Cláudio Schvartsman

Evaluation of rapid sequence intubation in the pediatric emergency department

OBJECTIVES To describe the experience of the emergency department of a pediatric hospital with rapid sequence intubation (RSI) and to identify the factors associated with successful intubation. METHODS This prospective, observational, cross-sectional study conducted from July 2005 to December 2007 consisted of collection of data regarding tracheal intubations performed at the emergency department of Instituto da Criança of Hospital das Clínicas, School of Medicine, Universidade de São Paulo. Successful tracheal intubations were the ones performed at the first attempt. RESULTS One-hundred and seventeen tracheal intubations were performed; 80% of them were RSIs; 79% of patients had underlying diseases; acute respiratory failure was the cause of tracheal intubation in 40%; success rate was 39%; second-year pediatric resident physicians were responsible for 74% of tracheal intubations; positive pressure ventilation was performed in 74% of procedures, with less frequent use among patients who were successfully intubated (p = 0.002). Midazolam was the sedative used in 80% of procedures, and rocuronium was the neuromuscular blocker in 100%; complications of RSI were described in 80% of intubations, with decreased oxygen saturation being reported in 47% and lower decrease in those patients successfully intubated (p < 0.001); difficulties related to tracheal intubation were less frequent in the successful procedures (p < 0.001). CONCLUSION RSI is the method of choice for tracheal intubations performed in the emergency department (80%). In spite of the low success rate (39%) in the present study, RSI has proven to be a safe method, with a low incidence of severe complications. The success of tracheal intubation using RSI seems to be directly related to the preparation of the procedure and the health professionals experience. Thus, we conclude that further training of resident physicians and health professionals working in the emergency department is required.

Elevated C-reactive protein and spontaneous bacterial peritonitis in children with chronic liver disease and ascites.

Objectives: The aims of this study were to compare laboratory indices of spontaneous bacterial peritonitis (SBP) and noninfected ascites in children with chronic liver disease and to determine the infectious agents involved in SBP. Methods: The medical records of 90 children with chronic liver disease and ascites studied between January 2005 and August 2011 were reviewed for laboratory data of diagnostic significance in SBP. Standard laboratory tests included blood cell count, coagulation indices, liver and renal function tests, C-reactive protein (CRP), serum sodium concentration, serum albumin, and serum cultures. Ascitic fluid obtained from 152 paracentesis procedures was assayed for cytology, Gram stains, neutrophil counts, and bacteriological cultures. Results: The SBP group manifested significantly lower albumin levels and elevated CRP levels, prothrombin times, international normalized ratios, and leukocyte number (P < 0.05 in each case). CRP was shown to be an independent variable in the prediction of SBP. Values of serum creatinine, sodium concentration, urea, total bilirubin and differential leukocyte shift were comparable in SBP and noninfected ascites. Streptococcus pneumoniae was the most prevalent infectious agent in the ascitic fluid (44%). Conclusions: CRP may be useful in early detection and monitoring of SBP in children with liver disease.

Long‐Term Efficacy of Oxybutynin for Palmar and Plantar Hyperhidrosis in Children Younger than 14 Years

Oxybutynin for treating hyperhidrosis in children has been evaluated only in short‐term studies. We aimed to investigate the long‐term effects of oxybutynin in treating children with palmar and plantar hyperhidrosis who had not undergone surgery and who were monitored for at least 6 months (median 19.6 mos). A cohort of 97 patients was evaluated retrospectively, with particular attention to 59 children (ages 4–14 yrs) who were treated for longer than 6 months. Their quality of life (QOL) was evaluated using a validated clinical questionnaire before and after 6 weeks of pharmacologic therapy. A self‐assessment of hyperhidrosis was performed after 6 weeks and after the last consultation. By their final office visit, more than 91% of the children with hyperhidrosis treated with oxybutynin experienced moderate or great improvement in their level of sweating and 94.9% experienced improvement in QOL. More than 90% of children reported improvement of hyperhidrosis at other sites. Dry mouth was the most common side effect. Oxybutynin appears to be an effective treatment option for children with hyperhidrosis, and positive results are maintained over the long term (median 19.6 mos).

Parental smoking patterns and their association with wheezing in children.

OBJECTIVE: To investigate parental smoking patterns and their association with wheezing in children. METHODS: We performed a case-control study that included 105 children between 6 and 23 months of age who were divided into two groups: cases (children with 3 previous episodes of wheezing) and controls (healthy children without wheezing). The childrens exposure to cigarette smoking was estimated using a questionnaire completed by the mothers and by the childrens urinary cotinine levels. RESULTS: Based on both the questionnaire results and cotinine levels, exposure to cigarette smoking was higher in the households of cases in which the incidence of maternal smoking was significantly higher than that of paternal smoking. Children in this group were more affected by maternal smoking and by the total number of cigarettes smoked inside the house. Additionally, the questionnaire results indicated that the risk of wheezing was dose dependent. The presence of allergic components, such as atopic dermatitis and siblings with allergic rhinitis and asthma, greatly increased the odds ratio when wheezing was associated with cotinine levels. CONCLUSION: Children exposed to tobacco smoke have an increased risk of developing wheezing syndrome. This risk increases in association with the number of cigarettes smoked inside the house and the presence of other allergic components in the family.

Early-life weight and weight gain as predictors of obesity in Brazilian adolescents

OBJECTIVE: To test whether weight and the weight gain rate during different age periods are associated with being overweight/obese at 10 years of age. METHODS: A nested case-control study was performed in a clinical historic cohort that was selected based on medical records from the Albert Einstein Hospital Social Program in São Paulo, Brazil. A sample of 378 eutrophic and overweight/obese children was analyzed. RESULTS: After adjusting for birth weight and gestational age, the likelihood of being overweight/obese at 10 years of age was 4.04-fold greater when progressing from one quartile of weight gain to the immediately superior quartile in the first semester of life and 3.24-fold greater when this occurred from 2-5 years of age. A one-quartile change in weight gain in the first semester was associated with a 0.5 z-score increase in BMI at age 10. A robust independent effect of weight at age 5 confirmed that earlier weight gain was an important predictor. CONCLUSIONS: The amount of weight gain during the first 6 months of life and between 2 and 5 years of age and weight at age 5 were important predictors of overweight/obesity at 10 years of age.

High-fidelity simulation versus case-based discussion for teaching medical students in Brazil about pediatric emergencies

OBJECTIVE: To compare high-fidelity simulation with case-based discussion for teaching medical students about pediatric emergencies, as assessed by a knowledge post-test, a knowledge retention test and a survey of satisfaction with the method. METHODS: This was a non-randomized controlled study using a crossover design for the methods, as well as multiple-choice questionnaire tests and a satisfaction survey. Final-year medical students were allocated into two groups: group 1 participated in an anaphylaxis simulation and a discussion of a supraventricular tachycardia case, and conversely, group 2 participated in a discussion of an anaphylaxis case and a supraventricular tachycardia simulation. Students were tested on each theme at the end of their rotation (post-test) and 4–6 months later (retention test). RESULTS: Most students (108, or 66.3%) completed all of the tests. The mean scores for simulation versus case-based discussion were respectively 43.6% versus 46.6% for the anaphylaxis pre-test (p=0.42), 63.5% versus 67.8% for the post-test (p=0.13) and 61.5% versus 65.5% for the retention test (p=0.19). Additionally, the mean scores were respectively 33.9% versus 31.6% for the supraventricular tachycardia pre-test (p=0.44), 42.5% versus 47.7% for the post-test (p=0.09) and 41.5% versus 39.5% for the retention test (p=0.47). For both themes, there was improvement between the pre-test and the post-test (p<0.05), and no significant difference was observed between the post-test and the retention test (p>0.05). Moreover, the satisfaction survey revealed a preference for simulation (p<0.001). CONCLUSION: As a single intervention, simulation is not significantly different from case-based discussion in terms of acquisition and retention of knowledge but is superior in terms of student satisfaction.

Avaliação e transporte da criança traumatizada

OBJETIVO: Devido ao impacto determinado pelo trauma na populacao infanto-juvenil no que diz respeito a mortalidade, morbidade e consequencias sociais geradas, nossos objetivos concentram-se nas peculiaridades da avaliacao pre-hospitalar, em ambiente hospitalar e ainda durante o transporte do paciente traumatizado pediatrico. FONTES DE DADOS: Pesquisa eletronica realizada nas bases Cochrane para revisoes sistematicas e estudos controlados, MEDLINE e LILACS nos ultimos 5 anos e revisao de referencias anteriores em publicacoes significativas, utilizando as seguintes palavras-chave: trauma, trauma pediatrico, exame primario, exame secundario, atendimento hospitalar, transporte pre-hospitalar e inter-hospitalar. SINTESE DOS DADOS: Diferentes estrategias compoem a sistematizacao do atendimento de criancas e adolescentes traumatizados. Entretanto, quase todas comportam a necessidade de conhecer as particularidades da populacao a ser tratada, no que diz respeito a idade, ao processo de crescimento e desenvolvimento e, finalmente, compondo o atendimento com os recursos minimamente aceitaveis e disponiveis. CONCLUSOES: O principio de maior importância diz respeito a nao determinar lesao adicional. Mantendo a visao sistematica das diferentes peculiaridades quanto a abordagem das vias aereas, ventilacao, circulacao com controle de hemorragias, exame minineurologico e exposicao, alem do exame secundario, com o preparo do transporte pre-hospitalar e inter-hospitalar quando necessario, serao esperados melhores resultados.

First experience with multiple mini interview for medical school admission in Brazil: Does it work in a different cultural scenario?

Abstract Purpose: Evaluation of non-cognitive skills never has been used in Brazil. This study aims to evaluate Multiple Mini Interviews (MMI) in the admission process of a School of Medicine in São Paulo, Brazil. Methods: The population of the study comprised 240 applicants summoned for the interviews, and 96 raters. MMI contributed to 25% of the applicants’ final grade. Eight scenarios were created with the aim of evaluating different non-cognitive skills, each one had two raters. At the end of the interviews, the applicants and raters described their impressions about MMI. The reliability of the MMI was analyzed using the Theory of Generalization and Many-Facet Rasch Model (MFRM). Results: The G-study showed that the general reliability of the process was satisfactory (coefficient G = 0.743). The MMI grades were not affected by the raters’ profile, time of interview (p = 0.715), and randomization group (p = 0.353). The Rasch analysis showed that there was no misfitting effects or inconsistent stations or raters. A significant majority of the applicants (98%) and all the raters believed MMIs were important in selecting students with a more adequate profile to study medicine. Conclusions: The general reliability of the selection process was excellent, and it was fully accepted by the applicants and raters.

Higher burnout scores in paediatric residents are associated with increased brain activity during attentional functional magnetic resonance imaging task.

Burnout syndrome is common in healthcare workers. We evaluated its prevalence in paediatric residents and investigated its influence on cerebral function correlations, using functional magnetic resonance imaging (MRI), when they carried out an attentional paradigm.

Hypotonic solution decreases serum sodium in infants with moderate bronchiolitis

To investigate the influence of hypotonic parenteral hydration on serum and urinary sodium and osmolality in infants with moderate bronchiolitis.