José Sabino de Oliveira

[Blood pressure in school children and adolescents - The Belo Horizonte study]

OBJECTIVE: To investigate epidemiological aspects of blood pressure (BP) levels, and the prevalence of arterial hypertension in a representative sample of the whole elementary and high school population of the city of Belo Horizonte (state of Minas Gerais, southeastern Brazil). To describe the blood pressure levels found and the prevalence of BP levels above the 90th and 95th percentiles in the first and second measurements. To evaluate prevalence using four different normality references separately to assess the impact of choice of reference. To study the frequency at which the studentś blood pressure has been evaluated.METHODS: In an observational cross-sectional epidemiological study, we studied a sample of 1005 students, aged 6 to 18 year, randomized from an universe of 486,166 students from the 521 public and private elementary and high schools in the city. Each student was evaluated by means of a personal interview, anthropometric measurements, and two blood pressure measurements in a single visit and at a 10-minute interval.RESULTS: The systolic and diastolic blood pressure levels, by age and gender, were slightly lower than those described by the Task Force Report (1987) and by Rosner et al. (1993). The prevalence of BP levels (systolic or diastolic) over the 95th percentile were, according to the reference used: 8.7% - Task Force Report (1987); 5.5% - Rosner et al. (1993); 6.5% - Update on the Task Force Report (1996); and 9.8% - the 95th percentile from our own study. In the second measurement these prevalence rates dropped to 4.9%; 2.4%; 3.5% and 5.8%, respectively.CONCLUSIONS: We present a detailed description (mean values and standard deviations, and the 90th, 95th and 99th percentiles by age and gender) of the BP levels found in both measurements. Mean values and upper percentiles found in this study are very close to those found in the American references, which validates the current use of these references in Brazil. The prevalence of 9.0% of BP levels above the 90th percentile in two measurements made at random hints at the number of children who should be monitored for hypertension, and reinforces the importance of routine evaluation of blood pressure at every pediatric examination.

Premature acute myocardial infarction in a child with nephrotic syndrome.

Abstract We report a case of acute myocardial infarction in a nephrotic child. A 7-year-old boy with a 4-year history of steroid-unresponsive nephrotic syndrome due to mesangial proliferation disease presented with acute vomiting and chest pain. An electrocardiogram showed ST elevation and pathological Q waves in leads consistent with anterior and septal myocardial infarction. Subsequent cardiac catheterization showed no evidence of atherosclerotic coronary artery disease, and thrombotic occlusion of the anterior descending coronary artery was the likely cause of the event. Myocardial scintigraphy showed extensive myocardial damage. The child had no long history of extreme hypercholesterolemia or hypertriglyceridemia. The case suggests that children with long-lasting nephrotic syndrome may be at increased risk for ischemic cardiovascular events, due to hyperlipidemia as well as a hypercoagulability state. The literature is reviewed regarding the relationship between nephrotic syndrome and the incidence of ischemic heart disease.

Perfil das condutas médicas que antecedem ao óbito de crianças em um hospital terciário

OBJECTIVE: To study the profile of care provided to pediatric patients suffering fatal outcomes at a university hospital, including: description of models, comparisons between units, associated factors, participants involved and records of decisions made. METHODS: Cross-sectional study. One of the investigators reviewed the medical and nursing records of deceased patients. Interviews were held and questionnaires filled out with the care team members over a period of 12 months (May 1, 2002 to April 30, 2003). RESULTS: The study included 106 cases. The most frequent treatment patterns at the hospital were: withholding advanced life support (51.9%) and unsuccessful cardiopulmonary resuscitation (44.3%). The decision to make a do-not-resuscitate order occurred later in the intensive care unit (p < 0.05). The restricted care category was more prevalent in the neonatal unit and among patients with chronic diseases that limit survival (p < 0.05). The professionals that most often participated in the decision-making process were the units treating physician and resident (52.8%) and the medical team (31.1%). Parents or guardians were observed to have been involved in 20.8% of cases. For the entire hospital, seven cases (6.6%) of ambiguous or discordant cardiopulmonary resuscitation procedures were found. CONCLUSIONS: Procedures involving limitation of therapy are frequent, especially in the neonatal unit. Diagnosis of brain death and withdrawal of advanced life support are, nevertheless, rare. Decisions to grant do-not-resuscitate orders are generally mate late, especially in the intensive care unit. In this sample procedures for full participation in decisions and for recording decisions were imperfect.

Paralisia diafragmática unilateral reversível associada a envenenamento loxoscélico sistêmico

This paper reports a case of loxoscelism associated with reversible right hemidiaphragmatic paralysis. The diagnosis of loxoscelism was based upon the description of the spider by the patient himself and by the typical clinical findings which included necrosis at the site of the bite with a scarlet fever-like skin rash, intravascular hemolysis, hemoglobinuria, coagulation disturbances and acute renal failure. The treatment was supportive with full recovery of these abnormalities. The diagnosis of diaphragmatic paralysis was based upon the elevation of the right hemidiaphragm in a full inspired film 5,8 cm above the left hemidiaphragm and in its imobility detected through a radioscopic examination. A chest x-ray film taken before the envenomation did not show any sign of diafragm paralysis as did another chest x-ray film taken one month after the spider bite. These findings lead to suspect the diaphragmatic paralysis to be related to the venom action or to another systemic complication of loxoscelism.This paper reports a case of loxoscelism associated with reversible right hemidiaphragmatic paralysis. The diagnosis of loxoscelism was based upon the description of the spider by the patient himself and by the typical clinical findings which included necrosis at the site of the bite with a scarlet fever-like skin rash, intravascular hemolysis, hemoglobinuria, coagulation disturbances and acute renal failure. The treatment was supportive with full recovery of these abnormalities. The diagnosis of diaphragmatic paralysis was based upon the elevation of the right hemidiaphragm in a full inspired film 5,8 cm above the left hemidiaphragm and in its imobility detected through a radioscopic examination. A chest x-ray film taken before the envenomation did not show any sign of diafragm paralysis as did another chest x-ray film taken one month after the spider bite. These findings lead to suspect the diaphragmatic paralysis to be related to the venom action or to another systemic complication of loxoscelism.

Venomous animal accidents in childhood

OBJECTIVE: To highlight the importance of venomous animal accidents in childhood. The conducts are based on the proposals of the Ministério da Saúde do Brasil [Ministry of Health of Brazil] to standardize medical care in this kind of accident. This article shows the importance of early clinical diagnosis and assistance.METHODS: Review of international and national literature that includes original articles, official standards and books.RESULTS: Pediatricians may always feel insecure when they have to attend children who had venomous animal accidents because this kind of pathology is not very common. This article tries to offer easy guidelines and describes the main steps to be followed. Besides, peculiar or unusual aspects of these accidents are to be found in the literature referred to in the end of this article. Venomous animal accidents are always more severe in children, therefore resulting in higher mortality and sequelae. We assert that the early antivenom sera is extremely helpful.CONCLUSIONS: The systematization of the assistance may guarantee that the essential steps are followed thus making the assistance itself more effective. This is the purpose of the guidelines presented in this article.

[Pneumothorax and pulmonary intersticial emphysema: treatment with selective bronchial occlusion and high frequency ventilation]

OBJECTIVE: Our purpose was to report the use of selective bronchial occlusion with a balloon catheter, associated with high frequency ventilation for a successful treatment of a persistent left hypertensive pneumothorax associated with left bronchopleural fistula and severe bilateral pulmonary intersticial emphysema.METHODS: A newborn infant of 20 hours of age was referred to our ICU for treatment of severe respiratory distress and hemodynamic failure after spontaneous hypertense left pneumothorax. Despite being submitted to conventional mechanical ventilation, volume resuscitation and vasoactive drugs infusion, the patient worsened. Therefore, he underwent selective occlusion of the main left bronchus, a measure that can be effective to interrupt gas flow to the affected lung in situations like lung injury with air leak. In order to avoid worsening intersticial emphysema and air leak, high frequency ventilation was associated. This method is characterized by very low tidal volume, lower than the rest functional capacity, and is indicated in acute respiratory failure associated with air leak syndrome.RESULTS: Selective left main bronchus occlusion and high frequency ventilation were successfully used to treat the patient who, after that, presented a favorable outcome with full hemodynamic and respiratory recovery.CONCLUSION: Selective left main bronchus occlusion permitted mechanical ventilation of the contralateral side and high frequency ventilation allowed adequate oxygenation and ventilation maintenance with decrease of the risk of lung injury and also allowed recovery from the interstitial emphysema.