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UNLABELLED: Very low birth weight preterm newborns weighing less than 1500 g were randomized to receive human milk supplemented with FM 85® or not. They have similar bone mineral content (BMC) at baseline, but, at the end of study, BMC was increasingly higher in the FM 85® group. INTRODUCTION: The purpose of this study is to evaluate the effectiveness of a human milk supplement (FM 85®; Nestlé, Vevey, Switzerland) developed for the purpose of improving nutrition, including bone mineralization, in very low birth weight preterm newborns. METHODS: Preterm infants weighing less than 1500 g at birth admitted to the neonatal intensive care unit of a university hospital were studied. During hospitalization, they were fed at least 50 % of human milk. Newborns with ≥20 days of age were randomly assigned to the intervention group (n = 19) to receive human milk supplemented with FM 85® or to a control group (n = 19) to receive human milk only. Anthropometric measurements, whole-body bone densitometry (DXA), and biochemical tests were performed at study entry and at the end of the study (shortly before discharge when the infant had reached 2000 g). RESULTS: There were no start- or end-of-study differences between the two groups, except for daily increase in length (p = 0.010). At baseline, both groups had similar BMC: 5.49 ± 3.65 vs. 4.34 ± 2.98 g (p = 0.39) for the intervention and control group, respectively. However, at the end of the study, BMC was higher in the intervention group: 10.3 ± 4.71 vs. 6.19 ± 3.23 g (p = 0.003). The mean increase in BMC during the observation period was 4.90 ± 4.46 g for the intervention group and 1.86 ± 3.17 g for the control group (p = 0.020). Serum alkaline phosphatase levels were higher in the control group (720 ± 465 vs. 391 ± 177 IU/L; p = 0.007). CONCLUSIONS: Our data suggest that supplementation of human milk with FM 85® leads to improved bone mineralization in very low birth weight preterm newborns.

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Injuries and deaths among children left unattended in motor vehicles are frequent and the rates are increasing. Injuries associated with motor vehicle power windows usually affect children, in particular children under 6 years of age. This case report is about a child who was asphyxiated because of a motor vehicle power window closing. She was rapidly resuscitated and recovered fully. A brief review of the literature, epidemiology, and preventive measures to avoid this type of injury is also presented.

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O objetivo deste trabalho é descrever sobre mecanismos da hiperglicemia e resistência à insulina na sepse grave e choque séptico, suas repercurssões em morbimortalidade nas Unidades de Tratamento Intensivo Pediátrico, assim como resultados e segurança do uso da insulina. Realizou-se revisão bibliográfica no banco de dados Medline no período de 1998 a 2005, utilizando os termos insulina, hiperglicemia, sepse e choque séptico. Estudos em adultos, relatam benefícios em mortalidade e morbidade com controle glicêmico estrito e uso de insulina. Os trabalhos envolvendo pacientes pediátricos, na maioria retros, apontam para resultados semelhantes. Os riscos de hipoglicemia não parecem significativos. Embora ainda não se disponha de evidências adequadas, parece prudente oferecer, aos pacientes pediátricos, controle glicêmico e uso de insulina quando necessário. Sugere-se protocolo clínico de controle glicêmico e uso da insulina nestes pacientes.

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PURPOSE: Based on our preclinic studies with autologous unfractionated bone marrow (AUBM) via coronary sinus with transitory occlusion, a clinic study in patients with chronic stable angina was designed. The objectives were to evaluate safety, tolerance and feasibility. METHODS AND MATERIALS: A multicenter prospective study with inclusion and exclusion criteria defined by an Independent Clinical Committee was carried out. Fourteen patients underwent transcoronary sinus administration of freshly aspirated and filtered AUBM (60-120 ml). Safety and tolerance were evaluated. Feasibility was evaluated with Seattle Angina Questionnaire (SAQ), Canadian Cardiovascular Society (CCS) angina classification (baseline-Day 180), myocardial perfusion (baseline-Day 90) with independent core laboratory and coronary angiography (baseline and Day 30). RESULTS: There were no changes in the safety and tolerance parameters. Preliminary clinical efficacy at Day 180 disclosed a significant improvement of 38%, evaluated by the SAQ. The CCS angina classification shows that the mean angina class was 3.0+/-0.55 at baseline and improved to 2.0+/-0.00 at Day 180 (P <.001). Semiquantitative radionuclide perfusion imaging (core lab) showed a significant improvement at Day 90 in 13/14 patients, with a mean improvement of 24% at rest (P <.01) and 33% at stress (P <.05). Coronary angiography showed more collateral vessels in 9/14 patients. CONCLUSIONS: We can conclude that AUBM via coronary sinus with transitory occlusion is tolerable and safe. Significant improvement in the myocardial perfusion at Day 90 and in the quality of life at Day 180 was observed.

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PURPOSE: The aim of the investigation is to study myocardial injury on pig model with two objectives: (1) feasibility of stimulating angiogenesis with fresh autologous bone marrow; (2) administration of the same fresh autologous bone marrow via coronary sinus with transitory occlusion. METHODS: A controlled study was done in animal model with three phases, in a study group of 12 pigs (bone marrow administration) as well as in control group of 4 pigs (saline administration). Phase 1-production of coronary stenosis and myocardial injury; Phase 2-two weeks later, administration of bone marrow through coronary sinus with 10 min occlusion in the study group and saline solution in the control group. Phase 3-two weeks later, histological staining with hematoxylin-eosin and inmunohistochemical staining with monoclonal antibody for smooth muscle alpha-actin were conducted on both study and control groups. RESULTS: The percentage of angionenesis observed in the study group was 91% and 0% in control group. Counting of positive actin in affected and control areas showed statistically significant differences in relation to both groups: study group (1.37 vs. 0.79) and control group (0.47 vs. 0.51). The percentage of mononuclear immature cells observed in the myocardium in the study group was 25% and in the control group was 0%. There was no increment in the coronary collateral circulation when comparing coronary angiography. CONCLUSIONS: Autologous bone marrow in animal model with experimental myocardial injury enhances angiogenesis, as well as vessels with smooth muscles. The transitory occlusion of the coronary sinus might be an effective way to administer cells as those from the bone marrow.

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OBJECTIVE: To describe the possible clinical and laboratory effects of exogenous surfactant instillation into the tracheal tube of a child with severe acute bronchiolitis undergoing mechanical ventilation. CASE REPORT: a 2-month-old girl with clinical diagnosis of acute viral bronchiolitis underwent mechanical ventilation. She required high positive inspiratory peak pressure (35 to 45 cmH(2)O) and high inspiratory fraction of oxygen (FiO(2) = 0.9), but showed no clinical response or improvement in the arterial blood gas analysis. An exogenous surfactant (Exosurf(R), Glaxo - 50 mg/kg) was used to facilitate the use of a less aggressive ventilatory strategy. RESULTS: Four hours after surfactant administration, it was possible to reduce the positive peak inspiratory pressure (PIP) from 35 to 30 cmH(2)O, and FiO(2) from 0.9 to 0.6; and to increase the positive end-expiratory pressure (PEEP) from 6 to 9 cmH(2)O. During this period the paO(2)/FiO(2) ratio increased from 120 to 266. At the end of 24 hours, FiO(2) could be reduced to 0.4. DISCUSSION: Surfactant inactivation may be a decisive factor in the unfavorable evolution of some severe cases of acute bronchiolitis. The tracheal instillation of exogenous surfactant, in these cases, allows us to adopt less aggressive ventilatory strategies, and promotes rapid clinical responses.

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OBJECTIVE: To analyze the short-term effects of prone positioning on the oxygenation of mechanically-ventilated children suffering from severe hypoxemia. MATERIALS AND METHODS: A prospective, nonrandomized trial (each patient as his/her own control) was conducted between July 1998 and July 1999. Mechanically-ventilated children with peak inspiratory pressure greater than or equal to 30 cm H(2)O, FiO(2) greater than or equal to 0.5, and PaO(2)/FiO(2) ratio less than or equal to 200 were included in the study. Each patient was kept in the prone position for two hours, returning to the supine position after this period. Oxygenation was assessed by means of PaO(2)/FiO(2) in the supine position (one hour before prone positioning), one hour after prone positioning, and one hour after returning to the supine position. Patients who presented an increase of at least 20 in PaO(2)/FiO(2) were considered responsive. The results were compared by Student t-test, Friedman test, chi-square test, Fishers exact test, and confidence interval. RESULTS: Eighteen children (10 males), whose mean age was 11.5 -/+11.5 months, with initial PaO(2)/FiO(2) of 96.06 -/+ 41.78, participated in the study. After one hour in the prone position, 27.7% of the patients (5/18) improved their PaO(2)/FiO(2) ratio (P=0.045). Six of these patients presented reduced lung compliance (four of them had acute respiratory distress syndrome); and twelve patients showed increased airway resistance (six of them presented bronchiolitis). No significant difference was observed between these two groups (reduced lung compliance x increased airway resistance) in terms of age, sex, duration of ventilation prior to change in position, peak inspiratory pressure, FiO(2), severity of hypoxemia, and outcome. CONCLUSION: Prone positioning during mechanical ventilation of children with severe hypoxemia may improve the PaO(2)/FiO(2) ratio in the first hour.

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OBJECTIVE: To study the efficacy of intravenous magnesium sulfate and intravenous salbutamol in the treatment of severe asthma in children. METHODS: Randomized, double-blind, placebo-controlled clinical trial, including children above 2 years of age with severe acute asthma admitted to the observation ward of the Pediatric Intensive Care Unit of Hospital São Lucas. All patients received conventional treatment (oxygen, corticoids, beta-adrenergics) on admission, and later received one of the following solutions: a) IVMg (50 mg/kg); b) intravenous salbutamol (1 micro g/kg); c) saline solution. Clinical assessments, electrolyte concentration, and arterial blood gas analyses were recorded before intravenous infusion and one hour after that. RESULTS: Fifty patients participated in this study (of whom 53% were females, mean age = 4.5 years). There were no significant differences among the three groups. The group that received IVMg presented lower blood pressure during administration, which reached normal levels one hour afterwards, along with an increase in serum magnesium (P<0,001) and serum pH, and reduction of PaCO(2). The group that received intravenous salbutamol had lower respiratory rate (P=0.05) and higher blood pressure (P=0.01), and one hour after administration, these patients showed decreased respiratory rate (P=0.02); lower levels of serum potassium (P=0.009); higher pH, and reduced PaCO(2). This group required fewer nebulizations (P=0.009), fewer nebulizations per day (P<0.001) and less oxygen therapy than the IVMg and placebo groups. Acidosis was more persistent (P<0.01) in the placebo group. No difference as to the length of hospital stay was observed in any of the three groups. Artificial ventilation was necessary in 10% of the patients. CONCLUSIONS: The early intravenous administration of magnesium sulfate, especially salbutamol, achieved a rapid clinical response with excellent prognosis and no significant side effects.

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An experimental development based on the combination of microwaves action with one of the methods of silver staining by Del Río Hortega is presented. Material from pathological tissues and culture of fungi were studied. Besides morphological studies, were considered the causes of reduction from ionic to metalic silver, some characteristics of the silver reagent and its relationship with histochemical constitution of cellular walls. It is pointed the rapidity in fungi demonstration, the satisfactory definition of affected tissues, the advantages of working with a stable reagent, the omission of carcinogenetic substances, the possibility of stain fungical structures in previously stained materials with anilinic techniques, and the extent of the method to cultured materials without necessity of previous formaldehidic fixation.

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An experimental development based on the combination of microwaves action with one of the methods of silver staining by Del Río Hortega is presented. Material from pathological tissues and culture of fungi were studied. Besides morphological studies, were considered the causes of reduction from ionic to metalic silver, some characteristics of the silver reagent and its relationship with histochemical constitution of cellular walls. It is pointed the rapidity in fungi demonstration, the satisfactory definition of affected tissues, the advantages of working with a stable reagent, the omission of carcinogenetic substances, the possibility of stain fungical structures in previously stained materials with anilinic techniques, and the extent of the method to cultured materials without necessity of previous formaldehidic fixation.

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OBJECTIVES: (a) to evaluate the effect on oxygenation and ventilation of rabbits with induced surfactant depletion when they are submitted to a conventional mechanical ventilation, plus a small dose of exogenous surfactant; (b) to compare this group with another group submitted to a High Frequency Oscillation (HFO) without exogenous surfactant administration.METHODS: Twenty New Zealand White rabbits weighing (-/+ 3 kg) were anaesthetized and artificially induced to a endogenous surfactant depletion by successively lung lavage with normal saline (aliquots of 25 ml/kg) until to reach a persistent PaO(2) less than 100 mmHg when submitted to a mechanical ventilation in a pressure control mode with a target tidal volume of 10ml/kg, PEEP of 5cm H(2)O, FiO(2) 1.0, respiratory rate 30/min, and inspiratory time of 0.65 s. Then the rabbits were divided in (a) CMV+S group, submitted to a conventional mechanical ventilation plus exogenous surfactant replacement; (b) HFO group, submitted to a High Frequency Oscillation Ventilation. Arterial blood gases were measured at control period, post lung lavage, 15, 16 and 120 minutes after treatment started. The groups were compared using Student t test.RESULTS: The post lung lavage PaO(2) in both groups was lower than 50mmHg (p=0.154), increasing after 15 min of treatment to 254 mmHg (CMV+S) and 288 mmHg (HFO, p=0.626). The PaO(2) at 60 and 120 minutes were higher (p=0.001) in the HFO group (431 e 431 mmHg) when compared with the CMV+S group, which showed a progressive fall (148 e 126 mmHg). At 60 minutes of treatment, the PaCO(2) was lower (p=0.008) in the CMV+S group (29 versus 41 mmHg).CONCLUSIONS: In ARDS animal model a protect mechanical ventilation strategy as HFO by itself promotes a fast and persistent increase in the oxygenation, with superior levels than those observed in animals treated with conventional mechanical ventilation plus exogenous surfactant replacement.

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OBJECTIVE: To study the distribution of Tc-99m DTPA radioaerosol when heliox or oxygen are used in the nebulization of children and adolescents with chronic obstructive pulmonary disease during pulmonary ventilation scintigraphy. MATERIAL AND METHODS: Clinical randomized and controlled trial. Patients with chronic obstructive pulmonary disease (5 to 18 years old) who required pulmonary scintigraphy between March 1996 and September 1998 were included. Obstruction of the lower airway was measured by spirometry. Patients were randomized into two groups according to the gas used for nebulization during scintigraphy: heliox (80% helium and 20% oxygen) or oxygen. Scintigraphy studies were expressed as slope of the cumulative pulmonary radioactivity uptake curve and as the maximal cumulative radioactivity in the lung. The mean diameter of the Tc-99m DTPA particles generated by heliox and oxygen was measured by laser diffraction. RESULTS: Ten patients were allocated in each group. There were no statistical differences (P>0.05) in terms of gender, main diagnosis, signs of malnutrition, mean values of weight, height, body area, or spirometry results. The mean slope in the heliox group (5,039-/+1,652) was significantly different (P=0.018) from the mean slope of the oxygen group (3,410-/+1,100). The mean slope of patients with severe airflow obstruction in the heliox group was statically different (P=0.017) from the mean slope of patients with airflow obstruction in the oxygen group. In both groups, patients without evidence of airflow obstruction were similar in terms of mean slopes (P=0.507) and mean cumulative radiation in the lung (P=0.507). The mean diameter of heliox-generated Tc-99m DTPA particles was 2.13 m (-/+0.62). This was statistically different (P=0.004) from the mean diameter of oxygen-generated particles (0.88-/+0.99 m). CONCLUSIONS: Nebulization with heliox was more efficacious than nebulization with oxygen for distribution and dispersion of Tc-99m DTPA radioaerosol in the lungs of children and adolescents with chronic obstructive pulmonary disease submitted to ventilation scintigraphy. The benefits of heliox over oxygen are more evident in the presence of lower airway obstruction. Without airway obstruction, we did not observe any difference in the distribution and dispersion of radioaerosol in the lungs. Although the mean diameter of the Tc-99m DTPA particles generated by heliox and oxygen was significantly different, the particles generated by both gases were still within the recommended range (between 1 and 5 m). Therefore, this difference does not account for the effects of heliox observed in this study.

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An experimental development based on the combination of microwaves action with one of the methods of silver staining by Del RÝo Hortega is presented. Materials from normal and pathological tissues were studied. The stuff were fixed in 10 formalin and received a paraffined embedding. The impregnation was made with ammoniacal silver carbonate in a domestic microwave oven during twelve seconds at 375 w. As a result of this, a time shortage of the technique, the high degree of definition of the nuclear, cytoplasmatic and extracellular matrix (collagenus fibbers with an unsteady reticular representation) details and the easy visualization of mitosis was observed. Also, omitting the reduction, they were clearly evidenced the argirophilics granules (melanin pigment)

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An experimental development based on the combination of microwaves action with one of the methods of silver staining by Del RYo Hortega is presented. Materials from normal and pathological tissues were studied. The stuff were fixed in 10 formalin and received a paraffined embedding. The impregnation was made with ammoniacal silver carbonate in a domestic microwave oven during twelve seconds at 375 w. As a result of this, a time shortage of the technique, the high degree of definition of the nuclear, cytoplasmatic and extracellular matrix (collagenus fibbers with an unsteady reticular representation) details and the easy visualization of mitosis was observed. Also, omitting the reduction, they were clearly evidenced the argirophilics granules (melanin pigment)

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OBJECTIVE: Review the theoretical bases of the therapeutic approach for volumetric resuscitation of the infant in shock and the evolutionary process that take to the pharmacological support to the circulationMETHODS: References were obtained from computerized searches on the National Library of Medicine (Medline), recent review articles and personal files. RESULTS: Shock and septic shock is the leading cause of mortality in critically ill patients. The septic shock is an extremely complex disease process leading to progressive multiple organ failure. Its presentation may be subtle or catastrophic. Successful management depends on an understanding of the pathophysiology of the syndrome, allowing rapid, appropriate resuscitation. Treatment often requires aggressive correction of volume deficit, maintenance of adequate perfusion pressure with inotropic and vasopressor, mechanical ventilation and others therapies. CONCLUSIONS: The management of the shock in children presents a challenge for the pediatrician. Hemodynamic and respiratory instability should be anticipated. Management requires multisystemic and careful intervention.

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OBJECTIVE: Review the theoretical bases on the maintenance of the acid-basic balance, the pathophysiology of the disturbances and its therapeutics in the child.METHODS: References were obtained from computerized searches on the National Library of Medicine (Medline), recent review articles and personal files.RESULTS: Acid-basic disturbances are frequently found in critical ill children. Their pathophysiology and main causes are a complex and multifactorial process. The management depends on precocious diagnosis and of the understanding of the base cause. The treatment should be adjusted for each disturbance and its base cause. Frequently it requests an aggressive correction and continuous monitoring.CONCLUSIONS: The knowledge of the physiology of the acid-basic balance as well as the understanding of the pathophysiology of the main disturbances associated to the clinical situations represent a challenge for the pediatrician. The management of acid-basic balance demands appropriate and careful intervention.

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An experimental development based on the combination of microwaves action with one of the methods of silver staining by Del Río Hortega is presented. Materials from normal and pathological tissues were studied. The stuff were fixed in 10% formalin and received a paraffined embedding. The impregnation was made with ammoniacal silver carbonate in a domestic microwave oven during twelve seconds at 375 w. As a result of this, a time shortage of the technique, the high degree of definition of the nuclear, cytoplasmatic and extracellular matrix (collagenus fibbers with an unsteady reticular representation) details and the easy visualization of mitosis was observed. Also, omitting the reduction, they were clearly evidenced the argirophilics granules (melanin pigment).

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