Drug-resistant tuberculosis in six hospitals in Rio de Janeiro, Brazil

SETTING: Tuberculosis (TB) drug resistance survey in six hospitals in Rio de Janeiro, Brazil. OBJECTIVE: To estimate resistance to at least one drug (DR) and multidrug resistance (MDR) and identify associated factors. DESIGN: One-year cross-sectional survey. Hospitals were included as a convenience sample. RESULTS: Of 595 patients investigated, 156 (26.2%) had previously undergone anti-tuberculosis treatment, 433 (72.8%) were not previously treated and information on the remaining 6 was not available. Overall, DR and MDR rates were high, at respectively 102 (17.1%, 95%CI 14.3-20.5) and 44 (7.4%, 95%CI 5.5-9.9) cases. Among individuals not previously treated, 17 had MDR (3.9%, 95%CI 2.4-6.3) and diagnosis in a TB reference hospital was independently associated with MDR (prevalence ratio [PR] 3.3, 95%CI 1.2-8.7) after multivariate analysis. Among previously treated individuals, 27 had MDR (17.3%, 95%CI 11.7-24.2). MDR-TB was independently associated with diagnosis in a TB reference hospital (PR 3.6, 95%CI 1.5-8.7), male sex (PR 2.3,95%CI 1.2-4.4) and dyspnoea (PR 0.3, 95%CI 0.1-0.7). CONCLUSION: We found high levels of DR- and MDR-TB. Our study design did not permit us to determine the contribution of community versus nosocomial transmission. Further studies are needed to establish this. Nevertheless, hospitals should be recognised as a potential source of transmission of resistant TB strains and urgent measures to avoid nosocomial TB transmission should be taken.

Access to tuberculosis diagnosis in Itaborai City, Rio de Janeiro, Brazil: the patient`s point of view

SETTING: Itaborai Municipality in Rio de Janeiro, Brazil. OBJECTIVE: To evaluate access to tuberculosis (TB) diagnosis for users of the Family Health Program (FHP) and Reference Ambulatory Units (RAUs). DESIGN : A cross-sectional study was conducted in Itaborai City, Rio de Janeiro, Brazil. Between July and October 2007, a sample of 100 TB patients registered consecutively with the TB Control Program was interviewed using the primary care assessment tool. The two highest scores, describing `almost always` and `always`, or `good` and `very good`, were used as a cut-off point to define high quality access to diagnosis. RESULTS: FHP patients were older and had less education than RAU interviewees. Sex and overcrowding did not differ in the two groups. Patient groups did not differ with regard to the number of times care was sought at a unit, transport problems, cost of attending units and availability of consultation within 24 h. Adequate access to diagnosis was identified by 62% of the FHP patients and 53% of the RAU patients (P = 0.01). CONCLUSION: In Itaborai, Rio de Janeiro, TB patients believe that the FHP units provide greater access to TB diagnosis than RAUs. These findings will be used by the Department of Health to improve access to diagnosis in Itaborai.

Knowledge and practices of medical students to prevent tuberculosis transmission in Rio de Janeiro, Brazil

Objectives. To describe knowledge, practices, and associated factors of medical students to prevent transmission of tuberculosis (TB) in five medical schools. Methods. Cross-sectional survey of undergraduate medical students in preclinical and in early and late clinical years. Information was obtained on sociodemographic profile, previous lectures on TB, knowledge about TB transmission, exposure to patients with active pulmonary TB, and use of respiratory protective masks. Results. Among 1 094 respondents, 575 (52.6%) correctly answered that coughing, speaking, and sneezing can transmit TB. Early [adjusted odds ratio = 4.0 (3.0, 5.5)] and late [adjusted odds ratio = 4.2 (3.1, 5.8)] clinical years were associated with correct answers, but having had previous lectures on TB was not. Among those who had previous lectures on TB, the rate of correct answers increased from 42.1% to 61.6%. Among 332 medical students who reported exposure to TB patients, 194 (58.4%) had not used protective masks. More years of clinical experience was associated with the use of masks [adjusted odds ratio = 2.9 (1.4, 6.1)], while knowledge was inversely associated with the use of masks [adjusted odds ratio = 0.4 (0.2, 0.6)]. Conclusions. Many medical students are not aware of the main routes of TB infection, and lectures on TB are not sufficient to change knowledge and practices. Regardless of knowledge about TB transmission, students engage in risky behaviors: more than two-thirds do not use a protective mask when examining an active TB case. We suggest innovative, effective active learning experiences to change this scenario.

Modeling upper eyelid kinematics during spontaneous and reflex blinks

To test a mathematical model for measuring blinking kinematics. Spontaneous and reflex blinks of 23 healthy subjects were recorded with two different temporal resolutions. A magnetic search coil was used to record 77 blinks sampled at 200 Hz and 2 kHz in 13 subjects. A video system with low temporal resolution (30 Hz) was employed to register 60 blinks of 10 other subjects. The experimental data points were fitted with a model that assumes that the upper eyelid movement can be divided into two parts: an impulsive accelerated motion followed by a damped harmonic oscillation. All spontaneous and reflex blinks, including those recorded with low resolution, were well fitted by the model with a median coefficient of determination of 0.990. No significant difference was observed when the parameters of the blinks were estimated with the under-damped or critically damped solutions of the harmonic oscillator. On the other hand, the over-damped solution was not applicable to fit any movement. There was good agreement between the model and numerical estimation of the amplitude but not of maximum velocity. Spontaneous and reflex blinks can be mathematically described as consisting of two different phases. The down-phase is mainly an accelerated movement followed by a short time that represents the initial part of the damped harmonic oscillation. The latter is entirely responsible for the up-phase of the movement. Depending on the instantaneous characteristics of each movement, the under-damped or critically damped oscillation is better suited to describe the second phase of the blink. (C) 2010 Elsevier B.V. All rights reserved.

Spontaneous Blinking in Patients With Graves` Upper Eyelid Retraction

Purpose: To describe spontaneous blink kinematics in Graves` upper eyelid retraction (UER). Methods: The magnetic search coil technique was used to record spontaneous blinks of 15 healthy subjects (aged 23-56 years, 15 eyelids) and 15 patients with Graves` UER (aged 22-62 years, 15 eyelids) during a 5-min period of video observation, and the signals were digitized at 200 Hz (12 bits). Overall, a total of 2,798 blinks were recorded for the controls and 1,860 for the patients. The distance between pupil center and upper eyelid margin in the primary position of gaze (MRD) was measured with the Image J software. Results: The blinking rate of patients was lower than that of control subjects, with a mean (+/-SEM) blinking rate (blinks/min) of 13.0 +/- 1.7 for patients and of 20.0 +/- 2.1 for the controls (t = 2.58, P = 0.016). There were no statistically significant differences in blink amplitude between controls (22.7 +/- 3.1 degrees) and Graves` patients (24.7 +/- 3.3 degrees). However, while only 22% of the blinks performed by controls were smaller than MRD, this rate was 78% for patients. In addition, in blinks larger than 25, patients showed lower down-phase velocity than controls. Conclusions: Patients with Graves` UER show reduced blinks rates and abnormal blink kinematics, which might be related to the development of exposure keratitis in this disease.

The relationship between two types of upper eyelid movements: Saccades and pursuit

PURPOSE. To establish the relationship between upper eyelid saccades and upper eyelid pursuit movements. METHODS. Upper eyelid saccades and periodic sinusoidal upper eyelid pursuit movements were recorded in a sample of controls and patients with Graves upper eyelid retraction. A video-computerized system was used to register both types of movements that accompanied 60 of eye rotation across the upper and lower hemifields. The forced harmonic oscillator model was used to fit saccadic and pursuit movements. RESULTS. Mean mid-pupil eyelid distance for the Graves patients (6.6 +/- 1.1 mm) was significantly higher than for the controls (4.6 +/- 0.8 mm; t = 7.18; P < 0.00001). Despite the difference in the upper eyelid resting position, saccades and pursuit eyelid movements of both groups were extremely well fitted by underdamped solutions and steady forced solutions of the harmonic oscillator model, respectively. For the controls, the amplitude of the pursuit movements was well correlated with the upward and downward saccades. The amplitude of the eyelid movements of the Graves patients (saccades and pursuit) was significantly reduced compared with that of the controls. CONCLUSIONS. Saccadic and pursuit movements of the upper eyelid can be described by the harmonic oscillator model. In healthy subjects and Graves patients, the amplitude of pursuit lid movements is correlated to the saccade amplitude. Pursuit eyelid movements are more difficult to register than saccades, and their measurements do not allow clear separation of the relaxation and contraction properties of the upper eyelid retractors.

Molecular characteristics of extended-spectrum beta-lactamase-producing Escherichia coli from Rio de Janeiro, Brazil

Twenty-five extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli clinical isolates from Rio de Janeiro, Brazil were characterized by isoelectric focusing, PCR and sequencing of bla(ESBL) genes, plasmid-mediated quinolone resistance determinants, phylogenetic groups, replicon typing, pulsed-field electrophoresis, and multilocus sequencing typing. Twenty-three (92%) ESBL-producing E. coli isolates were positive for bla(CTX-M) genes, aac(6`)-lb-cr, and qnrB. Genetic relatedness of ESBL producers clustered seven (28%) CTX-M-15-producing isolates as sequence type (ST) 410, clonal complex (CC) 23, and two (8%) as clone O25-ST131. Our results illustrate the predominance of phylo-group A (52%), ST410 (CC 23) and CTX-M-15 among ESBL-producing E. coli isolates from hospitals in Rio de Janeiro.

Prevalence of anti-Toxoplasma gondii and anti-Neospora caninum antibodies in sheep from Mossoro, Rio Grande do Norte, Brazil

Toxoplasma gondii is an obligate intracellular parasite with a variety of hosts, responsible for reproductive problems and economic losses in sheep flocks. Neospora caninum was recently identified and its clinical presentation in sheep is similar to that of toxoplasmosis, which can cause repeated abortions, though less frequently in this species. In order to confirm the prevalence of these agents in the city of Mossoro, Rio Grande do Norte, Brazil, 409 serum samples from adult sheep (364 females and 45 males) were tested by the indirect immunofluorescence antibody test, using cut-off point at a dilution of 1:64 and 1:50 for T. gondii and N. caninum, respectively. From the 35 properties examined, 23 (65.7%)had at least one seropositive animal for T gondii and six (17.1%) for N. caninum. The prevalence of seropositive animals for T. gondii was 20.7% and for N. caninum 1.8%. There was no association between the presence of the agent`s antibody and gender, reports of reproductive problems and presence of dogs and/or cats in the properties. T. gondii is well distributed and N. caninum has low prevalence in sheep and in the properties of the studied region. (C) 2008 Elsevier B.V. All rights reserved.

Prevalence and risk factors for anti-Toxoplasma gondii antibodies in goats of the Serido Oriental microregion, Rio Grande do Norte state, Northeast region of Brazil

The prevalence and risk factors for anti-Toxoplasma gondii antibodies were investigated in goats of the Serido Oriental microregion, Rio Grande do Norte state, Northeast region of Brazil. Three hundred and sixty-six blood samples from goats collected by jugular venopuncture were used. For the serologic diagnosis of Toxoplasma gondii infection, the indirect fluorescent-anti body test (IFAT) with cut-off value 1:64 was carried out. The prevalence of anti-T. gondii antibodies was 30.6% [95% CI = 25.9-35.6%] with titers ranging from 1:64 to 1: 16,384. The multivariate logistic regression analysis showed that the risk factors associated to anti-T. gondii antibodies were presence of cats in the herd, extensive/semi-intensive management systems and lack of mineral supplementation. (c) 2008 Elsevier B.V. All rights reserved.

Angiomyolipomatous hamartoma of the upper lip: A rare case in an 8-month-old child and differential diagnosis

Hamartoma is a proliferation of normal tissues that are considered endogenous to the site of occurrence. In the head and neck region, hamartomas composed of other tissues different from blood and lymphatic vessels (hemangiomas and lymphangiomas) are very uncommon. We report an unusual case of upper lip angiomyolipomatous hamartoma in an 8-month-old patient. The patient underwent surgical treatment and the 1-year follow-up revealed no signs of recurrence. Angiomyolipomatous hamartoma is a very rare condition in the paediatric population group, especially in the head and neck region. It should be considered in the differential diagnosis of congenital lesions in childhood. (C) 2010 European Association for Cranio-Maxillo-Facial Surgery.

Vertical Root Fracture in Upper Premolars with Endodontic Posts: Finite Element Analysis

Upper premolars restored with endodontic posts present a high incidence of vertical root fracture (VRF). Two hypotheses were tested: (1) the smaller mesiodistal diameter favors stress concentration in the root and (2) the lack of an effective bonding between root and post increases the risk of VRF. Using finite element analysis, maximum principal stress was analyzed in 3-dimensional intact upper second premolar models. From the intact models, new models were built including endodontic posts of different elastic modulus (E = 37 or E = 200 GPa) with circular or oval cross-section, either bonded or nonbonded to circular or oval cross-section root canals. The first hypothesis was partially confirmed because the conditions involving nonbonded, low-modulus posts showed lower tensile stress for oval canals compared to circular canals. Tensile stress peaks for the nonbonded models were approximately three times higher than for the bonded or intact models, therefore confirming the second hypothesis. (J Endod 2009;35:117-120)

Long-term effects of pharyngeal flaps on the upper airways of subjects with velopharyngeal insufficiency

Objectives: To investigate the long-term effects of pharyngeal flap surgery (PFS) on nasal and nasopharyngeal dimensions of patients with velopharyngeal insufficiency (VPI) and to correlate the findings with the onset of respiratory complaints after surgery. Design/Participants: Prospective study in 58 nonsyndromic patients with repaired cleft palate and VPI, evaluated 2 days before and 5 months (POST1) and 1 year (POST2) after PFS, on average. Patients were divided into two groups: one consisting of patients with postoperative respiratory complaints (RC group) and the other without complaints (NRC group). Interventions: Superiorly based PFS. Main Outcome Measures: Respiratory complaints (self reports of mouth breathing, snoring, and other sleep obstructive events) assessed at POST1 and POST2, and minimum nasal (NCSA) and nasopharyngeal (NPA) cross-sectional areas assessed by rhinomanometry at POST2. Results: Respiratory complaints were reported by 55% and 36% of the patients evaluated at POST1 and POST2, respectively. Posterior rhinomanometry showed a significant postoperative reduction of mean NCSA in the RC and NRC groups (p < .05), to subnormal levels in some of them. The decrease was more pronounced in the RC group. No significant changes in NCSA were observed by anterior rhinomanometry. Similar results were obtained when NPA was assessed by modified anterior rhinomanometry. Conclusion: In the long-term, PFS yielded a significant reduction in upper airways dimensions beyond what should be expected and associated with persistent respiratory complaints in some cases.

Prevalence of Upper Cervical Vertebrae Anomalies in Patients With Cleft Lip and/or Palate and Noncleft Patients

Objectives: To investigate the prevalence of upper cervical vertebrae anomalies in patients with isolated cleft lip, isolated cleft palate, and complete cleft lip and palate, as well as to compare the prevalence of these anomalies between groups, between genders, and with noncleft patients. Design: Retrospective cross-sectional study of randomly selected patients. Setting: Radiology Section, Hospital for Rehabilitation of Craniofacial Anomalies and Department of Orthodontics, Bauru School of Dentistry, University of Sao Paulo, Sao Paulo, Brazil. Participants: The sample comprised 300 lateral cephalograms of cleft patients, aged 12 to 13 years, of both genders, from the files of the Hospital for Rehabilitation of Craniofacial Anomalies-University of Sao Paulo and 300 lateral cephalograms from noncleft patients of the Department of Orthodontics, Bauru School of Dentistry. Cephalograms of patients with syndromes were not included. Method: Radiographs were interpreted on a film viewer by a single examiner; the profiles of vertebrae were traced on acetate paper, and cervical vertebrae anomalies were registered and categorized into posterior arch deficiencies, fusion, and association of both. Main Outcome Measures: Statistical comparison of groups using the chi-square test. Results: In the cleft group, 38.67% of the patients had cervical vertebrae anomalies. Of those in the noncleft sample, 31% showed anomalies of the cervical spine. This difference was statistically significant. There was no statistically significant difference when the types of clefts were compared with each other or when both genders were compared in both samples. Conclusions: This study confirms the association between clefts and cervical anomalies. Additional research on this topic is necessary.

Warthin Tumor of the Upper Lip: An Unusual Location of a Benign Salivary Gland Tumor

Warthin tumor (papillary cystadenoma lymphomatosum) is a benign salivary gland tumor involving almost exclusively the parotid gland. The lip is a very unusual location for this type of tumor, which develops only rarely in minor salivary glands. The case of 42-year-old woman with Warthin tumor arising in minor salivary glands of the upper lip is reported.