Danilo Blank

A puericultura hoje: um enfoque apoiado em evidências

OBJETIVO: a promocao da saude e atividade essencial do pediatra, mas ainda pouco fundamentada em evidencias cientificas. Este artigo estuda o apoio cientifico para as principais intervencoes preventivas, quando, como e quem deve realiza-las. FONTES DOS DADOS: revisao sistematica da literatura recente, por meio de busca nos bancos de dados Medline e Lilacs, usando as palavras puericultura, supervisao de saude e promocao de saude (em ingles e portugues); revisao nao sistematica das referencias bibliograficas de capitulos de livros; busca nao sistematica na Internet de organizacoes que emitem recomendacoes sobre supervisao de saude; e selecao de artigos classicos na area. SINTESE DOS DADOS: o pediatra deve integrar-se com outros profissionais na prestacao de servicos preventivos, bem como estabelecer parcerias efetivas com todos os setores da comunidade. E essencial aprimorar as habilidades em comunicacao. O numero ideal de consultas de supervisao de saude nunca foi estabelecido; os procedimentos devem ser adaptados individualmente, segundo fatores de risco contextuais familiares e comunitarios. Ha documentacao cientifica da efetividade de consulta pre-natal, orientacao preventiva, triagem metabolica, imunizacao, triagem de visao e audicao. A monitorizacao do crescimento e a triagem do desenvolvimento tem que ser racionalizadas. A repeticao sistematica do exame fisico completo e de exames de laboratorio nao esta justificada. CONCLUSOES: o pediatra tem um papel fundamental na promocao de saude da crianca e do adolescente, mas suas acoes na area da puericultura nao devem mais ser totalmente empiricas. Ha inumeros recursos, apoiados em evidencias cientificas, para guia-lo quanto aos procedimentos mais efetivos.

Controle de injúrias sob a ótica da pediatria contextual

OBJECTIVE: To describe the relationship between injury control and contextual pediatrics. SOURCES OF DATA: Quasi-systematic review of MEDLINE, SciELO and LILACS databases, using combinations of the words contextual, community, injury, accident and violence; and non-systematic review of book chapters and classic articles. SUMMARY OF THE FINDINGS: Safety depends on the interaction of family habits, cultural patterns and surroundings. Contextual pediatrics sees the child, the family, and the community as a continuum; health diagnosis (sequential observation of problems and assets) is one of its cornerstones. Changing intrapersonal factors for injuries requires the use of both passive and active strategies. Family and cultural risk factors for injury: home overcrowding, moving, poverty, and young, illiterate and unemployed parents. The main neighborhood factors: material deprivation and traffic. Cultural factors: illiteracy, unsafe products, lack of mass transportation, handguns, workplaces without safety rules, faulty community organization, lack of communication between social sectors, inadequate legislation, low priority for safety among government actions, lack of economic resources, and low academic commitment with the field of safety. CONCLUSIONS: The pediatricians roles include strengthening of the longitudinal relationship with families, integrated interdisciplinary work, constructive intervention, partnership with community, counseling on injury risks pertaining to each developmental stage, by using lists with explicit processes and contents, and by handing out written materials. Active advocacy for safety promotion in different environments, besides the clinical setting.

A propósito de cenários e atores: de que peça estamos falando? Uma luz diferente sobre o cenário da prática dos médicos em formação

O medico moderno precisa agucar seus atributos humanos, adaptar-se a contextos variados e manter a educacao permanente. A formacao medica nao costuma ocorrer no contexto da pratica clinica real, mas no hospital, com enfase na doenca. As Diretrizes Curriculares Nacionais dos Cursos de Graduacao em Medicina preconizam a articulacao entre a universidade e o sistema de saude e a habilitacao a educacao permanente. Logo, os cenarios da pratica devem ser os ambulatorios proprios dos servicos de saude, com um aprendizado voltado para as necessidades de saude da comunidade. Existe hoje um fortalecimento da Medicina Clinica Academica, que combina cuidados de saude com pesquisa, ensino e administracao. O aluno deve assimilar a visao moderna da relacao medico-paciente, respeitando as decisoes compartilhadas, tarefa que exige trabalhar habilidades em comunicacao. As instituicoes de ensino e de assistencia a saude sao coadjuvantes neste processo, bem como os meios de comunicacao. A insercao no cenario da pratica medica tem que ser integrada a todas as disciplinas do curso, permeando o curriculo e permitindo que o estudante volte sua atencao para as necessidades de saude da comunidade. Estabelecer um curriculo inovador exige que os educadores compreendam o esgotamento do modelo tradicional de ensino, fundamentado na doenca e na transmissao de conhecimentos, que afasta o aluno da visao pratica da Medicina. O enfoque pedagogico moderno enfatiza aspectos formativos. Seus principais dominios sao: comportamento do paciente, atitude e papel do medico, interacoes medico-paciente e fatores socioculturais relativos aos cuidados com a saude.

Brazilian knowledge production in the field of child and adolescent health

OBJECTIVES To assess (a) the trend of MEDLINE citation of pediatrics articles associated with Brazilian institutions from 1990 through 2004; (b) the number of Brazilian pediatrics articles published in journals with the highest impact factor; and (c) the regional distribution of institutions. METHODS PubMed search limited to ages 0 to 18 years, English language, MEDLINE and humans subsets, Brazilian affiliation. For each year, we compared the articles retrieved to the whole of MEDLINE citations with the same search limits, except for affiliation, as well as to the total Brazilian scientific production cited in MEDLINE, without age limits. We made a descriptive analysis, and used the chi-square test for trend. Data concerning publication in journals with the highest impact factor were aggregated into three-year periods. RESULTS A total of 7,222 Brazilian pediatrics articles were listed in MEDLINE from 1990 through 2004, corresponding to 0.95% of all articles concerning the age group from 0 to 18 years. There was a fivefold increase in the absolute number of Brazilian articles along the study period. The ratio of Brazilian to total articles increased from 0.51 to 1.60% (p < 0.01). Scientific knowledge production remains strongly concentrated in the Southeast of Brazil. CONCLUSION Brazilian research activities in pediatrics have had a steady upward trend, which relates to the proportional growth of the Brazilian scientific production as a whole.

Pursuing efficiency : international visibility of the scientific production of Brazilian graduate programs in child and adolescent health from 1998 through 2003

OBJECTIVE To assess the trend in the number of published articles by Brazilian graduate programs in child and adolescent health and the proportion of such publications cited in MEDLINE and Thomson Scientifics Journal Citation Reports (JCR), using the former database as a proxy for efficiency and the latter as an indicator of visibility. METHODS We assessed the trends of 14 graduate programs concerning the number of theses, dissertations, and articles cited in MEDLINE and JCR, through secondary data from the latest two triennial evaluations carried out by the Brazilian Federal Agency for the Improvement of Higher Education (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) between 1998 and 2000 and between 2001 and 2003). RESULTS The number of published articles increased (1,520 to 1,917), as did the median number of articles cited both in MEDLINE (32.5 to 45) and in JCR (24.5 to 27). The median number of dissertations rose from 19.5 to 26.5; the median number of theses went up from 12 to 13.5. The median number of faculty advisors decreased (21.5 to 18.4). CONCLUSION Graduate programs in child and adolescent health became more efficient in producing knowledge through the publication of more articles with broader international visibility. Such trend was contradictorily accompanied by a diminishing number of advisors.

Injury control in South America: the art and science of disentanglement.

Injury control in a vast number of the American people remains in the 20th century while the injury pandemic shows a 21st century face While musing upon the request to write an indigenous pediatrician’s perspective of the state of play of injury control in South America, particularly as to why matters remain at a rather primitive level and what could be done to move things along, I was struck by this news item: a newspaper in my hometown in southern Brazil reported that a unidentified motorcyclist had fired two gunshots at a brand new mobile speed camera. This camera had replaced a similar one that had been destroyed a month before by two enraged characters armed with iron bars.w1 w2 This seemingly simple account actually offers insights into a variety of issues: undue weapon carrying, speeding vehicles, novel traffic calming strategies, newish high tech devices, meager safety knowledge discrimination, sheer public unawareness, violence at-large, and—of course—a middle income developing country with mostly inconsistent and inequitable public health priorities. Does this sound too entangled for the ordinary reader’s liking? Well, bienvenido a Sudamerica! The injury problem in South America, as worrisome as in the rest of the world, bears some specific circumstances that are worthy of attention. First, up to 29 years, injuries account for nearly six million disability adjusted years of life lost each year—around 17% of the burden of disease.1 This means we face a graver public health problem than most. Second, although the region is by and large free from wars, interpersonal violence has been a frighteningly growing cause of death and disablement from the age of 5 through adolescence.1–3 Figure 1 shows death rates associated with the main causes of injury in selected countries. While homicide rates may be quite similar to those …

The challenges and consolidation of a scientific journal

1. Editor do Jornal de Pediatria. 2. Editores associados do Jornal de Pediatria. 3. Membro do Conselho Editorial do Jornal de Pediatria. Existem atualmente cerca de vinte mil revistas médicas no mundo e, mesmo assim, este é um mercado ainda em expansão. Trata-se de um mercado exigente, competitivo e pouco tolerante ou complacente com equívocos. Isto explica o surgimento e também a saída de circulação de revistas médicas a cada mês. Mas que mercado é este? Quais são as regras que o regulamentam? Quais são seus componentes? Os clientes de uma revista médica estão distribuídos em pelo menos três grupos: os leitores, os colaboradores e os patrocinadores. Conquistar e harmonizar os interesses destes grupos permite que uma revista científica torne-se respeitada, lida e auto-sustentável. O desequilíbrio conseqüente ao predomínio dos interesses de um destes grupos sobre os demais poderá acarretar problemas tais como: elitização, perda de credibilidade, dúvidas quanto à isenção e falta de impacto. Atingir tal equilíbrio é o grande desafio para a estabilidade e o crescimento de uma revista científica. Inicialmente, o corpo editorial precisa descobrir e atrair seus clientes. No caso do Jornal de Pediatria, devemos intuir (antever, imaginar) os interesses dos quase 15.000 assinantes, para que se tornem realmente leitores. Ao mesmo tempo, obter o reconhecimento e nos tornarmos atraentes para que os pesquisadores dos mais diversos centros de pesquisa do país veiculem preferentemente seus trabalhos em nossa revista. Por outro lado, precisamos viabilizar o custo de produção e distribuição, que se tem mantido constante nos últimos anos: ao redor de quarenta mil dólares americanos por tiragem; o que significa mais de trezentos mil dólares anuais (seis números regulares e dois suplementos). Para que tenhamos uma qualidade editorial mantida, este aporte financeiro é vital. Identificados os componentes (clientes), como avaliar sua satisfação? Quais os marcadores para verificar seu interesse e a qualidade do produto oferecido? Os desafios e a afirmação de uma revista científica

Injury control from the perspective of contextual pediatrics

OBJECTIVE To describe the relationship between injury control and contextual pediatrics. SOURCES OF DATA Quasi-systematic review of MEDLINE, SciELO and LILACS databases, using combinations of the words contextual, community, injury, accident and violence; and non-systematic review of book chapters and classic articles. SUMMARY OF THE FINDINGS Safety depends on the interaction of family habits, cultural patterns and surroundings. Contextual pediatrics sees the child, the family, and the community as a continuum; health diagnosis (sequential observation of problems and assets) is one of its cornerstones. Changing intrapersonal factors for injuries requires the use of both passive and active strategies. Family and cultural risk factors for injury: home overcrowding, moving, poverty, and young, illiterate and unemployed parents. The main neighborhood factors: material deprivation and traffic. Cultural factors: illiteracy, unsafe products, lack of mass transportation, handguns, workplaces without safety rules, faulty community organization, lack of communication between social sectors, inadequate legislation, low priority for safety among government actions, lack of economic resources, and low academic commitment with the field of safety. CONCLUSIONS The pediatricians roles include strengthening of the longitudinal relationship with families, integrated interdisciplinary work, constructive intervention, partnership with community, counseling on injury risks pertaining to each developmental stage, by using lists with explicit processes and contents, and by handing out written materials. Active advocacy for safety promotion in different environments, besides the clinical setting.

Injury prevention and control: will we or will we not step out of the twentieth century?

Firstly, we should draw attention to the blatant mismatch between the importance of the topic - from the point of view of the morbidity/mortality of children and adolescents - and the scarcity of studies dedicated to it. We should all pause to consider two important and detailed documents, published recently by the WHO and UNICEF, that reiterate what many people appear not to wish to see: that injuries are an enormous public health problem for children and adolescents(2,3). Table 1, based on data from WHO, speaks for itself: in the poorer countries of the Americas, external causes are responsible for 53% of the total burden of the 10 principal diseases among children from five to 14 years of age. Even including the first years of life, with all their peculiarities, the significance of injuries is remarkable. The UNICEF report, which is restricted to mortality, points out that 98% of child and adolescent deaths caused by injuries occur in developing countries, and highlights the following risk factors: poverty, young single mothers, mothers with low level of education, poor housing, large families, and use of alcohol and drugs by the parents(2). Further, according to The Global Burden of Disease report (a milestone in defining injury as a public health priority), external causes represent 15% of the global burden of death and disability, the Third World paying twice the toll. Furthermore, such rate is predicted to increase by 20% in the next 20 years. This is, therefore, very much our problem, and one which, despite all the bad forecasts, we continue to underestimate.... Language: pt

Kids in the back seat: Brazil's strides in enforcing its new traffic law

Editor,—Primary care pediatricians like myself, who are often asked to lecture on child and adolescent auto safety promotion to both peers and lay people, naturally have their attention drawn to studies like the one so meticulously devised and carried out by Braver et al for the solid information they provide.1 This article provides very useful data demonstrating, among other issues of interest, the lower risk of children in the rear seat sustaining injuries, whether or not the car is equipped with a passenger-side airbag, even though a greater risk reduction could be demonstrated for vehicles having such a device. This particularly concerns us, safety promoters of the so-called less industrialized counties, …