Avaliação do prognóstico com a utilização de dois escores de mortalidade em terapia intensiva pediátrica de nível de atendimento terciário

A redução da mortalidade é um objetivo fundamental das unidades de terapia intensiva pediátrica (UTIP). O estágio de gravidade da doença reflete a magnitude das comorbidades e distúrbios fisiológicos no momento da internação e pode ser avaliada pelos escores prognósticos de mortalidade. Os dois principais escores utilizados na UTIP são o Pediatric Risk of Mortality (PRISM) e o Pediatric Index of Mortality (PIM). O PRISM utiliza os piores valores de variáveis fisiológicas e laboratoriais nas primeiras 24 horas de internação enquanto o PIM2 utiliza dados da primeira hora de internação na UTIP e apenas uma gasometria arterial. Não há consenso na literatura, entre PRISM e PIM2, quanto à utilidade e padronização na admissão na terapia intensiva para as crianças e adolescentes, principalmente em uma UTI de nível de atendimento terciário. O objetivo do estudo foi estabelecer o escore de melhor performance na avaliação do prognóstico de mortalidade que seja facilmente aplicável na rotina da UTIP, para ser utilizado de forma padronizada e contínua. Foi realizado um estudo retrospectivo onde foram revisados os escores PRISM e PIM2 de 359 pacientes internados na unidade de terapia intensiva pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, considerada uma unidade de atendimento de nível terciário. A mortalidade foi de 15%, o principal tipo de admissão foi clinico (78%) sendo a principal causa de internação a disfunção respiratória (37,3%). Os escores dos pacientes que foram a óbito mostraram-se maiores do que o dos sobreviventes. Para o PRISM foi 15 versus 7 (p = 0,0001) e para o PIM2, 11 versus 5 (p = 0,0002), respectivamente. Para a amostra geral, o Standardized Mortality Ratio (SMR) subestimou a mortalidade tanto para o PIM2 quanto para o PRISM [1,15 (0,84 - 1,46) e 1,67 (1,23 - 2,11), respectivamente]. O teste de Hosmer-Lemeshow mostrou calibração adequada para ambos os escores [x2 = 12,96 (p = 0,11) para o PRISM e x2 = 13,7 (p = 0,09) para o PIM2]. A discriminação, realizada por meio da área sob a curva ROC, foi mais adequada para o PRISM do que para o PIM2 [0,76 (IC 95% 0,69 - 0,83) e 0,65 (IC 95% 0,57 - 0,72), respectivamente, p= 0,002]. No presente estudo, a melhor sensibilidade e especificidade para o risco de óbito do PRISM foi um escore entre 13 e 14, mostrando que, com o avanço tecnológico, o paciente precisa ter um escore mais elevado, ou seja, maior gravidade clínica do que a população original, para um maior risco de mortalidade. Os escores de gravidade podem ter seus resultados modificados em consequência: do sistema de saúde (público ou privado), da infraestrutura da UTIP (número de leitos, recursos humanos, parque tecnológico) e indicação da internação. A escolha de um escore de gravidade depende das características individuais da UTIP, como o tempo de espera na emergência, presença de doença crônica complexa (por exemplo, pacientes oncológicos) e como é realizado o transporte para a UTIP. Idealmente, estudos multicêntricos têm maior significância estatística. No entanto, estudos com populações maiores e mais homogêneas, especialmente nos países em desenvolvimento, são difíceis de serem realizados

The Use of the Rey 15-Item Test and Recognition Trial to Evaluate Suboptimal Effort in Neuropsychological Assessment with a Pediatric Mild TBI Sample

The utilization of symptom validity tests (SVTs) in pediatric assessment is receiving increasing empirical support. The Rey 15-Item Test (FIT) is an SVT commonly used in adult assessment, with limited research in pediatric populations. Given that FIT classification statistics across studies to date have been quite variable, Boone, Salazar, Lu, Warner-Chacon, and Razani (2002) developed a recognition trial to use with the original measure to enhance accuracy. The current study aims to assess the utility of the FIT and recognition trial in a pediatric mild traumatic brain injury (TBI) sample (N = 112; M = 14.6 years), in which a suboptimal effort base rate of 17% has been previously established (Kirkwood & Kirk, 2010). All participants were administered the FIT as part of an abbreviated neuropsychological evaluation; failure on the Medical Symptom Validity Test (MSVT) was used as the criterion for suspect effort. The traditional adult cut-off score of(99%), but poor sensitivity (6%). When the recognition trial was also utilized, a combination score of(sensitivity = 64%, specificity = 93%). Results indicate that the FIT with recognition trial may be useful in the assessment of pediatric suboptimal effort, at least among relatively high functioning children following mild TBI.

The Utility of the CVLT-C as an Embedded Validity Indicator After Pediatric Mild Traumatic Brain Injury.

Results of neuropsychological examinations depend on valid data. Whereas clinicians previously believed that clinical skill was sufficient to identify non-credible performance by examinees on standard tests, research demonstrates otherwise. Consequently, studies on measures to detect suspect effort in adults have received tremendous attention in the previous twenty years, and incorporation of validity indicators into neuropsychological examinations is now seen as integral. Few studies exist that validate methods appropriate for the measurement of effort in pediatric populations. Of extant studies, most evaluate standalone measures originally developed for use with adults. The present study examined the utility of indices from the California Verbal Learning Test – Children's Version (CVLT-C) as embedded validity indicators in a pediatric sample. Participants were 225 outpatients aged 8 to 16 years old referred for clinical assessment after mild traumatic brain injury (mTBI). Non-credible performance (n = 39) was defined as failure of the Medical Symptom Validity Test (MSVT). Logistic regression demonstrated that only the Recognition Discriminability index was predictive of MSVT failure (OR = 2.88, p < .001). A cutoff of z ≤ -1.0 was associated with sensitivity of 51% and specificity of 91%. In the current study, CVLT-C Recognition Discriminability was useful in the identification of non-credible performance in a sample of relatively high-functioning pediatric outpatients with mTBI. Thus, this index can be added to the short list of embedded validity indicators appropriate for pediatric neuropsychological assessment.

Recovery from Pediatric Brain Injury: A Preliminary Comparison of Longitudinal Data on Psychological Symptomology and Mental Health Treatment

Objective: To document the course of psychological symptomology, mental health treatment, and unmet psychological needs using caregiver reports in the first 18 months following pediatric brain injury (BI). Method: Participants included 28 children (aged 1-18 years) who were hospitalized at a children's hospital's rehabilitation unit. Caregiver reports of children's psychological symptoms, receipt of mental health treatment, and unmet psychological needs were assessed at one month, six months, 12 months, and 18 months post-BI. Results: Caregivers reported a general increase in psychological symptoms and receipt of mental health treatment over the 18 months following BI; however, there was a substantial gap between the high rate of reported symptoms and low rate of reported treatment. Across all four follow-up time points there were substantial unmet psychological needs (at least 60% of sample). Conclusions: Findings suggest that there are substantial unmet psychological needs among children during the first 18 months after BI. Barriers to mental health treatment for this population need to be addressed.

Optic neuritis in pediatric population: A review in current tendencies of diagnosis and management

Optic neuritis is an inflammation of the optic nerve and may be related to different systemic conditions. The clinical presentation of this pathology usually includes sudden loss of visual acuity (VA) which may be unilateral or bilateral, visual field restriction, pain with eye movements, dyschromatopsia, a relative afferent pupillary defect and optic disk swelling. Optic neuritis in children has specific clinical features and a better prognosis than in adulthood. Although usually appears an underlying viral disease, the main concern for practitioners is the relationship of optic neuritis with multiple sclerosis. In addition to the classical techniques as magnetic resonance imaging (MRI), current tendencies of diagnosis for eye practitioners include new imaging devices as optical coherence tomography (OCT), useful to show a thinning of the retinal fibers layer (RFL) after the inflammatory episode. Regarding the management of these patients, short-term intravenous steroid dosages seem to be the best option to treat acute attacks characterized by a very poor bilateral VA.

Lactato sérico como marcador de prognóstico na sépsis em idade pediátrica : artigo de revisão

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Assessing the role played by biofilms on adenoidal surface in a pediatric population

Adenoids are a mass of lymphatic tissue located within the nasopharynge. This work aims assessing the relationship between the formation of bacterial biofilms on the adenoid surface and the incidence of infections in the pediatric age.

Pediatric nursing : a text-book for nurses /

Includes index.

The effects of safety seat legislation on pediatric trauma. Final report.

Transportation Department, Office of University Research, Washington, D.C.

Treating family violence in a pediatric hospital : a program of training, research and services /

Shipping list no.: 88-77-P.

Pediatric emergency medical services training program. Final report.

Mode of access: Internet.