Perfil de neonatos e lactentes cardiopatas e o cuidado interdisciplinar da enfermagem cardiológica, neonatológica e obstétrica / Profile of neonates and infants with heart disease and the interdisciplinary care of cardiac, neonatal and obstetric nursing

INTRODUÇÃO: As cardiopatias congênitas são a maior causa de complicações cardíacas nos neonatos e lactentes exigindo assistência especializada durante a internação em Unidade Terapia Intensiva Neonatal (UTIN). OBJETIVO: Identificar o perfil sociodemográfico dos neonatos e lactentes menores de um ano e a assistência de enfermagem interdisciplinar entre enfermeiros na UTIN. MÉTODOS: Estudo exploratório, descritivo, prospectivo, realizado em uma instituição pública de São Paulo. A amostra foi composta por neonatos e lactentes cardiopatas menores de um ano internados na UTIN. Foram coletados do prontuário: dados do parto, data de nascimento, tipo de cardiopatia congênita e perfil clínico. O projeto foi aprovado pelo Comitê de Ética em Pesquisa protocolo CAAEE: 62788122.2.0000.5462. RESULTADOS PRELIMINARES: Verificou-se que nove neonatos ou lactentes, com a idade média de 5 meses (12 dias a 11 meses), do sexo masculino (6;66,7%) de cor branca (7;77.8%), residentes em São Paulo tinham ao nascimento, a idade gestacional média de 38,5% semanas (35 a 40 semanas), sendo a termo (8;88,9%), nascido de parto vaginal (5;55.6%), Apgar variando de asfixia moderada a sem asfixia e peso entre 2525g a 3495g. Nelas, prevaleceram as cardiopatias congênitas cianóticas (8;36,36%), com indicação de cirurgia reparativa e correção ventricular (47,36%). As crianças mantiveram em média 8 dispositivos entre sondas, drenos e cateteres em seu pós-operatório. Conhecimentos sobre pré-natal, parto, nascimento e cardiopatias são imprescindíveis no plano assistencial ao binômio mãe-filho. Assim a interface interdisciplinar entre obstetrícia, neonatologia e cardiologia torna-se essencial para uma prática avançada em enfermagem em que o profissional desenvolve competências e habilidades para prestação de assistência integral no processo de saúde-doença, devido à complexidade e especificidade dos cuidados exigidos por portadores de cardiopatias congênitas em tratamento. CONCLUSÃO: A identificação preliminar do perfil clínico dos neonatos e lactentes com cardiopatia congênita, na maioria cianótica, a terapêutica cirúrgica e uso de dispositivos requer competências de práticas avançadas, integradas e humanizadas de enfermeiros atuantes em UTIN cardiológica. O diagnóstico precoce, intra útero poderia possibilitar a condução do parto sem risco de sofrimento fetal, bem como a evolução pós-parto de maior resolutividade com presença de profissionais para atendimento de neonatos cardiopatas, minimizando riscos de agravos e sequelas, bem como melhor condução terapêutica em instituição especializada.

Italian pediatric nutrition survey.

INTRODUCTION: the prevalence of malnutrition in children and its impact on clinical outcomes is underrecognized by clinicians in Italy as well as worldwide. A novel definition of pediatric malnutrition has been recently proposed by a working group of the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), based on the correlation between illness and the use of zscores of anthropometric measurements. AIM: to investigate the prevalence of malnutrition and related nutritional support among hospitalized children in Italy, in a nationwide survey performed in a single day (16/4/2015). METHODS: an open access website (http://nday.biomedia.net) was used to collected data from 73 hospitals and 101 wards in 14 Italian regions (1994 patients). Anonymous information was collected on hospitals' characteristics, patient's anthropometry, admission diagnosis, presence of chronic diseases and use of nutritional support: oral nutritional supplements (ONS), enteral nutrition (EN) or parenteral nutrition (PN). Z-scores of anthropometric measurements, calculated with Epi Info 7.1.5, defined nutritional status: wasting was identified by BMI or Weight-for-Length z-score (<-1 mild, <-2 moderate, <-3 severe), stunting by Height-for-Age Z-score <-2. WHO 2006 and CDC 2000 growth charts were used respectively for children younger and older than 2 years old. RESULTS: 1790 complete records were obtained for hospitalized patients aged 0-20 years, with median age 6.16 (0.1-20 years and 53.3% males). 52.9% were aged 0-6 years and 58.8% of children suffered from chronic diseases. Wasting was detected in 28.7% of the total sample with higher occurrence observed in age ranges 0-6 and 14-20 years, while 17.3% of patients showed stunting; surprisingly almost 27% of them were aged 0-2. A ranking of the admission diagnosis with the highest rate of malnutrition was complied. The prevalence of wasting was significantly (p < 0.005) higher amongst children with chronic diseases (34.1% vs. 27.1%); stunting prevalence tripled in patients with chronic disease (24.5% vs. 8.3%). Only 23.5% of malnourished children (17%, 25.6% and 36.7%, respectively mild, moderate and severe malnutrition) received nutritional support: 11.7% received oral nutrition supplements (ONS, modular or complete), 11.5% enteral nutrition (EN, 6.4% via nasogastric tube, 5.1% via gastrostomy) and 6.8 % received parenteral nutrition (PN); in some patients a combination of two. Nutritional support is more commonly used among stunting patients, 39.5% of children under treatment. CONCLUSION: Malnutrition of any grade was observed in nearly 1/3 and stunting in 17% of the reported hospitalized children, and it is likely to be underrecognized as the nutritional support reached only a small part of the malnourished children.

[Anorexia nervosa and hyperactivity in adolescence: psychiatric and internal medicine features]. / Anoressia nervosa e iperattività in adolescenza: correlati psichiatrici e internistici.

AIM: The aim of the present study was to verify the influence of hyperactivity on internistic and psychiatric parameters in early onset anorexia nervosa restricting type (ANR). METHODS: Seventy-three adolescent females (mean age 13.5 years, SD: 2.27) with a diagnosis of ANR (DSM-IV-TR) were consecutively enrolled in the Child and Adolescent Eating Disorders Unit of the IRCCS-Stella Maris and assessed by an extensive clinical protocol. All patients completed: psychiatric evaluation for description of the DCA and comorbidities; pediatric assessment including complete auxological data, blood pressure, heart rate and other electro/echo cardiographic and biohumoral parameters. The hyperactivity was estimated by the application of the "Structured Interview for Anorexic and Bulimic Disorder-Expert Form" (Item 40) in the context of clinical observation. Subjects were identified according to their level of hyperactive (ANR+H) and non-hyperactive (ANR-H) activity. RESULTS: In the ANR+H group heart rate, leptin, sodium, potassium and gamma plasma proteins significantly differ compared to the group ANR-H. Patients with hyperactivity also have a complete form of ANR in 94% of cases compared with 66.7% of non-hyperactive; significant differences were found also in thought and attention CBCL and YSR subscales, combined with major internalizing problems. CONCLUSION: This study provides preliminary data which can orient research towards the development of specific treatments for the hyperactivity, in order to improve the prognosis and thus avoid the chronicity of the disorder and the development of complications in adult life.

Placental barrier breakage in preeclampsia: ultrastructural evidence.

OBJECTIVE: It is known that the placenta acts as an immunological barrier between the mother and fetal "graft" allowing two antigenically different organisms to tolerate one another. Preeclampsia may be considered as a fetal rejection consequent to severe damage at placental endothelial and syncytiotrophoblast level. In order to verify this placental barrier damage we undertook the present study by electron microscopy. STUDY DESIGN: 14 placentae from preeclaptic women, and the same number of placentae from healthy controls were examined. RESULTS: The results showed that endothelial cells from preeclamptic placentae express various and severe alterations, consisting of swollen and bulbous cytoplasm, degenerated inter-endothelial junctions with consequent crossing of fetal blood cells outside the vessels. CONCLUSIONS: These lesions could be the ultrastructural evidence of the placental barrier breakage leading to rejective reaction we presumed to be basis of preeclampsia.

HLA-DR in couples associated with preeclampsia: background and updating by DNA sequencing.

The placenta acts as an immunological barrier between the mother and the fetal "graft", allowing two antigenically different organisms to tolerate one another. In placentae from preeclamptic women, we have demonstrated, by an ultrastructural assessment and an immunohistochemical study, a placental barrier breakage leading to the mixing of maternal and fetal antigenically different blood. This condition could be responsible for the triggering of a maternal rejection reaction that we presume to be at the basis of the preeclamptic syndrome. Thus, we have investigated the Human Leukocyte class II DR antigens (HLA-DR), whose role in self and non-self recognition is well known, in women with preeclampsia, their partners and in control couples using the serological Terasaki tecnique. The results showed a statistically significant increase of HLA-DR homozygosity and a reduced antigenic variety in the preeclamptic women and their partners with respect to controls. In this update, we have examined the 2nd exon of the human gene, HLA-DRB1, on the short arm of the chromosome 6 using DNA sequence-based typing (S-BT) PCR in 56 preeclamptic couples and 64 control couples. The results have confirmed the significant excess of HLA-DR homozygosity in couples associated with preeclampsia versus controls. From our results, it emerges that HLA-DR homozygosity and the reduced antigenic variety seem to be associated to a major risk for preeclampsia, which further appears to be a "couple's disease".

Increased HLA-DR homozygosity associated with pre-eclampsia.

It is generally accepted that maternal recognition of paternally derived fetal antigens occurs during normal pregnancy and may be beneficial for implantation and maintenance of gestation. Thus, we have investigated the human leukocyte class II DR antigens (HLA-DR), whose role in self and non-self recognition is well known, in women with pre-eclampsia, their partners and in control couples. The HLA-DR antigens were tested in 70 pre-eclamptic primigravidae women and their partners and 70 healthy control couples using the serological Terasaki technique. Our results did not show any particular HLA-DR antigen to be correlated with pre-eclampsia, but a statistically significant increase of only one identifiable HLA-DR antigen, which was presumed to express homozygosity at the HLA-DR locus, in the pre-eclamptic women and their partners: 67.1 versus 7. 9% in the control couples (P < 0.000001). The analysis of HLA-DR compatibility between pre-eclamptic women and their partners showed a statistically highly significant increase of the female-to-male compatibility (P = 0.0003) and a lower but significant male-to-female compatibility in comparison with controls (P = 0.014). From our results, it emerges that HLA-DR homozygosity and reduced antigenic disparity seem to be associated to a major risk for pre-eclampsia, which consequently appears to be a 'couple's disease'.

[Superselective monolateral subarachnoid anesthesia in saphenectomy by long stripping]. / L'anestesia subaracnoidea monolaterale superselettiva nella safenectomia per stripping lungo.

The authors describe a recent anaesthetic technique: the subarachnoid monolateral superselective anaesthesia. Currently they use it in the surgical operation of "long stripping" saphenectomy. They argue on the utility of codifying this technique for its numberless advantages and discuss on the opportunity to perform day-hospital saphenectomy.

Micronuclei in lymphocytes of young patients under antileukemic therapy.

The micronucleus test in peripheral blood lymphocytes was employed in the cytogenetic monitoring of children with acute lymphocytic leukemia (ALL), who had undergone chemotherapy and radiotherapy. Patients were treated with a variety of drugs, which included vincristine, methotrexate, daunomycin and prednisone; they also underwent cranial irradiation at the end of the first intensive phase of therapy. The first group under study consisted of 15 subjects on therapy, who showed a marked increase in micronucleated lymphocytes (mean: 19.96 +/- 12.96%) as a consequence of treatment compared with the control group (mean: 3.67 +/- 1.55%), while lower average values were obtained from 15 other subjects at the end of treatment (mean: 13.16 +/- 8.44%). A group of 6 patients was monitored during the entire period of therapy, namely at diagnosis, after 3 months of therapy, throughout maintenance therapy and at the end of it. The whole treatment lasted about 2 years. The results revealed a marked increase in basal micronucleus frequency, due to therapy: the micronucleated lymphocyte frequency remained significantly high throughout the treatment for almost all patients. These data clearly suggest the validity of the methodology in pointing out the role played by antileukemic agents in inducing somatic genetic damage.

[EEG in the diagnosis of brain death. A rare bioelectrical artifact]. / L'EEG nella diagnosi di morte cerebrale. Un raro artefatto bioelettrico.

The Authors, starting from a clinical observation of brain death, demonstrate that an EEG tracing can undergo some modifications which are linked to the flask distension of the endotracheal tube. In fact, when there is a passage of air between the wall of the tube and the wall of the windpipe passage that we have when the flask is not adequately full of air, we get some bioelectrical modifications. This kind of modifications influence the tracing itself and they are also able to engender the suspicious of a renewal of cerebral activity.

[Myasthenia gravis and pregnancy. Review of the literature and considerations on the immunoprotective effect of alpha-fetoprotein through the observation of a clinical case]. / Miastenia gravis e gravidanza. Revisione della letteratura e considerazioni sull'azione immuniprotettiva dell' alpha-fetoproteina attraverso l'osservazione di un caso clinico.

Myasthenia gravis is an autoimmune disorder characterized by a reduction of muscular strength. It is associated with production of anti-acetylcholine-receptor antibodies and with the consequent decrease of muscular acetylcholine receptors. The Authors have studied this pathology during the pregnancy and the puerperium in a myasthenic patient and in her newborn, evaluating seric AChRAbs title and seric alpha-fetoprotein levels, to investigate the possible correlation among these parameters and MG. The study shows that with low seric levels of AChRAbs the mother had a progressive symptomatological impairment of MG from 36th week of pregnancy to term and in puerperium too; the newborn didn't show any sign of pathology. The possible immuno-protective role of alpha-FP in maternal and fetal MG evolution is discussed.