A relação entre família e escola e a perspectiva de minimização das dificuldades comportamentais e cognitivas apresentadas por adolescentes com Síndrome do Alcoolismo Fetal (SAF): estudos de casos na cidade de Manaus

Dissertação de mestrado em Educação Especial (área de especialização em Dificuldades de Aprendizagem Específicas)

Sex differences in the fetal heart rate variability indices of twins

Aims: To evaluate the differences in linear and complex heart rate dynamics in twin pairs according to fetal sex combination [male-female (MF), male-male (MM), and female-female (FF)]. Methods: Fourteen twin pairs (6 MF, 3 MM, and 5 FF) were monitored between 31 and 36.4 weeks of gestation. Twenty-six fetal heart rate (FHR) recordings of both twins were simultaneously acquired and analyzed with a system for computerized analysis of cardiotocograms. Linear and nonlinear FHR indices were calculated. Results: Overall, MM twins presented higher intrapair average in linear indices than the other pairs, whereas FF twins showed higher sympathetic-vagal balance. MF twins exhibited higher intrapair average in entropy indices and MM twins presented lower entropy values than FF twins considering the (automatically selected) threshold rLu. MM twin pairs showed higher intrapair differences in linear heart rate indices than MF and FF twins, whereas FF twins exhibited lower intrapair differences in entropy indices. Conclusions: The results of this exploratory study suggest that twins have sex-specific differences in linear and nonlinear indices of FHR. MM twins expressed signs of a more active autonomic nervous system and MF twins showed the most active complexity control system. These results suggest that fetal sex combination should be taken into consideration when performing detailed evaluation of the FHR in twins.

Fetal behavior and heart rate in twin pregnancy: a review

Fetal movements and fetal heart rate (FHR) are well-established markers of fetal well-being and maturation of the fetal central nervous system. The purpose of this paper is to review and discuss the available knowledge on fetal movements and heart rate patterns in twin pregnancies. There is some evidence for an association or similarity in fetal movement incidences or FHR patterns between both members of twin pairs. However, the temporal occurrence of these patterns seems to be for the most part asynchronous, especially when stricter criteria are used to define synchrony. The available data suggest that fetal behavior is largely independent of sex combination, fetal position, and presentation. Conversely, chorionicity appears to have some influence on fetal behavior, mainly before 30 weeks of gestation. There is preliminary evidence for the continuity of inter-individual differences in fetal activity and FHR patterns over pregnancy. Comparisons between studies are limited by large methodological differences and absence of uniform concepts and definitions. Future studies with high methodological quality are needed to provide a more comprehensive knowledge of normal fetal behavior in twin pregnancy.

Mother’s anxiety and depression and associated risk factors during early pregnancy: effects on fetal growth and activity at 20–22 weeks of gestation

To examine effects of mother's anxiety and depression and associated risk factors during early pregnancy on fetal growth and activity. Repeated measures of mother's anxiety (State-Anxiety Inventory (STAI-S)) and depression (Edinburgh Postnatal Depression Scale (EPDS)) and related socio demographics and substance consumption were obtained at the 1st and 2nd pregnancy trimesters, and fetus' (N = 147) biometric data and behavior was recorded during ultrasound examination at 20-22 weeks of gestation. Higher anxiety symptoms were associated to both lower fetal growth and higher fetal activity. While lower education, primiparity, adolescent motherhood, and tobacco consumption predicted lower fetal growth, coffee intake predicted lower fetal activity. Vulnerability of fetal development to mother's psychological symptoms as well as to other sociodemographic and substance consumption risk factors during early and mid pregnancy is suggested.

Prenatal dysthymia versus major depression effects on maternal cortisol and fetal growth

To determine differences between pregnant women diagnosed with Dysthymia versus Major Depression, depressed pregnant women (N=102) were divided by their diagnosis into Dysthymic (N=48) and Major Depression (N=54) groups and compared on self-report measures (depression, anxiety, anger, daily hassles and behavioral inhibition), on stress hormone levels (cortisol and norepinephrine), and on fetal measurements. The Major Depression group had more self-reported symptoms. However, the Dysthymic group had higher prenatal cortisol levels and lower fetal growth measurements (estimated weight, femur length, abdominal circumference) as measured at their first ultrasound (M=18 weeks gestation). Thus, depressed pregnant women with Dysthymia and Major Depression appeared to have different prenatal symptoms.

Electrocardiographic Alterations in Patients Hospitalized with Leptospirosis in the Brazilian City of Salvador

OBJECTIVE: To report the frequency and types of electrocardiographic alterations in patients with leptospirosis in the first 24 hours of hospitalization. METHODS: We analyzed the electrocardiograms of 157 patients admitted to the Hospital Couto Maia in the city of Salvador, in the State of Bahia, Brazil, from March 1998 to June 1999. The electrocardiograms were performed in the first 24 hours after hospital admission, independent of the clinical manifestations of the patients. RESULTS: The mean ± SD for patients' age was 35.5± 13.7 (median = 32) years, and jaundice was present in 95.5% of them. Alterations in the electrocardiogram were detected in 68.2% (107/157) of the patients (95% confidence interval = 60.6% - 75.1%). Atrial fibrillation was the most frequent arrhythmia, occurring in 10.8% (17/157) of the patients. Other frequent findings were alterations in ventricular repolarization detected in 38.9% (61/157) of patients and first-degree atrioventricular block in 10.2% (16/157). The patients with atrial fibrillation were older and had higher levels of creatinine and aminotransferases. CONCLUSION: In this sample, approximately 2/3 of the patients had electrocardiographic alterations after hospital admission. Of the major arrhythmias, atrial fibrillation was the most frequent, and the patients with this arrhythmia had evidence of more severe disease. The relation between the presence and type of electrocardiographic alteration and the prognosis of leptospirosis is yet to be assessed.

Electrocardiographic and Blood Pressure Alterations During Electroconvulsive Therapy in Young Adults

OBJECTIVE - To study cardiovascular alterations in young patients with no apparent organic disease who underwent electroconvulsive therapy. METHODS - The study comprised 47 healthy patients (22 males and 25 females) with a mean age of 30.3 years, who underwent electroconvulsive therapy. Ambulatory blood pressure monitoring and continuous electrocardiographic monitoring (Holter monitor) were performed during 24 hours. Blood pressure and heart rate were assessed 4 hours prior to electric shock administration, during electric shock administration, and 3 hours after electric shock administration. Arrhythmias and alterations in the ST segment in 24 hours were recorded. RESULTS - On electroconvulsive therapy, a significant increase in blood pressure and heart rate was observed and the measurements returned to basal values after 25 minutes. Three females had tracings with depression of the ST segment suggesting myocardial ischemia prior to and after electroconvulsive therapy. Coronary angiography was normal. No severe cardiac arrhythmias were diagnosed. CONCLUSION - 1) Electroconvulsive therapy is a safe therapeutic modality in psychiatry; 2) it causes a significant increase in blood pressure and heart rate; 3) it may be associated with myocardial ischemia in the absence of coronary obstructive disease; 4) electroconvulsive therapy was not associated with the occurrence of severe cardiac arrhythmias.

Vector electrocardiographic alterations after percutaneous septal ablation in obstructive hypertrophic cardiomyopathy: possible anatomic causes

OBJECTIVE: Analyze the dromotropic disturbances (vector-electrocardiographic), and the possible anatomic causes, provoked by selective alcohol injection in the septal branch, for percutaneous treatment, of obstructive hypertrophic cardiomyopathy. METHODS: Ten patients with a mean age of 52.7 years underwent percutaneous septal ablation (PTSA) from october 1998; all in functional class III/IV). Twelve-lead electrocardiogram was performed prior to and during PTSA, and later electrocardiogram and vectorcardiogram according to Frank's method. The patients were followed up for 32 months. RESULTS: On electrocardiogram (ECG) prior to PTSA all patients had sinus rhythm and left atrial enlargement, 8 left ventricular hypertrophy of systolic pattern. On ECG immediately after PTSA, 8 had complete right bundle-branch block; 1 transient total atrioventricular block; 1 alternating transient bundle-branch block either right or hemiblock. On late ECG 8 had complete right bundle-branch block confirmed by vectorcardiogram, type 1 or Grishman. CONCLUSION: Septal fibrosis following alcohol injection caused a predominance of complete right bundle-branch block, different from surgery of myotomy/myectomy.

Study of the cardiac alterations in HIV-infected children consequent to the antiretroviral therapy: prospective study of 47 cases

OBJECTIVE: Detect of cardiac alterations in children with AIDS and compare their evolution with the administration of only one anti-retroviral and the recent cases who received drugs in combination. METHODS: We prospectively studied 47 children in 3 groups: group 1, 20 cases treated only with zidovudine; group 2, 10 patients treated initially with zidovudine and later with a combination of drugs and in group 3, 17 patients, who receiced two or three since the beginning. In all patients it was done chest X-ray, EKG and echocardiography every 6 months and after death complete pathological study. RESULTS: Among the 45 patients cases 26 (57%) were index cases. Malnutrition, diarrhea tachycardia, signs of congestive heart failure, pericardial effusion, abnormal ventricular repolarization and arrhythmias were more frequent in group 1. Echocardiographic abnormalities were present in 10 (50%) children of group 1. They were less frequent in the others two groups. In regard to the outcome in group 1, two patients had worsening of sings of cardiomyopaty and 4 died. Cardiac dysfunction in all cases of group 2 and 3 improved with the medication. CONCLUSION:- The children who received combination and their cardiac alterations had more favorable outcome than those who received only one drug.

Estudo pré-natal da hiper-refringência endocárdica fetal e sua relação com toxoplasmose materna

OBJETIVO: Estudar, comparativamente, um grupo de fetos de mães com toxoplasmose aguda ou recente e um grupo sem doença sistêmica, analisando-se a presença de alterações da refringência endocárdica. MÉTODOS: Avaliados 91 fetos cujas mães tinham diagnóstico de toxoplasmose aguda ou recente, detectados por soroconversão ou presença de títulos elevados de IgM e IgG, confirmados através do teste de captura e comparados com um grupo controle constituído de 182 fetos, selecionados a partir de uma população de baixo risco, participante de um programa de rastreamento de cardiopatias pré-natais. RESULTADOS: Não houve diferença significativa entre as idades médias gestacionais (29,2±4,6 semanas; 29,2±4,6 semanas) e maternas (25,7±6,7 anos; 26±5,4 anos) nos dois grupos. Áreas de hiperecogenicidade endocárdica observadas em 69 fetos com toxoplasmose materna (75,8%) e em apenas 6 fetos do grupo controle (3,3%) (p<0,001). Em 52 dos casos do grupo de estudo (75,4%) a hiper-refringência endocárdica era difusa e em 17 (24,3%), focal. No grupo controle, uma distribuição focal foi observada em 5 fetos (83,3%). CONCLUSÃO: A imagem ecocardiográfica pré-natal de hiper-refringência endocárdica focal ou difusa é mais prevalente em gestações com toxoplasmose materna do que naquelas normais, existindo associação entre a presença de hiperecogenicidade endocárdica fetal e doença materna.

Aneurisma do átrio direito associado à hidropisia fetal: diagnóstico por ecocardiografia fetal

Os aneurismas de átrio direito são entidades raramente relatadas na prática cardiológica, especialmente em vida intra-uterina, e podendo ser confundidos com derrame pericárdico e anomalia de Ebstein da valva tricúspide. Apresentamos revisão da literatura e ilustramos com caso de diagnóstico pré-natal de aneurisma de átrio direito cursando com sinais de hidropisia.

Participación de las células de la cresta neural en el desarrollo de anomalías inducidas por agentes exógenos (síndrome fetal alcohólico y embriopatía por ácido retinoico)

En la etapa embrionaria temprana de los vertebrados, las células de la cresta neural (CCN) se segregan del tubo neural y se distribuyen con patrones temporales y espaciales muy precisos, contribuyendo a la formación de muchos derivados: neuronas y glía del sistema nervioso periférico, parte del sistema endócrino, sistema pigmentario y la mayor parte de los tejidos cráneo-faciales. Las bases morfogenéticas de esta movilización de las CCN se asocian con la disponibilidad de componentes de la matriz extracelular, con fenómenos de apoptosis selectiva, y con la expresión de genes homeóticos, de proteínas transportadoras de retinoides y de receptores de ácido retinoico (AR). En consecuencia, el mecanismo que define el comportamiento de las CCN migratorias asume una especial importancia, desde que cualquier fallo producido en estos "reguladores topográficos" podrá alterar la ordenada traslocación de CN, induciendo una dismorfogénesis. (...) Objetivos: 1) Analizar el comportamiento dinámico de la etapa migratoria temprana de las CCN de niveles cefálico y troncal expuestas a etanol o AR in vitro. 2) Evaluar la posible reversibilidad de los efectos del etanol y del AR sobre la morfología y dinámica migratoria de las CCN de niveles cefálico y troncal in vitro. 3) Analizar los componentes del citoesqueleto asociados con los cambios de forma y motilidad celular en CCN de niveles cefálico y troncal expuestas a etanol y AR in vitro. Los resultados del proyecto permitirán aportar al conocimiento de los mecanismos básicos que regulan la movilidad de poblaciones celulares de gran importancia para el desarrollo humano. Los datos obtenidos servirán de base para futuros enfoques de biología molecular tendientes a innovar aspectos del diagnóstico, pronóstico y prevención de patologías humanas de creciente prevalencia provocadas por el etanol (FAS) y los retinoides (RAE).

Influência da gestação na evolução clínica materno-fetal de portadoras de cardiomiopatia hipertrófica

OBJETIVOS: Estudar a evolução clínica de gestantes com CMH, a influência da gestação sobre o curso natural da CMH e a freqüência da doença nos filhos dessas mulheres no início da infância. MÉTODOS: Foi realizado um estudo prospectivo em 35 portadoras de CMH com a mesma idade e classe funcional (CF). Vinte e três estavam grávidas (grupo G), e 12 pacientes que não estavam grávidas serviram como controle (grupo NG). Foram realizadas avaliações clínicas mensais, bem como eletrocardiograma e ecocardiograma transtorácico Os desfechos para os filhos foram taxas de natimortalidade e prematuridade e investigação de CMH durante a infância. RESULTADOS: Não houve mortes em nenhum dos dois grupos. A ocorrência de arritmias cardíacas foi significantemente maior (p< 0,05) no grupo NG (33,3% vs. 13,4%), e não foram observadas diferenças nos índices de insuficiência cardíaca (30,3% vs. 16,6%) ou acidente vascular cerebral isquêmico (4,3% vs. 8,3%) entre os grupos (p > 0,05). No grupo NG, a necessidade de hospitalização para tratamento de complicações cardíacas foi mais freqüente (p = 0,05) em pacientes com história familiar de CMH (71,4% vs. 25,0%). Doze pacientes (52%) foram submetidas à cesariana por razões obstétricas, sete bebês (30,4%) nasceram prematuramente e um bebê (4,3%) teve morte neonatal. Uma criança teve diagnóstico clínico de CMH, e seu estudo genético identificou mutação no gene da cadeia pesada da b-miosina, situado no cromossomo 14. CONCLUSÃO: Insuficiência cardíaca é uma complicação freqüente em portadoras de CMH durante a gravidez, principalmente em pacientes com antecedentes familiares da doença, mas não altera o curso natural da CMH. Em uma criança, o exame clínico identificou HMC no início da infância.

Aprendizaje durante la ontogenia temprana: Estudio de la participación del sistema opioide en la modulación de aprendizajes mediados por el etanol. LEARNING AND EARLY ONTOGENY: ANALYSIS OF THE INVOLVEMENT OF OPIOID SYSTEM IN FETAL AND INFANTILE ETHANOL-MEDIATED EXPERIENCIES.

Este plan de trabajos es continuidad de una línea de investigación centrada en evaluar los mecanismos responsables de la adquisición, expresión y persistencia de experiencias con el etanol. A partir de ello, indagar acerca de los efectos de esta experiencia sobre comportamientos de búsqueda y autoadministración de etanol en neonatos e infantes de rata. Se pretende analizar la participación del sistema opiáceo en los mecanismos implicados en una memoria fetal y/o infantil, generada como consecuencia de la exposición etílica. En una primera etapa, nos proponemos establecer de qué manera experiencias prenatales con la droga modulan el patrón de auto-administración de alcohol y otros reforzadores, como sacarosa. En este primer bloque de experimentos realizaremos manipulaciones fetales para determinar con mayor grado de especificidad la posible acción del sistema opiáceo en los mecanismos de adquisición de una memoria etílica prenatal. Se realizarán administraciones de etanol y el antagonista opiáceo, directamente a nivel fetal, y se evaluará esta experiencia en un paradigma de condicionamiento neonatal positivo, mediado por la droga. De acuerdo a la evidencia previa, esperamos que la exposición prenatal con la droga facilite la expresión de conductas de consumo y búsqueda del etanol o hacia las claves que señalizan al psicotrópico, tanto durante la infancia como en el neonato. A su vez, cuando la droga es presentada bajo los efectos de un antagonista opiáceo esperamos que estas conductas muestren un perfil similar a las desplegadas por sujetos controles. El segundo bloque de experimentos ha sido ideado con el objeto de indagar acerca de la posible participación del sistema opiáceo en la modulación de los aspectos reforzantes de la droga, a través de un esquema de auto-administración etílica infantil. Se utilizará un paradigma de condicionamiento instrumental adaptado para ratas infantes que consta de dos instancias, una de adquisición de la conducta instrumental (DPs 14-17) en la cual los animales reciben un pulso de refuerzo, como consecuencia de la ejecución de la conducta operante. En una segunda fase se analiza el patrón de búsqueda del reforzador ya que se registra la respuesta instrumental, sin que ocurra el refuerzo por la misma. Para analizar la participación del sistema opiáceo, durante la fase de adquisición de la conducta operante (DPs 16 y 17) los animales serán re-expuestos a mínimas cantidades del reforzador, bajo los efectos de un antagonista opiáceo, momentos previos al ensayo instrumental correspondiente para cada uno de estos días (Exp. 3). Esperamos que el bloqueo del sistema opiáceo, durante esta re-exposición al etanol, sea suficiente para disminuir el patrón de respuesta instrumental hacia el refuerzo etílico. Un último experimento incorporará un tercer evento de re-exposición al etanol -bajo los efectos del antagonista- previo al ensayo de extinción de la conducta instrumental (DP 18). Este nuevo evento tiene por objeto analizar la participación de este sistema neurobiológico en los mecanismos de búsqueda de etanol. Si el sistema opiáceo participa en la modulación de patrones tanto de búsqueda como consumatorios del reforzamiento por etanol, se espera que la re-exposición a la droga bajo los efectos del antagonista, inhiba estas respuestas tanto durante la sesión de adquisición, como de extinción de la conducta operante. Este proyecto intenta profundizar en el conocimiento de los mecanismos que regulan reconocimiento, aceptación, búsqueda y consumo de etanol, como consecuencia de experiencias tempranas con la droga. A su vez, es importante identificar y estudiar los sistemas neurobiológicos involucrados en estos mecanismos. Es por ello que se intenta determinar el rol que ejerce el sistema opiáceo en la adquisición de estas experiencias etílicas a nivel fetal e infantil, que se conoce promueven la búsqueda y el consumo de la droga. Our work is directed to analyze the involvement of the opioid system in the generation of pre- and early postnatal ethanol-related memories. As a first step, maternal manipulations with ethanol will be done. Infants will be evaluated in a paradigm of infantile self-administration of different reinforcers (ethanol, sucrose or water), employing a model of operant conditioning adapted to infant rats. A second experiment will be conducted in order to analyze if a central administration of ethanol, directly to the fetus, modifies subsequent patterns of neonatal conditioned responses to an artificial nipple, mediated by ethanol reinforcing effects. Fetal presentation of ethanol will be accompanied with the injection of an opioid antagonist in order to analyze the involvement of this system in acquisition processes of a fetal ethanol-mediated memory. A second set of studies will be conducted to analyze appetitive and consummatory behaviors in an infant model of ethanol self-administration. Involvement of opioid system in the acquisition or expression of this experience will be also inquired. Infant rats (PDs14-17) have to display a target behavior (nose-poke) to gain access to 5% sucrose or 3.75% ethanol. On PD18 an extinction session will be included. At PDs16-17, 6-hr before training, pups will be re-exposed to ethanol under opioid antagonism effects (naloxone). In a follow up experiment, a re-exposure trial will be included at PD18. Prior extinction, pups will receive naloxone and will be re-exposed to ethanol. We aim to observe if opioid system is modulating etha¬nol reinforcing effects, in terms of both appetitive and consummatory behaviors.

Evolução e prognóstico materno-fetal da cirurgia cardíaca durante a gravidez

FUNDAMENTO: A cirurgia cardíaca favorece o prognóstico materno em casos refratários à terapêutica clínica, contudo associa-se a riscos ao concepto quando realizada durante a gravidez. OBJETIVO: Analisar a evolução e o prognóstico materno-fetal de gestantes submetidas à cirurgia cardíaca no ciclo gravídico-puerperal. MÉTODOS: Estudou-se a evolução de 41 gestações de mulheres que tiveram indicação de cirurgia cardíaca no ciclo gravídico puerperal. A cardiotocografia fetal foi mantida durante o procedimento nas pacientes com idade gestacional acima de 20 semanas. RESULTADOS: A média da idade materna foi de 27,8 ± 7,6 anos, houve predomínio da valvopatia reumática (87,8%), e 15 dessas (41,6%) foram submetidas à reoperação, devido à disfunção de prótese valvar. A média do tempo de circulação extracorpórea foi de 87,4 ± 43,6 min, e a hipotermia foi utilizada em 27 casos (67,5%). Treze mães (31,7%) não apresentaram intercorrências e tiveram seus recém-nascidos vivos e saudáveis. A evolução pós-operatória das demais 28 gestações (68,3%) mostrou: 17 complicações maternas (41,5%); três óbitos (7,3%); 12 perdas fetais (29,2%) e quatro casos de malformação neurológica (10%), dois dos quais evoluíram para óbito tardio. Houve uma perda de seguimento após a cirurgia. Nove pacientes (21,9%) foram operadas em caráter de emergência, situação que influenciou (p < 0.001) o prognóstico materno. CONCLUSÃO: A cirurgia cardíaca durante a gravidez permitiu sobrevida materna em 92,7% e nascimento de crianças saudáveis em 56,0% das pacientes que apresentaram complicações cardíacas refratárias à terapêutica clínica. O pior prognóstico materno teve correlação com a cirurgia em caráter de emergência.