Transcutaneous Posterior Tibial Nerve Stimulation: An Adjuvant Treatment for Intractable Constipation in Children

BACKGROUND

Functional constipation can lead to painful defecations, fecal incontinence, and abdominal pain, significantly affecting a child's quality of life. Treatment options include non-pharmacological and pharmacological approaches, but some cases are intractable and require alternative interventions like neuromodulation. A subtype of neuromodulation, called Transcutaneous Posterior Tibial Nerve Stimulation (TPTNS), comprises electrical stimulation at the ankle level, by means of electrodes fixed to the skin. TPTNS is a minimally invasive, easy-to-apply technique that can potentially improve constipation symptoms in the pediatric population by stimulating the sacral nerves.

AIM

To evaluate the clinical results and applicability of TPTNS as an adjuvant treatment for children and adolescents with functional constipation.

METHODS

Between April 2019 and October 2021, 36 patients diagnosed with functional constipation according to the Rome IV Criteria were invited to participate in the study. The study followed a single-center, uncontrolled, prospective cohort design. Patients received TPTNS for 4 or 8 weeks, with assessments conducted immediately after the periods of TPTNS and 4 weeks after the end of the intervention period. The data normality distribution was determined by the Shapiro-Wilk test. The Wilcoxon test and Student's t-test for paired samples were used to compare quantitative variables, and the McNemar test was used to compare categorical variables.

RESULTS

Of the 36 enrolled patients, 28 children and adolescents with intractable function constipation completed the study, receiving TPTNS for 4 weeks. Sixteen patients (57.1%) extended the intervention period for 4 extra weeks, receiving 8 weeks of intervention. TPTNS led to significant improvements in stool consistency, frequency of defecation, and bowel function scores, with a reduction in abdominal pain. Quality of life across physical and psychosocial domains showed substantial enhancements. The quality of life-related to bowel habits also improved significantly, particularly in lifestyle, behavior, and embarrassment domains. The positive effects of this intervention are seen relatively early, detected after 4 weeks of intervention, and even 4 weeks after the end of the intervention. TPTNS was well-tolerated, with an adherence rate of approximately 78%, and no adverse effects were reported.

CONCLUSIONS

TPTNS is an adjuvant treatment for intractable functional constipation, improving bowel function and quality of life. The effects of TPTNS were observed relatively early and sustained even after treatment cessation.

Developing Ice Cream for Mucositis Management and Improving the Nutritional Support for Pediatric Cancer Patients

  Introduction: Mucositis is one of the main complications of cancer treatment, associated with several nutritional limitations and the ability to cause secondary infections. Cryotherapy is a low-cost treatment consistent with clinical practice guidelines for treating patients with mucositis. Objective: To develop and evaluate the acceptance of ice cream for the prevention and treatment of mucositis and nutritional support of pediatric cancer patients. Method: Based on knowledge about the side effects of chemotherapy (especially in oral and gastrointestinal mucositis) and the nutritional needs of pediatric cancer patients, a literature search for ingredients that could meet the study’s objectives was undertaken. Food Technology Laboratory of the São Paulo State University (Unesp), Botucatu campus, and in partnership with Sorvetes Naturais ice cream shop in the municipality of Botucatu-SP, produced the ice cream. An acceptance test was applied in ten patients undergoing cancer treatment and 30 individuals in the control group using the 5-point mixed facial hedonic scale. Results: The final formula consisted of semi-skimmed lactose-free milk, extra virgin coconut oil, oat flour, honey, chamomile, Fortini® food supplement, demerara sugar, and stabilizer/emulsifier. 90% of patients undergoing cancer treatment rated the final product as “liked” or “loved it,” compared to 63% of the control group. Conclusion: Development of an ice cream that met the objectives of the study was possible through the choice of its composition. Honey and chamomile can favor the prevention of mucositis, and other ingredients offer the caloric density and protein supply.

Impaired Health-Related Quality of Life in Brazilian Children with Chronic Abdominal Pain: A Cross-Sectional Study

PURPOSE

We compared the health-related quality of life (HRQOL) of children and adolescents with functional abdominal pain disorders (FAPDs) and organic abdominal pain disorders (ORGDs).

METHODS

This was a single-center, cross-sectional, observational study. The PedsQL 4.0 generic cores scales parent proxy-report was administered to parents/caregivers of 130 and 56 pediatric patients with FAPDs and ORGDs respectively on their first visit. The self-reported pain intensity in the patients was assessed using a visual analog scale (VAS) and facial affective scale (FAS).

RESULTS

Irritable bowel syndrome was the most prevalent FAPDs, and the most prevalent ORGDs were reflux esophagitis (41.1%) and gastritis associated with Helicobacter pylori (21.4%). There was no difference in HRQOL among patients diagnosed with ORGDs and FAPDs (p>0.05). Patients with ORGDs and FAPDs had lower HRQOL Scale scores than healthy Brazilian and American children's references, with a high proportion of children at risk for impaired HRQOL (p<0.0001). There was no difference in the VAS and the FAS scores between the ORGDs and the FAPDs. FAPDs had a higher prevalence of girls' and couples' disagreement (p<0.02), although poor school performance (p<0.0007) and bullying (p<0.01) were higher in patients with ORGD.

CONCLUSION

This study revealed that there was a difference in impaired HRQOL between patients with ORGDs and FAPDs. Thus, considering the high prevalence of chronic abdominal pain in children, a well-founded treatment plan is necessary for a multidisciplinary cognitive-behavioral Pain management program.

Labeling food allergens in the packaged food pyramid groups in Brazil: analysis of descriptions, ambiguities, and risks

OBJECTIVE

The aim of this study was to evaluate allergenic labeling components of packaged foods for "What is the quality of food labels?" and "What is the group of Brazilian Food Pyramid that 'May contain' is predominant?."

METHODS

The photographs of 916 products were obtained, of which 518 were analyzed. Data from each label were evaluated according to Brazilian Food Pyramid Groups (i.e., Cereals, Fruits, & Vegetables; Soybean & products; Milk & dairy products; Meat & eggs; Fats & oils; and Sugars & sweets). Ten items were analyzed in each label, namely, the presence of a list of ingredients, alert phrase for allergy sufferers, grouping of the alert phrase, phrase location, uppercase phrase, the phrase in bold, the color of alert phrase contrasting to the background, adequate font size, do not claim the absence for any allergen with the ingredients, and others factors that make it difficult to read. For the second question, a structured questionnaire was completed, and products were classified into two categories, namely, "Contain" and "May contain."

RESULTS

The quality of the label was appropriate, and 69% of packaged foods had at least one allergen. The information "May contain" were higher in cow's milk (Cereals and Meat & eggs), soy (Soybean & products), and egg protein (Cereals). Soybean & products were the highest insecurity group.

CONCLUSIONS

Brazilian health professionals can count on good-quality labeling of packaged products. Consequently, they could promote patients' and parents/caregivers' education to consult the labels and manage the risks in processed foods about precautionary allergen labeling. Soybean & products were the most significant insecurity for food choices between Brazilian Pyramid Groups.

Rotulagem de alérgenos alimentares em alimentos embalados segundo grupos alimentares da pirâmide brasileira: análise da descrição, riscos e ambiguidades

RESUMO Objetivo: Avaliar os componentes alergênicos da rotulagem de alimentos embalados e responder “Qual é a qualidade da rotulagem?” e “Qual é o grupo de alimentos em que a expressão ‘Pode conter’ é predominante?”. Métodos: Foram obtidas fotografias de 916 produtos, dos quais 518 foram analisados. Os dados dos rótulos foram avaliados de acordo com os grupos da pirâmide alimentar brasileira (Cereais, Frutas & Vegetais; Soja & Derivados; Leite & Laticínios; Carne & Ovos; Gorduras & Óleos; Açúcares & Doces). Dez itens foram analisados nos rótulos: presença de lista de ingredientes; frase de alerta para alérgicos; frase de alerta; local da frase; frase em letras maiúsculas; frase em negrito; a cor da frase de alerta contrastando com o fundo; tamanho de fonte adequado; não alegar ausência de qualquer alérgeno; outros fatores de difícil leitura. Para a segunda questão, foi respondido questionário estruturado, e os produtos classificados em categorias: “Contém” e “Pode conter”. Resultados: A qualidade do rótulo foi adequada e 69% dos alimentos embalados continham pelo menos um alérgeno. A informação “Pode conter” foi mais identificada em: proteína do leite (Cereais e Carnes e ovos), soja (Soja & derivados) e proteína do ovo (Cereais). Soja e derivados foi o grupo alimentar de maior insegurança. Conclusões: Profissionais de saúde podem contar com rotulagem de boa qualidade dos produtos embalados e, consequentemente, promover a educação de pais/cuidadores para consultar os rótulos e gerenciar os riscos em alimentos processados. Soja e produtos são os alimentos com maior insegurança entre os Grupos da Pirâmide Brasileira.

Pediatric Functional Constipation Questionnaire-Parent Report (PedFCQuest-PR): development and validation

OBJECTIVE

Developing and validating a disease-specific instrument in the Brazilian Portuguese language to assess the Health-Related Quality of Life of children with functional constipation, applied to parents/caregivers.

METHODS

The process of developing the questionnaire was carried out in the following steps: items generation concerning functional constipation; elaboration of the preliminary questionnaire; assessment by health professionals; identifying problems or inconsistencies by the researchers; improvement of the questions; obtaining a final questionnaire named Pediatric Functional Constipation Questionnaire-Parent Form (PedFCQuest-PR) with 26 questions divided into four domains. Responses options use a Likert scale based on the events of the last four weeks. The process of validation was an observational, cross-sectional study in a sample of 87 parents/caregivers of children from 5 to 15 years of age diagnosed with Functional constipation according to the Rome IV Criteria. The questionnaire was applied simultaneously to the Pediatric Quality of Life Inventory 4.0 (PedsQL TM 4.0) as a control.

RESULTS

The questionnaire validation included 87 parents/caregivers. The children's median age was 8.2 years, with a long time of constipation symptoms associated with fecal incontinence in approximately two-thirds. Internal consistency reliability for the Total Scale Score of PedFCQuest-PR by Coefficient Alpha of Cronbach score was 0.86. Convergent and divergent validity of PedFCQuest-PR was demonstrated by correlating the domains of both questionnaires.

CONCLUSION

This study provides evidence that PedFCQuest-PR is a reliable instrument. The results showed a high degree of internal consistency and validity of the instrument for future applications.

Clinical Features and Outcomes of Very-Early-Onset Inflammatory Bowel Disease in Brazilian Children

We report on 20 Brazilian children under 6 years of age with very-early-onset inflammatory bowel disease naive to treatment. The clinical, laboratory, and histopathologic findings at diagnosis and outcomes were reviewed: 13 had ulcerative colitis (UC) and 7 had Crohn disease (CD). The final diagnostic pattern was as follows: 4 children had neonatal-onset (1 UC and 3 CD), 8 had infantile subtype (4 UC and 4 CD), and 8 had UC beyond the neonatal and infantile period. Both forms of inflammatory bowel disease were severe and extensive at diagnosis, with a high prevalence of bloody diarrhea, reflecting the colonic location of the disease. UC was predominantly pancolonic, CD was isolated in the colon and associated with perianal disease. Children with CD were younger than those with UC, were significantly more nutritionally impaired, and had more complications. This study shows that very-early-onset inflammatory bowel disease has an aggressive clinical course with 2 distinct phenotypes, UC and CD, with differences in severity, clinical behavior, and inflammatory pattern but with a preponderance of colonic involvement in both types.

A protocol for an interventional study on the impact of transcutaneous parasacral nerve stimulation in children with functional constipation

INTRODUCTION

Transcutaneous parasacral nerve stimulation (TPNS) via electrodes placed over the sacrum can activate afferent neuronal networks noninvasively, leading to sacral reflexes that may improve colonic motility. Thus, TPNS can be considered a promising, noninvasive, and safe method for the treatment of constipation. However, there is no published study investigating its use in children with functional constipation. This is a single-center, prospective, longitudinal, and interventional study designed to assess the applicability and clinical outcomes of TPNS in functionally constipated children.

PATIENT CONCERNS

Parents or guardians of patients will be informed of the purpose of the study and will sign an informed consent form. The participants may leave the study at any time without any restrictions.

DIAGNOSIS

Twenty-eight children (7-18 years old) who were diagnosed with intestinal constipation (Rome IV criteria) will be included.

INTERVENTIONS

The patients will be submitted to daily sessions of TPNS for a period of 4 or 8 weeks and will be invited to participate in semistructured interviews at 3 or 4 moments: 1 week before the beginning of TPNS; immediately after the 4 and/or 8 weeks of TPNS; and 4 weeks after the end of the intervention period. In these appointments, the aspects related to bowel habits and quality of life will be assessed.

OUTCOMES

This study will evaluate the increase in the number of bowel movements and stool consistency, the decrease in the number of episodes of retentive fecal incontinence, and the indirect improvement in the overall quality of life.

CONCLUSION

we expect that this study protocol can show the efficacy of this promising method to assist the treatment of children with functional constipation.

Transcutaneous posterior tibial nerve stimulation in children and adolescents with functional constipation: A protocol for an interventional study

INTRODUCTION

A vast majority of children with functional constipation respond to the standard medical treatment. However, a subset of patients may present with an unsatisfactory response and only minor improvement of symptoms. Transcutaneous posterior tibial nerve stimulation (PTNS) involves electrical stimulation of the posterior tibial nerve at the level of the ankle, transcutaneously through electrodes fixated on the overlying skin. Stimulation of the tibial nerve can modulate urinary and defecatory function through the stimulation of sacral nerves. Thus, transcutaneous PTNS can be considered a very promising, noninvasive, and safe method to be used in the pediatric age group. However, there is still no published study that has investigated its use in children for the treatment of intestinal constipation. This is a single-center, prospective, longitudinal, and interventional study designed to assess the applicability and clinical outcomes of transcutaneous PTNS in children with functional intestinal constipation. Children will be submitted to daily sessions of transcutaneous PTNS for a period of 4 weeks. All children will also be invited to participate in semistructured interviews, 1 in each of the 3 assessments: 1 week before the start of the intervention; immediately after the 4 weeks of intervention; and 4 weeks after the end of the intervention period. In these interviews, the aspects related to bowel habits and quality of life will be assessed. This project aims to evaluate the clinical outcomes of transcutaneous PTNS in children with functional intestinal constipation and the applicability of this kind of treatment.

CONCLUSIONS

This protocol intended to demonstrate the efficacy of this promising method to increase the number of bowel movements and the stool consistency, to reduce the number of episodes of retentive fecal incontinence, and to indirectly improve the overall quality of life.

Combinations of laxatives and green banana biomass on the treatment of functional constipation in children and adolescents: a randomized study

OBJECTIVES

Evaluate the effect of combinations of green banana biomass and laxatives in children and adolescents with chronic constipation.

METHODS

This was a randomized study of 80 children and adolescents with functional constipation according to the Rome IV Criteria, who were divided into five groups: (1) green banana biomass alone; (2) green banana biomass plus PEG 3350 with electrolytes; (3) green banana biomass plus sodium picosulfate; (4) PEG 3350 with electrolytes alone; and (5) sodium picosulfate alone. Primary outcome measure was the reduction of the proportion of patients with Bristol Stool Form Scale ratings 1 or 2. Secondary outcome measures were: increase of the proportion of >3 bowel movements/week and reduction of the proportion of fecal incontinence, straining on defecation, painful defecation, blood in stool, abdominal pain, and decreased laxative doses.

RESULTS

On consumption of green banana biomass alone, a statistically significant reduction was observed in the proportion of children with Bristol Stool Form Scale rating 1 or 2, straining on defecation, painful defecation, and abdominal pain. Conversely, no reduction was observed in fecal incontinence episodes/week, blood in stool, and no increase was observed in the proportion of children with >3 bowel movements/week. The percentage of children who required decreased laxative dose was high when green banana biomass was associated with sodium picosulfate (87%), and PEG 3350 with electrolytes (63%). Green banana biomass alone and associated with laxatives was well tolerated, and no adverse effects were reported.

CONCLUSION

Green banana biomass is advantageous as an adjunct therapy on functional constipation, mainly for reducing doses of laxatives.

Helicobacter pylori infection is high in paediatric nonulcer dyspepsia but not associated with specific gastrointestinal symptoms

AIM

The association between Helicobacter pylori infection and gastrointestinal symptoms is debatable in childhood. We examined the potential relationship between H. pylori infection and gastrointestinal symptoms in Brazilian children with nonulcer dyspepsia.

METHODS

This prospective observational study analysed 240 Brazilian children and adolescents (68.7% girls) with chronic nonulcer dyspepsia, who underwent upper gastrointestinal endoscopy and biopsy. Their mean age was 9.8 years (range 4-17). Upper gastrointestinal symptoms, including abdominal pain, nausea, burning, early satiety, belching and weigh loss, were evaluated by a questionnaire and H. pylori infection was determined by histopathology of gastric biopsies.

RESULTS

H. pylori infection was identified in 123/240 patients (52%). There was no significant association between the H. pylori infection and gastrointestinal symptoms and no relationship between the infection and abdominal pain or pain characteristics. However, nausea was significantly associated with the H. pylori infection, with an odds ratio of 1.76 and 95% confidence interval of 1.1-2.94 p < 0.03. Symptoms lasting longer than 12 months were significantly more frequent in children with pangastritis than in those with antral gastritis (p < 0.05).

CONCLUSION

The prevalence of H. pylori infection was high in Brazilian children with nonulcer dyspepsia, but was not associated with specific signs and symptoms, except for nausea.

Treinamento esfincteriano anal: estudo transversal em crianças de 3 a 6 anos de idade

OBJETIVO: Avaliar o treinamento do controle esfincteriano anal em crianças, por meio de entrevista aplicada aos pais ou cuidadores. MÉTODOS: Estudo de corte transversal em crianças sadias, aplicando-se um questionário estruturado para 100 responsáveis por crianças entre três e seis anos de idade. RESULTADOS: 97% das crianças foram treinadas em casa pelas mães e 92% delas utilizaram a intuição, a experiência com o filho anterior e o aprendizado com as avós. O treinamento do controle esfincteriano anal e vesical foi iniciado simultaneamente em 84% dos casos, sendo o controle anal adquirido primeiramente em 41% das crianças. As mães com escolaridade menor e das classes C-D-E iniciaram o treinamento mais precocemente, sendo um dos fatores relatados o custo das fraldas. Não houve diferença entre meninos e meninas para idade de início e duração do treinamento. As crianças apresentavam a maioria dos "sinais de prontidão" para o início do treinamento e, das crianças que foram treinadas no vaso sanitário, uma pequena parcela utilizou redutor e apoio para os pés. Não houve aumento significativo de constipação intestinal após o treinamento e não foram observados casos de encoprese. CONCLUSÕES: As mães foram as responsáveis pelo treinamento esfincteriano anal e o iniciaram sem auxílio especializado. Nas classes sociais C-D-E, o custo das fraldas foi determinante para o início do treinamento esfincteriano anal.

Refluxo gastroesofágico: estudo comparativo da receptividade e sensibilidade entre seriografia e ultrassonografia

OBJETIVO: Estudo comparativo da receptividade (colaboração) e sensibilidade da seriografia do esôfago, estômago e duodeno em relação à ultrassonografia do esôfago intra-abdominal em pacientes com suspeita de refluxo gastroesofágico. MATERIAIS E MÉTODOS: Foram incluídos no estudo 42 pacientes pediátricos (26 masculinos, com idade média de 33,64 ± 34,33 meses, e 16 femininos, com idade média de 31,02 ± 35,56 meses) com suspeita de refluxo gastroesofágico, os quais foram submetidos, inicialmente, a seriografia do esôfago, estômago e duodeno, e posteriormente, a ultrassonografia do esôfago intra-abdominal. RESUL-TADOS: A análise estatística comparativa entre os sexos e as idades sugere não haver evidência de associação com a colaboração, tanto para a seriografia do esôfago, estômago e duodeno como para a ultrassonografia do esôfago intra-abdominal. Entretanto, na classificação quanto ao tipo de colaboração, a técnica de seriografia do esôfago, estômago e duodeno apresentou menos de 50% de colaboração, enquanto 80,49% dos pacientes colaboraram com a ultrassonografia do esôfago intra-abdominal. Quanto à sensibilidade do diagnóstico de refluxo gastroesofágico, a técnica de ultrassonografia do esôfago intra-abdominal (85,7%) foi significativamente superior à de seriografia do esôfago, estômago e duodeno (47,6%). CONCLUSÃO: O presente estudo sugere que se proceda a ultrassonografia do esôfago intra-abdominal, mesmo na ausência de refluxo gastroesofágico na seriografia do esôfago, estômago e duodeno.

Prevalência de sobrepeso/obesidade em crianças e adolescentes com constipação crônica funcional

OBJETIVO: Avaliar a prevalência do sobrepeso/obesidade em um grupo de crianças com constipação crônica funcional. MÉTODOS: Estudo retrospectivo com 257 crianças de dois a 15 anos com constipação crônica funcional diagnosticada segundo critérios de Roma II, atendidas consecutivamente em clínica terciária de gastroenterologia pediátrica. Informações demográficas, clínicas, diagnósticas e antropométricas foram obtidas de prontuários. O índice de massa corporal (IMC) foi calculado e utilizou-se a referência do Centers for Disease Control para determinar o percentil de IMC para idade e gênero. Crianças com percentil de IMC>85 foram consideradas com sobrepeso/obesidade; as com percentis > 5 e <85 foram classificadas como eutróficas. RESULTADOS: Para as variáveis sociodemográficas e clínicas, não houve diferença estatisticamente significante entre os subgrupos sobrepeso/obesidade e eutrofia. A prevalência de crianças constipadas com sobrepeso/obesidade foi de 24,4%. A média dos percentis do subgrupo sobrepeso/obesidade foi 94,4±4,3; a das eutróficas foi 45,3±24,2. A prevalência de sobrepeso/obesidade foi similar em ambos os sexos e grupos etários (<7 anos e >7 anos). CONCLUSÕES: Os subgrupos dos eutróficos e sobrepeso/obesidade foram homogêneos nas características sociodemográficas e clínicas, sugerindo que tais variáveis não influenciaram na prevalência do excesso de peso. A prevalência estimada de sobrepeso/obesidade entre as crianças com constipação crônica funcional está dentro dos valores esperados para a população pediátrica brasileira.

Constipação crônica na infância: quanto estamos consultando em Gastroenterologia Pediátrica?

OBJETIVO: Comparar dois períodos em relação ao atendimento de constipação crônica - Tempo A (1992 a 1995) e Tempo B (2002 a 2005), avaliando o número de consultas por problemas gastrintestinais; o número e a porcentagem de consultas de crianças com constipação crônica; e o número de atendimentos de crianças com constipação crônica por período de atendimento. MÉTODOS: No Tempo A, 359 pacientes foram atendidos em um período de quatro horas por semana. No Tempo B, 624 pacientes foram atendidos em três períodos de quatro horas, totalizando 12 horas por semana. RESULTADOS: Houve aumento no número absoluto de pacientes, no número de consultas por problemas gastrintestinais (2,8 vezes) e no número de consultas por constipação crônica (2,6 vezes) no Tempo B, em relação ao Tempo A. Houve manutenção na proporção de consultas por constipação crônica: média de 35,6% no Tempo A e 34,6% no Tempo B. Ocorreu aumento no número de períodos de atendimento no Tempo B (2,9 vezes maior), com igual número de consultas por período de atendimento (média de 17,4 no Tempo A e 16,6 no Tempo B) e de consultas por constipação crônica por período de atendimento (média de 6,1 no Tempo A e 5,5 no Tempo B). CONCLUSÕES: O aumento no número absoluto, e não na proporção de atendimentos por constipação crônica, pode ter ocorrido pela manutenção da prevalência populacional deste distúrbio, gerando demanda contida de encaminhamento pelo pediatra generalista. O despreparo do pediatra generalista para o atendimento deste problema poderia levar a um aumento no número de encaminhamentos aos pediatras especialistas.

[Antistreptolysin O titer profile in acute rheumatic fever diagnosis]

OBJECTIVE: To determine ASO titer profile by establishing ARF differential diagnoses of other diseases with high levels of ASO antibodies. METHODS: We investigated 78 patients with ARF at onset and follow-up, 22 with isolated chorea at onset, 45 with recurrent oropharyngeal tonsillitis, and 23 with recent flare of juvenile idiopathic arthritis. We tested ASO with automated particle-enhanced immunonephelometric assay (Behring(R)-Germany). The ASO (IU/ml) titers were assessed at the following time intervals: 0-7 days, 1-2 weeks, 2-4 weeks, 1-2 months, 2-4 months, 4-6 months, 6-12 months, 1-2 years, 2-3 years, 3-4 years, and 4-5 years after onset of ARF. RESULTS: ASO titers in patients diagnosed with ARF had a significant increase up to the 2-4-month time interval (P<0.0001). Baseline levels were observed afterwards in patients under regular penicillin prophylaxis. The levels of ASO in ARF were also significantly higher than in patients with isolated chorea, recurrent oropharyngeal infections or juvenile idiopathic arthritis (P=0.0025), when age-matched samples of these groups were compared. The testacute;s sensitivity was 73.3% and the specificity was 57.6%, and it was calculated taking into account the upper limit of normality at 320 IU/ml, as well as the established diagnosis of ARF. The testacute;s specificity and positive predictive value increased with rising or higher titers, being higher with titers above 960 UI/ml. CONCLUSION: This reappraisal of ASO profile in ARF patients indicates a remarkable response during the acute phase, and that points to the extent to which ASO levels may differentiate ARF from other diseases with high levels of ASO antibodies, as coincidental but unrelated streptococcal infection or chronic arthritis flareup.

[Treatment of membranous subaortic stenosis with balloon dilatation]

PURPOSE

This study sought to evaluate the immediate and follow-up results of percutaneous balloon dilatation for the treatment of membranous subaortic stenoses.

METHODS

Fourteen patients with mean age 11.4 +/- 5.2 years, were submitted to the procedure. They were selected when the echocardiogram showed a thin subaortic membrane that was far from the aortic valve, no fibro-muscular obstruction and only mild or moderate aortic regurgitation. After measuring the pressure gradient and analysis of the angiographic features, the balloon dilatation was made by applying a fast manual inflation until the balloon waist disappeared. The balloon diameter was the same as that of the outflow tract of left ventricle, immediately bellow the aortic valve. Pressure measurement, left ventriculogram and aortogram were repeated. Doppler echocardiogram was repeated in the following day, after 3 months and every 6 months thereafter.

RESULTS

All 17 procedures were successful. The mean gradient was 76.1 +/- 21.2 mmHg before and 29.8 +/- 8.8 mmHg after dilatation (p < 0.01). There was no increase in aortic regurgitation or death after the procedure or during the follow-up. Twelve patients were discharged 24h after the procedure. Surgical treatment for femoral artery thrombosis was performed in 2 patients. In the follow-up of 33.3 +/- 23.6 months, 4 patients developed restenosis and 3 of them were submitted to successful redilatation.

CONCLUSION

We conclude that in selected cases, the procedure is safe and effective, and restenosis may be treated by percutaneous balloon redilatation.

Transcatheter occlusion of patent ductus arteriosus using coil embolization

We studied 31 procedures of coil embolization for occlusion of ductus arteriosus, attempted in 29 patients. The mean age was 4.8+/-3.4 years (1-16 years) and the mean diameter of ductus was 1.8+/-0.7 mm (0.8-3.1 mm). Femoral artery approach was used and aortogram in 90 degrees lateral view was performed. Through a Judkin right coronary catheter, the coil was delivered for occlusion of the ductus. In 5 cases, 2 coils were delivered using retrograde and anterograde techniques. Successful placement of coil was accomplished in 29 procedures. Coils 0.038 inch (diameter)-5 cm (length)-5 mm (helical diameter) (Cook, Inc) were used in 16 procedures, coils 0.035 inch-5 cm-5 mm in 9, coil 0.038 inch-8 cm-8 mm in 1, two coils 0.038 inch-5 cm-5 mm in 2, coils 0.038 inch-5 cm-5 mm+0.038 inch-5 cm-8 mm in 1, and 2 coils 0.035 inch-5 cm-5 mm in 2. Aortogram 20 min after the occlusion, showed residual shunt in 9. Coil migration occurred in a ductus type B in the following day. One patient developed severe haemolysis, due to a change in the coil position, 12 h after the procedure. Echodopplercardiogram 4 to 6 h after the procedure showed a residual shunt in 5 patients, 24 h after in 3 and 30 days after, in 1(3.8%). Heparin therapy started 10 days after occlusion of the ductus, caused reappearance of the shunt in 1 patient. This technique is simple and effective, but complications may occur hours or days after successful ductus occlusion.

Initial experience with balloon dilatation of supravalvar aortic stenosis

Primary balloon dilatation of supravalvar aortic stenosis was attempted in three patients: a 20 year old woman, a seven month old boy, and a 12 year old girl. Balloon catheters (Mansfield) with diameters of 25 mm, 8 mm, and 15 mm were used in the three patients respectively. The systolic pressure gradient across the aortic narrowing decreased considerably and the diameter of the constricted area increased significantly. Balloon dilatation was feasible and provided good immediate results and sustained relief of supravalvar aortic stenosis in these three patients. However, a larger study is needed to establish the place of this procedure in treatment.

[Diagnosis and therapeutic follow-up of patients with massive pulmonary emboli by two-dimensional echocardiography]

PURPOSE

The aim of the study was to analyse the role of 2D echocardiogram (ECHO) in the diagnosis of massive pulmonary embolism (PE), and in the follow-up after fibrinolytic or surgical treatment.

METHODS

Echocardiographic studies were retrospectively analysed in seven patients, 5 male, mean age 37 +/- 19 years, with massive pulmonary embolism (PE) confirmed by pulmonary angiography. Six of them were submitted to fibrinolytic therapy with IV streptokinase (SK), and one underwent surgery. The diagnosis of PE by ECHO was made by the detection of thrombi in the pulmonary vascular bed. ECHO measurements included the right ventricular diastolic diameter (RVDD), interventricular septal motion (IVS), acceleration time (AcT), and peak pulmonary artery pressure (PAP).

RESULTS

The ECHO study diagnosed thrombi in five out of seven patients (71%), mainly if they were present in the right main pulmonary artery (four cases -80%). It was also able to locate one out of five patients with thrombus in the right lobar artery and one out of two patients in the left main pulmonary artery; it was unable to identify six patients with involvement of the left lobar arteries. Four out of five patients with PE, diagnosed by ECHO, were submitted to fibrinolytic therapy, and one underwent surgery. The follow-up study showed dissolution of the thrombus in three of those with SK and in the one with surgical treatment. The initial ECHO study showed five out of 7 patients with increased RVDD, 5/7 patients with abnormal IVS motion, and all of them with decreased AcT (64 +/- 16 ms). The PSP was 64.4 +/- 22.8 mmHg by ECHO, versus 75.4 +/- 24.03 mmHg by angiography (r = 0.78; p = 0.11). There was a reduction of the RVDD (30 +/- 5.02 to 23 +/- 2.2) and an increased of the AcT (50 +/- 10.8 to 106.67 +/- 16) at the serial examination.

CONCLUSION

The ECHO study is an important tool for the diagnosis of PE, informing about pulmonary pressure, presence and position of thrombus, and treatment results.

[Salvage coronary angioplasty in a young patient with Takayasu arteritis and myocardial infarction]

A 16 year old boy with Takayasu's disease was admitted with myocardial infarction. Thrombolytic therapy with intravenous streptokinase showed no signs of reperfusion. Rescue angioplasty of the left descending coronary artery was performed with success.

[Double aortic arch associated with stenosis of left pulmonary artery]

Case report on a 6-year-old patient with vascular ring, due to double aortic arch. The patient was asymptomatic. The barium-filled esophagus showed bilateral indentations and a large posterior indentation. Echocardiographic study in notch suprasternal view revealed features of this pathology. The diagnosis was made by the cineangiocardiographic study that showed double aortic arch with separate carotid and subclavian arteries arising from each arch. The right arch was larger than the left, and the descending aorta was on the left side. There was severe left pulmonary artery stenosis associated. The clinical management was chosen, because the patient was asymptomatic.

[Transluminal coronary angioplasty combined with cardiomyoplasty in the treatment of coronary disease associated with dilated cardiomyopathy]

A 53-year-old white female candidate to cardiomyoplasty to control heart failure class III (NYHA). Submitted to coronary angioplasty, presented at the coronarography 75% obstruction of the left anterior descending (LAD) artery and at the left ventriculography diffuse and severe hypocontractility ejection fraction (EF) = 17%. After primary success of the coronary dilatation, she was operated on with a good surgical outcome. Six months after the surgery, she did well clinically (class II) and at the coronarography the LAD artery presented free from restenosis or progression of the disease and the left ventriculography showed improvement of the ventricular function (EF = 28%).

[Survival and predictive factors of late mortality in the surgical treatment of aortic stenosis]

PURPOSE

Study of 161 patients submitted to aortic valve replacement due to aortic stenosis to evaluate survival and predictive factors of late mortality.

METHODS

The mean age was 45.8 years +/- 13.2 and 122 patients were men. Surgical mortality was 6.8%. The survival actuarial curve showed 59.28% of the patients alive after 16 years. Among the survival 62.3% +/- 10% were event free, including prosthesis thrombosis, thromboembolism, infective endocarditis and reoperation. Symptoms, age, gradient LV/Ao, ejection fraction (EF) and the compliance (CO) were related to prognosis. Sudden death after surgery was studied, with incidence of the 0.8 events/100 patients year.

RESULTS

The asymptomatic patients had better evolution than symptomatic (p less than 0.05). The age above 60 years was not predictive of the prognosis in 10 years of follow-up, but no patients survived after 10 years. The gradient LV/Ao was not an important factor in the survival. The group with EF greater than 50% had 66.4% of survival, while the group with EF less than 50% survival was 39%. Normal or decreased compliance was not important in the survival. All patients with EF less than 50% always has decreased CO. Fifteen patients were dead due to heart failure and the most important predictive factor was the left ventricular dysfunction (p = 0.02).

CONCLUSION

In aortic stenosis: a) severe ventricular dysfunction does not preclude the surgical treatment; b) the actuarial analysis suggests that EF less than 50% determines worse prognosis and always occurs with decreased CO; c) the excellent evolution of the asymptomatic patients does not generalize the surgical treatment in this phase; d) the incidence of the sudden death was not high after the surgical treatment; e) patients with pre-operative left ventricular dysfunction had greater mortality due to heart failure, than patients with normal left ventricular function; f) despite of the morbid events our results confirm the real benefit of the surgical treatment in the aortic stenosis.

[Traumatic ventricular septal defect. A case report]

A 34 years old woman, without previous cardiac symptoms, suffered a closed thoracic trauma in a car accident. Three days after presented dyspnea and orthopnea. Physical examination revealed a systolic murmur consistent with ventricular septal defect (VSD). Doppler echocardiography and angiography confirmed the presence of a muscular VSD with severe left-to-right shunt. Surgical intervention was indicated and VSD closure was performed with a patch, through a right atrium approach. Third degree atrioventricular block developed after surgery and a definitive pacemaker was implanted. The patient is asymptomatic and without murmurs in postoperative follow-up.

Clinical and laboratory signs of reperfusion: are they reliable?

We studied 101 patients (88 men and 13 women, mean age 54.5 +/- 10 years) who arrived at the hospital during the first 6 hours of acute myocardial infarction evolution. Our objective was to assess the reliability of clinical and laboratory signs of recanalization using intravenous streptokinase as a thrombolytic agent. The mean time between the beginning of infusion and coronary arteriography was 53.83 +/- 43 hours. The positive predictive values for pain, arrhythmia, ST segment and enzymes were 97.9%, 94.2%, 91.8% and 90.8%, respectively; the negative predictive values were 46.8%, 40.8%, 37.2%, and 50% in the same order. Sensitivity was 65.7%, 62.8%, 58.4% and 77.6% and specificity 95.6%, 86.9%, 82.6% and 73.9%, respectively. The positive predictive value, calculated on the basis of the presence of each variable alone or in association showed a probability of recanalization of 76.9% for one sign, 84% for two, 96.3% for three and 100% for all four. When we compared the positive predictive values of each variable according to the interval between the beginning of pain and admission to the hospital (during the first 3 hours or between 3 and 6 hours) our results were 100%/94% for pain (P = NS), 97%/88% for arrhythmia (P = NS), 100%/75% for ST segment (P = 0.004), and 97%/80% for enzymes (P = 0.019). The same analysis applied to negative predictive values showing 22%/62% (P = 0.007), 17%/55% (P = 0.008), 21%/47% (P = NS), 27%/61% (P = NS) for pain, arrhythmia, ST segment and enzymes, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulmonary artery aneurysm. Report of 2 cases]

The clinical suspicion of pulmonary artery aneurysm was made in two patients from the clinical signs and radiographic features. The echocardiographic studies showed features concerned with this pathology, and hemodynamic studies confirmed the diagnosis by pulmonary angiography. Both patients presented pulmonary valve insufficiency due to the huge pulmonary artery and dilatation of the valvular annulus. Other congenital malformations of the heart and pulmonary hypertension were not present in these patients. Surgical treatment was indicated in both patients. Surgery in patient no. 2 consisted of resection of the main pulmonary artery aneurysm and replacement with a valved conduit bovine pericardium and anastomosed with a patch of bovine pericardium connecting the left and right pulmonary arteries. The postoperative period was uneventful.

[Gastric emptying in children. VI. Evaluation of the cumulative effect of the water low temperature]

A study was carried out on 12 male and female nursing infants suffering from different pathologies but showing no disorders of the gastrointestinal tract during the study. Each patient was submitted to three gastric emptying tests carried out at 24 hours intervals and denoted A, B and C. The test meal, administered through a nasogastric tube, consisted of distilled water containing phenolsulfonphthalein is label. In test A, the water was at room temperature (+/- 27 degrees C) both at the beginning of the test and 5 minutes later. In test B, the water was first at room temperature, and was followed 5 minutes later by cold water (+/- 4 degrees C). In test C, cold water was administered both at the beginning of the test and 5 minutes later. The results showed that cold water following a meal of water at room temperature (test B) caused a significant delay in gastric emptying. However, when administered after a previous meal of cold water (test C), cold water only caused a tendency towards inhibition of gastric emptying. The data permit us to conclude that administration of water at low temperature inhibits the process of gastric fluid emptying, but repeated administration of cold water does not cause a cumulative inhibitory effect, at least at the time interval studied here. We discuss the possible mechanisms involved in the effect of temperature on the gastric emptying process, as well as the implications of the results obtained.

[Gastric emptying in children. V. Effect of the replacement of glucose by sucrose in a solution for oral rehydration]

A study was carried out on 18 children of both sexes aged 3 to 32 months (median 8 months) and weighing 3440 to 9520 grams (median 5120 grams). Each child was submitted to three consecutive gastric emptying tests at 24 hour intervals, using three solutions of different composition. The children were divided into two groups: Group I: twelve children submitted to the gastric emptying test 10 minutes after the administration of the test meal; Group II: six children submitted to the gastric emptying test 30 minutes after the administration of the test meal. The hydrating solutions used in the study consisted of the basic electrolyte composition recommended by the World Health Organization, and only differed in terms of the amount of sugar added. Solution A contained 20 grams of glucose per liter, solution B, 20 grams of sucrose per liter, and solution C, 40 grams of sucrose per liter. Gastric retention, expressed as a percentage of the volume of the test meal, was similar for solutions A and C and significantly higher than for solution B in Group I. In Group II, gastric retention of solution B also tended to be lower than for solutions A and C, although no statistically significant differences were observed between the three solutions.(ABSTRACT TRUNCATED AT 250 WORDS)