Paulo Sucasas Costa

A randomized, controlled, crossover trial of oral midazolam and hydroxyzine for pediatric dental sedation

The effectiveness of oral midazolam in pediatric dentistry is controversial. This randomized, controlled, crossover, double blind clinical trial was conducted in order to study the effect of midazolam, used either alone or in association with hydroxyzine, during child dental treatment. Thirty seven dental sedation sessions were carried out on 11 ASA I uncooperative children less than five years-old. In each appointment children were randomly assigned to groups: P - placebo, M - midazolam (1.0 mg/kg), or MH - midazolam (0.75 mg/kg) plus hydroxyzine (2.0 mg/kg). Vital signs (blood pressure, breathing rate, pulse and oxygen saturation) and behavior parameters (consciousness, crying, movement, overall behavior) were evaluated every 15 minutes. Friedman and Wilcoxon statistical tests were used to compare groups and different moments in the same group. Normal values of vital signs were usually registered. Heart rate increased in groups P and M as the session went on. Group M presented less crying and movement at the first 15 minutes of treatment. Group MH caused more drowsiness at the beginning of the session. Overall behavior was better in group M than in groups P or MH. Group M produced effective sedation in 77% of the cases, and group MH did so in 30.8%. It was concluded that midazolam was effective and safe, and its association with hydroxyzine did not lead to additional advantages in pediatric dental sedation.

Rotavirus Gastroenteritis in Children in 4 Regions in Brazil: A Hospital-Based Surveillance Study

BACKGROUND Rotavirus is a major cause of gastroenteritis in children. Knowledge of rotavirus genotypes is important for vaccination strategies. METHODS During 2005-2006, rotavirus surveillance studies were conducted in São Paulo, Salvador, Goiânia, and Porto Alegre, Brazil. Stool samples were collected from children <5 years of age who had diarrhea and were screened by the Rotaclone Enzyme Immunoassay for the presence of rotavirus. Confirmed rotavirus-positive samples were characterized for P and G genotypes by reverse-transcriptase polymerase chain reaction. RESULTS A total of 510 stool samples were collected. Of these, 221 (43.3%) were positive for rotavirus. Overall, G9 was the predominant G type, followed by G2, and G1; P[4] and P[8] were the predominant P types. The most frequent G/P genotype combination detected was G2P[4], followed by G9P[8], G9P[4], and G1P[8]. G2P[4] was the predominant type in Goiânia and Salvador; G9P[8] and G1P[8] were predominant in São Paulo and Porto Alegre, respectively. CONCLUSIONS The prevalence, seasonality, and genotype distribution of rotavirus infection varied in different regions in Brazil. With immunization programs, continuous monitoring of rotavirus types is important to detect novel and emerging strains.

Detection of calicivirus from fecal samples from children with acute gastroenteritis in the West Central region of Brazil

The objective of this study was to describe the circulation of caliciviruses in the West Central region of Brazil and its correlation with childrens gender and age, as well as with the year and months of the sample collection. Reverse transcriptase-polymerase chain reaction was performed to detect the human calicivirus genome in 1006 fecal samples that were collected in Goiânia (n = 696) and Brasília (n = 310). Viral RNA was detected in 8.6% of the samples. No significant difference in viral prevalence was found regarding gender, age or year of the sample. However, it was observed that in Goiânia, there is a higher incidence of caliciviruses from September to March. The analysis employing three primer pairs demonstrated that the Ni/E3 or JV12/13 primer pairs, which detect norovirus (NoV), detected 41 positive samples while the 289/290 primer pair, which detects NoV or sapovirus, detected the remaining 46 samples. Calicivirus circulates in the West Central region of Brazil and for better detection of this virus it is important to use more than one primer pair. Also, we conclude that the seasonality presented by this virus is related to higher humidity in the period.

Rotavirus A infections and reinfections: genotyping and vaccine implications.

OBJETIVOS: Identificar Rotavirus A em criancas com diarreia aguda, determinando os genotipos G e P prevalentes e avaliar a ocorrencia de infeccoes e reinfeccoes por rotavirus do grupo A em criancas. METODOS: Foram estudadas, prospectivamente, criancas com doenca diarreica aguda e identificacao de Rotavirus A em Goiânia (GO), durante o periodo de julho de 2000 a outubro de 2002. Igual numero de criancas, pareadas por idade e sexo, que nao apresentavam diarreia aguda e sem identificacao de rotavirus nas amostras fecais a admissao ao estudo, representou o grupo controle. Foram analisadas a ocorrencia de infeccoes ou reinfeccoes sintomaticas ou assintomaticas por rotavirus durante o periodo de estudo, durante um ano de seguimento em ambos os grupos. Todas as amostras positivas foram submetidas a genotipagem G e P atraves das reacoes de RT-PCR e Nested PCR. RESULTADOS: A infeccao por rotavirus ocorreu em 37,2% (77 de 207 amostras fecais) das criancas com diarreia aguda durante o periodo do estudo. Os genotipos G e P identificados foram, simultaneamente: G1 (62,3%), G9 (34,4%) e G4 (3,3%) e P[8] (59%), P[6] (7,7%), P[6]+P[8] (23,1%), P[4]+P[8] (7,7%) e P[4]+P[6] (2,6%). As associacoes de genotipos G e P identificados durante o estudo foram: G1P[8] (77,8%), G9P[8] (11,1%), G4P[8] (5,6%) e G1P[6] (5,6%). Nao houve reinfeccao por rotavirus nos pacientes do grupo Rotavirus A (+) durante o periodo de seguimento, enquanto duas criancas do grupo controle apresentaram infeccoes sintomaticas por rotavirus durante o mesmo periodo. CONCLUSOES: Os genotipos G e P predominantes correspondem aos das candidatas atuais a vacina contra rotavirus. Nao houve reinfeccao por rotavirus pelo periodo de um ano em relacao a todos os genotipos identificados.

A randomized double-blinded trial of chloral hydrate with or without hydroxyzine versus placebo for pediatric dental sedation

Chloral hydrate and hydroxyzine are a drug combination frequently used by practitioners to sedate pediatric dental patients, but their effectiveness has not been compared to a negative control group in humans. The aim of this crossover, double-blinded study was to evaluate the effect of these drugs compared to a placebo, administered to young children for dental treatment. Thirty-five dental sedation sessions were carried out on 12 uncooperative ASA I children aged less than 5 years old. In each session patients were randomly assigned to groups P (placebo), CH (chloral hydrate 75 mg/kg) and CHH (chloral hydrate 50 mg/kg plus hydroxyzine 2.0 mg/kg). Vital signs and behavioral variables were evaluated every 15 min. Comparisons were statistically analyzed using Friedman and Wilcoxon tests. P, CH and CHH had no differences concerning vital signs, except for breathing rate. All vital signs were in the normal range. CH and CHH promoted more sleep in the first 30 min of treatment. Overall behavior was better in CH and CHH than in P. CH, CHH and P were effective in 62.5%, 61.5% and 11.1% of the cases, respectively. Chloral hydrate was safe and relatively effective, causing more satisfactory behavioral and physiological outcomes than a placebo.

Combined oral midazolam–ketamine better than midazolam alone for sedation of young children: a randomized controlled trial

BACKGROUND.  There is a lack of clinical trials on paediatric dental sedation. AIM.  We investigated whether young childrens behaviour improves during dental treatment with oral ketamine/midazolam compared with midazolam alone or no sedation. DESIGN.  Healthy children under 36 months of age, presenting early childhood caries were randomly assigned to receive protective stabilization plus: combined oral midazolam (0.5 mg/kg) and ketamine (3 mg/kg) (MK), or oral midazolam (1.0 mg/kg) (MS), or no sedative (PS). One observer scored childrens behaviour using the Ohio State University Behavior Rating Scale (OSUBRS) at determined points in a dental exam (no sedative) and treatment session. Data were analysed using nonparametric bivariate tests. RESULTS.  Forty-one children were included. In the dental exam session, the sum of OSUBRS scores was similar for the three groups (P = 0.81). In the treatment session, the MK produced more cooperative behaviour than MS and PS (P = 0.01), longer sessions (P = 0.04), and a pattern of homogeneous OSUBRS scores from the reception area (before sedative administration) to the end of the session (P = 0.06). No immediate and post-discharge side effects were observed in groups MK and MS. CONCLUSIONS.  The combination of oral midazolam and ketamine is efficacious for guiding the behaviour of children under 3 years old.

Post-discharge adverse events following pediatric sedation with high doses of oral medication.

OBJECTIVE To compare the occurrence of post-discharge adverse events in children having received a high dose of either chloral hydrate (CH) or midazolam (MZ) during outpatient dental treatment. STUDY DESIGN A repeated-measures study design was carried out with 42 children treated at a sedation center. The sample comprised 103 dental sedation sessions among 22 male and 20 female patients, 1-8 years old, receiving either MZ (1.0-1.5 mg/kg) or CH (70.0-100.0 mg/kg). During treatment, a single observer recorded intraoperative adverse events. Twenty-four hours later, the observer called the childs main caregiver seeking information on further adverse events. Data analysis involved descriptive and bivariate statistics and the general estimating equation for repeated measures. RESULTS The most common intraoperative and post-discharge adverse events were hallucination (3.9%) and excessive sleep (41.9%), respectively. The chance of the occurrence of an adverse event following oral pediatric sedation was lesser among the children who received MZ than those who received CH (OR: 0.09; 95% CI: 0.01-0.88). CONCLUSIONS High doses of CH were associated with post-discharge adverse events in children having undergone pediatric dental sedation, whereas high doses of MZ were not associated with these events in pediatric patients.

Molecular characterization of the NSP4 gene of human group A rotavirus samples from the West Central region of Brazil

Nonstructural protein 4 (NSP4), encoded by group A rotavirus genome segment 10, is a multifunctional protein and the first recognized virus-encoded enterotoxin. The NSP4 gene has been sequenced, and five distinct genetic groups have been described: genotypes A-E. NSP4 genotypes A, B, and C have been detected in humans. In this study, the NSP4-encoding gene of human rotavirus strains of different G and P genotypes collected from children between 1987 and 2003 in three cities of West Central region of Brazil was characterized. NSP4 gene of 153 rotavirus-positive fecal samples was amplified by reverse transcriptase-polymerase chain reaction and then sequenced. For phylogenetic analysis, NSP4 nucleotide sequences of these samples were compared to nucleotide sequences of reference strains available in GenBank. Two distinct NSP4 genotypes could be identified: 141 (92.2%) sequences clustered with NSP4 genotype B, and 12 sequences (7.8%) clustered with NSP4 genotype A. These results reinforce that further investigations are needed to assess the validity of NSP4 as a suitable target for epidemiologic surveillance of rotavirus infections and vaccine development.

Exacerbation of asthma and airway infection: is the virus the villain?

Abstract Objective To review the available literature on the association between acute viral respiratory tract infection and the onset of asthma exacerbations, identifying the most prevalent viruses, detection methods, as well as preventive and therapeutic aspects. Sources A search was conducted in PubMed, Lilacs, and SciELO databases, between the years 2002 and 2013, using the following descriptors: asthma exacerbation, virus, child, and acute respiratory infection. Summary of the findings A total of 42 original articles addressing the identification of respiratory viruses during episodes of asthma exacerbation were selected, mostly cross-sectional studies. There was a wide variation in the methodology of the assessed studies, particularly in relation to the childrens age and methods of collection and viral detection. The results indicate that, in up to 92.2% of exacerbations, a viral agent was potentially the main triggering factor, and human rhinovirus was the most frequently identified factor. The pattern of viral circulation may have been responsible for the seasonality of exacerbations. The association between viral infections and allergic inflammation appears to be crucial for the clinical and functional uncontrolled asthma, but few studies have evaluated other triggering factors in association with viral infection. Conclusions Respiratory viruses are present in the majority of asthmatic children during episodes of exacerbation. The involved physiopathological mechanisms are yet to be fully established, and the synergism between allergic inflammation and viral infection appears to determine uncontrolled disease. The role of other triggering and protective agents is yet to be clearly determined.

Astrovirus infection in children living in the Central West region of Brazil

This study presents data regarding the circulation of astrovirus in Goiânia-GO and Brasília-DF. These viruses were detected in fecal samples from hospitalized children up to five years old with and without acute gastroenteritis. A total of 1244 fecal samples were collected in two periods, 1994 to 1996 (Brasília) and 1998 to 2002 (Goiânia and Brasília), and were analyzed for viral RNA using the reverse transcription-polymerase chain reaction (RT-PCR). Positivity rates of 4.3 and 0.5% for astrovirus were observed in children with acute gastroenteritis and those without gastroenteritis, respectively. Among children with gastroenteritis no statistically significant difference was seen with regards to viral positivity rates in relation to gender and age. However, a higher incidence rate was observed for children from Brasília aged 36 months or more. Overall, astroviruses occurred predominantly from September to March in the two cities, suggesting a seasonal pattern for these viruses which coincides with the highest relative air humidity period. The results of this study highlight the importance of astrovirus as an etiologic agent of acute gastroenteritis in children of the Central West region of Brazil.