Community acquired pneumonia among pediatric outpatients in Salvador, Northeast Brazil, with emphasis on the role of pneumococcus.

Pneumonia is one of the leading causes of hospitalization and death among children in developing countries, and mortality due to pneumonia has been associated with S. pneumoniae infection. This investigation was designed to describe the antimicrobial susceptibility and serotype patterns of pneumococcal strains recovered from the blood of children with community-acquired pneumonia (CAP) and to assess the clinical findings of pneumococcal bacteremic patients with pneumonia. In a 26 month prospective study, blood cultures were obtained as often as possible from children (<16 years of age) diagnosed with CAP in two emergency rooms. Antimicrobial drug susceptibility tests and serotyping were performed when pneumococcus was identified. We studied 3,431 cases and cultured blood samples from 65.5% of those. Pneumococcus was recovered from 0.8% of the blood samples. The differences in age, somnolence, wheezing and hospitalization among children with and without pneumococcal bacteremia were statistically significant. Pneumococcal bacteremia was age-related (mean 1.63 +/- 1.55; median 0.92) and associated with somnolence and hospitalization among children with CAP. One strain was recovered from pleural fluid. Penicillin resistance was detected in 21.0% (4/19) of the strains at an intermediate level, whereas 63.0% of the strains were resistant to trimethoprim-sulfamethoxazole. The most common serotypes were 14 and 6B, and these serotypes included the resistant strains. Eight of our 18 isolates from blood were of types included in the heptavalent conjugate pneumococcal vaccine, recently licensed in the USA.

Cardiac hydatid cyst in a child.

Cardiac hydatid cyst is a rare disease, especially in children. An 11-year-old boy with a previous anaphylactic reaction and episodes of abdominal pain was admitted for workup of an acquired long systolic murmur. Echocardiographic investigation disclosed a tumor of the right ventricular anterior wall, with multiple loculations. Magnetic resonance imaging characterized it as a multilobular tumor with cyst formation and disclosed another cyst in the right pulmonary artery. With a positive ELISA reaction the child was admitted for surgery with the diagnosis of cardiac and pulmonary hydatid cysts. Cardiac surgery was performed with good results, followed by medical treatment with albendazole.

Use of marijuana and other drugs by college students of São Paulo, Brazil.

Drug usage in a sample of 1,069 college students of São Paulo, Brazil, was investigated. The highest lifetime prevalence was reported for alcohol (82%) and tobacco (39%) followed by inhalants (28%), marijuana (26%), over-the-counter tranquilizers and stimulants (17%), and cocaine (10%). Current use is considerably smaller. Marijuana users were classified as having a "Stable," "Descending," and "Once" pattern of consumption frequency. These patterns were orderly related to sex, socioeconomic status, use of drugs, drug approval, and peer group. Drug usage appeared as predominantly social-recreational in this population, although the risk of misuse for "Stable" students should be evaluated.

[Left cor triatriatum. Clinical and echocardiographic polymorphism]. / Cor triatriatum sinister. Polimorfismo clínico e ecocardiográfico.

Four cases of cor triatriatum in children aged from 4 days to 12 months are described. In one case isolated classical form of the disease occurred, and in the other it was associated respectively to ventricular septal defect, anomalous pulmonary venous connexion and persistence of left superior venae cava. One child had successful surgical correction, two died before surgery could be attempted and one waits operation. Relevant clinical and investigational data are described and the role of echocardiography as an excellent diagnostic tool is stressed. We conclude that isolated form of cor triatriatum can simulate primary lung disease and when associated to other cardiac anomalies it has an earlier diagnosis due to early referral. Surgical results and prognosis depend not only on associated anomalies but also on early diagnosis.

[Heart surgery without previous heart catheterization, in pediatric cardiology]. / Cirurgia cardíaca sem cateterismo cardíaco prévio, em cardiologia pediátrica.

STUDY OBJECTIVE: To determine the influence of echocardiography in the preoperative diagnosis of heart diseases in children. DESIGN: Retrospective study. SETTING: Hospitalized children admitted in Departments of Pediatric Cardiology and Cardiothoracic Surgery. PATIENTS: Children of both sexes, aged from neonate to 14 years old, with heart disease who underwent cardiac surgery. MATERIAL AND METHODS: From January 1989 to July 1990, 220 consecutive cardiac surgeries were performed in children with heart disease. The initial diagnosis was based on data from clinical examination, electrocardiogram, thorax X-Ray and echocardiogram (M-mode, 2D, conventional and colour Doppler). Patients were separated in three groups according to their ages: newborn infants less than 28 days old; infants less than 12 months old; children more than 1 year old and less than 14 years old. Patients were separated according to the investigations used further for preoperative diagnosis: whether they had or not cardiac catheterization performed prior to surgery. RESULTS: From 220 surgical interventions performed, 124 were "open heart" surgeries (9 neonates, 28 infants and 87 children) and the remaining had "closed heart" operations (14 neonates, 37 infants and 45 children). Preoperative diagnosis was mainly dependent on echocardiography, dispensing catheterization in 90 cardiac interventions. The diagnosis was confirmed at surgery or at autopsy. There were 9 deaths, 3 of which occurred in patients not submitted to cardiac catheterization. CONCLUSIONS: Echocardiography is a reliable method for investigation and establishment of the preoperative diagnosis of heart diseases in children. Its use may further reduce the need for diagnostic catheterization in children, particularly in risk groups.

[Surgery for infectious endocarditis]. / Cirurgia na endocardite infecciosa.

OBJECTIVE: to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results. DESIGN: retrospective analysis on clinical data, surgery and follow up. SETTING: patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon. PATIENTS AND INTERVENTIONS: sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis. MEASUREMENTS AND RESULTS: the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals. CONCLUSION: the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

Patterns of marihuana smoking among Brazilian students.

Changes in frequency of marihuana smoking over time were investigated by interviewing forty-seven Brazilian students from São Paulo between 18 and 24 years old, of both sexes. From their report, it was concluded that the course of smoking frequency follows two predominant patterns. In one of them, the 'Stable Pattern', subjects report increasing consumption up to a peak frequency where they remain for a relatively long and stable period of time. In the other one, the 'Descending Pattern', subjects report a gradual increase up to a peak, followed by a clear decline in rate of use. Two other patterns were also detected in a small number of subjects. The diversity of patterns identified stresses the difficulty in predicting the course of marihuana smoking frequency by young people. The relationship between marihuana smoking and the use of other drugs was also investigated. The only drugs that were reported to be regularly consumed by the majority of subjects were alcohol and tobacco, while 90% of the subjects reported having tried at least one other illegal drug.

Functional anatomy of severe mitral regurgitation in active rheumatic carditis.

The mechanism of severe mitral regurgitation (MR) due to active rheumatic carditis is ill defined. This study involved 73 patients, aged 7 to 27 years (mean 13), with severe MR and active rheumatic carditis who were subjected to surgery. Sixty-one were studied retrospectively (group 1) and 12 prospectively (group 2). Active rheumatic carditis was diagnosed according to the modified Jones' criteria, morphologic appearances of the heart at operation and histology of the valve. All patients had preoperative 2-dimensional echocardiographic and intraoperative assessment of the mitral valve apparatus. The presence of mitral valve prolapse--defined as failure of leaflet edge coaptation resulting in systolic displacement of the free edge of the involved leaflet toward the left atrium--was determined in all patients. Mitral anular diameter and maximal systolic chordal length were measured at 2-dimensional echocardiography in group 2 patients and compared to values obtained from matched control subjects. Anular and chordal dimensions in 6 of the group 2 patients were correlated with precise measurements obtained at surgery. Mitral valve prolapse involving the anterior leaflet was detected on echocardiography and confirmed at surgery in 69 patients (94%). Mitral anular dilatation was observed at operation in 70 patients (96%). Maximal anular diameter was significantly greater (p less than 0.0001) than in matched control subjects (37 +/- 4 vs 23 +/- 2 mm). The mean anular dimension measured at surgery (36 +/- 3 mm) was similar to that obtained by echocardiography and individual values using the 2 methods correlated well (r = 0.93). Chordal elongation was observed in 66 patients at operation (90%).(ABSTRACT TRUNCATED AT 250 WORDS)

Valvuloplasty for rheumatic mitral valve disease. A surgical challenge.

From January 1981 through February 1985, 241 patients with rheumatic mitral valve disease (mean age 21.5 +/- 11.8 years) were subjected to comprehensive mitral valvuloplasty. One hundred seven patients (44.4%) were 15 years or younger and 63 (26.1%) were 12 years or younger. One hundred seventy five patients had pure or predominant regurgitation (mean age 19.3 +/- 10.7 years) and 40 (16.6%) had active rheumatic carditis at the time of the operation. Almost all patients (229) were in New York Heart Association Functional Class III or IV. The techniques used included shortening of anterior leaflet chordae tendineae (136 patients), resection of secondary, tertiary, and basal posterior leaflet chordae (156 patients), commissurotomy (113 patients), and implantation of a Carpentier ring (164 patients). Current operative mortality is 1.9%. The survivors were followed up for 576 patient-years (mean 2.64 +/- 1.32 years). Late mortality was 2.60% per patient-year and was valve related in 1.04% per patient-year. Reoperation was required in 25 patients (4.34% per patient-year), mostly (72%) in the first year. There were only two cases (0.35% per patient-year) of thromboembolism and three cases (0.52% per patient-year) of infective endocarditis. Hence valve failure occurred at a linearized rate of 6.08% per patient-year but was fatal in only 22% of the patients. There was no relationship between valve failure and the type of lesion or procedure performed, but reoperation was required more frequently in patients aged 12 years or less (7.33% per patient-year) than in those older than 12 years (3.29% per patient-year) (p less than 0.05). Actuarial survival rate at 41/2 years was 90%, and 82% of the patients were free from valve-related complications. Valve function after valvuloplasty was assessed clinically. Eighty-four percent of the patients had a good immediate result, but this figure dropped to 69% at the end of the follow-up period (p less than 0.05). The remainder had moderate valve dysfunction. However, 85% of the patients remain in New York Heart Association Functional Class I. Mitral valvuloplasty is an excellent alternative to valve replacement in young patients with rheumatic mitral valve disease. Persistent or reactivated rheumatic carditis may be a significant factor of valve failure, and penicillin prophylaxis is mandatory after operation.

Isolated replacement of a prosthesis or a bioprosthesis in the mitral valve position.

The operative results of 249 mitral valvular reoperations performed in 215 patients from 1974 through 1986 were reviewed to identify groups at greater risk. Two to 4 reoperations were performed in 28 patients. The mean interval between the first and second valve procedures was 47 +/- 40 months. The most common indications for reoperation were degeneration of bioprostheses (44%) and thrombosis of mechanical prostheses (26%). Thirty patients (12%) died. This rate was significantly higher (p less than 0.02) than that for primary valve procedures performed during the same period. The mortality rate for elective reoperations was 7%. Mortality rates were higher among patients with prosthetic valve endocarditis (6 of 17 cases, 35%), in those undergoing operation on an emergency basis (19 of 82, 23%) and when tricuspid valve replacement or anuloplasty was also performed (9 of 38, 24%) (p less than 0.02). No significant correlation was found between mortality rates and the age or sex of the patients and the types of prosthesis used originally.