Spontaneous resolution rates of vesicoureteral reflux in Brazilian children: A 30-year experience

Objective: We evaluated clinical characteristics of primary vesicoureteral reflux (VLJR) in infants in a 30-year period in Brazil with special reference to the relation of renal parenchymal damage to urinary tract infection and gender. Materials and Methods: From 1975 through 2005, 417 girls (81.6%) and 94 boys (18.4%) with all grades of reflux were retrospectively reviewed. Patients were categorized by the worst grade of reflux, maintained on antibiotic prophylaxis and underwent yearly voiding cystourethrography until the reflux was resolved. VUR was considered resolved when a follow-up cystogram demonstrated no reflux. Surgical correction was recommended for those who fail medical therapy, severe renal scarring or persistent VUR. Results: Grades I to V VUR resolved in 87.5%, 77.6%, 52.8%, 12.2% and 4.3%, respectively. Renal scars were present at presentation in 98 patients (19.2%). Neither gender nor bilaterality versus unilaterality was a helpful predictor of resolution. The significant difference was found among the curves using the log rank (p < 0.001) or Wilcoxon (p < 0.001) test. Conclusion: Despite the current use of screening prenatal ultrasound, many infants are still diagnosed as having vesicoureteral reflux only after the occurrence of urinary tract infection in our country. Scarring may be associated to any reflux grade and it may be initially diagnosed at any age but half of the scars are noted with higher grades of reflux (IV and V). The incidence of reflux related morbidity in children has significantly diminished over the last three decades.

Insulinoterapia, controle glicêmico materno e prognóstico perinatal - Diferença entre o diabetes gestacional e o clínico

PURPOSE: to evaluate the insulin therapy protocol and its maternal and perinatal outcome in patients with clinical or gestational diabetes in a high risk reference service. METHODS: descriptive and prospective study including 103 pregnant women with gestational or clinical diabetes treated with insulin and attended by the reference service from October 2003 to December 2005. Gemellarity, miscarriages, unfinished prenatal care and deliveries not attended by the service were excluded. The gestational age at the beginning of the treatment, dosage, doses/day, increment of insulin (UI/kg), glycemic index (GI) and perinatal outcomes were compared. ANOVA, Fisher's exact test and Goodman's test considering p<0.05 were used. RESULTS: multiparity (92 versus 67.9%), pre-gestational body mass index (BMI) >25 kg/m 2 (88 versus 58.5%), weight gain (WG) <8 kg (36 versus 17%) and a high increment of insulin characterized the gestational diabetes. For the patients with clinical diabetes, despite the highest GI (120 mg/dL (39.2 versus 24%)) at the end of the gestational period, insulin therapy started earlier (47.2 versus 4%), lasted longer (56.6 versus 6%) and higher doses of insulin (92 versus 43 UI/day) were administered up to three times a day (54.7 versus 16%). Macrosomia was higher among newborns from the cohort of patients with gestational diabetes (16 versus 3.8%), being the only significant neonatal outcome. There were no neonatal deaths, except for one fetal death in the cohort of patients with clinical diabetes. There were no differences in the other neonatal complications in both cohorts, and most of the newborns were discharged from hospital up to seven days after delivery (46% versus 55.8%). CONCLUSIONS: the analysis of these two cohorts has shown differences in the insulin therapy protocol in quantity (UI/day), dosage (UI/kg weight) and number of doses/day, higher for the clinical diabetes cohort, and in the increment of insulin, higher for the gestational diabetes cohort. Indirectly, the quality of maternal glycemic control and the satisfactory perinatal outcome have proven that the treatment protocol was adequate and did not depend on the type of diabetes.

Diabetes and pregnancy: An update of the problem

Pregnancies complicated by diabetes account for about 7% of all pregnancies attended by the Brazilian Unified Healthcare System (SUS) and are one of the main causes of maternal/perinatal morbidity and mortality in Brazil. Considering the importance of this topic, this article presents an update of diabetes classification, diagnostic criteria, maternal/perinatal outcomes, and both clinical and obstetric prenatal care. Even though there is no consensus about screening and diagnostic standards, the investigation of hyperglycemia in all risk pregnancies is recommended. The importance of adequate metabolic control is emphasized in order to improve maternal and neonatal outcomes. Finally, the development of educational programs is encouraged, viewing not only good gestational outcome but also long-term changes in the lifestyle of these women. © by São Paulo State University.

Avaliação da assistência pré-natal e puerperal desenvolvidas em região do interior do Estado de São Paulo em 2005

Objectives: to evaluate the structure and process of the prenatal and puerperal care given by Direção Regional de Saúde (DIR) XI, at the city of Botucatu, State of São Paulo, Brazil. Methods: an evaluation of resources and activities developed during prenatal and puerperal care in twenty municipalities comprising DIR XI which had adhered the Prenatal and Birth Humanization Program until 2003. Interviews with city managers and analysis of 385 sampled patient charts taking into account recommendations by the Health Department. Results: structure analysis showed that caregiving was centered on medical work; basic equipment and instruments were available; 85.2% of patients began prenatal care with up to 120 days of pregnancy, and 75.9% had at least six prenatal consultations. The active search for absentees and strategies for early prenatal care initiation were observed in 30% and 50% of the municipalities, respectively. Process indicators showed that 3.6% of women had six prenatal consultations, one puerperal consultation, all basic exams and tetanus immunization. Recording of gestational age, arterial blood pressure and weight was of approximately 90%; 58.7% of the women underwent childbirth review and 31.5% were vaccinated. Conclusions: the performance of the set of activities is a challenge to prenatal care at DIR XI.

Mecanismo de centralização: Da insuficiência placentária à adaptação circulatória fetal

The application and development of obstetric Dopplervelocimetry provide a basis for the investigation of placental insuf ciency and demonstrate the dynamic behavior of fetal circulation during hypoxia. In clinical practice, assessing hemodynamics in three vascular regions involved in pregnancy, namely the uterine, umbilical and middle cerebral arteries, has become routine. Roughly, the cerebral artery expresses the balance between uterine artery oxygen supply and umbilical artery oxygen uptake. Currently, when such balance is unfavorable, the fetal cardiac reserve is investigated by assessing the venous duct. However, determining and interpreting vascular resistance indexes is not an easy task. The starting point is to know the physiopathology of placental insuf ciency and fetal circulatory adaptation through which Doppler con rmed its role in the assessment of fetal well-being.

Sistema de Informação Pré-Natal: análise crítica de registros em um município paulista.

The prenatal assistance is one of the health care pillars. This study aimed to conduct a critical evaluation of the SIS Prenatal in a city of São Paulo State, to compare its data with the local assistance and to verify the registry of pregnant women attended at Health Care Centers. It was analyzed the pregnant women records through consultation at Health Regional Unit and municipal health service. There were inconsistencies between the system and local registry. The failures were related to the inadequate filling of attendance files, besides scarce control of pregnant women files and scheduling on health centers. The results suggest the need for better planning of actions for the improvement of prenatal service quality.

Associação entre condição periodontal de gestantes e variáveis maternas e de assistência à saúde

Objective: To evaluate the periodontal condition of pregnant women and to analyze the influence of maternal variables - socioeconomic-demographic data, health, deleterious habits and access to dental service - and the existence of the Family Health Program (FHP) at the public assistance services to pregnant women. Method: This evaluation was part of a cohort study with pregnant women and children conducted in two cities of the São Paulo State, one of which with an implemented FHP. Oral examinations were done using the Community Periodontal and Periodontal Attachment Loss Indexes, and semi-structured interviews with the pregnant women at their homes. Data were analyzed statistically by the chi-square test and Fisher's exact test at 5% significance level (α=0.05). Results: All pregnant women (n=119) registered at the public health service of each city were examined. The mean age was 24.7 years; 61.4% were black or black/white mixed-race women; most (65.5%) earned 2-3 minimum wages, and only 6.7% initiated higher education. Only 8% of the patients presented periodontal health. Bleeding and calculus were observed in 66% of them, and shallow and deep periodontal pockets in 20%. Periodontal attachment loss > 4 mm was observed in 24% of the pregnant women. The group was homogeneous as to the maternal characteristics, age (p=0.0384) and smoking (p=0.0102) being the only factors associated with periodontal disease. The existence of a FHP at the public assistance service was not associated with a lower prevalence of the disease. Conclusion: The findings of this study show a high prevalence of periodontal alterations during pregnancy, with no influence from the existence of a FHP on the observed conditions. Among the risk variables, age and smoking were the factors associated with the presence of periodontal disease. There is a need for a better planing and accomplishment of oral health actions during the prenatal period.

Efeito da exposição à fumaça de cigarro durante a prenhez e a lactação de ratas e sua prole sobre parâmetros séricos e morfométricos

PURPOSE: to investigate the effect of cigarette smoke exposure on body and tissue weight gain, serum parameters and milk yield during pregnancy and lactation in rats, and the impact on offspring from birth toil young adulthood. METHODS: 40 Wistar pregnant rats were randomly divided into: CG - not exposed to cigarette smoke and sacrificed at the end of pregnancy; CL - not exposed to cigarette smoke and sacrificed at the end of lactation; FG - exposed to cigarette smoke and sacrificed at the end of pregnancy; FL - exposed to cigarette smoke and sacrificed at the end of lactation. The offspring were separated by gender and divided according to their mothers' groups. Tissue weight, body weight and serum parameters were evaluated in rats and offspring. Milk yield per pup was calculated. RESULTS: body weight was decreased in FL during lactation (CL=267.0±7.2; FL=235.5±7.2 g*, *p<0.05). Adipose tissue was not detected in the CL and FL groups, and was reduced in FG compared to CG (CG=3.3±0.3; FG=2.4±0.3 g*, *p<0.05). Rats exposed to cigarette smoke had higher blood glucose levels (CG=113±17, CL=86±16, FG=177±21*, FL=178±23 mg/dL*, *p<0.05 CG versus FG e CL versus FL), CL and FL groups presented lower HDL-cholesterol with no change in total cholesterol. Finally, rats exposed to cigarette smoke had lower milk yield compared to unexposed rats (CL=6.7±0.4, FL=5.4±0.3 g*, *p<0.05). In offspring from the FG and FL groups, there was a decrease of body weight from birth to young adulthood, with no changes in gastrocnemius, liver or heart weights in any group, and adipose tissue was no detected in female offspring. There was an increase in blood glucose in offspring of both sexes from rats exposed to cigarette smoke (males: Pcg=107±10.5, Pcl=115±8.6, Pfg=148±16.8*, Pfl=172±11.2**; females: Pcg=109±27.2, Pcl=104±9.7, Pfg=134±20.0*, Pfl=126±13.3**; p<0.05 *Pcg versus Pfg and **Pcl versus Pfl). CONCLUSIONS: exposure to cigarette smoke provokes impairment of morphometric and serum parameters during pregnancy and lactation both in mothers and offspring, which is maintained during young adulthood.

Ausência de arteriosclerose na porção intramiocárdica das artérias coronárias: Um mistério a ser resolvido?

Several studies show that portions of intramyocardial coronary arteries are spared of arteriosclerosis, involving morphological, embryological, biochemical and pathophysiological aspects. Endothelial function is significantly affected in the segment of transition, as estimated by the vasoactive response to Ach. These findings suggest that myocardial bridge can provide protection against arteriosclerosis by counteracting the negative effects of endothelial dysfunction. The intramyocardial portion's protection phenomenon deserves further scientific research on all research fronts. Improved morphological, biomechanical and especially physiological and embryological knowledge may be the key to a future window of opportunity for chronic arterial disease therapy and prevention. In addition, this review discusses possible therapeutic approaches for symptomatic coronary ischemia caused by myocardial bridges.

Risk factors for low birth weight in Botucatu city, SP state, Brazil: A study conducted in the public health system from 2004 to 2008

Background: Low birth weight (LBW), defined as birth weight less than 2500 g, has a complex etiology and may be a result of premature interruption of pregnancy or intrauterine growth restriction. The objective of this study was to provide information on determinants of LBW and contribute to the understanding of the problem in Brazil. Methods. A case-control study was conducted in Botucatu city, SP state, Brazil. The study population consisted of 2 groups with 860 newborns in each group as follows: low weight newborns (LWNB) and a control group (weight ≤ 2500 g). Secondary data from 2004 to 2008 were collected using the Live Birth Certificate (LBC) and records from medical charts of pregnant women in Basic Health Units (BHU) and in the Public University Hospital (UH). Variables were as follows: maternal socio-demographic characteristics, pregnancy and birth conditions including quality of prenatal care according to 3 criteria. They were based on parameters established by the Ministry of Health (MH), one of them, the modified Kessner Index. The multivariable analysis by logistic regression was used to evaluate the association between variables and LBW. Results: According to the analysis, the factors associated with LBW were as follows: prematurity (OR = 56.98, 95% CI 29.52-109.95), twin pregnancy (OR = 20.00, 95% CI 6.25-100.00), maternal smoking (OR = 2.12, 95% CI 1.33-3.45), maternal malnourishment (OR = 2.30, 95% CI 1.08-5.00), maternal obesity (OR = 2.30, 95% IC 1.18-4.48), weight gain during pregnancy less than 5 kg (OR = 2.63, 95% CI 1.35-5.00) and weight gain during pregnancy more than 15 kg (OR = 2.26, 95% CI 1.16-4.41). Adequacy of prenatal care visits adjusted to gestational age was less frequent in the LBW group than in the control group (68.7% vs. 80.5%, x 2 p < 0.001). According to the modified Kessner Index, 64.4% of prenatal visits in the LWNB group were adequate. Conclusion: LWNB are a quite heterogeneous group of infants concerning their determinants and prevention actions against LBW and the follow-up of these infants have also been very complex. Therefore, improvement in the quality of care provided should be given priority through concrete actions for prevention of LBW. © 2012 Fonseca et al; licensee BioMed Central Ltd.

Congenital diaphragmatic Bochdaleck hernia: Case report

Congenital diaphragmatic Bochdaleck hernia is an anatomical defect of the diaphragm, which allows protrusion of abdominal viscera into the chest, causing serious pulmonary and cardiac complications in the neonate. In this study we aimed to present a case of congenital Bochdaleck hernia. We investigated a 40 weeks old child, with a pregnancy carried out in a public hospital in Passo Fundo, Rio Grande do Sul, Brazil. We suggest that if diagnosis occurs in the prenatal period, the prognosis of this disease improves. As a consequence, it allows the parity of the fetus to occur in a higher complexity center, optimizing the chances of survival. © 2012 Lava et al.; licensee BioMed Central Ltd.

Effect of superstimulatory treatments on the expression of genes related to ovulatory capacity, oocyte competence and embryo development in cattle.

Multiple ovulation (superovulation) and embryo transfer has been used extensively in cattle. In the past decade, superstimulatory treatment protocols that synchronise follicle growth and ovulation, allowing for improved donor management and fixed-time AI (FTAI), have been developed for zebu (Bos indicus) and European (Bos taurus) breeds of cattle. There is evidence that additional stimulus with LH (through the administration of exogenous LH or equine chorionic gonadotrophin (eCG)) on the last day of the superstimulatory treatment protocol, called the 'P-36 protocol' for FTAI, can increase embryo yield compared with conventional protocols that are based on the detection of oestrus. However, inconsistent results with the use of hormones that stimulate LH receptors (LHR) have prompted further studies on the roles of LH and its receptors in ovulatory capacity (acquisition of LHR in granulosa cells), oocyte competence and embryo quality in superstimulated cattle. Recent experiments have shown that superstimulation with FSH increases mRNA expression of LHR and angiotensin AT(2) receptors in granulosa cells of follicles >8 mm in diameter. In addition, FSH decreases mRNA expression of growth differentiation factor 9 (GDF9) and bone morphogenetic protein 15 (BMP15) in oocytes, but increases the expression of both in cumulus cells, without diminishing the capacity of cumulus-oocyte complexes to generate blastocysts. Although these results indicate that superstimulation with FSH is not detrimental to oocyte competence, supplementary studies are warranted to investigate the effects of superstimulation on embryo quality and viability. In addition, experiments comparing the cellular and/or molecular effects of adding eCG to the P-36 treatment protocol are being conducted to elucidate the effects of superstimulatory protocols on the yield of viable embryos.

Effects of heat stress on development, quality and survival of Bos indicus and Bos taurus embryos produced in vitro

Heat stress is an important cause of poor development and low survival rates in bovine embryos. Experiments were conducted to test the hypothesis that Bos indicus embryos are more resistant to heat stress than are Bos taurus embryos. In experiment 1, Nelore and Jersey embryos from oocyte pick-up-derived oocytes were submitted to heat stress (96 hours post-insemination, 41 °C, 6 hours), developmental ratios were assessed at Day 7 (Day 0 = day of fertilization), and blastocysts were frozen for RNA extraction. Experiment 2 evaluated expression of COX2, CDX2, HSF1, and PLAC8 in previously frozen blastocysts. In experiment 3, Nellore and Angus embryos from oocyte pick-up-derived oocytes were submitted to heat stress (96 hours post-insemination, 41 °C, 12 hours) and transferred to recipients on Day 7. In experiment 4, embryos developed as in experiment 3 were fixed for Terminal deoxynucleotidyl transferase dUTP nick end labeling labeling and total cell counting. In experiment 1, heat stress decreased the percentage of Jersey oocytes that became blastocysts, but had no effect on Nellore embryos (34.6%, 25.0%, 39.5%, and 33.0% for Jersey control, Jersey heat-stressed, Nellore control, and Nellore heat-stressed oocytes, respectively; P < 0.05). In experiment 2, heat stress decreased (P < 0.05) expression of CDX2 and PLAC8, with higher expression of these genes in Nellore embryos than in Jersey embryos. Heat stress also decreased (P < 0.05) expression of COX2 in Jersey embryos, but had no effect on Nellore embryos. Expression of HSF1 was decreased (P < 0.05) by heat stress in both breeds, with a greater effect in Nellore embryos. In experiment 3, heat stress tended (P = 0.1) to decrease the percentage of pregnancies among cows (Day 30 to 35) that received Angus embryos. In experiment 4, heat stress increased (P < 0.05) the percentage of apoptotic blastomeres, but had no breed-specific effects. In addition, Nellore embryos had fewer (P < 0.05) Terminal deoxynucleotidyl transferase dUTP nick end labeling- positive blastomeres than did Angus embryos. We concluded that the detrimental effects of heat stress were dependent upon embryo breed and were more evident in Bos taurus embryos than in Bos indicus embryos. © 2013 Elsevier Inc.

Supplementation with the histone deacetylase inhibitor trichostatin A during in vitro culture of bovine embryos

Summary Trichostatin A (TSA) is a histone deacetylase inhibitor that induces histone hyperacetylation and increases gene expression levels. The aim of the present study was to establish a suitable condition for the use of TSA in in vitro cultures of bovine embryos, and to determine whether TSA would increase blastocyst rates by improvement of chromatin remodelling during embryonic genome activation and by increasing the expression of crucial genes during early development. To test this hypothesis, 8-cell embryos were exposed to four concentrations of TSA for different periods of time to establish adequate protocols. In a second experiment, three experimental groups were selected for the evaluation of embryo quality based on the following parameters: apoptosis, total cell number and blastocyst hatching. TSA promoted embryonic arrest and degeneration at concentrations of 15, 25 and 50 nM. All treated groups presented lower blastocyst rates. Exposure of embryos to 5 nM for 144 h and to 15 nM for 48 h decreased blastocyst hatching. However, the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay (TUNEL) assay revealed similar apoptosis rates and total cell numbers in all groups studied. Although, in the present study, TSA treatment did not improve the parameters studied, the results provided background information on TSA supplementation during in vitro culture of bovine embryos and showed that embryo quality was apparently not affected, despite a decrease in blastocyst rate after exposure to TSA. © Cambridge University Press 2011.

High dosage folic acid supplementation, oral cleft recurrence and fetal growth

Objectives: To evaluate the effects of folic acid supplementation on isolated oral cleft recurrence and fetal growth. Patients and Methods: The study included 2,508 women who were at-risk for oral cleft recurrence and randomized into two folic acid supplementation groups: 0.4 and 4 mg per day before pregnancy and throughout the first trimester. The infant outcome data were based on 234 live births. In addition to oral cleft recurrence, several secondary outcomes were compared between the two folic acid groups. Cleft recurrence rates were also compared to historic recurrence rates. Results: The oral cleft recurrence rates were 2.9% and 2.5% in the 0.4 and 4 mg groups, respectively. The recurrence rates in the two folic acid groups both separately and combined were significantly different from the 6.3% historic recurrence rate post the folic acid fortification program for this population (p = 0.0009 when combining the two folic acid groups). The rate of cleft lip with palate recurrence was 2.9% in the 0.4 mg group and 0.8% in the 4 mg group. There were no elevated fetal growth complications in the 4 mg group compared to the 0.4 mg group. Conclusions: The study is the first double-blinded randomized clinical trial (RCT) to study the effect of high dosage folic acid supplementation on isolated oral cleft recurrence. The recurrence rates were similar between the two folic acid groups. However, the results are suggestive of a decrease in oral cleft recurrence compared to the historic recurrence rate. A RCT is still needed to identify the effect of folic acid on oral cleft recurrence given these suggestive results and the supportive results from previous interventional and observational studies, and the study offers suggestions for such future studies. The results also suggest that high dosage folic acid does not compromise fetal growth. © 2013 by the authors; licensee MDPI, Basel, Switzerland.