[Accidents with children in the region of Campinas, Brazil] / Acidentes com crianças e sua evolução na região de Campinas, SP.

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.

Use of undiluted whole cow's milk is effective for the routine treatment of children with acute diarrhea and severe dehydration.

A comparison is made between two groups of children aged 1-24 months and admitted to a teaching University Hospital due to acute diarrhea and severe dehydration. One group (n = 119) received a diluted cow's milk formula and the other (n = 109) a full-strength formula. Duration of diarrhea was similar: In the group that received full-strength milk weight gain was greater during diarrhea (5.03 vs. 1.80 g/kg/day, P < 0.01) and during the hospital stay (5.39 vs. 2.33 g/kg/day, P < 0.001). Weight for height z-scores and weight for height as percentage of median improved during the hospital stay only in the group that received the full-strength formula. Full-strength cow's milk seems to be an adequate routine regimen even for children with acute diarrhea that must be treated for severe dehydration. In developing countries diarrhea and dehydration are a disease of small children. As rates of exclusive breast feeding are low, mainly in the urban setting, cow's milk is the main and sometimes the only food available. Lactose-free formulae are priced out of reach of the poor people and in Latin America there is no accepted tradition for use of fermented milk products. Our study is an indication that use of undiluted cow's milk may be effective for the routine treatment of acute diarrhea in children that must be treated as inpatients due to severe dehydration.

Simultaneous measurements of chylomicron lipolysis and remnant removal using a doubly labeled artificial lipid emulsion: studies in normolipidemic and hyperlipidemic subjects.

An artificial chylomicron-like lipid emulsion doubly labeled with tri[(N)3H]oleoylglycerol ([3H]TO) and cholesteryl [1-14C]oleate ([14C]CO) was infused intravenously into human subjects with the purpose of simultaneously measuring the plasma disappearance rates (residence time, RT) of [14C]CO, which represents solely the splanchnic organ uptake of the remnant chylomicron core, and of [3H]TO, which combines the remnant disappearance with the shedding off of chylomicron triglycerides by the action of lipoprotein lipase. Thus, the fraction of the particle triglyceride content that is removed before the remnant is taken up is expressed as a delipidation index (DI = 1 - RT of [3H]TO/RT of [14C]CO. The present procedure has an advantage over the use of chylomicrons labeled with retinyl ester or radioactive triglycerides alone that represent, respectively, the chylomicron remnant or the whole particle metabolism only. When normal subjects as well as primary hyperlipidemic subjects were studied, the plasma triglyceride concentration was directly related to [14C]CO RT and [3H]TO RT, but inversely related to the delipidation index. There may be different patterns of relations between these parameters of chylomicron metabolism in primary and in secondary hyperlipidemias, as well as under the action of drugs that influence the metabolism of lipoproteins.

[Rapid intravenous rehydration in acute diarrhea]. / Rehidratación endovenosa rápida en diarrea aguda.

With the use of oral rehydration, the need for the use of endovenous rehydration has decreased considerably. Albeit, the use is still necessary in severely dehydrated patients or when oral rehydration fails. Textbooks produced in developed countries recommend slow administration of fluids to correct dehydration in 12 to 24 hours. In developing countries, due to the great number of severely dehydrated patients, this approach is not useful. We developed, during the last 20 years, an approach to intravenous rehydration that permits rehydration of the severely ill patient in a much shorter time (2 to 3 hours) and permits an early refeeding. It can be used in all patients, even newborns or malnourished. No laboratory tests are necessary. Only a small number of simple and readily available solutions are used to prepare the electrolyte mixtures.

PIP: This work argues that rapid intravenous rehydration is desirable in cases of acute diarrhea. It provides detailed instructions for preparing and administering the correct solutions and for recognizing patients who are hyponatremia or suffering from acute acidosis. With widespread use of oral rehydration therapy, i.v. rehydration is limited to patients with acute dehydration or contraindications to oral rehydration. For purposes of prognosis, dehydration is usually classified according to the concentration of serum sodium or the degree of fluid loss. The objectives of i.v., rehydration are to eliminate the deficits of water and electrolytes, replace losses so that the patient will not become dehydrated again, and permit early feeding. The water deficit is variable and may amount to 100-150 ml/kg in the severely dehydrated. The sodium deficit is 9-17 mmol/kg and the potassium deficit is 3-15 mmol/kg. Early feeding after no more than 8 hours of fasting is currently considered more effective in preventing malnutrition in children with diarrhea and dehydration. Since the presence of deficits prevents feeding, the initial period of dehydration should not be prolonged beyond 4 hours. In developed countries, i.v. rehydration takes place over 12-24 hours with periods of fasting of 24-48 hours, but the mortality associated with this method of treatment in dehydrated children with diarrhea is higher. To meet its objectives, i.v., rehydration should take place in 3 phases, a rapid initial phase followed by simultaneously occurring phases of maintenance and of replacement in which normal and abnormal losses are replaced. The initial rapid phase should restore the normal perfusion of vital organs by eliminating deficits of sodium and water in no more than 2 hours. All sings of dehydration should disappear. The weight of the child before dehydration and thus the weight loss is seldom known, but experience with the method allows adequate approximations to be made. The solution used in almost all patients is a mixture of physiological solution of NaCl .9% and 5% dextrose solution (PS:DS5% 1:1). The only exceptions are patients with very low sodium levels or severe acidosis, who can be recognized by the experienced practitioner based on their characteristic clinical symptoms. The final concentration of sodium in the solution is .45% of NaCl and that of dextrose 2.5%. The patient is always reevaluated after 1 hour of treatment to detect possible complications. Treatment of hyponatremia and acidosis requires adjusting levels in the 1st hour of treatment with special formulas so that the standard formula may be administered. Instructions are provided for calculating the quantity and content of fluids for the maintenance and replacement stages, which are customarily administered in segments of 6-8 hours.

Effects of simvastatin, bezafibrate and gemfibrozil on the quantity and composition of plasma lipoproteins.

Simvastatin, 10-40 mg/d (n = 11), bezafibrate, 600 mg/d (n = 6), and gemfibrozil, 1200 mg/d (n = 5) were administered for 12 weeks after a 4-week placebo period to subjects with initial plasma levels (mg/100 ml. mean +/- SD) of cholesterol (346 +/- 77), and of triglycerides (180 +/- 54). Total LDL-C plasma concentration was lowered 32% by simvastatin and 35% by bezafibrate, but only bezafibrate diminished the triglyceride (41%) and increased HDL-C plasma levels (35%). Plasma lipoprotein fractions obtained by discontinuous gradient ultracentrifugation, namely, VLDL, lighter LDL (LDL-1), heavier LDL (LDL-2) and bulk HDL were chemically analyzed. Simvastatin and bezafibrate significantly diminished the quantity of VLDL and LDL-1 particles, although barely modifying their composition. Neither drug influenced the LDL-2 plasma concentration. Bezafibrate increased the total plasma HDL level little interfering with its chemical composition. Gemfibrozil was the least effective of all drugs but decreased the lipid and protein contents and their ratios in VLDL and LDL-2.

[Oral rehydration--some current aspects]. / Hidratacão oral--alguns aspectos atuais.

Some findings in a recent study (1982), with metabolic balances, in five severely dehydrated infants (with weight above the 10th percentile) are commented. An oral solution, for maintenance was administered, after an initial intravenous infusion of half isotonic saline (100 cc/kg). The composition of the fluid was: Na 45 mEq/l, K 33 mEq/l, CL 78 mEq/l and glucose 2,8%. Metabolic balance were performed for the first six days of recovery. A similar group of infants, treated only with intravenous fluid was used for comparison. Results have shown that: 1) the sodium concentration was enough to achieve positive sodium balances, but only due to an intense reduction of renal sodium excretion; 2) the amount of potassium was well tolerated and hyperkalemia was not observed; 3) improvement of acid base status was satisfactory even without the use of bicarbonate in the oral solution.

Hidratacao oral - alguns aspectos atuais. / Oral rehydration - some current aspects

Sao comentados alguns achados de estudo recente (1982) sobre balanco metabolico em cinco lactentes com desidratacao grave (com peso acima do percentil 10). Apos uma fase inicial de hidratacao venosa com soro fisiologico ao meio (100 cc/kg) foi administrada uma solucao oral para manutencao.A composicao da solucao oral era: Na 45 mEq/l. K 33 mEq/l, C1 78 mEq/l e glicose 2,8%. O balanco metabolico foi avaliado nos primeiros 6 dias de recuperacao. Um grupo de lactentes de mesmas caracteristicas, tratado apenas com hidratacao venosa, foi usado como controle. Os resultados mostraram que: 1) a concentracao de sodio foi suficiente para atingir balancos positivos de sodio, mas somente devido a uma intensa reducao da sua excrecao renal; 2) a quantidade de potassio foi bem tolerada e nao se observou hipercalemia; 3) a melhora do equilibrio acido-basico foi satisfatoria mesmo sem uso de bicarbonato na solucao oral

Hidratacao parenteral em criancas marasmaticas com diarreia. Necessidades de agua, sodio e potassio. / Parenteral hydration in marasmic infants with diarrhea. Needs of water, sodium and potassium

Estudaram-se, pela tecnica de balanco, sete lactentes marasmaticos durante a recuperacao da desidratacao por diarreia com o objetivo de se avaliar as necessidades de agua, sodio e potassio a ser utilizada na hidratacao parenteral de lactentes em condicoes semelhantes. O tratamento foi padronizado em todos os pacientes que consistiu em hidratacao intravenosa, inicialmente, seguida por realimentacao progressiva. A necessidade media de agua de manutencao foi calculada ao redor de 93 ml/100 cal/dia, obtida somando-se duas quantidades medias: a agua de excrecao renal obrigatoria (excrecao da carga de solutos = 38 ml/100 cal/dia) e a agua eliminada com perdas insensiveis (atraves da pele e pulmoes = 65 ml/100 cal/dia). Desse total, subtraiu-se 10 ml/100 cal/dia de agua endogena, calculada a partir do metabolismo de hidratos de carbono, proteinas e gorduras. As necessidades de manutencao media de sodio e potassio foram respectivamente 3,0 e 2,5 mEq/100 cal/dia para a cobertura das perdas na situacao estudada

[Oral rehydration in pediatrics]. / Reidratação oral em pediatria.

A review of recent developments in the field of oral rehydration in pediatrics, is presented. To verify the viability of commercially available solution for oral rehydration, 4 available preparations were analysed. Small differences in electrolyte composition were observed but the preparations differed in osmolal content. These differences are explained by the different amounts of carbohydrate added to the electrolyte mixture. Due to their high osmolal content, some of the preparations are unsuitable for oral rehydration.

Treatment of diarrheal dehydration.

A regimen for the treatment of diarrheal dehydration is presented. It was devised for use in conditions found in developing countries. Application to large number of patients has been successful. One of its characteristics is the infusion at the start of treatment of a larger amount of fluid than generally recommended. The advantages of magnesium supplementation and phosphate supplementation have been studied. Fecal electrolyte composition has been studied during recovery from diarrheal dehydration. Components of acid balance and generation have been measured with the "net acid" balance technique.

PIP: A regimen for treating diarrheal dehydration is presented which was devised specifically for use in developing countries. Also reported is the author's experience when using this regimen for rehydration on a large population of people with diarrheal diseases. The fluid therapy recommended has 3 phases: reparation, maintenance, and replacement. The fluid therapy is designed to reduce the volume of the extracellular fluid compartment by reestablishing normal tissue perfusion and normal renal regulatory function. The main difference between this regimen and previously published procedures is an emphasis on correction of sodium and chloride deficit within the first 2-3 hours of therapy. To this end, the authors recommend infusion at the start of treatment of a larger amount of fluid than heretofore recommended. Also discussed are the advantages of magnesium supplementation and phosphate supplementation is some cases. Also studied was fecal electrolye composition during recovery from diarrheal dehydration as a gauge for measuring rehydration effectiveness. The net balance technique was used to measure components of acid balance and generation. Tables and graphs present data on urine and fecal component losses during diarrheal dehydration and rehydration.

[Metabolism and effects of phosphorus in eutrophic infants dehydrated from diarrhea]. / Metabolismo y efectos del fósforo en lactantes eutróficos deshidratados por diarrea

To verify whether there is a state of phosphate depletion in dehydrated infants with diarrhea and whether phosphate administration affects recovery from metabolic acidosis, two groups of infants were studied. All were males, from 1 to 7 months old, and in good nutritional state. The control group was treated with a standard regimen of I.V. fluids initially, followed by feedings of a diluted milk formula starting on the 2nd day of treatment. The study group, in addition to this standard regimen, received sodium phosphate (Na2HPO4/Na2HPO4, 4:1, pH 7.4), initially by the I.V. route and thereafter orally with the feedings, at the dose of 2mM/kg/day. During the first 6 days of treatment, daily electrolyte (Na, K, Ca, Mg. Cl and P) and nitrogen balances were recorded. Hydrogen ion excretion (NH4 + TA--HCO3) was determined daily. Clinical findings and course were similar in the two groups. No untoward effects were observed with phosphate administration. In the control group, P balance was negative during all the periods and losses were in excess of those expected from nitrogen losses, thus suggesting a state of depletion. In the P-treated group however, P retention was not demonstrated in the first 2 days, finding a not suggestive of a P depleted state. Linear regressions between both daily and cumulative balances of P-nitrogen-free and Ca indicated a close correlation, thus suggesting that these two ions are mobilized concommitantly.