Combinação fluticasona e azelastina intranasal no tratamento de adolescentes com rinite alérgica de difícil controle / Combination of intranasal fluticasone and azelastine for difficult-to-control allergic rhinitis in adolescents

Introdução: A rinite alérgica (RA) tem prevalência elevada e é responsável por impacto significativo da qualidade de vida destes pacientes, refletindo-se negativamente no desempenho escolar, na vida social ou no trabalho. A associação de propionato de fluticasona e cloridrato de azelastina (PF-AZE) tem sido recomendada no tratamento de pacientes com rinite alérgica de difícil controle. Objetivo: Avaliar a resposta ao tratamento com PF+AZE administrado a crianças e adolescentes com RA persistente moderada-grave (RAPMG) de difícil controle. Métodos: Ensaio clínico aberto não controlado prospectivo com intervenção terapêutica em que participaram adolescentes (n = 65) com RAPMG de difícil controle acompanhados em ambulatório especializado. Resultados: Houve melhora estatisticamente significante de todas as variáveis estudadas, o que mostrou melhor controle da rinite com a combinação PF+AZE. Utilizando-se a diferença mínima clinicamente importante como parâmetro de avaliação, 83% dos pacientes tiveram melhora da doença. Não houve relato de evento adverso grave, gosto amargo foi relatado por 38,5% dos pacientes e dois interromperam o esquema por evento adverso. Conclusão: A combinação PF+AZE foi bem tolerada, segura e eficaz no tratamento de pacientes com RAPMG. Eventos adversos locais foram os mais comumente relatados.

Introduction: Allergic rhinitis has a high prevalence and is responsible for a significant impact on the quality of life of affected individuals, reflecting negatively on school performance, social life, and work. An association of fluticasone propionate and azelastine hydrochloride (PF+AZE) has been recommended for patients with difficult-to-control allergic rhinitis. Objective: To evaluate treatment response to PF+AZE in adolescents with difficult-to-control moderate/severe persistent allergic rhinitis (MSPAR). Methods: This was a prospective, open-label, uncontrolled clinical trial for a therapeutic intervention in adolescents with difficult-to-control MSPAR treated at a specialized outpatient clinic. Results: There was significant improvement in all studied variables, showing better MSPAR control with PF+AZE. Using the clinically important minimum difference as an evaluation parameter, 83% of the patients improved. There were no reports of serious adverse events; a bitter taste was reported by 38.5% of patients, and 2 discontinued use due to an adverse event. Conclusion: PF+AZE was a well-tolerated, safe, and effective treatment for MSPAR. The most commonly reported adverse events were local.

Congenital Urethrovaginal Fistula with Blind-Ending Vagina in a Female Pseudohermaphrodite Dog with Urinary Incontinence.

An 8 mo old male Doberman pinscher was referred for investigation of persistent urinary incontinence. Physical examination revealed urine leakage and abnormal external genitalia. A computed tomography scan identified a large fluid-filled cavity extending from the caudoventral abdomen displacing the colon and urinary bladder. No retained testicles were identified. A retrograde urethrogram study found a linear communication, cranial to the pubic brim between the urethra to the fluid-filled cavity (fistula). Exploratory celiotomy was performed, and an entire female reproductive tract with a blind-ending vagina and a urethrovaginal fistula was found. En bloc gonad hysterectomy was performed, the fistula was transected, and a careful urethral reconstruction was performed. The urinary incontinence resolved immediately after surgery, and no complications were reported. Mild urinary incontinence recurred 4 days following patient discharge, and a urine bacterial culture was positive for Klebsiella spp. An antibiotic course was prescribed, and the incontinence fully resolved. Congenital urogenital abnormalities should always be considered in young animals presenting with urinary incontinence. Here, a young female pseudohermaphrodite dog with a naturally occurring congenital urethrovaginal fistula is described. Exploratory surgery was required for definitive diagnosis and surgical intervention yielded a good medium-term outcome with resolution of clinical signs.

Repeated bouts of pulmonary tuberculosis in a hunting cat: reinfection or recrudescence?

CASE SUMMARY: A 7-year-old neutered male Siamese cat was referred for investigation of weight loss and hypercalcaemia (3.3 mmol/l; reference interval 2-3 mmol/l). Haematology, serum biochemistry, thoracic imaging, bronchoalveolar lavage (BAL), Ziehl-Neelsen staining of the BAL fluid and interferon gamma release assay (IGRA) were compatible with pneumonia caused by the less pathogenic member of the Mycobacterium tuberculosis complex, that is, M microti (the 'vole bacillus'), which is common in cats in the UK. Treatment with azithromycin, rifampicin and marbofloxacin was given for 2 months, followed by 4 months of azithromycin and marbofloxacin. Treatment recommendations for tuberculous pneumonia have since changed. The cat remained asymptomatic for 1 year but went on to develop M microti pneumonia on five other occasions, and was treated for 6-12 months on each occasion. The patient's clinical signs, hypercalcaemia and radiographic/CT pulmonary pathology always resolved completely, and the IGRA became negative, before antimycobacterial treatment was stopped. This suggests cure followed by reinfection owing to avid hunting behaviour. Alternatively, this could represent recrudescence of dormant disease. This case has previously been included in a study that described a series of cases of feline tuberculosis. RELEVANCE AND NOVEL INFORMATION: This case shows that M microti infection in cats can present as recurrent episodes of pneumonia, even after prolonged treatment courses.

The duration of antibiotic treatment is associated with carriage of toxigenic and non-toxigenic strains of Clostridioides difficile in dogs.

Clostridioides difficile is a leading cause of human antibiotic-associated diarrhoeal disease globally. Zoonotic reservoirs of infection are increasingly suspected to play a role in the emergence of this disease in the community and dogs are considered as one potential source. Here we use a canine case-control study at a referral veterinary hospital in Scotland to assess: i) the risk factors associated with carriage of C. difficile by dogs, ii) whether carriage of C. difficile is associated with clinical disease in dogs and iii) the similarity of strains isolated from dogs with local human clinical surveillance. The overall prevalence of C. difficile carriage in dogs was 18.7% (95% CI 14.8-23.2%, n = 61/327) of which 34% (n = 21/61) were toxigenic strains. We found risk factors related to prior antibiotic treatment were significantly associated with C. difficile carriage by dogs. However, the presence of toxigenic strains of C. difficile in a canine faecal sample was not associated with diarrhoeal disease in dogs. Active toxin was infrequently detected in canine faecal samples carrying toxigenic strains (2/11 samples). Both dogs in which active toxin was detected had no clinical evidence of gastrointestinal disease. Among the ten toxigenic ribotypes of C. difficile detected in dogs in this study, six of these (012, 014, 020, 026, 078, 106) were ribotypes commonly associated with human clinical disease in Scotland, while nontoxigenic isolates largely belonged to 010 and 039 ribotypes. Whilst C. difficile does not appear commonly associated with diarrhoeal disease in dogs, antibiotic treatment increases carriage of this bacteria including toxigenic strains commonly found in human clinical disease.

Priorities on treatment and monitoring of diabetic cats from the owners' points of view.

OBJECTIVES: The aims of this study were to evaluate: owners' perceptions and priorities on the treatment and monitoring of feline diabetes mellitus (DM); the perceived effectiveness of the communication between veterinarians and clients regarding disease management; and the impact DM has on the owners' everyday lives and human-pet bonds. METHODS: An initial questionnaire, then an adapted second questionnaire, were available to owners of cats with DM on vetprofessionals.com . RESULTS: A total of 748 questionnaires were completed. At diagnosis, fewer than half of veterinarians discussed how to recognise unstable diabetes (46%) or home blood glucose monitoring (HBGM) (40%). Owners were disappointed that the importance of diet on diabetic remission/stabilisation and HBGM were not discussed. Only 49% of respondents were supervised by a veterinarian/veterinary nurse while first drawing up insulin and injecting their cat. Websites/online forums that owners found themselves were most useful when learning about their cat's diabetes (76% agreed). Over a third of cats (39%) were not fed a 'diabetic' diet but, impressively, 71% of owners used HBGM. Initial concerns about costs, boarding, the effect on their daily life and potential negative impact on the human-pet bond reduced significantly after initiating treatment (P <0.0001). CONCLUSIONS AND RELEVANCE: Caring for a diabetic cat requires significant owner commitment, plus support by the veterinary team for the owner and their cat. It is difficult to discuss all aspects of this complex disease with the owner in a single consultation; hence, it is important to involve the entire veterinary team in owner education and provide owners with informative material (eg, useful websites, printouts). Understanding owners' priorities, fears, and which monitoring methods have helped others, is paramount to achieve owner compliance and satisfaction, and so improve the health and welfare of diabetic cats. This study provides useful information on the management of feline DM, which can be instrumental in educating future owners.

Acanthosis nigricans as a clinical marker of insulin resistance among overweight adolescents.

PURPOSE: Acanthosis nigricans (AN) is a hyperpigmented dermatosis associated with obesity and insulin resistance (IR). There is no consensus whether AN extension scoring offers added value to the clinical estimation of IR. In this study we aimed to assess and score AN using both a short and an extended version of the scale proposed by Burke et al. and analyze the relationships of both versions with hyperinsulinemia and IR. METHODS: We analyzed data from 139 overweight adolescents (body mass index ≥85th percentile) aged 12-18 with (n=67) or without (n=72) AN who were followed at a pediatric obesity clinic. RESULTS: Adolescents with AN had higher levels of insulin (d=0.56, P=0.003) and HOMA-IR (d=0.55, P=0.003) compared to those without. Neither the short nor the extended versions of AN scores explained either hyperinsulinemia (ß=1.10, P=0.316; ß=1.15, P=0.251) or IR (ß=1.07, P=0.422; ß=1.10, P=0.374). The presence of AN alone predicted hyperinsulinemia and the presence of IR in 7.3% (ß=2.68, P=0.008) and 7.1% (ß=2.59, P=0.009) of adolescents, respectively. CONCLUSION: Screening for AN at the neck and axilla is a noninvasive and cost-effective way to identify asymptomatic overweight adolescents with or at risk of developing IR.

Clinical characteristics of patients with cerebellar ataxia associated with anti-GAD antibodies.

METHODS: This retrospective and descriptive study evaluated the clinical characteristics and outcomes of patients with CA-GAD-ab. RESULT: Three patients with cerebellar ataxia, high GAD-ab titers and autoimmune endocrine disease were identified. Patients 1 and 2 had classic stiff person syndrome and insidious-onset cerebellar ataxia, while Patient 3 had pure cerebellar ataxia with subacute onset. Patients received intravenous immunoglobulin therapy with no response in Patients 1 and 3 and partial recovery in Patient 2. CONCLUSION: CA-GAD-ab is rare and its clinical presentation may hamper diagnosis. Clinicians should be able to recognize this potentially treatable autoimmune cerebellar ataxia.

Clinical characteristics of patients with cerebellar ataxia associated with anti-GAD antibodies / Características clínicas de pacientes com ataxia cerebelar associada a anticorpos anti-GAD

ABSTRACT The enzyme glutamic acid decarboxylase (GAD), present in GABAergic neurons and in pancreatic beta cells, catalyzes the conversion of gamma-aminobutyric acid (GABA). The cerebellum is highly susceptible to immune-mediated mechanisms, with the potentially treatable autoimmune cerebellar ataxia associated with the GAD antibody (CA-GAD-ab) being a rare, albeit increasingly detected condition. Few cases of CA-GAD-ab have been described. Methods This retrospective and descriptive study evaluated the clinical characteristics and outcomes of patients with CA-GAD-ab. Result Three patients with cerebellar ataxia, high GAD-ab titers and autoimmune endocrine disease were identified. Patients 1 and 2 had classic stiff person syndrome and insidious-onset cerebellar ataxia, while Patient 3 had pure cerebellar ataxia with subacute onset. Patients received intravenous immunoglobulin therapy with no response in Patients 1 and 3 and partial recovery in Patient 2. Conclusion CA-GAD-ab is rare and its clinical presentation may hamper diagnosis. Clinicians should be able to recognize this potentially treatable autoimmune cerebellar ataxia.

RESUMO A enzima ácido glutâmico descarboxilase (GAD), presente nos neurônios GABAérgicos e células beta do pâncreas, catalisa a conversão do ácido gama-aminobutírico (GABA). O cerebelo é altamente susceptível a mecanismos imunomediados, sendo a ataxia cerebelar associada ao anticorpo anti-GAD (CA-GAD) uma doença potencialmente tratável. Embora rara, sua frequência é crescente, com poucos casos descritos. Métodos Estudo retrospectivo e descritivo avaliando características clínicas e desfechos da CA-GAD. Resultados Três pacientes com CA-GAD, altos títulos de anti-GAD e doença endócrina autoimune foram identificados. Os pacientes 1 e 2 tinham síndrome da pessoa rígida em forma clássica e apresentação insidiosa da ataxia cerebelar, enquanto o paciente 3 tinha ataxia cerebelar pura e apresentação subaguda. Os pacientes 1 e 3 não melhoraram com imunoglobulina intravenosa e o paciente 2 teve recuperação parcial. Conclusão A CA-GAD é rara e pode ter apresentação clínica desafiadora. Os médicos devem ser capazes de reconhecer essa forma potencialmente tratável de ataxia cerebelar autoimune.

Nystagmus in a newborn: a manifestation of Joubert syndrome in the neonatal period.

Joubert syndrome is a rare disorder, usually autosomal recessive, with a prevalence of 1:80,000 to 1:100,000. This disease presents most commonly as breathing irregularities, although the two major clinical criteria are hypotonia and developmental delay, sometimes associated with ocular movement abnormalities. The severity of the presentation varies, ranging from mild cases with normal intelligence to severe developmental delays associated with early death. We report a case of a newborn who presented to the emergency department for absent ocular fixation and torsional nystagmus without other neurological abnormalities. Her cranial MR showed cerebellar vermis agenesis and a molar tooth sign. Her laboratory evaluation, and renal and abdominal ultrasound were normal. An electroretinogram showed mixed retinal dystrophy and an AHI1 homozygous missense c.1981T>C mutation was identified (parents are carriers). Throughout infancy, she has shown mild developmental delay and hypotonia, but no respiratory abnormalities. Owing to variable expressivity, a high level of suspicion is required.

Arthritis, eosinophilia, and autoimmune liver disease: a diagnostic challenge.

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown etiology. It is composed of immune-mediated liver injury and significant immunological aspects. Arthritis can be observed in patients with AIH before recognition of the disease, which can lead to a diagnostic challenge. Although there are few reported cases in literature, peripheral blood eosinophilia might also play a part in such diagnosis. We report an intriguing case of a 41-year-old man who presented to our service with arthritis and eosinophilia as initial manifestations and was eventually diagnosed with overlap syndrome: AIH and primary sclerosing cholangitis. The present report aims to include eosinophilia among the clinical features of AIH, highlighting the possibility of its detection before the onset of either articular or hepatic disturbances.

Valor nutricional de dietas veiculadas em revistas não científicas / Nutritional value of diets disclosed in non-scientific magazines

Avaliar o valor nutricional de dietas para emagrecimento veiculadas em revistas não científicas. Métodos: Estudo quantitativo transversal, realizado em dois momentos: primeira investigação, em 2007, e segunda, em 2009, obtendo-se 120 dietas de emagrecimento, selecionadas aleatoriamente de 24 revistas, distribuídas em três grupos, de acordo com o custo. Avaliou-se os cardápios quanto a calorias, macronutrientes, micronutrientes e fibras, utilizando o programa Diet Pro 2. Para análise dos resultados empregou-se o software SPSS, versão 15.0. Os valores estão apresentados em média, desvio padrão e intervalos de confiança. Foi utilizado a ANOVA two way, com posteriores comparações pareadas de Tukey para o estudo quantitativo dos nutrientes em cada grupo de revista e momento estudado. Para comparação entre as médias dos valores obtidos nas dietas e as recomendações preconizadas usou-se o teste t-Student. O nível de significância foi de 5,0%. Resultados: A oferta energética apresentou-se superior em 2007. Com o passar do tempo, a média proteica das dietas diminuiu, a lipídica permaneceu semelhante e a glicídica aumentou. De acordo com os valores recomendados, as dietas se caracterizaram como hipoglicídica, hiperproteica e normolipídica. Os micronutrientes analisados apresentaram oferta inferior à recomendação, nos dois anos analisados. A oferta de fibras aumentou no segundo, em relação ao primeiro momento, porém não atingiu o recomendado. Conclusão: As dietas apresentaram inadequações de macro e micronutrientes, nos dois anos estudados, com desequilíbrio entre seus componentes.

To assess the nutritional value of weight-loss diets disclosed in non-scientific magazines. Methods: A quantitative cross-sectional study carried out in two phases (first investigation in 2007; second investigation in 2009), in which 120 weight-loss diets were randomly selected from 24 magazines divided into three groups based on cost. The menus were evaluated with regard to calories, macronutrients and fiber, using the Diet Pro 2 program. The SPSS program (version 15.0) was used for statistical analysis, with the results expressed as mean, standard deviation and confidence intervals. Two-way analysis of variance (ANOVA) with Tukey?s paired post hoc comparison was used for the quantitative study of the nutrients in each group of magazines and each phase of the study. The Student?s t-test was used for the comparisons of mean values obtained with the diets and established recommendations. The level of significance was set at 5.0%. Results: The energy supply was higher in 2007. Over time, mean protein content in the diets diminished, lipid content remained similar and glucose content increased. Based on the recommended values, the diets were characterized as hypoglycemic, high-protein and normolipidemic. The content of micronutrients was lower than recommended amounts in both years assessed. The fiber content increased in the second year in relation to the first, but did not reach the recommended level. Conclusion: Diets showed inadequacies of macro and micronutrients in the two studied years, with an imbalance between their components.