Traumatismo cardíaco com retenção de corpo estranho em criança de sete anos

This is a case report about a seven year-old child who arrived at Emergency Department of Hospital da Restauração with gunshot wound on precordial area and clinical signs of cardiac tamponade. The roentgenogram showed 27 retained pellets in cardiac area. Thoracotomy was performed and repaired a cardiac wound in right ventricule. The patient developed conduction disturbance and valvar defect, but was discharged on the tenth postoperative day. Diagnosis, treatment and complications of retained projectiles are discussed.

Decorticação pleural precoce no tratamento do empiema pleural complicado na criança

Os autores avaliam dez casos de empiema pleural tratados inicialmente pela drenagem pleural fechada e que tiveram evolução desfavorável e arrastada. Pacientes que evoluíram com septação do empiema, persistência de fístula broncopleural de alto débito ou de falta de expansão pulmonar após a drenagem pulmonar foram submetidos a estudo pela tomografia computadorizada e encaminhados para a decorticação pleural precoce como alternativa para o tratamento. Todos os pacientes tratados desta forma tiveram uma rápida melhora clínica, evoluindo com boa expansão pulmonar, recebendo alta hospitalar num prazo máximo de dez dias após a cirurgia. Concluem os autores que tal procedimento é seguro devendo ser considerado para o tratamento do empiema pleural de má evolução.

Cisto de colédoco em criança

We report the case of a one-year and two-months-old child with a choledochal cyst tYpe I of Alonso-Lej and Todani's classification , diagnosed through abdominal ultrasound. The surgical treatment was cholecistectomy and choledochal cyst excision with Roux-in-Y hepatic- jejunostomy. Minor complications were observed during early postoperative recovery. Long-term flow-up has been uneventiful, with overall improvement.

Síndrome da veia cava superior em criança

The authors describe a case of benign superior vena cava syndrome post phlebotomy in childhood, including exams for diagnosis and possible treatment.

Estado atual do diagnóstico e tratamento da apendicite aguda na criança: avaliação de 300 casos

OBJETIVOS: Avaliar o estado atual do diagnóstico e tratamento da apendicite aguda em crianças operadas em dois grandes hospitais quaternários da cidade de São Paulo, no período de 30 meses. MÉTODO: Nossa casuística constou de 300 crianças operadas por apendicite aguda no período de 1998 a 2000 (65% do sexo masculino e 35% feminino). Foram analisadas as variáveis idade, sexo, manifestações clínicas, tempo gasto para o diagnóstico, achados de exame físico, laboratoriais e cirúrgicos, antimicrobianos administrados, complicações pós-operatórias e tempo de internação. Utilizou-se o teste t de Student para avaliar duas variantes e Análise de Variâncias quando mais de duas. RESULTADOS: Diagnosticou-se inicialmente apendicite aguda em apenas 63% dos casos, tendo os 35% restantes, diagnóstico de abdome agudo cirúrgico. O tempo decorrido na realização do diagnóstico foi superior a 24 horas em 57,4% dos casos, denotando retardo importante na sua elaboração. Dor abdominal (85,3%) e irritação peritoneal (82%) em fossa ilíaca direita foram os sinais e sintomas mais freqüentes. Identificou-se leucocitose em 83% dos pacientes e leucocitúria em 39,7 %. Em 92,4% das radiografias simples de abdome encontramos imagens sugestivas de apendicite aguda. A ultra-sonografia abdominal foi diagnóstica em 80,1% dos casos. Utilizaram-se esquemas antimicrobianos especialmente para agentes gram-negativos e anaeróbicos. A principal complicação foi infecção da ferida cirúrgica, não tendo sido observada mortalidade no grupo. A média de internação foi de 5.2 e 6,0 dias para meninos e meninas respectivamente. CONCLUSÃO: Mesmo com melhor conhecimento sobre apendicite aguda, refinamento técnico, laboratorial, radiológico e uso de antibioticoterapia adequada, o tempo de para diagnóstico e a morbidade ainda se mantém alta na idade pediátrica.

O papel da cirurgia torácica vídeo-assistida - CTVA - no tratamento da pneumonite necrosante na criança

OBJETIVO: Avaliar o papel da cirurgia torácica vídeo-assistida (CTVA) no tratamento das complicações pleurais da pneumonite necrosante (PN) na criança, em sua fase aguda. MÉTODO: Avaliação prospectiva de sete pacientes com idades entre quatro e sete anos, portadores de empiema pleural com PN, com diagnóstico confirmado por tomografia computadorizada de tórax (TC) e cirurgia. Realizou-se a descorticação pulmonar com esvaziamento do pleuris, desbridamento e ressecção do tecido pulmonar comprometido, e drenagem torácica, através de videotoracoscopia com três portais. Foram avaliados no pós-operatório a curva térmica, o leucograma, o tempo de drenagem torácica e a permanência hospitalar. RESULTADOS: Houve re-expansão pulmonar completa em todos os pacientes tratados pela CTVA, com rápida melhora do estado geral, queda de temperatura e da leucocitose na primeira semana pós-tratamento. O período de drenagem pós-CTVA variou de sete a 17 dias, e a permanência hospitalar póscirúrgica foi menor quando comparada com dados da literatura em que o tratamento utilizado foi a drenagem torácica com antibioticoterapia ou a cirurgia a céu aberto. CONCLUSÕES: A utilização da CTVA como coadjuvante no tratamento da PN acompanhada de complicações pleurais, tem papel importante na aceleração da recuperação clínica do paciente, proporcionando a reexpansão mais rápida do pulmão colapsado, com melhoria das condições respiratórias.

Videocirurgia na criança: estado da arte. Experiência com 1408 procedimentos no Instituto da Criança "Pedro de Alcântara"

A videocirurgia em Cirurgia Pediátrica encontra um imenso campo de aplicações ainda, infelizmente, pouco explorado. São poucos os serviços que utilizam rotineiramente essa via de acesso e são escassas as referências nacionais publicadas. O Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr) há uma década e meia a utiliza e hoje a videocirurgia é a via de primeira escolha para tratar, entre outras doenças, o refluxo gastresofagiano, a colecistopatia calculosa, o testículo não palpável e o megaesôfago. Neste artigo relataremos a experiência em videocirurgia pediátrica do ICr, adquirida com 1408 pacientes operados, para divulgar e popularizar esta via de acesso, útil e benéfica para um grande número de situações e ainda subutilizada em Cirurgia Pediátrica.

Studies of the small bowel surface by scanning electron microscopy in infants with persistent diarrhea

We describe the ultrastructural abnormalities of the small bowel surface in 16 infants with persistent diarrhea. The age range of the patients was 2 to 10 months, mean 4.8 months. All patients had diarrhea lasting 14 or more days. Bacterial overgrowth of the colonic microflora in the jejunal secretion, at concentrations above 10(4) colonies/ml, was present in 11 (68.7%) patients. The stool culture was positive for an enteropathogenic agent in 8 (50.0%) patients: for EPEC O111 in 2, EPEC O119 in 1, EAEC in 1, and Shigella flexneri in 1; mixed infections due to EPEC O111 and EAEC in 1 patient, EPEC O119 and EAEC in 1 and EPEC O55, EPEC O111, EAEC and Shigella sonnei in 1. Morphological abnormalities in the small bowel mucosa were observed in all 16 patients, varying in intensity from moderate 9 (56.3%) to severe 7 (43.7%). The scanning electron microscopic study of small bowel biopsies from these subjects showed several surface abnormalities. At low magnification (100X) most of the villi showed mild to moderate stunting, but on several occasions there was subtotal villus atrophy. At higher magnification (7,500X) photomicrographs showed derangement of the enterocytes; on several occasions the cell borders were not clearly defined and very often microvilli were decreased in number and height; in some areas there was a total disappearance of the microvilli. In half of the patients a mucus-fibrinoid pseudomembrane was seen partially coating the enterocytes, a finding that provides additional information on the pathophysiology of persistent diarrhea.

Serum hexosaminidase and ß-glucuronidase activities in infants: effects of age and sex

We investigated the effect of age and sex on the serum activity of hexosaminidase (HEX) and ß-glucuronidase (BGLU) in 275 normal term infants aged 12 h to 12 months. Up to six weeks of life, HEX was significantly higher in boys (P<=0.023). During the age period of 1-26 weeks, BGLU was also higher in boys, but differences were significant only at 2-6 and 7-15 weeks (P<=0.016). The developmental pattern of HEX and BGLU was sex dependent. HEX activity increased in both sexes from 4-7 days of life, reaching a maximum of 1.4-fold the birth value at 2-6 weeks of age in boys (P<0.001) and a maximum of 1.6-fold at 7-15 weeks in girls (P<0.001). HEX activity gradually decreased thereafter, reaching significantly lower levels at 27-53 weeks than during the first three days of life in boys (P = 0.002) and the same level of this age interval in girls. BGLU increased in both sexes from 4-7 days of age, showing a maximum increase at 7-15 weeks (3.3-fold in boys and 2.9-fold in girls, both P<0.001). Then BGLU decreased in boys to a value similar to that observed at 4-7 days of age. In girls, BGLU remained elevated until the end of the first year of life. These results indicate a variation of HEX and BGLU activities during the first year of life and a sex influence on their developmental pattern. This observation should be considered in the diagnosis of GM2 gangliosidosis and mucopolysaccharidosis type VII.

Amino acid composition of parturient plasma, the intervillous space of the placenta and the umbilical vein of term newborn infants

The objective of the present study was to determine the levels of amino acids in maternal plasma, placental intervillous space and fetal umbilical vein in order to identify the similarities and differences in amino acid levels in these compartments of 15 term newborns from normal pregnancies and deliveries. All amino acids, except tryptophan, were present in at least 186% higher concentrations in the intervillous space than in maternal venous blood, with the difference being statistically significant. This result contradicted the initial hypothesis of the study that the plasma amino acid levels in the placental intervillous space should be similar to those of maternal plasma. When the maternal venous compartment was compared with the umbilical vein, we observed values 103% higher on the fetal side which is compatible with currently accepted mechanisms of active amino acid transport. Amino acid levels of the placental intervillous space were similar to the values of the umbilical vein except for proline, glycine and aspartic acid, whose levels were significantly higher than fetal umbilical vein levels (average 107% higher). The elevated levels of the intervillous space are compatible with syncytiotrophoblast activity, which maintain high concentrations of free amino acids inside syncytiotrophoblast cells, permitting asymmetric efflux or active transport from the trophoblast cells to the blood in the intervillous space. The plasma amino acid levels in the umbilical vein of term newborns probably may be used as a standard of local normality for clinical studies of amino acid profiles.

Contrast sensitivity threshold measured by sweep-visual evoked potential in term and preterm infants at 3 and 10 months of age

Although healthy preterm infants frequently seem to be more attentive to visual stimuli and to fix on them longer than full-term infants, no difference in visual acuity has been reported compared to term infants. We evaluated the contrast sensitivity (CS) function of term (N = 5) and healthy preterm (N = 11) infants at 3 and 10 months of life using sweep-visual evoked potentials. Two spatial frequencies were studied: low (0.2 cycles per degrees, cpd) and medium (4.0 cpd). The mean contrast sensitivity (expressed in percentage of contrast) of the preterm infants at 3 months was 55.4 for the low spatial frequency (0.2 cpd) and 43.4 for the medium spatial frequency (4.0 cpd). At 10 months the low spatial CS was 52.7 and the medium spatial CS was 9.9. The results for the term infants at 3 months were 55.1 for the low spatial frequency and 34.5 for the medium spatial frequency. At 10 months the equivalent values were 54.3 and 14.4, respectively. No difference was found using the Mann-Whitney rank sum T-test between term and preterm infants for the low frequency at 3 or 10 months or for the medium spatial frequency at 3 or 10 months. The development of CS for the medium spatial frequency was equally fast for term and preterm infants. As also observed for visual acuity, CS was equivalent among term and preterm infants, suggesting that visual experience does not modify the development of the primary visual pathway. An earlier development of synapses in higher cortical visual areas of preterm infants could explain the better use of visual information observed behaviorally in these infants.

Th-1 and Th-2 cytokine production in infants with virus-associated wheezing

Wheezing associated with respiratory viral infections in infancy is very common and results in high morbidity worldwide. The Th1/Th2 pattern of immune response in these patients remains unclear and previous studies have shown controversial results. The aim of the present study was to compare the type of Th1/Th2 cytokine response between infants with acute bronchiolitis, recurrent wheezing and upper respiratory infections from a developing country. Infants younger than 2 years of age admitted to Hospital São Lucas, Porto Alegre, RS, Brazil, between May and November 2001, with an acute episode of wheezing associated with viral respiratory infection were selected. Subjects with upper respiratory infections from the emergency department were selected for the control group. Interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) levels from nasal aspirates were determined by ELISA from peripheral mononuclear cell cultures. Twenty-nine subjects with acute bronchiolitis, 18 with recurrent wheezing and 15 with upper respiratory infections were enrolled. There were no differences in family history of atopy or parental smoking between groups. Oxygen requirement was similar for the acute bronchiolitis and recurrent wheezing groups. The percentage of positive tests for the cytokines studied and the IFN-gamma/IL-4 ratio was similar for all groups. Comparison of the polarized Th1/Th2 cytokine results for the various groups showed no specific pattern of cytokine production. Infants with wheezing from a developing country do not show any specific predominant pattern of Th1/Th2 cytokine production, suggesting that multiple factors may be involved in the pathogenesis of this illness.

Risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants

Data were prospectively obtained from exclusively breast-fed healthy term neonates at birth and from healthy mothers with no obstetric complication to determine risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants. Thirty-four neonates with a weight loss > or = 10% were diagnosed between April 2001 and January 2005. Six of 18 infants who were eligible for the study had hypernatremia. Breast conditions associated with breast-feeding difficulties (P < 0.05), primiparity (P < 0.005), less than four stools (P < 0.001), pink diaper (P < 0.001), delay at initiation of first breast giving (P < 0.01), birth by cesarean section (P < 0.05), extra heater usage (P < 0.005), extra heater usage among mothers who had appropriate conditions associated with breast-feeding (P < 0.001), mean weight loss in neonates with pink diaper (P < 0.05), mean uric acid concentration in neonates with pink diaper (P < 0.0001), fever in hypernatremic neonates (P < 0.02), and the correlation of weight loss with both serum sodium and uric acid concentrations (P < 0.02) were determined. Excessive weight loss occurs in exclusively breast-fed infants and can be complicated by hypernatremia and other morbidities. Prompt initiation of breast-feeding after delivery and prompt intervention if problems occur with breast-feeding, in particular poor breast attachment, breast engorgement, delayed breast milk "coming in", and nipple problems will help promote successful breast-feeding. Careful follow-up of breast-feeding dyads after discharge from hospital, especially regarding infant weight, is important to help detect inadequate breast-feeding. Environmental factors such as heaters may exacerbate infant dehydration.

A randomized double-blind clinical trial of the effect of non-absorbable oral polymyxin on infants with severe infectious diarrhea

The present study evaluated the effect of non-absorbable oral polymyxin on the duodenal microflora and clinical outcome of infants with severe infectious diarrhea. Polymyxin was chosen because classic enteropathogenic Escherichia coli was more sensitive to this antibiotic. Twenty-five infants were randomly assigned to a 7-day treatment with oral polymyxin (2.5 mg/kg in 4 daily doses) or placebo. Duodenal and stool cultures were performed before and after the treatment. Five patients were excluded during the study because of introduction of parental antibiotic therapy due to clinical sepsis (N = 3) or rapid clinical improvement (N = 2). In the polymyxin group, small bowel bacterial overgrowth occurred in 61.5% of the cases (8/13) before treatment and in 76.9% (10/13) after treatment. In the placebo group these values were 71.4% (5/7) and 57.1% (4/7), respectively. By the 7th day, clinical cure was observed in 84.6% of the cases (11/13) in the polymyxin group and in 71.4% (5/7) in the placebo group (P = 0.587). Considering all 25 patients included in the study, clinical cure occurred on the 7th day in 12/14 cases (85.7%) in the polymyxin group and 6/11 cases (54.5%) in the placebo group (P = 0.102). Clinical sepsis occurred in 3/11 (27.3%) of the patients in the placebo group and in none (0/14) in the polymyxin group (P = 0.071). Oral polymyxin was not effective in reducing bacterial overgrowth or in improving the clinical outcome of infants hospitalized with severe infectious diarrhea. Taking into account the small sample size, the rate of cure on the 7th day and the rate of clinical sepsis, further studies with greater number of patients are necessary to evaluate these questions.

Cortisol and 17-a-hydroxy-progesterone levels in infants with refractory hypotension born at 30 weeks of gestation or less

Refractory hypotension is frequent in very low-birth weight infants, whose hypothalamic-pituitary-adrenal axis has been suggested to be immature. The objective of the present study was to evaluate basal cortisol and 17-a-OH-progesterone in the first 36 h of life in preterm infants with and without refractory hypotension (mean arterial blood pressure below the lower limit for gestational age throughout the study despite aggressive volume expansion and use of vasopressors). Thirty-five infants with £30 weeks of gestation and a birth weight £1250 g, with no postnatal use of corticosteroid or death in the first 48 h were studied. Mean arterial pressure was measured every 4 h during the first 48 h. Cortisol and 17-a-OH-progesterone were determined at 12 and 36 h and patients were divided into refractory hypotensive (N = 15) and control (N = 20) groups. The groups were not different regarding type of delivery, use of prenatal corticosteroid, requirement of mechanical ventilation, use of vasopressor drugs, morphine, fentanyl, prophylactic indomethacin, and mean sample timing. Although refractory hypotensive newborns were more immature, were smaller, suffered more deaths after 48 h of life and had a higher SNAPPE-2 score, their cortisol and 17-a-OH-progesterone levels were not different from controls at 12 h and at 36 h. The increase of cortisol in newborns with refractory hypotension 36 h after birth was significantly higher than in controls. Despite the fact that refractory hypotensive very low-birth weight neonates were submitted to a very stressful condition, their cortisol and 17-a-OH-progesterone levels were similar to controls.