The spectral profile of cortical activation during a visuospatial mental rotation task and its correlation with working memory.

Introduction: The search for a cortical signature of intelligent behavior has been a longtime motivation in Neuroscience. One noticeable characteristic of intelligence is its association with visuospatial skills. This has led to a steady focus on the functional and structural characteristics of the frontoparietal network (FPN) of areas involved with higher cognition and spatial behavior in humans, including the question of whether intelligence is correlated with larger or smaller activity in this important cortical circuit. This question has broad significance, including speculations about the evolution of human cognition. One way to indirectly measure cortical activity with millisecond precision is to evaluate the event-related spectral perturbation (ERSP) of alpha power (alpha ERSP) during cognitive tasks. Mental rotation, or the ability to transform a mental representation of an object to accurately predict how the object would look from a different angle, is an important feature of everyday activities and has been shown in previous work by our group to be positively correlated with intelligence. In the present work, we evaluate whether alpha ERSP recorded over the parietal, frontal, temporal, and occipital regions of adolescents performing easy and difficult trials of the Shepard-Metzler's mental rotation task, correlates or are predicted by intelligence measures of the Weschler's intelligence scale. Methods: We used a database obtained from a previous study of intellectually gifted (N = 15) and average intelligence (N = 15) adolescents. Results: Our findings suggest that in challenging task conditions, there is a notable difference in the prominence of alpha event-related spectral perturbation (ERSP) activity between various cortical regions. Specifically, we found that alpha ERSP in the parietal region was less prominent relative to those in the frontal, temporal and occipital regions. Working memory scores predict alpha ERSP values in the frontal and parietal regions. In the frontal cortex, alpha ERSP of difficult trials was negatively correlated with working memory scores. Discussion: Thus, our results suggest that even though the FPN is task-relevant during mental rotation tasks, only the frontal alpha ERSP is correlated with working memory score in mental rotation tasks.

Implicit motor imagery performance and cortical activity throughout the menstrual cycle.

Studies show that female motor and visuospatial skills are modulated by the menstrual cycle. Implicit motor imagery, meaning the involuntary imagination of movements during a task, involves kinesthetic, visual, and spatial aspects of the corresponding action and can be investigated by using the hand laterality judgment task (HLJT). In this study we aimed to investigate whether implicit motor imagery performance and cortical activity are altered throughout the menstrual cycle, as demonstrated by motor skills in females. Thus, 31 healthy women underwent HLJT during the menstrual, follicular and luteal phases of their menstrual cycles. Right-handed participants had to recognize the laterality (right or left) of hands presented in different views (palm or back) and orientations on a computer screen. Test performance and EEG event-related potentials were analyzed. Participants performed better in the test in the follicular and luteal phases when compared to the menstrual phase, and the accuracy of the test was positively correlated with estradiol levels in the follicular phase. The difference between medial and lateral hand orientations for rotation-related negativity was significant in the medial and left parieto-occipital regions only in the follicular phase. These findings suggest positive modulating action of estradiol in performing implicit motor imagery.

Effect of the Menstrual Cycle on Electroencephalogram Alpha and Beta Bands During Motor Imagery and Action Observation.

Female sex steroids (FSS) can affect the motor system, modulating motor cortex excitability as well as performance in dexterity and coordination tasks. However, it has not yet been explored whether FSS affects the cognitive components of motor behavior. Mu is a sensorimotor rhythm observed by electroencephalography (EEG) in alpha (8-12 Hz) and beta (15-30 Hz) frequency bands in practices such as motor imagery (MI) and action observation (AO). This rhythm represents a window for studying the activity of neural circuits involved in motor cognition. Herein we investigated whether the alpha-mu and beta-mu power in the sensorimotor region (C3 and C4, hypothesis-driven approach) and the alpha and beta power over frontal, parietal, and occipital regions (data-driven approach) are modulated differently in the menstrual, follicular, and luteal phases of menstrual cycles in right-handed dominant women. To do so, these women underwent MI and AO in the three menstrual cycle phases. The spectral activity of the cortical regions for the alpha and beta bands were compared between phases of the menstrual cycle and a correlation analysis was also performed in relation to estrogen and progesterone levels. For the hypothesis-based approach, beta-mu event-related desynchronization (ERD) was significantly stronger in the C3 channel in the follicular phase than in the menstrual and luteal phases. For the data-driven approach, beta ERD during MI was higher in the follicular phase than in the menstrual and luteal phases in the frontal region. These findings suggest the effect of FSS on executive movement control. No effect of menstrual cycle phases was observed in cortical areas investigated during OA, but alpha and beta bands correlated positively with the follicular phase plasma estradiol level. Thus, the attenuation of alpha and beta bands referring to mirror neuron activities appears to be associated with inhibition of cortical activity when estradiol levels are lower, improving cognitive processing of motor action.

RIGHT AORTIC ARCH ASSOCIATED WITH AGENESIS OF THE LEFT INTERNAL CAROTID ARTERY - AN EXTREMELY RARE CASE REPORT.

INTRODUCTION: A right aortic arch and agenesis of internal carotid artery (ICA) are both extremely rare vascular devel- opment anomalies. Etiology of the both anomalies might be associated with the abnormal regression of the dorsal aorta. Most cases of ICA are asymptomatic due to sufficient collateral circulation and it is usually an incident finding on head and neck imaging by color Doppler ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI). ICA agenesis has a significant association - 24-67% - with intracranial aneurysms and their early detection can spare the patient serious complications. CLINICAL CASE: A 28-year-old male had a single episode of hypertension that motivated the realization of several tests. During the investigation he was submitted to a duplex ultrasonography that revealed a diffuse narrowing of the left common carotid artery (CCA), with a markedly decrease in the peak systolic velocity and the absence of the left internal carotid artery (ICA) was suspected. Contrast-enhanced computed tomography (CT) demonstrated no abnormalities, such as cerebral infarc- tion or intracranial vascular malformations, but confirmed a right-sided aortic-arch, with anomalous origin of the left subcla- vian artery with a common origin of both CCAs and the absence of the left ICA. Examination of the head CT in bone window demonstrated an absence of the left internal carotid canal. CONCLUSION: This clinical case emphasizes the importance of recognizing this condition due to the associated hemody- namic changes and in order to discover and evaluate other additional vascular malformations (aneurysms, collateral channels) and their life threatening potential risks (subarachnoid hemorrhage or ischemia). Also, it has a special importance in case of planning carotid or trans-sphenoidal hypophyseal surgery. To our knowledge, only 8 cases have been reported right aortic arch associated with agenesis of the left internal carotid artery.

Sleep during COVID-19 lockdown: A cross-cultural study investigating job system relevance.

Our study aimed to assess the change in the sleep patterns during the Coronavirus lockdown in five regions (Austria/Germany, Ukraine, Greece, Cuba and Brazil), using online surveys, translated in each language. Part of the cohort (age 25-65, well-educated) was collected directly during lockdown, to which retrospective cross-sectional data from and after lockdown (retrospective) questionnaires were added. We investigated sleep times and sleep quality changes from before to during lockdown and found that, during lockdown, participants had (i) worse perceived sleep quality if worried by COVID-19, (ii) a shift of bedtimes to later hours during workdays, and (iii) a sleep loss on free days (resulting from more overall sleep during workdays in non-system relevant jobs), leading to (iv) a marked reduction of social jetlag across all cultures. For further analyses we directly compared system relevant and system irrelevant jobs, because it was assumed that the nature of the lockdown's consequences is dependent upon system relevance. System relevant jobs were found to have earlier wake-up times as well as shorter total sleep times on workdays, leading to higher social jetlag for people in system relevant jobs. Cultural differences revealed a general effect that participants from Greece and Ukraine had later bedtimes (on both work and free days) and wake-up times (on workdays) than Cuba, Brazil and Austria, irrespective of COVID-19 lockdown restrictions.

Neuroendocrine appendiceal tumor and endometriosis of the appendix: a case report.

INTRODUCTION: Endometriosis of the appendix is very uncommon, accounting for only about 1% of all cases of endometriosis. However, endometriosis is found in the appendix in approximately 8-13% of patients with deep infiltrating endometriosis and is particularly common in patients with severe forms of deep infiltrating endometriosis. Neuroendocrine tumors are the most common neoplasms of the appendix and may be misdiagnosed when there are multiple endometriosis lesions in the pelvis. CASE PRESENTATION: We describe a case of a Caucasian patient with deep infiltrating endometriosis with rectal involvement, retrocervical lesions, and a right ovarian endometrioma with no suspected lesions in the appendix. She underwent laparoscopy and, after a systematic intraoperative evaluation, suspected involvement of the appendix was observed. The patient underwent ovarian cystectomy, excision of the pelvic endometriosis lesions, appendectomy, and anterior stapler discoid resection. Histopathological analysis of the appendix revealed endometriosis and a well-differentiated neuroendocrine carcinoma at the appendix tip. DISCUSSION: Our patient's case emphasizes the need to approach these lesions carefully and strengthens the indication for appendectomy when the appendix is affected in the setting of endometriosis. Despite the more likely diagnosis of appendiceal endometriosis, neuroendocrine tumors cannot be ruled out by imaging examinations, and both conditions can occur in the same patient.

The role of frontal and parietal cortex in the performance of gifted and average adolescents in a mental rotation task.

Visual-spatial abilities are usually neglected in academic settings, even though several studies have shown that their predictive power in science, technology, engineering, and mathematics domains exceeds that of math and verbal ability. This neglect means that many spatially talented youths are not identified and nurtured, at a great cost to society. In the present work, we aim to identify behavioral and electrophysiological markers associated with visual spatial-ability in intellectually gifted adolescents (N = 15) compared to age-matched controls (N = 15). The participants performed a classic three-dimensional mental rotation task developed by Shepard and Metzler (1971) [33] while event-related potentials were measured in both frontal and parietal regions of interest. While response time was similar in the two groups, gifted subjects performed the test with greater accuracy. There was no indication of interhemispheric asymmetry of ERPs over parietal regions in both groups, although interhemispheric differences were observed in the frontal lobes. Moreover, intelligence quotient and working memory measures predicted variance in ERP's amplitude in the right parietal and frontal hemispheres. We conclude that while gifted adolescents do not display a different pattern of electroencephalographic activity over the parietal cortex while performing the mental rotation task, their performance is correlated with the amplitude of ERPs in the frontal cortex during the execution of this task.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function. The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO. Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017). The primary outcome of this study was to investigate the prevalence of cannulation-related complications on VA ECMO and to determine its effect on patient morbimortality. RESULTS: Eighty-two patients underwent ECMO during the period of study, 56,1% were male with a mean age of 55,8 years. The VA mode was used in 61 patients, 56 with peripheral cannulation. Femoral arterial access was established in 52 patients (73% percutaneously). Vascular complications were observed in 28,6% of the VA femoral ECMOs: 12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed limb ischemia. For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal: 8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction. There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation. CONCLUSIONS: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%). PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.

Confirmatory factor analysis of the Questionnaire on the Health Staff's Perceptions Regarding Doutores da Alegria's Interventions.

A confirmatory analysis was performed to validate the Questionnaire on the Health Staff's Perceptions Regarding Doutores da Alegria's Intervention, a 40-item instrument designed to assess pediatric staff's perceptions regarding the effects of Doutores da Alegria, a Brazilian hospital clowning professional organization. Eight dimensions were evaluated: the permanence of Doutores da Alegria's interventions; Doutores da Alegria's intrapersonal and interpersonal effects on their relation to health staff; themselves; staff-children; and staff-family relationships; as well as their effect on staff's cultural development; children's relation to their own disease; and families' attitude regarding their child's condition. In all, 567 health professionals from 13 Brazilian hospitals participated. The instrument's good psychometric features are acknowledged.

Arterial Vascular Complications in Peripheral Venoarterial Extracorporeal Membrane Oxygenation Support.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has been evolved as a life-saving measure for patients requiring emergent support of respiratory and cardiac function.The femoral artery is the standard site for vascular access when initiating adult venoarterial (VA) ECMO.Cannulation-related complications are a known source of morbidity and it has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications (up to 70%). In patients with severe peripheral arterial disease (PAD) these risks are even higher and its presence may be considered a relative contraindication for femoral artery cannulation. METHODS: Retrospective institutional review of patients requiring ECMO (January 2011-August 2017).The primary outcome of this study was to investigate the prevalence of cannulation- -related complications on VA ECMO and to determine its effect on patient morbimortality.We evaluated demographics and co-morbidities data.Patients were divided into two groups (complications present VS not present) and statistic analysis was performed to determine the impact of different variables such as co-morbidities,cannulation strategy and time on ECMO in each group.Operative reports were reviewed to analyze the surgical procedures implied for treating vascular complications. RESULTS: Eighty-two patients underwent ECMO therapy during the period of study, 56,1% were male with a mean age of 55,8 years.The median time on the ECMO device was 5,5 days.The VA mode was used in 61 patients, 56 with peripheral cannulation.Femoral arterial access was established in 52 patients (73% percutaneously).Vascular complications were observed in 28,6% of the VA femoral ECMOs:12 acute limb ischemias and 3 major hemorrhages. At the time of femoral cannulation, distal peripheral catheter (DPC) was placed in 5 patients and none developed subsequent limb ischemia.For those who developed limb ischemia, several interventions were performed: DPC placement in 9 cases, fasciotomy in 4 and 2 major amputations. Thirty patients underwent arterial cannulas open surgical removal:8 underwent balloon catheter trombectomy and 5 needed femoral reconstruction.There was an association between PAD (p=0,03) and ischemic cardiopathy (p=0,02;OR 4,5) with the present of vascular complications after ECMO implantation.VA femoral ECMO mortality was 69,2% (n=36).Vascular complications after ECMO support are not associated with higher mortality rates (p>0,05). CONCLUSION: Cannulation of femoral vessels remains associated with considerable rates of vascular events (28.6%).PAD and ischemic cardiopathy are associated with vascular complications in this form of cannulation.Physical examination and the assessment of ankle-brachial índex before ECMO implantation is therefore recommended.Improved efforts at preventing these complications need to be developed to avoid additional morbidity in an already critical patient population.

Rapid Pacing for Thoracic Endovascular Aortic Repair: a Case Report.

INTRODUCTION: Endovascular aortic interventions are suitable alternatives to open surgery, being less invasive and having lower mortality and complications. Accurate positioning of the stent graft is a critical point because of systolic thrush. Techniques used to prevent it include pharmacological (antihypertensive drugs, nitroglycerin, adenosine) and mechanical methods (temporary caval occlusion by balloon). Rapid Right Ventricular Pacing (RRVP) is an emerging alternative with good patient tolerance and low level of complications. METHODS: A 79 years-old male, American Society of Anaesthesiology (ASA) status 3 (hypertension, chronic obstructive pulmonary disease and hyperuricemia), with an aortic arch aneurysm previously submitted to an ascendant aortic debranching, was proposed for Thoracic Endovascular Aortic Repair (TEVAR). ASA standard, invasive blood pressure, depth of anaesthesia and cerebral oximetry monitoring were used. RESULTS: Patient was sedo-analgesiated with Midazolam 2mg and Fentanyl 100mcg. A flow directed Pacing catheter was passed through an 8.5FR introducer inserted in right internal jugular vein. RRVP was tested to a cardiac frequency of 180 without patient complaint. Two vascular Valiant Thoracic endoprosthesis were placed through a femoral access. At the time of testing position and prothesis deployment, RRVP was started and systolic blood pressure dropped to 50mmHg. After stopping the RRVP in both placements, normal rhythm and blood pressure were observed. No relevant changes in cerebral monitoring were found. Final angiography showed no endoleak of prosthesis. The patient was admitted at Post- -Anaesthetic Care Unit and discharged after 24hours. CONCLUSION: RRVP results in accelerated heart rate, with consequent decrease of intra-aortic blood flow, allowing more precise graft deployment without displacement, which is associated with lower incidence of endoleak. The faster onset of RRVP and rapid return to normal values can shorten the duration of the procedure. The procedure is done with minimal sedation, important in individuals with poor clinical status. This also allows to continually monitor the patient's neurologic status, possibly detecting any prosthetic displacement or acute event. Most complications are puncture- related. Rhythm-associated complications can occur in patients with heart diseases. In this case, no cardiac events were found. RRVP has been used in TEVAR with reliable results and is a good option for difficult cases. It's associated with a lower incidence of complications and less secondary effects than traditional measures, allowing to maintain patients with mild sedation, shortening hospital's length of stay. RRVP seems to be advantageous over traditional methods of controlling blood pressure in patients submitted to TEVAR.

[Percutaneous Endovascular Aortic Repair with Local Anesthesia - One Day Surgery]. / Tratamento Endovascular do Aneurisma da Aorta Abdominal por Via Percutânea e Anestesia Local ­ One Day Surgery.

INTRODUCTION: To evaluate the results of the abdominal aortic aneurism endovascular treatment (EVAR), percutaneously and with local anesthesia, according to the concept of one day surgery. MATERIAL AND METHODS: Unicentric, retrospective analysis of patients with aorto-iliac aneurysmal disease, consecutively treated by EVAR with percutaneous access trough the Preclose technique (pEVAR), according to the outpatient criteria, with one overnight stay in the hospital. The technical success, exclusion of the aneurysmal sac, endoleak, re-intervention and mortality were evaluated. RESULTS: Twenty consecutive patients (all male; mean age 74.65 years) were treated by EVAR with percutaneous access and local anesthesia, from which 95% (19) presented with abdominal aortic aneurysm and 5% (1) common iliac aneurysm. All implants were sucessfully performed, with an initial endoleak rate of 10% (2), determined by one type 1a endoleak successfully corrected intra-operatively and one type 2a endoleak diagnosed in the first imaging control, which sealed spontaneously on the second control. Initial technical success for percutaneous closure was 97.5%, with one case reported of femoral pseudo-aneurism, posteriorly treated by percutaneous thrombin injection. Median length of stay was one day [1-10], with a mean follow-up of 11.4 months [1-36]. Both the re-intervention and mortality rate are 0% for the selected period. CONCLUSION: Our one day surgery model for the outpatient treatment of abdominal aortic aneurysm by the pEVAR technique is innovative, safe and effective, as long as the selection criteria are respected.

Introdução: Avaliar os resultados do tratamento endovascular do aneurisma da aorta abdominal (EVAR) por via percutânea e anestesia local, segundo o conceito de one day surgery.Material e Métodos: Análise retrospetiva, unicêntrica dos doentes com doença aneurismática aorto-ilíaca, consecutivamente submetidos a tratamento endovascular do aneurisma da aorta abdominal por via percutânea (pEVAR) pela técnica de Preclose, seguindo critérios de ambulatorização com pernoita após o procedimento. O sucesso técnico, exclusão do saco aneurismático, endoleak, reintervenção e tempo de internamento foram avaliados.Resultados: Vinte doentes consecutivos (todos homens, idade média 74,65 anos) foram tratados por pEVAR e anestesia local, dos quais 95% (19) apresentavam aneurisma da aorta abdominal e 5% (1) aneurisma da artéria ilíaca comum. Todos os implantes foram realizados com sucesso, com uma taxa de endoleak inicial de 10% (2), à custa de um endoleak 1a corrigido intraoperatoriamente com sucesso, e um endoleak 2a diagnosticado na primeira angio-tomografia computorizada pós-operatória, que selou espontaneamente no controlo aos 6 meses. O sucesso técnico inicial do encerramento percutâneo foi de 97,5%, com um caso reportado de pseudo-aneurisma femoral, corrigido posteriormente por injeção percutânea de trombina. A mediana de internamento foi de 1 dia [1-10], com follow-up médio de 11,4 meses [1-36]. A reintervenção e mortalidade são de 0% no período descrito. Conclusão: O tratamento ambulatório do aneurisma da aorta abdominal por via endovascular com acesso percutâneo segundo o nosso modelo de one day surgery é inovador, seguro e eficaz, respeitando os critérios de seleção.

Sistema adesivo universal e cimento resinoso universal em coroas cerâmicas: relato de caso / Universal adhesive system and resin cement for all-ceramics crowns: case report

A demanda por restaurações estéticas que mimetizem os dentes naturais é crescente, e as cerâmicas são uns dos materiais que melhor reproduzem as características do esmalte e da dentina. A cimentação adesiva é considerada uma etapa crítica, complexa e sensível. O cimento resinoso RelyX™ Ultimate (3M Espe) apresenta polimerização dual, excelente aderência e fácil manipulação. Sua associação com o Single Bond™ Universal (3M Espe) o torna um material prático e de fácil utilização, pois o adesivo funciona como agente de pré-tratamento para todo tipo de material restaurador, além de possuir ativador de polimerização química, o DCA (3M Espe). O objetivo deste trabalho é ressaltar, por meio de um relato de caso, as vantagens do uso do Cimento RelyX Ultimate associado ao Sistema Adesivo Single Bond Universal, na cimentação de uma coroa cerâmica IPS E-max (Ivoclar Vivadent) e de uma coroa metalocerâmica IPS d’Sign (Ivoclar Vivadent)...

The demand for esthetic restorations that mimic natural teeth is increasing, and ceramic materials best reproduce the characteristics of enamel and dentin. Adhesive cementation is considered a critical, complex and sensitive step. A dual-cure resin cement with excellent bonding properties and easy handling was used (RelyX™ Ultimate, 3M ESPE), associated with an universal adhesive system (Single Bond™ Universal, 3M ESPE). This adhesive system is user-friendly and acts as a pretreatment agent for all types of restorative material, in addition to have a chemical activator (DCA by 3M ESPE). The aim of this case report is to highlight the advantages of using an universal cement associated with an adhesive for cementation of all-ceramic crowns (IPS E-max and IPS d’Sign, Ivoclar Vivadent)...

Tratamento do enfisema pulmonar avançado: Cirurgia redutora de volume pulmonar ou broncoscopia? / Treatment of advanced emphysema: Surgery or bronchoscopy?

A doença pulmonar obstrutiva crônica (DPOC) é uma grande causa de morbidade e mortalidade. O enfisema pulmonar, uma das formas clínicas da DPOC, se caracteriza pelo desenvolvimento progressivo de aprisionamento aéreo, alterações da arquitetura alveolar e hiperinsuflação pulmonar. Sua história natural é a evolução para a doença pulmonar terminal e necessidade de transplante pulmonar. Entretanto, sabe-se que uma redução da hiperinsuflação pulmonar é capaz de reestabelecer algumas das propriedades mecânicas do sistema respiratório e assim melhorar os volumes e a função pulmonar destes pacientes, com melhora da qualidade de vida e sobrevida. Há pelo menos duas formas de tratamento invasivo,baseadas nestes princípios fisiopatológicos, disponíveis na prática clínica: a cirurgia redutora do volume pulmonar (CRVP) e a redução volumétrica endoscópica (REV). Desta forma, este artigo abordará os aspectos relacionados ao emprego da CRVP e da RVE, de modo a discutir as evidências que sustentam o uso destas técnicas no tratamento do enfisema pulmonar avançado, bem como duas limitações.

Cryptococcosis, silicosis, and tuberculous pseudotumor in the same pulmonary lobe.

Tuberculosis and cryptococcosis are infectious diseases that can result in the formation of single or multiple nodules in immunocompetent patients. Exposure to silica is known to raise the risk of infection with Mycobacterium tuberculosis. We report the case of an elderly man with no history of opportunistic infections and no clinical evidence of immunodeficiency but with a six-month history of dry cough and nocturnal wheezing. A chest X-ray revealed a mass measuring 5.0 × 3.5 cm in the right upper lobe. The diagnostic approach of the mass revealed tuberculosis. The histopathological analysis of the surrounding parenchyma reveled silicosis and cryptococcosis. Cryptococcosis was also found in masses identified in the mediastinal lymph nodes. The surgical approach was indicated because of the degree of pleuropulmonary involvement, the inconclusive results obtained with the invasive and noninvasive methods applied, and the possibility of malignancy. This case illustrates the difficulty inherent to the assessment of infectious or inflammatory pulmonary pseudotumors, the differential diagnosis of which occasionally requires a radical surgical approach. Despite the presence of respiratory symptoms for six months, the first chest X-ray was performed only at the end of that period. We discuss the possible pathogenic mechanisms that might have led to the combination of three types of granulomatous lesions in the same lobe, and we emphasize the need for greater awareness of atypical presentations of pulmonary tuberculosis.

Cryptococcosis, silicosis, and tuberculous pseudotumor in the same pulmonary lobe / Tuberculose pseudotumoral, criptococose e silicose no mesmo lobo pulmonar

Tuberculosis and cryptococcosis are infectious diseases that can result in the formation of single or multiple nodules in immunocompetent patients. Exposure to silica is known to raise the risk of infection with Mycobacterium tuberculosis. We report the case of an elderly man with no history of opportunistic infections and no clinical evidence of immunodeficiency but with a six-month history of dry cough and nocturnal wheezing. A chest X-ray revealed a mass measuring 5.0 × 3.5 cm in the right upper lobe. The diagnostic approach of the mass revealed tuberculosis. The histopathological analysis of the surrounding parenchyma reveled silicosis and cryptococcosis. Cryptococcosis was also found in masses identified in the mediastinal lymph nodes. The surgical approach was indicated because of the degree of pleuropulmonary involvement, the inconclusive results obtained with the invasive and noninvasive methods applied, and the possibility of malignancy. This case illustrates the difficulty inherent to the assessment of infectious or inflammatory pulmonary pseudotumors, the differential diagnosis of which occasionally requires a radical surgical approach. Despite the presence of respiratory symptoms for six months, the first chest X-ray was performed only at the end of that period. We discuss the possible pathogenic mechanisms that might have led to the combination of three types of granulomatous lesions in the same lobe, and we emphasize the need for greater awareness of atypical presentations of pulmonary tuberculosis.

A tuberculose e a criptococose são infecções que podem cursar com a formação de nódulos isolados ou múltiplos em pacientes imunocompetentes. A exposição à sílica reconhecidamente eleva o risco de doença pelo Mycobacterium tuberculosis. Apresentamos o caso de um paciente idoso sem antecedentes de infecções oportunistas, sem evidência clínica atual de imunodeficiência, com história de tosse seca e sibilos, principalmente noturnos, com duração de seis meses, cuja radiografia de tórax evidenciava uma imagem tumoral medindo 5,0 × 3,5 cm em lobo superior do pulmão direito. A abordagem diagnóstica da massa evidenciou tratar-se de tuberculose, e a análise histopatológica do parênquima circunvizinho revelou a presença de criptococose e de silicose. Criptococose foi diagnosticada também em massas linfonodais mediastinais. A conduta cirúrgica foi imposta pelo grau de comprometimento pleuropulmonar localizado, pelo caráter inconclusivo das abordagens diagnósticas invasivas e não invasivas realizadas, assim como pela possibilidade de tratar-se de neoplasia. Este caso ilustra a dificuldade inerente ao diagnóstico diferencial de massas pulmonares de natureza infecciosa ou inflamatória simulando neoplasia, o que ocasionalmente impõe uma conduta cirúrgica radical. Apesar da presença de sintomas respiratórios por seis meses, a primeira radiografia do tórax só foi realizada tardiamente. São discutidos os possíveis mecanismos patogenéticos que possam ter levado a associação de três tipos de granulomatose no mesmo lobo pulmonar e é enfatizada a necessidade de uma maior divulgação das apresentações atípicas da tuberculose pulmonar.

[False aneurysm of the superficial temporal artery. Clinical report and literature review]. / Falso aneurisma da artéria temporal superficial: caso clínico e revisão da literatura.

Traumatic injuries of the external carotid artery and its branches are relatively rare in clinical practice and they may occur following head injuries. The superficial temporal artery is particularly susceptible to injury, given to its superficial course and the fact that it is overlying the temporal bone. The authors report the clinical case of a 88 years-old female treated of a false aneurysm of the superficial temporal artery and they proceed to a review of the literature.

Possible cause-effect relation between estrogen and focal nodular hyperplasia: case report / Possível relação de causa-efeito entre estrogênio e hiperplasia nodular focal: relato de caso

A 22-year-old female patient sought medical care due to an asymptomatic solid nodule in the liver, incidentally diagnosed by abdominal ultrasound. She reported the use of an estrogen-based oral contraceptive for approximately 3 years. She denied smoking or alcohol drinking. Her mother had a history of nonalcoholic steato-hepatitis and her maternal grandmother had a hepatic hemangioma. Physical examination revealed an asymptomatic patient with discretely painful palpation of the right hypochondrium close to the xiphoid appendix. Ultrasound examination revealed a 5.9 x 4.1 cm hypoechogenic nodule in the left lobule and computed tomography revealed a 5.3 x 6.3 x 4.5 cm focal lesion in the 2/3 segments...

Paciente do sexo feminino, 22 anos, procurou auxílio médico devido a um nódulo sólido no fígado, assintomático, diagnosticado incidentalmente por ultrassonografia de abdome. Relatava uso de anticoncepcional oral, à base de estrógeno, por cerca de 3 anos. Negava tabagismo e etilismo. Mãe apresentava história de esteato-hepatite não alcoólica e avó materna era portadora de hemangioma hepático. Ao exame físico, apresentava-se assintomática, com palpação discretamente dolorosa do hipocôndrio direito próximo ao apêndice xifóide. Ao exame ultrasonográfico apresentava um nódulo hipoecogênico no lóbulo esquerdo de 5,9 x 4,1 cm e à tomografia computadorizada apresentava lesão focal nos segmentos 2/3 de 5,3 x 6,3 x 4,5 cm...

Fatores de risco de complicações pulmonares em pacientes com sarcoma após toracotomia para a ressecção de nódulos pulmonares / Risk factors for pulmonary complications in patients with sarcoma after the resection of pulmonary nodules by thoracotomy

OBJETIVO: Identificar os fatores de risco para complicações pulmonares em pacientes com sarcoma após serem submetidos a toracotomia para a ressecção de nódulos pulmonares. MÉTODOS: Estudo de coorte retrospectivo com 68 pacientes consecutivos com diagnóstico de sarcomas e submetidos a 174 toracotomias para a ressecção de nódulos pulmonares. A variável dependente foi definida como a ocorrência de qualquer complicação pulmonar pós-operatória. As variáveis independentes foram relacionadas com o paciente, o diagnóstico de base e o tipo de procedimento cirúrgico. Os dados foram analisados segundo um modelo multivariado de estimação de equações generalizadas, com uma função de ligação logística e uma estrutura de correlação simétrica. RESULTADOS: Houve 24 complicações (13,8 por cento; IC95 por cento: 9,0-19,8), incluindo um óbito. Os pacientes que apresentaram complicações pós-operatórias tiveram um tempo médio de internação duas vezes superior àqueles sem complicações (18,8 ± 10,0 dias vs. 8,6 ± 6,0 dias; p < 0,05). As variáveis que se correlacionaram com o desfecho foram o tipo de ressecção (em cunha ou anatômica; OR = 3,6; IC95 por cento: 1,5-8,8), necessidade de transfusão sanguínea (OR = 9,8; IC95 por cento: 1,6-60,1) e número de nódulos ressecados (OR = 1,1; IC95 por cento: 1,0-1,1). O modelo multivariado obtido exibiu uma área sob a curva ROC de 0,75 (IC95 por cento: 0,65-0,85). CONCLUSÕES: As complicações pulmonares pós-operatórias após a ressecção de nódulos pulmonares em pacientes com sarcoma não foram raras, ocorrendo em cerca de 10 por cento dos procedimentos. A ocorrência dessas complicações pode ser antecipada pelo uso de ressecção não em cunha, necessidade de hemotransfusão e maior número de nódulos ressecados. Assim, já no pós-operatório imediato, é possível identificar pacientes de risco, que devem ser estritamente monitorizados durante o período pós-operatório imediato. Para esses pacientes, todas as medidas preventivas devem ser tomadas.

OBJECTIVE: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. METHODS: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. RESULTS: Complications were observed in 24 patients (13.8 percent, 95 percent CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95 percent CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95 percent CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95 percent CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95 percent CI: 0.65-0.85). CONCLUSIONS: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10 percent of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

Relationship between plasma cells and hepatic stellate cells in autoimmune hepatitis.

Autoimmune hepatitis is an inflammatory chronic disease of the liver, which frequently results in cirrhosis. The present study aimed to verify the relationship between plasma cells and stellate cells in autoimmune hepatitis. Thirty-three pre-treatment, 11 post-treatment, and 10 normal liver biopsies were reviewed. Sirius Red staining (for semi-quantitative analysis of hepatic fibrosis) and immunohistochemistry were carried out: double staining for smooth muscle α-actin and plasma cell marker (for detection and localization of activated hepatic stellate cells and plasma cells, respectively); and single staining for glial fibrillary acid protein (for detection of hepatic stellate cells). We found an increase in the stellate cell population, mainly with an activated phenotype in autoimmune hepatitis, compared to the control group (liver specimens with no histological evidence of liver disease, obtained from patients undergoing hepatic resection for benign liver mass). A positive significant correlation was observed between stellate cells and scores of fibrosis (measured by Sirius Red) and the number of plasma cells. Additionally, there was a co-localization of plasma cells and activated stellate cells. We also observed a reduction in the number of plasma cells, hepatic stellate cells, and fibrosis in patients who had successfully been treated and had a second liver biopsy post-treatment. Our findings support that the number of plasma cells can be a surrogate marker for the severity of liver disease, reflecting the number of hepatic stellate cells and the amount of fibrosis. It remains to be seen if this is a result of a direct interaction between the plasma cells and hepatic stellate cells or the response to the same stimulus that affects both cellular types.