Exuberant Hand-Foot-Mouth Disease: An Immunocompetent Adult with Atypical Findings.

Non-polio enteroviruses are ubiquitous viruses responsible for a wide spectrum of disease in people of all ages, although infection and illness disproportionately affect infants and young children. Hand-foot-mouth disease (HFMD) is an enteroviral clinical syndrome most frequently caused by coxsackievirus-A16 and enterovirus-A71. Since 2008, a novel coxsackievirus-A6 genotype has been associated with more severe HFMD in both children and adults, presenting with a unique constellation of findings, and whose prevalence has been increasing over the last few years. In this case report, an atypical clinical picture of confirmed enterovirus HFMD is described in an immunocompetent adult, with exuberant clinical findings, clinically consistent with coxsackievirus-A6 infection. This case report highlights the importance of awareness of the clinical presentation of this increasingly common infection in adults. LEARNING POINTS: Hand-foot-mouth disease (HFMD) caused by coxsackievirus-A6 is associated with more severe illness in adults, and presents with a peculiar constellation of findings that include delayed-onset skin desquamation and nail dystrophy.The prevalence of coxsackievirus-A6 HFMD has been increasing over the last few years.Dactylitis-like inflammatory signs on the distal extremities of the fingers can be a manifestation during the viral illness and may precede nail dystrophy.

Epigastric Pain and Weight Loss - A Case of Wilkie's Syndrome.

Superior mesenteric artery syndrome (SMA syndrome) or Wilkie's syndrome is a rare etiology of duodenal obstruction due to compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. Physical and laboratory findings are often non-specific but imaging methods are useful for diagnosing the condition. A 46-year-old female patient presented to the outpatient clinic of our internal medicine department with a 2-year history of epigastric pain, nausea, early satiety and weight loss of 15 kg. Previous studies were inconclusive. The patient underwent computed tomography enterography and its findings were consistent with SMA syndrome. Currently the patient is being followed by General Surgery and Nutrition and is under nutritional measures in order to optimize her body mass index to decrease possible surgical complications. This case report emphasizes the importance of clinical suspicion and careful investigation when considering less common etiologies for frequent gastrointestinal symptoms. LEARNING POINTS: Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal system obstruction and its diagnosis is often delayed.This syndrome should be suspected in the differential diagnosis of patients with persistent nausea, abdominal pain and significant weight loss.

Isolation and Characterization of Microsatellite Markers for Soybean Looper (Lepidoptera: Noctuidae).

We constructed 13 microsatellite markers for Chrysodeixis includens (Walker), a serious crop pest in the Americas. All SSR (Simple Sequence Repeat) markers were polymorphic, with no evidence of linkage disequilibrium between any loci in any population. The total number of alleles per locus ranged from 5 for L3, L9, and L11 to 26 for L6; the mean number of alleles per locus in three populations of C. includens ranged from 2.33 for L3 to 14.67 for L6. Hardy-Weinberg equilibrium (HWE) deviation was not observed in four loci for at least one population (L3, L5, L9, L10). Markers L6, L7, L8, L10, L11, L12, and L13 showed a frequency of null alleles > 0.2 for at least one population. STRUCTURE and F-statistics revealed low population structure among the populations (FST = 0.013) and a high degree of inbreeding (FIS = 0.658). The SSR markers developed here will be useful in future studies on the ecology, demography, host dynamics, and gene flow of C. includens. This information is essential to understand the recent status of C. includens as a key pest in South America.

Association between Periodontitis and Hyperglycemia / Associação entre Periodontite e Hiperglicemia

ABSTRACT Objective: The objective of this study was to analyze the prevalence of undiagnosed hyperglycemia in individuals with periodontitis. Methods: The sample was composed of randomly selected individuals that had signed-up for treatment at the Newton Paiva University dental clinic. The volunteers were divided in two groups, the first composed by individuals without periodontitis (n = 30) and the second by individuals with periodontitis (n = 20). All participants answered a questionnaire about habits and overall health condition. Salivary flow was quantified and periodontal examination evaluated bleeding when probed, probing depth and clinical attachment level. Through laboratory tests, the fasting glucose and the glycated hemoglobin levels were quantified. Results: In the sample studied a higher percentage of individuals with hyperglycemia among those with periodontitis than those without periodontitis was identified. Conclusion: It is suggested, therefore, that the request of laboratory tests to check glucose levels becomes a part of the dental treatment protocol of individuals with periodontitis.

RESUMO Objetivo: O objetivo desse estudo foi analisar a prevalência de hiperglicemia não diagnosticada em indivíduos com periodontite. Métodos: A amostra foi composta por indivíduos selecionados aleatoriamente que se inscreveram para tratamento no Curso de Odontologia do Centro Universitário Newton Paiva, Belo Horizonte, Minas Gerais. A amostra foi dividida em dois grupos, o dos indivíduos sem periodontite (n=30) e o dos indivíduos com periodontite (n=20). Todos responderam a um questionário sobre hábitos e condição de saúde geral. Também tiveram o fluxo salivar quantificado e passaram por um exame periodontal para avaliação do sangramento gengival, da profundidade de sondagem e do nível de inserção clínica. Através de exames laboratoriais, quantificou-se a glicemia em jejum e os níveis de hemoglobina glicada. Resultados: Na amostra estudada foi identificado maior percentual de indivíduos com hiperglicemia no grupo com periodontite do que no grupo sem periodontite. Conclusão: Sugere-se, portanto, que a solicitação de exames laboratoriais para avaliação dos níveis glicêmicos faça parte do protocolo odontológico de atendimento dos indivíduos com periodontite.

Lymph node retrieval rates in melanoma: a quality assessment parameter.

INTRODUCTION: Regional lymph node dissection (rlnd) for melanoma with nodal metastasis is a specialized procedure that is associated with improved disease-specific survival in selected patients. Furthermore, there is evidence that a higher lymph node retrieval rate (lnrr) is associated with improved local control. Currently, no consensus has been reached on the definition of an adequate lnrr. A minimum lnrr has been proposed as a quality assessment parameter that has to be validated. METHODS: We conducted a retrospective cohort analysis at the Princess Margaret Cancer Centre (University Health Network, Toronto, ON). The lnrrs for all patients who underwent rlnd for malignant cutaneous melanoma during 2000-2010 were recorded. Indications for rlnd were a positive sentinel lymph node biopsy or clinical lymphadenopathy (palpable or radiologically detected). RESULTS: Of the 207 identified rlnds, 146 (70.5%) were subsequent to a positive sentinel lymph node biopsy, and 61 (29.5%) were performed for clinical lymphadenopathy. The median lnrr was 24 nodes (range: 9-47 nodes; 10th percentile: 14 nodes) for axillary rlnd, 12 nodes (range: 5-30 nodes; 10th percentile: 8 nodes) for inguinal rlnd, and 16 nodes (range: 10-21 nodes; 10th percentile: 11 nodes) for ilioinguinal rlnd. The results were similar when comparing patients with positive sentinel lymph nodes and those with clinical lymphadenopathy, and the same surgical techniques were used in both groups. CONCLUSIONS: The lnrrs at our institution are similar to rates reported at other tertiary-care melanoma centres. A minimum acceptable lnrr can be considered a quality assessment parameter in the surgical management of melanoma with nodal metastasis.

Homozygosity for a factor XII mutation in one female and one male patient with hereditary angio-oedema.

Hereditary angio-oedema (HAE) with normal C1 inhibitor is associated with heterozygous mutations in the factor XII gene (FXII-HAE). We report two Brazilian FXII-HAE families segregating the mutation c.983 C>A (p.Thr328Lys). In each family, one patient with a homozygous mutation was found. The homozygous female patient in family 1 displayed a severe phenotype. However, this falls within the clinical phenotype spectrum reported for heterozygous female mutation carriers. The homozygous male patient in family 2 also showed a severe phenotype. This finding is intriguing, as to our knowledge, it is the first such report for a male FXII-HAE mutation carrier. In the rare instances in which male mutation carriers are affected, a mild phenotype is typical. The present findings therefore suggest that homozygous FXII-HAE mutation status leads to a severe phenotype in females and males, and to an increased risk of manifest symptoms in the latter.

The glue-clot technique: a new technique description for small calyceal stone fragments removal.

During the last 20 years, the technology advancement of small flexible ureterorenoscopes has dramatically changed the management of renal calculi. Retrograde intrarenal surgery (RIRS) has currently a high impact on active stone treatment, and it is increasingly used worldwide. Nevertheless, kidney stone fragmentation and direct removal of fragments require many passages of the ureteroscope, is often time-consuming, and may be very difficult through anatomical and technical factors. We describe a simple, feasible and efficient technique for small stone fragments retrieval, which are often difficult to remove during RIRS.

Beyond selectivity: are behavioral avoidance and hormesis likely causes of pyrethroid-induced outbreaks of the southern red mite Oligonychus ilicis?

Secondary pest outbreak is a counterintuitive ecological backlash of pesticide use in agriculture that takes place with the increase in abundance of a non-targeted pest species after pesticide application against a targeted pest species. Although the phenomenon was well recognized, its alternative causes are seldom considered. Outbreaks of the southern red mite Oligonychus ilicis are frequently reported in Brazilian coffee farms after the application of pyrethroid insecticides against the coffee leaf miner Leucoptera coffeella. Selectivity favoring the red mite against its main predatory mites is generally assumed as the outbreak cause, but this theory has never been tested. Here, we assessed the toxicity (and thus the selectivity) of deltamethrin against both mite species: the southern red mite and its phytoseid predator Amblyseius herbicolus. Additionally, behavioral avoidance and deltamethrin-induced hormesis were also tested as potential causes of red mite outbreak using free-choice behavioral walking bioassays with the predatory mite and life-table experiments with both mite species, respectively. Lethal toxicity bioassays indicated that the predatory mite was slightly more susceptible than its prey (1.5×), but in more robust demographic bioassays, the predator was three times more tolerant to deltamethrin than its prey, indicating that predator susceptibility to deltamethrin is not a cause of the reported outbreaks. The predator did not exhibit behavioral avoidance to deltamethrin; however insecticide-induced hormesis in the red mite led to its high population increase under low doses, which was not observed for the predatory mite. Therefore, deltamethrin-induced hormesis is a likely cause of the reported red mite outbreaks.

Burnout and career choice motivation in medical students.

BACKGROUND: Burnout is a stress-induced syndrome, which affects medical students. Some environmental and personal factors can favor burnout onset and its serious consequences as dropping out, sleep disorders, depression, and suicide. The motivation for choosing medicine is a personal aspect that can modulate the distress with academic demands. METHODS: We applied self-administered questionnaires in 277 medical students to investigate the predictive role of career choice motivations on burnout dimensions. Specifically, we studied the influence of the main reasons for choosing medicine on emotional exhaustion, cynicism, and academic efficacy. RESULTS: Intellectual curiosity, professional autonomy, altruism, and interest in human relationships were the most common reasons for choosing medicine. However, the medical students motivated by personal illness or family member's illness or death revealed a significant greater emotional exhaustion when compared with the students with other motivations. CONCLUSION: The students who apply for medical school motivated by illness/death experiences are at a great risk for burnout. We suggest that students who are at risk for emotional exhaustion can be identified at the admission of medical school. Primary prevention strategies for burnout should consider this risk group.

Laparoscopic cryotherapy for small renal masses: Current State.

OBJECTIVES: To provide an up-to-date review of the available literature on laparoscopic cryotherapy for small renal masses (SRMs) including technique description, indications and outcomes. METHODS: A systematic literature search was conducted in March 2012, using MEDLINE and EMBASE via Ovid databases, to identify studies on laparoscopic cryotherapy for SRMs published during the last 10 years. Only English-language and human-based full manuscripts reporting case series studies with >20 participants, patient characteristics, efficacy and safety data were included. RESULTS: No randomised controlled trials (RCTs)were identified. In total, 27 full reports addressing laparoscopic cryoablation (LCA) for SRMs were selected. The number of patients per study ranged from 20 to 144. Mean age of treated patients across the series ranged from 62 to 73 years. Mean size of renal tumors ranged from 2.7 to 4 cm, being in most cases <3 cm. The number of cryoprobes used for cryoablation ranged from 1 to 6, and only 10 series described the use of 17-gauge (1.47 mm) third-generation needles. Overall, more than 55% of all ablated lesions were pathologically confirmed RCC. Mean follow-up ranged from 9 to 93 months. Only 7 series presented a long-term follow-up of more than 36 months. Most studies were limited by a relatively short follow-up. At least four urologic groups reported intermediate- and long-term outcomes. Persistence rates ranged from 0% to 17% and recurrence rates ranged from 0% to 14%. Overall complication rates ranged from 0% to 40%. CONCLUSIONS: Retrospective observational data and a few prospective series on LCA of SRMs show acceptable oncological 3- to 5-year outcomes with a low recurrence rate. It has proven to be a safe procedure with an overall low complication rate. It is mainly indicated for SRMs in elderly patients affected by co-morbidity and high surgical risk bearing tumours in the anterior valve of the kidney or in contact with the ureter or neighbouring organs.

An update on percutaneous nephrolithotomy: lessons learned from the CROES PCNL Global Study.

Since its introduction in late 1970's, percutaneous nephrolithotomy (PNL) has undergone an evolution in both equipment and technique. This evolution still continues today in the era of minimally invasive treatment options, and is evidenced by the numerous publications. PNL is generally advantageous in the management of large renal stones (>1.5-2 cm) with high stone-free rates and considerable complication rates. However this technique is especially competing with retrograde intrarenal surgery and laparoscopic techniques. Therefore the CROES Global PNL Study Group prospectively collected data of over 5800 patients managed with PNL worldwide and analyzed the data in detail, producing more than 25 scientific papers. And this update focuses on the lessons learned from the CROES PCNL Global Study.

Queimadura elétrica no Hospital Federal do Andaraí de 1997 a 2010: análise de 152 casos / Electrical burn in Andaraí Federal Hospital from 1997 to 2010: 152 cases analysis

relativamente pequena, mas causam, invariavelmente, lesões em estruturasprofundas. Esse tipo de trauma apresenta distribuição bimodal, com um pico na infância, em ambiente doméstico, e outro em adultos jovens, em ambiente de trabalho. Objetivo: O objetivo deste estudo é apresentar o levantamento estatístico de traumas elétricos do Centro de Tratamento de Queimados Dr. Oscar Plaisant no Hospital Federal do Andaraí/Rio de Janeiro, no período de 14 anos (janeiro de 1997 e dezembro de 2010). Método: Foi realizado estudo retrospectivo transversal, com a coleta de dados por meio de análise de prontuários.Resultados: Foram identificadas 1773 internações no CTQ-HFA, sendo 9% do total de etiologia elétrica, em que o sexo masculino representou a maioria. Dentre as faixas economicamente ativas, de 20 a 59 anos, reporta-se 58,5% do total de casos, com predomínio de acidentes no trabalho, somando 26,3%. Tal fato remete a influência desse trauma na renda da população, bem como nos gastos que ele gera, principalmente, à saúde pública. Quanto à superfície corpórea queimada (SCQ), 25% dos pacientes apresentavam menos de 10% de SCQ. Conclusão: Em decorrência da gravidade e da complexidade do trauma elétrico, a medida mais eficaz para reduzir a morbidade e a mortalidade é a prevenção. Além disso, são necessárias unidades de cuidados com equipe qualificada e centros de tratamento intensivo bem equipados.

Introduction: The electrical trauma can affect a relatively small surface area, but causing invariably lesions in deep structures. This type of injury has a bimodal distribution, in children this happens at home and in young adults at work environment. Objective: The aimis to represent a statistical analysis of electrical trauma at the Center for Treatment of Burn at the Hospital Dr. Oscar Plaisant Federal Andaraí / Rio de Janeiro, in the period of 14-year (January 1997 to December 2010). Methods: A retrospective cross-sectional data collection through analysis of medical records. Results: 1773 admissions in the CTQ-HFA were identified, 9% of total is electrical burn,in which males represented the majority. Among the age from 20 to59 years, reports to 58.5% of total cases, with a predominance of accidents at work, totaling 26.3%. This fact shows the influence of trauma on the income of a population, and spending in public health. When analyzing body surface area burned (BSA), 25% of patients hadless than 10% BSA. Conclusion: Due to the gravity and complexity of electrical trauma, the most effective measure to reduce morbidity and mortality is prevention. In addition, care units with qualified staff and well equipped intensive care units are necessary.

Design and technology in the development of potters' lathes for modeling with terracota: the case of Cabo de Santo Agostinho.

This article reports the experience of the design team of the Laboratory The Imaginary in the process of developing an electric potter's lathe which respects the biomechanics of the body, helps to development the task, maintains the archetype of traditional equipment, and improves the mechanical efficiency of the power transmission system. The design method used was based on the axes of research, analysis, development and monitoring, and focused on the product and with partners: the artisans and engineering and production teams. The main results point to ergonomic improvements in the biomechanical and dimensional aspects, and a decrease in the risk of accidents and occupational diseases. The experience of this case also highlights the gains arising from the relationship between design, engineering and users (artisans) in developing products with a design that can be easily replicated for other communities of potters in the state. This and other actions are part of the outlook of the Laboratory the Imaginary which in partnership with local authorities, wishes to see the craft activities continue and to give value to the culture of the city.

The early days of pandemic (H1N1) 2009 virus infection in the central region of Portugal.

BACKGROUND: The first case of pandemic (H1N1) 2009 virus infection was diagnosed in the central region of Portugal on June 16, 2009, in a woman infected in Canada. METHODS: The aim of our study was, first to characterize the clinical and epidemiologic aspects of all the patients with clinical manifestations included in the definition of case for investigation with samples submitted to diagnosis of the pandemic (H1N1) 2009 virus infection, in the central region of Portugal; second to assess the precision of the case definition of case for investigation considered in the study according to the presence or the absence of fever at the moment of clinical observation. We reviewed the medical records of all the patients presenting with Influenza like-illness classified as case for investigation and the first cases of patients infected with the new pandemic (H1N1) 2009 virus, diagnosed in the central region of Portugal during the pandemic period between June and August, 2009, were analyzed. Real-time reverse-transcriptase polymerase-chain-reaction (RT-PCR) testing was used to confirm the pandemic (H1N1) 2009 virus infection. Data collection was performed on a standardized paper format in agreement with the General Health Directorate. RESULTS AND DISCUSSION: Pandemic (H1N1) 2009 virus infection was confirmed in 255 patients. Overall, median age was 23 years and 42.7 % were included in the category of 20 to 29 years. Confirmed infection in patients with less than 2 years or greater than 50 years was a rare event. The first cases were imported from Europe, namely France, Spain and England. On a second phase, pandemic (H1N1) 2009 virus infection was acquired in the south of Portugal (Algarve), before de diagnosis of the first domestic case. The incidence rate for pandemic (H1N1) 2009 virus infection was 10.7 per 100,000 persons and was different according to the district. It was higher in the district of Coimbra and Guarda were the main roads connecting to Europe are. The median calculated incubation period for the for pandemic (H1N1) 2009 virus infection was 2 days. The length of the clinical manifestations until the patients look for medical observation had a median time of 2 days. All the cases were of mild to moderate severity. No deaths were observed. CONCLUSIONS: The early days of pandemic (H1N1) 2009 virus infection was mild in our region. Most affected patients were young adults, with the extreme categories ages of life being spared. Early detection and diagnosis, combined with stringent isolation and treatment procedures could have slowed the spread of the infection in our region.

Insecticide survival and behavioral avoidance in the lacewings Chrysoperla externa and Ceraeochrysa cubana.

Insecticide impact on non-target species, such as insect predators and parasitoids, is an ever-growing concern in agriculture and recent studies have been shifting focus from lethal to sub-lethal effects since they may prevail in field conditions, although more difficult to assess. Synthetic insecticides are the main concern, but the recent spread of biopesticide use in agriculture draws attention, particularly the main botanical insecticide currently in use - azadirachtin. Here we assessed the lethal and behavioral sub-lethal response of predatory larvae of the lacewing species Chrysoperla externa and Ceraeochrysa cubana to two frequently used synthetic insecticides, malathion and permethrin, and to the bioinsecticide azadirachtin. The recommended field concentration of the synthetic insecticides led to low survival time of lacewing larvae from both species, in contrast with azadirachtin. However, all three compounds led to 100% mortality of the lacewing larvae from both species. Insecticide repellence (i.e., avoidance without contact) was similar for both synthetic insecticides in both species, but azadirachtin was a stronger repellent for C. externa, but not C. cubana. In addition, insecticide irritability (i.e., avoidance after contact) occurred in both lacewing species to all three insecticides tested. The notion that natural compounds are safer than synthetic compounds to non-target species is refuted in the present study, which also detected significant irritability to all of the insecticides regardless of their origin, and species-specific repellence elicited particularly by azadirachtin. Therefore, bioinsecticides should not be exempted from risk assessment, and non-target sub-lethal effects should not be neglected when considering potential insecticide use in agriculture.

[Prevalence of hereditary hemochromatosis among healthy workers. Diagnostic value of transferrin saturation assay]. / Prevalencia de hemocromatosis en trabajadores sanos. Importancia de añadir en la analítica de perfil bioquímico una saturación de transferrina.

AIM: Hereditary hemochromatosis is the most common inherited disorder in white population (2-8 cases per 1000 habitants). Hemochromatosis is characterized by increased intestinal absorption of iron leading to its deposition into multiple organs. An early diagnosis and proper management with frequent phlebotomies are known to improve life expectancy and quality of life. Diagnosis is suggested by an elevated Transferrin saturation (TS) (more than 60%). METHOD: Prospective study of the level of TS among 1131 healthy workers, who came to the Security and Hygiene Official Centre for their annual revision had been undertaken. RESULTS: Twenty-wo workers had high TS; in 10 of them the increase of TS was confirmed on repeated determinations. Liver biopsy was performed in six (and refused by the other four), eventually a diagnosis of hemochromatosis was confirmed in three (in-group prevalence of 2.6 per 1000 people). CONCLUSIONS: In our experience, TS is the most appropriate initial screening test for detecting hereditary hemochromatosis in a normal population.

[The Miller Fisher syndrome. Review of the cases of the Santa Maria Hospital]. / A síndroma de Miller Fisher. Revisão da casuística do Hospital de Santa Maria.

A benign syndrome of acute ophthalmoplegia, ataxia, and areflexia is commonly known as the Miller Fisher syndrome. It is generally believed that Miller Fisher syndrome is a type of Guillain-Barré syndrome, but several authors believe it to be a separate clinical entity caused by a central nervous system lesion. Eight patients with Miller Fisher syndrome diagnosis, admitted to our department in the last 20 years, were reviewed. Neurophysiological studies were carefully reviewed. Our patients had a clinical presentation and evolution identical to that described previously. Neurophysiological abnormalities were found in all patients and were characteristic of a sensory axonal neuropathy, with damage of the facial nerves and occasional demyelination of peripheral nerves. The pattern of abnormalities is distinct from the usual features seen in Guillain-Barré syndrome. The CT scan, MRI, and Evoked Potentials investigations in our patients did not confirm central nervous system lesion. Nevertheless we did not exclude the possibility of coexisting damage to the central nervous system in some patients, as shown in Chronic Inflammatory Demyelinating Polyneuropathy.

Periprosthetic fractures in patients with total knee arthroplasties.

Ten patients with total knee arthroplasties sustained periprosthetic fractures. Nine of these were supracondylar fractures, and one occurred in the middle one-third of the tibia. These patients were treated with conservative methods in two cases and internal fixation with plate and screws in three cases. The remaining five patients were treated with intramedullary fixation using a specially designed revision prosthesis with long intramedullary stems. The best results wer achieved through the revision arthroplasty, based on walking ability, range of motion, and early rehabilitation.