Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children

Objective To examine the ability of the criteria proposed by the WHO to identify pneumonia among cases presenting with wheezing and the extent to which adding fever to the criteria alters their performance. Design Prospective classification of 390 children aged 2-59 months with lower respiratory tract disease into five diagnostic categories, including pneumonia. WHO criteria for the identification of pneumonia and a set of such criteria modified by adding fever were compared with radio-graphically diagnosed pneumonia as the gold standard. Results The sensitivity of the WHO criteria was 94% for children aged <24 months and 62% for those aged >= 24 months. The corresponding specificities were 20% and 16%. Adding fever to the WHO criteria improved specificity substantially (to 44% and 50%, respectively). The specificity of the WHO criteria was poor for children with wheezing (12%). Adding fever improved this substantially (to 42%). The addition of fever to the criteria apparently reduced their sensitivity only marginally (to 92% and 57%, respectively, in the two age groups). Conclusion The authors' results reaffirm that the current WHO criteria can detect pneumonia with high sensitivity, particularly among younger children. They present evidence that the ability of these criteria to distinguish between children with pneumonia and those with wheezing diseases might be greatly enhanced by the addition of fever.

Schwannoma in the lower lip mucosa: Unexpected diagnosis

Schwannoma is a benign tumor arising from nerve-sheath Schwann cells. When it affects the mouth, the lips are rarely involved. A MEDLINE search in the English literature from 1969 to 2009 revealed only 17 documented cases of schwannomas of the lip. This report describes the unusual case of a 52-year-old man who developed a schwannoma of the lower lip. Histopathologic examination and immunohistochemical staining studies were performed. Although rare, schwannoma should be considered in the differential diagnosis of any nodule or mass in the oral mucosa. (Quintessence Int 2010; 41: 769-771)

Effect of Short-term High-Dose Creatine Supplementation on Measured GFR in a Young Man With a Single Kidney

It currently is unknown whether creatine supplementation is safe for people with or at risk of kidney disease. We report on the short-term effects of creatine supplementation on kidney function in a young man with a single kidney and mildly decreased glomerular filtration rate (GFR). A 20-year-old man who had undergone unilateral nephrectomy and presented with mildly decreased GFR without kidney damage underwent a trial with 35 days of creatine supplementation (20 g/d for 5 days followed by 5 g/d for the next 30 days) and had his kidney function monitored. After the intervention, (51)Cr-EDTA clearance (pre, 81.6 mL/min/1.73 m(2); post, 82.0 mL/min/1.73 m(2)), proteinuria (protein excretion: pre, 130 mg/d; post, 120 mg/d), and electrolyte levels were unchanged. Albuminuria, serum urea level, and estimated creatinine clearance were decreased (pre, 4.6 mg/d; post, 2.9 mg/d; pre, 37 mg/d; post, 28 mg/dL; and pre, 88 mL/min/1.73 m(2); post, 71 mL/min/1.73 m(2), respectively), whereas serum creatinine level was slightly increased (pre, 1.03 mg/dL; post, 1.27 mg/dL), falsely suggesting kidney function impairment. This prospective report suggests that short-term creatine supplementation may not affect kidney function in an individual with a single kidney, mild decreased GFR, and ingesting a high-protein diet (ie, 2.8 g/kg/d). This finding has great relevance considering that creatine-induced kidney disease has been a growing concern, even for healthy people. Am J Kidney Dis 55: e7-e9. (C) 2010 by the National Kidney Foundation, Inc.

Relação conjugal, violência psicológica e complementaridade fusional

Neste artigo abordamos um tipo específico de dinâmica conjugal marcada pela violência psicológica. Na clínica com casais, temos observado situações nas quais são utilizadas agressões verbais e humilhações, que afetam a auto-estima e a capacidade de reação e decisão da pessoa agredida. Forma-se um laço perverso caracterizado por um movimento recíproco no sentido do domínio do parceiro, com condições e exigências que submetem a ambos, levando a um tipo de relação na qual impera a complementaridade fusional. O discurso característico da contemporaneidade, de obtenção de prazer e busca da perfeição nos relacionamentos amorosos e da presença do modelo igualitário nas relações homem/mulher, põe em destaque esse tipo de dinâmica relacional. Observa-se, em alguns casos, uma fixação do modelo "homem-ativo-fálico/mulher-passiva-castrada" que permanece subjacente à mudança dos tempos.

New species of Trachycorystes Bleeker, with comments on other species of the genus (Ostariophysi: Siluriformes: Auchenipteridae)

A new species of Trachycorystes from the rio Aripuanã, above Dardanelos and Andorinhas falls, is described. The new species is distinguished from the only other species of the genus, T. trachycorystes, by the following characteristics: jaws of equal length (vs. lower jaw prognathous in T. trachycorystes); skull roof covered by thick (vs. thin) integument; inner mental barbel very thin and short not reaching base of outer barbel (vs. extending to or beyond base of outer mental barbel); dorsal-fin spine serrated posteriorly, smooth or rough anteriorly (vs. serrated anteriorly and smooth or rough posteriorly); caudal fin shallowly forked (vs. emarginate); and gas bladder simple, without diverticula (vs. with three posterior diverticula). Comments and data on the nominal species Trachycorystes trachycorystes are provided. Trachycorystes cratensis Miranda Ribeiro, 1937, is allocated to the genus Trachelyopterus Valenciennes, 1840, and another local catfish species, Parotocinclus aripuanensis Garavello, 1988, has its type locality reassigned.

Inequalities in access and utilization of dental services: a cross-sectional study in an area covered by the Family Health Strategy

This cross-sectional study aimed to investigate the presence of inequalities in the access and use of dental services for people living in the coverage area of the Family Health Strategy (FHS) in Ponta Grossa, Paraná State, Brazil, and to assess individual determinants related to them. The sample consisted of 747 individuals who answered a pre-tested questionnaire. Data analysis was performed by chi-square test and Poisson regression analysis, obtaining explanatory models for recent use and, by limiting the analysis to those who sought dental care, for effective access. Results showed that 41% of the sample had recent dental visits. The lowest visit rates were observed among preschoolers and elderly people. The subjects who most identified the FHS as a regular source of dental care were children. Besides age, better socioeconomic conditions and the presence of a regular source of dental care were positively associated to recent dental visits. We identified inequalities in use and access to dental care, reinforcing the need to promote incentives to improve access for underserved populations.

The expression of vulnerability through infant mortality in the municipality of Embu

CONTEXTO E OBJETIVO: A mortalidade infantil expressa uma conjunção de fatores relacionados às condições de vida, trabalho e acesso aos serviços de saúde, e a identificação desses fatores pode contribuir para definição de intervenções em saúde. O objetivo deste trabalho foi analisar a expressão da vulnerabilidade e conseqüentes diferenças de acesso aos serviços de saúde e na ocorrência de óbitos em menores de um ano no município do Embu. TIPO DE ESTUDO E LOCAL: Estudo descritivo, no município de Embu. MÉTODOS: Foram coletados dados secundários (declarações de óbitos) e primários (entrevistas a famílias de crianças residentes do município do Embu, falecidas nos anos de 1996 e 1997, antes de completarem um ano). Variáveis estudadas foram relacionadas às condições de vida, renda e trabalho, à assistência pré-natal, ao parto e à atenção à saúde da criança, as quais foram comparadas com resultados obtidos em estudo realizado no ano de 1996. RESULTADOS: Verificaram-se diferenças estatisticamente significantes quanto a renda, trabalho sem carteira assinada e acesso a plano privado de saúde entre famílias de crianças que foram ao óbito. Verificaram-se, também, diferenças quanto ao acesso e à qualidade da assistência pré-natal, à freqüência de baixo peso ao nascer e a intercorrências neonatais. CONCLUSÕES: A situação de emprego/desemprego foi decisiva na determinação da estabilidade familiar, conferindo maior vulnerabilidade para ocorrência de óbitos infantis, somada às condições de acesso e à qualidade dos serviços de saúde

A novel mutation in the glycogen synthase 2 gene in a child with glycogen storage disease type 0

Background: Glycogen storage disease type 0 is an autosomal recessive disease presenting in infancy or early childhood and characterized by ketotic hypoglycemia after prolonged fasting and postprandial hyperglycemia and hyperlactatemia. Sixteen different mutations have been identified to date in the gene which encodes hepatic glycogen synthase, resulting in reduction of glycogen storage in the liver. Case Presentation: Biochemical evaluation as well as direct sequencing of exons and exon-intron boundary regions of the GYS2 gene were performed in a patient presenting fasting hypoglycemia and postprandial hyperglycemia and her parents. The patient was found to be compound heterozygous for one previously reported nonsense mutation (c. 736 C>T; R243X) and a novel frameshift mutation (966_967delGA/insC) which introduces a stop codon 21 aminoacids downstream from the site of the mutation that presumably leads to loss of 51% of the COOH-terminal part of the protein. The glycemia and lactatemia of the parents after an oral glucose tolerance test were evaluated to investigate a possible impact of the carrier status on the metabolic profile. The mother, who presented a positive family history of type 2 diabetes, was classified as glucose intolerant and the father, who did not exhibit metabolic changes after the glucose overload, had an antecedent history of hypoglycemia after moderate alcohol ingestion. Conclusion: The current results expand the spectrum of known mutations in GYS2 and suggest that haploinsufficiency could explain metabolic abnormalities in heterozygous carriers in presence of predisposing conditions.

The characteristics of depressive symptoms in medical students during medical education and training: a cross-sectional study

Background: Medical education and training can contribute to the development of depressive symptoms that might lead to possible academic and professional consequences. We aimed to investigate the characteristics of depressive symptoms among 481 medical students (79.8% of the total who matriculated). Methods: The Beck Depression Inventory (BDI) and cluster analyses were used in order to better describe the characteristics of depressive symptoms. Medical education and training in Brazil is divided into basic (1(st) and 2(nd) years), intermediate (3(rd) and 4(th) years), and internship (5(th) and 6(th) years) periods. The study organized each item from the BDI into the following three clusters: affective, cognitive, and somatic. Statistical analyses were performed using analysis of variance (ANOVA) with post-hoc Tukey corrected for multiple comparisons. Results: There were 184 (38.2%) students with depressive symptoms (BDI > 9). The internship period resulted in the highest BDI scores in comparison to both the basic (p < .001) and intermediate (p < .001) periods. Affective, cognitive, and somatic clusters were significantly higher in the internship period. An exploratory analysis of possible risk factors showed that females (p = .020) not having a parent who practiced medicine (p = .016), and the internship period (p = .001) were factors for the development of depressive symptoms. Conclusion: There is a high prevalence towards depressive symptoms among medical students, particularly females, in the internship level, mainly involving the somatic and affective clusters, and not having a parent who practiced medicine. The active assessment of these students in evaluating their depressive symptoms is important in order to prevent the development of co-morbidities and suicide risk.

The practice of Information Architecture of websites in Brazil

The project of Information Architecture is one of the initial stages of the project of a website, thus the detection and correction of errors in this stage are easier and time-saving than in the following stages. However, to minimize errors for the projects of information architecture, a methodology is necessary to organize the work of the professional and guarantee the final product quality. The profile of the professional who works with Information Architecture in Brazil has been analyzed (quantitative research by means of a questionnaire on-line) as well as the difficulties, techniques and methodologies found in his projects (qualitative research by means of interviews in depth with support of the approaches of the Sense-Making). One concludes that the methodologies of projects of information architecture need to develop the adoption of the approaches of Design Centered in the User and in the ways to evaluate its results.

Endomyocardial Biopsy as Risk Factor in the Development of Tricuspid Insufficiency After Heart Transplantation

Objective. Endomyocardial biopsy (EMB), which is used to monitor for rejection, may cause tricuspid regurgitation (TR) after orthotopic heart transplantation (OHT). The purpose of this investigation was to examine the occurrence of tricuspid valve tissue in myocardial specimens obtained by routine EMB performed after OHT. Patients and Methods. From January 2000 to July 2008, 125 of the patients who underwent OHT survived more than I month. Their follow-up varied from I month to 8.5 years (mean, 5.1 +/- 3.7 years). EMB was the gold standard examination and myocardial scintigraphy with gallium served as a screen to routinely monitor rejection. Results. Each of 428 EMB including 4 to 7 fragments, totaling 1715 fragments, were reviewed for this study. The number of EMB per patient varied from 3 to 8 (mean, 4.6 +/- 3.5). Histopathological analysis of these fragments showed tricuspid tissue in 4 patients (3.2%), among whom only I showed aggravation of TR. Conclusions. EMB remains the standard method to diagnose rejection after OLT. It can be performed with low risk. Reducing the number of EMB using gallium myocardial scintigraphy or other alternative methods as well as adoption of special care during the biopsy can significantly minimize trauma to the tricuspid valve.

Differences Between ""Classical"" Risk Factors for Infections Caused by Methicillin-Resistant Staphylococcus aureus (MRSA) and Risk Factors for Nosocomial Bloodstream Infections Caused by Multiple Clones of the Staphylococcal Cassette Chromosome mec Type IV MRSA Strain

OBJECTIVE. To identify risk factors associated with nosocomial bloodstream infections caused by multiple clones of the staphylococcal cassette chromosome mec (SCCmec) type IV strain of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN. An unmatched case-control study (at a ratio of 1 : 2) performed during the period from October 2002 through September 2003. SETTING. A 2,000-bed tertiary care teaching hospital affiliated with the University of Sao Paulo in Sao Paulo, Brazil. METHODS. Case patients (n = 30) were defined either as patients who had a bloodstream infection due to SCCmec type IV strains of MRSA diagnosed at least 48 hours after hospital admission or as neonates with the infection who were born in the hospital. Control patients (n = 60) were defined as patients with SCCmec type III MRSA infection diagnosed at least 48 hours after hospital admission. Genes n = 60 encoding virulence factors were studied in the isolates recovered from case patients, and molecular typing of the SCCmec type IV MRSA isolates was also done by pulsed-field gel electrophoresis and multilocus sequence typing. RESULTS. In multivariate analysis, the following 3 variables were significantly associated with having a nosocomial bloodstream infection caused by SCCmec type IV strains of MRSA: an age of less than 1 year, less frequent use of a central venous catheter (odds ratio [OR], 0.07 [95% confidence interval {CI}, 0.02-0.28]; P = .001), and female sex. A second analysis was performed that excluded the case and Pp. 001 control patients from the neonatal unit, and, in multivariate analysis, the following variables were significantly associated with having a nosocomial bloodstream infection caused by SCCmec type IV strains of MRSA: less frequent use of a central venous catheter (OR, 0.12 [95% CI, 0.03-0.55]; P = .007), lower Acute Physiology and Chronic Health Evaluation II score on admission (OR, 0.14 [95% CI, 0.03-0.61];), less frequent surgery (OR, 0.21 [95% CI, 0.06-0.83];), and female sex (OR, 5.70 [95% CI, 1.32-24.66]; P =.020). P = .009 Pp. 025 Pp). Of the 29 SCCmec type IV MRSA isolates recovered from case patients, none contained the Panton-Valentine leukocidin, gamma-hemolysin, enterotoxin B or C, or toxic shock syndrome toxin-1. All of the isolates contained genes for the LukE-LukD leukocidin and alpha-hemolysin. Genes for enterotoxin A were present in 1 isolate, and genes for beta-hemolysin were present in 3 isolates. CONCLUSIONS. ""Classical"" risk factors do not apply to patients infected with the SCCmec type IV strain of MRSA, which is an important cause of nosocomial bacteremia. This strain infects a patient population that is less ill and has had less frequent invasive procedures than a patient population infected with the multidrug-resistant strain of SCCmec type III MRSA. We found that virulence factors were rare and that Panton-Valentine leukocidin was absent. There were multiple clones of the SCCmec type IV strain in our hospital. Children under 1 year of age were at a higher risk. There was a predominant clone ( sequence type 5) in this patient population.

Celecoxib as an adjunct in the treatment of depressive or mixed episodes of bipolar disorder: a double-blind, randomized, placebo-controlled study

Objective To investigate whether the cox-2 inhibitor celecoxib has antidepressant effects in bipolar disorder (BD) patients during depressive or mixed phases. Methods We studied 28 DSM-IV BD patients who were experiencing a depressive or mixed episode and were on a stable dose of a mood stabilizer or atypical antipsychotic medication. Subjects were randomized to receive 6 weeks of double-blind placebo or celecoxib (400 mg/day) treatment. Current mood stabilizer or antipsychotic medication remained at the same doses during the trial. Results Intention-to-treat analysis showed that the patients receiving celecoxib had lower Hamilton Depression Rating Scale (HamD) scores after 1 week of treatment compared to the patients receiving placebo, but this difference was not statistically significant (p=0.09). The improvement in the first week of treatment was statistically significant when the analysis included only the subjects who completed the full 6-week trial (p=0.03). The two groups did not differ significantly on depressive or manic symptoms from the second week until the end of the trial. Celecoxib was well tolerated with the exception of two subjects who dropped out of the study due to rash. Conclusions Our findings suggest that adjunctive treatment with celecoxib may produce a rapid-onset antidepressant effect in BD patients experiencing depressive or mixed episodes. Copyright (C) 2008 John Wiley & Sons, Ltd.

Pediatric epilepsy surgery and sudden unexpected death epilepsy: the contribution of a Brazilian epilepsy surgery program

Individuals with epilepsy are at higher risk of death than those from the general population, and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Epilepsies in the pediatric group are more frequently associated with known potentially risk factors for SUDEP, and a treatment resulting in an improved seizure control may also decrease mortality. The aim of this study is to identify the incidence of SUDEP in a group of operated-on children and adolescents. We analyzed 267 patients up to 18 years old, with medically intractable epilepsy submitted to surgery. We considered the age at surgery, the seizure type, the pathological findings, and the seizure outcome. Data were prospectively collected, according to the protocols of our institution`s ethics committee. The percentage of boys was 58.05. A good outcome was achieved in 72.6% of the cases and a bad outcome in 27.4%. Nine patients died during follow-up, six from clinical complications, and one from SUDEP. All patients who died during the long-term follow-up had persisted with refractory postoperative seizures. The patient who died from SUDEP died during a generalized tonic-clonic seizure. Of the patients, 72.6% had excellent postoperative outcome, and one patient died of SUDEP. All patients who died had had disabling seizures` persistence. The surgical treatment of epilepsy in children and adolescents is an efficient therapy for the medically intractable symptomatic epilepsies and also for the reduction of mortality and SUDEP risks.

What is the best equation to estimate the basal energy expenditure of climacteric women?

Objectives The methods currently available for the measurement of energy expenditure in patients, such as indirect calorimetry and double-labelled water, are expensive and are limited in Brazil to research projects. Thus, equations for the prediction of resting metabolic rate appear to be a viable alternative for clinical practice. However, there are no specific equations for the Brazilian population and few studies have been conducted on Brazilian women in the climacteric period using existing and commonly applied equations. On this basis, the objective of the present study was to investigate the concordance between the predictive equations most frequently used and indirect calorimetry for the measurement of resting metabolic rate. Methods We calculated the St. Laurent concordance correlation coefficient between the equations and resting metabolic rate calculated by indirect calorimetry in 46 climacteric women. Results The equation showing the best concordance was that of the FAO/WHO/UNU formula (0.63), which proved to be better than the Harris & Benedict equation (0.55) for the sample studied. Conclusions On the basis of the results of the present study, we conclude that the FAO/WHO/UNU formula can be used to predict better the resting metabolic rate of climacteric women. Further studies using more homogeneous and larger samples are needed to permit the use of the FAO/WHO/UNU formula for this population group with greater accuracy.