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The new coronavirus outbreak determined the closure of schools and universities around the world. In Brazil, implementation of online teaching faced many challenges, especially for public schools. We analyzed, via an online questionnaire, the speech of children aged 6 to 11 years old to evaluate their thoughts about virtual classes. The results showed a significant negative correlation between children’s learning perception and their feelings about online classes. A duration longer than 3 hours for the virtual classes was associated with students perceiving them as “boring” and “tiresome”; and children who did not enjoy being taught in front of a screen also perceived their learning during this period as “poor”. Possible psychological impacts for children under confinement, like fear and stress may have contributed to these perceptions. Our limitations were: the small sample size compared with Brazil’s population and, also the concentration of answers in the southern (the richest and most developed) region. When giving children predefined answers, we could not be able to realize the true dimension of their emotions. The results showed that there is a need for institutions to prepare a good virtual environment for teaching, with proper training for the staff involved and attractive classes, able to captivate the students’ attention and allow better learning. In a vast territory like Brazil, there is a need of proper public policies and funding to allow better internet access and reduce educational inequality. Families shall be warned to pay attention to children’s signs of poor mental health, once confinement may be a trigger for symptoms of anxiety and depression, a synergistic conjunction that is able to deteriorate the capacity of attention and our children’s ability of learning.

Objective: Acute respiratory distress syndrome (ARDS) can be a devastating condition in children with cancer and alveolar recruitment maneuvers (ARMs) can theoretically improve oxygenation and survival. The study aimed to assess the feasibility of ARMs in critically ill children with cancer and ARDS. Methods: We retrospectively analyzed 31 maneuvers in a series of 12 patients (median age of 8.9 years) with solid tumors (n=4), lymphomas (n=2), acute lymphoblastic leukemia (n=2), and acute myeloid leukemia (n=4). Patients received positive end-expiratory pressure from 25 up to 40 cmH20, with a delta pressure of 15 cmH2O for 60 seconds. We assessed blood gases pre- and post-maneuvers, as well as ventilation parameters, vital signs, hemoglobin, clinical signs of pulmonary bleeding, and radiological signs of barotrauma. Pre- and post-values were compared by the Wilcoxon test. Results: Median platelet count was 53,200/mm3. Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs. Hemoglobin levels remained stable 24 hours after ARMs, and signs of pneumothorax, pneumomediastinum, or subcutaneous emphysema were absent. Fraction of inspired oxygen decreased significantly after ARMs (FiO2; p=0.003). Oxygen partial pressure (PaO2)/FiO2 ratio increased significantly (p=0.0002), and the oxygenation index was reduced (p=0.01), but all these improvements were transient. Recruited patients’ 28-day mortality was 58%. Conclusions: ARMs, although feasible in the context of thrombocytopenia, lead only to transient improvements, and can cause significant hemodynamic instability. RESUMO Objetivo: A síndrome do desconforto respiratório agudo (SDRA) pode ser uma condição devastadora em crianças com câncer e as manobras de recrutamento alveolar (MRA) podem melhorar a oxigenação e a sobrevida. O objetivo foi avaliar a viabilidade das MRA em crianças gravemente doentes com câncer e SDRA. Métodos: Analisamos retrospectivamente 31 manobras em 12 pacientes (idade mediana de 8,9 anos), com tumores sólidos (n=4), linfomas (n=2) e leucemias linfoide (n=2) e mieloide agudas (n=4). Os pacientes receberam pressão expiratória final positiva de 25 a 40 cmH20, com delta de pressão de 15 cmH2O por 60 segundos. Gasometrias foram analisadas pré e pós-manobras, bem como os parâmetros de ventilação, sinais vitais, hemoglobina, sinais clínicos de sangramento pulmonar e sinais radiológicos de barotrauma. Valores foram comparados com o teste de Wilcoxon. Resultados: A contagem mediana de plaquetas era de 53.200/mm3. Após as manobras, em dois pacientes, a pressão arterial média declinou mais de 20%, e quatro necessitaram de aumento de drogas vasoativas. A hemoglobina permaneceu estável 24 horas após a MRA, sem sinais de pneumotórax, pneumomediastino ou enfisema subcutâneo. Houve diminuição significativa nas frações inspiradas de oxigênio (FiO2; p=0,003). A relação pressão arterial de oxigênio (PaO2)/FiO2 aumentou (p=0,002), e o índice de oxigenação caiu (p=0,01), mas essas melhoras foram transitórias. A mortalidade em 28 dias foi de 58%. Conclusões: As MRA, embora viáveis no contexto da trombocitopenia, levam apenas a melhorias transitórias e podem causar instabilidade hemodinâmica significativa.

Objective: To evaluate the clinical course and respiratory parameters of mechanically ventilated children with cancer suffering from sepsis-related acute respiratory distress syndrome. Methods: This 2-year prospective, longitudinal, observational cohort study enrolled 29 children and adolescents. Clinical data, measurements of blood gases and ventilation parameters were collected at four different time points. Fluctuations between measurements as well as differences in estimated means were analyzed by linear mixed models in which death within 28 days from the onset of acute respiratory distress syndrome was the primary endpoint. Results: There were 17 deaths within 28 days of acute respiratory distress syndrome onset and another 7 between 29 - 60 days. Only 5 patients survived for more than 60 days. Nine (31%) patients died as a direct consequence of refractory hypoxemia, and the others died of multiple organ failure and catecholamine-refractory shock. In 66% of the measurements, the tidal volume required to obtain oxygen saturation equal to or above 90% was greater than 7mL/kg. The estimated means of dynamic compliance were low and were similar for survivors and non-survivors but with a negative slope between the first and final measurements, accompanied by a negative slope of the tidal volume for non-survivors. Non-survivors were significantly more hypoxemic, with PaO2/FiO2 ratios showing lower estimated means and a negative slope along the four measurements. Peak, expiratory and mean airway pressures showed positive slopes in the non-survivors, who also had more metabolic acidosis. Conclusions: In most of our children with cancer, sepsis and acute respiratory distress syndrome progressed with deteriorating ventilation indexes and escalating organic dysfunction, making this triad nearly fatal in children.

To obtain pharmacokinetic and pharmacodynamic data for vancomycin in a cohort of critically ill pediatric oncology patients, we analyzed 256 measurements of vancomycin concentrations in 94 patients. Variables were tested as possible risk factors for vancomycin-related nephrotoxicity or death for 28 days. We found the following: mean vancomycin trough serum concentration, 15.6 ± 12.4 μg/mL; mean vancomycin clearance, 0.16 ± 0.098 L/h/kg; and mean vancomycin distribution volume, 1.04 ± 0.11 L/kg. Only 13.6% of serum trough level measurements were between 15 and 20 μg/mL. The trough levels showed a strong correlation with the AUC (area under the curve of serum concentrations vs. time over 24 h to the minimum inhibitory concentration ratio), with a 94% positive predictive value for AUC/MIC ≥ 400, but only for MIC=1. The doses that are currently used (60 mg/kg/d) attained the therapeutic target (AUC/MIC ≥ 400) in only 56% of measurements, considering MIC=1. A serum trough level of ≥ 20 μg/mL was an independent risk for nephrotoxicity (P = 0.0008; odds ratio = 17.83). Vancomycin-related nephrotoxicity was a predictor of death for up to 28 days (P = 0.003, odds ratio = 7.68). Currently administered doses of vancomycin do not reach the therapeutic target for critical cancer patients, particularly if staphylococci isolates have a MIC>1.

BACKGROUND: Usual treatment regimens with vancomycin often fail to provide adequate serum levels in patients with severe infections. METHODS: Retrospective analysis of vancomycin trough serum measurements. The following parameters were calculated by Bayesian analysis: vancomycin clearance, distribution volume, and peak estimated concentrations. The area under the concentration curve (AUC) (total daily dose/24 h clearance of vancomycin) was used to determine the effectiveness of treatment through the ratio of AUC/minimum inhibitory concentration (MIC) above 400, using MIC = 1 µg/mL, based on isolates of Staphylococci in cultures. RESULTS: Sixty-one vancomycin trough measurements were analyzed in 31 patients. AUC/MIC > 400 was obtained in 34 out of 61 dosages (55.7%), but the mean vancomycin dose required to achieve these levels was 81 mg/kg/day. In cases where the usual doses were administered (40-60 mg/kg/day), AUC/MIC > 400 was obtained in nine out of 18 dosages (50%), in 13 patients. Trough serum concentrations above 15 mg/L presented a positive predictive value of 100% and a negative predictive value of 71% for AUC/MIC > 400. CONCLUSION: Higher than usual vancomycin doses may be required to treat staphylococcal infections in children with oncologic/hematologic diseases. Since the best known predictor of efficacy is the AUC/MIC ratio, serum trough concentrations must be analyzed in conjunction with MICs of prevalent Staphylococci and pharmacokinetic tools such as Bayesian analysis.

We analyzed retrospectively the neuroimaging exams of children with a confirmed diagnosis of dyslexia and correlated our findings with the evaluation of higher cortical functions. We studied 34 medical files of patients of the Ambulatory of Neuro-difficulties in Learning, FCM/UNICAMP. All of them had been sent to the ambulatory with primary or secondary complaints of difficulties at school and were submitted to neuropsychological evaluation and imaging exam (SPECT). From the children evaluated 58.8% had exams presenting dysfunction with 47% presenting hypoperfusion in the temporal lobe. As for the higher cortical functions, the most affected abilities were reading, writing and memory. There was significance between the hypoperfused areas and the variables schooling, reading, writing, memory and mathematic reasoning. The SPECTs showed hypoperfusion in areas involved in the reading and writing processes. Both are equivalent in terms of involved functional areas and are similar in children with or without specific dysfunctions in neuroimaging. Analisamos retrospectivamente exames de neuroimagem de crianças com diagnóstico de dislexia e correlacionamos os achados com avaliação das funções corticais superiores. Estudamos 34 prontuários de pacientes atendidos no Ambulatório de Neuro-Dificuldades de Aprendizado, FCM/UNICAMP, no período de 1994 a 2002. Todas foram encaminhadas com queixa primária ou secundária de dificuldade escolar e submetidas à avaliação neuropsicológica e exame de imagem (SPECT). Das crianças avaliadas, 58,8% apresentaram exames alterados. Dentre as alterações, 16 possuíam hipoperfusão no lobo temporal. Nas funções corticais superiores, as habilidades mais prejudicadas foram leitura, escrita e memória. Houve significância entre as áreas hipoperfundidas com a variável escolaridade, leitura, escrita, memória e raciocínio matemático. Os SPECTs mostraram hipoperfusão em áreas envolvidas nos processos de leitura/escrita. Ambos se equivalem em termos de áreas funcionais e são semelhantes nas crianças com e sem alterações específicas à neuroimagem.

Background and aims Little is known about drugs pharmacokinetics and pharmodynamics in children. Renal and hepatic functions are not mature yet. Many drugs are used “off-label”. So, children are more susceptible to adverse drug events (ADE) than adults. As many drugs are used in pediatric intensive care units (PICU), we expect to find many ADE in this setting. Our aims are to describe ADE found in PICU and identify risk factors for their development. Methods Six-month prospective cohort of all patients admitted to a single PICU. ADE were identified by active search and classified by Naranjo’s algorithm. Risk factors were identified by multivariate analysis. Results 240 pediatric admissions occurred and 110 ADE were observed in 84 patients. Median age was 51 months. Only 39 of 240 patients didn’t have chronic status. Principal ADE were hyponatremia, hyperglycemia, hypokalemia. Drugs involved in most ADE were antibiotics, diuretics, antiepileptic, sedatives and analgesics and steroids. Age under 4 years, length of stay in PICU and number of drugs used are risk factors to ADE. Conclusions There were 64.7 ADE/1000 patients-day in the present study. Hyponatremia, hypokalemia and hyperglycemia are the commonest ADE found. Age under 4, length of stay in PICU and number of drugs used are risk factors to ADE development.

Objectives: To describe adverse drug events (ADEs) in children under intensive care, identify risk factors and tools that can detect ADEs early, and the impact on length of stay (LOS). Design: A prospective observational study. Setting: Paediatric intensive care unit of a tertiary care teaching hospital. Patients: 239 patients with a mean age of 67.5 months representing 1818 days of hospitalisation in intensive care unit. Interventions: Active search of charts and electronic patient records using triggers. The statistical analysis involved linear and logistic regression. Measurements and main results: The average LOS was 7.6 days. There were 110 proven, probable and possible ADEs in 84 patients (35.1%). We observed 138 instances of triggers. The major classes of drugs associated with events were: antibiotics (n=41), diuretics (n=24), antiseizures (n=23), sedatives and analgesics (n=17) and steroids (n=18). The number of drugs administered was most related to the occurrence of ADEs and also to the LOS (p