BPD patients with PTSD, raising the possibility that reduced amygdalar volume in BPD patients cannot be explained by comorbid PTSD.

The inter-observer variation of chest radiograph reading in acute lower respiratory tract infection among children†

This study assessed the inter‐observer agreement in the interpretation of several radiographic features in the chest radiographs (CXR) of 803 children aged 2–59 months with non‐severe acute lower respiratory tract infection (ALRI). Inclusion criteria comprised: report of respiratory complaints, detection of lower respiratory findings, and presence of pulmonary infiltrate on the CXR taken on admission and read by the pediatrician on duty. Data on demographic and clinical findings on admission were collected from children included in a clinical trial on the use of amoxicillin (ClinicalTrials.gov Identifier NCT01200706). CXR was later read by two independent pediatric radiologists blinded to clinical information and pneumonia was finally diagnosed if there was agreement on the presence of pulmonary infiltrate or pleural effusion. The kappa index (κ) of agreement was calculated. The radiologists agreed that 774 (96.4%) and 3 (0.4%) CXR were appropriate or inappropriate for reading, respectively, and that 222 (28.7%) and 459 (59.3%) CXR presented or did not present pneumonia. In intent to treat analysis, that is, considering the 803 enrolled patients, κ for the presence of pneumonia was 0.725 (95% CI: 0.675–0.775). The overall agreement was 78.7% (normal CXR [n = 385, 60.9%], pneumonia [n = 222, 35.1%], other radiological diagnosis [n = 22, 3.5%], inappropriate for reading [n = 3, 0.5%]). The most frequent radiological findings were alveolar infiltrate (33.2%) and consolidation (32.9%) by radiologist 1 and consolidation (28.3%) and alveolar infiltrate (19.3%) by radiologist 2. Concordance for consolidation was 86.7% (k = 0.683, 95%CI: 0.631–0.741). Agreement was good between two pediatric radiologists when diagnosis of pneumonia among children with non‐severe ALRI was compared. Pediatr Pulmonol. 2013; 48:464–469.

Association between bacterial infection and radiologically confirmed pneumonia among children.

Background: The role of chest radiograph (CXR) among children with community-acquired pneumonia is controversial. We aimed to assess if there is association between a specific etiology and radiologically confirmed pneumonia. Methods: This was a prospective cross-sectional study. Based on report of respiratory complaints and fever/difficulty breathing plus the detection of pulmonary infiltrate/pleural effusion on the CXR taken upon admission read by the pediatrician on duty, children <5-year-old hospitalized with community-acquired pneumonia were enrolled. On admission, clinical data and biological samples were collected to investigate 19 etiological agents (11 viruses and 8 bacteria). CXR taken upon admission was independently read by a pediatric radiologist blinded to clinical data. Results: The study group comprised 209 cases with evaluated CXR and establishment of a probable etiology. Radiologically confirmed pneumonia, normal CXR and other radiographic diagnoses were described for 165 (79.0%), 36 (17.2%) and 8 (3.8%) patients, respectively. Viral infection was significantly more common among patients without radiologically confirmed pneumonia (68.2% vs. 47.9%; P = 0.02), particularly among those with normal CXR (66.7% vs. 47.9%; P = 0.04) when compared with patients with radiologically confirmed pneumonia. Bacterial infection was more frequent among cases with radiologically confirmed pneumonia (52.1% vs. 31.8%; P = 0.02). Likewise, pneumococcal infection was more frequently detected among children with radiologically confirmed pneumonia in regard to children with normal CXR (24.2% vs. 8.3%; P = 0.04). Sensitivity (95% confidence interval) of radiologically confirmed pneumonia for pneumococcal infection was 93% (80–98%), and negative predictive value (95% confidence interval) of normal CXR for pneumococcal infection was 92% (77–98%). Conclusion: Bacterial infection, especially pneumococcal one, is associated with radiologically confirmed pneumonia.

Differences in Evolution of Children with Non-severe Acute Lower Respiratory Tract Infection With and Without Radiographically Diagnosed Pneumonia.

ObjectiveTo identify differences in the evolution of children with non-severe acute lower respiratory tract infection between those with and without radiographically diagnosed pneumonia.DesignProspective cohort study.SettingA public university pediatric hospital in Salvador, Northeast Brazil.PatientsChildren aged 2-59 months.MethodsBy active surveillance, the pneumonia cases were prospectively identified in a 2-year period. Each case was followed-up for changes in various clinical symptoms and signs. Demographic, clinical and radiographic data were recorded in standardized forms. Exclusion was due to antibiotic use in the previous 48 hours, signs of severe disease, refusal to give informed consent, underlying chronic illness, hospitalization in the previous 7 days or amoxicillin allergy. Chest X-ray (CXR) was later read by at least 2 independent pediatric radiologists.Main Outcome MeasuresRadiographic diagnosed pneumonia based on agreed detection of pulmonary infiltrate or pleural effusion in 2 assessments.ResultsA total of 382 patients receiving amoxicillin were studied, of whom, 372 (97.4%) had concordant radiographic diagnosis which was pneumonia (52%), normal CXR (41%) and others (7%). By multivariate analysis, age (OR=1.03; 95% CI: 1.02–1.05), disease ≥ 5days (OR = 1.04; 95% CI: 1.001-1.08), reduced pulmonary expansion (OR = 3.3; 95% CI: 1.4–8.0), absence of wheezing (OR = 0.5; 95% CI: 0.3–0.9), crackles on admission (OR = 2.0; 95% CI: 1.2–3.5), inability to drink on day 1 (OR = 4.2; 95% CI: 1.05–17.3), consolidation percussion sign (OR = 7.0; 95% CI: 1.5–32.3), tachypnea (OR = 2.0; 95% CI: 1.09–3.6) and fever (OR = 3.6; 95% CI: 1.4–9.4) on day 2 were independently associated with pneumonia. The highest positive predictive value was at the 2nd day of evolution for tachypnea (71.0%) and fever (81.1%).ConclusionPersistence of fever or tachypnea up to the second day of amoxicillin treatment is predictive of radiographically diagnosed pneumonia among children with non-severe lower respiratory tract diseases.