Temporal trends and spatial clusters of high risk for maternal death due to COVID-19 pre and during COVID-19 vaccination in Brazil: a national population-based ecological study

OBJECTIVE

This study comprehensively analyzed the temporal and spatial dynamics of COVID-19 cases and deaths within the obstetric population in Brazil, comparing the periods before and during mass COVID-19 vaccination. We explored the trends and geographical patterns of COVID-19 cases and maternal deaths over time. We also examined their correlation with the SARS-CoV-2 variant circulating and the social determinants of health.

STUDY DESIGN

This is a nationwide population-based ecological study.

METHODS

We obtained data on COVID-19 cases, deaths, socioeconomic status, and vulnerability information for Brazil's 5570 municipalities for both the pre-COVID-19 vaccination and COVID-19 vaccination periods. A Bayesian model was used to mitigate indicator fluctuations. The spatial correlation of maternal cases and fatalities with socioeconomic and vulnerability indicators was assessed using bivariate Moran.

RESULTS

From March 2020 to June 2023, a total of 23,823 cases and 1991 maternal fatalities were recorded among pregnant and postpartum women. The temporal trends in maternal incidence and mortality rates fluctuated over the study period, largely influenced by widespread COVID-19 vaccination and the dominant SARS-CoV-2 variant. There was a significant reduction in maternal mortality due to COVID-19 following the introduction of vaccination. The geographical distribution of COVID-19 cases and maternal deaths exhibited marked heterogeneity in both periods, with distinct spatial clusters predominantly observed in the North, Northeast, and Central West regions. Municipalities with the highest Human Development Index reported the highest incidence rates, while those with the highest levels of social vulnerability exhibited elevated mortality and fatality rates.

CONCLUSION

Despite the circulation of highly transmissible variants of concern, maternal mortality due to COVID-19 was significantly reduced following the mass vaccination. There was a heterogeneous distribution of cases and fatalities in both periods (before and during mass vaccination). Smaller municipalities and those grappling with social vulnerability issues experienced the highest rates of maternal mortality and fatalities.

Multitargeted molecular docking and dynamics simulation studies of flavonoids and volatile components from the peel of Citrus sinensis L. (Osbeck) against specific tumor protein markers

Citrus sinensis (L.) Osbeck (Rutaceae), commonly known as the sweet orange, is a popular and widely consumed fruit with several medicinal properties. The present study aimed to perform the in silico screening of 18 flavonoids and eight volatile components from the peel of C. sinensis against apoptotic and inflammatory proteins, metalloprotease, and tumor suppressor markers. Flavonoids obtained higher probabilities than volatile components against selected anti-cancer drug targets. Hence, the data from the binding energies against the essential apoptotic and cell proliferation proteins substantiate that they may be promising compounds in developing effective candidates to block cell growth, proliferation, and induced cell death by activating the apoptotic pathway. Further, the binding stability of the selected targets and the corresponding molecules were analyzed by 100 ns molecular dynamics (MD) simulations. Chlorogenic acid has the most binding affinity against the important anti-cancer targets iNOS, MMP-9, and p53. The congruent binding mode to different drug targets focused on cancer shown by chlorogenic acid suggests that it may be a compound with significant therapeutic potential. Moreover, the binding energy predictions indicated that the compound had stable electrostatic and van der Waal energies. Thus, our data reinforce the medicinal importance of flavonoids from C. sinensis and expand the need for more studies, seeking to optimize results and amplify the impacts of further in vitro and in vivo studies. Communicated by Ramaswamy H. Sarma.

Prevalence and Risk Factors for Dysphonia in Preschoolers at Five Years Old in a Capital City in the Northeast of Brazil

GOALS

Identifying the prevalence and risk factors of childhood dysphonia in children turning 5 years old; and assess the link with the interactional, behavioral, sociodemographic, economic, and biological indicators METHOD: Analytical, transversal, nested within a birth cohort 5 years after its creation. Original cohort biologic data were recovered from the previous database. The current demographic and personal data were acquired from the official health institutions where the individuals were found. We managed to find 371 preschoolers, both sexes, enrolled in 141 public and private schools. Face-to-face interviews were performed with mothers regarding maternal and child health and biological, sociodemographic, economic, interactional-affective, and behavioral indicators. Speech therapists used the Consensus of Auditory-Perceptual Evaluation of Voice authorized for Portuguese for the perceptual-auditory judgment of children's voices. Bivariate and multivariate analyzes of the data were performed. A significance level of 5% (P < 0.05) was considered in all analyses.

RESULTS

The prevalence of mild-moderate general dysphonia occurred in 26.4% of the preschoolers assessed with tense, rough, and breathy voice quality; low pitch; strong loudness and laryngeal resonance. There was a contrast between preschoolers with dysphonia, calm temperament, and family income of up to three minimum wages and those without these characteristics. We also have noted that a greater chance of dysphonia occurred in preschoolers with a calm temperament, family income of up to three minimum wages, nocturnal bruxism up to 3 years old and who did not use a pacifier.

CONCLUSION

There was a high prevalence of dysphonia at 5 years old. Biological indicators have an impact on voice, while interactional, behavioral, sociodemographic, and economic indicators have a higher impact. There is a great need for investments in prevention, promotion, and vocal treatment to minimize negative socio-educational impacts and provide higher quality of life for children at greater risk for dysphonia.

Live, Attenuated, Tetravalent Butantan-Dengue Vaccine in Children and Adults

BACKGROUND

Butantan-Dengue Vaccine (Butantan-DV) is an investigational, single-dose, live, attenuated, tetravalent vaccine against dengue disease, but data on its overall efficacy are needed.

METHODS

In an ongoing phase 3, double-blind trial in Brazil, we randomly assigned participants to receive Butantan-DV or placebo, with stratification according to age (2 to 6 years, 7 to 17 years, and 18 to 59 years); 5 years of follow-up is planned. The objectives of the trial were to evaluate overall vaccine efficacy against symptomatic, virologically confirmed dengue of any serotype occurring more than 28 days after vaccination (the primary efficacy end point), regardless of serostatus at baseline, and to describe safety up to day 21 (the primary safety end point). Here, vaccine efficacy was assessed on the basis of 2 years of follow-up for each participant, and safety as solicited vaccine-related adverse events reported up to day 21 after injection. Key secondary objectives were to assess vaccine efficacy among participants according to dengue serostatus at baseline and according to the dengue viral serotype; efficacy according to age was also assessed.

RESULTS

Over a 3-year enrollment period, 16,235 participants received either Butantan-DV (10,259 participants) or placebo (5976 participants). The overall 2-year vaccine efficacy was 79.6% (95% confidence interval [CI], 70.0 to 86.3) - 73.6% (95% CI, 57.6 to 83.7) among participants with no evidence of previous dengue exposure and 89.2% (95% CI, 77.6 to 95.6) among those with a history of exposure. Vaccine efficacy was 80.1% (95% CI, 66.0 to 88.4) among participants 2 to 6 years of age, 77.8% (95% CI, 55.6 to 89.6) among those 7 to 17 years of age, and 90.0% (95% CI, 68.2 to 97.5) among those 18 to 59 years of age. Efficacy against DENV-1 was 89.5% (95% CI, 78.7 to 95.0) and against DENV-2 was 69.6% (95% CI, 50.8 to 81.5). DENV-3 and DENV-4 were not detected during the follow-up period. Solicited systemic vaccine- or placebo-related adverse events within 21 days after injection were more common with Butantan-DV than with placebo (58.3% of participants, vs. 45.6%).

CONCLUSIONS

A single dose of Butantan-DV prevented symptomatic DENV-1 and DENV-2, regardless of dengue serostatus at baseline, through 2 years of follow-up. (Funded by Instituto Butantan and others; DEN-03-IB ClinicalTrials.gov number, NCT02406729, and WHO ICTRP number, U1111-1168-8679.).

Anti-inflammatory natural products modulate interleukins and their related signaling markers in inflammatory bowel disease: A systematic review

This review aims to identify in vivo studies investigating the potential of plant substances and their natural molecules in managing inflammatory bowel disease (IBD). Specifically, the objective is to examine the impact of these substances on interleukins and other key inflammatory signaling markers. Relevant articles published up to December 2022 were identified through a search of the PubMed, Scopus, Web of Science, and Embase databases. The search used keywords including "inflammatory bowel disease", "medicinal plants", "natural molecules", "anti-inflammatory", and "ulcerative colitis", and identified 1,878 potentially relevant articles, of which 89 were included in this review after completion of the selection process. This study provides preclinical data on natural products (NPs) that can potentially treat IBD, including ulcerative colitis. The main actions of these NPs relate to their effects on nuclear factor kappa B (NF-κB), the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling pathway, the regulation of T helper 17/regulatory T cells balance, and oxidative stress. The ability of these NPs to inhibit intestinal inflammation appears to be dependent on lowering levels of the pro-inflammatory cytokines tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, and IL-17, via the Jun N-terminal kinase (JNK)1, NF-κβ-p65, and STAT3 pathways. In addition, NPs were shown to reduce oxidative stress and the severity of ulcerative colitis, as well as increase the activity of antioxidant enzymes. These actions suggest that NPs represent a promising treatment for IBD, and potentially have greater efficacy and safety than current treatments.

Growth and Nutritional Biomarkers in Brazilian Infants with Cow's Milk Allergy at Diagnosis and 18-Month Follow-Up: A Prospective Cohort Study

Purpose

This study aimed to describe the growth, body protein status, and micronutrient biomarkers of Brazilian infants with cow's milk allergy (CMPA) at baseline and at 18 months of follow-up in comparison with their healthy peers.

Methods

Thirty infants with CMPA younger than six months of age were included in this longitudinal study, and their nutritional status was compared with that of 24 non-allergic age-matched children. Anthropometric measurements were used to assess growth, and blood and urine samples were analyzed for protein and micronutrient status. Mixed linear models adjusted for birth weight, socioeconomic status, infant feeding at baseline, weight-for-age, C-reactive protein, serum albumin, micronutrient dietary supplementation, and salt consumption were employed to evaluate the evolution of nutritional parameters throughout the follow-up period.

Results

Overall, the mean age of the children at enrolment was 2.9 (standard deviation 1.7) months, and 29 children (53.7%) were male. Infants with CMPA showed a higher prevalence of functional iron depletion (transferrin saturation <20) (p=0.027), lower serum ferritin (p=0.009), and lower urinary iodine (p=0.034) levels than non-allergic children at baseline. Patients with CMPA showed a higher increment in weight-for-age and length-for-age over time than those in the control group (p<0.01). Mixed linear analyses showed a significantly lower increase in serum vitamin B12 (s-B12) (p=0.001) and urinary iodine (p<0.001) concentrations over time compared to the control group.

Conclusion

Infants with CMPA on a cow's milk elimination diet had a higher weight and length at 18 months of follow-up but showed signs of inadequate iron, iodine, and B-12 vitamin status.

The Use of Nanocarriers to Enhance the Anti-neuroinflammatory Potential of Dietary Flavonoids in Animal Models of Neurodegenerative Diseases: A Systematic Review

BACKGROUND

Neurodegenerative diseases (NDs) have become a common and growing cause of mortality and morbidity worldwide, especially in older adults. The natural flavonoids found in fruits and vegetables have been shown to have therapeutic effects against many diseases, including NDs; however, in general, flavonoids have limited bioavailability to the target cells. One promising strategy to increase bioavailability is to entrap them in nanocarriers.

OBJECTIVE

This article aims to review the potential role of nanocarriers in enhancing the anti-neuroinflammatory efficacy of flavonoids in experimentally induced ND.

METHODS

A literature search was conducted in the scientific databases using the keywords "neurodegenerative", "anti-neuroinflammatory", "dietary flavonoids," "nanoparticles", and "therapeutic mechanisms".

RESULTS

A total of 289 articles were initially identified, of which 45 articles reported on flavonoids. After completion of the selection process, five articles that met the criteria of the review were selected for analysis. Preclinical studies identified in this review showed that nanoencapsulated flavonoids attenuated cognitive impairment and seizure, improved behavioral patterns, and reduced levels of astrocytes. Importantly, they exhibited strong antioxidant properties, increasing the levels of antioxidant enzymes and reducing oxidative stress (OS) biomarkers. Moreover, nanocarrier-complexed flavonoids decreased the levels of the pro-inflammatory cytokines, interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α), by inhibiting nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and nod-like receptor protein 3 inflammasome activation (NLRP3). They also had remarkable effects on important ND-related neurotransmitters, improved cognitive function via cholinergic neurotransmission, and increased prefrontal cortical and hippocampal norepinephrine (NE) and 5-hydroxytryptamine (5-HT).

CONCLUSION

Nanoencapsulated flavonoids should, therefore, be considered a novel therapeutic approach for the treatment of NDs.

Juvenile xanthogranuloma as a differential diagnosis for sellar and suprasellar lesions in child: Case report and review of literature

Juvenile xanthogranuloma (JXG) is a rare type of non-Langerhans cell histiocytosis. Its systemic form affects 4% of patients. Lesions in the Central Nervous System (CNS) occur in 2% of systemic cases. Sellar JXG should be one of the differential diagnoses for sellar lesions in young. This is a 15-year-old patient with non-specific headache, progressive visual loss and magnetic resonance imaging showing sellar lesion with suprasellar extension. The patient underwent microsurgery by pterional craniotomy with partial resection of the tumor. Pathology evidenced JXG. It progressively evolved with impairment of neuroendocrine functions, new lesions in different CNS locations and death two years after diagnosis. Sellar JXG without cutaneous manifestations is rare. There are no specific findings of the disease. Diagnosis requires additional tests, being defined by pathological analysis. Total resection presents a greater potential control comparing to partial resection. Even so, some patients may have progressive disease with poor clinical outcome.

Pediatric Dysphonia and the Access to Voice Therapy: A Study in Speech Therapy Services Available in a Capital City in the Northeast of Brazil

OBJECTIVES

Defining the laryngeal and vocal alterations in the pediatric group studied in private speech therapy facilities; and estimating the time period between the problem being identified by the parents and the access to the proper provided services.

METHODS

A cross-sectional analytical observational research with data collected from medical records by the speech therapist of each private facility. A written form was prepared and sent to the speech therapists of the 40 existing facilities. We received 124 of them from the pediatric group being assisted in 15 of the facilities. The form included questions about gender, age, vocal complaints; general degree of dysphonia; otorhinolaryngological diagnosis of vocal fold alterations; the age that the problem was identified by the parents and the beginning of speech therapy. The larynx was examined by videonasopharyngolaryngoscopy, and voice quality by auditory-perceptual assessment.

RESULTS

The time period between the identification of the participant's dysphonia by the parents and the start of speech therapy was considered long (3.5years). The group showed variance in the proportion of nodule and cyst between genders. The highest prevalence of nodules occurred in boys; and the cyst in girls. Moderate general dysphonia occurred between 4 and 17years old, average age of 7years and 7months, with greater distribution between 5 and 10years of age.

CONCLUSIONS

The average time delay until the start of speech therapy was 3.5years, more frequently in the 5-10years group and due to nodules in boys and cysts in girls.

Impact of the Koala Project on clinical outcomes of preterm infants in two maternity hospitals

OBJECTIVE

To describe the impact of the Koala project (Actively Controlling Target Oxygen) on clinical outcomes in patients born with less than 36 weeks of gestation, in two maternity hospitals, comparing before and after the strategy implementation.

METHODS

This is an intervention study with 100 preterm infants with gestational age ≤36 weeks, who used oxygen in two maternity hospitals between January 2020 and August 2021. One of the hospitals was a private institution and the other was philanthropic. The goal for the target oxygen saturation with this project was 91-95%. Comparisons between the two stages (before and after the implementation of the project) were made evaluating the outcomes of retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, and deaths. The continuous variables were described using mean, median, standard deviation and interquartile interval. The significance level adopted was 5% and the software used was R Core Team 2021 (version 4.1.0).

RESULTS

After oxygen control use according to the Koala protocol, there was a significant reduction in the cases of retinopathy of prematurity (p<0.001) and bronchopulmonary dysplasia (p<0.001). There were no deaths in the second stage, and there was a non-significant increase in the absolute number of necrotizing enterocolitis cases.

CONCLUSIONS

The Koala project seems to be an effective and feasible strategy to reduce adverse situations in the management of premature children, but research with a greater sample is needed.

Health functions and related molecular mechanisms of Miconia genus: A systematic review

The Miconia genus is traditionally used in folk medicine in Brazil and other tropical American countries and is represented by 282 species in this region. It is a multifaceted genus of medicinal plants widely used to treat rheumatoid arthritis (RA), pain, inflammatory diseases, and many more therapeutic applications. In the present study, we systematically identify and discuss the literature on in vivo and in vitro studies focusing on the therapeutic potentials and related molecular mechanisms of the Miconia genus. The review also assessed phytochemicals and their pharmacological properties and considered safety concerns related to the genus. Literature searches to identify studies on the Miconia genus were carried out through four main electronic databases, namely PubMed, Embase, Scopus, and Web of Science limited to Medical Subjects Headings (MeSH) and Descriptores en Ciencias de la Salud (DCS) (Health Sciences Descriptors) to identify studies published up to December 2022. The relevant information about the genus was gathered using the keywords 'Miconia', 'biological activities', 'therapeutic mechanisms', 'animal model, 'cell-line model', 'antinociceptive', 'hyperalgesia', 'anti-inflammatory', and 'inflammation'. The therapeutic potentials and mechanisms of action of 14 species from genus Miconia were examined in 18 in vitro studies and included their anti-inflammatory, anticancer, analgesic, antibacterial, cytotoxic, mutagenic, antioxidant, anti-leishmanial, antinociceptive, schistosomicidal, and anti-osteoarthritis potentials, and in eight in vivo studies, assessing their analgesic, antioxidant, antinociceptive, and anti-osteoarthritis activities. Some of the main related molecular mechanisms identified are the modulation of cytokines such as IL-1β, IL-6, and TNF-α, as well as the inhibition of inflammatory mediators and prostaglandin synthesis. The limited number of studies showed that commonly available species from the genus Miconia are safe for consumption. Miconia albicans Sw.Triana and Miconia rubiginosa (Bonpl.) DC was the most frequently used species and showed significant efficacy and potential for developing safe drugs to treat pain and inflammation.

Spatial clusters, social determinants of health and risk of COVID-19 mortality in Brazilian children and adolescents: A nationwide population-based ecological study

Background

Data regarding the geographical distribution of cases and risk factors for COVID-19 death in children and adolescents are scarce. We describe the spatial distribution of COVID-19 cases and deaths in paediatric population and their association with social determinants of health in Brazil.

Methods

This is a population-based ecological study with a spatial analysis of all cases and deaths due to COVID-19 in Brazil among children and adolescents aged 0-19 years from March 2020 to October 2021. The units of analysis were the 5570 municipalities. Data on COVID-19 cases and deaths, social vulnerability, health inequities, and health system capacity were obtained from publicly available databases. Municipalities were stratified from low to very high COVID-19 incidence and mortality using K-means clustering procedures, and spatial clusters and relative risks were estimated using spatial statistics with Poisson probability models. The relationship between COVID-19 estimates and social determinants of health was explored by using multivariate Beta regression techniques.

Findings

A total of 33,991 COVID-19 cases and 2424 deaths among children and adolescents aged 0-19 years were recorded from March 2020 to October 2021. There was a spatial dependence for the crude mortality coefficient per 100,000 population in the paediatric population aged 0-19 years (I Moran 0·10; P < 0·001). Forty municipalities had higher mortality rates, of which 20 were in states from the Northeast region. Seven spatial clusters were identified for COVID-19 mortality, with four clusters in the Northeast region and three in the North region. Municipalities with higher social inequality and vulnerability had higher COVID-19 mortality in the paediatric population.

Interpretation

The main clusters of risk for mortality among children and adolescents were identified in municipalities in the North and Northeast regions, which are the regions with the worst socioeconomic indicators and greatest health disparities in the country. Our findings confirmed the higher burden of COVID-19 for Brazilian paediatric population in municipalities with higher social inequality and vulnerability and worse socioeconomic indicators. To reduce the burden of COVID-19 on children, mass immunisation is necessary.

Funding

None.

Natural products modulating interleukins and other inflammatory mediators in tumor-bearing animals: A systematic review

BACKGROUND

Cancer is a group of diseases characterized by abnormal cell growth and proliferation. Natural products are a potentially important source for bioactive phytochemicals in the management of cancer, which regulate a broad range of biological events via the modulation of interleukins (ILs), pro- and anti-inflammatory modulators, and other cancer hallmark-mediated signaling pathways.

PURPOSE

To systematically review the literature to identify in vivo studies investigating the anticancer properties of medicinal plants and natural molecules as modulators of ILs and their related pro- and anti-inflammatory signaling markers in tumor-bearing animals.

METHODS

Articles published in English were searched, without any constraint in respect of countries. The electronic databases PubMed, Embase, Scopus, and Web of Science were used for the literature search for studies published between January 2010 and January 2022. The search terms used included medicinal plants, anticancer, antineoplasic agent, ILs, cytokine, and their combinations. A manual search to detect any articles not found in the databases was also made. The identified studies were then critically reviewed and relevant data were extracted and summarized.

RESULTS

Natural products were found to modulate ILs, including IL-1β, IL-2, IL-4, IL-6, IL-8, IL-18, IL-23, and IL-12, and interferon gamma; increase tissue inhibitor metalloprotease; decrease vascular endothelial growth factor, tumor necrosis factor alpha, granulocyte macrophage colony-stimulating factor, and nuclear factor kappa B; augment immunity by increasing the major histocompatibility complexes II and CD4+, cluster of differentiation 8 + T cell and class II trans-activator expression; and heighten the action of antioxidant enzymes, which are involved in the detoxification of free radicals and reactive oxygen species.

CONCLUSION

Natural products discussed in this review show great potential to regulate ILs and weaken associated pro- and anti-inflammatory signaling markers in tumor-bearing animals. Flavonoids, polyphenols, polysaccharides, alkaloids and tannins are important phytochemicals in the modulation of ILs, especially pro-inflammatory ones. However, in terms of future research, the importance of clinical trials to investigate their beneficial properties should be warranted.

Clinical characteristics and risk factors for maternal deaths due to COVID-19 in Brazil: a nationwide population-based cohort study

BACKGROUND

Monitoring the characteristics and associated factors for death among pregnant and postpartum women with coronavirus disease 19 (COVID-19) is necessary. We investigated the clinical characteristics and risk factors associated with maternal deaths in a nationwide cohort of Brazil.

METHODS

This was a population-based cohort of all pregnant and postpartum women hospitalised with COVID-19 notified to the Sistema de Informação de Vigilância Epidemiológica da Gripe of Brazil (SIVEP-Gripe), from February 2020 to September 2021. The primary outcome was time to in-hospital death, with risk factors analysed with univariable and multivariable Cox proportional hazards regression models.

RESULTS

Cumulative observation time was 248 821 person-days from hospital admission to the end of follow-up for 15 105 individuals. There were 1858 deaths (12.3%) for a maternal mortality rate of 7.5 (95% CI 7.1-7.8) per 1000 patients-days. The cumulative mortality increased over time. Black/Brown ethnicity had a higher risk of death than women self-identifying as White. Women in the North, Northeast, Central-West and Southeast regions had higher risk of death than women in the South region. The characteristics independently associated with death were a postpartum status on admission [adjusted hazard ratio, HR 1.4 (95% confidence interval, CI 1.2-1.6)], pre-existing clinical conditions [adjusted HRs 1.2 (95%CI 1.1-1.3) for one and 1.3 (95%CI 1.1-1.5) for two comorbidities], hypoxaemia on admission [adjusted HR 1.2 (95%CI 1.1-1.4)] and requiring non-invasive [adjusted HR 2.6 (95%CI 2.1-3.3)] or invasive ventilatory support [adjusted HR 7.1 (95%CI 5.6-9.2)].

CONCLUSION

In Brazil, the in-hospital maternal mortality rate due to COVID-19 is high and the risk of death increases with the length of hospitalisation. Socio-demographic and biological factors are associated with an increased risk of maternal death. The presence of respiratory signs and symptoms should be considered early markers of disease severity and an adequate management is necessary. Our findings reinforce the need for vaccination of pregnant and postpartum women against COVID-19.

Effects of the COVID-19 pandemic on routine pediatric vaccination in Brazil

BACKGROUND

COVID-19 pandemic has disrupted health services, including vaccination demand. We describe the impact of the COVID-19 pandemic on routine pediatric vaccination in Brazil.

METHODS

We conducted a retrospective analysis of all vaccine doses provided to children aged 0-6 years from January 2019 to December 2020. We obtained data stratified by age group (0 to 2 years and >2 to 6 years) and Brazilian region. Difference-in-difference (DiD) analyses were performed to compare vaccine uptake in the pre-pandemic (January-February), stay-at-home (March-June), and reopening (July-December) periods.

RESULTS

The number of vaccine doses administered declined in the stay-at-home period. For children aged 0 to 2 years, the highest reductions were recorded in the North (-25.3%), Northeast (-16.8%) and Central-West (-10.2%) regions. For children aged >2 to 6 years, the highest decline was observed in the North (DiD = -27.2%) and South (DiD = -14.0%) regions. The number of vaccine doses administered in the reopening period has slightly increased in all regions.

CONCLUSIONS

Vaccination decreased during the COVID-19 pandemic. Although the number of doses recovered in part during the reopening phase, additional strategies, such as increased public awareness and vaccination booster campaigns are required.

Engaging local health research communities to enhance long-term capacity building in Brazil

The '2019 Research Capacity Network (REDe) workshop series' was an initiative led by Brazil-based REDe coordinators and The Global Health Network (TGHN) in partnership with Brazilian researchers interested in arboviruses. This workshop initiative has provided crucial training to the local research community offering transferable skills to effectively respond to health emergencies, with an impact beyond arboviral diseases, as evidenced by further activities undertaken during the COVID-19 pandemic. The success of this approach resulted from several factors, especially the workshops' local leadership and the combination of in-person training with online sharing of the resources generated in the local language. Analytics data from REDe online platform evidenced the wider reach of the shared resources to a larger audience than the workshop attendees. Importantly, the impact of this approach extends beyond the workshop series per se, with workshop participants afforded access to wider training, career development and collaborative opportunities through REDe and TGHN platforms. In addition, this initiative design resulted in the development of new collaborations between the workshop leaders and other local researchers, who have been jointly writing research projects and applying for grants. As a result, REDe has become a highly dynamic community of practice for health researchers in the region, strengthening the research culture and improving connectivity. Here, we describe the design and implementation of this initiative and demonstrate the value of integrating local expertise, and a practical workshop series format with digital dissemination of research resources and training materials to generate a vibrant and robust community of practice.

Spatial clusters, social determinants of health and risk of maternal mortality by COVID-19 in Brazil: a national population-based ecological study

BACKGROUND

Detailed information on how socio-economic characteristics are related to COVID-19 incident cases and maternal deaths is needed. We investigated the spatial distribution of COVID-19 cases and maternal deaths in Brazil and their association with social determinants of health.

METHODS

This was a population-based ecological study with a spatial analysis of all cases and deaths of COVID-19 in the obstetric population. Data on COVID-19 cases and deaths in the obstetric population, social vulnerability, health inequities, and health system capacity at the municipal level were obtained from several publicly sources in Brazil. A Bayesian empirical local model was used to identify fluctuations of the indicators. Spatial statistic tests were used to identity the spatial clusters and measure the municipalities' risk of COVID-19 in the obstetric population. Beta regression was used to characterise the association between socio-economic indicators and the burden of COVID-19.

FINDINGS

A total of 13,858 cases and 1,396 deaths due to COVID-19 were recorded in Brazil from March 2020 to June 2021. There was a variation in the number of cases per municipality, with 105 municipalities with rates from 2,210 to 3,884 cases and 45 municipalities with rates from 3,884 to 7,418 cases per 100,000 live births. The maternal mortality ratio also varied widely across municipalities. There was a spatial dependence on smoothed maternal mortality rates (I Moran 0•10; P = 0•010), and 15 municipalities had higher risk of maternal deaths. Municipalities characterized by lower health resources and higher socioeconomic inequalities presented the highest rates of incidence and maternal mortality by COVID-19.

INTERPRETATION

In Brazil, COVID-19 cases and deaths in the obstetric population had a heterogeneous geographical distribution, with well-defined spatial clusters mostly located in the countryside. Municipalities with a high degree of socioeconomic dissimilarities showed higher maternal mortality rates than areas with better social and infrastructure indicators.

FUNDING

None.

Prevalence of intestinal parasitic infections in Brazil: a systematic review

INTRODUCTION

Parasitic infections are considered a major public health problem due to their associated morbimortality and negative impact on physical and intellectual development, especially in the at-risk pediatric group. Periodic prophylactic administration of antiparasitic agents against soil-transmitted helminths is recommended by the World Health Organization (WHO) to control parasitic infections and disease burden. We aimed to evaluate the prevalence of intestinal parasitic infections in Brazil.

METHODS

We performed a systematic review by searching the literature found in the PubMed, LILACS, and SciELO databases, followed by a meta-analysis of the proportions from studies published in English, Portuguese, and/or Spanish from January 2000 to May 2018. This systematic review was registered in the PROSPERO database (CRD42018096214).

RESULTS

The prevalence of intestinal parasitic infections (protozoa and/or helminths) in Brazil was 46% (confidence interval: 39-54%), with 99% heterogeneity. Prevalence varied by region: 37%, 51%, 50%, 58%, and 41% in the Southeast, South, Northeast, North, and Central-West regions, respectively. Most studies (32/40) evaluated children (<18 years) and found an average prevalence of 51%. Children also had the highest prevalence in all four regions: Central-West (65%), South (65%), North (58%), Northeast (53%), and Southeast (37%). However, most studies evaluated specific populations, which may have created selection bias. Presumably, this review of intestinal parasitic diseases in Brazil includes the most studies and the largest population ever considered.

CONCLUSIONS

The prevalence of intestinal parasitic infections is high in Brazil, and anthelmintic drugs should be administered periodically as a prophylactic measure, as recommended by the WHO.

Factors associated with extubation failure in very low birth weight infants: a cohort study in the northeast Brazil

OBJECTIVES

Identifying and understanding the main risk factors associated with extubation failure of very low birthweight (VLBW) infants in different populations can subsequently help in establishing better criteria while taking decision of extubation. The aim of the study was to identify factors associated with extubation failure in VLBW infants.

METHODS

A cohort study of VLBW infants who underwent their first extubation between April 2018 and December 2019 in a Neonatal Intensive Care Unit, Alagoas, Brazil, were included in this study. Extubation failure was defined as reintubation within seven days of extubation. Relative risks of predictive variables different between the extubation success group (ES) and extubation failure group (EF) were estimated with a robust Poisson regression model.

RESULTS

Out of the 112 infants included, 26 (23%) cases exhibited extubation failure. Extremely low birth weight (RR 2.55, 95% CI 1.07, 6.06), mechanical ventilation duration for first extubation greater than seven days (RR 2.66, 95% CI 1.10, 6.45), vaginal delivery (RR 2.07, 95% CI 1.03, 4.18) and maternal chorioamnionitis (RR 4.89, 95% CI 1.26-18.98) remained independently associated with extubation failure. EF had a significant greater need for respiratory support, longer oxygen therapy duration, more bronchopulmonary dysplasia (BPD) and longer length of hospital stay, even when adjusted for confounding variables.

CONCLUSIONS

Extremely low birth weight infants needing mechanical ventilation, wherein the duration for first extubation was longer than seven days, with vaginal delivery and maternal chorioamnionitis failed more frequently at the first attempt of extubation. And this failure increased the risk of BPD and the length of hospital stay.

SARS-CoV-2 has been circulating in northeastern Brazil since February 2020: evidence for antibody detection in asymptomatic patients

We screened stored samples collected before COVID-19 had been reported in Brazil. 989 samples were tested for SAR-CoV-2 antibodies using two different methods; 16 (1.6%) were positive (7 (43.8%) IgM, 3 (18.8%) IgG and 6 (37.5%) IgG/IgM positive), suggesting SARS-CoV-2 had circulated before the first reported COVID-19 case in Brazil.

Zika Brazilian Cohorts (ZBC) Consortium: Protocol for an Individual Participant Data Meta-Analysis of Congenital Zika Syndrome after Maternal Exposure during Pregnancy

Despite great advances in our knowledge of the consequences of Zika virus to human health, many questions remain unanswered, and results are often inconsistent. The small sample size of individual studies has limited inference about the spectrum of congenital Zika manifestations and the prognosis of affected children. The Brazilian Zika Cohorts Consortium addresses these limitations by bringing together and harmonizing epidemiological data from a series of prospective cohort studies of pregnant women with rash and of children with microcephaly and/or other manifestations of congenital Zika. The objective is to estimate the absolute risk of congenital Zika manifestations and to characterize the full spectrum and natural history of the manifestations of congenital Zika in children with and without microcephaly. This protocol describes the assembly of the Consortium and protocol for the Individual Participant Data Meta-analyses (IPD Meta-analyses). The findings will address knowledge gaps and inform public policies related to Zika virus. The large harmonized dataset and joint analyses will facilitate more precise estimates of the absolute risk of congenital Zika manifestations among Zika virus-infected pregnancies and more complete descriptions of its full spectrum, including rare manifestations. It will enable sensitivity analyses using different definitions of exposure and outcomes, and the investigation of the sources of heterogeneity between studies and regions.

Socio-economic inequalities and COVID-19 incidence and mortality in Brazilian children: a nationwide register-based study

Objectives

This study aimed to estimate the incidence and mortality rates of coronavirus disease 2019 (COVID-19) in Brazilian children and to analyze its relationship with socio-economic inequalities in a state-level analysis.

Study design

This is a nationwide register-based study.

Methods

To estimate the incidence and mortality rates of COVID-19 in Brazilian children aged 0–19 years, we extracted data of confirmed cases and deaths from the de-identified microdata catalog and official bulletins of the 27 Brazilian states' health department websites until September 3, 2020. Social and economic inequalities were evaluated using the Social Vulnerability Index and Gini coefficient, respectively. The relationship between COVID-19 rates in Brazilian children and socio-economic vulnerability at the state level was analyzed using Spearman's rank correlation.

Results

Of the 3,998,055 individuals with COVID-19 included in our database, 335,279 (8.4%) were children aged 0–19 years. Eight hundred deaths in children were registered, which accounts for about 0.7% of the deaths related to COVID-19 in the country. There were important differences in the incidence and mortality rates among Brazilian regions, and a correlation between mortality rates and social (ρ = 0.519; P-value = 0.007; effect magnitude: moderate) and economic (ρ = 0.615; P-value < 0.001; effect magnitude: strong) inequalities was found in a state-level analysis.

Conclusions

This population-based study showed important regional differences in COVID-19 estimates for children in Brazil and a relationship between mortality rates and socio-economic inequalities. The knowledge of sociogeographic differences in the estimates of COVID-19 is crucial to planning societal strategies and local decision-making to mitigate the effects of disease in the pediatric population.

•

Adverse outcomes due to coronavirus disease 2019 (COVID-19) are not only the result of individual clinical characteristics.

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This population-based study showed a relationship between mortality rates of COVID-19 among Brazilian children and socio-economic inequalities.

•

There are important regional differences in COVID-19 estimates for children in Brazil.

•

The knowledge of sociogeographic differences in the estimates of COVID-19 is crucial to planning societal strategies and local decision-making to mitigate the effects of disease in the pediatric population.

Coronavirus disease-19 deaths among children and adolescents in an area of Northeast, Brazil: why so many?

OBJECTIVE

To describe COVID-19 deaths among children and adolescents in Sergipe, Brazil.

METHODS

Ecological study of all COVID-19 reported cases and deaths occurring in children and adolescents < 19 years of age in Sergipe reported by the health surveillance and mortality information systems of Sergipe's Health Secretary and hospital records.

RESULTS

Of 37 deaths of children < 19 years old were reported up to 30 September 2020, corresponding to 4.87 deaths for 100 000 population < 19 years old. Most deaths occurred among infants (44.1/100 000), and this age group had the highest case fatality rate (15.3 %). Most children had comorbidities such as chronic neurological diseases (n = 7; 19%) and prematurity (n = 4; 11%). Most children who died (n = 18; 49%) were not admitted to intensive care units (ICUs).

CONCLUSION

COVID-19 mortality in children and adolescents in Sergipe was higher than in other Brazilian states and in high-income countries. A large proportion of the deaths occurred among children with comorbidities and a minority of children were admitted to ICU, reflecting the limited provision of such beds in the State. Newborns and infants are a high-risk group that must have priority in health public policy.

Primary Health Care in Brasil in the times of COVID-19: changes, challenges and perspectives

The pandemic of Coronavirus Disease 2019 (COVID-19) has put pressure on countries' health systems. Although attention is mostly directed at the hospital sector, since many critically ill people will need intensive care, Primary Health Care (PHC) has also been disrupted. In Brasil, a universal and free health system has existed since the 1988 Constitution, which re-organized the PHC to attend the population. However, like other countries, the Brazilian health system is being overloaded with the increase in the large number of COVID-19 cases. It is worth reflecting on the changes and challenges in PHC during the COVID-19 pandemic in Brasil.

Family COVID-19 cluster analysis of an infant without respiratory symptoms

Diagnosing cases of coronavirus disease (COVID-19) with only non-respiratory symptoms has been challenging. We reported the diagnosis of a child who tested positive for COVID-19 with abdominal pain/diarrhea and tracked his family cluster. One member of the family tested positive for COVID-19 on real-time reverse-transcription polymerase chain reaction assay and three other family members had anti-SARS-CoV-2 antibodies.

Prolonged Fecal Shedding of SARS-CoV-2 in Pediatric Patients: A Quantitative Evidence Synthesis

The aim of the study was to investigate differences in viral shedding in respiratory and fecal samples from children with novel coronavirus disease 19. We searched PubMed, SCOPUS, Embase, and Web of Science databases to identify pediatric studies comparing the pattern of fecal and respiratory shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. Summary estimates were calculated using random-effects models. Four studies reporting data from 36 children were included. A higher proportion of children had viral shedding in stools after 14 days of symptoms onset compared to respiratory samples (risk ratio = 3.2, 95% confidence interval 1.2-8.9, I2 = 51%). Viral RNA shedding was longer in fecal samples with a mean difference of approximately 9 days (mean difference = 8.6, 95% confidence interval 1.7-15.4, I2 = 77%) compared with respiratory samples. SARS-CoV-2 shedding seems to be present in feces for a longer time than in the respiratory tract of children. Although fecal SARS-CoV-2 presence in feces do not confirm its transmissibility, the high and fast spread of the novel coronavirus disease 19 worldwide indicate other transmission routes are also plausible.

Essential oils and its bioactive compounds modulating cytokines: A systematic review on anti-asthmatic and immunomodulatory properties

BACKGROUND

Asthma, the main inflammatory chronic condition affecting the respiratory system, is characterized by hyperresponsiveness and reversible airway obstruction, recruitment of inflammatory cells and excessive production of mucus. Cytokines as biochemical messengers of immune cells, play an important role in the regulation of allergic inflammatory and infectious airway processes. Essential oils of plant origin are complex mixtures of volatile and semi volatile organic compounds that determine the specific aroma of plants and are categorized by their biological activities.

PURPOSE

We reviewed whether essential oils and their bioactive compounds of plant origin could modulate cytokines' immune responses and improve asthma therapy in experimental systems in vitro and in vivo.

METHODS

Electronic and manual search of articles in English available from inception up to November 2018 reporting the immunomodulatory activity of essential oils and their bioactive compounds for the management of asthma. We used PubMed, EMBASE, Scopus and Web of Science. Publications reporting preclinical experiments where cytokines were examined to evaluate the consequence of anti-asthmatic therapy were included.

RESULTS

914 publications were identified and 13 were included in the systematic review. Four articles described the role of essential oils and their bioactive compounds on bronchial asthma using cell lines; nine in vivo studies evaluated the anti-inflammatory efficacy and immunomodulating effects of essential oil and their secondary metabolites on cytokines production and inflammatory responses. The most important immunopharmacological mechanisms reported were the regulation of cytokine production, inhibition of reactive oxygen species accumulation, inactivation of eosinophil migration and remodeling of the airways and lung tissue, modulation of FOXP3 gene expression, regulation of inflammatory cells in the airways and decreasing inflammatory mediator expression levels.

CONCLUSION

Plant derived essential oils and related active compounds have potential therapeutic activity for the treatment of asthma by modulating the release of pro-inflammatory (TNF-α, IL-1β, IL-8), Th17 (IL-17), anti-inflammatory (IL-10), Th1 (IFN-γ, IL-2, IL-12) and Th2 (IL-4, IL-5, IL-6, IL-13) cytokines and the suppression of inflammatory cell accumulation.

Modulation of interleukin expression by medicinal plants and their secondary metabolites: A systematic review on anti-asthmatic and immunopharmacological mechanisms

BACKGROUND

Asthma is one of the most common chronic inflammatory conditions of the lungs in modern society. Asthma is associated with airway hyperresponsiveness and remodeling of the airways, with typical symptoms of cough, wheezing, shortness of breath and chest tightness. Interleukins (IL) play an integral role in its inflammatory pathogenesis. Medicinal herbs and secondary metabolites are gaining considerable attention due to their potential therapeutic role and pharmacological mechanisms as adjunct tools to synthetic bronchodilator drugs.

PURPOSE

To systematically review the literature on the use of single or mixed plants extracts therapy in vivo experimental systems for asthma, emphasizing their regulations on IL production to improve lung.

METHODS

Literature searches were performed on PubMed, EMBASE, Scopus and Web of Science databases. All articles in English were extracted from 1999 up to September 2019, assessed critically for data extraction. Studies investigating the effectiveness and safety of plant extracts administered; inflammatory cell count, immunoglobulin E (IgE) production and regulation of pro-inflammatory cytokine and T helper (Th) 1 and Th2-driven cytokine expression in bronchoalveolar lavage fluid (BALF) and lung of asthmatic animals were included.

RESULTS

Four hundred and eighteen publications were identified and 51 met the inclusion criteria. Twenty-six studies described bioactive compounds from plant extracts. The most frequent immunopharmacological mechanisms described included reduction in IgE and eosinophilic recruitment, decreased mucus hypersecretion and airway hyperreactivity, enhancement of the balance of Th1/Th2 cytokine ratio, suppression of matrix metallopeptidase 9 (MMP-9) and reversal of structural alterations.

CONCLUSION

Plant extract therapies have potential control activities on asthma symptoms by modulating the secretion of pro-inflammatory (IL-1β, IL-8), Th17 (IL-17), anti-inflammatory (IL-10, IL-23, IL-31, IL-33), Th1 (IL-2, IL-12) and Th2 (IL-4, IL-5, IL-6, IL-13) cytokines, reducing the level of biomarkers of airway inflammation.

SPATIAL DISTRIBUTION OF NEWBORNS WITH SICKLE CELL TRAIT IN SERGIPE, BRAZIL

Objective:

To use the spatial distribution of the sickle cell trait (SCT) to analyze the frequency of hemoglobin S (HbS) carriers in Sergipe.

Methods:

The sample consisted of all individuals born in Sergipe from October 2011 to October 2012 who underwent neonatal screening in the public health system. Tests were carried out in basic health units and forwarded to the University Hospital laboratory, where they were analyzed. We used spatial autocorrelation (Moran’s index) to assess the spatial distribution of heterozygous individuals with hemoglobinopathies.

Results:

Among 32,906 newborns, 1,202 showed other types of hemoglobin besides Hemoglobin A. We found a positive correlation between the percentage of black and multiracial people and the incidence of SCT. Most SCT cases occurred in the cities of Aracaju (n=273; 22.7%), Nossa Senhora do Socorro (n=102; 8.4%), São Cristóvão (n=58; 4.8%), Itabaiana (n=39; 4.2%), Lagarto (n=37; 4.01%), and Estância (n=46; 4.9%).

Conclusions:

The spatial distribution analysis identified regions in the state with a high frequency of HbS carriers. This information is important health care planning. This method can be applied to detect other places that need health units to guide and care for sickle cell disease patients and their families.

Avaliação da qualidade do pré-natal a partir das recomendações do Programa de Humanização no Pré-natal e Nascimento

Resumo O Programa de Humanização no Pré-natal e Nascimento (PHPN) estabelece um pacote mínimo de procedimentos a serem oferecidos a todas as gestantes durante o pré-natal. O objetivo deste estudo foi analisar a qualidade do pré-natal no estado de Sergipe a partir das recomendações do PHPN. Trata-se de um estudo transversal, com abordagens descritiva e analítica, vinculado à pesquisa Nascer em Sergipe, realizada entre junho/2015 e abril/2016. Foram avaliadas 768 puérperas proporcionalmente distribuídas entre todas as maternidades do estado (n = 11). A coleta dos dados ocorreu por meio de entrevista face a face e visualização do cartão de pré-natal. Os resultados mostraram uma cobertura elevada da assistência pré-natal (99,3%; n = 763), porém pouco mais da metade destas mulheres iniciaram seu acompanhamento antes da 16ª semana gestacional (57%; n = 435) e 74,4% (n = 570) compareceram a seis ou mais consultas. Constatou-se que 16,6% (n = 127) das gestantes foram consideradas de alto risco e quase metade delas continuou o acompanhamento com profissionais enfermeiros. A orientação sobre a maternidade de referência para o parto foi referida por 61,3% e 29,4% procuraram mais de um serviço para a parturição. Concluiu-se que houve uma alta cobertura do pré-natal em Sergipe, porém com problemas relacionados à sua adequação ao PHPN.

Brazilian pediatricians' adherence to food allergy guidelines-A cross-sectional study

Food allergy is an emerging clinical condition in pediatrics, so recommendations on its management have been widely published. Studying pediatricians' adherence to these clinical practice guidelines (CPG) and understanding the reasons for their non-compliance can help to promote better management of this condition. A cross-sectional study was conducted by a survey among Brazilian pediatricians, randomly selected during the 38th Brazilian Congress of Pediatrics, which took place in October, 2017. A validated questionnaire with 16 questions addressing knowledge and practice on food allergy, as well as self-reported adherence to international guidelines was applied. Of the total of 415 pediatricians from all regions of the country who were surveyed, only 69 (16.7%) had a satisfactory adherence rate (≥80%). Adequate adherence to the guidelines was associated with the variables: 'evaluating more than 10 children with suspected cow's milk allergy (CMA) per month'; 'having read the Brazilian consensus'; or 'being aware of any international food allergy guideline'. In 8 of the 10 questions that assessed conscious adherence, a minority of those surveyed (20.3-42.3% variation) stated that they knew that their response was in line with the guidelines. This finding was statistically significant (p<0.05) in 7 of these 8 questions. The self-reported adherence of Brazilian pediatricians to international food allergy guidelines was low. Pediatricians who evaluated a higher number of children with suspected CMA or who were aware of the recommendations, had a higher rate of adherence. The results of the survey found that lack of resource was the major reported barrier to guideline adherence but lack of awareness must be a relevant non perceived barrier. This study shows the pediatricians´ self-reported adherence to food allergy guidelines in a widely overview for the first time in Brazil. More studies are necessary to investigate adherence to guidelines by pediatricians in other countries and to develop strategies to improve adherence.

Orofacial anthropometric measures in full-term newborns

PURPOSE

To describe and compare the anthropometric measurements and the orofacial proportions of healthy term newborns (NB) according to sex, from a public maternity hospital in the state of Sergipe, northeastern Brazil.

METHODS

Descriptive and analytical randomized study was carried out. The participants included were 46 randomly selected healthy and full-term RNs of both sexes. A digital caliper was used to measure measurements (in millimeters) with the NB supine and occluded lips. Twice different, previously trained researchers measured each NB. Data were described using simple and percentage frequencies. The mean differences were assessed using the Mann-Whitney test, with a significance of 5%. Associations evaluated by the Fisher Exact test, and Cohen D size effects were calculated.

RESULTS

Differences were found between the groups for the anthropometric measurements: midface third height (glabella-subnasal or sn-g) and bottom (subnasal-gnathion or sn-gn); and filter heights (upper-lip subnasal or sn-ls), the upper lips (subnasal-estomus or sn-sto), and lower (stomatal-gnathion or sto-gn), which was always greater in males. The orofacial proportions studied did not show differences between sexes.

CONCLUSION

The study showed the presence of sexual dimorphism for the measures of the face at birth in the population born in Aracaju, Sergipe.

Analysis of neonatal mortality risk factors in Brazil: a systematic review and meta-analysis of observational studies

OBJECTIVE

To identify, using a systematic review and meta-analysis of observational studies, which risk factors are significantly associated with neonatal mortality in Brazil, and to build a comprehensive national analysis on neonatal mortality.

SOURCES

This review included observational studies on neonatal mortality, performed between 2000 and 2018 in Brazilian cities. The MEDLINE, Elsevier, Cochrane, LILACS, SciELO, and OpenGrey databases were used. For the qualitative analysis, the Newcastle-Ottawa Scale was used. For the quantitative analysis, the natural logarithms of the risk measures and their confidence intervals were used, as well as the DerSimonian and Laird method as a random effects model, and the Mantel-Haenszel model for heterogeneity estimation. A confidence level of 95% was considered.

SUMMARY OF FINDINGS

The qualitative analysis resulted in six studies of low and four studies of intermediate-low bias risk. The following exposure factors were significant: absence of partner, maternal age ≥35 years, male gender, multiple gestation, inadequate and absent prenatal care, presence of complications during pregnancy, congenital malformation in the assessed pregnancy, Apgar<7 at the fifth minute, low and very low birth weight, gestational age≤37 weeks, and caesarean delivery.

CONCLUSION

The most significant risk factors presented in this study are modifiable, allowing aiming at a real reduction in neonatal deaths, which remain high in the country.

Maternal characteristics and type of prenatal care associated with peregrination before childbirth

OBJECTIVE

To analyze the maternal characteristics and type of prenatal care associated with peregrination before childbirth among pregnant women in a northeastern Brazilian state.

METHODS

Quantitative and transversal study, with descriptive and analytical approaches, part of the Nascer em Sergipe research held between June 2015 and April 2016. A total of 768 puerperal women proportionally distributed across all maternities of the state (n = 11) were evaluated. Data were collected in interviews and from prenatal records. The associations between antepartum peregrination and the exposure variables were described in absolute and relative frequencies, crude and adjusted odds ratios and their respective confidence intervals.

RESULTS

Antepartum peregrination was reported by 29.4% (n = 226) of the interviewees, most of whom sought care in a single service before the current one (87.6%; n = 198). It should be noted that antepartum peregrination was less frequent among women aged ≥ 20 years old (OR = 0.50; 95%CI 0.34–0.71), with high education level (OR = 0.42; 95%CI 0.31–0.59) and a paid job (adjusted OR = 0.59; 95%CI 0.41–0.82), who had been instructed during prenatal care about the referral maternity for childbirth (adjusted OR = 0.88; 95%CI 0.42–0.92), and who used the private service to receive prenatal (adjusted OR = 0.44; 95%CI 0.18–0.86) or childbirth (adjusted OR = 0.96; 95%CI 0.66–0.98) care. No statistical evidence of associations between gestational characteristics and the occurrence of peregrination was observed.

CONCLUSIONS

Antepartum peregrination suffers interference from the mother’s socioeconomic characteristics, the type of prenatal care received and the source of funding for childbirth.

Elevated prevalence of high-risk HPV in healthy oral mucosa of users and nonusers of drugs in Northeastern Brazil

Variable rates of HPV infection have been reported in healthy oral mucosa worldwide. The main objective of this study was to detect and genotype HPV infection in users and nonusers of drugs with clinically healthy mucosa from the Northeast Brazil. Samples from 105 patients were amplified using the primers MY09/MY11 and GP5+/GP6+, and genotyping was performed by multiplex-PCR for HPV-6/11, 16 and 18. A total of 81.9% samples were positive. Among drug users, 84.5% presented the virus and 20.4% showed multiple infections. Among non-drug users, 78.7% were positive and 13.5% had multiple infections. Limited information is available on oral HPV in Brazilian population, especially for drug users, and our results showed higher HPV infection rates in both users and nonusers of drugs. More studies and researches focused on drug users including factors like sexual behavior, nutrition and cultural habits are necessary to enhance the comprehension of this relationship, and develop preventive strategies.

PERINATAL CARE IN A NORTHEASTERN BRAZILIAN STATE: STRUCTURE, WORK PROCESSES, AND EVALUATION OF THE COMPONENTS OF ESSENTIAL NEWBORN CARE

OBJECTIVE

To describe the structure and the processes of care for pregnant women/newborn infants, including the Essential Newborn Care (ENC), in maternity hospitals in Sergipe State, Brazil.

METHODS

A cross-sectional study carried out between June 2015 and April 2016 in all maternity hospitals of Sergipe with more than 500 deliveries/year (n=11). A questionnaire on the existing structure and work processes was administered to the managers. Subsequently, a representative number of postpartum women from these hospitals were interviewed (n=768). Their medical records, as well as newborn infants' records, were also analyzed.

RESULTS

Sergipe has 78 beds of Neonatal Intensive Care Unit (NICU) and 90 beds of Intermediate Care Unit (IMCU) to meet spontaneous and programmed demand. Only six maternity hospitals (54.5%) performed the risk classification, and four (36.3%) had protocols for high-risk parturient care. Regarding the ENC components, only 41% (n=315) of the women had early skin-to-skin contact with their babies, 33.1% (n=254) breastfed in the first hour of life, and 18% (n=138) had a companion always during birth.

CONCLUSIONS

The distribution of NICU beds between capital city and other cities of the State is adequate, considering Brazilian guidelines. However, there was a low adherence to the protocols for hypertensive and hemorrhagic emergencies, and a low coverage of humanization policies, pregnancy risk classification and ENC practices, especially breastfeeding in the first hour of life, and companion always during birth.

Ansiedade e Depressão na Morbidade Materna Grave e Near Miss

RESUMO Com o objetivo de verificar a prevalência da ansiedade e depressão em mulheres com morbidade materna grave (near miss), foi realizado estudo de coorte transversal, com 549 mulheres. Para tanto, foram utilizados o Inventário de Beck de Depressão (BDI) e o Inventário de Ansiedade (BAI). Na análise estatística, aplicaram-se o teste do qui-quadrado de Pearson e o U-Mann-Whitney, além de Razões de Chances brutas e seus Intervalos com 95% de confiança. Houve maior prevalência e maior chance de desenvolver a ansiedade e depressão na MMG/NM, bem como a relação positiva e significativa entre ambos. Considera-se a associação do ponto de vista psicológico, como um fator grave e impactante na saúde mental da mulher.

Objectively measured physical activity levels and sedentary time in children and adolescents with sickle cell anemia

The aim of this study was to identify the levels of physical activity and sedentary behaviour of children and adolescents with sickle cell disease (SCA) compared to healthy individuals. A cross-sectional study with a quantitative approach was performed at a reference center for the treatment of patients with hemoglobinopathies in northeastern Brazil. Patients were recruited between October 2015 and January 2017. Eligible participants answered a Physical Activity Questionnaire for Older Children and Adolescents (PAQ-C) and were instructed to use an ActiGraph wGT3X-BT triaxial accelerometer for seven consecutive days. Fifty patients (and their 50 controls matched for age and sex) were then evaluated. We observed lower moderate (19.2 ± 11.9 and 27.1 ± 13.8 min/d; p<0.01) and vigorous PA (3.6 ± 4.1 and 7.8 ± 7.4 min/d; p<0.01) in cases than controls, respectively. There was also a significant difference among cases and controls in the following variables: total of steps (51010 ± 19600 and 59105 ± 22650; p = 0.04) and "total caloric expenditure" (1015 ± 516 and 2404 ± 1308; p<0.01), with the lowest values for the patients with SCA for all variables. Children and adolescents with SCA presented lower levels of physical activity than healthy children and adolescents, either when evaluated by PAQs or by accelerometer.

The influence of mode of delivery on neonatal and maternal short and long-term outcomes

OBJECTIVE

To evaluate the impact of mode of delivery on breastfeeding incentive practices and on neonatal and maternal short and long-term complications.

METHODS

A cohort study was conducted between June 2015 and April 2016 with 768 puerperal women from 11 maternities in Sergipe, interviewed in the first 24 hours, 45-60 days and 6-8 months after delivery. Associations between breastfeeding incentive practices, neonatal and maternal, both short-term and late complications, and the exposure variables were evaluated by the relative risk (95%CI) and the Fisher exact test.

RESULTS

The C-section newborns had less skin-to-skin contact immediately after delivery (intrapartum C-section: 0.18, 95%CI 0.1-0.31 and elective C-section: 0.36, 95%CI 0.27-0.47) and less breastfeeding within one hour of birth (intrapartum C-section: 0.43, 95%CI 0.29-0.63 and elective C-section: 0.44, 95%CI 0.33-0.59). Newborns from elective C-section were less frequently breastfed in the delivery room 0.42 (95%CI 0.2-0.88) and roomed-in less 0.85 (95%CI 0.77-0.95). Women submitted to intrapartum C-section had greater risk of early complications 1.3 (95%CI 1.04-1.64, p = 0.037) and sexual dysfunction 1.68 (95%CI 1.14-2.48, p = 0.027). The frequency of neonatal complications, urinary incontinence and depression according to the mode of delivery was similar.

CONCLUSIONS

The C-section was negatively associated with breastfeeding incentive practices; in addition, C-section after labor increased the risk of early maternal complications and sexual dysfunction.

Intervention time until discharge for newborns on transition from gavage to exclusive oral feeding

Purpose Measure the intervention time required for transition from gavage to exclusive oral feeding, comparing newborns exposed exclusively to the mother's breast with those who, in addition to breastfeeding, received supplementation using a cup or baby bottle. Methods Analytical, longitudinal, cohort study conducted with 165 newborns (NB) divided into groups according to severity of medical complications (G1-with no complications; G2-with significant complications), and into subgroups according to feeding mechanism (A and B). All NBs were low birth weight, on Kangaroo Mother Care, and breast stimulated according to medical prescription and hospital routine. Regarding feeding pattern, subgroup A comprised NBs exclusively breastfed at hospital discharge, whereas subgroup B was composed of NBs fed through cup/bottle at some time during hospitalization. The number of days spent in each stage of transition was recorded for each NB. Results History of clinical complications significantly influenced total intervention time. Study participants in subgroups G1-A (10 days), G1-B (9 days), and G2-A (12 days) displayed greater chances of early discharge compared with those in subgroup G2-B (16 days). Conclusion NBs with no important history of clinical complications displayed greater chances of early hospital discharge. NBs with significant history of clinical complications that underwent gavage to exclusive breastfeeding transition presented smaller intervention time than those that required supplementation using cup/bottle. Feeding transition using the gavage-to-exclusive oral feeding technique is recommended for Speech-language Pathology practice in Neonatology.

Flavonoids as Th1/Th2 cytokines immunomodulators: A systematic review of studies on animal models

BACKGROUND

Flavonoids are naturally occurring compounds, extensively distributed in plants. T helper (Th)1 and Th2 cytokines balance plays an essential role in the reaction of inflammatory, allergic and infectious processes and transplantation rejection.

PURPOSE

This systematic review focuses on various classes of flavonoids with a view to evaluate whether Th1/Th2 cytokine-mediated pathways of immunoenhancement could reduce immune overwhelming reactions.

METHODS

Articles in English published from inception to December 2017 reporting flavonoids with immunomodulatory activity for the management of immune-mediated disorders were acquired from PubMed, EMBASE, Scopus and Web of Science and a animal experiments where Th1 and Th2 cytokines were investigated to assess the outcome of immunoregulatory therapy were included.

CHAPTERS

1809 publications were identified and 26 were included in this review. Ten articles described the effect of flavonoids on allergic inflammation in an animal model of asthma; eleven in vivo studies evaluated the immunomodulating and immunosuppressive effects of flavonoids on Th1/Th2 cytokines production and five reports described the regulatory role of flavonoids for Th1/Th2 cytokine responses to experimental arthritis and myocarditis. Modulation of Th1/Th2 cytokine balance, inhibition of eosinophil accumulation and remodeling of the airways and lungs, downregulation of Notch and PI3K signaling pathways, regulation of CD4 + /CD8 + lymphocytes ratio and decreasing inflammatory mediator expressions levels are among the most important immunopharmacological mechanisms for the retrieved flavonoids.

CONCLUSION

Naturally occurring flavonoids discussed in the present article have optimal immunomodulation to prevent immune-mediated disorders through management of Th1/Th2 cytokine balance.

Practices and obstetric interventions in women from a state in the Northeast of Brazil

OBJECTIVE

To describe practices and interventions used during labor and childbirth and factors associated with such practices in puerperae in the state of Sergipe.

METHOD

A cross-sectional study with 768 postpartum women from 11 maternity hospitals interviewed 6 hours after delivery, and hospital records review. The associations between best practices and interventions used during labor and delivery with exposure variables were described using simple frequencies, percentages, crude and adjusted odds ratio (ORa) with the confidence interval.

RESULTS

Of the women in the study, 10.6% received food and 27.8% moved during labor; non-pharmacological methods for pain relief were performed in 26.1%; a partogram was filled in 39.4% of the charts; and an accompanying person was present in 40.6% of deliveries. Oxytocin, amniotomy and labor analgesia were used in 59.1%, 49.3% and 4.2% of women, respectively. Lithotomy position during childbirth was used in 95.2% of the cases, episiotomy in 43.9% and Kristeller maneuver in 31.7%. The variables most associated with cesarean section were private financing (ORa=4.27, 95CI 2.44-7.47), higher levels of education (ORa=4.54, 95CI 2.56-8.3) and high obstetric risk (ORa=1.9, 95CI 1.31-2.74). Women whose delivery was funded privately were more likely to have an accompanying person present (ORa=2.12, 95CI 1.18-3.79) and to undergo labor analgesia (ORa=4.96, 95CI 1.7-14.5).

CONCLUSION

Best practices are poorly performed and unnecessary interventions are frequent. The factors most associated with c-section were private funding, greater length of education and high obstetric risk.

Severe Maternal Morbidity: post-traumatic suffering and social support

ABSTRACT Objective: To assess the relationship of post-traumatic stress symptoms and the perception of social support in women submitted to Severe Maternal Morbidity (SMM). Method: A prospective cohort study, with 549 women from public hospitals. The Impact of Events and Social Support scales were used. Results: Women with SMM were from the State countryside (p=0.046), with low schooling (p=0.039) and did not work (p<0.001). They presented higher consumption of alcoholic beverages (p<0.001), did not perform prenatal (p<0.001), and were older (28.15 ± 28 years). Women with SMM had higher mean values of avoidance behavior (24.32, SD: 4.16), intrusive thinking (18.28, SD: 3.80), lower social support (0.11, SD: 0.001) with large effect size and lower social support satisfaction (0.69; SD: 0.19), with small effect size. Conclusion: SMM is a differential and negative factor for women’s mental health, and social support can favor their coping.