Influence of structural features on Portuguese toddler child care quality

Whereas child care quality has been extensively studied in the U.S., there is much less information about the quality of child care in other countries.With one of the highest maternal employment rates in Europe, it is important to examine child care in Portugal. Thirty toddler classrooms in child care centers were observed. The purpose of this studywas to determine whether structural features account for overall toddler child care quality. Results showed younger and better-paid teachers provided better toddler child care quality. Space available per childwas not a statistically significant predictor of toddler child care quality.Overall quality results suggest some issues to be addressed by early education policy makers and indicate the need to promote quality in Portuguese toddler child care programs.

Fatal disseminated paracoccidioidomycosis in a two-year-old child

A two year-old female child was admitted at the Pediatric Intensive Care Unit in a septic shock associated with a lymphoproliferative syndrome, with history of fever, adynamia and weight loss during the last two months. On admission, the main clinical and laboratory manifestations were: pallor, jaundice, disseminated enlarged lymph nodes, hepatosplenomegaly, crusted warts on face, anemia, eosinophilia, thrombocytopenia, increased direct and indirect bilirubin, alkaline phosphatase, and gammaglutamyl transpeptidase. A parenteral administration of fluids, dobutamine and mechanical ventilation was started, without improvement of the clinical conditions. A direct examination of exsudate collected from cervical lymph node revealed numerous oval-to-around cells with multiple budding, like a "pilot wheel" cell, suggesting Paracoccidioides brasiliensis. Even though treatment with intravenous sulfamethoxazole-trimethoprine was soon started, the child died 36 hours after hospital admission. Disseminated paracoccidioidomycosis was confirmed in the autopsy. This is the youngest case of paracoccidioidomycosis in children reported in the literature.

Lupus Myelopathy in a Child

A 5-year-old female developed, after a 7-month period of fever, anorexia, weight loss, and a transitory cutaneous erythematous eruption, a severe acute transverse myelopathy, with a partial recovery of motor and sensory function. She had positive antinuclear and antidouble-stranded DNA antibodies but no antiphospholipid antibodies. Six months later she had massive proteinuria and restarted treatment with steroids and cyclophosphamide. Our patient is one of the youngest reported with lupus myelopathy. We discuss the clinical presentation, the magnetic resonance imaging findings, and other relevant laboratory studies of this rare but serious complication of systemic lupus erythematosus.

Adolescents and School Asthma Knowledge and Attitudes

Introduction: bronchial asthma is a chronic disease that affects a high percentage of adolescents, with a significant restriction of daily activities, and is a cause of school absenteeism. The relationships between adolescents and asthma disease in school were assessed, with a view to improving knowledge about the asthmatic adolescent. Methods: a survey was conducted in the Lisbon metropolitan area, covering urban (Lisbon) and rural (Lourinh˜a ) zones and including 1879 students and 81 teachers from the 7th to 9th high school years. The study groups were asthmatic students, their peers, and teachers. A self-administered questionnaire was applied to collect information. The results were compared with a reference group of 91 asthmatic students attending our Department of Immunoallergy-Hospital Dona Estefânia. Cotinine urinary measurements were made in a sample of asthmatics and a control group. Results: the prevalence of current asthma among students was 10%. Estimates of asthma annual burden among 7th to 9th year students from Lisbon and Lourinh˜a high schools included 4,307 days missed from school, 4,148 medical consultations and a minimum of 351 hospital emergency care and 80 hospital admissions. Exposure to passive smoking was not significantly different between asthmatic students and theirs peers. Cotinine urinary measurements did not discriminate between exposed and non-exposed individuals. Cigarette smoking was almost as common among adolescent asthmatics (5.4%) as it was in non-asthmatic subjects (6.7%). However, 55% of asthmatics mentioned active and passive smoking as an asthma exacerbating factor. Asthmatic students, theirs peers and teachers showed a deficient knowledge about asthma (mean group scores: 17.6; 14.2 and 17.7 of a possible 30), particularly in the areas related to asthma recognition and its management. Asthmatics attending our Allergy Department had the highest scores. All groups showed tolerance in the sense of a positive and understanding attitude toward a person with asthma. However, traditional beliefs about asthma disease (dependence, inferiority...) were confirmed. A positive correlation between knowledge levels and tolerance attitudes was found. Conclusion: in view of the dimension of the asthma problem in adolescence and its social and economic impact, it is justifiable to assess the need for the implementation of asthma education programs in schools in order to improve asthma management by the adolescents and their schools.

Prevalence of Asthma in a Portuguese Countryside Town:Repercussions on Absenteeism and Self-Concept

Background: Childhood asthma represents an increasing health problem and is the leading cause of hospital admission and absenteeism in children with chronic disease. It also compromises quality of life, eventually contributing to disturbances in self-concept. Self-concept is a recent and global perspective of “the self” and relates to skills, self-image and self-esteem. Little information is available on this topic and there are no data from Portuguese countryside towns. Objective: The aim of this study was to determine the prevalence of asthma among all school children in the 5th and 6th grades in a Portuguese countryside town and to establish its possible correlation with absenteeism and self-concept. Methods: In April 2002, two questionnaires were administered in the presence of the researcher to a group of 950 children attending different schools. The children completed the internationally renowned questionnaires: ISAAC and the Self-Concept Scale by Susan Harter. Results: Our sample (n = 818) had a mean age of 11 years (10-15 years) and a male-to-female ratio of 1/1. The cumulative prevalence of asthma was11.9% and that of active asthma was 8.8 %; 63.9% of asthmatics were male and 36.1 % were female. The mean age of asthmatics was 11.34 years and 74 % had active symptoms. Comparison of this group of 97 asthmatic children with the remaining children revealed a statistically significant correlation between the presence of asthma and school absenteeism (global: p = 0.04; gymnastics: 0.05). Regarding the Self-Concept Scale a statistically significant association was found between the presence of asthma and school achievement (p = 0.027), physical appearance (p = 0.015), behavior (p < 0.000) and self-esteem (p < 0.000). No statistically significant correlations were found in social acceptance (p = 0.289) or athletic competence (p = 0.085). Asthmatic boys had higher self-concept scores than girls, except in the domain of behavior. Conclusions: Twelve percent of the population studied was asthmatic. In asthmatic children, absenteeism was higher and self-concept was lower for almost all domains, except social acceptance and athletic achievement, probably due to overprotection.

Cardiac Hydatid Cyst in a Child

Cardiac hydatid cyst is a rare disease, especially in children. An 11-year-old boy with a previous anaphylactic reaction and episodes of abdominal pain was admitted for workup of an acquired long systolic murmur. Echocardiographic investigation disclosed a tumor of the right ventricular anterior wall, with multiple loculations. Magnetic resonance imaging characterized it as a multilobular tumor with cyst formation and disclosed another cyst in the right pulmonary artery. With a positive ELISA reaction the child was admitted for surgery with the diagnosis of cardiac and pulmonary hydatid cysts. Cardiac surgery was performed with good results, followed by medical treatment with albendazole.

Active cycle breathing techniques como técnica de higiene brônquica na asma: estudo piloto

RESUMO: Relevância e Objectivos: O objectivo deste estudo consistiu em verificar a eficácia e segurança de uma técnica de higiene brônquica – Active Cycle breathing technique (ACBT), na remoção de secreções e desinsuflação em crianças asmáticas. É uma técnica recente, que ainda não foi estudada nesta população. Metodologia: A amostra foi constituída por um total de 14 crianças, com idades compreendidas entre os 6 e 18 anos, com o diagnóstico de asma. Foi dividida em dois grupos: grupo de controlo, constituído por asmáticos estáveis e grupo experimental constituído por asmáticos pós-crise. Ambos receberam o mesmo tratamento, que consistiu numa única sessão de ACBT. Realizaram um exame da função respiratória (variáveis FEV1, PEF, MEF75%, RV e FRC) antes e após a aplicação da técnica. Mediu-se a Saturação de O2 antes, a meio e no fim da aplicação da técnica. Por último, pesaram-se as secreções recolhidas durante a sessão de tratamento. Resultados: Como resultados, quando omparamos o antes e após aplicação do ACBT, obtivemos diferenças significativas no RV (p <0,05) e FRC (p <0,05); muito significativa na Sa02 (p <0,01) e peso de secreções, nos asmáticos pós crise. Ocorreu uma melhoria significativa da saturação (p <0,05) em asmáticos estáveis, não havendo secreções. Não houve efeitos adversos nem broncoespasmo em ambos os grupos.Conclusão: O ACBT é uma técnica que promove a remoção de secreções e diminuição da insuflação na população de asmáticos.--------------------ABSTRACT:Relevance and Goals: the goal of this study was to verify the efficiency and security of a bronchial hygienic technique - Active Cycle Breathing Technique (ACBT) – in the obstruction and insufflation of asthmatic children. This is a new technique that has not yet been studied in this population. Procedures: The subjects were 14 children aged between 6 and 18 years old with asthma diagnosis. They were divided in two groups: the control group with stable asthmatics and the experimental group with post-crisis asthmatics. Both received the same treatment that was a single session of ACBT. They made a lung function test before and after the application of the technique (variables FEV1, PEF, MEF75%, RV and FRC). The level of O2 saturation was measured before, during and after the procedure. In the end, the secretions collected during the treatment were weighted. Results: We observed a significant difference on RV (p ˂0,05), FRC (p ˂0,05), Sa02 (p ˂0,01) and in the weight of the secretions in the post-crisis asthmatics after ACBT. There was a significant improvement of saturation (p ˂0,05) only in the stable asthmatics. There were no adverse effects or bronchospasm in both groups.

Detection of EBV-DNA in serum samples of an immunosuppressed child during a three years follow-up: association of clinical and PCR data with active infection

Twenty-four whole blood and serum samples were drawn from an eight year-old heart transplant child during a 36 months follow-up. EBV serology was positive for VCA-IgM and IgG, and negative for EBNA-IgG at the age of five years old when the child presented with signs and symptoms suggestive of acute infectious mononucleosis. After 14 months, serological parameters were: positive VCA-IgG, EBNA-IgG and negative VCA-IgM. This serological pattern has been maintained since then even during episodes suggestive of EBV reactivation. PCR amplified a specific DNA fragment from the EBV gp220 (detection limit of 100 viral copies). All twenty-four whole blood samples yielded positive results by PCR, while 12 out of 24 serum samples were positive. We aimed at analyzing whether detection of EBV-DNA in serum samples by PCR was associated with overt disease as stated by the need of antiviral treatment and hospitalization. Statistical analysis showed agreement between the two parameters evidenced by the Kappa test (value 0.750; p < 0.001). We concluded that detection of EBV-DNA in serum samples of immunosuppressed patients might be used as a laboratory marker of active EBV disease when a Real-Time PCR or another quantitative method is not available.

Mother-to-child transmission of different HIV-1 subtypes among ARV Naïve infected pregnant women in Nigeria

The rate of mother-to-child transmission (MTCT) of HIV as well as the implications of the circulating multiple subtypes to MTCT in Nigeria are not known. This study was therefore undertaken to determine the differential rates of MTCT of HIV-1 subtypes detected among infected pregnant women before ARV intervention therapy became available in Nigeria. Twenty of the HIV-positive women who signed the informed consent form during pregnancy brought their babies for follow-up testing at age 18-24 months. Plasma samples from both mother and baby were tested for HIV antibody at the Department of Virology, UCH, Ibadan, Nigeria. All positive samples (plasma and peripheral blood mononuclear cells - PBMCs) were shipped to the Institute of Tropical Medicine, Antwerp, Belgium, where the subtype of the infecting virus was determined using the HMA technique. Overall, a mother-to-child HIV transmission rate of 45% was found in this cohort. Specifically, 36.4%, 66.7% and 100% of the women infected with HIV-1 CRF02 (IbNg), G and B, respectively, transmitted the virus to their babies. As far as it can be ascertained, this is the first report on the rate of MTCT of HIV in Nigeria. The findings reported in this paper will form a useful reference for assessment of currently available therapeutic intervention of MTCT in the country.

Toxoplasma-IgM and IgG-avidity in single samples from areas with a high infection rate can determine the risk of mother-to-child transmission

Anti-Toxoplasma IgG-avidity was determined in 168 serum samples from IgG- and IgM-positive pregnant women at various times during pregnancy, in order to evaluate the predictive value for risk of mother-to-child transmission in a single sample, taking the limitations of conventional serology into account. The neonatal IgM was considered the serologic marker of transmission. Fluorometric tests for IgG, IgM (immunocapture) and IgG-avidity were performed. Fifty-one of the 128 pregnant women tested gave birth in the hospital and neonatal IgM was obtained. The results showed 32 (62.75%) pregnant women having high avidity, IgM indexes between 0.6 and 2.4, and no infected newborn. Nineteen (37.25%) had low or inconclusive avidity, IgM indexes between 0.6 and 11.9, and five infected newborns and one stillbirth. In two infected newborns and the stillbirth maternal IgM indexes were low and in one infected newborn the only maternal parameter that suggested fetal risk was IgG-avidity. In the present study, IgG-avidity performed in single samples from positive IgM pregnant women helped to determine the risk of transmission at any time during pregnancy, especially when the indexes of the two tests were analysed with respect to gestational age. This model may be less expensive in developing countries where there is a high prevalence of infection than the follow-up of susceptible mothers until childbirth with monthly serology, and it creates a new perspective for the diagnosis of congenital toxoplasmosis.

Fatal septicemia caused by Chromobacterium violaceum in a child from Colombia

A 4-year old child living in Colombia presented with a history of fever and severe abdominal pain for four days. The patient developed pneumonia, septic shock, multiple organ failure and died on the fifth day of hospitalization. Chromobacterium violaceum was isolated from admission blood cultures and was resistant to ampicillin, cephalosporins, carbapenems and aminoglycosides.

Exercise-Induced Intraventricular Obstruction in a Child with Near Syncope and Chest Pain During Exercise

We report the case of a 10-year-old girl with two episodes of light-headedness and chest pain during exercise. She had an unremarkable clinical record, physical examination, ECG, and echocardiogram. Noninvasive ischemia tests were positive, but coronary angiography was normal. Exercise stress echocardiogram revealed an exercise-induced intra-left-ventricular obstruction with a peak gradient of 78 mmHg and replicated her symptoms. After starting beta-blocker therapy her clinical status improved and no residual obstruction was detected. The authors review this unsuspected clinical condition, seldom reported in the adult population and, to our knowledge, never before in a child.

HIV-1-mother-to-child transmission and associated characteristics in a public maternity unit in Presidente Prudente, Brazil

In children, vertical transmission is the main form of HIV infection. Our aim was to determine the prevalence of HIV-1 vertical transmission in mother-infant pairs in a public maternity ward in Presidente Prudente, SP. Additionally; we sought to identify characteristics associated with this form of transmission. The files of 86 HIV-1-infected mothers and their newborns referred to a Public Hospital from March 2002 to March 2007 were analyzed. The HIV-1-RNA viral load of the newborns was determined by bDNA. The HIV-1 vertical-transmission rate was 4.6%. Children that were born in the pre-term period and breastfed were at a higher risk of HIV-1 infection (p = 0.005 and p = 0.017 respectively) than children born at term and not breastfed. Prophylactic therapy with zidovudine after birth for newborns was associated with a lower risk of infection (p = 0.003). The number of newborns weighing < 2,500 g was significantly higher for infected children (p = 0.008) than for non-infected newborns. About 22.9% of mothers did not know the HIV-1 status of their newborns eight months after delivery. The study suggests that it is necessary to increase the identification of HIV-1 infection in pregnant women and their newborns as well as to offer and explain the benefits of ARV prophylaxis.

Successful Handling of Disseminated BCG Disease in a Child with Severe Combined Immunodeficiency

In high-burden countries, Mycobacterium bovis Bacillus Calmette-Guérin (BCG) vaccine is administered in newborn to prevent severe Mycobacterium tuberculosis infection. Because life-threatening disseminated BCG disease may occur in children with primary immunodeficiency, vaccination strategy against tuberculosis should be redefined in non-high-burden countries. We report the case of a patient with X-linked severe combined immunodeficiency (SCID) who developed disseminated BCG disease, highlighting the specific strategies adopted.

Mecanismos de inflamação brônquica resultantes da exposição a factores ambientais

RESUMO Tratando-se a asma de uma doença respiratória, desde há várias décadas que tem sido abordada a hipótese de que factores ambientais, nomeadamente os relacionados com a qualidade do ar inalado, possam contribuir para o seu agravamento. Para além dos aeroalergenos, outros factores ambientais como a poluição atmosférica estarão associados às doenças respiratórias. O ar respirado contém uma variedade de poluentes atmosféricos, provenientes quer de fontes naturais quer de origem antropogénica, nomeadamente de actividades industriais, domésticas ou das emissões de veículos. Estes poluentes, tradicionalmente considerados como um problema de foro ambiental, têm sido cada vez mais encarados como um problema de saúde pública. Também a qualidade do ar interior, tem sido associada a queixas respiratórias, não só em termos ocupacionais mas também em exposições domésticas. Dentro dos principais poluentes, encontramos a matéria particulada (como as PM10), o O3, NO2, e os compostos orgânicos voláteis (COVs). Se é verdade que os três primeiros têm como principais fontes de exposição a combustão fóssil associada aos veículos automóveis, já os COVs (como o benzeno, tolueno, xileno, etilbenzeno e formaldeído) são poluentes mais característicos do ar interior. Os mecanismos fisiopatológicos subjacentes à agressão dos poluentes do ar não se encontram convenientemente esclarecidos. Pensa-se que após a sua inalação, induzam um grau crescente de stress oxidativo que será responsável pelo desenvolvimento da inflamação das vias aéreas. A progressão do stress oxidativo e da inflamação, associarse- ão posteriormente a lesão local (pulmonar) e sistémica. Neste trabalho pretendeu-se avaliar os efeitos da exposição individual a diversos poluentes, do ar exterior e interior, sobre as vias aéreas, recorrendo a parâmetros funcionais, inflamatórios e do estudo do stress oxidativo. Neste sentido, desenvolveu-se um estudo de painel na cidade de Viseu, em que foram acompanhadas durante 18 meses, 51 crianças com história de sibilância, identificadas pelo questionário do estudo ISAAC. As crianças foram avaliadas em quatro Visitas (quatro medidas repetidas), através de diversos exames, que incluíram execução de espirometria com broncodilatação, medição ambulatória do PEF, medição de FENO e estudo do pH no condensado brônquico do ar exalado. O estudo dos 8-isoprostanos no condensado brônquico foi efectuado somente em duas Visitas, e o do doseamento de malonaldeído urinário somente na última Visita. Para além da avaliação do grau de infestação de ácaros do pó do colchão, para cada criança foi calculado o valor de exposição individual a PM10, O3, NO2, benzeno, tolueno, xileno, etilbenzeno e formaldeído, através de uma complexa metodologia que envolveu técnicas de modelação associadas a medições directas do ar interior (na casa e escola da criança) e do ar exterior. Para a análise de dados foram utilizadas equações de estimação generalizadas com uma matriz de correlação de trabalho uniforme, com excepção do estudo das associações entre poluentes, 8-isoprostanos e malonaldeído. Verificou-se na análise multivariável a existência de uma associação entre o agravamento dos parâmetros espirométricos e a exposição aumentada a PM10, NO2, benzeno, tolueno e etilbenzeno. Foram também encontradas associações entre diminuição do pH do EBC e exposição crescente a PM10, NO2, benzeno e etilbenzeno e associações entre valores aumentados de FENO e exposição a etilbenzeno e tolueno. O benzeno, o tolueno e o etilbenzeno foram associados com maior recurso a broncodilatador nos 6 meses anteriores à Visita e o tolueno com deslocações ao serviço de urgência. Os resultados dos modelos de regressão que incluíram o efeito do poluente ajustado para o grau de infestação de ácaros do pó foram, de uma forma geral, idênticos ao da análise multivariável anterior, com excepção das associações para com o FENO. Nos modelos de exposição com dois poluentes, com o FEV1 como variável resposta, somente o benzeno persistiu com significado estatístico. No modelo com dois poluentes tendo o pH do EBC como variável resposta, somente persistiram as PM10. Os 8-isoprostanos correlacionaram-se com alguns COVs, designadamente etilbenzeno, xileno, tolueno e benzeno. Os valores de malonaldeído urinário não se correlacionaram com os valores de poluentes. Verificou-se no entanto que de uma forma geral, e em particular mais uma vez para os COVs, as crianças mais expostas a poluentes, apresentaram valores superiores de malonaldeído na urina. Verificou-se que os poluentes do ar em geral, e os COVs em particular, se associaram com uma deterioração das vias aéreas. A exposição crescente a poluentes associou-se não só com obstrução brônquica, mas também com FENO aumentado e maior acidez das vias aéreas. A exposição crescente a COVs correlacionou-se com um maior stress oxidativo das vias aéreas (medido pelos 8-isoprostanos). As crianças com exposição superior a COVs apresentaram maiores valores de malonaldeído urinário. Este trabalho sugere uma associação entre exposição a poluentes, inflamação das vias aéreas e stress oxidativo. Vem reforçar o interesse dos poluentes do ar, nomeadamente os associados a ambientes interiores, frequentemente esquecidos e que poderão ser explicativos do agravamento duma criança com sibilância.-----------ABSTRACT: Asthma is a chronic respiratory disease that could be influenced by environmental factors, as allergens and air pollutants. The air breathed contains a diversity of air pollutants, both from natural or anthropogenic sources. Atmospheric pollution, traditionally considered an environmental problem, is nowadays looked as an important public health problem. Indoor air pollutants are also related with respiratory diseases, not only in terms of occupational exposures but also in domestic activities. Particulate matter (such as PM10), O3, NO2 and volatile organic compounds (VOCs) are the main air pollutants. The main source for PM10, O3, NO2 exposure is traffic exhaust while for VOCs (such as benzene, toluene, xylene, ethylbenzene and phormaldehyde) the main sources for exposure are located in indoor environments. The pathophysiologic mechanisms underlying the aggression of air pollutants are not properly understood. It is thought that after inhalation, air pollutants could induce oxidative stress, which would be responsible for airways inflammation. The progression of oxidative stress and airways inflammation, would contribute for the local and systemic effects of the air pollutants. The present study aimed to evaluate the effects of individual exposure to various pollutants over the airways, through lung function tests, inflammatory and oxidative stress biomarkers. In this sense, we developed a panel study in the city of Viseu, that included 51 children with a history of wheezing. Those children that were identified by the ISAAC questionnaire, were followed for 18 months. Children were assessed four times (four repeated measures) through the following tests: spirometry with bronchodilation test, PEF study, FENO evaluation and exhaled breath condensate pH measurement. 8-isoprostane in the exhaled breath condensate were also measured but only in two visits. Urinary malonaldehyde measurement was performed only in the last visit. Besides the assessment of the house dust mite infestation, we calculated for each child the value of individual exposure to a wide range of pollutants: PM10, O3, NO2, benzene, toluene, xylene, ethyl benzene and formaldehyde. This strategy used a complex methodology that included air pollution modelling techniques and direct measurements indoors (homes and schools) and outdoors. Generalized estimating equations with an exchangeable working correlation matrix were used for the analysis of the data. Exceptions were for the study of associations between air pollutants, malonaldehyde and 8-isoprostanes. In the multivariate analysis we found an association between worsening of spirometric outcomes and increased exposure to PM10, NO2, benzene, toluene and ethylbenzene. In the multivariate analysis we found also negative associations between EBC pH and exposure to PM10, NO2, benzene, ethylbenzene and positive associations between FENO and exposure to ethylbenzene and toluene. Benzene, toluene and ethylbenzene were associated with increased use of bronchodilator in the 6 months prior to the visit and toluene with emergency department visits. Results of the regression models that included also the effect of the pollutant adjusted for the degree of infestation to house dust mites, were identical to the previous models. Exceptions were for FENO associations. In the two-pollutant models, with the FEV1 as dependent variable, only benzene persisted with statistical significance. In the two pollutant model with pH of EBC as dependent variable, only PM10 persisted. 8-isoprostanes were well correlated with some VOCs, namely with ethylbenzene, xylene, toluene and benzene. Urinary malonaldehyde did not present any correlation with air pollutants exposure. However, those children more exposed to air pollutants (namely to VOCs), presented higher values of malonaldehyde. It was found that air pollutants in general, and namely VOCs, were associated with deterioration of the airways. The increased exposure to air pollutants was associated not only with airways obstruction, but also with increased FENO and higher acidity of the airways. The increased exposure to VOCs was correlated with increased airways oxidative stress (measured by 8-isoprostane). Children with higher levels of exposure to VOCs had higher values of urinary malonaldehyde. This study suggests a relation between air pollution, airways inflammation and oxidative stress. It suggests also that attention should be dedicated to air quality as air pollutants could cause airways deterioration.