A critical review and update on autoimmune encephalitis: understanding the alphabet soup / Revisão crítica e atualizações em encefalites autoimunes: entendendo a sopa de letrinhas

ABSTRACT Autoimmune encephalitis (AE) comprises a group of diseases mediated by antibodies against neuronal cell surface or synaptic antigens, such as ion channels or neurotransmitter receptors. New clinical syndromes and their associated antibodies were and are still being characterized over the last two decades. The fact that their main clinical features are interdisciplinary, - encompassing neuropsychiatric symptoms, cognitive dysfunction, epileptic seizures, movement and sleep disorders - has led to a surge of interest in this field. Some of these diseases present with a well-defined syndrome, being recognizable on clinical grounds. Correct diagnosis is important since AE are potentially treatable diseases, despite their severity. On the other hand, an increasing number of neuronal antibodies being described casts doubt upon the way we should utilize antibody testing and interpret results. In this article we review, summarize and update the current knowledge on antibody mediated encephalitis.

RESUMO As encefalites autoimunes compreendem um grupo de doenças mediadas por anticorpos contra antígenos de superfície neuronal ou sinapse, como canais iônicos ou receptores de neurotransmissores. Novas síndromes clínicas e os anticorpos a elas associados foram e ainda estão sendo caracterizados ao longo das últimas duas décadas. Dado que suas principais características clínicas são interdisciplinares, isto é, incluem -se sintomas neuropisquiátricos, disfunção cognitiva, crises epilépticas, distúrbio do movimento e do sono, há uma grande onda de interesse sobre esse campo de conhecimento. Algumas dessas doenças apresentam-se com uma síndrome bem definida, sendo possível reconhecê-las clinicamente. Diagnosticá-las corretamente é importante uma vez que se trata de doenças potencialmente tratáveis apesar da gravidade que lhes é característica. Por outro lado, o número crescente de anticorpos sendo descritos causam dúvida frequente sobre qual o melhor teste a solicitar e como interpretá-los. Nós aqui apresentamos uma revisão atualização resumida do conhecimento atual sobre as encefalites mediadas por anticorpos.

What's new in insomnia? Diagnosis and treatment / Quais a novidades em insônia? Diagnóstico e tratamento

ABSTRACT Although, insomnia is one of the most common diseases that health professionals face in their practice, it receives little attention in medical training. Diagnosis is based on a careful history taking, and physicians must be aware of the diagnostic criteria. Insomnia should not be considered a symptom, but a comorbid condition. Although cognitive behavioral therapy (CBT) has been the mainstay treatment for insomnia for many years, it is usually regarded as a novel therapeutic strategy, both because of scarcity of qualified psychologists and of limited knowledge about insomnia among physicians. GABA receptor acting drugs are being abandoned in the treatment of insomnia because of abuse and dependence potential and accident risk. Two main current therapeutic options with the best scientific evidence are the tricyclic antidepressant, doxepin, and a new melatoninergic receptor agonist, ramelteon. Newer drugs to treat insomnia are in the pipeline. Hypocretine blocking agents will be marketed in the near future.

RESUMO Embora a insônia seja uma das doenças mais comuns encontrada por profissionais de saúde em sua prática quotidiana, está ainda é negligenciada nos currículos médicos. O diagnóstico baseia-se em anamnese cuidadosa e os médicos devem conhecer os critérios diagnósticos. A insônia não deve ser considerada apenas um sintoma, mas uma comorbidade. Apesar de a terapia cognitivo comportamental (TCC) para insônia ser a principal opção terapêutica há muito anos, esta modalidade terpêutica ainda é considerada uma nova estratégia pela escassez de psicólogos qualificados e pelo desconhecimento médico acerca da insônia. Os fármacos que atuam nos receptores GABA vêm sendo abandonados no tratamento da insônia devido ao potencial de abuso e dependência e pelo risco de acidentes. As duas principais opções terapêutica para insônia com melhor evidência científica são um antigo antidepressivo tricíclico, a doxepina, e um novo agonista do receptor melatoninérgico, a ramelteona. Novas drogas para insônia estão em processo de aprovação regulatória e comercialização. As mais próximas de serem liberadas para o mercado são as drogas bloqueadoras do sistema da hipocretina.

Vestibular migraine / Migrânea vestibular

ABSTRACT Vestibular migraine (VM) remains an underdiagnosed condition, often mistaken with brainstem aura. VM is defined by recurrent vestibular symptoms in at least 50% of migraine attacks. Diagnosis is established by clinical criteria based on the International Classification of Headache Disorders (ICHD-3). Estimated prevalence of VM is 1 to 2.7% of the adult population. Vestibular symptoms usually appear after the headache. VM pathophysiology remains poorly understood. Vertigo may occur before, during, after the migraine attack, or even independently, and may last seconds to hours or days. Pathophysiological mechanisms for VM are still poorly understood and are usually extrapolated from migraines. Differential diagnoses include Ménière's disease, benign paroxysmal positional vertigo, brainstem aura, transient ischemic attack, persistent perceptual postural vertigo, and episodic type 2 ataxia. Specific treatment recommendations for vestibular migraine are still scarce.

RESUMO Migrânea vestibular (MV) é pouco diagnosticada e comumente confundida com aura de tronco. A MV, definida por sintomas vestibulares recorrentes em até 50% das crises de migrânea. O diagnóstico baseia-se em critérios clínicos, descritos no International Classification of Headache Disorders (ICHD-3). Estima-se prevalência de MV em 1 a 2.7% da população adulta. Sintomas vestibulares geralmente ocorrem mais tardiamente comparados à cefaleia. A vertigem pode surgir antes, durante, depois, ou mesmo independentemente da crise de enxaqueca, com duração de segundos a horas ou dias. Pouco se conhece acerca da fisiopatologia da MV, que é geralmente extrapolada dos conhecimentos sobre migrânea. Diagnósticos diferenciais incluem: Doença de Ménière, Vertigem posicional paroxística benigna, aura de tronco, ataque isquêmico transitório, vertigem postural perceptual persistente e ataxia episódica tipo 2. Especialistas recomendam o mesmo tratamento que para enxaqueca. Estudos sobre o tratamento específico da migrânea vestibular ainda são escassos.

Cannabidiol and epilepsy in Brazil: a current review / Canabidiol e epilepsia no Brasil: uma revisão atual

ABSTRACT Background: Cannabidiol (CBD) has become a promising therapeutic option in the treatment of epilepsy. Recent studies provide robust evidence that CBD is effective and safe. Limitations in current knowledge and regulatory issues still limit CBD use. CBD use regarding epilepsy types still lacks clear guidelines. Objective: To critically review the main current pharmacological features and clinical issues regarding CBD use in epilepsy, to provide current regulatory background regarding CBD use in Brazil, and to suggest a practical CBD therapeutic guide in Brazil. Methods: Non-systematic literature review (up to February 2022) of current concepts of CBD and epilepsy, including the authors' personal experience. Results: Five pivotal trials have led to CBD approval as an adjunctive treatment for Dravet and Lennox-Gastaut syndromes, and for the tuberous sclerosis complex. Efficacy of CBD in other drug-resistant epilepsies remains not completely understood. CBD adverse event profile and drug interactions are better understood. CBD is well tolerated. In Brazil, CBD is not classified as a medication, but as a product subject to a distinct regulatory legislation. CBD is still not offered by the National Brazilian health system, but can be purchased in authorized pharmacies or imported under prescription and signed informed consent. Conclusion: CBD is a recognized novel treatment for epilepsy. Future well-designed studies and public health strategies are needed to offer widespread access to CBD, and to improve the quality of life of people living with epilepsy in Brazil.

RESUMO Antecedentes: O canabidiol (CBD) é uma terapêutica promissora no tratamento da epilepsia. Estudos recentes trouxeram evidências robustas sobre a eficácia e segurança do CBD. Lacunas no conhecimento atual e questões legais limitam seu uso. Não há consenso sobre o manejo do CBD nos diferentes tipos de epilepsia. Objetivo: Revisar criticamente os principais aspectos farmacológicos e clínicos atuais do uso do CBD em epilepsia e sugerir um guia terapêutico prático no Brasil. Métodos: Revisão não-sistemática da literatura até fevereiro de 2022 de conceitos atuais sobre CBD e epilepsia, associado a experiência dos autores. Resultados: Cinco estudos principais levaram à aprovação do CBD como tratamento adjuvante nas síndromes de Dravet, Lennox-Gastaut e na esclerose tuberosa. A eficácia em outras epilepsias fármaco-resistentes ainda não está bem estudada. Eventos adversos e interações medicamentosas são comuns. O CBD é bem tolerado. No Brasil, o CBD não é classificado como medicamento, mas como produto sujeito a diferente regras regulatórias. O acesso ao CBD ainda é restrito, e este não é fornecido pelo sistema público de saúde brasileiro. O CBD pode ser adquirido no Brasil em farmácias autorizadas ou por importação, sob prescrição especial e termo de consentimento informado. Conclusão: O CBD é uma realidade no tratamento da epilepsia. Estudos futuros e políticas públicas são necessários para permitir amplo acesso do CBD melhoraria da qualidade de vida de pessoas com epilepsia no Brasil.

Official Position of the Brazilian Association of Bone Assessment and Metabolism (ABRASSO) on the evaluation of body composition by densitometry—part II (clinical aspects): interpretation, reporting, and special situations

Abstract Objective: To present an updated and evidence-based guideline for the use of dual-energy x-ray absorptiometry (DXA) to assess body composition in clinical practice. Materials and methods: This Official Position was developed by the Scientific Committee of the Brazilian Association of Bone Assessment and Metabolism ( Associação Brasileira de Avaliação Óssea e Osteometabolismo , ABRASSO) and experts in the field who were invited to contribute to the preparation of this document. The authors searched current databases for relevant publications in the area of body composition assessment. In this second part of the Official Position, the authors discuss the interpretation and reporting of body composition parameters assessed by DXA and the use of DXA for body composition evaluation in special situations, including evaluation of children, persons with HIV, and animals. Conclusion: This document offers recommendations for the use of DXA in body composition evaluation, including indications, interpretation, and applications, to serve as a guiding tool in clinical practice and research for health care professionals in Brazil.

Postural balance, handgrip strength and mobility in Brazilian children and adolescents with osteogenesis imperfecta

Abstract Objective To describe postural balance, handgrip strength and mobility in children and adolescents with different types of osteogenesis imperfecta. Methods Cross-sectional study. Fifty selected subjects diagnosed with types I (n = 11), III (n = 21), and IV (n = 18), followed up at Brazilian reference center for osteogenesis imperfecta in the Midwest region, aged 2-21 years (9.2 ± 5.0), were enrolled in this study. Children and adolescents were evaluated for postural balance in the upright position with eyes-open and eyes-closed conditions, handgrip strength and the mobility domain (Pediatric Dysfunction Assessment Inventory). Data normality and difference between groups was verified. Results Handgrip strength was significantly lower in people with type III of osteogenesis imperfecta when compared to the osteogenesis imperfecta types I and IV, and to the age-specific reference data. Center of pressure length and mean velocity in the condition with eyes closed were worse compared to the open-eyes condition for children and adolescents with type I of osteogenesis imperfecta. There were worse results in the mobility domain for the participants classified with the most severe type of osteogenesis imperfecta. Conclusions It was observed that the severity of the osteogenesis imperfecta disease affected handgrip strength and locomotor function assessed by the mobility domain. Comparing osteogenesis imperfecta types, the higher the severity of osteogenesis imperfecta, the lower the handgrip strength. These results can contribute to new strategies of treatment focused on improving functional capacity and quality of life in people with osteogenesis imperfecta.

Biópsia de linfonodo sentinela para melanoma cutâneo na vida real: análise de 47 casos tratados em clínica privada no Brasil / Sentinel lymph node biopsy for cutaneous melanoma in a real life setting: analysis of 47 cases treated at a private clinic in Brazil

Introdução: O status do linfonodo sentinela (LNS) tem se mostrado o mais importante fator prognóstico independente no melanoma cutâneo (MC) em estágio I-II. Poucos artigos sobre MC em clínicas privadas (CP) estão disponíveis. Objetivo: Apresentar dados clínicos e histológicos, complicações e frequência de envolvimento do LS em pacientes com MC acompanhados em CP de dermatologia/oncologia cutânea em São Paulo/Brasil, submetidos a biópsia de LS (BLNS). Métodos: Coorte retrospectiva e unicêntrica de pacientes atendidos em CP de junho/1998 a janeiro/2020. Prontuários eletrônicos foram analisados. O período mínimo para considerar paciente elegível foi de um ano. Resultados: Identificamos 215 MC em 184 pacientes (1,2 melanoma/paciente). No total, 47 pacientes (25,5%) foram submetidos à BLNS e 59 LN à exame histológico (1,2 LNS/paciente), sendo que 10,9% foram positivo. A identificação do LNS ocorreu em 95,7%. Dezoito (72,0%) das 25 lesões do tronco drenavam para cadeias únicas, enquanto em 7 pacientes drenavam para cadeias múltiplas. A taxa de complicação foi de 6,0%. Conclusão: O percentual de pacientes com MC submetidos a BLNS, positividade de LS, cadeias de drenagem e complicações neste estudo foram semelhantes aos estudos em pacientes do hemisfério norte. As características clínicas e epidemiológicas dos pacientes com MC diferem acentuadamente entre os pacientes de CP e do serviço público de saúde.

Background: Sentinel Lymph Node (SLN) status has been shown to be the strongest independent prognostic factor of cutaneous melanoma (CM) stage I-II patients. Few papers on CM at private clinics (PC) are available. Objective: To present clinical and histologic data, complications and frequency of SLN involvement in CM patients diagnosed and followed at a dermatology/cutaneous oncology PC in São Paulo/Brazil, who were submitted to SLNB. Methods: Retrospective, single-center cohort of patients who attended PC from June 1998 to Jan 2020. Electronic files were selected and analyzed. Minimum period for considering the patient eligible was 1 year. Results: 215 CM lesions were identified in 184 patients(1.2 melanoma/patient). Forty-seven patients (25.5%) were submitted to SLNB and 59 SLN for histologic examination (1.2 SLN/patient). 10,9% tested positive. SLN identification happened in 95.7%. In 38/47 (80,8%) patients single LBD was found, while multiple-LBD was found in 9/47(19.1%). Eighteen(72,0%) out of 25 trunk lesions drained to single basins, while in 7 patients multiple LBD was found. Complication rate was 6,0%. Conclusion: Percentage of CM patients that undergo SLNB, node positivity for metastasis, draining basins and complications in this study were similar to studies in northern hemisphere patients. Clinical and epidemiologic characteristics of CM patients differ markedly between PC and PHS patients.

Medical students with performance difficulties need wide support: Initial results of an academic tutoring program

BACKGROUND: Even students with previous academic success may face challenges that affect their academic performance. Many medical schools offer programs to students at the risk of academic failure, to ensure that they succeed in the course. OBJECTIVE AND METHODS: In this report we describe a pioneering academic tutoring program developed at a Brazilian medical school and discuss the initial results of the program based on the feedback from tutors and data regarding the progression of students in the medical course. RESULTS: In 2018, 33 students enrolled into the program. Students' performance difficulties were mainly associated with mental health problems and socioeconomic vulnerability. Of the 33 students, 27 (81.8%) were assisted by the Mental Health Support Service and 16 (48.5%) were assisted by the Social Assistance Service. In addition to the planning academic activity class load, tutors were able to assist students in solving socioeconomic issues, carrying out personal support interventions with the promotion of self-esteem, and presenting suggestions for behavioral changes in their routine. For most students (72%), the action plan proposed by the tutors was successful. Eight of the 14 (57%) students in the fourth year progressed to the final two years of in-hospital practical training (internship). CONCLUSIONS: The Academic Tutoring Program showed positive results for most of the students. Close monitoring and tutor intervention allowed students with poor academic performance to overcome the low performance cycle. These important tasks demand time and energy from tutors, and institutional recognition of these professionals is essential for the successful maintenance of the program.

Cetoacidose diabética e pancreatite secundárias à peg-asparaginase / Diabetic ketoacidosis and pancreatitis secondary to peg-asparaginase

RESUMO: Objetivos: Apresentar um caso raro de cetoacidose diabética (CAD) e pancreatite secundários ao uso de PEG-asparaginase em paciente pediátrico em tratamento para leucemia linfoblástica aguda (LLA) e alertar quanto aos sinais que remetem a esses diagnósticos. Descrição do caso: Adolescente do sexo feminino, 10 anos e 11 meses, em tratamento para LLA e uso prévio de PEG-asparaginase há seis dias da internação, admitida com choque hipotensivo grave e encaminhada à Unidade de Terapia Intensiva. Inicialmente o quadro foi interpretado como choque séptico. Em seguida a anamnese detalhada e os exames laboratoriais direcionaram para os diagnósticos de CAD e pancreatite, iniciando-se as intervenções específicas. Recebe alta hospitalar após 30 dias, sem necessidade de insulinoterapia, mas com reposição de enzimas pancreáticas. Comentários: Geralmente, às crianças com LLA gravemente enfermos e leucopênicos, atribui-se apenas o diagnóstico de sepse, que é um diagnóstico prioritário. Entretanto, no grupo em uso de PEG-asparaginase, o pediatra emergencista deve estar alerta ao raciocínio diferencial envolvendo CAD e pancreatite, o que pode ser bem difícil inicialmente. O alerta dos diagnósticos diferenciais do choque séptico, mesmo que raros, na assistência a pacientes oncológicos pediátricos, além da correta e pronta identificação do quadro e seu manejo apropriado, correlacionam-se diretamente ao sucesso terapêutico e, em algumas situações, à sobrevivência do paciente. (AU)

ABSTRACT: Objectives: We present a rare case of diabetic ketoacidosis (DKA) and pancreatitis secondary to the use of PEG-asparaginase in a pediatric patient being treated for acute lymphoblastic leukemia (ALL) and draw attention to the signs that refer to these diagnoses. Case description: A female adolescent, aged 10 years and 11 months, undergoing treatment for ALL, used PEG-asparaginase for 6 days prior to admission. She was hospitalized due to severe hypotensive shock and was then referred to the intensive care unit. Initially, the clinical condition was interpreted as septic shock. However, detailed anamnesis and results of laboratory tests led to the diagnoses of DKA and pancreatitis; hence, appropriate interventions were initiated. She was discharged after 30 days without the need for insulin therapy but received pancreatic enzyme replacement therapy. Comments: Generally, diagnosing severely ill and leukopenic children with ALL is only attributed to sepsis, which is a priority diagnosis. However, in the group treated with PEG-asparaginase, the pediatric emergency specialist should consider differential reasoning in patients with DKA and pancreatitis, which can be quite difficult to assess initially. Alertness towards the differential diagnoses of septic shock, although rare, in the care of pediatric oncology patients, in addition to the correct and prompt identification of the condition and provision of appropriate management, directly correlates with treatment success and, in some situations, the improvement in patient's survival. (AU)

Acute Disseminated Encephalomyelitis in COVID-19: presentation of two cases and review of the literature / Encefalomielite disseminada aguda associada a COVID-19: relato de dois casos e revisão de literatura

ABSTRACT Background: Neurological manifestations of COVID-19 are still incompletely understood. Neurological manifestations may be due to direct viral effect on neurons and glial cells, to an immune-mediated response to the virus, or to a hypercoagulable state and associated endothelial damage, as well as to severe systemic disease with prolonged intensive care unit stay. Objective: To describe two patients with severe SARS-CoV-2 infection and delayed recovery of consciousness after sedation withdrawal, in whom MRI disclosed multifocal white matter brain lesions, compatible with the diagnosis of acute disseminated encephalomyelitis. Methods: Observational report of two cases of severe COVID-19 infection in patients from two tertiary hospitals in São Paulo, Brazil. Results: These patients underwent neurologic and systemic evaluation for delayed awakening after sedation withdrawal. MRI displayed multifocal centrum semiovale lesions, suggestive of demyelinating inflammation. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for SARS-CoV-2 was negative in both cases. Conclusion: A recurrent pattern of multifocal white matter lesions can occur in COVID-19 patients, possibly associated with delayed awakening. Additional studies are necessary to elucidate the role of the viral infection and of inflammatory and immune-mediated associated changes in neurological manifestations of COVID-19.

RESUMO Introdução: As manifestações neurológicas causadas pela COVID-19 ainda não estão completamente elucidadas. O comprometimento neurológico pode decorrer de um efeito viral direto em neurônios ou em células gliais, a efeito imunomediado em resposta à infecção viral, ou de um efeito secundário a estados de hipercoagulabilidade e danos endoteliais, assim como decorrente de complicações sistêmicas graves relacionadas a cuidados intensivos prolongados na unidade de terapia intensiva. Objetivo: Descrever dois pacientes com recuperação tardia do nível de consciência após a retirada da sedação associados à infecção grave pelo SARS-CoV-2, que apresentaram lesões multifocais de substância branca, compatíveis com o diagnóstico de encefalomielite disseminada aguda. Métodos: Estudo observacional, com relato de dois casos de infecção grave pela COVID-19, em dois hospitais terciários na cidade de São Paulo, Brasil. Resultados: Os pacientes foram submetidos à investigação sistêmica e neurológica para avaliação de estado alterado de consciência após retirada de sedação. A ressonância magnética de crânio evidenciou lesões multifocais no centro semioval, sugestivos de processo inflamatório desmielinizante. Análise liquórica evidenciou PCR negativo para SARS-CoV-2 em ambos os casos. Conclusão: Lesões multifocais de substância branca podem ocorrer em pacientes com COVID-19, possivelmente associadas a estados alterados de consciência. Estudos adicionais são necessários para determinar o processo fisiopatológico da infecção viral e dos estados inflamatórios e imunomediados na gênese das manifestações neurológicas causadas pela COVID-19.

Intensity of pain, disability and psychosocial factors in women with chronic pelvic pain: cross-sectional study / Intensidade da dor, incapacidade funcional e fatores psicossociais em mulheres com dor pélvica crônica: um estudo transversal

ABSTRACT BACKGROUND AND OBJECTIVES: Chronic pelvic pain can be considered one of the main causes of morbidity and functional disability in women. The influence of psychosocial factors on chronic pelvic pain has been little explored in the literature. This study sought to characterize the profile of chronic pelvic pain in women, the presence of psychosocial factors and the association with pain and disability. METHODS: This cross-sectional study included women with chronic pelvic pain. Data on pain, disability and psychosocial factors was collected using specific questionnaires. Analysis of frequency, central tendency and dispersion were presented. Pearson's correlation test was used to verify the correlation between pain, disability and psychosocial factors. The statistical significance was set as alpha=95%. RESULTS: The study consisted of 25 women, with a mean age of 45.4 years. The mean pain intensity at the time of the assessment was 4.76±3.39. The mean disability was 4.01±2.32. Anxiety presented a mean of 7.16±3.36 and stress 7.04±3.16. The level of disability had a negative correlation with pain intensity (r = -0.474; p=0.017), with the pain severity domain (r=-0.566; p=0.003) and with kinesiophobia (r = -0.550; p=0.001). CONCLUSION: Women with chronic pelvic pain had moderate levels of pain intensity and disability. The psychosocial factors with the highest mean score were anxiety and stress. The intensity of pain and disability were correlated with each other and with kinesiophobia.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor pélvica crônica pode ser considerada uma das principais causas de morbidade e incapacidade funcional para as mulheres. A influência dos fatores psicossociais na dor pélvica crônica foi pouco explorada na literatura. O objetivo deste estudo foi caracterizar o perfil da dor pélvica crônica em mulheres, bem como buscar a presença de fatores psicossociais e a associação com dor e incapacidade. MÉTODOS: Estudo transversal que incluiu mulheres com dor pélvica crônica. Os dados referentes da dor, incapacidade e os fatores psicossociais foram coletados utilizando questionários específicos. Foram apresentadas as análises de frequência, tendência central e dispersão dos dados. O teste de correlação de Pearson foi utilizado para verificar a correlação entre dor, incapacidade e fatores psicossociais. O valor de significância estatística adotado foi de alfa=95%. RESULTADOS: O estudo foi composto por 25 mulheres, com média de idade de 45,4 anos. A intensidade de dor média no momento da avaliação foi de 4,76±3,39. A média de incapacidade foi de 4,01±2,32. A ansiedade apresentou média de 7,16±3,36 e estresse 7,04±3,16. O nível de limitação funcional teve correlação negativa com a intensidade da dor (r= -0,474; p=0,017), com o domínio gravidade da dor (r=-0,566; p=0,003) e com cinesiofobia (r= -0,550; p=0,001). CONCLUSÃO: As mulheres com doença pélvica crônica apresentaram níveis moderados de intensidade de dor e limitação funcional. Os fatores psicossociais com maior pontuação média foram a ansiedade e estresse. A intensidade de dor e o nível de limitação funcional estiveram correlacionados entre si e com a cinesiofobia.

Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital / Consultas neurológicas e diagnósticos em um grande hospital universitário dedicado a COVID-19

ABSTRACT Background: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. Objective: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. Methods: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. Results: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). Conclusions: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

RESUMO Introdução: Mais de um terço dos pacientes com COVID-19 apresentam sintomas neurológicos que variam de anosmia a AVC e encefalopatia. Além disso, doenças neurológicas prévias podem exigir tratamento especial e estar associadas a piores desfechos. Não obstante, o papel dos neurologistas na COVID-19 é provavelmente pouco reconhecido. Objetivo: O objetivo deste estudo foi relatar os motivos para solicitar consultas neurológicas por clínicos e intensivistas em um hospital dedicado à COVID-19. Métodos: Estudo retrospectivo realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil, um centro dedicado à COVID-19 com 900 leitos (incluindo 300 leitos para unidades de terapia intensiva). O diagnóstico de COVID-19 foi confirmado por SARS-CoV-2-RT-PCR em swabs nasais. Todas as interconsultas de neurologia hospitalar entre 23 de março e 23 de maio de 2020 foram analisadas. Os neurologistas realizaram o exame neurológico, avaliaram todos os dados disponíveis para diagnosticar a patologia neurológica e solicitaram exames adicionais conforme necessidade. Diagnósticos difíceis foram estabelecidos em reuniões de consenso. Após o diagnóstico, os neurologistas participaram da condução dos casos. Resultados: Foram solicitadas consultas neurológicas para 89 de 1.208 (7,4%) em pacientes internados por COVID-19 durante o período. Os principais diagnósticos neurológicos incluíram: encefalopatia (44,4%), acidente vascular cerebral (16,7%), doenças neurológicas prévias (9,0%), crises epilépticas (9,0%), transtornos neuromusculares (5,6%), outras lesões encefálicas agudas (3,4%) e outros sintomas leves inespecíficos (11,2%). Conclusões: A maioria das consultas neurológicas em um hospital dedicado à COVID-19 foi solicitada para condições graves que poderiam afetar o desfecho clínico. Os médicos na linha de frente devem ser capazes de reconhecer sintomas neurológicos. Os neurologistas são membros importantes da equipe médica no atendimento hospitalar à COVID-19.

Photocatalytic Degradation of Textile dye Orange-122 Via Electrospray Mass Spectrometry

Abstract This work reports the study of the potential application of Zn/TiO2 catalysts, obtained by the sol-gel method, in processes of environmental decontamination through the reactions of photodegradation of textile dye, followed by electrospray mass spectrometry. The catalysts synthesis was performed according to a 2² factorial design with repetition at the central point. The characterization techniques used were: N2 adsorption measurements (BET method), scanning electron microscopy with energy dispersive X-ray (MEV/EDS), X-ray diffraction and point of zero charge (PZC). The photocatalytic tests were performed in batch in the presence of sunlight, and to evaluate the degradation kinetics study, a rapid direct injection electrospray mass spectrometry (DI-ESI-MS) method has been developed. By the photocatalytic tests, the calcination temperature of 400 °C has shown the best results of discoloration for the reactive Orange-122 dye (99.76%) in a reaction time of 2h. The discoloration kinetics were a pseudo-first order, and a statistical analysis was performed to investigate the effects of the variables and to optimize the conditions of discoloration to the dye. After the reactional time of 2 h, an ion of m/z 441.5 was detected by ESI-MS, indicating that the photocatalytic process was effective for the degradation of the dye to secondary compounds.

Histologic review of melanomas by pathologists trained in melanocytic lesions may change therapeutic approach in up to 41 9% of cases

Abstract: Melanoma Guidelines of the Brazilian Dermatology Society recommend histologic review by pathologists trained in melanocytic lesions whenever possible. Out of 145 melanoma cases identified at a private clinic in São Paulo/Brazil, 31 that had been submited to histologic review were studied to evaluate whether revision had led to change in therapeutic approach.. Differences in original/reviewed reports were found in 58.1% (n=18) of the reports, leading to changes in therapeutic approach in 41.9% (n=13). Change in diagnosis was observed in 6 out of 31 (19,3%) cases. These findings suggest that second opinion by pathologists trained in melanocytic lesions is likely to show significant differences from the original report.

Avaliação da aptidão física e funcional de idosos com prática de atividade física diferenciada / Evaluation of physical and functional fitness of older people with practice of differentiated physical activity / Evaluación de la aptitud física y funcional de los ancianos con práctica de actividad física diferenciada

O objetivo foi verificar e comparar o efeito da prática de exercício físico na aptidão física em idosos, com prática de atividades físicas diferenciadas e específicas. Como metodologia, foram formados 3 grupos de idosos e realizados testes por meio de protocolos e anamnese. Os resultados nos mostram que a atividade física regular nos grupos ativos apresenta diferença significativa no desempenho global quando comparado com o grupo sedentário. Concluiu-se que a prática de atividade física ou lúdica regular melhora o desempenho global dos idosos.

The objective was to verify and compare the effect of physical exercise practice on physical fitness in the elderly, with practice of differentiated and specific physical activities. As a methodology, 3 groups of elderly were formed and performed tests through protocols and anamnesis. The results show that regular physical activity in the active groups presents a significant difference in overall performance when compared to the sedentary group. It was concluded that the practice of regular physical activity or play improves the overall performance of the elderly.

El objetivo fue verificar y comparar el efecto de la práctica de ejercicio físico en la aptitud física en ancianos, con práctica de actividades físicas diferenciadas y específicas. Como metodología, se formaron 3 grupos de ancianos y se realizaron pruebas a través de protocolos y anamnesis. Los resultados nos muestran que la actividad física regular en los grupos activos presenta una diferencia significativa en el desempeño global en comparación con el grupo sedentario. Se concluyó que la práctica de actividad física o lúdica regular mejora el desempeño global de los ancianos.

Brazilian Academy of Neurology (2006 - 2016) / Academia Brasileira de Neurologia (2006 - 2016)

ABSTRACT Brazil is a heterogeneous country with continental dimensions. The different characteristics of cultural, socioeconomic, and demographic status of the population drive different strategies for neurological care. This knowledge helps the understanding of the current scenario with the consequent possibility of preparing for future challenges. We used data from annual internal forms of the Brazilian Academy of Neurology (BAN) since 2006 and the survey for all BAN members (3,240) in 2016. The geographic distribution of BAN members in Brazil follows the demographic concentration of the population. Participation of members from big cities was the most prevalent, 18.7% of participants were young neurologists, and 36.7% of neurologists had more than of 20 years of neurological practice. The improvement of knowledge of neurological practice in Brazil will be useful for BAN leadership in planning future actions. The BAN must make an effort to aggregate a greater number of neurologists, offering updating support contributing to health policies to disseminate neurological care in Brazil.

RESUMO O Brasil é um país heterogêneo com dimensões continentais. As diferentes características culturais, do padrão socioeconômico e demográfico da população direcionam diferentes estratégias de atenção neurológica. Este conhecimento ajuda a entender o cenário atual para consequente preparação para os desafios futuros. Utilizamos informações dos relatórios anuais de Academia Brasileira de Neurologia (ABN) desde 2006, além de dados de uma pesquisa para os membros da ABNr ealizada em 2016. A distribuição geográfica dos membros da ABN no Brasil segue a concentração demográfica da população. A participação na pesquisa dos membros das grandes cidades foi a mais prevalente. 18,7% eram neurologistas jovens e 36,7% tinham mais de 20 anos de prática neurológica. O aperfeiçoamento do conhecimento da prática neurológica no Brasil será útil para a liderança da ABN planejar ações futuras. A ABN deve se esforçar para agregar um maior número de neurologistas, oferecendo constante atualização e apoio profissional contribuindo para políticas de saúde para disseminar o conceito de doenças neurológicas no Brasil.

The importance of recognizing faciobrachial dystonic seizures in rapidly progressive dementias / A importância do reconhecimento das crises distônicas faciobraquiais nas demências rapidamente progressivas

ABSTRACT Background: Creutzfeldt-Jakob Disease (CJD) is the prototypical cause of rapidly progressive dementia (RPD). Nonetheless, efforts to exclude reversible causes of RPD that mimic prion disease are imperative. The recent expanding characterization of neurological syndromes associated with antibodies directed against neuronal cell surface or sympathic antigens, namely autoimmune encephalitis is shifting paradigms in neurology. Such antigens are well known proteins and receptors involved in synaptic transmission. Their dysfunction results in neuropsychiatric symptoms, psychosis, seizures, movement disorders and RPD. Faciobrachial dystonic seizure (FBDS) is a novel characterized type of seizure, specific for anti-LGI1 encephalitis. Objective: In order to improve clinical recognition we report the cases of two Brazilian patients who presented with characteristic FDBS (illustrated by videos) and anti-LGI1 encephalitis. Methods: We have included all patients with FBDS and confirmed anti-LGI1 encephalitis and video records of FDBS in two tertiary Brazilian centers: Department of Neurology of Hospital das Clínicas, Sao Paulo University, Sao Paulo, Brazil and Hospital Geral de Fortaleza, Fortaleza, Brazil between January 1, 2011 and December 31, 2015. Results: Both patients presented with clinical features of limbic encephalitis associated with FBDS, hyponatremia and normal CSF. None of them presented with tumor and both showed a good response after immunotherapy. Conclusion: FBDSs may be confounded with myoclonus and occurs simultaneously with rapid cognitive decline. Unawareness of FDBS may induce to misdiagnosing a treatable cause of RPD as CJD.

RESUMO Embasamento: A doença de Creutzfeldt-Jakob (DCJ) é o protótipo de demência rapidamente progressiva (DRP). No entanto, é imperativo que sejam excluídas causas reversíveis de DRPs que possam simular doença priônica. A recente caracterização de síndromes neurológicas associadas a anticorpos direcionados contra antígenos de superfície neuronal ou sinapse, assim denominadas de encefalites autoimunes, está mudando paradigmas em neurologia. Esses antígenos estão envolvidos na transmissão sináptica, sendo que as disfunções destes podem resultar em sintomas neuropsiquiátricos, psicose, crises epilépticas, distúrbios do movimento e DRP. A crise distônica faciobraquial (CDFB) é um tipo de crise recentemente caracterizada e específica da encefalite anti-LGI1. Objetivo: Para promover um melhor reconhecimento da doença relatamos os casos de 2 pacientes brasileiros que apresentaram CDFBs (ilustradas com vídeos) associadas à encefalite anti-LGI1. Métodos: Foram incluídos todos os pacientes com CDFBs e encefalite anti-LGI1 confirmados em 2 centros brasileiros terciários: Departamento de Neurologia do Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brasil e o Hospital Geral de Fortaleza entre 01 de janeiro de 2011 e 31 de dezembro de 2015. Resultados: Ambos os casos apresentaram quadro clinico típico de encefalite límbica associada a CDFBs e exame do LCR sem alterações. Nenhum caso associou-se à presença de neoplasia e ambos apresentaram boa resposta à imunoterapia. Conclusão: A CDFB podem ser confundidas com mioclonias e ocorrer simultaneamente com rápido declínio cognitivo, o seu não reconhecimento pode induzir ao diagnóstico errôneo de uma causa potencialmente tratável de DRP como sendo DCJ.

Brazilian guidelines for diagnosis, treatment and follow-up of primary cutaneous melanoma - Part II

Abstract The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?.

Extratemporal abnormalities in phosphorus magnetic resonance spectroscopy of patients with mesial temporal sclerosis / Anormalidades extratemporais na espectroscopia de fósforo por ressonância magnética em pacientes com esclerose mesial temporal

ABSTRACT Objective We evaluated extratemporal metabolic changes with phosphorus magnetic resonance spectroscopy (31P-MRS) in patients with unilateral mesial temporal sclerosis (MTS). Method 31P-MRS of 33 patients with unilateral MTS was compared with 31 controls. The voxels were selected in the anterior, posterior insula-basal ganglia (AIBG, PIBG) and frontal lobes (FL). Relative values of phosphodiesters- PDE, phosphomonoesters-PME, inorganic phosphate - Pi, phosphocreatine- PCr, total adenosine triphosphate [ATPt = γ- + a- + b-ATP] and the ratios PCr/ATPt, PCr/γ-ATP, PCr/Pi and PME/PDE were obtained. Results We found energetic abnormalities in the MTS patients compared to the controls with Pi reduction bilaterally in the AIBG and ipsilaterally in the PIBG and the contralateral FL; there was also decreased PCr/γ-ATP in the ipsilateral AIBG and PIBG. Increased ATPT in the contralateral AIBG and increased γ-ATP in the ipsilateral PIBG were detected. Conclusion Widespread energy dysfunction was detected in patients with unilateral MTS.

RESUMO Objetivo Nós avaliamos as alterações metabóblicas através da espectroscopia de fósforo por ressonância magnética (31P-MRS) em pacientes com esclerose mesial temporal (EMT) unilateral. Método 31P-MRS de 33 pacientes com EMT unilateral foram comparadas aos de 31 controles. Foram selecionados os voxels nas regiões insulonuclear anterior e posterior (RINA e RINP) e frontal (RF). Os valores relativos de fosfodiésteres – PDE, fosfomonoésteres- PME, fosfato inorgânico- Pi, fosfocreatina –PCr, adenosina trifosfato total [ATPt = γ- + a- + b-ATP] e as razões PCr/ATPt, PCr/γ-ATP, PCr/Pi e PME/PDE foram obtidas. Resultados Nós encontramos anormalidades em pacientes com EMT em comparação aos controles. Redução de Pi nas RINA bilateralmente, RINP ipsilateral e RF contralateral, redução de PCr/γ-ATP nas RINA e RINP ipsilaterais foram detectadas. Aumentos de ATPT na RINA contralateral e aumento de γ-ATP na RINP ipsilateral também foram encontradas. Conclusão Disfunção energética difusa foi encontrada em pacientes com EMT unilateral.