Crowding: risk factor or protective factor for lower respiratory disease in young children?

Abstract Background To study the effects of household crowding upon the respiratory health of young children living in the city of São Paulo, Brazil. Methods Case-control study with children aged from 2 to 59 months living within the boundaries of the city of São Paulo. Cases were children recruited from 5 public hospitals in central São Paulo with an acute episode of lower respiratory disease. Children were classified into the following diagnostic categories: acute bronchitis, acute bronchiolitis, pneumonia, asthma, post-bronchiolitis wheezing and wheezing of uncertain aetiology. One control, crudely matched to each case with regard to age (<2, 2 years old or more), was selected among healthy children living in the neighborhood of the case. All buildings were surveyed for the presence of environmental contaminants, type of construction and building material. Plans of all homes, including measurements of floor area, height of walls, windows and solar orientation, was performed. Data were analysed using conditional logistic regression. Results A total of 313 pairs of children were studied. Over 70% of the cases had a primary or an associated diagnosis of a wheezing illness. Compared with controls, cases tended to live in smaller houses with less adequate sewage disposal. Cases and controls were similar with respect to the number of people and the number of children under five living in the household, as well the number of people sharing the child's bedroom. After controlling for potential confounders, no evidence of an association between number of persons sharing the child's bedroom and lower respiratory disease was identified when all cases were compared with their controls. However, when two categories of cases were distinguished (infections, asthma) and each category compared separately with their controls, crowding appeared to be associated with a 60% reduction in the incidence of asthma but with 2 1/2-fold increase in the incidence of lower respiratory tract infections (p = 0.001). Conclusion Our findings suggest that household crowding places young children at risk of acute lower respiratory infection but may protect against asthma. This result is consistent with the hygiene hypothesis.

Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial

Abstract Introduction Noninvasive ventilation (NIV), as a weaning-facilitating strategy in predominantly chronic obstructive pulmonary disease (COPD) mechanically ventilated patients, is associated with reduced ventilator-associated pneumonia, total duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay, and mortality. However, this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be elucidated. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask (OM) in patients with acute respiratory failure (ARF). Methods A randomized, prospective, controlled, unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period. Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure, after following the ICU weaning protocol. Patients were randomized immediately before elective extubation, being randomly allocated to one of the study groups: NIV or OM. We compared both groups regarding gas exchange 15 minutes, 2 hours, and 24 hours after extubation, reintubation rate after 48 hours, duration of mechanical ventilation, ICU length of stay, and hospital mortality. Results Forty patients were randomized to receive NIV (20 patients) or OM (20 patients) after the following extubation criteria were met: pressure support (PSV) of 7 cm H2O, positive end-expiratory pressure (PEEP) of 5 cm H2O, oxygen inspiratory fraction (FiO2) ≤ 40%, arterial oxygen saturation (SaO2) ≥ 90%, and ratio of respiratory rate and tidal volume in liters (f/TV) < 105. Comparing the 20 patients (NIV) with the 18 patients (OM) that finished the study 48 hours after extubation, the rate of reintubation in NIV group was 5% and 39% in OM group (P = 0.016). Relative risk for reintubation was 0.13 (CI = 0.017 to 0.946). Absolute risk reduction for reintubation showed a decrease of 33.9%, and analysis of the number needed to treat was three. No difference was found in the length of ICU stay (P = 0.681). Hospital mortality was zero in NIV group and 22.2% in OM group (P = 0.041). Conclusions In this study population, NIV prevented 48 hours reintubation if applied immediately after elective extubation in patients with more than 3 days of ARF when compared with the OM group. Trial Registration number ISRCTN: 41524441.

Risk factors for swallowing dysfunction in stroke patients

CONTEXT: Stroke is a frequent cause of dysphagia. OBJECTIVE: To evaluate in a tertiary care hospital the prevalence of swallowing dysfunction in stroke patients, to analyze factors associated with the dysfunction and to relate swallowing dysfunction to mortality 3 months after the stroke. METHODS: Clinical evaluation of deglutition was performed in 212 consecutive patients with a medical and radiologic diagnosis of stroke. The occurrence of death was determined 3 months after the stroke. RESULTS: It was observed that 63% of the patients had swallowing dysfunction. The variables gender and specific location of the lesion were not associated with the presence or absence of swallowing dysfunction. The patients with swallowing dysfunction had more frequently a previous stroke, had a stroke in the left hemisphere, motor and/or sensitivity alterations, difficulty in oral comprehension, alteration of oral expression, alteration of the level of consciousness, complications such as fever and pneumonia, high indexes on the Rankin scale, and low indexes on the Barthel scale. These patients had a higher mortality rate. CONCLUSIONS: Swallowing evaluation should be done in all patients with stroke, since swallowing dysfunction is associated with complications and an increased risk of death.

Mortalidade pós-neonatal no território brasileiro: uma revisão da literatura

O presente trabalho trata-se de revisão sistemática, referente ao período de 2004 a 2009, sobre o tema mortalidade pós-neonatal. Teve o objetivo de identificar como se colocam na literatura, as causas da morte e a relação com as condições socioeconômicas. Foram selecionados 27 artigos, 74,4% publicados em periódicos da área da Saúde Pública e 66,7%, de desenho do tipo ecológico. Quase a totalidade versava sobre grupos de causas e seus componentes (66,7%), seguidos pelo terço restante, sobre a identificação dos fatores determinantes dos óbitos. A região Sudeste produziu mais de 37% dos estudos. Na maioria dos municípios e estados brasileiros, a redução superou 50% no final da década de 1990. Dentre os grupos de causas de óbitos, predominou o grupamento diarreia-pneumonia, seguido pelas malformações congênitas. As condições de vida segundo indicadores socioeconômicos - moradia, saneamento básico, educação e acesso à saúde - foram determinantes para os maiores índices de mortalidade pós-neonatal por causas passíveis de redução.

Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure: demographics, etiologic and pulmonary histologic analysis

OBJECTIVES: Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life. METHODS: This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression. RESULTS: In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema. CONCLUSIONS: For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported.

Increased fibroblast telomerase expression precedes myofibroblast α-smooth muscle actin expression in idiopathic pulmonary fibrosis

OBJECTIVE: This study sought to identify the relationship between fibroblast telomerase expression, myofibroblasts, and telomerase-mediated regulatory signals in idiopathic pulmonary fibrosis. METHODS: Thirty-four surgical lung biopsies, which had been obtained from patients with idiopathic pulmonary fibrosis and histologically classified as usual interstitial pneumonia, were examined. Immunohistochemistry was used to evaluate fibroblast telomerase expression, myofibroblast α-smooth muscle actin expression and the tissue expression of inter leu kin-4, transforming growth factor-β, and basic fibroblast growth factor. The point-counting technique was used to quantify the expression of these markers in unaffected, collapsed, mural fibrosis, and honeycombing areas. The results were correlated to patient survival. RESULTS: Fibroblast telomerase expression and basic fibroblast growth factor tissue expression were higher in collapsed areas, whereas myofibroblast expression and interleukine-4 tissue expression were higher in areas of mural fibrosis. Transforming growth factor-β expression was higher in collapsed, mural fibrosis and honeycombing areas in comparison to unaffected areas. Positive correlations were found between basic fibroblast growth factor tissue expression and fibroblast telomerase expression and between interleukin-4 tissue expression and myofibroblast α-smooth muscle actin expression. Negative correlations were observed between interleukin-4 expression and basic fibroblast growth factor tissue expression in areas of mural fibrosis. Myofibroblast α-smooth muscle actin expression and interleukin-4 tissue expression in areas of mural fibrosis were negatively associated with patient survival. CONCLUSION: Fibroblast telomerase expression is higher in areas of early remodeling in lung tissues demonstrating typical interstitial pneumonia, whereas myofibroblast α-smooth muscle actin expression predominates in areas of late remodeling. These events seem to be regulated by basic fibroblast growth factor and interleukin-4 tissue expression, respectively.

Perineal rectosigmoidectomy on treatment of rectal procidentia: analysis of 48 cases

OBJECTIVE: To evaluate results obtained in 48 cases of perineal rectosigmoidectomy in patients with rectal procidentia. METHODS: 48 medical records of patients undergoing PRS were analyzed, retrospectively. RESULTS: Before surgery, 44 patients (77.1%) reported complaints of anal mass and rectal bleeding was reported 13 times (22.8%). The period of hospitalization was 3.91 days (2 to 12 days). Women were the majority (85.4%). The mean age was 73.8 years (49 to 101 years). The average time of surgery was 72 minutes (40 to 90 minutes). Mechanical anastomosis was performed in 72.9% and manual in 27.1%. Among the 12 (25%) patients with fecal incontinence, continence was achieved in 2 cases. Postoperative complications occurred in five cases - 10.5% (two pneumonia and three anastomotic leakages). Recurrence was verified in four patients (8,3%). There were no deaths related to the procedure. CONCLUSION: Perineal rectosigmoidectomy is a good surgical option for rectal procidentia, with low morbidity and mortality, low recurrence rate and short hospitalization length.

Evidence on the best chlorhexidine concentration to perform oral hygiene: meta-analysis

Although scientific literature has demonstrated the relevance of oral hygiene with chlorhexidine in preventing ventilation-associated pneumonia, there is a wide variation of concentrations, frequency and techniques when using the antiseptic. The aim of this research was to assessthe best chlorhexidine concentration used to perform oral hygiene to prevent ventilation-associated pneumonia. A systematic review followed by four meta-analysis using chlorhexidine concentration as criterion was carried out. Articles in English, Spanish or Portuguese indexed in the Cochrane, Embase, Lilacs, PubMed/Medline and Ovid electronic databases were selected. The research was carried out from May to June 2011. The primary outcome measure of interest was ventilation-associated pneumonia. Ten primary studies were divided in four groups (Gl-4), based on chlorhexidine concentration criterion. Gl (5 primary studies, chlorhexidine 0.12%) showed homogeneity among studies and the use of chlorhexidine represented a protective factor. G2 (3 primary studies, chlorhexidine 0.20%) showed heterogeneity among studies and chlorhexidine did not represent a protective factor. G3 (2 primary studies, chlorhexidine 2,00%) showed homogeneity among studies and the use of chlorhexidine was significant. G4 (10 primary studies with different chlorhexidine concentrations) showed homogeneity among studies and the common Relative Risk was significant. Statistic analyses showed a protective effect of oral hygiene with chlorhexidine in preventing ventilation-associated pneumonia. However, it was not possible to identity a standard to establish optimal chlorhexidine concentration.

Frequency of Toxocara infection in children attended by the health public service of Maringá, south Brazil.

The lack of specific laboratorial diagnosis methods and precise symptoms makes the toxocariasis a neglected disease in Public Health Services. This study aims to determine the frequency of Toxocara spp. infection in children attended by the Health Public Service of Hospital Municipal de Maringá, South Brazil. To evaluate the association of epidemiological and clinical data, and observational and cross-section study was carried out. From 14,690 attended children/year aged from seven month to 12 years old, 450 serum samples were randomly collected from September/2004 to September/2005. A questionnaire was used to evaluate epidemiological, clinical and hematological data. An ELISA using Toxocara canis larval excretory-secretory products as antigen detected 130 (28.8%) positive sera, mainly between children from seven month to five years old (p = 0.0016). Significant correlation was observed between positive serology for Toxocara, and frequent playing in sandbox at school or daycare center (p = 0.011) and the presence of a cat at home (p = 0.056). From the families, 50% were dog owners which exposed soil backyards. Eosinophilia (p = 0.776), and signs and symptoms analyzed (fever p = 0.992, pneumonia p = 0.289, cold-like symptoms p = 0.277, cough p =0.783, gastrointestinal problems p = 0.877, migraine p = 0.979, abdominal pain p = 0.965, joint pain p = 0.686 and skin rash p = 0.105) could not be related to the presence of anti-Toxocara antibodies. Therefore, two asthmatics children showed titles of1:10,240 and accentuated eosinophilia (p = 0.0001). The authors emphasize the needs of prevention activities.