Atualização em síndrome da apnéia obstrutiva do sono na infância

A prevalência de SAOS em crianças é de 0,7-3%, com pico de incidência nos pré-escolares. Fatores anatômicos (obstrução nasal severa, más-formações craniofaciais, hipertrofia do tecido linfático da faringe, anomalias laríngeas, etc.) e funcionais (doenças neuromusculares) predispõem à SAOS na infância. A principal causa da SAOS em crianças é a hipertrofia adenotonsilar. As manifestações clínicas mais comuns são: ronco noturno, pausas respiratórias, sono agitado e respiração bucal. A oximetria de pulso noturna, a gravação em áudio ou vídeo dos ruídos respiratórios noturnos e a polissonografia breve diurna são métodos úteis para triagem dos casos suspeitos de SAOS em crianças, e o padrão-ouro para diagnóstico é a polissonografia em laboratório de sono durante uma noite inteira. Ao contrário dos adultos com SAOS, as crianças costumam apresentar: menos despertares associados aos eventos de apnéia, maior número de apnéias/hipopnéias durante o sono REM e dessaturação mais acentuada da oxihemoglobina mesmo nas apnéias de curta duração. O tratamento da SAOS pode ser cirúrgico (adenotonsilectomia, correção de anomalias craniofaciais, traqueostomia) ou clínico (higiene do sono, pressão positiva contínua nas vias aéreas - CPAP).

Alterações orofaciais em doenças alérgicas de vias aéreas

OBJETIVO: Apontar as possíveis alterações orofaciais decorrentes do sintoma obstrução nasal em pacientes portadores de doenças alérgicas de vias aéreas superiores, por meio de revisão de literatura. FONTES DE DADOS: Levantamento bibliográfico utilizando bancos de dados eletrônicos, como Medline, Ovid, SciELO e Lilacs, com as palavras-chave asthma, rhinitis e mouth breathing, abrangendo os 30 últimos anos. Foram incluídos artigos de revisão, estudos observacionais e ensaios clínicos. SÍNTESE DOS DADOS: A obstrução nasal é encontrada freqüentemente em doenças alérgicas de vias aéreas, como rinite e asma. A respiração bucal decorrente da obstrução nasal pode interferir de maneira direta no desenvolvimento infantil, com alterações no crescimento do crânio e orofacial, na fala, na alimentação, na postura corporal, na qualidade do sono e no desempenho escolar. CONCLUSÕES: Devido à variedade de alterações orofaciais encontradas na criança respiradora bucal decorrente de obstrução nasal por doenças alérgicas de vias aéreas, é necessário realizar diagnóstico e tratamento precoces por uma equipe multidisciplinar, composta por médico, ortodontista e fonoaudiólogo, contemplando a visão de uma via respiratória única, que traz conseqüências ao crescimento e desenvolvimento do sistema motor oral.

Ambulatory blood pressure monitoring in children with obstructive sleep apnea and primary snoring

Objective: To evaluate the systemic blood pressure (BP) during daytime and nighttime in children with sleep breathing disorders (SBD) and compare parameters of BP in children with diagnosis of obstructive sleep apnea syndrome (OSA) to those one with primary snoring (PS).Methods: Children, both genders, aged from 8 to 12 years, with symptoms of SBD realized an overnight polysomnography followed by a 24 h recording of ambulatory BP.Results: All subjects presented with a history of snoring 7 nights per week. Children who have apnea/hipoapnea index >= four or a apnea index >= one presented a mean BP of 93 +/- 7 mmHg and 85 +/- 9 mmHg diurnal and nocturnal respectively whereas children who have a apnea/hipoapnea < four or a apnea index < one presented 90 +/- 7 mmHg and 77 +/- 2 mmHg. Eight children out of fourteen, from OSA group, lost the physiologic nocturnal dipping of the blood pressure. Among OSA children 57% were considered non-dippers. Two (16%) have presented absence of nocturnal dipping among children with primary snoring. The possibility of OSA children loosing physiologic blood pressure dipping was 6.66 higher than the possibilities of patients from PS group.Discussion: Our results indicate that children with sleep apnea syndrome exhibit a higher 24 h blood pressure when compared with those of primary snoring in form of decreased degree of nocturnal dipping and increased levels of diastolic and mean blood pressure, according to previous studies in literature. OSA in children seems to be associated to the development of hypertension or other cardiovascular disease. (C) 2012 Elsevier B.V. All rights reserved.

Xantogranuloma órbito-palpebral: relato de caso

Xantogranuloma é doença histiocítica, caracterizada por lesões amareladas na pele ou na derme, acompanhadas ou não de alterações hematológicas ou neoplasias. O objetivo deste é relatar o caso de uma mulher de 39 anos, com queixa de inchaço progressivo nas pálpebras superiores, há 6 anos, indolor, sem alterações sistêmicas. O exame histológico mostrou infiltração maciça da pele, tecido muscular e gordura orbitária por histiócitos xantomatosos e abundantes células gigantes do tipo Touton. O diagnóstico foi de xantogranuloma do adulto. Os autores comentam os diagnósticos diferenciais, assim como a necessidade de exames periódicos, devido ao risco de associação com doenças sistêmicas malignas.

Anestesia peribulbar com ropivacaína como alternativa ao bloqueio neuromuscular para facectomia em cães

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Hemodynamic effects of butorphanol in desflurane-anesthetized dogs

Objective To evaluate the effects of butorphanol on cardiopulmonary parameters in dogs anesthetized with desflurane and breathing spontaneously.Study design Prospective, randomized experimental trial.Animals Twenty dogs weighing 12 +/- 3 kg.Methods Animals were distributed into two groups: a control group (CG) and butorphanol group (BG). Propofol was used for induction and anesthesia was maintained with desflurane (10%). Forty minutes after induction, the dogs in the CG received sodium chloride 0.9% (0.05 mL kg(-1) IM), and dogs in the BG received butorphanol (0.4 mg kg(-1) IM). The first measurements of body temperature (BT), heart rate (HR), arterial pressures (AP), cardiac output (CO), cardiac index (CI), central venous pressure (CVP), stroke volume index (SVI), pulmonary arterial occlusion pressure (PAOP), mean pulmonary arterial pressure (mPAP), left ventricular stroke work (LVSW), systemic (SVR) and pulmonary (PVR) vascular resistances, respiratory rate (fR), and arterial oxygen (PaO(2)) and carbon dioxide (PaCO(2)) partial pressures were taken immediately before the administration of butorphanol or sodium chloride solution (T0) and then at 15-minute intervals (T15-T75).Results In the BG, HR, AP, mPAP and SVR decreased significantly from T15 to T75 compared to baseline. fR was lower at T30 than at T0 in the BG. AP and fR were significantly lower than in the CG from T15 to T75. PVR was lower in the BG than in the CG at T30, while PaCO(2) was higher compared with T0 from T30 to T75 in the BG and significantly higher than in the CG at T30 to T75.Conclusions and clinical relevance At the studied dose, butorphanol caused hypotension and decreased ventilation during desflurane anesthesia in dogs. The hypotension (from 86 +/- 10 to 64 +/- 10 mmHg) is clinically relevant, despite the maintenance of cardiac index.

Alternative Treatment Modalities for Immature Intruded Permanent Incisors: Report of 2 Cases

Intrusion of permanent teeth is one of the most severe types of traumatic injuries. Different treatment strategies have been proposed, and the best approach for each case depends on the stage of root development, severity of the intrusive luxation, presence of alveolar fracture and number of intruded teeth. The purpose of this paper is to describe the treatment management of 2 cases of severely intruded immature permanent maxillary central incisors in 71/2- and 8-year-old children. In case 1, the traumatized tooth was treated by surgical repositioning, while in case 2 watchful waiting for spontaneous re-eruption was the treatment of choice. Treatment strategies were successful in both cases, as demonstrated by the continuation of root development, maintenance of pulp vitality, and absence of signs of per/apical pathosis during the follow-up period. Regardless of the treatment strategy, traumatically intruded teeth should undergo periodical clinical and radiographic surveillance on a long-term basis to allow early detection of possible complications. (Pediotr Dent 2009;31:340-5) Received March 11, 2008 vertical bar Last Revision June 25, 2008 vertical bar Revision Accepted July 16, 2008

Moebius Syndrome: Clinical Manifestations in a Pediatric Patient

Moebius syndrome is a congenital, nonprogressive disorder clinically characterized by loss of facial expression, impaired stomatognathic system functions, incapacity to close the eyelids, and several oral impairments. The purpose of this paper was to present the clinical manifestations and the dental treatment in a 5-year, 2-month-old male Moebius syndrome patient. The child presented with facial asymmetry, difficulty performing facial mimic movements and pronouncing some letters, and compromised suction, mastication, breathing, and deglutition. An intraoral examination revealed hypofunction of the perioral muscles, cheeks and tongue, ankyloglossia, anterior open bite, and absence of carious lesions and dental anomalies. The dental treatment consisted of frenectomy and further placement of a removable orthodontic appliance with a palatal crib for correction of the anterior open bite. After 12 months of follow-up, anterior open bite decreased and speech, deglutition, and mastication improved. (Pediatr Dent 2009;31:289-93) Received March 8, 2008 vertical bar Lost Revision July 22, 2008 vertical bar Revision Accepted July 28, 2008

Involvement of L-glutamate and ATP in the neurotransmission of the sympathoexcitatory component of the chemoreflex in the commissural nucleus tractus solitarii of awake rats and in the working heart-brainstem preparation

Peripheral chemoreflex activation with potassium cyanide (KCN) in awake rats or in the working heart-brainstem preparation (WHBP) produces: (a) a sympathoexcitatory/pressor response; (b) bradycardia; and (c) an increase in the frequency of breathing. Our main aim was to evaluate neurotransmitters involved in mediating the sympathoexcitatory component of the chemoreflex within the nucleus tractus solitarii (NTS). In previous studies in conscious rats, the reflex bradycardia, but not the pressor response, was reduced by antagonism of either ionotropic glutamate or purinergic P2 receptors within the NTS. In the present study we evaluated a possible dual role of both P2 and NMDA receptors in the NTS for processing the sympathoexcitatory component (pressor response) of the chemoreflex in awake rats as well as in the WHBP. Simultaneous blockade of ionotropic glutamate receptors and P2 receptors by sequential microinjections of kynurenic acid (KYN, 2 nmol (50 nl)(-1)) and pyridoxalphosphate-6-azophenyl-2',4'-disulphonate (PPADS, 0.25 nmol (50 nl)(-1)) into the commissural NTS in awake rats produced a significant reduction in both the pressor (+38 +/- 3 versus +8 +/- 3 mmHg) and bradycardic responses (-172 +/- 18 versus -16 +/- 13 beats min(-1); n = 13), but no significant changes in the tachypnoea measured using plethysmography (270 +/- 30 versus 240 +/- 21 cycles min(-1), n = 7) following chemoreflex activation in awake rats. Control microinjections of saline produced no significant changes in these reflex responses. In WHBP, microinjection of KYN (2 nmol (20 nl)(-1)) and PPADS (1.6 nmol (20 nl)(-1)) into the commissural NTS attenuated significantly both the increase in thoracic sympathetic activity (+52 +/- 2% versus +17 +/- 1%) and the bradycardic response (-151 +/- 17 versus -21 +/- 3 beats min(-1)) but produced no significant changes in the increase of the frequency of phrenic nerve discharge (+0.24 +/- 0.02+0.20 +/- 0.02 Hz). The data indicate that combined microinjections of PPADS and KYN into the commissural NTS in both awake rats and the WHBP are required to produce a significant reduction in the sympathoexcitatory response (pressor response) to peripheral chemoreflex activation. We conclude that glutamatergic and purinergic mechanisms are part of the complex neurotransmission system of the sympathoexcitatory component of the chemoreflex at the level of the commissural NTS.

Ventrolateral medulla mechanisms involved in cardiorespiratory responses to central chemoreceptor activation in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Chemosensory control by commissural nucleus of the solitary tract in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

The use of calcium hydroxide and mineral trioxide aggregate on apexification of a replanted tooth: a case report

To report the outcome of the endodontic treatment of a reimplanted central maxillary incisor with open apex after 8 years and 7 months of follow-up.This case report presents the treatment of a right central maxillary incisor of an 8-year old white male patient with history of traumatic avulsion and immediate replantation. The endodontic therapy consisted of periodical changes of calcium hydroxide dressing and a definitive root canal filling with mineral trioxide aggregate (MTA). The treatment was successful without pathologies up to 7 years of follow-up. After the institution of orthodontic treatment a localized and late root resorption was noticed at the last radiographic examination (8 years and 7 months postoperative follow-up). Moreover, the use of MTA promoted a mild crown grey discoloration.

Efeito de um programa de treinamento de facilitação neuromuscular proprioceptiva sobre a mobilidade torácica

A proposta deste estudo foi analisar o efeito de um programa de treinamento de membros superiores baseado nas técnicas de facilitação neuromuscular proprioceptiva (FNP) sobre a mobilidade torácica. Foram estudadas 24 voluntárias sedentárias, idade 22,9 ± 2,9 anos, divididas em grupo controle (GC), que não participou do treinamento, e grupo treinado (GT). O protocolo de treinamento físico foi constituído por um programa de exercícios de FNP, realizado três vezes por semana, durante quatro semanas. Os dois grupos foram submetidos à avaliação da mobilidade torácica por meio de cirtometria, antes e após o período de treinamento. Os dados colhidos foram analisados estatisticamente, com nível de significância α = 5%. Os valores da cirtometria axilar e xifoideana do GC antes e após o período de intervenção não apresentaram alterações significativas (p>0,05). No GT os valores das variáveis foram significantemente maiores após a intervenção (p<0,05). em conclusão, o protocolo de FNP utilizado parece ser um programa de exercícios eficiente, por promover aumento na cirtometria em um curto período de tempo, sugerindo que pode ser utilizado como recurso fisioterapêutico para o desenvolvimento da mobilidade torácica.

The inguinal macroglands of the frog Physalaemus nattereri (Leptodactylidae): structure, toxic secretion and relationship with deimatic behaviour

Amphibian skin is characterized by the presence of mucous glands, related to cutaneous breathing, reproduction and water balance, and granular glands, related to the production of toxins used in defence. In some species the granular glands can form accumulations in certain regions of the body. This is the case for inguinal macroglands of the leptodactylid frog Physalaemus nattereri, where these structures form a pair of black discs associated with deimatic behaviour. The morphology of the inguinal macroglands and their secretion were studied in this species and correlated to deimatic behaviour. The inguinal macroglands are formed from elongated granular glands that, in contrast with the granular glands of the rest of the skin, have small spherical granules with a proteinic content. In the dermis of the whole body, except for the inguinal macroglands and the inguinal region, a well-developed calcified dermal layer is observed. During deimatic behaviour these macroglands discourage a potential predator from attacking, but if visual cues are insufficient and the predator persists in the attack, atoxic secretion is eliminated in its mouth. This elimination is favoured by the absence of a calcified dermal layer in the macroglands, which makes the dermal region softer than the rest of the dorsal skin.

Pulmonary receptors in reptiles: discharge patterns of receptor populations in snakes versus turtles

This study examines the effects of lung inflation/deflation with and without CO2 on the entire population of pulmonary receptors in the vagus nerve in two species of snakes and two species of turtles. We asked the question, how does the response of the entire mixed population of pulmonary stretch receptors (PSR) and intrapulmonary chemoreceptors (IPC) in species possessing both differ from that in species with only PSR? This was studied under conditions of artificial ventilation with the secondary goal of extending observations on the presence/absence of IPC to a further three species. Our results indirectly illustrate the presence of IPC in the Burmese python and South American rattlesnake but not the side necked turtle, adding support to the hypothesis that IPC first arose in diapsid reptiles. In both species of snake, CO2-sensitive discharge (presumably from IPC) predominated almost to the exclusion of CO2-insensitive discharge (presumably arising from PSR) while the opposite was true for both species of turtle. The data suggest that for animals breathing air under conditions of normal metabolism there is little to distinguish between the discharge profiles of the total population of receptors arising from the lungs in the different groups. Interestingly, however, under conditions of elevated environmental CO2 most volume-related feedback from the lungs is abolished in the two species of snakes, while under conditions of elevated metabolic CO2, it is estimated that volume feedback from the lungs would be enhanced in these same species.