WERTHER BRUNOW DE CARVALHO

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Departamento de Pediatria, Faculdade de Medicina - Docente
LIM/36 - Laboratório de Pediatria Clínica, Hospital das Clínicas, Faculdade de Medicina - Líder

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  • article 0 Citação(ões) na Scopus
    Effects of serum sodium and chloride levels in the outcome of critically ill pediatric patients in the post-operative period of liver transplantation
    (2023) LUGLIO, Michele; CARVALHO, Werther B. de; TANNURI, Uenis; TANNURI, Ana Cristina A.; MATSURA, Rodrigo Hideki; FRANCA, Gardenia Morais; DELGADO, Artur F.
    BackgroundSodium and chloride disturbances have attracted increasing attention in recent years. Many pathophysiological effects are associated with hyperchloremia, including reduction in mean arterial pressure and acute renal disease. Pediatric patients undergoing liver transplantation are at risk of developing various electrolyte and biochemical abnormalities, with an impact on their postoperative outcomes.ObjectiveTo analyze the impacts of serum sodium and chloride levels on prognosis of Pediatric Liver Transplant receptors.MethodsThis was a retrospective analytical observational study performed in a single transplant reference center in Sao Paulo, Brazil. Included patients were pediatric patients who underwent liver transplantation between January 2015 and July 2019. Statistical regression analysis and General Estimating Equations analysis were performed to evaluate the impacts of sodium and chloride disturbances on the development of acute renal failure and mortality.ResultsA total of 143 patients were included in this study. The main diagnosis was Biliary Atresia (62.9%). Twenty-seven patients died (18.9%), and graft dysfunction was the main cause of death (29.6%). The only variable individually associated with 28-days mortality was PIM-3 score (HR 1.59, CI 95% 1.165-2.177, p = 0.004). Forty-one patients (28.6%) developed moderate or severe AKI. PIM-3 score (OR 3.052, 95% CI 1.56-5.97, p = 0.001), hypernatremia (OR 3.49, 95% CI 1.32-9.23, p = 0.012), and hyponatremia (OR 4.24, 95% CI 1.52-11.85, p = 0.006) were independently associated with the development of moderate/severe AKI.ConclusionsIn pediatric patients after liver transplantation, PIM-3 score, and abnormal serum sodium levels were correlated with AKI development.
  • article 10 Citação(ões) na Scopus
    Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference
    (2023) MORROW, Brenda; AGULNIK, Asya; CARVALHO, Werther Brunow de; CHISTI, Mohammod Jobayer; LEE, Jan Hau
    OBJECTIVES: Diagnosis of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) is challenging and remains poorly described. We conducted a review of the literature to optimize recognition of PARDS in RLS and to provide recommendations/statements for clinical practice and future research in these settings as part of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES: MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION: We included studies related to precipitating factors for PARDS, mechanical ventilation (MV), pulmonary and nonpulmonary ancillary treatments, and long-term outcomes in children who survive PARDS in RLS. DATA EXTRACTION: Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS: The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Seventy-seven studies were identified for full-text extraction. We were unable to identify any literature on which to base recommendations. We gained consensus on six clinical statements (good practice, definition, and policy) and five research statements. Clinicians should be aware of diseases and comorbidities, uncommon in most high-income settings, that predispose to the development of PARDS in RLS. Because of difficulties in recognizing PARDS and to avoid underdiagnosis, the PALICC-2 possible PARDS definition allows exclusion of imaging criteria when all other criteria are met, including noninvasive metrics of hypoxemia. The availability of MV support, regular MV training and education, as well as accessibility and costs of pulmonary and nonpulmonary ancillary therapies are other concerns related to management of PARDS in RLS. Data on long-term outcomes and feasibility of follow-up in PARDS survivors from RLS are also lacking. CONCLUSIONS: To date, PARDS remains poorly described in RLS. Clinicians working in these settings should be aware of common precipitating factors for PARDS in their patients. Future studies utilizing the PALICC-2 definitions are urgently needed to describe the epidemiology, management, and outcomes of PARDS in RLS.
  • article 0 Citação(ões) na Scopus
    Three-dimensional Ultrasound Evaluation of Lung Volume in Fetuses with Abdominal Wall Defect
    (2023) NISHIE, Estela Naomi; OSMUNDO-JUNIOR, Gilmar de Souza; MOHAMED, Samirah Hosney Mahmoud; TANNURI, Ana Cristina Aoun; GIBELLI, Maria Augusta Bento Cicaroni; CARVALHO, Werther Brunow de; PERES, Stela Verzinhasse; FRANCISCO, Rossana Pulcineli Vieira; BRIZOT, Maria de Lourdes
    Introduction: Abdominal wall defects (AWD) interfere with postnatal respiratory parameters. We aimed to evaluate lung volume (LV) in fetuses with AWD using three-dimensional (3D) ultrasound (US) and to correlate AWD with the type (omphalocele and gastroschisis) and size of the defect and neonatal morbidity and mortality.Methods: This prospective study included 72 pregnant women with fetuses with AWD and a gestational age <25 weeks. Abdominal volume, 3D US LV, and herniated volume were acquired every 4 weeks up to 33 weeks. LV was compared with normal reference curves and correlated with abdominal and herniated volumes.Results: Omphalocele (p<0.001) and gastroschisis (p<0.001) fetuses had smaller LV than did normal fetuses. LV was positively correlated with abdominal volume (omphalocele, r=0.86; gastroschisis, r=0.88), whereas LV was negatively correlated with omphalocele-herniated volume/abdominal volume (p<0.001, r= -0.51). LV was smaller in omphalocele fetuses that died (p=0.002), were intubated (p=0.02), or had secondary closure (p<0.001). In gastroschisis, a smaller LV was observed in fetuses discharged using oxygen (p=0.002).Discussion/Conclusion: Fetuses with AWD had smaller 3D LV than normal fetuses. Fetal abdominal volume was inversely correlated with LV. In omphalocele fetuses, a smaller LV was associated with neonatal mortality and morbidity.
  • article 1 Citação(ões) na Scopus
    Monocyte-to-HDL ratio and non-HDL cholesterol were predictors of septic shock in newborns
    (2022) FONSECA, Fernanda Andrade Macaferri da da; ESPOSITO, Aline Paulino; SILVA, Maria Helena Baptista Nunes da; NUNES, Valeria Sutti; CAZITA, Patricia Miralda; FERREIRA, Guilherme Silva; CECCON, Maria Esther Jurfest Rivero; CARVALHO, Werther Brunow de; CARNEIRO-SAMPAIO, Magda; PALMEIRA, Patricia
    Background: The association between lipoprotein levels and late-onset neonatal sepsis has shown controversial results. The aims are to assess lipid profile, cytokines, and Monocyte-to-HDL (M/H) ratio as diagnostic and prog-nostic markers for late-onset neonatal sepsis.Methods: This prospective study included 49 septic neonates and 17 controls. Cholesterol (CT), Triglyceride (TG), Very-Low-Density (VLDLc), Low-Density (LDLc), and High-Density Lipoproteins (HDLc) were measured at admis-sion (D0) and on days 3, 7 and 10 to evaluate septic shock outcomes. Cytokines and monocytes were evaluated by flow cytometry.Results: Septic newborns showed higher IL-6 and IL-8 at D0 and CT levels on D7 and on D10, which also presented higher TG, VLDLc and non-HDL cholesterol concentrations than controls. The septic shock group (n = 22) revealed a higher number of male subjects, CRP, IL-6, IL-8 and IL-10 levels, while lower TG, HDLc, monocyte numbers and M/H ratio at admission compared to the non-shock group (n = 27). M/H ratio and non-HDL choles-terol on D0 were risk factors for septic shock (OR = 0.70, 0.49-0.99; OR = 0.96, 0.92-0.99, respectively). Decreasing levels from D0 to D3 of CT (OR = 0.96, 0.93-0.99), VLDLc (OR = 0.91, 0.85-0.98), and non-HDL cholesterol (OR = 0.92, 0.87-0.98) were also predictors of septic shock.Conclusions: Lower M/H ratios and non-HDL cholesterol at admission and decreasing levels of cholesterol, VLDLc and non-HDL cholesterol during a hospital stay are associated with the development of septic shock in newborns with late-onset neonatal sepsis.
  • article 61 Citação(ões) na Scopus
    Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)
    (2023) EMERIAUD, Guillaume; LOPEZ-FERNANDEZ, Yolanda; IYER, Narayan Prabhu; BEMBEA, Melania M.; AGULNIK, Asya; BARBARO, Ryan P.; BAUDIN, Florent; BHALLA, Anoopindar; CARVALHO, Werther Brunow de; CARROLL, Christopher L.; CHEIFETZ, Ira M.; CHISTI, Mohammod J.; CRUCES, Pablo; CURLEY, Martha A. Q.; DAHMER, Mary K.; DALTON, Heidi J.; ERICKSON, Simon J.; ESSOURI, Sandrine; FERNANDEZ, Analia; FLORI, Heidi R.; GRUNWELL, Jocelyn R.; JOUVET, Philippe; KILLIEN, Elizabeth Y.; KNEYBER, Martin C. J.; KUDCHADKAR, Sapna R.; KORANG, Steven Kwasi; LEE, Jan Hau; MACRAE, Duncan J.; MADDUX, Aline; I, Vicent M. Alapont; MORROW, Brenda M.; NADKARNI, Vinay M.; NAPOLITANO, Natalie; NEWTH, Christopher J. L.; PONS-ODENA, Marti; QUASNEY, Michael W.; RAJAPREYAR, Prakadeshwari; RAMBAUD, Jerome; RANDOLPH, Adrienne G.; RIMENSBERGER, Peter; ROWAN, Courtney M.; SANCHEZ-PINTO, L. Nelson; SAPRU, Anil; SAUTHIER, Michael; SHEIN, Steve L.; SMITH, Lincoln S.; STEFFEN, Katerine; TAKEUCHI, Muneyuki; THOMAS, Neal J.; TSE, Sze Man; VALENTINE, Stacey; WARD, Shan; WATSON, R. Scott; YEHYA, Nadir; ZIMMERMAN, Jerry J.; KHEMANI, Robinder G.
    OBJECTIVES:We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN:International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING:Not applicable. PATIENTS:Patients with or at risk for PARDS. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS:PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.
  • article 10 Citação(ões) na Scopus
    Born into an isolating world: family-centred care for babies born to mothers with COVID-19
    (2023) DOWSE, G.; PERKINS, E. J.; STEIN, H. M.; CHIDINI, G.; DANHAIVE, O.; ELSAYE, Y. N.; CARVALHO, W. B.; ALNAQEEB, N.; ROOZE, S.; CETINKAYA, M.; VETTER-LARACY, S.; PILAR-ORIVE, F. J.; TORPIANO, P.; FERRI, W. A. Goncalves; BUONSENSO, D.; ROGDO, B.; MEDINA, A.; POLITO, A.; BROUWER, C. N. M.; KNEYBER, M. C. J.; LUCA, D. De; TINGAY, D. G.; REGISTRY, Espnic Covid-Paediatric Neonatal E. P. I. C. E. M. T. R. E.
    Background The benefits of facilitating breastmilk feeding and close contact between mother and neonate (family-centred care; FCC) in the perinatal period are well-established. The aim of this study was to determine how the delivery of FCC practices were impacted for neonates born to mothers with perinatal SARS-CoV-2 infection during the COVID-19 pandemic. Methods Neonates born to mothers with confirmed SARS-CoV-2 infection during pregnancy were identified from the 'EsPnIC Covid paEdiatric NeonaTal REgistry' (EPICENTRE) multinational cohort between 10 March 2020 and 20 October 2021. The EPICENTRE cohort collected prospective data on FCC practices. Rooming-in and breastmilk feeding practice were the main outcomes, and factors influencing each were determined. Other outcomes included mother-baby physical contact prior to separation and the pattern of FCC components relative to time and local site guidelines. Findings 692 mother-baby dyads (13 sites, 10 countries) were analysed. 27 (5%) neonates were positive for SARS-CoV-2 (14 (52%) asymptomatic). Most sites had policies that encouraged FCC during perinatal SARS-CoV-2 infection for most of the reporting period. 311 (46%) neonates roomed-in with their mother during the admission. Rooming-in increased over time from 23% in March-June 2020 to 74% in January-March 2021 (boreal season). 330 (93%) of the 369 separated neonates had no FCC physical contact with their mother prior, and 319 (86%) were asymptomatic. Maternal breastmilk was used for feeding in 354 (53%) neonates, increasing from 23% to 70% between March-June 2020 and January-March 2021. FCC was most impacted when mothers had symptomatic COVID-19 at birth. Interpretation This is the largest report of global FCC practice during the COVID-19 pandemic to date. The COVID-19 pandemic may have impacted FCC despite low perinatal transmission rates. Fortunately, clinicians appear to have adapted to allow more FCC delivery as the COVID-19 pandemic progressed.
  • article 4 Citação(ões) na Scopus
    Development of a prognostic model for pediatric acute liver failure in a Brazilian center
    (2022) COLLETI JUNIOR, Jose; TANNURI, Ana Cristina Aoun; TANNURI, Uenis; DELGADO, Artur Figueiredo; CARVALHO, Werther Brunow de
    Objective: Pediatric acute liver failure (PALF) is a heterogeneous, rare, and severe condition, which outcome is survival due to liver spontaneous recovery or death. The patients who do not recover may be allocated to liver transplantation, which is the standard treatment. This study aimed to build a prognostic model to support the clinical decision to indicate liver transplanta-tion for patients with PALF in a Brazilian center. Methods: The authors retrospectively analyzed the clinical variables of 120 patients in the liver transplantation program of the 'Children's Institute of the University of Sa similar to o Paulo, Brazil. The authors conducted a univariate analysis of variables associated with survival in PALF. Logistic multivariate analysis was performed to find a prognostic model for the outcome of patients with pediatric acute liver failure. Results: Risk factors were analyzed using univariate analysis. Two prognostic models were built using multiple logistic regression, which resulted in 2 models: model 1(INR/ALT) and model 2 (INR/Total bilirubin). Both models showed a high sensitivity (97.9%/96.9%), good positive predic-tive value (89.5%/90.4%), and accuracy (88.4%/88.5%), respectively. The receiver operating characteristic was calculated for both models, and the area under the curve was 0.87 for model 1 and 0.88 for model 2. The Hosmer-Lemeshow test showed that model 1 was good. Conclusion: The authors built a prognostic model for PALF using INR and ALT that can contribute to the clinical decision to allocate patients to liver transplantation. (c) 2022 Sociedade Brasileira de Pediatria.
  • article 5 Citação(ões) na Scopus
    Use of budesonide associated with a pulmonary surfactant to prevent bronchopulmonary dysplasia in premature newborns- A systematic review
    (2023) MORAES, Lucas Hirano Arruda; COELHO, Rachel Mocelin Dias; BEOZZO, Glenda Priscila Neves dos Santos; YOSHIDA, Renata de Araujo Monteiro; DINIZ, Edna Maria de Albuquerque; CARVALHO, Werther Brunow de
    Objective: Among the mechanisms proposed for the development of bronchopulmonary dysplasia is the increase in the pulmonary inflammatory process and oxidative stress. Thus, the control of this process may result in improvements in bronchopulmonary dysplasia-related outcomes. This study aims to analyze the current scientific evidence regarding the use of budesonide, a potent anti-inflammatory drug, associated with a pulmonary surfactant to prevent bronchopulmonary dysplasia.Methods: A systematic review of the literature was performed on the Embase and MEDLINE plat-forms, and studies that compared budesonide with pulmonary surfactant versus pulmonary sur-factant for treating respiratory distress syndrome were included. The primary outcome was a reduction in bronchopulmonary dysplasia or death. Results: Four randomized clinical trials and two observational studies were included in this systematic review. Three of the randomized clinical trials found a reduction in bronchopulmonary dysplasia or death in the use of budesonide with the surfactant, all the other studies (1 clinical trial and 2 observa-tional studies) found no statistical differences between the groups for the primary outcomes. The three main studies showed a reduction in the primary outcome; however, all studies showed great heteroge-neity regarding the type of surfactant (poractant or beractant) and the method of administration. Conclusion: Robust clinical studies, in a heterogeneous population, using porcine surfactant associated with budesonide, with administration by a minimally invasive technique are necessary for there to be a recommendation based on scientific evidence for its widespread use.(c) 2022 Sociedade Brasileira de Pediatria.
  • article 0 Citação(ões) na Scopus
    Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis
    (2023) MATSUSHITA, Felipe Yu; KREBS, Vera Lucia Jornada; CARVALHO, Werther Brunow De
    Objective: Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates. Methods: A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity. Results: Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive). Conclusions: Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.
  • article 0 Citação(ões) na Scopus
    Risk factors for shunting at 12 months following open fetal repair of spina bifida by mini-hysterotomy
    (2023) ROCHA, Luana Sarmento Neves da; BUNDUKI, Victor; CARDEAL, Daniel Dante; AMORIM FILHO, Antonio Gomes de; NANI, Fernando Souza; PERES, Stela Verzinhasse; CARVALHO, Werther Brunow de; FRANCISCO, Rossana Pulcineli Vieira de; CARVALHO, Mario Henrique Burlacchini de
    Objectives: Open spina bifida (OSB) is the most common neural tube defect. Prenatal repair reduces the need for ventriculoperitoneal shunting (VPS) due to hydrocephalus from 80-90% to 40-50%. We aimed to determine which variables work as risk factors for VPS at 12 months of age in our population. Methods: Thirty-nine patients underwent prenatal repair of OSB by mini-hysterotomy. The main outcome was occurrence of VPS in the first 12 months of life. Logistic regression was used to estimate the odds ratios (OR) between prenatal variables and the need for shunting. Results: VPS at 12 months occurred in 34.2% of the children. Larger ventricle size before surgery (62.5% >= 15 mm; 46.2% between 12 and 15 mm; 11.8% <12 mm; p=0.008), higher lesion level (80% >L2, vs. 17.9% <= L3; p=0.002; OR, 18.4 [2.96-114.30]), and later gestational age at surgery (25.25 +/- 1.18 vs. 24.37 +/- 1.06 weeks; p=0.036; OR, 2.23 [1.05-4.74]) were related to increased need for shunting. In the multivariate analysis, larger ventricle size before surgery (>= 15 mm vs. <12 mm; p=0.046; OR, 1.35 [1.01-1.82]) and higher lesion level (>L2 vs. <= L3; p=0.004; OR, 39.52 [3.25-480.69]) were risk factors for shunting. Conclusions: Larger ventricle size before surgery (>= 15 mm) and higher lesion level (>L2) are independent risk factors for VPS at 12 months of age in fetuses undergoing prenatal repair of OSB by mini-hysterotomy in the studied population.