Treatment of pemphigus vulgaris and pemphigus foliaceus: experience with 71 patients over a 20 year period

Forty one cases of pemphigus vulgaris and thirty cases of pemphigus foliaceus were investigated at Hospital Universitário Clementino Fraga Filho from 1978 to 1999. They were divided into two treatment groups: one group received up to 100 mg of oral prednisone daily and the other group received >120 mg daily. The dose up to 100 mg provided good initial control of pemphigus vulgaris and pemphigus foliaceus and did not increase the mortality rate associated to disease. The dose >120 mg induced higher morbidity. These data allowed us to establish a regimen of oral prednisone (1-2 mg/kg/daily) with maximum of 120 mg daily in the treatment of pemphigus vulgaris and pemphigus foliaceus.

Auditoria energética às unidades de cogeração e central térmica

A tese de mestrado teve como objetivo o estudo e análise do funcionamento das centrais de cogeração e térmica da fábrica da Unicer em Leça do Balio, com o intuito de melhorar a sua eficiência, propondo alterações processuais. O trabalho realizado consistiu no reconhecimento das instalações, seguido da formulação e resolução dos balanços de energia globais. Com o acompanhamento diário do funcionamento foi possível propor melhorias sem custos que se revelaram muito benéficas, registando-se um aumento nas recuperações térmicas e por consequência no Rendimento Elétrico Equivalente (R.E.E.), na eficiência da instalação da cogeração e da central térmica. Na cogeração registou-se um aumento de 36,2% na potência recuperada em água quente, aproximadamente 600 kW, sendo já superior à prevista pelo projeto. Na caldeira recuperativa registou-se um ligeiro aumento de 4,0% na potência recuperada. Deste modo o rendimento térmico da central aumentou 6,4%, atingindo os 40,8% e superando os 40,4% projetados. O rendimento global final foi de 83,1% o que representa um aumento de 6,3%. O R.E.E. em Maio de 2014 foi de 76,3%, superior ao valor em Junho de 2013 em 8,7%. Tendo como referência o valor alvo de 70,5% para o R.E.E. apontado no início do estágio, nos últimos 8 meses o seu valor tem sido sempre superior e em crescimento. Existe ainda a possibilidade de aproveitar a energia térmica de baixa temperatura que está a ser dissipada numa torre de arrefecimento, no mínimo 40 kW, num investimento com um período de retorno de investimento máximo de 8,1 meses. Na central térmica registou-se um aumento do rendimento para a mesma quantidade de energia produzida na central, pois esta é a principal variável do processo. Em 2014 a produção de energia apresentou um valor inferior a 2013, 6,9%, e a eficiência registou um acréscimo de 2,0%. A incorporação de biogás na alimentação de combustível à caldeira bifuel não pareceu comprometer significativamente a eficiência da central térmica, pelo que a sua utilização é benéfica. Com o aumento das recuperações térmicas na central de cogeração foram estimadas poupanças de gás natural equivalentes a 3,3 GWh, o que significa 120.680€ economizados nos últimos 11 meses do trabalho. É esperado uma poupança de 18.000€ mensais com a melhoria do funcionamento obtida nas duas centrais.

Use of selective medium for Burkholderia cepacia isolation in respiratory samples from cystic fibrosis patients

Burkholderia cepacia colonizes cystic fibrosis (CF) patients. We evaluated the impact of the use of a selective medium in the rate of B. cepacia recovery from respiratory samples of CF patients. During a 6-month period, respiratory samples were collected from 106 CF patients and cultivated on selective media including a B. cepacia selective medium. Confirmation of the identity of B. cepacia isolates was carried out by species specific PCR and determination of genomovar status performed by a sequential PCR approach. Results of B. cepacia isolation during this period were compared to the preceding two years, when the sample processing was identical except for the lack of the B. cepacia selective medium. B. cepacia was isolated in 11/257 (4.2%) of the samples using the selective medium, in contrast with the preceding two years, when it was isolated in 6/1029 samples (0.58%), p < 0.0001. Identity of all 11 isolates was confirmed by PCR and genomovar determination was accomplished in all but one isolate. These results suggest that the use of a selective medium increases recovery rate of B. cepacia from respiratory samples.

Nonlinear dynamics of the patient’s response to drug effect during general anesthesia

In today’s healthcare paradigm, optimal sedation during anesthesia plays an important role both in patient welfare and in the socio-economic context. For the closed-loop control of general anesthesia, two drugs have proven to have stable, rapid onset times: propofol and remifentanil. These drugs are related to their effect in the bispectral index, a measure of EEG signal. In this paper wavelet time–frequency analysis is used to extract useful information from the clinical signals, since they are time-varying and mark important changes in patient’s response to drug dose. Model based predictive control algorithms are employed to regulate the depth of sedation by manipulating these two drugs. The results of identification from real data and the simulation of the closed loop control performance suggest that the proposed approach can bring an improvement of 9% in overall robustness and may be suitable for clinical practice.

Lupus Myelopathy in a Child

A 5-year-old female developed, after a 7-month period of fever, anorexia, weight loss, and a transitory cutaneous erythematous eruption, a severe acute transverse myelopathy, with a partial recovery of motor and sensory function. She had positive antinuclear and antidouble-stranded DNA antibodies but no antiphospholipid antibodies. Six months later she had massive proteinuria and restarted treatment with steroids and cyclophosphamide. Our patient is one of the youngest reported with lupus myelopathy. We discuss the clinical presentation, the magnetic resonance imaging findings, and other relevant laboratory studies of this rare but serious complication of systemic lupus erythematosus.

Alterações da Actividade Autonómica Durante o Teste de Inclinação em Doentes com Fibrilhação Auricular Paroxística: Análise com Wavelets

The autonomic nervous system (ANS) is known to be an important modulator in the pathogenesis of paroxysmal atrial fibrillation (PAF). Changes in ANS control of heart rate variability (HRV) occur during orthostatism to maintain cardiovascular homeostasis. Wavelet transform has emerged as a useful tool that provides time-frequency decomposition of the signal under investigation, enabling intermittent components of transient phenomena to be analyzed. AIM: To study HRV during head-up tilt (HUT) with wavelet transform analysis in PAF patients and healthy individuals (normals). METHODS: Twenty-one patients with PAF (8 men; age 58 +/- 14 yrs) were examined and compared with 21 normals (7 men, age 48 +/- 12 yrs). After a supine resting period, all subjects underwent passive HUT (60 degrees) while in sinus rhythm. Continuous monitoring of ECG and blood pressure was carried out (Task Force Monitor, CNSystems). Acute changes in RR-intervals were assessed by wavelet analysis and low-frequency power (LF: 0.04-0.15 Hz), high-frequency power (HF: 0.15-0.60 Hz) and LF/HF (sympathovagal) were calculated for 1) the last 2 min of the supine period; 2) the 15 sec of tilting movement (TM); and 3) the 1st (TT1) and 2nd (TT2) min of HUT. Data are expressed as means +/- SEM. RESULTS: Baseline and HUT RR-intervals were similar for the two groups. Supine basal blood pressure was also similar for the two groups, with a sustained increase in PAF patients, and a decrease followed by an increase and then recovery in normals. Basal LF, HF and LF/ HF values in PAF patients were 632 +/- 162 ms2, 534 +/- 231 ms2 and 1.95 +/- 0.39 respectively, and 1058 +/- 223 ms2, 789 +/- 244 ms2 and 2.4 +/- 0.36 respectively in normals (p = NS). During TM, LF, HF and LF/HF values for PAF patients were 747 +/- 277 ms2, 387 +/- 94 ms2 and 2.9 +/- 0.6 respectively, and 1316 +/- 315 ms2, 698 +/- 148 ms2 and 2.8 +/- 0.6 respectively in normals (p < 0.05 for LF and HF). During TF1, LF, HF and LF/ HF values for PAF patients were 1243 +/- 432 ms2, 302 +/- 88 ms2 and 7.7 +/- 2.4 respectively, and 1992 +/- 398 ms2, 333 +/- 76 ms2 and 7.8 +/- 0.98 respectively for normals (p < 0.05 for LF). During TF2, LF, HF and LF/HF values for PAF patients were 871 +/- 256 ms2, 242 +/- 51 ms2 and 4.7 +/- 0.9 respectively, and 1263 +/- 335 ms2, 317 +/- 108 ms2 and 8.6 +/- 0.68 respectively for normals (p < 0.05 for LF/HF). The dynamic profile of HRV showed that LF and HF values in PAF patients did not change significantly during TM or TT2, and LF/HF did not change during TM but increased in TT1 and TT2. CONCLUSION: Patients with PAF present alterations in HRV during orthostatism, with decreased LF and HF power during TM, without significant variations during the first minutes of HUT. These findings suggest that wavelet transform analysis may provide new insights when assessing autonomic heart regulation and highlight the presence of ANS disturbances in PAF.

Bites by coral snakes (Micrurus spp.) in Campinas, State of São Paulo, Southeastern Brazil

Coral snakes (Micrurus spp.) are the main representatives of the Elapidae in South America. However, bites by these snakes are uncommon. We retrospectively reviewed the data from 11 individuals bitten by coral snakes over a 20-year period; four were confirmed (snake brought for identification) and seven were highly suspected (neuromuscular manifestations) cases of elapid envenoming. The cases were classified as dry-bite (n = 1, caused by M. lemniscatus; did not receive antivenom), mild (n = 2, local manifestations with no acute myasthenic syndrome; M. frontalis and Micrurus spp.), moderate (n = 5, mild myasthenia) or severe (n = 3, important myasthenia; one of them caused by M. frontalis). The main clinical features upon admission were paresthesia (local, n = 9; generalized, n = 2), local pain (n = 8), palpebral ptosis (n = 8), weakness (n = 4) and inability to stand up (n = 3). No patient developed respiratory failure. Antivenom was used in ten cases, with mild early reactions occurring in three. An anticholinesterase drug was administered in the three severe cases, with a good response in two. No deaths were observed. Despite the high toxicity of coral snake venoms, the prognosis following envenoming is good. In serious bites by M. frontalis or M. lemniscatus, the venom of which acts postsynaptically, anticholinesterases may be useful as an ancillary measure if antivenom is unavailable, if there is a delay in obtaining a sufficient amount, or in those patients given the highest recommended doses of antivenom without improvement of the paralysis or with delayed recovery.

Impacto das medidas de conservação de energia em projeto na redução da intensidade de utilização de matérias-primas na construção de um edifício

O presente trabalho pretende mostrar que a aplicação de medidas de conservação de energia (MCE) pode representar uma redução da intensidade de utilização de matérias-primas na construção de um edifício. Mais concretamente, pode representar uma redução da utilização de materiais e equipamentos, e como consequência, uma redução no esforço económico ao primeiro investimento. Podendo posteriormente representar uma redução na utilização de energia durante o período de funcionamento do edifício. A aplicação de MCE no sector da construção tem vindo a ser uma prática corrente nos novos edifícios e edifícios sujeitos a grandes intervenções de reabilitação. Esta prática deve-se à obrigatoriedade de cumprimento de requisitos regulamentares aplicados à otimização do desempenho energético dos edifícios e dos seus sistemas técnicos, nomeadamente, o RCCTE e o RSECE, entretanto revogados pelo REH e pelo RECS, respetivamente. A implementação de MCE apresenta, na maioria dos casos, benefícios económicos para o promotor do edifício, uma vez que se traduz muitas vezes, na otimização do dimensionamento dos sistemas de Aquecimento, Ventilação e Ar Condicionado (AVAC). Esta otimização permite reduzir os custos associados ao primeiro investimento, bem como na utilização de energia por parte do utilizador, logo na redução dos custos de exploração. No entanto, a falta de quantificação dos impactos do dimensionamento dos sistemas AVAC, da redução de utilização de energia e da análise do custo-benefício da sua aplicação pode condicionar o interesse na sua implementação. Neste contexto, surge a presente dissertação, por iniciativa do Instituto Soldadura e Qualidade (ISQ), aplicado a um caso prático de um edifício já construído e propriedade daquela empresa. Com este trabalho pretende-se avaliar o contributo efetivo das MCE implementadas na fase de projeto e na fase de construção, quer na otimização da dimensão de sistemas e equipamentos AVAC, por via da redução das necessidades energéticas, quer na redução de utilização de energia, permitindo, de seguida, uma avaliação custo-benefício.Na base do caso de estudo está o ECOTERMOLAB, o edifício acima referido, adquirido pelo ISQ para instalação de um laboratório de formação, investigação e desenvolvimento na área da energia. Após aquisição pelo ISQ, o edifício sofreu várias alterações/beneficiações, entre as quais a implementação de MCE, tais como, a aplicação de isolamento térmico na envolvente opaca (paredes, pavimentos e coberturas), duplicação dos vãos envidraçados simples, conferindo-lhes melhores caraterísticas térmicas, e pela aplicação de proteções solar. Foram ainda adotadas MCE aos sistemas AVAC, designadamente, pela adoção de recuperadores de calor nas Unidades de Tratamento de Ar Novo (UTAN’s) e de variadores de velocidade nas bombas de circulação de água e nos ventiladores de ar das UTAN’s. Pretendia o ISQ concluir se a aplicação de todas as MCE contribuiu de forma efetiva para o dimensionamento de sistemas e equipamentos AVAC de menor capacidade e, consequentemente, numa redução de utilização de energia. Em sequência, pretendia avaliar a viabilidade económica da aplicação de todas as MCE, estimando o sobrecusto inicial e o tempo necessário para o retorno financeiro daquele investimento. Para alcançar os objetivos propostos, procedeu-se à simulação energética dinâmica do ECOTERMOLAB, utilizando o programa EnergyPlus. Primeiro foi simulada uma situação base do edifício, sem quaisquer MCE. Posteriormente foi caraterizada cada uma das situações de aplicação das MCE, com o objetivo de avaliar o respetivo impacto individual na utilização de energia pelos sistemas AVAC. Por último foram assumidas todas as soluções em conjunto para avaliar o impacto final de todas as MCE na utilização de energia dos sistemas AVAC, bem como no seu dimensionamento. Das simulações dinâmicas foram obtidos os valores das necessidades de aquecimento e arrefecimento, de energia utilizada pelos sistemas AVAC e de caudais de água aquecida e arrefecida circulada. Com estes valores foi feita uma estimativa de dimensionamento dos equipamentos e componentes AVAC para as situações da aplicação de todas as MCE no ECOTERMOLAB e a sua ausência. A partir da diferença dos custos de aquisição dos respetivos equipamentos e dos valores de poupança em energia foi realizado o estudo da viabilidade económica da implementação das MCE neste edifício. Este estudo permitiu concluir que a aplicação das MCE no ECOTERMOLAB levou à redução da dimensão na generalidade dos equipamentos e componentes AVAC. Permitiu, ainda, concluir que houve uma diminuição de utilização de energia por parte destes sistemas e equipamentos para o aquecimento e arrefecimento. Conclui-se ainda que o período de retorno (Payback) do sobrecusto inicial, estimado em 37.822€ é de, aproximadamente, onze anos e meio, para um valor atual líquido (VAL) de 8.061€ e à taxa interna de rentabilidade (TIR) de 7,03%.

Survival of Trypanosoma cruzi in sugar cane used to prepare juice

Chagas disease can be transmitted to man by many different means, including contact with infected triatomine feces, blood transfusion, laboratory accidents, organ transplants, and congenital or oral routes. The latter mode has received considerable attention recently. In this assay, we evaluate the survival of Trypanosoma cruzi contaminating sugar cane used to prepare juice, as well as the viability and capacity for infection by the parasite after recovery. Thirty triatomines were contaminated with T. cruzi Y strain and 45 days later pieces of sugar cane were contaminated with the intestinal contents of the insects. The pieces were ground at different intervals after contamination (time = 0, 1, 4, 6, 12 and 24 hours) and the juice extracted and analyzed. Different methods were used to show T. cruzi in the juice: direct analysis, hematocrit tube centrifugation and QBC, and experimental inoculation in 47 female BALB/c mice (five control mice and seven mice for each interval examined (five inoculated orally and two intraperitoneally). Positive results were found using the direct analysis and QBC methods for juice prepared up to 12 hours after initial contamination. However, by the centrifugation technique, positivity was found only up to four hours after contamination of the sugar cane. Inoculated animals showed parasitemia during a 14 day observation period, demonstrating the high survival rate of T. cruzi in sugar cane.

Frequency of soil contamination by Toxocara canis eggs in the south region of São Paulo municipality (SP, Brazil) in a 18 month period

Soil contamination by embryonic eggs of Toxocara canis is the main source of human infection by this ascarid larvae resulting, sometimes, in the occurrence of visceral larva migrans syndrome. The objective of the present research is to determine the frequency of T. canis eggs in soil samples monthly collected in nine public places, located at the South Region of São Paulo municipality in a 18-month period, from February 2004 to July 2005. The soil samples collected were treated with a 30% antiformine solution and with a sodium dichromate solution (d = 1.40) and microscopic slides were prepared and examined under light microscopy for searching T. canis eggs. Two peaks of higher frequency had been found, one in February - May 2004 and the other in April - July 2005.

No Fate But What We Make: a Case of Full Recovery After Out-of-Hospital Cardiac Arrest

An 80 years old man suffered a cardiac arrest shortly after arrival to his local health department. Basic Life Support was started promptly and nine minutes later, on evaluation by an Advanced Life Support team, the victim was defibrillated with a 200J shock. When orotracheal intubation was attempted, masseter muscle contraction was noticed: on reevaluation, the victim had pulse and spontaneous breathing.Thirty minutes later, the patient had been transferred to an emergency department. As he complained of chest pain, the ECG showed a ST segment depression in leads V4 to V6 and laboratory tests showed cardiac troponine I slightly elevated. A coronary angiography was performed urgently: significant left main plus three vessel coronary artery disease was disclosed.Eighteen hours after the cardiac arrest, a quadruple coronary artery bypass grafting operation was undertaken. During surgery, a fresh thrombus was removed from the middle left anterior descendent artery. Post-operative course was uneventful and the patient was discharged seven days after the procedure. Twenty four months later, he remains asymptomatic.In this case, the immediate call for the Advanced Life Support team, prompt basic life support and the successful defibrillation, altogether, contributed for the full recovery. Furthermore, the swiftness in the detection and treatment of the acute reversible cause (myocardial ischemia in this case) was crucial for long-term prognosis.

Multidimensional Scalling Analysis of the World Economy During the Period 1972-2012

The last 40 years of the world economy are analyzed by means of computer visualization methods. Multidimensional scaling and the hierarchical clustering tree techniques are used. The current Western downturn in favor of Asian partners may still be reversed in the coming decades.

Influence of variables on centrifuge-flotation technique for recovery of Toxocara canis eggs from soil

The purpose of this study was to evaluate the influence of variables in a flotation technique for the recovery of Toxocara canis eggs from soil. The trials were done under standardized conditions on one gram of previously sterilized soil samples contaminated with 200 eggs of T. canis. The following variables were evaluated in serial steps: sieving; type of wash; time of stirring; resuspension of sediment; solution flotation. Centrifuge-flotation in sodium nitrate (d = 1.20 g/cm³) was adopted as an initial technique, using Tween 80 (0.2%) and decinormal sodium hydroxide as solutions for washing the samples. Ten tests were done to compare the variables, using counting in triplicate. The sieving of the material reduced significantly the recovery of eggs (p < 0.001) and the number of eggs recovered was higher when the sediment was resuspended (p < 0.05). After standardization, flotation solutions sodium chloride, zinc sulfate, sodium dichromate, magnesium sulfate, and sodium nitrate (d = 1.20g/cm³) were compared. The best results were obtained by using zinc sulfate solution. In conclusion, the chances of recovering T. canis eggs from samples using flotation solutions can be increased by washing of soil twice using distilled water, and resuspension of sediment. On the other hand, the sieving procedure can drastically reduce the number of eggs.

Laparoscopic Assisted Vaginal Hysterectomy Versus Vaginal Hysterectomy

Introduction: Hysterectomy is the commonest gynecologic operation, performed for malignant and benign conditions. There are many approaches to hysterectomy for benign disease. Studies comparing the techniques have showed that vaginal hysterectomy has benefits in terms of reduced hospital stay, faster recovery and less operating time. Objective: The purpose of this study is to compare the surgical and immediate postoperative outcomes of Laparoscopic Assisted Vaginal Hysterectomy (LAVH) with those of Vaginal Hysterectomy (VH). Methods: Retrospective descriptive study, comparing two groups of women who underwent LAVH or VH in our department during a 24 months period, from January 2009 to December 2010. The two groups were compared regarding age, vaginal deliveries, previous abdominal surgery, uterine and adnexal pathology, intra-operative and post-operative complications, uterus weight, blood loss and number of days until discharge. Results: In our study 42 LAVH and 99 VH were included, with a patient mean age of 47 and 59, respectively. The most frequent indication for hysterectomy was fibroids (80%) for LAVH and POP(58.6%) for HV. In LAVH group 47.6% of patients had previous abdominal surgery, vs 28.2% in VH group. The medium operative time was 167 minutes for LAVH vs 99 minutes for HV. The intra-operative complications were one case (2%) of accidental incision of rectum in LAVH, and one bladder incision in the VH (1%). There were 3 conversions to laparotomy for difficult technique (7%) in LAVH group. There were no significant post-operative complications for LAVH. In VH group there were 2 cases of haemoperitoneum (2%) and 1 case requiring blood transfusion (1%). The mean time for discharge was 4.23 days for LAVH and 4.46 days for VH. Conclusions: In our study, the main advantage for VH was the reduced operative time. In terms of time to discharge there was no difference between the 2 groups. The main intra-operative complication of LAVH was the risk of conversion to laparotomy, but post-operatively this procedure had fewer complications than VH. In conclusion, LAVH is a safe option for women requiring hysterectomy in cases where VH is anticipated to be technically difficult.