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Cutaneous tuberculosis is a rare manifestation of extrapulmonary tuberculosis caused by Mycobacterium tuberculosis in most cases and rarely by Mycobacterium bovis. Diagnosis may be challenging due to a wide range of clinical findings and similarities to other chronic dermatoses, leading to delayed treatment. We present a case of scrofuloderma in a 4-year-old girl that arose from a contiguous spread from the anterior mediastinum with associated pulmonary involvement.

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ABSTRACT Introduction: Traditional teaching, a lecturer-centered approach, has been the default methodology in medical schools. In the last decades, there has been a shift in health education towards methods that encourage the student's active participation. It has been proved that active methodologies increase engagement, and this was particularly necessary during the COVID-19 pandemic, when active methodologies were crucial to raise student participation in online classes. Objective: This study aimed to measure student satisfaction and participation in online classes utilizing active learning methods during the COVID-19 pandemic. Methods: We gathered data from anonymous surveys completed by fourth-year medical students during 18 months of online classes of pediatrics at a public medical school in Brazil. Classes were taught using flipped classroom and case-based learning methodology. Results: One hundred and twenty-one students took part in this survey. Satisfaction level with case-based learning classes in the discipline was high (53% very satisfied; 39% satisfied; 6% neutral; 2% unsatisfied). Most of the students (70%) answered that, in general, they prefer CBL to expositive classes (16% prefer expositive classes; 14% are neutral). Reading compliance was good: 81% read 75-100% of the texts, and 19% read 50-74% of them. Conclusion: The implementation of the active learning curriculum for the discipline of pediatrics demonstrated to be successful considering the participation of the students and their satisfaction level.

RESUMO Introdução: Metodologias de ensino tradicionais, baseadas em aulas expositivas, têm sido usadas como padrão nas escolas médicas. Nas últimas décadas, têm ocorrido mudanças na educação médica no sentido de adotar métodos que encorajem a participação ativa dos alunos. Foi provado que as metodologias ativas aumentam o engajamento e isso foi particularmente necessário durante a pandemia da COVID-19, quando as metodologias ativas foram cruciais para aumentar a participação dos estudantes nas aulas virtuais. Objetivo: Este estudo objetivou medir a satisfação e o nível de participação dos alunos com aulas virtuais baseadas em metodologias ativas durante a pandemia da COVID-19. Método: Foram compilados dados de pesquisa anônima respondida por estudantes brasileiros do quarto ano de Medicina de uma universidade pública federal que cursaram a disciplina de pediatria durante um período de 18 meses. As metodologias usadas foram sala de aula invertida e aprendizado baseado em casos clínicos. Resultado: Participaram desta pesquisa 121 estudantes. O nível de satisfação com a metodologia foi alto (53% = muito satisfeito; 39% = satisfeito; 6% = indiferente; 2% = insatisfeito). A maioria dos alunos (70%) respondeu preferir ter aulas com as metodologias ativas empregadas, em comparação com aulas expositivas (16% preferem aulas expositivas; 14% são indiferentes). A adesão à leitura dos textos (sala de aula invertida) foi boa: 81% dos alunos leram entre 75% e 100% dos textos, e 19% leram entre 50% e 74% dos textos disponibilizados. Conclusão: A implementação de metodologias ativas na disciplina demonstrou ter sido bem-sucedida, considerando a participação e o nível de satisfação dos alunos.

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Abstract Objective: This study aimed to describe the clinical and laboratory findings of patients diagnosed with pleural tuberculosis at two hospitals in southern Brazil. Methods: Patients aged < 18 years were evaluated retrospectively. The patients' medical and epidemiological history, tuberculin skin test results, radiological and pathological findings, and pleural fluid analysis results were retrieved. Results: Ninety-two patients with pleural tuberculosis were identified. The mean age was 10.9 years old. Twenty-one percent were children aged six years or less. The most common symptoms were fever (88%), cough (72%), and chest pain (70%). Unilateral pleural effusion was observed in 96% of the cases. Lymphocyte predominance was found in 90% of the pleural fluid samples. The adenosine deaminase activity of the pleural fluid was greater than 40 U/L in 85% of patients. A diagnosis of community-acquired pneumonia with antibiotic prescriptions was observed in 76% of the study population. Conclusions: Tuberculosis etiology must be considered in unilateral pleural effusion in a child with contact with a case of tuberculosis. Pleural fluid biomarkers contribute to the diagnosis of pleural tuberculosis in children and adolescents.

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OBJECTIVE: This study aimed to describe the clinical and laboratory findings of patients diagnosed with pleural tuberculosis at two hospitals in southern Brazil. METHODS: Patients aged < 18 years were evaluated retrospectively. The patients' medical and epidemiological history, tuberculin skin test results, radiological and pathological findings, and pleural fluid analysis results were retrieved. RESULTS: Ninety-two patients with pleural tuberculosis were identified. The mean age was 10.9 years old. Twenty-one percent were children aged six years or less. The most common symptoms were fever (88%), cough (72%), and chest pain (70%). Unilateral pleural effusion was observed in 96% of the cases. Lymphocyte predominance was found in 90% of the pleural fluid samples. The adenosine deaminase activity of the pleural fluid was greater than 40 U/L in 85% of patients. A diagnosis of community-acquired pneumonia with antibiotic prescriptions was observed in 76% of the study population. CONCLUSIONS: Tuberculosis etiology must be considered in unilateral pleural effusion in a child with contact with a case of tuberculosis. Pleural fluid biomarkers contribute to the diagnosis of pleural tuberculosis in children and adolescents.

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Stress and burnout can result in errors, reduction in patient safety, and decreased productivity. They can cause absenteeism, depression, destructive behavior, alcohol, drug abuse, and even suicide. Several factors lead to professional stress, many of which are out of one's control, thus making intervention impossible. Physicians often neglect their health and ignore stress and burnout. They often deny the existence of stress as a way of adapting to it, which is an ineffective method of coping with this problem that can lead to negative coping strategies. For managing stress and burnout, it is paramount to recognize situations/conditions that may trigger them, identify their signs, and invest in well-being strategies. In this article, well-being promotion is addressed with a focus on strategies that can be used at the individual level. Topics such as stress management and resilience should be valued in medical training and profession. As long as they form a part of the "hidden curriculum", well-being will continue to be undervalued, when in fact it should be seen as fundamental to the health of professionals and patients.

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OBJECTIVE: To evaluate the accuracy of determining the adenosine deaminase (ADA) level, the 2'-deoxyadenosine/ADA ratio, and the LDH/ADA ratio in pleural fluid for the diagnosis of pleural tuberculosis (PT) in children and adolescents. METHODS: This was a retrospective cross-sectional study conducted at a tertiary hospital in a high-tuberculosis-incidence area, between 2001 and 2018. All patients with ADA in pleural fluid and a confirmed diagnosis of PT (cPT) or parapneumonic effusion (PPE) were included. RESULTS: The cPT and PPE groups comprised 25 and 68 individuals, respectively. At a cutoff of 40 U/L, ADA measurement showed the following: sensitivity, 88%; specificity, 31%; positive predictive value (PPV), 32%; negative predictive value (NPV), 88%; and overall accuracy, 46%. The best cutoffs were an ADA level of 125 U/L, a 2'-deoxyadenosine/ADA ratio of 0.5, and an LDH/ADA ratio of 8.3, with AUC of 0.67, 0.75, and 0.82, respectively. The sensitivity, specificity, PPV, NPV, and overall accuracy of the 125 U/L ADA cutoff were 84%, 65%, 47%, 92%, and 70%, respectively, compared with 79%, 79%, 59%, 91%, and 79%, respectively, for the 8.3 LDH/ADA ratio cutoff. Changing the LDH/ADA ratio cutoff to 3.0 increased the specificity to 98%. CONCLUSIONS: The ADA level and the 2'-deoxyadenosine/ADA ratio are not good biomarkers for the diagnosis of PT in pediatric patients. Determination of the LDH/ADA ratio provides the best overall accuracy for the diagnosis of PT in such patients.

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ABSTRACT Objective: To evaluate the accuracy of determining the adenosine deaminase (ADA) level, the 2'-deoxyadenosine/ADA ratio, and the LDH/ADA ratio in pleural fluid for the diagnosis of pleural tuberculosis (PT) in children and adolescents. Methods: This was a retrospective cross-sectional study conducted at a tertiary hospital in a high-tuberculosis-incidence area, between 2001 and 2018. All patients with ADA in pleural fluid and a confirmed diagnosis of PT (cPT) or parapneumonic effusion (PPE) were included. Results: The cPT and PPE groups comprised 25 and 68 individuals, respectively. At a cutoff of 40 U/L, ADA measurement showed the following: sensitivity, 88%; specificity, 31%; positive predictive value (PPV), 32%; negative predictive value (NPV), 88%; and overall accuracy, 46%. The best cutoffs were an ADA level of 125 U/L, a 2'-deoxyadenosine/ADA ratio of 0.5, and an LDH/ADA ratio of 8.3, with AUC of 0.67, 0.75, and 0.82, respectively. The sensitivity, specificity, PPV, NPV, and overall accuracy of the 125 U/L ADA cutoff were 84%, 65%, 47%, 92%, and 70%, respectively, compared with 79%, 79%, 59%, 91%, and 79%, respectively, for the 8.3 LDH/ADA ratio cutoff. Changing the LDH/ADA ratio cutoff to 3.0 increased the specificity to 98%. Conclusions: The ADA level and the 2'-deoxyadenosine/ADA ratio are not good biomarkers for the diagnosis of PT in pediatric patients. Determination of the LDH/ADA ratio provides the best overall accuracy for the diagnosis of PT in such patients.

RESUMO Objetivo: Avaliar a acurácia da determinação do nível de adenosina desaminase (ADA), da relação 2'-desoxiadenosina/ADA e da relação LDH/ADA no líquido pleural para o diagnóstico de tuberculose pleural (TP) em crianças e adolescentes. Métodos: Estudo transversal retrospectivo realizado em um hospital terciário em uma área de alta incidência de tuberculose entre 2001 e 2018. Todos os pacientes com determinação de ADA no líquido pleural e com diagnóstico confirmado de TP (TPc) ou de derrame parapneumônico (DPP) foram incluídos. Resultados: Os grupos TPc e DPP foram compostos por 25 e 68 indivíduos, respectivamente. Num ponto de corte de 40 U/L, a medida de ADA mostrou o seguinte: sensibilidade, 88%; especificidade, 31%; valor preditivo positivo (VPP), 32%; valor preditivo negativo (VPN), 88%; e acurácia geral, 46%. Os melhores pontos de corte foram ADA de 125 U/L, relação 2'-desoxiadenosina/ADA de 0,5 e relação LDH/ADA de 8,3, com ASC de 0,67, 0,75 e 0,82, respectivamente. A sensibilidade, especificidade, VPP, VPN e acurácia geral do ponto de corte de 125 U/L para ADA foram de 84%, 65%, 47%, 92% e 70%, respectivamente, em comparação com 79%, 79%, 59%, 91% e 79%, respectivamente, para o ponto de corte de 8,3 para a relação LDH/ADA. Ao alterar o ponto de corte da relação LDH/ADA para 3,0 a especificidade aumentou para 98%. Conclusões: O nível de ADA e a relação 2'-desoxiadenosina/ADA não são bons biomarcadores para o diagnóstico de PT em pacientes pediátricos. A determinação da relação LDH/ADA fornece a melhor acurácia geral para o diagnóstico de PT nesses pacientes.

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Médicos, enfermeiros e outros profissionais de saúde passam boa parte do tempo se comunicando e coordenando atividades de cuidado. Apesar disso, o treinamento em habilidades de comunicação interpessoal e de trabalho em equipe tem sido historicamente pouco enfatizado. O principal objetivo do trabalho em equipe é melhorar os desfechos no cuidado ao paciente. A necessidade de trabalhar em equipe vem sendo cada vez mais frequente no cuidado à saúde. Assim, é relevante conhecer os elementos fundamentais para o seu bom funcionamento, assim como os principais fatores com potencial de prejudicá-lo. Neste artigo, os seguintes tópicos serão discutidos: classificação das equipes de cuidado à saúde; princípios determinantes para o sucesso das equipes; e as principais barreiras que podem comprometer seu funcionamento. Existe um reconhecimento crescente sobre a importância do trabalho em equipe (em oposição ao rígido gerenciamento hierárquico) no cuidado ao paciente. A resistência à mudança nos métodos de trabalho imposta pela tradição de décadas deve ser enfrentada por meio de um processo educacional, de forma que este artigo visa a contribuir para essa finalidade. (AU)

Physicians, nurses, and other health care professionals spend a great amount of time communicating and coordinating care activities. Nevertheless, interpersonal communication and teamwork skills have been historically underemphasized in professional training. The ultimate goal of teamwork efforts is to improve patient care outcomes. The need for interdisciplinary teamwork has been increasing in the health care setting. Thus, the main attributes needed in a good interdisciplinary team should be known, as well as the factors that could lead to a poor team performance. In this study, we discuss the definition and classification of teamwork in health care, the fundamental principles for successful teamwork, and the main barriers to effective teamwork. The importance of teamwork has been increasingly recognized in health care. However, decades of tradition have hindered changes in the way health care is provided, and educational processes should be used as an approach to deal with this situation. The present study intends to contribute to this purpose. (AU)

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The objective of this study was to compare the positive detection rates obtained using the Oxoid IMAGEN® direct immunofluorescence assay (designated as IF) with those obtained using the CLART® PneumoVir multiplex RT-PCR DNA microarray assay (designated as RT-PCR) in the diagnosis of respiratory viruses in hospitalized children. This was a retrospective study of 62 individuals < 18 years old who had nasopharyngeal aspirates collected for virus identification in a tertiary university hospital in south Brazil between January 1st, 2014 and December 31st, 2014. All 62 nasopharingeal aspirates were analyzed using both assay methods. The main outcome to be measured was the difference in the proportion of test samples returning a positive virus detection result between the IF and the RT-PCR. The McNemar test was used for data analysis and the results showed that the RT-PCR and the IF methods produced 55 (88.7 %) and 17 (27.4 %) virus-positive samples, respectively (p < 0.001). The most prevalent virus was rhinovirus (45.5 % of the RT-PCR positive samples). The RT-PCR method increased the detection rates of human respiratory syncytial virus, influenza A virus and parainfluenza 3 virus. The RT-PCR and IF had concordant results in 19 samples (30.6 %) and discordant results in 43 samples (69.4 %). It is concluded that in comparison to the Oxoid IMAGEN® IF method, the CLART® PneumoVir multiplex RT-PCR method had a greater potential to contribute to the clinical management of hospitalized children due its greater ability in detecting respiratory viruses than the IF method.

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BACKGROUND: With advent of molecular diagnostic technologies, studies have reported detection of two or more respiratory viruses in about 30% of children with respiratory infections. However, prognostic role of coinfection remains unclear. OBJECTIVE: Evaluate relation between respiratory viral confection and illness severity in children. STUDY DESIGN: MEDLINE (through PUBMED), EMBASE, EBSCO, LILACS databases were searched up to March 2015 by two independent reviewers. Studies assessing severity of viral coinfection in patients aged less than 18 years were included. Standardized forms were used for data extraction of population, study design, clinical syndromes, virus combinations compared and severity outcomes. Risk of bias and quality of evidence were assessed through EPHPP and GRADE. Subgroup analysis was performed according to age and viral combinations. RESULTS: Of 5218 records screened, 43 were included in analysis. Viral coinfection did not influence risks of all outcomes assessed: length of stay (mean difference in days in coinfection, -0.10 [95% confidence interval: -0.51 to 0.31]), length of supplemental oxygen (-0.42 [-1.05 to 0.20]), need of hospitalization (odds ratio of coinfection, 0.96 [95% confidence interval: 0.61-1.51]), supplemental oxygen (0.94 [0.66 to 1.34]), need of intensive care (0.99 [0.64 to 1.54]), mechanical ventilation (0.81 [0.33 to 2.01]) and death (2.22 [0.83 to 5.95]). Sub-analyses according to age and viral combinations have not shown influence of these factors in outcomes. CONCLUSIONS: Respiratory viral coinfection did not increase severity in all outcomes assessed. Further studies are necessary to confirm this finding, especially regarding role of specific viral interactions.

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Pyroglutamic acid (also known as 5-oxoproline) is an organic acid intermediate of the gamma-glutamyl cycle. Accumulation of pyroglutamic acid is a rare cause of high anion gap metabolic acidosis. In the pediatric population, the congenital form of pyroglutamic acidemia has been extensively described. However, there are scarce reports of the acquired form of this condition in children. The urine test for organic acids confirms the diagnosis of pyroglutamic acidemia. We report the case of a 16-month-old girl who developed transient 5-oxoprolinemia associated with malnutrition and the use of acetaminophen and ampicillin for the treatment of acute otitis media and abdominal pain. The patient received 21-hour course of n-acetylcysteine with improvement of metabolic acidosis. This report highligts the need of considering pyroglutamic acidemia in the differencial diagnosis for high anion gap metabolic acidosis in pediatric patients with malnutrition and other risk factors...

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