Primórdios da pediatria brasileira / Early times of brazilian pediatrics

Carlos Arthur Moncorvo de Figueiredo é considerado o ?Pai da Pediatria Brasileira?, pois empreendeu várias ações na implantação da pediatria no país, em 1882. Participou ativamente da fundação da Policlínica Geral do Rio de Janeiro, com o primeiro serviço de moléstias da infância. Foi ainda responsável pela formação dos primeiros pediatras no país, por meio de seu Curso Livre, e pela implantação do ensino oficial da Pediatria no país, em decorrência de seu Memorial enviado às autoridades do Império.

Carlos Arthur Moncorvo de Figueiredo is considered the leader of the Brazilian pediatrics, because of his several actions aiming to introduce the discipline in the country in 1882. He participated actively in the foundation of Policlínica Geral do Rio de Janeiro, an institution which provided the first children-oriented care service in Brazil. He was responsible for training the first Brazilian pediatricians through his ?Free Course? and for implanting the official teaching of pediatrics in the country as a result of his petitionary letter sent to the imperial authorities.

Primórdios da pediatria brasileira / Early times of brazilian pediatrics

Carlos Arthur Moncorvo de Figueiredo é considerado o “Pai da Pediatria Brasileira”, pois empreendeu várias ações na implantação da pediatria no país, em 1882. Participou ativamente da fundação da Policlínica Geral do Rio de Janeiro, com o primeiro serviço de moléstias da infância. Foi ainda responsável pela formação dos primeiros pediatras no país, por meio de seu Curso Livre, e pela implantação do ensino oficial da Pediatria no país, em decorrência de seu Memorial enviado às autoridades do Império. (AU)

[Laboratory evolutive aspects of children under paracoccidioidomycosis treatment]. / Aspectos laboratoriais evolutivos de crianças em tratamento da paracoccidioidomicose.

The study of 38 children with paracoccidioidomycosis, aged up to 14, treated for 24 to 30 months with either a sulfonamide derivative or ketoconazole either alone or, after the use of amphotericin B. Laboratory data at admission were analyzed and compared with those of sequential tests after up to 30 months follow-up. Anemia, eosinophilia, increased bilirubin and aminotransferases normalized, in most patients, after three months treatment and hypoalbuminemia normalized after six months, suggesting that these laboratory findings are useful for monitoring early therapeutic response. Peripheral leucocytes, erythrocyte sedimentation rate, IgG, and serological titers for Paracoccidioides brasiliensis were increased and frequently normalized after nine to 12 months of treatment. They may be useful for monitoring the entire treatment and emphasize the need for long term treatment of paracoccidioidomycosis in children.

Aspectos laboratoriais evolutivos de crianças em tratamento da paracoccidioidomicose / Laboratory evolutive aspects of children under paracoccidioidomycosis treatment

Estudo de 38 crianças com paracoccidioidomicose, até 14 anos de idade, tratados por 24-30 meses, com um derivado sulfamídico ou cetoconazol, desde o início do tratamento ou em seguida ao uso da anfotericina B. Dados laboratoriais à admissão foram analisados e comparados com exames seqüenciais até 30 meses de acompanhamento. Anemia, eosinofilia e bilirrubinas e aminotransferases elevadas normalizaram-se, na maioria, até os três meses de tratamento e, hipoalbuminemia, até os seis meses, sugerindo que esses achados sejam bons parâmetros para o monitoramento da resposta terapêutica inicial. Leucócitos periféricos, velocidade de hemossedimentação, IgG e títulos sorológicos para o Paracoccidioides brasiliensis estavam elevados e normalizaram-se, freqüentemente, após nove a 12 meses de tratamento, o que sugere utilidade desses exames no monitoramento de todo o tratamento e enfatiza a necessidade de curso terapêutico prolongado da paracoccidioidomicose na infância.

The study of 38 children with paracoccidioidomycosis, aged up to 14, treated for 24 to 30 months with either a sulfonamide derivative or ketoconazole either alone or, after the use of amphotericin B. Laboratory data at admission were analyzed and compared with those of sequential tests after up to 30 months follow-up. Anemia, eosinophilia, increased bilirubin and aminotransferases normalized, in most patients, after three months treatment and hypoalbuminemia normalized after six months, suggesting that these laboratory findings are useful for monitoring early therapeutic response. Peripheral leucocytes, erythrocyte sedimentation rate, IgG, and serological titers for Paracoccidioides brasiliensis were increased and frequently normalized after nine to 12 months of treatment. They may be useful for monitoring the entire treatment and emphasize the need for long term treatment of paracoccidioidomycosis in children.

Clinical evolution of paracoccidioidomycosis in 38 children and teenagers.

Paracoccidioidomycosis (PCM) in children is rare, and its clinical progression is not clearly understood. The admission and post-admission clinical records of 38 children and teenagers aged up to 14 were studied who had been under treatment for 24-30 months. It is a consecutive case series, 17 retrospective and 21 prospective, from 1977 to 2000, admitted before and after 1990, respectively. The main clinical presentations were lymphatic, abdominal and cutaneous involvement, and fever. The alterations which disappeared more slowly were lymphadenomegaly, hepatomegaly, splenomegaly, and osteoarticular pain. Poor intestinal absorption, esophageal varices and splenic calcification were observed before treatment and persisted as sequelae. There was a satisfactory response to initial treatment in 56.7% of cases. Half the patients became asymptomatic in the ninth month of treatment, and 17+/-8% of cases presented with at least one symptom of the disease after 30 months of treatment. There were five deaths, and treatment failure was frequent and associated in part with the irregular use of antifungal. Treatment with ketoconazole was safe and effective. PCM is a serious systemic disease with slow evolution and high lethality, requiring treatment maintenance for a minimum of 24 months with careful and prolonged follow-up. Studies are necessary to evaluate the efficacy of different antifungals and the ideal treatment length for children with PCM.

Vacinação contra influenza em crianças infectadas pelo HIV: alterações imunológicas e na carga viral / Influenza vaccination in HIV infected children: immunologic and viral load changes

Objetivo: verificar se a vacinação contra influenza em crianças infectadas pelo HIV aumentaria a carga viral e reduziria os linfócitos T CD4+, conseqüentes à ativação da imunidade com antígenos dependentes do linfócito T. Métodos: estudo prospectivo descritivo, com 51 crianças infectadas pelo HIV, vacinadas contra influenza em 1999, em Florianópolis, Brasil. Coletaram-se amostras de sangue no dia da vacinação, 14 a 20 e 60 a 90 dias após, para determinação dos níveis da carga viral do HIV e de linfócitos T CD4+. A análise estatística constou dos testes ANOVA de Friedman, t de Student para amostras dependentes, Correção de Bonferroni e Wilcoxon. Resultados: a média de idade foi de 6,08 anos (1 a 12,9 anos). A mediana da contagem de linfócitos T CD4+ no dia da vacinação e nos dois momentos subseqüentes foi de 789, 645 e 768 células/mm3. Observou-se redução significativa na contagem de linfócitos T CD4+ entre a primeira e a segunda determinação (p=0,0001, teste de Wilcoxon), o mesmo não ocorrendo entre a primeira e a terceira. Não houve diferença significativa nas porcentagens de linfócitos T CD4+ entre a primeira aferição e a segunda. A mediana da carga viral em log10 cópias/ml foi de 4,38, 4,30 e 4,25, nos três momentos, respectivamente. Oito de 44 pacientes (18,2%) evidenciaram elevação >0,5 log10 cópias/ml na carga viral entre a primeira e segunda aferição, quatro dos quais retornaram aos níveis basais na terceira. Conclusões: não se observou alteração significativa na porcentagem de linfócitos T CD4+, apesar de ocorrer elevação da carga viral do HIV, de forma transitória, após vacinação contra influenza. Recomenda-se uma certa prudência na aplicação da vacina contra influenza para as crianças com condição clínica e imunológica não estável, principalmente se essas não estiverem sob terapêutica antiretroviral eficaz.

Objective: to identify whether influenza immunization in HIV infected children could increase HIV viral load and decrease CD4+ lymphocytes count as a consequence of the response induced by a T cell-dependent antigen. Methods: prospective, descriptive study, with 51 HIV infected children, vaccinated against influenza in 1999, in Florianópolis, Brazil. Blood samples were collected at three different moments: on the immunization day; between 14 and 20 days later; between 60 and 90 days later. Plasma levels of HIV viral load and CD4+ lymphocytes count were determined. Friedman ANOVA test, Student t-test for dependent samples, Bonferroni correction, and Wilcoxon matched test were performed for statistic analysis. Results: children’s mean age was 6.08 years (1 to 12.9 years). The medians of CD4+ lymphocyte count on vaccination day and at the other two moments were 789, 645 and 768 cells/ mm3, respectively. A significant reduction was observed in the CD4+ lymphocyte count between the first and the second analyses, but the same did not happen between the first and the third analyses. There was no significant difference of CD4+ lymphocyte percentage between the first and the second analyses. The median of HIV viral load values in log10 copies/ml was 4.38, 4.30 and 4.25, at the three moments respectively. Eight out of 44 patients (18.2%) showed increase > 0.5 log10 copies/ml in HIV viral load between the first and the second analyses and among these, four returned to levels close to their base levels in the third analysis. Conclusion: there was no significant change in the CD4+ lymphocyte percentage, in spite of a transitory increase in HIV viral load after influenza vaccination. Caution should be used when administering vaccine against flu to children with no stable clinical and immunological conditions, mainly if they are not under effective anti-retroviral therapeutics.

Tissue adhesives for a sutureless fadenoperation: an experimental study in a rabbit model.

PURPOSE: To use tissue adhesives for a sutureless Fadenoperation to eliminate perioperative risks related to the sutures. METHODS: In an in vivo procedure, 120 superior recti muscles in New Zealand White rabbits were subjected to the posterior fixation procedure, at a distance of 6 mm from the insertion point of the muscle. They were divided into four groups of 30 muscles, according to the material used to perform a myopexy: group 1 (control): nonabsorbable 5-0 polyester sutures; group 2: n-butyl-2-cyanoacrylate adhesive; group 3: fibrin glue; group 4: gelatin-resorcin-formaldehyde-glutaraldehyde (GRFG) adhesive. The animals were examined at 1, 7, 14, and 21 days after surgery. Afterward, they were killed, and their eyes were enucleated to measure the distance between the myopexy and the anatomic insertion point and to assure the strength of the bond with a dynamometer. Finally, a histologic examination was performed. RESULTS: Almost all eyes were clear after the third week, although group 4 presented the most intense inflammatory reaction. In histologic examination, groups 1 and 2 showed a chronic inflammatory reaction of the foreign-body type, with similar intensity. Fibrin glue induced minimal inflammation, but GRFG adhesive produced a pronounced reaction. Concerning the distance of the myopexy, groups 1 and 2 presented measures close to the expected distance of 6 mm, whereas groups 3 and 4 showed a greater variability. All groups performed well in the strength test, with no statistically significant differences among them. CONCLUSIONS: n-Butyl-2-cyanoacrylate adhesive performed best in the sutureless Fadenoperation, characterized by precision in the expected distance of myopexy, sufficient resistance to separation, and acceptable inflammatory reaction.

Subclinical rheumatic valvitis: a long-term follow-up.

In order prospectively to investigate the frequency and evolution of subclinical valvitis, we selected 40 consecutive patients suffering their initial attack of rheumatic fever, seen in our clinic from 1992 to 1994, and followed-up until 2001, with a mean period of follow-up of 8.1 years, and a standard deviation of 0.6 year. We also assembled a matched control group of 37 healthy children and adolescents. We discovered a murmur of mitral regurgitation in 28 (70.0%) of the patients. In 3 (7.5%) of these patients, there was also a murmur of aortic regurgitation. In the group of 28 symptomatic patients, Doppler echocardiography showed mitral regurgitation in all, and aortic regurgitation in 17. In the group of 12 patients without clinical evidence of cardiac involvement, Doppler echocardiography identified mitral regurgitation in 2, isolated in one and associated with aortic regurgitation in the other. Thus, the frequency of subclinical valvitis was 16.7%. In patients with subclinical valvitis only the aortic regurgitation regressed during the period of follow-up. In the group of 28 symptomatic patients, mitral regurgitation disappeared in 6 (21.4%), aortic regurgitation in 7 of the 17 having this feature (41.2%), while 2 patients (7.1%) developed mitral stenosis. The sensitivity and specificity of cardiac auscultation were, respectively, 93.3%, with 95% confidence intervals between 72.3% and 97.4%, and 100%, with 95% confidence intervals between 65.5% and 100%, for the diagnosis of mitral regurgitation, and 16.7%, with 95% confidence intervals between 4.4% and 42.3%, and 100%, with 95% confidence intervals between 81.5% and 100%, for that of aortic regurgitation. We conclude that the Doppler echocardiogram is an important means of diagnosing and assessing the evolution of subclinical rheumatic valvar lesions, which are not always transient. We suggest that Doppler echocardiography should be performed in all patients with acute rheumatic fever. Subclinical valvitis should be considered as mild carditis, provided that strict criterions are observed in the differential diagnosis from physiological regurgitation, and Doppler echocardiographic findings are analyzed in the context of the other manifestations of the disease.

Oportunidades perdidas de imunizaçäo antitetânica de gestantes de Juiz de Fora, Minas Gerais, Brasil / Missed opportunities for tetanus immunization of pregnant women in Juiz de Fora, Minas Gerais, Brazil

OBJETIVOS: Estimar as oportunidades perdidas de vacinaçäo antitetânica e a cobertura vacinal ao final da gravidez em gestantes de Juiz de Fora, Estado de Minas Gerais, Brasil. MÉTODOS: Entre 1º de janeiro e 31 de agosto de 1996, realizou-se um estudo transversal com 430 mulheres selecionadas aleatoriamente entre todas as gestantes de Juiz de Fora. As participantes foram entrevistadas a respeito do controle pré-natal, conhecimento sobre o tétano e vacinaçäo antitetânica. RESULTADOS: A idade das gestantes variou de 14 a 45 anos (média de 26,4 ± 6,9 anos); 420 eram de zona urbana e 10 de zona rural. O controle pré-natal foi feito pelo Sistema Unico de Saúde em 69,5 por cento (299) das mulheres; 27,6 por cento (119) utilizaram outros convênios; e 2,8 por cento (12) näo fizeram controle pré-natal. Trezentas e cinqüenta e duas mulheres (81,8 por cento) portavam o cartäo de controle pré-natal e 85,6 por cento (368) tiveram quatro ou mais consultas pré-natais. Com relaçäo ao conhecimento do tétano, 92,1 por cento (396) demonstraram conhecer a doença e sua gravidade. Dentre 430 gestantes, 359 (83,5 por cento) iniciaram a gestaçäo näo imunizadas contra o tétano: 104 foram imunizadas durante a gravidez em estudo e 255 permaneceram sem vacina até o puerpério, apesar do aumento significativo na chance de imunizaçäo com o aumento do número de visitas de pré-natal (OR = 2,7 para quatro ou mais visitas; P < 0,001). Foram de 70 por cento as oportunidades perdidas de imunizaçäo antitetânica na gestaçäo e de 40,6 por cento a cobertura vacinal das gestantes. CONCLUSÄO: A baixa cobertura vacinal, inferior aos níveis recomendados pela Organizaçäo Mundial da Saúde, e o índice elevado de oportunidades perdidas de imunizaçäo antitetânica apontam para a necessidade de se instituir uma estratégia de incentivo à vacinaçäo, direcionada aos profissionais de saúde em geral e especialmente àqueles responsáveis pelo atendimento das gestantes, tanto em postos de saúde quanto em clínicas privadas. Além disso, a rotina de vacinaçäo em Juiz de Fora deve ser intensificada.

[Influenza vaccination in HIV infected children: immunologic and viral load changes]. / Vacinação contra influenza em crianças infectadas pelo HIV: alterações imunológicas e na carga viral.

OBJECTIVE: To identify whether influenza immunization in HIV infected children could increase HIV viral load and decrease CD4+ lymphocytes count as a consequence of the response induced by a T cell-dependent antigen. METHODS: Prospective, descriptive study, with 51 HIV infected children, vaccinated against influenza in 1999, in Florianópolis, Brazil. Blood samples were collected at three different moments: on the immunization day; between 14 and 20 days later; between 60 and 90 days later. Plasma levels of HIV viral load and CD4+ lymphocytes count were determined. Friedman ANOVA test, Student t test for dependent samples, Bonferroni correction and Wilcoxon matched test were performed for statistical analysis. RESULTS: Children's mean age was 6.08 years (1 to 12.9 years). The medians of CD4+ lymphocyte count on vaccination day and at the other two moments were 789, 645 and 768 cells/mm(3), respectively. A significant reduction was observed in the CD4+ lymphocyte count between the first and the second analyses, but the same did not happen between the first and the third analyses. There was no significant difference of CD4+ lymphocyte percentage between the first and the second analyses. The median of HIV viral load values in log10 copies/ml was 4.38, 4.30 and 4.25, at the three moments respectively. Eight out of 44 patients (18.2%) showed increase > or =0.5 log 10 copies/ml in HIV viral load between the first and the second analysis and among these, four returned to levels close to their base levels in the third analysis. CONCLUSIONS: There was no significant change in the CD4+ lymphocyte percentage, in spite of a transitory increase in HIV viral load after influenza vaccination. Caution should be used when administering vaccine against flu to children with no stable clinical and immunological conditions, mainly if they are not under effective anti-retroviral therapeutics.

Vacinação contra influenza em crianças infectadas pelo HIV: alterações imunológicas e na carga viral / Influenza caccination in HIV infected children: immunologic and viral load changes

bjetivo: verificar se a vacinação contra influenza em crianças infectadas pelo HIV aumentaria a carga viral e reduziria os linfócitos T CD4+, conseqüentes à ativação da imunidade com antígenos dependentes do linfócito T.Métodos: estudo prospectivo descritivo, com 51 crianças infectadas pelo HIV, vacinadas contra influenza em 1999, em Florianópolis, Brasil. Coletaram-se amostras de sangue no dia da vacinação, 14 a 20 e 60 a 90 dias após, para determinação dos níveis da carga viral do HIV e de linfócitos T CD4+. A análise estatística constou dos testes ANOVA de Friedman, t de Student para amostras dependentes, Correção de Bonferroni e Wilcoxon.Resultados: a média de idade foi de 6,08 anos (I a 12,9 anos). A mediana da contagem de linfócitos T CD4+ no dia da vacinação e nos dois momentos subseqüentes foi de 789, 645 e 768 células/mm3. Observou-se redução significativa na contagem de linfócitos T CD4+ entre a primeira e a segunda determinação (p=O,OOO I, teste de Wilcoxon), o mesmo não ocorrendo entre a primeira e a terceira. Nãohouve diferença significativa nas porcentagens de linfócitos T CD4+ entre a primeira aferição e a segunda. A mediana da carga viral em logl0 cópias/ml foi de 4,38, 4,30 e 4,25, nos três momentos, respectivamente. Oito de 44 pacientes ( 18,2por cento ) evidenciaram elevação maior ou igual a 0,5 logl0 cópias/ml na carga viral entre a primeira e segunda aferição, quatro dos quais retomaram aos níveis basais na terceira. Conclusões: não se observou alteração significativa na porcentagem de linfócitos T CD4+...

[Missed opportunities for tetanus immunization of pregnant women in Juiz de Fora, Minas Gerais, Brazil]. / Oportunidades perdidas de imunização antitetânica de gestantes de Juiz de Fora, Minas Gerais, Brasil.

OBJECTIVE: To estimate the missed opportunities for tetanus vaccination and to determine the immunization coverage at the end of pregnancy in women living in the city of Juiz de Fora, which is in the state of Minas Gerais, Brazil. METHODS: A cross-sectional study was carried out of 430 women who were randomly selected from all the maternity hospitals in the city, from February through August 1996. The women were interviewed regarding prenatal care, their knowledge of tetanus, and tetanus immunization before or during the latest pregnancy. RESULTS: The age of the participants ranged from 14 to 45 years (mean = 26.4 +/- 6.9 years); 420 women lived in urban areas and 10 in rural areas. Prenatal care was from the Brazilian public Unified Health System in 69.5% of the women (299 of 430); 27.6% (119) received prenatal care through other types of providers; and 2.8% (12) did not receive prenatal care. Of the 430 participants, 352 of them (81.8%) had their prenatal care card with them during the interview; 85.6% (368) had four or more prenatal care visits. Regarding their knowledge of tetanus, 92.1% (396) knew about the disease and its severity. Out of the 430 women, 359 of them (83.5%) started the latest pregnancy without having had a tetanus vaccination; 104 were vaccinated during the latest pregnancy, so 255 had not been vaccinated by the time of delivery. This was in spite of the significant increase in the opportunities for being vaccinated with an increase in the number of prenatal visits. The odds ratio for pregnant women with four or more prenatal visits being vaccinated by the end of the pregnancy was 2.7 times that of the women with zero to three visits. Seventy percent of the opportunities for tetanus immunization were missed in the study population. The overall tetanus immunization coverage was 40.6% by the end of pregnancy. CONCLUSIONS: The low immunization coverage was below the level recommended by the World Health Organization. In combination with the high rate of missed opportunities for vaccination, this points to the need to implement a tetanus vaccination promotion strategy directed at health professionals in general but especially at those who provide care for pregnant women, in both public and private health clinics. In addition, the vaccination practices in Juiz de Fora should be strengthened.