Nevos Recorrentes. Uma Revis��o de 5 Anos

A persist��ncia de uma les��o melanoc��tica, em local onde tenha sido previamente excisado um nevo melanoc��tico pode colocar, cl��nica e histologicamente, problemas no diagn��stico diferencial com melanoma, designado por alguns autores como ���pseudomelanoma���. Neste estudo, os autores pretendem realizar uma an��lise comparativa entre os achados cl��nicos e histopatol��gicos das les��es melanoc��ticas prim��rias e dos nevos recorrentes. Procura-se tamb��m avaliar eventuais factores predisponentes para este fen��meno.

Vasculites Sist��micas Prim��rias da Inf��ncia

As vasculites sist��micas constituem um grupo de doen��as, pouco frequentes na inf��ncia, caracterizadas por inflama����o e necrose vascular. A sua tradu����o cl��nica �� heterog��nea, condicionada pelo tipo de vaso e org��o afectados. Recentemente foi proposta uma classifica����o das vasculites em idade pedi��trica, que tem em conta a dimens��o dos vasos envolvidos, sendo tamb��m validados crit��rios de diagn��stico para os tipos mais frequentes em crian��as. A presente revis��o tem como objectivo abordar os tipos mais frequentes de vasculites na inf��ncia, suas manifesta����es cl��nicas, diagn��stico e terap��utica.

Eritema Induratum de Bazin. Um Caso numa Doente com Tuberculose Ganglionar Activa

O Eritema induratum de Bazin �� uma doen��a rara, considerada uma reac����o de hipersensibilidade ao Mycobacterium tuberculosis. Caracteriza-se pelo aparecimento de n��dulos firmes, dolorosos, por vezes, ulcerados nos membros inferiores. Descrevemos o caso de uma doente do sexo feminino, 83 anos de idade, com queixas de aproximadamente 3 meses de dura����o de tumefac����o cervical direita indolor e de n��dulos subcut��neos de superf��cie eritematosa envolvendo ambas as pernas.

Artroscopia do Tornozelo Anterior vs Posterior. Compara����o de Resultados e Complica����es

Introdu����o: Recentemente t��m surgido debates na literatura internacional acerca da seguran��a e necessidade da abordagem artrosc��pica posterior para tratamento da patologia intra e extra articular do tornozelo. A artroscopia por via posterior realiza-se utilizando portais postero-interno e postero-externo, e com o doente em dec��bito ventral. Permite acesso �� regi��o posterior do tornozelo, articula����o subtalar, osso tr��gono, tend��es peroneias e tend��o do Longo flexor do Hallux, e ainda �� por����o posterior do ligamento deltoideu. Permite ainda uma melhor visualiza����o, menor morbilidade e recupera����o mais r��pida que na abordagem a c��u aberto. Neste estudo comparamos os resultados cl��nicos e funcionais e dos doentes submetidos a apenas a artroscopia anterior e dos doentes submetidos a artroscopia anterior e posterior do tornozelo, bem como as complica����es independentemente da patologia inicial. Material e M��todos: Estudo retrospectivo, tendo sido analisados os processos cl��nicos de todos os doentes submetidos a tratamento artrosc��pico do tornozelo em duas institui����es, pelo mesmo cirurgi��o. De um universo de 299 procedimentos artrosc��picos do tornozelo, exclu��mos todos os casos em que foi utilizada concomitantemente uma via aberta para tratamento de outras les��es. Obtiv��mos resultados cl��nicos e funcionais de 185 doentes, 97 homens, 88 mulheres, tendo sido aplicado o score Aofas para o retrop�� e tornozelo. Foi realizada artroscopia posterior em 87 doentes e anterior em 98 doentes. A m��dia de idades foi de 36 anos (17���59). O follow-up m��nimo foi de 6 meses (6���60). Cento e trinta e dois doentes apresentavam patologia de origem traum��tica, e destes, 105 estavam relacionados com acidentes de trabalho. Resultados: Artroscopia anterior: a m��dia do score Aofas foi de 87(43��� 100). Oitenta e sete doentes retomaram a sua atividade profissional ou desportiva previa, e 16 doentes ainda n��o retomaram atividade na altura da avalia����o. O tempo m��dio de retorno �� atividade previa foi de 4 meses (2���10). Registamos complica����es em 13 doentes. Estas incluem infec����o superficial das postas de entrada (3 casos), s��ndrome de dor regional complexa (3 casos), artrofibrose (2 casos), recidiva da les��o inicial (5 casos). Foram reoperados 6 doentes (2 casos de artrofibrose e 4 por recidiva da patologia inicial)Artroscopia anterior e posterior: a m��dia do score Aofas foi de 83 (38���100). Setenta e cinco doentes j�� retomaram a sua atividade pr��via, sendo que 10 ainda se encontram em tratamento. O tempo m��dio de retorno �� atividade foi de 4,3 meses (2��� 12). Regist��mos complica����es em 10 doentes (11,4%). Estas incluem 4 casos de les��o do nervo peroneal superficial, dos quais 3 recuperaram totalmente, 3 casos de artrofibrose, 2 casos de s��ndrome de dor regional complexa e 1 caso de infec����o superficial das portas de entrada. Foram reoperados 4 doentes, dos quais 2 por artrofibrose, 2 casos por recidiva da patologia inicial. Discuss��o: Constatamos que a m��dia do score Aofas e a taxa de complica����es �� sobrepon��vel entre as duas diferentes abordagens. Os nossos resultados, em termos de complica����es, s��o ligeiramente inferiores aos publicados na literatura internacional, quer para a artroscopia anterior, quer para a anterior e posterior, o 7 que poder�� estar relacionado com o elevado n��mero de doentes com les��es relacionadas com acidentes de trabalho. Conclus��o: A abordagem posterior n��o tem mais complica����es que a abordagem anterior isolada. Os resultados em doentes v��timas de acidente de trabalho s��o inferiores em ambas as abordagens. Os resultados e complica����es de ambas as abordagens s��o sobrepon��veis aos da literatura internacional.

Renal Replacement Therapy in Critically Ill Patients - What Modality Should We Choose?

A les��o renal aguda �� uma complica����o comum nas unidades de cuidados intensivos. A mortalidade do doente cr��tico que requer di��lise �� extremamente elevada, apesar dos avan��os significativos dos cuidados prestados a estes doentes. H�� v��rias d��cadas que se discute o tipo de modalidade dial��tica a oferecer a estes doentes (continua ou intermitente) e os principais fatores que pesam na decis��o cl��nica s��o os meios e a experi��ncia do centro, bem como a condi����o cl��nica do doente. V��rios estudos tentaram estabelecer a melhor abordagem ao doente cr��tico com les��o renal aguda e necessidade dial��tica, em termos de sobrevida do doente e recupera����o renal. Nesta revis��o tentarei resumir as evid��ncias dispon��veis sobre este tema.

Abcessos Renais - Revis��o

Baseados num caso de associa����o de abcessos renal, perirrenal e de quisto renal infectado, ocorrendo ap��s biopsia prost��tica, os autores fazem revis��o bibliogr��fica dos abcessos renais, classificados segundo caracter��sticas anat��micas perin��frico, cortical e cortico- -medular (nefrite bacteriana aguda focal/multifocal, pielonefrite enfisematosa e pielonefrite xantogranulomatosa). Os abcessos renais s��o mais frequentes em diab��ticos, menos vezes em alco��licos, desnutridos e imunodeprimidos, estando associados geralmente a pielonefrites recorrentes, refluxo vesicoureteral, lit��ase urin��ria, ou resultam de ��mbolos s��pticos hematog��neos originados em focos extra-renais de infec����o. A Escherichia coli �� respons��vel pela maioria dos casos, e menos vezes a Klebsiella Proteus, Enterobacter, Pseudomonas, e Estafilococo aureus. Descrevem-se a express��o cl��nica, complica����es evolutivas e diagn��stico radiol��gico, enfatizando-se as infec����es acompanhadas de forma����o de g��s. Referem-se op����es terap��uticas m��dico-cir��rgicas, cujas indica����es dependem do diagn��stico precoce, complica����es e factores predisponentes.

The Role of the Humoral Immune Response in the Molecular Evolution of the Envelope C2, V3 and C3 Regions in Chronically HIV-2 Infected Patients

BACKGROUND: This study was designed to investigate, for the first time, the short-term molecular evolution of the HIV-2 C2, V3 and C3 envelope regions and its association with the immune response. Clonal sequences of the env C2V3C3 region were obtained from a cohort of eighteen HIV-2 chronically infected patients followed prospectively during 2-4 years. Genetic diversity, divergence, positive selection and glycosylation in the C2V3C3 region were analysed as a function of the number of CD4+ T cells and the anti-C2V3C3 IgG and IgA antibody reactivity RESULTS: The mean intra-host nucleotide diversity was 2.1% (SD, 1.1%), increasing along the course of infection in most patients. Diversity at the amino acid level was significantly lower for the V3 region and higher for the C2 region. The average divergence rate was 0.014 substitutions/site/year, which is similar to that reported in chronic HIV-1 infection. The number and position of positively selected sites was highly variable, except for codons 267 and 270 in C2 that were under strong and persistent positive selection in most patients. N-glycosylation sites located in C2 and V3 were conserved in all patients along the course of infection. Intra-host variation of C2V3C3-specific IgG response over time was inversely associated with the variation in nucleotide and amino acid diversity of the C2V3C3 region. Variation of the C2V3C3-specific IgA response was inversely associated with variation in the number of N-glycosylation sites. CONCLUSION: The evolutionary dynamics of HIV-2 envelope during chronic aviremic infection is similar to HIV-1 implying that the virus should be actively replicating in cellular compartments. Convergent evolution of N-glycosylation in C2 and V3, and the limited diversification of V3, indicates that there are important functional constraints to the potential diversity of the HIV-2 envelope. C2V3C3-specific IgG antibodies are effective at reducing viral population size limiting the number of virus escape mutants. The C3 region seems to be a target for IgA antibodies and increasing N-linked glycosylation may prevent HIV-2 envelope recognition by these antibodies. Our results provide new insights into the biology of HIV-2 and its relation with the human host and may have important implications for vaccine design.

Aluminum and Sulphate Removal by a Highly Al-Resistant Dissimilatory Sulphate-Reducing Bacteria Community

A highly Al-resistant dissimilatory sulphatereducing bacteria community was isolated from sludge of the wetland of Urgeiri��a mine (community W). This community showed excellent sulphate removal at the presence of Al3+. After 27 days of incubation, 73,86 and 81% of sulphate was removed in the presence of 0.48, 0.90 and 1.30 mM of Al3+, respectively. Moreover,Al3+ was simultaneously removed: 55,85 and 78% of metal was removed in the presence of 0.48, 0.90 and 1.30 mM of Al3+, respectively. The dissociation of aluminiumlactate soluble complexes due to lactate consumption by dissimilatory sulphate-reducing bacteria can be responsible for aluminum removal, which probably precipitates as insoluble aluminium hydroxide. Phylogenetic analysis of 16S rRNA gene showed that this community was mainly composed by bacteria closely related to Desulfovibrio desulfuricans. However, bacteria affiliated to Proteus and Ralstonia were also present in the community.

Differential Internalization of Amphotericin B - Conjugated Nanoparticles in Human Cells and the Expression of Heat Shock Protein 70

Although a variety of nanoparticles (NPs) functionalized with amphotericin B, an antifungal agent widely used in the clinic, have been studied in the last years their cytotoxicity profile remains elusive. Here we show that human endothelial cells take up high amounts of silica nanoparticles (SNPs) conjugated with amphotericin B (AmB) (SNP-AmB) (65.4 12.4 pg of Si per cell) through macropinocytosis while human fibroblasts internalize relatively low amounts (2.3 0.4 pg of Si per cell) because of their low capacity for macropinocytosis. We further show that concentrations of SNP-AmB and SNP up to 400 mg/mL do not substantially affect fibroblasts. In contrast, endothelial cells are sensitive to low concentrations of NPs (above 10 mg/mL), in particular to SNP-AmB. This is because of their capacity to internalize high concentration of NPs and high sensitivity of their membrane to the effects of AmB. Low-moderate concentrations of SNP-AmB (up to 100 mg/mL) induce the production of reactive oxygen species (ROS), LDH release, high expression of pro-inflammatory cytokines and chemokines (IL-8, IL-6, G-CSF, CCL4, IL-1b and CSF2) and high expression of heat shock proteins (HSPs) at gene and protein levels. High concentrations of SNP-AmB (above 100 ug/mL) disturb membrane integrity and kill rapidly human cells(60% after 5 h). This effect is higher in SNP-AmB than in SNP.

Spectrum of Neurologic Complications in Chronic Lymphocytic Leukemia

Neurologic disease is believed to be an unusual complication during the course of chronic lymphocytic leukemia. Nevertheless, it has already been proven in autopsy series that the incidence of occult nervous system infiltration is much higher than was previously expected. The advent of more potent drugs to treat this lymphoproliferative disorder has brought a new hope for a possible cure in the future. However, an appropriate systemic treatment for central nervous system infiltration of this disease is still lacking. Also, due to the potent immunosuppressive properties of the agents used in the up-front treatment, for example, the purine nucleoside analogues, we have witnessed an increase in the incidence of opportunistic infections, with progressive multifocal leukoencephalopathy being one of the most serious. The goal of this review is to summarize the spectrum of neurologic derangements linked to chronic lymphocytic leukemia and to raise clinicians��� awareness to recognize the possibility of such associations.

Stress-Related Mucosal Disease: Incidence of Bleeding and the Role of Omeprazole in its Prophylaxis

BACKGROUND: Upper gastrointestinal bleeding is the severe complication of stress-related mucosal disease in hospitalized patients. In intensive care units (ICU), risk factors are well defined and only mechanical ventilation and coagulopathy proved to be relevant for significant bleeding. On the contrary, in non-ICU settings there is no consensus about this issue. Nevertheless, omeprazole is still widely used in prophylaxis of bleeding. The objective of our study was to evaluate the relevance of stress-related mucosal disease bleeding in patients admitted to an internal medicine ward, and the role of omeprazole in its prophylaxis. METHODS: We conducted a retrospective study in which we analysed consecutive patients who were admitted to our ward over a year. We recorded demographic characteristics of the patients, potential risk factors for stress-related mucosal disease (clinical data, laboratory, and medication), administration of prophylactic omeprazole, and total cost of this prophylaxis. Patients with active gastrointestinal bleeding on the admission were excluded. We recorded every upper gastrointestinal bleeding event with clinical relevance. RESULTS: Five hundred and thirty-five patients, mean age 70 years, mean length of stay 9.6+/-7.7 days; 140 (26.2%) patients were treated with 40 mg of omeprazole intravenously, 193 (36.1%) with 20mg of omeprazole orally, and 202 (37.8%) patients had no prophylaxis. There was only one episode (0.2%) of clinically relevant bleeding. CONCLUSION: In patients admitted to an internal medicine ward, incidence of upper gastrointestinal bleeding as a complication of stress-related mucosal disease is low. We found that there is no advantage in prophylaxis with omeprazole.

Edema Pulmonar de Press��o Negativa Ap��s Extuba����o Traqueal

O edema pulmonar de press��o negativa (EPPN) tamb��m descrito na literatura como edema agudo do pulm��o p��s-obstrutivo ou p��s-extuba����o traqueal, �� uma entidade rara, com uma incid��ncia de aproximadamente 0.1 % em doentes anestesiados. Os autores descrevem o caso, ocorrido ap��s extuba����o traqueal, de um doente submetido a orquidectomia por via laparosc��pica sob anestesia geral balanceada. Relatam a fisiopatologia, o padr��o radiol��gico e broncosc��pico e as medidas terap��uticas institu��das.

Interictal Spike EEG Source Analysis in Hypothalamic Hamartoma Epilepsy

Objective: The epilepsy associated with the hypothalamic hamartomas constitutes a syndrome with peculiar seizures, usually refractory to medical therapy, mild cognitive delay, behavioural problems and multifocal spike activity in the scalp electroencephalogram (EEG). The cortical origin of spikes has been widely assumed but not specifically demonstrated. Methods: We present results of a source analysis of interictal spikes from 4 patients (age 2���25 years) with epilepsy and hypothalamic hamartoma, using EEG scalp recordings (32 electrodes) and realistic boundary element models constructed from volumetric magnetic resonance imaging (MRIs). Multifocal spike activity was the most common finding, distributed mainly over the frontal and temporal lobes. A spike classification based on scalp topography was done and averaging within each class performed to improve the signal to noise ratio. Single moving dipole models were used, as well as the Rap-MUSIC algorithm. Results: All spikes with good signal to noise ratio were best explained by initial deep sources in the neighbourhood of the hamartoma, with late sources located in the cortex. Not a single patient could have his spike activity explained by a combination of cortical sources. Conclusions: Overall, the results demonstrate a consistent origin of spike activity in the subcortical region in the neighbourhood of the hamartoma, with late spread to cortical areas.

Analysis of the EEG Dynamics of Epileptic Activity in Gelastic Seizures Using Decomposition in Independent Components

Objective: Gelastic seizures are a frequent and well established manifestation of the epilepsy associated with hypothalamic hamartomas. The scalp EEG recordings very seldom demonstrate clear spike activity and the information about the ictal epilepsy dynamics is limited. In this work, we try to isolate epileptic rhythms in gelastic seizures and study their generators. Methods: We extracted rhythmic activity from EEG scalp recordings of gelastic seizures using decomposition in independent components (ICA) in three patients, two with hypothalamic hamartomas and one with no hypothalamic lesion. Time analysis of these rhythms and inverse source analysis was done to recover their foci of origin and temporal dynamics. Results: In the two patients with hypothalamic hamartomas consistent ictal delta (2���3 Hz) rhythms were present, with subcortical generators in both and a superficial one in a single patient. The latter pattern was observed in the patient with no hypothalamic hamartoma visible in MRI. The deep generators activated earlier than the superficial ones, suggesting a consistent sub-cortical origin of the rhythmical activity. Conclusions: Our data is compatible with early and brief epileptic generators in deep sub-cortical regions and more superficial ones activating later. Significance: Gelastic seizures express rhythms on scalp EEG compatible with epileptic activity originating in sub-cortical generators and secondarily involving cortical ones.