Radiological changes in lead poisoning.

INTRODUCTION: Lead poisoning in childhood remains an important public health concern. We highlight the radiological findings in a patient with a high blood lead concentration. CASE SUMMARY: A 7-year-old girl presented to hospital with abdominal pain, nausea, and asthenia. Laboratory tests showed severe hypochromic microcytic anemia, punctate basophilic stippling of erythrocytes, and a blood lead concentration of 880 µg/L (4.3 µmol/L). IMAGES: Radiographs of the femur, tibia, and fibula demonstrated dense metaphyseal bands ("lead lines"). On cranial computed tomography, we observed multiple speck-like and curvilinear hyperdensities involving subcortical regions, putamen, and left cerebellar hemisphere. CONCLUSION: In patients with lead poisoning, imaging of the brain and bones may show characteristic features. These imaging findings may point to the diagnosis of lead toxicity when these radiographic findings are discovered during the evaluation of vague complaints such as abdominal pain or mental status changes or when a blood lead concentration is not readily available.

Validação de simulador de emissões otoacústicas para o ensino em audiologia / Otoacoustic emissions simulator validation for audiology education / Validación del simulador de emisiones otoacuticas para la educación en audiología

O teste Emissões Otoacústicas (EOA) é parte da avaliação Audiológica para detecção precoce da surdez na infância. Desse modo, o aprendizado das EOA na graduação do curso de Fonoaudiologia é fundamental conforme a Diretriz Curricular Nacional (DCN). As diretrizes educacionais sugerem a inclusão de tecnologias de informação no ensino da graduação para melhor desempenho dos futuros profissionais da saúde. Objetivo: Validar o protótipo simulador OTOBABY para o Teste de Emissões Otoacústicas como ferramenta de ensino em Fonoaudiologia. Metodologia: Trata-se de uma pesquisa metodológica, experimental, com a participação de dez fonoaudiólogos professores e/ou preceptores, denominados juízes e 20 alunos de graduação de Fonoaudiologia em Belém do Pará/Brasil. Os juízes responderam a um questionário de validação de Escala Likert sobre a usabilidade e efetividade do simulador OTOBABY como ferramenta de ensino. Os alunos participaram de um curso de capacitação com o uso do protótipo e foram avaliados com checklists antes e depois do curso para a verificação da eficácia do simulador como instrumento de ensino. Os dados foram analisados estatisticamente com o teste de Wilcoxon. Resultados: O simulador alcançou 98% de aprovação como ferramenta de ensino para as EOA pelos juízes. Quanto a habilidade dos alunos, observou-se que era de 60,3%, antes do curso, obtendo-se um desempenho de 97,7% após curso com o OTOBABY. Conclusão: Conclui-se que o protótipo simulador OTOBABY foi aprovado e validado como um instrumento facilitador do aprendizado das Emissões Otoacústicas no ensino da prática Audiológica.

The Otoacoustic Emissions (OAE) test is part of the Audiological evaluation for early detection of childhood deafness. Thus, the learning of OAE in the undergraduate course of Speech Therapy is fundamental according to the National Curriculum Guideline (NCD). The educational guidelines suggest the inclusion of information technologies in undergraduate education for better performance of future health professionals. Objective: Validate the prototype OTOBABY simulator for the Otoacoustic Emissions Test as a teaching tool in Speech Therapy. Methodology: This is a methodological, experimental research, with the participation of ten phonoaudiologists, professors and/or preceptors, called judges and 20 undergraduate students of Speech Therapy in Belém do Pará/Brazil. The judges responded to a Likert Scale validation questionnaire on the usability and effectiveness of the OTOBABY simulator as a teaching tool. Students took part in a training course using the prototype and were evaluated with checklists before and after the course to verify the simulator's effectiveness as a teaching instrument. The data were statistically analyzed with the Wilcoxon test. Results: The simulator achieved 98% approval as a teaching tool for OAE by the judges. As for the ability of the students, it was observed that it was 60.3%, before the course, obtaining a performance of 97.7% after course with OTOBABY. Conclusion: It is concluded that the prototype simulator OTOBABY was approved and validated as a facilitator instrument of the learning of Otoacoustic Emissions in the teaching of Audiological practice.

La prueba EOA es parte de la evaluación auditiva para la sordera temprana en la niñez. En consecuencia, el aprendizaje de las EOA en el curso de posgrado de fonoaudiología es fundamental de acuerdo con la Directriz Nacional de Planes de Estudio (NCN). Las directrices educativas sugieren la inclusión de las tecnologías de la información en la enseñanza de cursos de pregrado para mejorar el desempeño de futuros profesionales de la salud. Objetivo: Validar el prototipo de simulador OTOBABY para la Prueba de Emisiones Otoacústicas como herramienta docente en fonoaudiología. Metodología: Estamos tratando con la investigación metodológica, experimental, con la participación de diez audiólogos de idiomas, profesores y/o preceptores, llamados jueces y 20 estudiantes universitarios de fonoaudiología en Belém do Pará/Brasil. Los jueces respondieron a un cuestionario de validación de la Escala Likert sobre la utilidad y la eficacia del simulador OTOBABY como instrumento de enseñanza. Los estudiantes participaron en un curso de capacitación utilizando el prototipo y fueron evaluados con checklists de verificación antes y después del curso para verificar la efectividad del simulador como instrumento educativo. Los datos se analizaron estadísticamente con el test de Wilcoxon. Resultados: El simulador alcanzó el 98% de la aprobación como herramienta de enseñanza para la EOA por parte de los jueces. En cuanto a la capacidad de los estudiantes, se observó que era del 60,3% antes del curso, alcanzando un desempeño del 97,7% después del curso con OTOBABY. Conclusión: Se concluye que el prototipo de simulador OTOBABY ha sido aprobado y validado como instrumento que facilita el aprendizaje de emisiones ópticas en la enseñanza de la práctica audiológica.

Validation of the Skindex-17 quality of life assessment instrument for a Brazilian population

Abstract Background: Health-related quality of life assesses how diseases affect the daily life of people; there are several generic instruments for this assessment in dermatology. Skindex was created in 1996; it is a multidimensional instrument, aiming to encompass some psychological and social aspects not yet addressed by other questionnaires. Among its versions (Skindex-29, 16, and 17), Skindex-17 had not been validated in Brazil. Objectives: To validate Skindex-17 for use in Brazilians with dermatological diseases. Methods: This was a methodological, cross-sectional, and prospective study of 217 patients attended at the Dermatology Service Outpatient Clinic, Faculdade de Medicina de Botucatu - Universidade Estadual Paulista (Botucatu, SP, Brazil), from December 2017 to September 2019. The following were evaluated: content validity, filling time, internal consistency, dimensional structure, concurrent validity (DLQI), temporal stability, and responsiveness. Results: The sample consisted of 71% women, mean age (SD) of 45 (16) years; phototypes II−IV accounted for 95% of the cases. Cronbach's alpha coefficients were 0.82 and 0.93 for the symptoms and psychosocial conditions, respectively. A high correlation was observed with the DLQI score: symptoms (rho = 0.69) and psychosocial conditions (rho = 0.75). The instrument's two-dimensional structure was confirmed through confirmatory factor analysis. Temporal stability (ICC > 0.9) and score responsiveness (p ≤ 0.02) were verified. The instrument was shown to be feasible in clinical practice due to the content validation performed by professionals and patients, as well as the low time spent completing it (< 5 min). Study limitations: Single-center study, with patients exclusively from the public healthcare system. Conclusions: Skindex-17 was shown to be a valid and consistent instrument for assessing quality of life among patients with dermatological diseases, in Brazil. Its two-dimensional structure was confirmed.

Prevalence and factors associated with depression and anxiety in patients with psoriasis.

OBJECTIVE: To identify the prevalence and factors associated with depression and anxiety in patients with psoriasis. BACKGROUND: Psoriasis is a chronic, non-contagious, autoimmune inflammatory skin disease associated with psychological comorbidities. DESIGN: A cross-sectional study conducted between March 2017-December 2018 in a dermatology infirmary and outpatient clinic of a public hospital in the inner State of São Paulo (Brazil). METHODS: We used questionnaires with sociodemographic data and clinical history, the HADS (Hospital Anxiety and Depression Scale), DLQI-BRA (Dermatology Life Quality Index) and PASI (Psoriasis Area Severity Index). The correlations between variables were explored using multivariate techniques. STROBE checklist was applied as the reporting guideline for this study (File S1). RESULTS: A total of 281 participants were included, of which the majority were female 146 (52%), with a mean age of 52.1 years (SD: 13.8), elementary school 154 (55%), married/cohabiting 209 (74%) and with low income 201 (72%). The median (p25-p75) time with the disease was 14 years (7-23). Regarding the quality of life, 31% of respondents reported being little affected by the disease. The prevalence of depression was 19% and that of anxiety was 36%. The multivariate analysis showed that the variables that influenced the anxiety and depression scores were as follows: DLQI-BRA, income, female sex, illness length and age. For the multiple correspondence analysis, the highest levels of anxiety and depression referred to women, middle age, lower income and low PASI. CONCLUSION: The prevalence of anxiety and depression symptoms was low. Female sex, income, age, illness length and quality of life were associated with anxiety and depression scores in patients with psoriasis. RELEVANCE TO CLINICAL PRACTICE: Due to the scarcity of studies in the field of nursing with psoriasis patients, we believe these findings contribute to the reorganisation of the care provided, allowing nurses to timely identify mood disorders such as anxiety and depression and adopt the necessary measures to a service and/or specialised referral.

Validation of the Skindex-17 quality of life assessment instrument for a Brazilian population.

BACKGROUND: Health-related quality of life assesses how diseases affect the daily life of people; there are several generic instruments for this assessment in dermatology. Skindex was created in 1996; it is a multidimensional instrument, aiming to encompass some psychological and social aspects not yet addressed by other questionnaires. Among its versions (Skindex-29, 16, and 17), Skindex-17 had not been validated in Brazil. OBJECTIVES: To validate Skindex-17 for use in Brazilians with dermatological diseases. METHODS: This was a methodological, cross-sectional, and prospective study of 217 patients attended at the Dermatology Service Outpatient Clinic, Faculdade de Medicina de Botucatu - Universidade Estadual Paulista (Botucatu, SP, Brazil), from December 2017 to September 2019. The following were evaluated: content validity, filling time, internal consistency, dimensional structure, concurrent validity (DLQI), temporal stability, and responsiveness. RESULTS: The sample consisted of 71% women, mean age (SD) of 45 (16) years; phototypes II-IV accounted for 95% of the cases. Cronbach's alpha coefficients were 0.82 and 0.93 for the symptoms and psychosocial conditions, respectively. A high correlation was observed with the DLQI score: symptoms (rho = 0.69) and psychosocial conditions (rho = 0.75). The instrument's two-dimensional structure was confirmed through confirmatory factor analysis. Temporal stability (ICC > 0.9) and score responsiveness (p ≤ 0.02) were verified. The instrument was shown to be feasible in clinical practice due to the content validation performed by professionals and patients, as well as the low time spent completing it (< 5 min). STUDY LIMITATIONS: Single-center study, with patients exclusively from the public healthcare system. CONCLUSIONS: Skindex-17 was shown to be a valid and consistent instrument for assessing quality of life among patients with dermatological diseases, in Brazil. Its two-dimensional structure was confirmed.

Dimensionality and psychometric analysis of DLQI in a Brazilian population.

BACKGROUND: The Dermatology Life Quality Index (DLQI) is the most commonly used instrument for clinical evaluation of the impact on health-related quality of life (HRQOL) in dermatological research protocols. The DLQI's classical psychometric properties have been considered adequate in validation studies from several countries. However, the structure of the DLQI is a matter of discussion, especially concerning the dimensionality and informative properties of its questions according to the item response theory (IRT). METHODS: Pooled data from studies in Brazil that utilized the DLQI to assess HRQOL in 14 dermatoses were reanalyzed. Classical psychometrical analysis, dimensionality assessment through parallel analysis and IRT (Samejima's ordinal model) analysis were performed. RESULTS: The sample consisted of 1286 patients with a mean age of 47 years (SD = 16), and the proportion of women was 59% (765). The DLQI scores ranged from 0 to 29, with a median (p25-p75) of 5 (2-11). All items indicated significant correlations with the total DLQI score (rho > 0.54). The Cronbach's alpha result was 0.90 (CI 95% 0.89-0.91). Parallel analysis indicated a unidimensional factor structure. According to IRT analysis, items q6 (sports) and q7 (work/study) exhibited insufficient fit to the model (p < 0.01), while the items that indicated the best discrimination and information functions were q2 (embarrassment), q3 (shopping/gardening), q4 (clothing) and q5 (social/leisure). The ordination of the scores was confirmed for all items. Most items revealed non-uniform behavior according to sex, age and type of disease. CONCLUSIONS: The DLQI exhibits adequate psychometric reliability and a unidimensional structure for assessing HRQOL in Brazilian dermatological patients. The DLQI's performance varies in the assessment of HRQOL in heterogeneous samples.

Extensive pyoderma gangrenosum-like lesions revealing a case of hyperzincemia and hypercalprotectinemia: when to suspect it?

Hyperzincemia and hypercalprotectinemia is a rare inflammatory disease caused by a mutation in the PSTPIP1 gene, with a dysregulation of calprotectin metabolism. Calprotectin is a zinc-binding protein with antimicrobial properties and pro-inflammatory action. The authors report the case of a 20 year-old girl with cutaneous ulcers comparable with pyoderma gangrenosum, growth failure and chronic anemia, who was given the diagnosis of hyperzincemia and hypercalprotectinemia. Measurement of serum zinc and calprotectin concentrations are indicated in these cases.

Results from chemoradiotherapy for squamous cell cervical cancer with or without intracavitary brachytherapy.

PURPOSE: The aim of this study is to compare the outcomes of intracavitary high-dose-rate brachytherapy (BT-IC) boost and external beam radiotherapy (EBRT) boost in patients treated with concomitant chemoradiotherapy for squamous cell carcinoma of the cervix. MATERIAL AND METHODS: It is a retrospective review of 92 patients with stage IB1-IVA cervical cancer treated with concomitant chemoradiotherapy between 2008 and 2013. All patients received pelvic 3D conformal EBRT (range, 45-50.4 Gy) concomitant with weekly cisplatin (40 mg/m2), and a BT-IC boost (37 patients: 4 fractions of 6 Gy prescribed to a point A) to the tumor or a 3D conformal EBRT boost (55 patients: 16.2 Gy), if the former was not technically feasible. RESULTS: The 5-year overall survival and recurrence-free survival rates for both groups were 68% and 55%, respectively. The 5-year overall survival and recurrence-free survival were better and statistically significant in the BT-IC group with 82% and 79%, respectively, as compared to the EBRT group with 58% and 38%, respectively. In multivariate analysis controlling for maximum tumor dimension, lymph node status, and FIGO stage, EBRT boost was associated with a statistical significant increase in the risk of recurrence (HR: 3.56; 95% CI: 1.27-10.02; p = 0.016) and a trend towards an increase in the risk of death (HR: 3.14; 95% CI: 0.97-10.17; p = 0.056). Lymph node status was also significantly associated with a greater risk of recurrence. CONCLUSIONS: BT-IC boost was associated with a lower recurrence rate and better overall survival and recurrence-free survival. EBRT boost patients had a three-fold increase in the risk of recurrence. Brachytherapy is essential in the treatment of cervical cancer and improved alternatives are needed for patients who are not candidates for standard brachytherapy applicators.

Extensive pyoderma gangrenosum-like lesions revealing a case of hyperzincemia and hypercalprotectinemia: when to suspect it?

Abstract Hyperzincemia and hypercalprotectinemia is a rare inflammatory disease caused by a mutation in the PSTPIP1 gene, with a dysregulation of calprotectin metabolism. Calprotectin is a zinc-binding protein with antimicrobial properties and pro-inflammatory action. The authors report the case of a 20 year-old girl with cutaneous ulcers comparable with pyoderma gangrenosum, growth failure and chronic anemia, who was given the diagnosis of hyperzincemia and hypercalprotectinemia. Measurement of serum zinc and calprotectin concentrations are indicated in these cases.

Paracoccidioidomycosis manifested by sarcoidosis-like cutaneous lesions and caused by Paracoccidioides brasiliensis sensu stricto (S1a)

Abstract: Molecular studies have shown more than one species of the genus Paracoccidioides to be the causal agent of paracoccidioidomycosis. Efforts have been made to correlate the identified species with epidemiological and clinical data of patients, aiming to determine the real meaning and impact of new species. Bearing this objective in mind, the authors report a clinical case of paracoccidioidomycosis, from São Paulo state, Brazil, that manifested as uncommon sarcoid-like cutaneous lesions and was caused by Paracoccidioides brasiliensis sensu stricto (S1a). The patient was treated with itraconazole 200mg/day for 12 months, with complete clinical remission.

Paracoccidioidomycosis manifested by sarcoidosis-like cutaneous lesions and caused by Paracoccidioides brasiliensis sensu stricto (S1a).

Molecular studies have shown more than one species of the genus Paracoccidioides to be the causal agent of paracoccidioidomycosis. Efforts have been made to correlate the identified species with epidemiological and clinical data of patients, aiming to determine the real meaning and impact of new species. Bearing this objective in mind, the authors report a clinical case of paracoccidioidomycosis, from São Paulo state, Brazil, that manifested as uncommon sarcoid-like cutaneous lesions and was caused by Paracoccidioides brasiliensis sensu stricto (S1a). The patient was treated with itraconazole 200mg/day for 12 months, with complete clinical remission.

Demodicosis as treatment complication of amicrobial pustulosis of the folds.

Amicrobial pustulosis of the folds is a chronic relapsing neutrophilic dermatosis characterized by sterile pustules compromising skin folds, scalp, face and periorificial regions. It predominantly affects women. Demodicosis is an inflammatory disease associated with cutaneous overpopulation of the mite Demodex spp., the pathogenesis of which is not completely established, but is frequently related to local immunodeficiency. A case of a young woman with amicrobial pustulosis of the folds, and isolated worsening of facial lesions, is reported; investigation revealed overlapping demodicosis. There was complete regression of lesions with acaricide and cyclin treatment. This case warns of a poorly diagnosed but disfiguring and stigmatizing disease, often associated with underlying dermatoses or inadvertent treatments on the face.

Demodicosis as treatment complication of amicrobial pustulosis of the folds

Abstract: Amicrobial pustulosis of the folds is a chronic relapsing neutrophilic dermatosis characterized by sterile pustules compromising skin folds, scalp, face and periorificial regions. It predominantly affects women. Demodicosis is an inflammatory disease associated with cutaneous overpopulation of the mite Demodex spp., the pathogenesis of which is not completely established, but is frequently related to local immunodeficiency. A case of a young woman with amicrobial pustulosis of the folds, and isolated worsening of facial lesions, is reported; investigation revealed overlapping demodicosis. There was complete regression of lesions with acaricide and cyclin treatment. This case warns of a poorly diagnosed but disfiguring and stigmatizing disease, often associated with underlying dermatoses or inadvertent treatments on the face.

Chemoradiotherapy completion and neutropenia risk in HIV patients with cervical cancer.

Cervical cancer (CC) is one of the acquired immunodeficiency syndrome (AIDS) defining diseases and the human immunodeficiency virus (HIV) infection is thought to relate with increased acute toxicity of chemoradiotherapy (CRT).We investigated the effect of HIV status in the incidence of neutropenia associated with cisplatin-based CRT for CC and its impact in treatment completion.This is a single-center retrospective cohort study. Data collection was performed for all the consecutive stage Ib-IV CC women treated with cisplatin-based CRT from 2012 to 2016, and with known HIV status.Sixty-one patients were included, 6 were HIV+. HIV+ patients had a higher risk of neutropenia at any cycle during cisplatin CRT [adjusted odds ratio (OR) 7.3, 95% confidence interval (95% CI) 1.02-52.3; P = .05]. Despite the absolute differences, mean neutrophil count was nonsignificantly lower in HIV+ women, both at baseline [4455/µL (interquartile range, IQR: 1830-6689) vs 6340 (IQR: 1720-18,970) for HIV-, P = .98] and at the end of treatment [1752/µL (IQR: 1100-2930) vs 3147/µL (IQR: 920-18,390) in HIV-; P = .06]. Moreover, when considering the effect of time, CRT seems to induce a consistent drop of neutrophils in both groups (P = .229). No febrile neutropenia events occurred.In HIV+ women, there were more CT cycle delays (P = .013), patients were more prone to use granulocyte colony-stimulating factor (G-CSF; HIV+ 40.0% vs HIV- 4.0%; P = .04) and less likely to complete at least 5 cycles of cisplatin (P = .02). All patients received adequate dose of pelvic RT, regardless of HIV status.HIV+ patients have a significantly increased risk of neutropenia during CRT treatment for CC and are less likely to complete chemotherapy with cisplatin.