[The limping child: a red flag for every physician]. / Het mankend kind: een rode vlag voor iedere medicus.

A limping gait pattern in a child is a red flag for every physician until proven otherwise. Among the most common causes are coxitis fugax, infection (septic arthritis, osteomyelitis), Perthes disease, and slipped capital femoral epiphysis, depending on the age of the patient. A high index of suspicion is required because clinical findings are often subtle, and the diagnosis may be present even if initial radiographs are negative. A missed or delayed diagnosis may have devastating consequences. Therefore, this paper describes the main characteristics of different causes of a limping child, based on four typical cases. Tools are provided to recognize each diagnosis. Early referral to a paediatric orthopaedic surgeon is recommended.

Pneumonia in mechanically ventilated patients: no diagnostic and prognostic value of different quantitative tracheal aspirates thresholds.

BACKGROUND: Diagnosis of pneumonia in ventilated patients is challenging due to the lack of specific and definitive clinical symptoms, laboratory data or radiological abnormalities. METHODS: Based on quantitative tracheal aspirate (QTA) results, three groups of patients were compared: <105 cfu/ml, ≥105 cfu/ml and <106 cfu/ml, and ≥106 cfu/ml. We recorded demographic variables, underlying diseases and severity of illness at ICU admission. On the day of pneumonia diagnosis, we registered temperature, leukocyte count, C-reactive protein, Sequential Organ Failure Assessment (SOFA) score, clinical pulmonary infection score (CPIS) and adequacy of empirical antimicrobial therapy. RESULTS: In 231 episodes, clinical presentation, laboratory data, severity of illness, CPIS, the presence of bacteremia and radiological score did not differ among the three groups. ICU and hospital mortalities were also similar in the three groups. Factors independently associated with in-hospital mortality were age, SOFA score and inappropriate antimicrobial therapy. The bacterial burden in the QTA was not included in the model. CONCLUSIONS: Quantification of tracheal aspirate samples may not be necessary in ventilated patients clinically suspected of having nosocomial pneumonia.

Animal model for endoscopic neurosurgical training: technical note.

OBJECTIVE: The learning curve for endonasal endoscopic and neuroendoscopic port surgery is long and often associated with an increase in complication rates as surgeons gain experience. We present an animal model for laboratory training aiming to encourage the young generation of neurosurgeons to pursue proficiency in endoscopic neurosurgical techniques. METHODS: 20 Wistar rats were used as models. The animals were introduced into a physical trainer with multiple ports to carry out fully endoscopic microsurgical procedures. The vertical and horizontal dimensions of the paired ports (simulated nostrils) were: 35×20 mm, 35×15 mm, 25×15 mm, and 25×10 mm. 2 additional single 11.5 mm endoscopic ports were added. Surgical depth varied as desired between 8 and 15 cm. The cervical and abdominal regions were the focus of the endoscopic microsurgical exercises. RESULTS: The different endoscopic neurosurgical techniques were effectively trained at the millimetric dimension. Levels of progressive surgical difficulty depending upon the endoneurosurgical skills set needed for a particular surgical exercise were distinguished. LEVEL 1 is soft-tissue microdissection (exposure of cervical muscular plane and retroperitoneal space); LEVEL 2 is soft-tissue-vascular and vascular-capsule microdissection (aorto-cava exposure, carotid sheath opening, external jugular vein isolation); LEVEL 3 is artery-nerve microdissection (carotid-vagal separation); LEVEL 4 is artery-vein microdissection (aorto-cava separation); LEVEL 5 is vascular repair and microsuturing (aortic rupture), which verified the lack of current proper instrumentation. CONCLUSION: The animal training model presented here has the potential to shorten the length of the learning curve in endonasal endoscopic and neuroendoscopic port surgery and reduce the incidence of training-related surgical complications.

Phagocytosis, oxidative burst, and produced reactive species are affected by iron deficiency anemia and anemia of chronic diseases in elderly.

Iron and oxidative stress have a regulatory interplay. During the oxidative burst, phagocytic cells produce free radicals such as hypochlorous acid (HOCl). Nevertheless, scarce studies evaluated the effect of either iron deficiency anemia (IDA) or anemia of chronic disease (ACD) on phagocyte function in the elderly. The aim of the present study was to determine the oxidative burst, phagocytosis, and nitric oxide (*NO) and HOCl, reactive species produced by monocytes and neutrophils in elderly with ACD or IDA. Soluble transferrin receptor, serum ferritin, and soluble transferrin receptor/log ferritin (TfR-F) index determined the iron status. The study was constituted of 39 patients aged over 60 (28 women and 11 men) recruited from the Brazilian Public Health System. Oxidative burst fluorescence intensity per neutrophil in IDA group and HOCl generation in both ACD and IDA groups were found to be lower (p < 0.05). The percentages of neutrophils and monocytes expressing phagocytosis in ACD group were found to be higher (p < 0.05). There was an overproduction of *NO from monocytes, whereas the fundamental generation of HOCl appeared to be lower. Phagocytosis, oxidative burst, and *NO and HOCl production are involved in iron metabolism regulation in elderly patients with ACD and IDA.

Changes in amounts of total salivary gland proteins of Lutzomyia longipallpis (Diptera: Psychodidae) according to age and diet.

Saliva plays important roles in facilitation of a bloodmeal, lubrication of mouthparts, and parasite transmission for some vector insects. Salivary composition changes during the lifetime of an insect, and differences in the salivary profile may influence its functions. In this report, the amount and profile of salivary gland protein of the American visceral leishmaniasis vector Lutzomyia longipalpis (Lutz & Neiva, 1912) were analyzed at different times of insect development and diet. Protein content from unfed female sand flies increased significantly with age, and a significant difference was observed in sugar-fed females during the first 10 d of adult life. Salivary protein content sharply decreased 1 d after blood feeding, with gradual increase in concentration the following days. SDS-polyacrylamide gel electrophoresis analysis revealed that most polypeptides present in the saliva of sugar-fed also were present in the saliva of blood-fed females. Understanding changes in sand fly's saliva contents at distinct days after emergence and the influence of a bloodmeal in this aspect may reveal the role played by saliva during leishmaniasis transmission.

[Causes of reoperations in patients with lumbar spinal stenosis treated with instrumentations]. / Causas de reintervención quirúrgica en pacientes con fijación lumbar intervenidospor estenosis de canal.

OBJECTIVE: In present study we analyze the causes leading to reoperation patients treated for lumbar spinal stenosis with laminectomy and lumbar instrumentation. MATERIAL AND METHODS: 74 patients operated between January of 1996 and December of 2000 with a minimum 4 year follow-up were seleted for the study. RESULTS: 16 patients (21.1%) underwent a new surgical intervention. The main cause for reoperation was stenosis of the adjacent level superiorly to the instrumentation (in 50%). Other causes were radicular fibrosis, persistence of stenosis after the surgery, neuropatic pain, failure of the instrumentation system, transpedicular screws misplacement and break of screws. CONCLUSIONS: Complications related with the initial surgical procedure are low, as half of the reoperations were due to stenosis of the segment superior to the fixation.

Causas de reintervención quirúrgica en pacientes con fijación lumbar intervenidos por estenosis de canal / Causes of reoperations in patients with lumbar spinal stenosis treated with instrumentations

Objetivo. En el presente trabajo analizamos las causas por las que se ha debido reintervenir a pacientes diagnosticados de estenosis de canal que habían sido tratados mediante descompresión quirúrgica y fijación lumbar. Material y métodos. Seleccionamos 74 pacientes entre enero de 1996 y diciembre de 2000 con un seguimiento mínimo de 4 años. Resultados. 16 (21,1%) fueron sometidos a una nueva intervención quirúrgica. La principal causa fue la estenosis de niveles adyacentes superiores a la instrumentación (en el 50%). Otras causas fueron la fibrosis perirradicular, la persistencia de estenosis tras la cirugía, el dolor neuropático, la desconexión del sistema de fijación, la compresión radicular por tornillos transpediculares y la rotura de tornillos. Conclusiones. Las complicaciones relacionadas con la técnica quirúrgica son bajas ya que la mitad de las reintervenciones en pacientes con estenosis del canal lumbar está producida por la estenosis del segmento superior a la fijación

Objective. In present study we analyzes the causes leading to reoperation patients treated for lumbar spinal stenosis with laminectomy and lumbar instrumentation. Material and methods. 74 patients operated between January of 1996 and December of 2000 with a minimum4 year follow-up were seleted for the study. Results. 16 patients (21 1%) underwent a new surgicall intervention. The main cause for reoperation was stenosis of the adjacent level superiorly to the instrumentation (in 50%). Other causes were radicular fibrosis, persistence of stenosis after the surgery, neuropatic pain, failure of the instrumentation system, transpedicular screws misplacement and break of screws. Conclusions. Complications related with the initial surgical procedure are low, as half of the reoperations were due to stenosis of the segment superior to the fixation

[Brain aneurysms: an infrequent cause of transient ischemic stroke]. / Aneurismas cerebrales: una causa infrecuente de accidente isquémico transitorio.

INTRODUCTION: Ischemic symptomatology related to the presence of saccular brain aneurysms is infrequent, and this makes it difficult to reach a widespread agreement about the most suitable treatment. CASE REPORT: A 17-year-old male with symptoms of little stroke produced by distal embolisation of an aneurysm in the middle cerebral artery. The patient was treated by endovascular aneurysm exclusion. CONCLUSIONS: In patients with no other identifiable cause of ischemic attacks, the possible presence of a brain aneurysm must be taken into account. First choice treatment is the obliteration of the aneurysm using endovascular techniques. If the approach to the aneurysm (either endovascular or surgical) entails a high risk for the patient, another possibility is to use antiplatelet drugs.

[Update in neurocysticercosis treatment]. / Actualizacion en el tratamiento de la neurocisticercosis.

INTRODUCTION: Neurocysticercosis is the most frequent central nervous system parasitosis, although quite infrequent in our country. Its rising incidence can be explained by immigration from regions of the world where this disease is endemic. OBJECTIVE: This paper reviews treatment options for this condition. PATIENTS AND METHODS. Eight patients have been diagnosed with neurocysticercosis in the last three years in our hospital. Patient age, sex, origin, symptoms, CT and MR images, diagnostic tests, treatment and duration of medical treatment and clinical and neuroradiological evolution are examined. RESULTS: Patient age ranged from 25 to 33 years, all eight came from South America and the most frequent initial symptom was an epileptic crisis. Two patients had a single lesion, six had multiple lesions and all eight showed the lesion in the parenchyma. Only 50% showed a positive serum ELISA test for Taenia solium. Initial treatment was surgical in only one patient and the other seven received albendazol. In one of the latter the drug was ineffective and surgery was undertaken. A ten month follow up period has found a favorable evolution in all the patients, who are all also asymptomatic at the present time. DISCUSSION AND CONCLUSIONS: Neurocysticercosis is more common among immigrants than the local population in Spain. The initial treatment should be medical, with surgery as an option for non responders. We believe that duration of the medical treatment will depend on the patient and the clinico radiological evolution of his/her disease.

Morphometric and phenetic studies of five geographical populations of Lutzomyia whitmani (Diptera: Psychodidae) in Brazil.

A morphometric survey examined adult specimens of Lutzomyia whitmani (Antunes & Coutinho) captured at 5 municipalities in southeastern and northeastern Brazil to compare the populations. The localities were Ilhéus (Bahia), Martinho Campos (Minas Gerais), Corte de Pedra (Bahia), Baturité (Ceará), and Amaraji (Pernambuco): all are known foci of American cutaneous leishmaniasis. Fifteen males and 15 females from each population were analyzed morphometrically for 42 and 37 characters, respectively. Statistical data alone were insufficient to discriminate among the 5 populations. Further analysis generated phenograms that indicated there were 2 spatial clusters: the 1st was composed of specimens from Ilhéus (Bahia) and Baturité (Ceará) and the 2nd of specimens from Martinho Campos (Minas Gerais), Corte de Pedra (Bahia), and Amaraji (Pernambuco). Although insufficient to define the taxonomic status of the populations studied, the results delineated the existence of biogeographical structuring within L. whitmani. Complementary studies on the susceptibility to Leishmania braziliensis infection in the 5 populations are in progress to clarify the relationship between the 2 biogeographical clusters and American cutaneous leishmaniasis transmission in those Brazilian regions.

[Outbreak of American cutaneous leishmaniasis in Canoa, Santo Amaro, Bahia, Brazil]. / Surto de leishmaniose tegumentar americana em Canoa, Santo Amaro, Bahia, Brasil.

An outbreak of American cutaneous leishmaniasis (ACL) was detected in the village of Canoa in 1993. A prospective observational study was outlined to determine the frequency rates and to clinically characterize the disease. A total of 555 people were followed up. There were 29 cases of ACL, 11 cases of probably previous ACL (scars) and 529 healthy individuals. Of these 529 individuals, 65 had a positive Montenegro reaction without any present or past evidence of leishmaniasis. The prevalence of ACL during the two years was 5.2% (29/555). The leishmania involved was Leishmania braziliensis and the vector, Lutzomyia intermedia. Evidence of infection was detected in dogs and horses. The high frequency of the disease among children under ten years, the similar sex distribution of cases and a component of familial aggregation suggest a peri- or intra-domiciliary transmission.

Comparison of the polymerase chain reaction and serology for the detection of canine visceral leishmaniasis.

The polymerase chain reaction (PCR) and serology was evaluated for the diagnosis of canine visceral leishmaniasis in Bahia, Brazil in a study of 125 dogs. The PCR was 100% sensitive in 25 dogs that had Leishmania demonstrated by either culture or hamster inoculation. It was 100% specific for 35 dogs from the northeastern United States, all were PCR negative. However, 22 of 54 Brazilian dogs that were culture-hamster inoculation-negative were positive by PCR. The nature of the PCR product was identified by hybridization with specific Leishmania probes. Whereas the sensitivity of serology in relationship to infection, as determined by hamster or culture assay was more than 80%, sensitivity of serology was only 63% when compared with PCR. These results raise questions about the use of serology to detect Leishmania infection in dogs, and suggest that the PCR might serve as a better gold standard to define Leishmania infection than culture or hamster inoculation.

[Intestinal geohelminthosis in man and domestic animals in the riverside sections of the Valdivia River Basin, Chile]. / Geohelmintosis intestinales en el hombre y animales domésticos de sectores ribereños de la cuenca del río Valdivia, Chile.

In March-October 1987 were analyzed 1295 coprological specimens in a sample of the human population who lives in riverside localities in the Valdivia River Basin, Chile. A 23.6% of examined persons presented infection by one or more helminth species. The prevalence of infection by Ascaris lumbricoides, Trichuris trichiura and Trichostrongylidae gen. sp. were 15.5, 12.7 and 0.2%, respectively. The prevalence of human ascariosis and trichuriosis were greater in pre-school and school children. The sex of the host and prevalence of geohelminthosis did not show any relationship. Prevalences of ascariosis and trichuriosis were higher in persons from houses with no sanitary fecal and water disposal. Over 35% and 20.7% of family groups showed infection by A. lumbricoides and T. trichiura, respectively in over 40% of the members of each group. Fecal samples from domestic mammals revealed the following prevalences rates for helminth infections: in dogs 19.0 and 15.2% for Toxocara canis and Uncinaria stenocephala respectively, in cats 65.1% for Toxocara cati, and in pigs 25.4 and 3.2% for Ascaris suum and Trichuris suis respectively. Some of these species are clearly demonstrated agents of zoonoses.

Effects of soil phosphorus on spore germination and hyphal growth of arbuscular mycorrhizal fungi.

The direct effects Of soil phosphorus on sport germination and hyphal growth of the arbuscular mycorrhizal fungi (AM), Glomus etunicatum Beck &Beck &Gerd., E3 and Scutellospora heterogama (Nicol &Gerd) Walker &Sanders, were investigated by means of two soil-agar plate experiments. In the first experiment, the percentage spore germination and hyphal length of G. etunicatum, measured at ten different P levels and three periods of incubation, were affected by the P status of the soil. The best correslation with P level in the soil occurred at 7 d of incubation for spore germination and at 14 d far hyphal growth and hyphal growth increment. Spore germination was stimulated when 12.5 µ PO g-1 was applied to the soil and decreased with further soil P increments. Hyphal growth decreased significantly with soil P amendments above 37.5 µg P g-1 In the second experiment including three different P levels and the three AM endophytes, soil P affected spore germination and hyphal growth, and both decreased at the high phosphate treatment for G. etunicatum and S. heterogama. The K3 spare germination was similar to the other two species, but the hyphal growth was poorer. S. heterogama was more sensitive to P fertilization than the Glomus spp. and for the three species the hyphal production was not proportional to spore size.

[Blastocystosis and other intestinal protozoan infections in human riverside communities of the Valdivia River basin, Chile]. / Blastocistosis y otras infecciones por protozoos intestinales en comunidades humanas ribereñas de la cuenca del Río Valdivia, Chile.

Between March and October 1987, the prevalence of infection by Blastocystis hominis and other intestinal protozoan, their relationship with the age and sex of the hosts, and the percentage of infected persons in family groups were determined in riverside communities of Valdivia River Basin, Chile. One or more intestinal protozoan species were determined in 72.5% of the examined persons. The prevalence was greater for B. hominis (61.8%). The prevalences of B. hominis, Endolimax nana and Entamoeba coli were greater in relation to the age of the host. The sex of the host and prevalence of infections by B. hominis and other species of intestinal protozoans did not show association. Prevalence of B. hominis was greater in persons from houses with no sanitary faeces disposal. Over 60% of the members of family groups showed infection by B. hominis in 53.1% of the groups compared to 2.4%-21.8% of infections by other protozoan species. Faecal samples of 45 pigs revealed 22.2% of infection by Blastocystis.

Ecological aspects of nematode parasites of introduced salmonids from Valdivia river basin, Chile.

Between 1986 and 1987, 666 fishes distributed among the following species introduced in Chile, and from different sectors of the Valdivia river basin (39 degrees 30'-40 degrees 00'S, 73 degrees 30'-71 degrees 45'W), were examined: 348 Salmo trutta, 242 Salmo gairdneri, 24 Cyprinus carpio and 52 Gambusia affinis holbrooki. The presence of Camallanus corderoi and Contracaecum sp. in S. gairdneri and of C. corderoi in S. trutta is recorded in Chile for the first time. Cyprinus carpio and G. a. holbrooki did not present infections by nematodes. The prevalence and mean intensity of the infections by nematodes presented significant differences among some sectors of the Valdivia river basin. In general, the prevalence and intensity of the infections by C. corderoi were greater than those by Contracaecum sp. The infections in S. gairdneri were higher than in S. trutta. The sex of the hosts had no influence on the prevalence and intensity of the infections by both nematodes. The length of the hosts did have an influence, except in the case of the infections by Contracaecum sp. in S. gairdneri. The infrapopulations of both nematode species showed over-dispersion in most cases. The diet of the examined salmonids suggests that they would become infected principally through the consumption of autochthonous fishes.

[Epidemiology of diphyllobothriasis in the Valdivia river basin, Chile]. / Epidemiología de la difilobotriasis en la cuenca del Río Valdivia, Chile.

In the Valdivia (Chile) river basin 1,295 inhabitants of 6 riverside districts were examined between March and October 1987 and showed a 1.2% of prevalence by Diphyllobothrium in the districts of Riñihue and Las Huellas. Prevalence of 5.3% and 9.8% respectively were registered in dogs of the districts of Riñihue and Malihue. No cat or pig infection was observed in the different districts. The parasites recovered after the treatment were identified as Diphyllobothrium latum. Human infection by D. latum in the districts affected results from the consumption of smoked or insufficiently cooked fish. The investigation of 1,450 fish (4 exotic species and 11 autochthonous ones), caught in the Valdivia river basin in 1986 and 1987, showed the existence of plerocercoids of D. latum and/or Diphyllobothrium dendriticum in Salmo gairdneri and Salmo trutta among exotic fish and in some autochthonous species. Prevalence and mean intensity in the infection of fish as well as the degree of aggregation in the infrapopulations varied in the different districts. Some species of fish would act as intermediary hosts and others as paratenic hosts in the life cycles of Diphyllobothrium spp. in the Valdivia river basin. An improvement in the conditions of basic sanitation, in sanitary education and in the treatment of infected persons is proposed as a means for the control of diphyllobothriasis in the districts affected.