Roberto José Negrão Nogueira

A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus

No periodo de janeiro de 1984 a maio de 1994, de 239 criancas com ate 15 anos de idade, picadas por escorpioes pertencentes as especies T.bahiensis (84,9%) e T.serrulatus (15,1%), 17 apresentaram envenenamento grave. Destes 17 pacientes, cuja idade variou de 1 a 11 anos (mediana=2anos), 14 foram picados por T.serrulatus e 3 por T.bahiensis. Todos receberam anti-veneno escorpionico i.v. entre 45 min. e 5 hs apos o acidente (mediana=2 horas). A admissao, as principais manifestacoes clinicas, alteracoes laboratoriais e eletrocardiograficas observadas foram: vomitos(17), sudorese profusa(15), taquicardia(14), prostracao(10), taquipneia (8), hipertensao arterial(7), hipotensao arterial(5), tremores(5), hipotermia(4), hiperglicemia(17), leucocitose (16/16), hipocaliemia(13/17), aumento da CK-MB (>6% da CK total)(11/12), hiperamilasemia(11/14), taquicardia sinusal(16/17) e padrao semelhante ao infarto do miocardio(11/17). A ecocardiografia, observou-se depressao da funcao sistolica ventricular esquerda em 6 pacientes, todos picados por T.serrulatus. Destes, 5 apresentaram edema pulmonar e 4 choque. Uma crianca de 2 anos de idade, picada por T. serrulatus, faleceu 65 horas apos o acidente devido insuficiencia respiratoria grave. Conclui-se que os acidentes graves determinados por T.serrulatus foram 26,2 vezes mais frequentes que os determinados por T.bahiensis (p<0,001).

Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases.

Trauma to the soft palate is a uncommon event during childhood. Stroke following intraoral trauma is also rare, but has been well documented by the current literature as a potentially serious complication. In this article, we report 2 cases of posttraumatic internal carotid artery thrombosis depicted by imaging studies. We discuss pathogenesis, and the literature is reviewed.

Accidents involving children in the region of Campinas, Brazil

OBJECTIVE: Evaluate prospectively the frequency and cause of accidents in children seen at the Pediatric Emergency Service of a University Hospital. The main aim is to subsidize the development of education and preventive programs.METHODS: Data of all children, less than 14 years old, from March 1997 to February 1998 were collected with a standard questionnaire.RESULTS: Accidents in 3,214 children were studied, 11.4% of the total. Males predominated (62.1%). Accidents were more common in the 9 to 13 year age group (33.4%), 2 to 5 year age group (27.2%) and 5 to 9 year group (25,5%). Traumatism, mainly due to falls, was the cause in 74%. Head trauma was important in the younger than 1 year, and trauma involving the extremities in the 9 to 13 age group. Bites and stings predominated in the 5 to 13 year age group, intoxication and foreign bodies in the 2 to 5 years age group. Burns predominated in the younger than 5 years. Most accidents (89.7%) were of low complexity but 20 patients had to be admitted to an ICU and 4 died in the Emergency Room.CONCLUSIONS: The child older than 9 years, male, with trauma of the extremities due to a fall was the most frequent case of accident. Prevention programs must be targeted to specific age ranges. Accidents are responsible for a great part of the overload of Emergency Services as 89.7% were of low complexity. Primary care health facilities personnel must be trained to manage accidents that do not involve complex procedures.

Changes in Home Parenteral Nutrition Practice Based on the Canadian Home Parenteral Nutrition Patient Registry.

Background: Since 2005, the Canadian home parenteral nutrition (HPN) registry has collected data on patients’ demography, outcomes, and HPN clinical practice. At annual meetings, Canadian HPN programs review and discuss results. Aim: To evaluate changes over time in patient demography, outcomes, and HPN clinical practice using the registry data. Methods: This retrospective study evaluated 369 patients who were prospectively entered in the registry. Two periods were compared for the first data entry: 2005–2008 (n = 182) and 2011–2014 (n = 187). Patient demography, indications for HPN, HPN regimen, nutrition assessment, vascular access, and number of line sepsis per 1000 catheter days were evaluated. Results: For 2011–2014 compared with 2005–2008, indications for HPN changed significantly, with an increased proportion of patients with cancer (37.9% vs 16.7%) and with fewer cases of short bowel syndrome (32% vs 65.5%); line sepsis rate decreased from 1.58 to 0.97 per 1000 catheter days; and the use of tunneled catheters decreased from 64.3% to 38.0% and was no longer the most frequently chosen vascular access method. In contrast, the proportion of peripherally inserted central catheters increased from 21.6% to 52.9%. In addition, there was a reduction in number and days of hospitalizations related to HPN, and favorable changes were noted in the prescription of energy, proteins, and trace elements. Conclusion: The Canadian HPN registry is useful in tracking trends in demography, outcomes, and clinical practice. Results suggest a shift in patient demography and line access with improvement in line sepsis, hospitalizations, and HPN prescriptions.

Factors impacting the growth and nutritional status of cystic fibrosis patients younger than 10 years of age who did not undergo neonatal screening

OBJECTIVE: The aim of this study was to evaluate by clinical and laboratory parameters how cystic fibrosis (CF) affects growth and nutritional status of children who were undergoing CF treatment but did not receive newborn screening. METHODS: A historical cohort study of 52 CF patients younger than 10 years of age were followed in a reference center in Campinas, Southeast Brazil. Anthropometric measurements were abstracted from medical records until March/2010, when neonatal screening program was implemented. Between September/2009 and March/2010, parental height of the 52 CF patients were also measured. RESULTS: Regarding nutritional status, four patients had Z-scores ≤-2 for height/age (H/A) and body mass index/age (BMI/A). The following variables were associated with improved H/A ratio: fewer hospitalizations, longer time from first appointment to diagnosis, longer time from birth to diagnosis and later onset of respiratory disease. Forced vital capacity [FVC(%)], forced expiratory flow between 25-75% of FVC [FEF25-75(%)], forced expiratory volume in the first second [FEV1(%)], gestational age, birth weight and early respiratory symptoms were associated with improved BMI/A. CONCLUSIONS: Greater number of hospitalizations, diagnosis delay and early onset of respiratory disease had a negative impact on growth. Lower spirometric values, lower gestational age, lower birth weight, and early onset of respiratory symptoms had negative impact on nutritional status. Malnutrition was observed in 7.7% of cases, but 23% of children had nutritional risk.

Anthropometric and body-mass composition suggests an intrinsic feature in Williams-Beuren syndrome

OBJECTIVE Although considered a well-known condition, there is only one study describing the body composition among individuals with Williams-Beuren syndrome. The aim was to characterize the nutritional status in Brazilian individuals with this condition. METHODS Cross-sectional study was designed to evaluate clinical and nutritional data of 17 Brazilian patients. Z-scores for height, weight, body mass index, triceps and subscapular skinfold thickness, arm circumference, arm muscle area, arm fat area were calculated. Wilcoxons test was used to investigate differences between the z-scores of the anthropometrical measures and zero. RESULTS Four children were considered stunted and two severely malnourished. The z-score mean value for height was -1.14 ± 1.00 (p-value = 0.004), for weight, -0.67 ± 1.19 (p-value = 0.0443), for arm circumference, -0.94 ± 1.14 (p-value = 0.0222), for triceps skinfold thickness, -0.59 ± 0.63 (p-value = 0.0042) and for arm fat area -0.67 ± 0.67 (p-value = 0.0061). CONCLUSION Short stature seen in this series confirms a previous study describing this feature in a German population, which would suggest it as an intrinsic feature in Williams-Beuren syndrome. In addition, skinfold thickness measures have not been previously performed in this syndrome and detected abnormalities in fat stores in this sample. Considering this method a fast and low-cost way to evaluate body composition, similar studies could be performed in other populations in order to better characterize this issue. Morbidity related with this genetics condition and information for clinical investigation and clinical follow-up are also discussed.

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial

Objective We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians. Design Randomised controlled trial. Setting A paediatric intensive care unit of a teaching hospital. Patients 80 children (aged 28 days to <14 years). Interventions Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique. Main outcome measures Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications. Results We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all). Conclusions Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience. Trial registration number RBR-4t35tk.

Hypophosphatemia, Hypomagnesemia, and Hypokalemia in Pediatric Patients Before and During Exclusive Individualized Parenteral Nutrition.

BACKGROUND Hypophosphatemia, hypomagnesemia, and hypokalemia occur in patients receiving parenteral nutrition (PN), mainly when the bodys stores are depleted due to fasting or inflammation. Although these disorders are potentially fatal, few studies have reported the incidence in the pediatric population. METHODS This study evaluated, in a historical cohort of pediatric patients, the prevalence of hypophosphatemia, hypokalemia, and hypomagnesaemia until 48 hours before initiation of PN infusion (P1) and from days 1-4 (P2) and days 5-7 (P3) of PN infusion and investigated if malnutrition, calories, and protein infusion were correlated to these disorders. RESULTS Malnutrition was present in 32.8% (n = 119) of the subjects; 66.4% of the patients were in the pediatric intensive care unit. Survival rate was 86.6%. P1 had the highest prevalence of mineral disorders, with 54 events (58.1%; P2, n = 35, 37.6%; P3, n = 4, 4.3%). Hypokalemia events were related to malnutrition (odds ratio, 2.79; 95% confidence interval, 1.09-7.14; P = .045). In the first 7 days, infused calories were below the amount recommended by current guidelines in up to 84.9% of patients, and protein infused was adequate in up to 75.7%. Protein infused above the recommendation in the first 4 days was related to hypomagnesaemia (odds ratio, 5.66; 95% confidence interval, 1.24-25.79; P = .033). CONCLUSION Hypophosphatemia, hypokalemia, and hypomagnesemia were frequent in hospitalized pediatric patients before and during the first 4 days of PN infusion. Patients with malnutrition had more chances of having hypokalemia, and those who received high protein infusion had an increased chance of developing hypomagnesemia.

ASSOCIAÇÃO DE MENINGITE E PERICARDITE NA DOENÇA PNEUMOCÓCICA INVASIVA: UM CASO RARO

ABSTRACT Objective: To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis. Case description: This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol. Comments: Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.

Selenium supplementation in pediatric patients using parenteral nutrition: Is it time to do something?

OBJECTIVE To analyze the nutritional status of selenium and verify the effect of its supplementation in pediatric patients during 14 days of parenteral nutrition (PN). METHOD This is a series of cases with patients followed for two weeks while using PN. Data collection was performed at the beginning (T0), in the 7th (T1) and 14th days of PN (T2). The supplemented group received 2 µg/kg/day of selenous acid. Weight and height were measured for nutritional status assessment. Tests requested: plasma selenium, albumin, pre-albumin, C-reactive protein (CRP), total cholesterol and HDL-cholesterol. RESULTS Fourteen (14) patients with inflammatory process and with low or very low weight for their ages were evaluated. In both groups (with and without supplementation), all patients had low selenium levels. Median plasma selenium concentrations were 17.4 µg/L (T0), 23.0 µg/L (T1) and 20.7 µg/L (T2). Increase and reduction of selenium occurred both in patients with high CRP and in those presenting normalization of this parameter. CONCLUSION Lower plasma selenium levels have been detected since the start of the research and supplementation (2 µg/kg/day of selenous acid) was not to enough to approach the reference values.