Maria Virgínia Peixoto Dutra

Valores de predição da avaliação neurológica e ultra-sonográfica cerebral neonatal em relação ao desenvolvimento de prematuros de muito baixo peso

OBJETIVO: Verificar os valores de predicao de dois exames (neurologico e ultra-sonografico) realizados no periodo neonatal, em relacao ao desenvolvimento neuromotor e cognitivo de prematuros. METODO: Foram estudados 70 prematuros com peso de nascimento inferior a 1.500g. A media do peso de nascimento e idade gestacional foram, respectivamente, 1.185g (DP:180) e 32,2 semanas (DP:1,4). Foi realizada avaliacao neurologica pelo metodo de Dubowitz e Dubowitz e ultra-sonografia cerebral por volta de 40 semanas de idade corrigida. Apos a alta do bercario estas criancas foram acompanhadas no ambulatorio de seguimento. RESULTADOS: Com idade media de 21 meses (DP: 4,9) corrigidos para a prematuridade, 25,7% das criancas apresentaram comprometimento neuromotor, e 20,3%, alteracao cognitiva. O exame neurologico neonatal foi mais sensivel que especifico em relacao a alteracao neuromotora (sensibilidade:77,7%, especificidade:57,6%), e cognitiva (sensibilidade: 78,5%, especificidade: 56,4%), e apresentou baixo valor de predicao tanto para alteracao neuromotora (38,9%) quanto cognitiva (31,4%). A ultra-sonografia apresentou elevada especificidade tanto para o desenvolvimento neuromotor (92,3%) quanto cognitivo (89,1%). O valor preditivo da ultra-sonografia foi satisfatorio para anormalidades neuromotoras (69,2%), porem baixo para as alteracoes cognitivas (50,0%). CONCLUSAO: A associacao dos dois exames com resultados anormais apresentou valores de predicao mais elevados para as anormalidades nas duas areas do desenvolvimento.

Ultra-sonografia mamária: avaliação dos critérios ecográficos na diferenciação das lesões mamárias

OBJECTIVE: Breast cancer is one of the most important causes of death in women. The association of different diagnostic methods has been successfully employed as a means to enhance early diagnosis. In this scenario, the interventional and diagnostic breast ultrasound has played a significant role. This study has two main objectives: to identify echographic criteria related to benignancy and malignancy and to analyze echographic characteristics, evaluating their role as malignancy predictors. MATERIALS AND METHODS: Echographic morphological criteria adopted in the images description were: shape, limits, contour, echogenicity, echotexture, echotransmission, lesion orientation, and secondary signs. Validation was sought on 450 echographic images compared with follow-up and histopathological results. RESULTS: Main benignancy criteria were: well defined shape, regular contour, precise limits, lesions isoechoic to fatty tissue, homogeneous echotexture, and horizontal orientation. The criteria more typically related to malignancy were: ill-defined shape, irregular contour, partially precise limits, and hypoechogenicity. Contour irregularity has presented the greatest sensitivity (92.7%) as well as the highest negative predictive value (98.2%), while vertical orientation of the lesion has presented the greatest specificity (99.3%), and ill-defined shape, the highest positive predictive value (91.0%). CONCLUSION: The standardization of the method for characterization and description of breast ultrasound images has resulted in reports uniformization and optimization, allowing more appropriate therapeutic decisions.

Lung mechanics and high-resolution computed tomography of the chest in very low birth weight premature infants

CONTEXT Premature infant lung development may be affected by lung injuries during the first few weeks of life. Lung injuries have been associated with changes in lung mechanics. OBJECTIVE To evaluate an association between lung mechanics and lung structural alterations in very low birth weight infants (birth weight less than 1500 g). DESIGN A cross-sectional evaluation of pulmonary mechanics (lung compliance and lung resistance) and high resolution computed tomography of the chest at the time of discharge, in 86 very low birth weight infants born at Instituto Fernandes Figueira, a tertiary public healthcare institution in Rio de Janeiro, Brazil. Lung compliance and resistance were measured during quiet sleep. High resolution computed tomography was performed using Pro Speed-S equipment. MAIN MEASUREMENTS Statistical analysis was performed by means of variance analysis (ANOVA/Kruskal Wallis). The significance level was set at 0.05. RESULTS Abnormal values for both lung compliance and lung resistance were found in 34 babies (43%), whereas 20 (23.3%) had normal values for both lung compliance and lung resistance. The mean lung compliance and lung resistance for the group were respectively 1.30 ml/cm H2O/kg and 63.7 cm H2O/l/s. Lung alterations were found via high-resolution computed tomography in 62 (72%) infants. Most infants showed more than one abnormality, and these were described as ground glass opacity, parenchymal bands, atelectasis and bubble/cyst. The mean compliance values for infants with normal (1.49 ml/cm H2O/kg) high resolution computed tomography, 1 or 2 abnormalities (1.31 ml/cm H2O/kg) and 3 or more abnormalities (1.16 ml/cm H2O/kg) were significantly different (p=0.015). Our data were insufficient to find any association between lung resistance and the number of alterations via high-resolution computed tomography. CONCLUSION The results show high prevalence of lung functional and tomographic abnormalities in asymptomatic very low birth weight infants at the time of discharge. They also show an association between lung morphological and functional abnormalities.

Fatores associados à morbidade respiratória entre 12 e 36 meses de vida de crianças nascidas de muito baixo peso oriundas de uma UTI neonatal pública

The aim of this paper was to estimate respiratory morbidity and its determinants for premature infants aged 12 to 36 months. The population comprised 84 infants from a cohort of very low birth weight premature infants. The outcome was the respiratory morbidity incidence rate. The relationship between the independent variables and respiratory morbidity was estimated using a Poisson regression model. From 12 to 24 months of age, 56.3% of children had experienced at least one episode of respiratory disease. >From 24 to 36 months, 38.1% of children were affected. Variables significantly associated with respiratory morbidity were bronchopulmonary dysplasia (RR = 1.9; 95%CI: 1.2-2.9), abnormal lung compliance (RR = 1.6; 95%CI: 1.1-2.3), neonatal pneumonia (RR = 2.8; 95%CI: 1.9-4.0), patent ductus arteriosus (RR = 1.6; 95%CI: 1.1-2.5), and respiratory morbidity in the first year of life (RR = 1.7; 95%CI: 1.2-2.5). The incidence of respiratory morbidity remains high in this group of high-risk infants, which calls for regular follow-up and effective interventions to prevent respiratory disease and to improve the quality of life of these children and their families.

Neonatal risk factors for respiratory morbidity during the first year of life among premature infants

CONTEXT AND OBJECTIVE There have been dramatic increases in very low birth weight infant survival. However, respiratory morbidity remains problematic. The aim here was to verify associations between pulmonary mechanics, pulmonary structural abnormalities and respiratory morbidity during the first year of life. DESIGN AND SETTING Prospective cohort study at Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro. METHODS Premature infants with birth weight < 1500 g were studied. Lung function tests and high-resolution chest tomography were performed before discharge. During the first year, infants were assessed for respiratory morbidity (obstructive airways, pneumonia or hospitalization). Neonatal lung tests and chest tomography and covariables potentially associated with respiratory morbidity were independently assessed using relative risk (RR). RR was subsequently adjusted via logistic regression. RESULTS Ninety-seven newborn infants (mean birth weight: 1113 g; mean gestational age: 28 weeks) were assessed. Lung compliance and lung resistance were abnormal in 40% and 59%. Tomography abnormalities were found in 72%; respiratory morbidity in 53%. Bivariate analysis showed respiratory morbidity associated with: mechanical ventilation, prolonged oxygen use (beyond 28 days), oxygen use at 36 weeks, respiratory distress syndrome, neonatal pneumonia and patent ductus arteriosus. Multivariate analysis gave RR 2.7 (confidence interval: 0.7-10.0) for simultaneous lung compliance and chest tomography abnormalities. Adjusted RR for neonatal pneumonia and mechanical ventilation were greater. CONCLUSIONS Upon discharge, there were high rates of lung mechanism and tomography abnormalities. More than 50% presented respiratory morbidity during the first year. Neonatal pneumonia and mechanical ventilation use were statistically significant risk factors.

Associação entre ângulo de fase, PRISM I e gravidade da sepse

BACKGROUND AND OBJECTIVES: Phase angle (PA) is the difference between voltage and current and can be used as an indicator of body cell mass. Clinical studies show that low phase angle is associated with morbidity and mortality of critical patients. The purpose of this study was to know the relation between phase angle and the Pediatric Risk of Mortality I (PRISM I) score, associating this score with the severity of sepsis. METHODS: A transversal study was performed at the Pediatric Intensive Care Unit (PICU) in Instituto Fernandes Figueira. The patients were classified according to age, gender, sepsis severity, cause of respiratory failure, PRISM I score, multiple organ dysfunction syndromes (MODS). Electrical bioimpedance analysis (BIA) was performed in all patients. Phase angle was calculated directly from reactance (Xc) and resistance (R). AF = arc-tangent reactance/resistance x 180o/Pi. RESULTS: 75 patients (68 septic) were evaluated. The incidence of septic shock was 39.7%, severe sepsis 42.6% and sepsis 17.6%. There was no significative statistical difference between the mean values of BIA and the categories of PRISM I, MODS, or the length of stay the PICU. The PAs lowest values (1.5o-2.2o) were associated to the greatest PRISMs scores (> 30%). CONCLUSIONS: Pediatric critical patients show low phase angle values, which might have prognostic implication.

Noise measurement in NICUs and incubators with newborns: a systematic literature review

Se trata de una revision sistematica de la literatura para evaluar la calidad metodologica de los estudios que midieron el ruido en las unidades neonatales. Despues de buscar en las bases electronicas Medline, Scielo, Lilacs, BDENF, WHOLIS, BDTD, Science Direct, NCBI y Scirus, y de busca manual, fueron incluidos 40 estudios que atendieron el criterio “mensurar ruido en unidades neonatales y/o incubadoras”. El instrumento de analisis critico fue validado por expertos en neonatologia y acustica – nota media 7,9 (DE = 1,3) – y la confiabilidad interobservador en 18 articulos resulto en un ICC de 0,89 (IC95% 0,75-0,95). Los indicadores de calidad fueron 50% mejores para los estudios que midieron solamente en el ambiente de la unidad, asociando las estrategias de mensuracion al area fisica. Los resultados revelaron gran variabilidad metodologica, lo que dificulta la comparacion y algunas veces representa alta probabilidad de sesgo. El rigor necesario para garantizar la validez interna y externa fue observado en pocos estudios.

A computed tomography scoring system to assess pulmonary disease among premature infants

CONTEXT AND OBJECTIVE High-resolution computed tomography (HRCT) is considered to be the best method for detailed pulmonary evaluation. The aim here was to describe a scoring system based on abnormalities identified on HRCT among premature infants, and measure the predictive validity of the score in relation to respiratory morbidity during the first year of life. DESIGN AND SETTING Prospective cohort study in Instituto Fernandes Figueira, Fundação Oswaldo Cruz. METHODS Scoring system based on HRCT abnormalities among premature newborns. The affected lung area was quantified according to the number of compromised lobes, in addition to bilateral pulmonary involvement. Two radiologists applied the score to 86 HRCT scans. Intraobserver and interobserver agreement were analyzed. The score properties were calculated in relation to predictions of respiratory morbidity during the first year of life. RESULTS Most of the patients (85%) presented abnormalities on HRCT, and among these, 56.2% presented respiratory morbidity during the first year of life. Scores ranged from zero to 12. There was good agreement between observers (intraclass correlation coefficient, ICC = 0.86, confidence interval, CI: 0.64-0.83). The predictive scores were as follows: positive predictive value 81.8%, negative predictive value 56.3%, sensitivity 39.1%, and specificity 90.0%. CONCLUSION The scoring system is reproducible, easy to apply and allows HRCT comparisons among premature infants, by identifying patients with greater likelihood of respiratory morbidity during the first year of life. Its use will enable HRCT comparisons among premature infants with different risk factors for respiratory morbidity.

Mensuração de ruído sonoro em unidades neonatais e incubadoras com recém-nascidos: revisão sistemática de literatura

Se trata de una revision sistematica de la literatura para evaluar la calidad metodologica de los estudios que midieron el ruido en las unidades neonatales. Despues de buscar en las bases electronicas Medline, Scielo, Lilacs, BDENF, WHOLIS, BDTD, Science Direct, NCBI y Scirus, y de busca manual, fueron incluidos 40 estudios que atendieron el criterio “mensurar ruido en unidades neonatales y/o incubadoras”. El instrumento de analisis critico fue validado por expertos en neonatologia y acustica – nota media 7,9 (DE = 1,3) – y la confiabilidad interobservador en 18 articulos resulto en un ICC de 0,89 (IC95% 0,75-0,95). Los indicadores de calidad fueron 50% mejores para los estudios que midieron solamente en el ambiente de la unidad, asociando las estrategias de mensuracion al area fisica. Los resultados revelaron gran variabilidad metodologica, lo que dificulta la comparacion y algunas veces representa alta probabilidad de sesgo. El rigor necesario para garantizar la validez interna y externa fue observado en pocos estudios.

Uma proposta de classificação ecográfica mamária

OBJETIVOS: as melhorias tecnologicas na qualidade da imagem tem aumentado a importância da ultra-sonografia no estudo das patologias mamarias. A necessidade de padronizacao para caracterizar, descrever e emitir laudos na analise das imagens motivaram o desenvolvimento de um sistema de classificacao de laudos ecograficos mamarios. METODOS: o sistema de classificacao proposto agrupou as imagens ecograficas mamarias em cinco classes: I - normal, II - benigna, III -indeterminada, IV - suspeita, V - altamente suspeita. As caracteristicas morfologicas ecograficas utilizadas para a descricao das imagens foram: forma, limites, contorno, ecogenicidade, ecotextura, ecotransmissao, orientacao e sinais secundarios. O teste padrao, numa casuistica de 450 lesoes, foi considerado o seguimento ecografico das lesoes por periodo de 6 a 24 meses e a histopatologia da peca cirurgica nos casos operados. RESULTADOS: a classificacao ecografica mamaria para o diagnostico de câncer de mama apresentou sensibilidade de 90,2% (IC: 82,8-94,9%) e especificidade de 96,2% (IC: 94,0-97,6%) O valor preditivo positivo foi de 84,1% (IC: 76,0-89,9%) e o valor preditivo negativo foi de 97,8% (IC: 95,9-98,9%), alcancando acuracia de 95,1%. CONCLUSOES: a adocao do sistema de classificacao ecografica resulta na uniformidade e otimizacao dos laudos. Facilita ainda a comparacao com a clinica, com os exames histopatologicos e de imagem mamaria, evitando procedimentos desnecessarios, conduzindo a condutas terapeuticas mais adequadas