Contact sensitization in pediatric patients with atopic dermatitis: a purpose for a new patch testing serie for the Portuguese population.

Summary: Atopic dermatitis is a common illness in pediatric age. Children with atopic dermatitis are prone to develop cutaneous sensitization due to skin barrier dysfunction and immune dysregulation. Recent studies have shown a higher prevalence of certain allergens, which identification may be clinically relevant and have implications for atopic dermatitis management. Considering the most prevalent and relevant allergens based on a retrospective analysis of 145 pediatric patients, 44.1% (n = 63) with atopic dermatitis, and comparing the positive results, we propose the application of an adapted baseline series with the most relevant 20 allergens for the Portuguese pediatric population with atopic dermatitis with recommendation for an evaluation of allergic contact dermatitis.

Water assessment using ultra-weak bioluminescence.

In this paper a method to evaluate the presence of microorganisms of the coliform group in water samples using the ultra-weak bioluminescence (UWB) is proposed. A series of UWB measurements and optical density measurements from cultures of both a set of standard E. coli strain samples, and a set of water samples from a river near Curitiba City in Brazil were performed. All samples were previously incubated at 37°C for 11h in nutritive medium before the temporal UWB emission profiles data were acquired for a period of 24h inside a dark chamber of an especially implemented instrumentation capable of doing photon counting measurements. For the optical density measurements, a spectrophotometer was used to acquire the growth kinetics of those cultures for a period of 13h, and the results compared to the UWB profiles. Periodic time-components analysis of the UWB data from both the set of standard E. coli samples and the set of the river's water samples were performed and compared to each other. The results have shown that the UWB temporal profiles resemble in some way the growth kinetics curve and the periodic time-components analysis is an effective way to discriminate between contaminated and non-contaminated samples, therefore the method may be viable for detecting coliforms in water samples in less time than usual methods.

Epicardial fat accumulation, cardiometabolic profile and cardiovascular events in patients with stages 3-5 chronic kidney disease.

BACKGROUND: It has been hypothesized that epicardial adipose tissue (EAT) exerts pathogenic effects on cardiac structures. We analysed the associations between EAT and both cardiovascular (CV) disease risk factors and CV events in patients with chronic kidney disease (CKD). PATIENTS AND METHODS: We included 277 nondialysed patients [median age 61, interquartile range (IQR) 53-68 years; 63% men] with stages 3-5 CKD in this cross-sectional evaluation. EAT and abdominal visceral adipose tissue (VAT) were assessed by computed tomography. Patients were followed for median 32 (IQR 20-39) months, and the composite of fatal and nonfatal CV events was recorded. RESULTS: With increasing EAT quartiles, patients were older, had higher glomerular filtration rate, body mass index, waist, VAT and coronary calcification, higher levels of haemoglobin, triglycerides, albumin, C-reactive protein and leptin and higher prevalence of left ventricular hypertrophy and myocardial ischaemia; total and high-density lipoprotein cholesterol, 25-hydroxy-vitamin D and 1, 25-dihydroxy-vitamin D progressively decreased. Associations between EAT and cardiac alterations were not independent of VAT. During follow-up, 58 CV events occurred. A 1-SD higher EAT volume was associated with an increased risk of CV events in crude [hazard ratio (HR) 1.41, 95% confidence interval (CI) (1.12-1.78) and adjusted (HR 1.55, 95% CI 1.21-1.99) Cox models. However, adding EAT to a standard CV disease risk prediction model did not result in a clinically relevant improvement in prediction. CONCLUSION: Epicardial adipose tissue accumulation in patients with CKD increases the risk of CV events independent of general adiposity. This is consistent with the notion of a local pathogenic effect of EAT on the heart or heart vessels, or both. However, EAT adds negligible explanatory power to standard CV disease risk factors.

Epicardial fat accumulation, cardiometabolic profile andcardiovascular events in patients with stages 3–5 chronickidney disease

Cordeiro AC, Amparo FC, Oliveira MAC,Amodeo C, Smanio P, Pinto IMF, Lindholm B,Stenvinkel P, Carrero JJ (Karolinska Institutet,Stockholm, Sweden; Dante Pazzanese Institute ofCardiology, S~ao Paulo; Dante Pazzanese Institute ofCardiology, S~ao Paulo; Dante Pazzanese Instituteof Cardiology, S~ao Paulo; Dante Pazzanese Instituteof Cardiology, S~ao Paulo, Brazil). Epicardialfat accumulation, cardiometabolic profile andcardiovascular events in patients with stages3–5 chronic kidney disease.

Effectiveness of thalidomide and tamoxifen in preventing neointimal hyperplasia in experimental vascular injury in rats.

INTRODUCTION: Chronic allograft vasculopathy is an important cause of graft loss. Considering the inflammatory response in the development of chronic vascular lesions, therapeutic approaches to target the inflammatory process may be useful. We sought to investigate the possible protective effects on balloon catheter-induced vascular injury of thalidomide and tamoxifen, 2 drugs with powerful anti-inflammatory, immunomodulatory, and antifibrotic effects, using an animal model that mimics the morphologic features of chronic allograft vasculopathy. METHODS: Male Wistar rats subjected to balloon catheter carotid injury (INJ) were treated with thalidomide (100 mg/kg), or tamoxifen (10 mg/kg), or vehicle. Contralateral right carotid arteries were used as uninjured controls. Morphometric and immunohistochemical analyses were performed at 14 days postinjury. RESULTS: Injured carotid arteries showed marked neointimal hyperplasia, which was significantly inhibited among animals treated with thalidomide or tamoxifen: neointimal/media ratios of 1.4 +/- 0.4 versus 0.2 +/- 0.1 versus 0.4 +/- 0.2, for INJ, INJ + Thalid, and INJ + Tamox; respectively (P < .001). The endothelial cell loss was significantly less pronounced among animals subjected to carotid balloon injury that were treated with thalidomide (24 +/- 14 vs 1 +/- 1 cells per section in INJ, respectively (P < .05). Therapy with either thalidomide or tamoxifen effectively maintained alpha-smooth muscle actin expression in the media, similar to uninjured arteries. In this setting, tamoxifen was additionally effective to prevent the migration of myofibroblasts in to the intima. CONCLUSION: Thalidomide and tamoxifen were effective to reduce neointimal hyperplasia secondary to vascular damage. The vasculoprotective effects of thalidomide were more pronounced to preserve endothelial cells, whereas tamoxifen inhibited smooth muscle cell migration and proliferation. A possible beneficial effect of combined therapy with thalidomide plus tamoxifen should be addressed in future studies.

Influence of single-nucleotide polymorphisms on C-reactive protein levels in chronic kidney disease before and after kidney transplantation.

INTRODUCTION: We sought to evaluate 2 single-nucleotide polymorphisms (SNPs) in the C-reactive protein (CRP) gene promoter region for their effects on CRP levels in chronic kidney disease (CKD) patients before and after a successful kidney transplantation. METHODS: Fifty CKD patients were evaluated before and at the first and second years after the graft. Two SNPs were studied, a bi-allelic (G-->A) at the -409 and a tri-allelic (C-->T-->A) variation at the -390 position in the CRP gene. RESULTS: All patients presented the -409GG genotype. At the -390 position, the "A" allele was not found; there were 15 "CC" patients, 11 "TT" patients, and 24 "CT" patients. CRP levels were different among patients with various genotypes (P < .019). Also the presence of the allele "T" was sufficient to determine differences in CRP levels both in pretransplantation (P = .045) and at 1 year posttransplantation (P = .011), but not at the second year (P = .448). CONCLUSION: SNPs at the -390 position of the CRP gene promoter region influence CRP basal levels in such a way that the "C" allele correlated with the lowest and the "T" with the highest. We did not observe this influence in our patients at the second year posttransplantation.

[Applied anatomy of the superior laryngeal nerve and surgical prophylactics of its lesions].

The article gives a brief historical reference on the discovery and investigation of the superior laryngeal nerve, the anatomical and clinical exploration of its topography, physiology and pathophysiology, as well as main variants of the correlations of the external branch of the nerve and the superior thyroid artery. The importance of superior laryngeal nerve is shown in the voice-forming function of the larynx. The incidence and main methods of prevention of intraoperative lesions of the nerve are described. The authors consider the potentials of clinical and instrumental diagnostics, as well as the effectiveness of treatment of traumas of the exterior branch of the superior laryngeal nerve during surgery for diseases of the thyroid gland.

Treatment of inflammatory myopathies.

Idiopathic inflammatory myopathies, notably polymyositis and dermatomyositis are comparatively uncommon diseases and few randomised, double blind placebo controlled trials have been done. Final validation of measures to assess outcome and response to treatment is awaited. Corticosteroids are an effective initial treatment, although rarely tested in randomised controlled trials. Unfortunately, not all patients respond to them and many develop undesirable side effects. There is thus a need for second line agents notably immunosuppressives or intravenous immunoglobulin. There are no defined guidelines or best treatment protocols agreed internationally and so the medical approach must be individualised, based on the severity of clinical presentation, disease duration, presence of extramuscular features, and prior therapy and contraindications to particular agents. There is still a significant percentage of non-responders (around 25%) and clinical relapses. Novel therapeutic approaches are now directed towards cytokine modulation and the use of monoclonal antibodies targeting B and T cells.

[Cervical perforating foreign body: case report]. / Corpo estranho perfurante cervical: relato de caso.

BACKGROUND: Neck perforations by foreign bodies are uncommon. The surgical approach depends on the extension of visceral wounds and the development of cervical or mediastinal infection. PURPOSE: The objective of this paper is to report a neck perforation trauma by a piece of wire, with associated laryngeal and hypopharyngeal wounds and extensive cervico-mediastinal emphysema. Anatomic and clinical correlations are discussed, as well as the management of the case. MATERIAL AND METHODS: A 28-year-old male patient suffered a perforating trauma in his neck by a piece of wire. This foreign body was laid in the retropharyngeal space, at the level of the sixth cervical vertebra, after perforating the larynx and hypopharynx. There are no similar cases previously reported. The imaging tests are presented. Despite the potential severity of the lesions, the patient had a favorable outcome, and no surgical approach was necessary. CONCLUSIONS: This case illustrates, by the imaging tests, the complex anatomy of the cervical fasciae and deep neck spaces, and confirms the possibility of conservative management in a great number of laryngeal and hypopharyngeal traumatic lesions.

Corpo estranho perfurante cervical: relato de caso / Cervical perforating foreign body: case report

As perfurações cervicais por corpos estranhos são incomuns. Sua abordagem cirúrgica depende do grau de lesão das vísceras cervicais e do desenvolvimento de sinais e sintomas de infecção cérvico-mediastinal. OBJETIVO: O presente artigo objetiva registrar a ocorrência de trauma perfurante cervical por fragmento de arame com lesão de laringe e hipofaringe dando origem a extenso enfisema cérvico-mediastinal. Correlações anátomo-clínicas e a conduta adotada são discutidas MATERIAL E MÉTODOS: O caso relatado é o de um indivíduo de 28 anos, do sexo masculino, vítima de ferimento perfurante na região cervical anterior por fragmento de arame. O corpo estranho assestou-se no espaço retrofaríngeo do doente, ao nível da 6a vértebra cervical, após perfurar a laringe e a hipofaringe. Não há caso semelhante relatado na literatura. A documentação radiológica do caso é apresentada. Apesar da potencial gravidade das lesões, o doente evoluiu bem e não necessitou de tratamento cirúrgico. CONCLUSÕES: O caso em questão, além de ilustrar, através dos exames de imagem, a complexa anatomia das fáscias e dos espaços cervicais profundos, demonstra a possibilidade da aplicação do tratamento conservador em grande parte das lesões traumáticas de laringe e hipofaringe.

Primary hyperparathyroidism in children: patient report and review of the literature.

Although primary hyperparathyroidism has rarely been described in pediatric patients, prompt diagnosis can avoid severe CNS and metabolic consequences. The aim of this paper is to report a 6 year-old girl whose first symptoms began at eight days of age with cyanosis, hypotonia, and upward gaze deviation. At 4 months, she was admitted due to neurologic disorders and recurrent infection, but the definite diagnosis was made only six years later. Her serum calcium levels are among the highest ever reported in the medical literature, reaching 25.5 mg/dl (6.36 mmol/l). Hypercalcemia, very high levels of parathormone (1550 ng/l--normal range 10-65) and bone deformities posed no problem to diagnosis when she first came to our attention. Nephrocalcinosis and impaired renal function were detected and this child had to be treated with diuretics (furosemide) and hydration that were able to lower her serum calcium levels. Imaging studies including 99mTc-sestamibi scan were not diagnostic. At surgery, the four parathyroid glands were mildly enlarged, with primary hyperplasia. The four glands were removed, cryopreserved, and 14 fragments (1 mm each) were autotransplanted to the braquioradial muscle of the left forearm. After a first phase of hypocalcemia (hungry-bone syndrome), treated with calcium and calcitriol, the calcium levels stabilized. The question is whether she will experience some degree of recovery from her neurological problems, since her severely high calcium levels have been maintained for such a long time.

Parathyroid carcinoma.

BACKGROUND: Parathyroid carcinoma is rare and represents 0.1% to 5% of the cases of hyperparathyroidism. New accounts are important to the understanding of these tumors. Experience in 9 cases is reported. METHODS: From 1970 to 1995, 10 patients with parathyroid carcinoma demonstrated by clinical course or pathologic features of malignancy were treated. The patient's clinical data, laboratory and imaging examinations, surgical findings, pathology, recurrences, and survival were analyzed. RESULTS: One male patient was excluded because of insufficient data. Average age was 51 years, with female:male ratio of 2:1. Average calcium level was 14,3 mg/dL. Palpable mass was found in 55%, bone disease in 89%, and renal disease in 78%. Four patients were reoperations. Five were operated on for hyperparathyroidism (1/tertiary). Capsular invasion was the most incident pathologic feature. Local recurrence occurred in 55%; neck node and bone metastasis in 11%, and lung in 33%. Two patients are alive and 5 died of disease. CONCLUSIONS: Parathyroid carcinoma has clinical and laboratory features that can help diagnosis at the first surgery. It seems to have variable malignancy.

Low prevalence of human papillomavirus in a geographic region with a high incidence of head and neck cancer.

BACKGROUND: The main purpose of this study was to determine the prevalence of human papillomavirus (HPV) infection in patients with head and neck carcinomas from Brazil. MATERIALS AND METHODS: Forty-five patients with head and neck squamous cell carcinoma were included in the study, from 1995 to 1996. Forty-two were male and 3 female, with age ranging from 32 to 82 years (median 61). Five patients (11%) did not have previous history of use of tobacco and 38 (90.5%) were heavy smokers. Tumor sites were pyriform sinus, 10; tongue, 11 (oral, 6; base, 5); larynx, 7; floor of mouth, 3; tonsil, 6; retromolar area, 3; inferior gingiva 2; buccal mucosa, 2; and maxillary sinus in 1 patient. Twenty-five were stage IV, 17 stage III, and 3 stage II. RESULTS: The presence of HPV DNA was detected in 5 of 45 patients (11%), all of them with HPV 16. Two patients had HPV DNA in normal mucosa and tumor tissue, 1 patient had HPV DNA only in the normal mucosa and tumor tissue, 1 patient had HPV DNA only in the normal mucosa, and 2 patients were positive for HPV DNA in tumor tissue. Four patients were male and 1 was female; 2 patients were nonsmokers. Three patients had tonsil carcinoma, 1 patient had a tongue carcinoma, and 1 patient had a pyriform sinus cancer. CONCLUSIONS: The role of chemical carcinogens seems to be more important in the genesis of head and neck cancer than is HPV infection. The presence of HPV DNA in 5 of 45 patients stimulates further investigation to determine the role of HPV as a risk factor for head and neck carcinoma.

[Incidence of oral cancer profile at a general hospital in Säo Paulo]. / Perfil de incidência do câncer oral em um hospital geral em São Paulo.

Cancer of the oral cavity are 4% of all cancers, being in 8th place in males and 11th in females. The world incidence in male sex is 7.9:100,000 and 2.2:100,000 in females. Squamous cell carcinoma is the most frequent, corresponding to 90-95% of the cases and tongue, lips and floor of the mouth are the most common sites. Fifty-four patients were surgically treated for cancer of the oral cavity in a General Hospital in São Paulo, during last ten years. It occurs more in males (81.5%), the age ranges of 35-97, with mean age of 58.1 years. Smoking was associated in 88.9%, at the time of treatment 50% of the patients had history of disease inferior of 6 months and 42% were T2 and 38% T4. These results agree with international literature and emphasize the importance of preventive aspects of this cancer.

Os espaços cervicais profundos e seu interesse nas infecçoes da regiäo / Deep neck spaces and their interest in cervical infections

As infecçoes dos espaços cervicais profundos, embora raras, associam-se a alta morbi-mortalidade. A abordagem cirúrgica faz-se necessaria na maioria dos casos e se baseia no conhecimento da complexa anatomia das fascias cervicais e dos espaços cervicais profundos. Objetivo. Apresentar consideraçoes anatomicas de interese pratico sobre fascias e espaços do pescoço, sua conceituaçao e nomenclatura, relatando, a título de exemplo, quatro casos de infecçoes dos espaços cervicais profundos. Material e Método. Sao apresentados um caso de angina de Ludwig complicada com mediastinite, pericardite, pneumonia, empiema pleural, fístula esofagica e choque séptico, um caso de abscesso cervical espontâneo em paciente diabético, um caso de abscesso de loja submandibular e um caso de abscesso parafaríngeo iniciado após manipulaçao dentaria. Nos quatro casos, a documentaçao imagenológica é rica e, em dois deles, evidencia o comprometimento de mais e um espaço profundo do pescoço. Conclusoes. A literatura enfatiza morbidade e mortalidade elevadas, etiologia diversificada (infecçoes dentarias, uso de drogas endovenosas, infecçoes do trato aerodigestivo alto e outras), a necessidade de traqueostomia em cerca de 50 por cento dos casos e o emprego da terapêutica combinada (antibioticoterapia e abordagem cirúrgica do pescoço). Os métodos imagenológicos, como a tomografia computadorizada, sao imprescindíveis no estudo de infecçoes dos espaços profundos do pescoço, tanto para a avaliaçao do sítio e extensao da afecçao, como para o planejamento terapêutico.

[Deep neck spaces and their significance in cervical infections]. / Os espaços cervicais profundos e seu interesse nas infecções da região.

BACKGROUND: Although rare, deep neck space infections are associated with high morbidity and mortality rates. The surgical approach is necessary in the majority of the cases, and the surgeon must know the complex anatomy of the cervical fasciae and deep neck spaces. PURPOSE: The anatomy of the cervical fasciae and deep neck spaces in reviewed. As an illustration, a series of deep neck space infections is presented. MATERIAL AND METHOD: Four clinical cases are reported: 1) a case of Ludwig's angina with several complications (mediastinitis, pericarditis, pneumonia, pleural effusion and empyema, esophageal fistula and septic shock), 2) a case of cervical abscess that appeared without apparent cause, in a young diabetic patient, 3) a case of abscess of the submandibular triangle, and 4) a case of parapharyngeal abscess that came forth after a dental treatment. Data from history taking, physical examination, X-rays, echography, CT scan and treatment and the follow-up are presented. The image tests were valuable and, in two of the cases, they demonstrated that more than one deep neck space were affected. CONCLUSIONS: The literature reinforces the high mortality and morbidity rates, the diversified etiology (dental infection, intravenous drug abuse, infections of the upper aerodigestive tract and others), and the tracheostomy indication made in about half of the cases. It stresses also the need for combined therapy (antibiotics and surgery). Evaluation with CT scan and other radiologic methods is indispensable to determine the site and extent of the process and to plan properly the treatment.

Site of peptic ulcer. comparison of hydrochloric acid output, pepsinogen and gastrin serum levels.

BACKGROUND/AIMS: Basal (BAO) and maximum (PAO) hydrochloric acid output after Histalog stimulation, basal pepsinogen (SPL-B), at 60 (SPL-60) and at 90 minutes (SPL-90), and basal gastrin (BG) levels were measured and compared in different gastric (GU) and duodenal (DU) ulcer sites. MATERIAL AND METHODS: Fifty nine patients with peptic ulcer were grouped according to Johnson's classification for gastric ulcers: type I (15), type II (16) type III (12) GU and (16) DU. Fifteen normal subjects were studied as controls. RESULTS: The BAO was greater in the DU than in the control or GU groups. No significant difference was noted in the production of hydrochloric acid after stimulation with Histalog. The SPL-B, at 60 and at 90 minutes was higher in type II GU than in the DU group and controls. The SPL-60 was higher in type II GU patients than in type III GU. Basal gastrin was higher in group DU and types II and III GU compared to the type I GU patients and controls. CONCLUSION: The topographic criteria for differentiating peptic ulcers has low discrimination capacity based on comparison of mean values of HCl acid production, pepsinogen and gastrin serum levels both basal and after stimulation with Histalog due to heterogeneity of these variables in group studies. In these studies, peptic ulcers from different sites should not be grouped as distinct entities except for type II gastric ulcers.

Posterior trapezius myocutaneous flap.

Since last decade, myocutaneous flaps have appeared among the most versatile and safest options for the reconstruction of defects caused by large oncological resections, in the head and neck area. Undoubtedly, the myocutaneous flap of the pectoralis major muscle is the most widespread and accepted, due to the long experience obtained through its use. Nevertheless, it presents some restrictions related not only to its rotation arch, but also to the esthetic consequences for the donor site in females. Over the last years, there has been a growing interest in the posterior trapezius myocutaneous flap (PTMF), which proved to be a valuable alternative for reconstruction in selected cases. The experience of the Department of Head and Neck Surgery, at the University of São Paulo Medical School-Hospital das Clínicas, using this technique, is reported here in a detailed description.

[Early detection of medullary thyroid carcinoma in multiple endocrine neoplasia type II]. / Detecção precoce do carcinoma medular de tireóide na neoplasia endócrina múltipla tipo II.

The early diagnosis of medullary thyroid carcinoma was made in two among six examined siblings belonging to two sibships that were offsprings of multiple endocrine neoplasia type II parents. The calcitonin secretory reserve was determined by a combined test using Ca++ (2 mg/kg) and pentagastrin (0.5 mcg/kg), intravenously. Two abnormal tests made on different days supported the diagnosis. Basal calcitonin levels were moderately high (90-500 pg/ml; NL = 15-85 pg/ml) and peak levels were also abnormal (480-1500 pg/ml; NL less than 320 pg/ml), in both cases. Total thyroidectomy associated to prophylactic resection of lymph nodes from central neck region were performed in both. A small nodule (3-5 mm) was found in each lobe in both cases. Pathological and immunocytochemical data supported the diagnosis of medullary thyroid carcinoma. C-cell hyperplasia was present in the peritumoral zones. Pheochromocytoma and definite hyperparathyroidism were not detected in these cases. Two years after surgery, basal and stimulated serum calcitonin levels remained normal. Carcinoembryonic antigen levels were and continue to be normal, in both. These seem to be the first cases published in this country in which this early diagnosis was made.