White piedra on pediatric scalp: A case report.

This case report describes a rare fungal infection, piedra alba, in a 5-year-old female initially misdiagnosed. Treatment with 2 % ketoconazole shampoo led to significant regression within a week, without the need for hair cutting. We discuss the importance of early and accurate diagnosis, highlighting potential hair damage and complications in immunocompromised cases. Dermatoscopy aided diagnosis, and 2 % ketoconazole demonstrated efficacy, emphasizing the need for a multidisciplinary approach and dermatological follow-up.

Neovagina in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Vaginoplasty Using Ileal Flap.

INTRODUCTION: Surgical treatment of patients with malformations of the female genital tract is a complex problem and there are different techniques described in the literature. The goal of all these techniques is the reconstruction of a neovagina that is anatomically similar to a vagina, with adequate length to facilitate sexual functioning and with the lowest risk of possible complications. The aim of this study is to describe the surgical technique for the reconstruction of a neovagina from an ileal segment without a vascular pedicle. MATERIAL AND METHODS: Description of a surgical technique developed in our tertiary university center in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. RESULTS: The vaginoplasty surgery using ileal flap was performed in three steps. In the first part of the intervention a laparoscopic hysterectomy with bilateral salpingectomy was performed. The second step consisted of isolating the ileal segment, ileal anastomosis and preparing the ileal segment. After the isolated segment was prepared, it was repositioned in a vagina mold to configure the neovagina. Finally, the third step included the adaptation of the vaginal mold with the ileal mucosa to the vesicorectal space. CONCLUSION: Ileal vaginoplasty without a vascular pedicle is an option that can be used to reconstruct the vagina, because it provides an excellent tissue for vaginal replacement. This technique can be used in patients with genital malformations of the genital tract with absence or vaginal hypoplasia.

Levator ani muscle avulsion in patients with pelvic floor dysfunction - Does it help in understanding pelvic organ prolapse?

INTRODUCTION: Levator ani muscle (LAM) lesions are an important factor in the development of female pelvic organ prolapse (POP). OBJECTIVE: To determine the prevalence of LAM avulsion by transperineal ultrasound. The second outcome is to evaluate the association between complete avulsion and the type, degree, and number of POP compartments involved. MATERIALS AND METHODS: This was a retrospective cohort study performed in a tertiary hospital that included patients with pelvic floor dysfunction evaluated from January 2016 to March 2020. The presence of LAM avulsion was diagnosed by 3D/4D pelvic floor transperineal ultrasound. We identified women with POP, and they were classified according to the POP-Q system. The association between complete avulsion and the type, degree and number of compartments were calculated using generalized logit models. RESULTS: 848 women were included in the analysis. A complete LAM avulsion was found in 195 patients (23 %). Patients with complete avulsion were 4.7 (CI: 1.98-11.5) times more likely to have POP than patients with partial avulsion. The anterior compartment was the most frequently affected (n = 605, 25.8 %). Women with severe stage POP were 3.13 times (CI: 1.90-5.16) more likely to have bilateral complete LAM avulsion than women with mild prolapse. Patients with three-compartment POP were 2.75 times (CI: 1.53-4.94) more likely to have unilateral complete LAM avulsion than women with POP in one compartment. CONCLUSION: The prevalence of LAM avulsion is high in patients with urogynecological symptoms. Patients with complete LAM avulsion are at greater risk of developing POP and have a more advanced stage of prolapse and involvement of multiple compartments.

Sebaceous breast carcinoma.

Breast sebaceous carcinoma is one of the rarest breast neoplasms, with less than 30 cases reported worldwide. Due to the rarity, the new WHO classification of breast tumors grouped these tumors among the ductal carcinoma. A detailed description of these cases is relevant due to the insufficient knowledge about the prognosis of this neoplasm. We report the clinical, histological, and immunohistochemical characteristics of a case of sebaceous carcinoma of the breast in an 81-year-old woman with a right breast nodule. The tumor was composed of nests of a varying mixture of sebaceous cells with abundant slightly vacuolated cytoplasm, surrounded by smaller oval-to-fusiform cells with eosinophilic cytoplasm without vacuolization. No lymph node metastases were present. The immunohistochemical reactions were positive for GATA3, EMA, CD15, and GCDFP15 (focal staining), and negative for RE, RP, and HER-2. The tumor was classified as triple-negative. Morphologically, the differential diagnoses included skin sebaceous carcinoma, lipid-rich carcinoma, apocrine carcinoma, and glycogen-rich clear cell carcinoma. Most of the previously reported cases were positive for RE and RP, which generally was associated with a better prognosis. However, some cases presented a more aggressive behavior with distant and lymph node metastases.

Measurement of Pubofemoral Distance in the Diagnosis of Developmental Dysplasia of the Hip: Sensitivity and Specificity.

OBJECTIVES: To evaluate the accuracy of measurement of the pubofemoral distance (PFD) for the diagnosis of developmental dysplasia of the hip (DDH), using the Graf method as the reference standard. METHODS: This was a prospective diagnostic accuracy study evaluating 1980 hips in at-risk neonates. The PFD measurement and the Graf method were performed at the same opportunity, with the hips in the same position (slightly flexed, adducted, and medially rotated). RESULTS: In our sample, the prevalence of DDH, defined as Graf type IIb or higher, was 15.6%. The mean PFD for dysplastic hips was 3.5 mm (median, 3.3 mm), whereas it was 3.0 mm (median, 2.9 mm) for nondysplastic hips. In both groups, there was a significant overlap between the PFD measurements and the Graf classifications. The PFD cutoff with the largest area under the receiver operating characteristic curve was 3.0 mm, which was found to have a sensitivity and specificity of 63.6 and 62.2%, respectively, with positive and negative predictive values of 31.2 and 71.4%, respectively, for the diagnosis of DDH. CONCLUSION: Measurement of the PFD shows good overall accuracy for the diagnosis of DDH. However, given its low-positive predictive value, it should not be considered to be a replacement for the Graf method.

Estratégias de aprendizado que funcionam: prática de estudo espaçado / Effective Learning Strategies: Practice Spaced Study

Adotar estratégias de estudo que sejam eficientes é algo óbvio. Não tão óbvio é determinar quais estratégias funcionam realmente. O esforço mental e o tempo gasto são fortes sugestões indiretas de uma pressuposta eficácia, mas isso é um erro. Colocadas lado a lado, muitas estratégias de força bruta se revelam fracas para se alcançar memorização, aprendizado e raciocínio. Dentre as estratégias de estudo que foram efetivamente testadas e mostraram resultados consistentes e positivos, temos a prática de estudo espaçado (DL). O DL consiste em estudar fazendo interrupções programadas entre as sessões de estudo, sendo os intervalos entre as sessões bastante variáveis (segundos, minutos, horas, dias, semanas ou meses). Comparado com o estudo em bloco único (ML), o DL é bastante superior. Há algumas teorias para explicar essa superioridade verificada: processamento deficiente, codificação variada, consolidação e recuperação de estudo. Seja qual for o real motivo da sua eficiência, adotá-la seria uma medida inteligente e necessária em tempos de excesso de estímulos e escassez de tempo. Infelizmente não há consenso dos autores acerca dos intervalos ideais, mas alguns dados combinados com o contexto de estudo indicam que é possível se chegar em intervalos realistas que trabalhem a favor de um bom aprendizado.

Sebaceous breast carcinoma

ABSTRACT Breast sebaceous carcinoma is one of the rarest breast neoplasms, with less than 30 cases reported worldwide. Due to the rarity, the new WHO classification of breast tumors grouped these tumors among the ductal carcinoma. A detailed description of these cases is relevant due to the insufficient knowledge about the prognosis of this neoplasm. We report the clinical, histological, and immunohistochemical characteristics of a case of sebaceous carcinoma of the breast in an 81-year-old woman with a right breast nodule. The tumor was composed of nests of a varying mixture of sebaceous cells with abundant slightly vacuolated cytoplasm, surrounded by smaller oval-to-fusiform cells with eosinophilic cytoplasm without vacuolization. No lymph node metastases were present. The immunohistochemical reactions were positive for GATA3, EMA, CD15, and GCDFP15 (focal staining), and negative for RE, RP, and HER-2. The tumor was classified as triple-negative. Morphologically, the differential diagnoses included skin sebaceous carcinoma, lipid-rich carcinoma, apocrine carcinoma, and glycogen-rich clear cell carcinoma. Most of the previously reported cases were positive for RE and RP, which generally was associated with a better prognosis. However, some cases presented a more aggressive behavior with distant and lymph node metastases.

Fake news: só mais uma enxugada de gelo / Fake news: just another ice wipe

Fake news é um novo nome para uma coisa velha. Esse problema, no formato atual, começou em 2016 na campanha à presidência dos EUA. Embora citado e comentado em demasia, é um assunto essencial, pois a desinformação parece estar avançando perigosamente em alguns campos da área da saúde. Os movimentos antivacina, negacionistas do aquecimento climático e até mesmo "terraplanistas" estão muitas vezespautando o debate. A chegada da Internet e das redes sociais potencializou o fenômeno das fake news, criando novas dinâmicasde disseminação de notícias falsas. A atual polarização política, câmeras de eco, arrastes emocionais e as teorias da dissonânciacognitiva e da racionalização motivada ajudam a entender o fenômeno. Combater esse tsunami de desinformação que afeta vários campos do conhecimento é um assunto premente, dadas as nocivas consequências das notícias falsas na sociedade. Além dos grupos de checagem organizados por veículos de imprensa tradicional, a educação e conscientização do público é um ponto central nessa guerra. Mas essa é uma empreitada complexa, devido aos arrastes emocionais que parecem neutralizar a capacidade crítica que pessoas instruídas deveriam ter. Na fotografia atual parecemos estar enxugando gelo, mas a persistência nessa luta é essencial para nos contrapormos à deseducação científica.

A retrospective analysis of the effectiveness of anterior pelvic organ prolapse repair with Prolift versus Elevate vaginal mesh.

OBJECTIVE: To compare the effectiveness of anterior pelvic organ prolapse (POP) repair using Prolift (Ethicon, Somerville, NJ, USA) or Elevate (American Medical Systems, Minnetonka, MN, USA) vaginal mesh at 12 months of follow-up. METHODS: A retrospective study was undertaken using the records for the first 50 Prolift procedures in 2007-2009 and the first 50 Elevate procedures in 2013-2015 performed at a tertiary urogynecology unit in Lisbon, Portugal. Postoperative follow-up occurred at 3, 6, and 12 months. The primary outcome was surgical efficacy using subjective and objective measures (vaginal bulge symptoms and POP quantification system according to the Weber criteria, respectively) at 12 months. RESULTS: Improvement according to the Weber criteria was noted for 10 (25%) of 40 women in the Prolift group and 21 (48%) of 44 in the Elevate group at 12 months (P=0.032). Additionally, the Ba point was higher with Elevate than with Prolift (-2.2 ± 1.1 vs -1.5 ± 1.5; P=0.031). Vaginal bulge symptoms were reported at 12 months by 7 (18%) women in the Prolift group and 3 (7%) in the Elevate group (P=0.021). CONCLUSION: Differences in anatomic results were apparent between the two vaginal mesh groups 12 months after surgery.

King's Health Questionnaire to assess subjective outcomes after surgical treatment for urinary incontinence: can it be useful?

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) are the mainstay of treatment for stress urinary incontinence, but the definition of success varies widely amongst studies. The King's Health Questionnaire (KHQ) was designed to evaluate the impact of urinary incontinence on the quality of life. We hypothesised that the KHQ could be useful for postoperative quantitative assessment of subjective outcomes. MATERIALS AND METHODS: This is a retrospective analysis of 204 patients who underwent incontinence surgery with transobturator MUS between 2004 and 2013. Follow-up was planned at 6, 12 and 24 months and success was evaluated using the cough stress test (objective cure) and the KHQ global score (subjective outcomes). Statistical analysis included receiver operating characteristic (ROC) curves to calculate a cut-off value for the KHQ global score to define subjective cure. The minimal clinically important difference was calculated with a distribution-based method (effect size) to estimate subjective improvement. RESULTS: Objective cure rates were 97 % and 95 % at 6 and 24 months respectively. ROC curves established the cut-off score at ≤ 31 for subjective cure, with sensitivity of 63-100 % and specificity of 82-88 %. Subjective cure rates were 80 % and 85 % at 6 and 24 months respectively. The minimal clinically important difference was set at 10 and an improvement of ≥ 10 points was defined as subjective improvement. Rates varied between 10 and 13 %. CONCLUSIONS: This study showed the value of the KHQ as an evaluation tool after UI surgery and determined clinically relevant threshold scores to define subjective outcomes.

Laparoscopic Vaginal-Assisted Hysterectomy With Complete Vaginectomy for Female-To-Male Genital Reassignment Surgery.

STUDY OBJECTIVE: Total hysterectomy with bilateral salpingo-oophorectomy and vaginectomy for genital reassignment surgery is a complex procedure that is usually performed with a combined vaginal and abdominal approach. The aim of this study was to describe the feasibility of laparoscopic vaginectomy in sex reassignment surgery. METHODS: We reviewed the relevant medical history, intra/postoperative complications, and surgical results of all patients diagnosed with gender dysphoria and submitted to totally laparoscopic gender confirmation surgery in our department between January 2007 and March 2015. In total, 23 patients underwent total hysterectomy with bilateral salpingo-oophorectomy and vaginectomy in a single intervention. The vaginal mucosa was conserved to be used for the penile neourethra during the subsequent phalloplasty. MEASUREMENTS AND MAIN RESULTS: The surgeries had an average operating time of 155 ± 42 minutes. No intraoperative complications were registered. In all patients, the vagina was totally removed, and, in most cases (n = 20), we were able to remove laparoscopically more than 50% of the vagina. Three patients had postoperative complications. One patient presented with hemoperitoneum on the second postoperative day; another presented with prolonged urinary retention, and a third patient developed a perineal hematoma 1 month after surgery. Patients were discharged less than 72 hours after surgery, except the patient who developed a postoperative hemoperitoneum. For all patients, we obtained an adequate specimen of vaginal mucosa to reconstruct the penile neourethra for the subsequent phalloplasty. CONCLUSION: This study suggests the feasibility of laparoscopic vaginectomy in genital reassignment surgery. The procedure can be executed as a continuation of the hysterectomy with the potential advantage of the laparoscopy providing better exposure of the anatomic structures with low blood losses (less than 500 mL) and few complications. Furthermore, using this approach, adequate-sized vaginal mucosa flaps were obtained for the urethral reconstruction.

Incontinence surgery in obese women: comparative analysis of short- and long-term outcomes with a transobturator sling.

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) are still discussed in complex incontinence situations, such as obesity, lacking sustained efficacy validation in this particular sub-population. We hypothesized that the outcomes of a transobturator MUS, such as TVT-O, do not differ according to body mass index (BMI) over a 4-year period. METHODS: We conducted a retrospective analysis of 281 women who underwent TVT-O at our institution, between 2004 and 2012. Patients were stratified into obese (BMI ≥ 30 kg/m(2)) or non-obese (BMI < 30 kg/m(2)). We compared preoperative and postoperative parameters, including objective cure (negative stress test), complications, and quality of life scores. Data were collected at 0, 6, 12, 24, and 48 months. We used Fisher's exact test for categorical variables and Student's t test or the Mann-Whitney U test for continuous variables. RESULTS: Baseline characteristics of the obese (n = 122) and non-obese groups (n = 159) were similar. We found no significant differences between groups in terms of objective cure rates at all follow-up evaluations, with 95.8 % and 95 % at 48 months in the non-obese and obese groups respectively. There were no significant differences in the cumulative complication rates of both groups. Quality of life assessment also showed no significant differences between groups at all follow-up visits. At 48 months our follow-up rate was 59 % (n = 96) and 60.4 % (n = 72) in the non-obese and obese group respectively (p = 0.9). CONCLUSIONS: The TVT-O procedure is effective and safe in the long term for stress incontinence treatment, regardless of BMI.

Route of delivery following successful external cephalic version.

OBJECTIVE: To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV). METHODS: A retrospective matched case-control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status. RESULTS: Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63). CONCLUSION: Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.

Assessment of analytical techniques for characterization of crystalline clopidogrel forms in patent applications

The aim of this study was to evaluate two important aspects of patent applications of crystalline forms of drugs: (i) the physicochemical characterization of the crystalline forms; and (ii) the procedure for preparing crystals of the blockbuster drug clopidogrel. To this end, searches were conducted using online patent databases. The results showed that: (i) the majority of patent applications for clopidogrel crystalline forms failed to comply with proposed Brazilian Patent Office guidelines. This was primarily due to insufficient number of analytical techniques evaluating the crystalline phase. In addition, some patent applications lacked assessment of chemical/crystallography purity; (ii) use of more than two analytical techniques is important; and (iii) the crystallization procedure for clopidogrel bisulfate form II were irreproducible based on the procedure given in the patent application.

Este trabalho tem como objetivo avaliar dois aspectos importantes em um pedido de patente de formas cristalinas de fármacos: (i) caracterização físico-química das formas cristalinas e (ii)o procedimento de preparo da forma II do fármaco clopidogrel, um blockbuster de vendas. Realizaram-se buscas em bancos de dados patentários on line. Os resultados mostraram que (i) a maioria dos pedidos de patente de formas cristalinas do clopidogrel não se adequam com proposta do INPI devido ao número insuficiente de técnicas analíticas utilizadas na caracterização da fase cristalina. Ainda, em alguns pedidos de patente não há a presença da avaliação da pureza química/cristalográfica; (ii) a importância de se utilizar mais de duas técnicas de avaliação e (iii) que não foi possível a reprodução da cristalização com o procedimento apresentado no pedido de patente.

Acute fetal asphyxia after gastric rupture in a pregnant patient with a gastric band.

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.

Primary breast cancer of the vulva: a case report.

The occurrence of primary breast cancer of the vulva is extremely rare (24 cases described in the English-language literature). We report a case of a primary breast carcinoma of the vulva. An 82-year-old woman presented with a nodule of the left labia minor, which was excised. The histologic examination revealed the presence of adenocarcinoma of mammary origin, positive for common breast markers and for estrogen and progesterone receptors. The study for orthotopic breast carcinoma was negative, as well as the study for metastatic disease. The diagnosis of primary breast carcinoma was established. Our patient was then submitted to pelvic and inguinal radiotherapy as well as an aromatase inhibitor (letrozole), and she remained completely asymptomatic. Because of the rarity of this condition, guidelines for therapy are unavailable. The management suggested in the literature is that of primary orthotopic breast neoplasm of a similar stage.

Ponseti Brasil: a national program to eradicate neglected clubfoot - preliminary results.

BACKGROUND: After hearing about the reproducible and excellent results of the Ponseti method for clubfoot treatment, a group of Brazilian orthopaedic surgeons organized and participated in a standardized national program to teach the Ponseti technique in 21 different cities across Brazil. METHODS: A total of 21 Ponseti symposiums were organized in a standard fashion from January, 2007 to December, 2008. They consisted of a two-day program with lectures, hands-on cast application, and discussion of local clinical cases presented by orthopaedic surgeons. Thirteen Brazilian orthopaedic surgeons, who had been trained by the University of Iowa or centers recognized by them, taught the method. Financial support for travel was provided by an English charity: La Vida (Vital Investment for Developing Aid in Latin America). The physicians who attended the symposiums answered questionnaires before and after the training. RESULTS: About 7% of the 8000 orthopaedic surgeons in Brazil (556 orthopaedic surgeons) were trained. These orthopaedic surgeons stated that they had treated about 4905 babies in the previous year via other methods, including extensive surgery. Seventeen percent of the surgeons did not know about the Ponseti technique at the start of the symposium. Eighty-eight percent reported they felt able to treat children with the Ponseti technique after the symposium. Ninety-four percent of respondents reported that the symposium changed their way of treating clubfoot CONCLUSIONS: These Ponseti symposiums brought about an exchange of medical information and empowered the participants. This program is a good educational tool which can be used in eradicating neglected clubfoot in Brazil.

Retinoic acid modulation of thyroid dual oxidase activity in rats and its impact on thyroid iodine organification.

The sodium-iodide symporter (NIS) mediates iodide uptake into the thyrocytes, which is important for the diagnosis and therapy of thyroid disorders. Decreased ability to uptake iodide in thyroid carcinomas reduces the efficacy of radioiodine therapy, and retinoic acid (RA) treatment reinduces iodide uptake. The effectiveness of treatment depends not only on iodide uptake but also on the ability of thyrocytes to organify iodine, which is catalyzed by thyroperoxidase (TPO) in the presence of H(2)O(2). Our goal was to determine the influence of RA on thyroid iodide uptake, iodine organification, and TPO and dual oxidase (DuOx) activities. Normal rats were treated with all-trans-RA or 13-cis-RA (100 or 1500 microg/100 g body weight (b.w.), s.c.) for 14 and 28 days. The 2 h thyroid radioiodine content significantly decreased in rats treated with all-trans-RA (100 microg/100 g b.w.) for 14 days. In this group, NIS function and TPO activity were unchanged, whereas DuOx activity was significantly decreased, which might have contributed to the decrease in iodine organification. Both doses of 13-cis-RA for 28 days increased the 15 min thyroid radioiodine uptake, while the 2 h radioiodide uptake increased only in rats treated with the highest dose of 13-cis-RA. While TPO activity did not change, H(2)O(2) generation was increased in this group, and serum thyroxine levels were normal. Since radioiodine half-life in the thyroid gland is important for treatment efficacy, our results highlight the importance of correctly choosing the RA isomer, the time and the dose of treatment, in order to improve the efficacy of radioiodine therapy.

Retinoic acid effects on thyroid function of female rats.

AIMS: Retinoic acid is widely used in dermatological treatment and thyroid cancer management; however its possible side-effects on normal thyroid function remains unknown. We aimed to determine the effects of retinoic acid on thyroid function of adult female rats. MAIN METHODS: Female Wistar rats were treated with all-trans-retinoic acid and 13-cis retinoic acid for 14 and 28 days. Then, rats were killed and thyroid function was evaluated. KEY FINDINGS: Serum T4 and thyrotropin levels remained unchanged, while serum T3 increased in animals treated with all-trans-retinoic acid for 14 days. No changes were observed in hepatic or renal type 1 iodothyronine deiodinase (D1) activities, while thyroid D1 was higher in animals treated for 14 days with all-trans-retinoic acid, which could be related to the increased serum T3 levels. 13-cis retinoic acid increased thyroid iodide uptake after 28 days. These results show effects of retinoic acid treatment on these thyroid proteins: sodium/iodide symporter and deiodinase. SIGNIFICANCE: Retinoic acid is able to interfere with normal thyroid function, increasing thyroid type 1 deiodinase activity, serum T3 levels and sodium/iodide symporter function. However, the effects are time- and retinoic acid isomer-dependent. Since serum thyrotropin levels did not change in any group, the effects observed are probably mediated by a direct retinoic acid effect on the normal thyroid.