Renato Machado Fiori

Congenital syphilis. Identification of two distinct profiles of maternal characteristics associated with risk.

Background Behavioral and socioeconomic factors create considerable obstacles to the elimination of congenital syphilis. A clear understanding of maternal risk factors is important to define interventions in every community. Goal The goal of this study was to investigate maternal risk factors for congenital syphilis. Study Design We conducted a case-control and descriptive analysis of 3 groups of live born infants and their mothers consisting of: group I (cases of congenital syphilis), group II (neonates without congenital syphilis whose mothers had been adequately treated for syphilis), and group III (random sample of newborn infants whose mothers have not had syphilis). Data were prospectively collected from personal interview and antenatal records. Results In the case-control study, including groups I and III, the maternal characteristics independently associated with congenital syphilis in the logistic regression were monthly per capita income under US

Periodontal disease in pregnancy and low birth weight

30 (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.1–7.4), single status (OR, 2.8; 95% CI, 1.1–7.8), and less than 6 prenatal visits (OR, 3.2; 95% CI, 1.3–8.1). Comparison between groups I and II (only mothers who have had syphilis) showed a strong protective association of prenatal care with congenital syphilis (OR, 0.05; 95% CI, 0.00–0.39). Additional analysis identified 2 separate profiles of maternal characteristics, one consisting of low socioeconomic status and the other of risk behaviors. Some women who had syphilis before or during pregnancy received adequate prenatal care and delivered infants without congenital syphilis. Most of these women had high-risk behaviors but they were, in general, less poor, older, and more educated than mothers of infants with congenital syphilis. Conclusions Risk behaviors and low socioeconomic characteristics constituted 2 separate maternal profiles associated with congenital syphilis. Socioeconomic risk factors interfered more with prenatal care. To become more effective, the strategies for prevention of congenital syphilis should be targeted to each maternal profile.

Perfil epidemiológico de dezesseis anos de uma unidade de terapia intensiva pediátrica

Introduction: It is known for a long time that tooth and gingival infections may have long distance organic repercussions. Recently, it has been suggested that periodontal disease in pregnancy could be a cause of low weight at birth. Objective: To evaluate the influence of periodontal disease in pregnancy on the birth weight of the newborn infants. Patients and Methods: Mothers who gave birth to low-birth-weight infants were randomly selected (Group 1 - G1; n=13). Immediately after inclusion of each mother in group 1, the mother of the next term newborn with birth weight of > 2,500 g (Group 2 - G2; n=13) was included as control. Mothers were examined by a periodontist who was not informed of the group the child belonged to. A probe was used to measure attachment loss of the alveolar bone. The extension index (EI) and severity index (SI) of the periodontal disease were determined. Results: Both groups of mothers were similar in terms of maternal age, parity, color of skin, height, nutrition, smoking, drinking, socioeconomic status, prenatal examinations, premature rupture of membranes, chorioamnionitis, bacteriuria, placenta previa , abruptio placentae, previous hypertensive disease, preeclampsia, and heart disease. The characteristics of the newborns were: birth weight - G1 = 1,804 ± 675 g x G2 = 3,030 ± 516 g; gestational age - G1 = 33 ± 5 weeks x G2 = 39 ± 2 weeks; length of stay in the neonatal intensive care unit (NICU) - G1 = 128 days x G2 = 0 days. Average EI: G1 = 89.788 ± 18.355 x G2 = 72.420 ± 20.717; p=0.033. Average SI: G1 = 1.377 ± 0.626 x G2 = 0.754 ± 0.413 (OR=18.3; CI95%: 2.5-133.3; p = 0.006). After adjustment for risk factors for low birth weight, such as smoking, maternal height, bacteriuria, and previous hypertension, the odds ratio for SI dropped to 7.2 (CI95% = 0.4-125.4; P = 0.176). Conclusion: The multivariate analysis indicated a marked association between periodontal disease measured by SI score and low birth weight. Our data suggested that periodontal disease during pregnancy may be a risk factor for low weight at birth.

Pyridoxine-Dependent Seizures Associated With Hypophosphatasia in a Newborn

OBJETIVO: Revisar e descrever os dados epidemiologicos dos pacientes admitidos em uma unidade de terapia pediatrica brasileira (UTIP) e compara-los aos aspectos clinicos associados aos indices de gravidade e mortalidade. Descrever as caracteristicas desses pacientes, incluindo os dados demograficos, prevalencia de doencas, indices de mortalidade e fatores associados. METODOS: Os dados foram coletados retrospectivamente de todos os pacientes admitidos na UTIP de um hospital universitario entre 1978 e 1994. Os dados foram expressos em percentagens e comparados pelo teste qui-quadrado, calculando-se o risco relativo (RR) com um intervalo de confianca de 95%, considerando-se um p<0,05. RESULTADOS: Foram selecionados 13.101 pacientes - em sua maioria meninos (58,4%) - com doenca clinica (73,1%), menores de 12 meses de idade (40,4%) e eutroficos (69,5%). O indice geral de mortalidade foi de 7,4%. Os pacientes menores de 12 meses de idade mostraram um RR de 1,86 (CI 1,65-2,10; p<0,0001), enquanto que a desnutricao mostrou um RR de 2,98 (IC 2,64-3,36; p<0,0001). CONCLUSOES: O levantamento epidemiologico mostrou que a mortalidade e maior entre desnutridos e menores de 12 meses de idade. A sepse foi a principal causa de morte.

Surfactant Deficiency in Transient Tachypnea of the Newborn

Pyridoxine dependency and congenital hypophosphatasia are unusual metabolic disorders. We report a female infant born from healthy consanguineous parents with shortening of limbs, detected during pregnancy by ultrasonography. Immediately after delivery, the baby was admitted to the neonatal intensive care unit because of respiratory distress. A bone radiograph showed hypomineralization of all bones, and serum alkaline phosphatase was very low (10 U/L). Within the first day of life, seizures (focal clonic and tonic) started. The seizures were refractory to phenobarbital and other antiepileptic drugs. The first electroencephalogram (EEG) showed a burst-suppression pattern. Pyridoxine was administered (50 mg/kg) and completely controlled the seizures. Antiepileptic drugs were discontinued, and a maintenance dose of pyridoxine (10 mg/day) was established. A postpyridoxine EEG revealed the disappearance of the burst-suppression pattern. The patient died at age 26 days. Pyridoxine-dependent seizures, when recognized early and treated, have a more favorable prognosis. However, hypophosphatasia detected at birth almost always has a lethal outcome. (J Child Neurol 2002;17:222-224).

Clinical features and follow-up of congenital syphilis.

OBJECTIVE To evaluate surfactant production and function in term neonates with transient tachypnea of the newborn (TTN). STUDY DESIGN Samples of gastric aspirates collected within 30 minutes of birth from 42 term newborns with gestational age ≥ 37 weeks (21 patients with TTN and 21 control subjects), delivered via elective cesarean delivery, were analyzed with lamellar body count and stable microbubble test. RESULTS Results of lamellar body counts and stable microbubble tests were significantly lower in the TTN group than in control subjects (P = .004 and .013, respectively). Lamellar body counts were significantly lower in infants with TTN requiring oxygen for ≥ 24 hours after birth than in infants requiring oxygen for < 24 hours (P = .029). When the cutoff point was 48 hours, the stable microbubble count was significantly lower in the group requiring oxygen for ≥ 48 hours than in the group requiring oxygen for < 48 hours (P = .047). CONCLUSIONS Term infants with TTN had low lamellar body counts associated with decreased surfactant function, suggesting that prolonged disease is associated with surfactant abnormalities.

Lamellar Body Count and Stable Microbubble Test on Gastric Aspirates from Preterm Infants for the Diagnosis of Respiratory Distress Syndrome

Objective The aim of this study was to investigate clinical features and outcomes of children treated for congenital syphilis (CS). Methods Infants born alive in the public sector of São Lucas Hospital, Porto Alegre, Brazil, 1997 to 2004, whose mothers had syphilis and neonates with CS born in other facilities and admitted during this period were included. Follow-up was performed from birth up to 5 years. Results Among 24,920 live births, 379 (1.5%) met the criteria for CS. A further 19 infants born in other hospitals were included, for a total of 398 with CS. We compared infants with CS with 120 infants whose mothers received adequate treatment of syphilis before delivery (total sample, 518 infants). Congenital syphilis was associated with delivery before 34 weeks, low birth weight, and small for gestational age. During the study period, 37 stillbirths with CS were detected. Result from the serum venereal disease research laboratory test was negative at birth in 17.5% of the neonates with CS, and in 4 infants, it became positive after the second day. Thirty percent of the infants with CS were reevaluated between 8 and 60 months, and most had a good outcome when managed according to standard guidelines. Sixteen infants (13.3%) had sequelae. Of these, 8 were symptomatic in the neonatal period, and 13 (81%) of 16 had laboratory/x-ray findings. All asymptomatic and 78% of symptomatic infants had nonreactive fluorescent treponemal antibody absorption test after 12 months of age. Conclusions Congenital syphilis remains an impacting disease that causes fetal and neonatal deaths, prematurity, low birth weight, and severe and irreversible sequelae in some children. This study confirms the value of standard guidelines for its management.

Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units

Background: Lamellar body count (LBC) in amniotic fluid is being used to identify infants at risk of respiratory distress syndrome (RDS) who would benefit from surfactant prophylaxis or very early therapy. The test in gastric aspirates of newborns has not been properly explored. Objective: The main objective of this research was to evaluate the performance of LBC alone or in combination with the stable microbubble test (SMT), done on gastric aspirates from preterm babies to predict RDS. Methods: A total of 34 preterm infants with RDS and 29 without RDS, with a gestational age between 24 and 34 weeks, were included in the study. Gastric fluid was collected in the delivery room. A diluent (dithiothreitol) allowed all samples to be processed, even the thickest and non-homogeneous ones, without centrifugation. The SMT was done for comparison. Results: The best cut-off value was <42,000 lamellar bodies/µl to predict RDS, with a sensitivity of 92% (95% CI 73–100%) and specificity of 86% (95% CI 77–95%). The area under the receiver-operating characteristic curve was 0.928 (95% CI 0.86–0.99). SMT showed similar results. LBC and SMT together in series (positive result if both tests were positive) showed a sensitivity of 100% and a specificity of 86%. Conclusion: LBC on gastric aspirates diluted in a solution of dithiothreitol can be rapidly and easily performed, and may be used alone or in combination with SMT as a predictor of RDS, allowing selective prophylaxis or very early treatment only in surfactant-deficient newborns.

Selective surfactant prophylaxis in preterm infants born at ≤31 weeks' gestation using the stable microbubble test in gastric aspirates

Objective To evaluate the modes of death and treatment offered in the last 24 h of life to patients dying in 10 Brazilian intensive care units (ICUs) over a period of 2 years. Design and setting Cross-sectional, multicentre, retrospective study based on medical chart review. The medical records of all patients that died in seven paediatric and three adult ICUs belonging to university and tertiary hospitals over a period of 2 years were included. Deaths in the first 24 h of admission to the ICU and brain death were excluded. Intervention Two intensive care fellows of each ICU were trained in fulfilling a standard protocol (κ=0.9) to record demographic data and all medical management provided in the last 48 h of life. The Student t test, Mann–Whitney U test, χ2 test and RR were used for data comparison. Measurements and main results 1053 medical charts were included (59.4% adult patients). Life support limitation was more frequent in the adult group (86% vs 43.5%; p<0.001). A ‘do not resuscitate’ order was the most common life support limitation in both groups (75% and 66%), whereas withholding/withdrawing were more frequent in the paediatric group (33.9% vs 24.9%; p=0.02). The life support limitation was rarely reported in the medical chart in both groups (52.6% and 33.7%) with scarce family involvement in the decision making process (23.0% vs 8.7%; p<0.001). Conclusion Life support limitation decision making in Brazilian ICUs is predominantly centred on the medical perspective with scarce participation of the family, and consequently several non-coherent medical interventions are observed in patients with life support limitation.

Prospective operationalization and feasibility of a glycemic control protocol in critically ill children

Abstract Objective: To evaluate the stable microbubble test (SMT) ability to select candidates for surfactant prophylaxis for respiratory distress syndrome (RDS). Study design: We followed patients treated according to a new routine for surfactant prophylaxis based on the SMT to determine timing of the initial dose of surfactant, proportion of infants using surfactant, and the predictive value of the SMT. Gastric secretions were collected after birth. Newborns with <25 microbubbles (MB)/mm2 received prophylactic surfactant. Surfactant was given only after confirmation of RDS (rescue therapy) to newborns with ≥25 MB/mm2. Results: Fifty-four (55%) had a low MB count and received prophylactic surfactant. Three out of 44 infants with a high MB count required rescue therapy (negative predictive value 93%; CI:81.3–98.6%). The median interval and interquartile range between surfactant administration and birth in the prophylaxis group was 20 (17–27) minutes. Surfactant was used in 23 of 28 (82%) infants born at <28 weeks of gestation and in 34 of 70 (49%) infants between 28 and 31 weeks. Conclusions: The SMT may be useful to determine surfactant prophylaxis (<30 min after birth). This approach may reduce costs and the number of unnecessary interventions.