Challenging Diagnosis of a Congenital Tracheal Malformation: Considerations From an Intensive Care Perspective.

Congenital tracheal stenosis is a rare airway malformation. A high index of suspicion is fundamental. The authors report a case of congenital tracheal stenosis in a 13-month-old male infant, with a challenging diagnosis from the intensive care perspective. At birth, the patient presented an anorectal malformation with a recto-urethral fistula so a colostomy with mucous fistula was performed in the neonatal period. At the age of seven months, he was admitted due to a respiratory infection, treated with steroids and bronchodilators, and discharged after three days without any complications. He underwent complete repair of tetralogy of Fallot when he was 11 months old, which was performed without any reported perioperative complications. However, at the age of 13 months, due to another respiratory infection, he presented more severe symptoms and required admission to the pediatric intensive care unit (PICU) for invasive mechanical ventilation. He was intubated on the first attempt. While monitoring the difference between peak inspiratory and plateau pressures, we observed a sustained elevated difference between pressures suggestive of increased airway resistance, thus raising the possibility of an anatomical obstruction. Laryngotracheoscopy confirmed distal tracheal stenosis (grade II) with four complete tracheal rings. In our case, the absences of perioperative challenges or complications in previous respiratory infections were not suggestive of a tracheal malformation. Furthermore, no difficulties were encountered during intubation due to the distal location of the tracheal stenosis. A careful appreciation of respiratory mechanics on the ventilator at rest and during tracheal aspirations was essential to suspect an anatomical defect.

The Dangerous Side of Being a Predator: Toxoplasma gondii and Neospora caninum in Birds of Prey.

Toxoplasma gondii and Neospora caninum are apicomplexan protozoa of major concern in livestock and T. gondii is also considered one of the major threats and a public health concern. These protozoa have a wide range of intermediate hosts, including birds. The present work aimed to assess the prevalence of these cyst-forming parasites in migratory and sedentary birds of prey. The skeletal muscle and myocardium of 159 birds of prey from Central Italy, belonging to 19 species and recovered across 6 Wildlife Recovery Centers/Care structures along the Italian migratory route, were collected specifically for molecular (PCR) and for histopathological analysis to detect T. gondii and N. caninum. For the molecular analysis, genomic DNA was extracted. The DNA was tested by sequence typing, targeting GRA6, 529 bp repeated element, B1, PK1, BTUB, SAG2, alt.SAG2, and APICO genes for T. gondii and to end-point PCR targeting NC5 gene for N. caninum. Thirty-seven out of the one hundred and fifty-nine analyzed samples tested positive for T. gondii with a prevalence of 23.27% and nine for N. caninum, with a prevalence of 5.66%. Thirty-two sequences were obtained from the thirty-seven isolates of T. gondii. Among these, 26 presented alleles compatible with type I strain in 1 or more loci, 4 with type II strain and 2 consisted of atypical strains. Toxoplasma gondii genetic variability in birds of prey confirms previous findings of wildlife as reservoirs of atypical strains. Results from the histology showed few protozoal tissue cysts in skeletal muscle (n. 4) and hearts (n. 2).

First report of Giardia duodenalis in pet rabbits in Brazil.

Giardia duodenalis is a flagellate protozoan that multiplies in the small intestine of a wide variety of hosts, animals and humans. It has a worldwide distribution, however it is considered a neglected disease by the World Health Organization (WHO). Nowadays, rabbits are being chosen as pets, especially by children. There are already reports of the occurrence of G. duodenalis in rabbits from other countries, but research has not been carried out in Brazil yet. Thus, the objective of our work was to verify the occurrence and molecularly characterize G. duodenalis that affect pet rabbits, through the polymerase chain reaction (PCR) in the northwest region of the state of São Paulo, Brazil. Fecal samples from 100 rabbits were collected, which later underwent a process of DNA extraction and amplification by nested-PCR (nPCR), using the SSU rRNA gene, and ß-giardin (bg), glutamate dehydrogenase (gdh) and triosephosphate isomerase (tpi) to determine the assemblage. A questionnaire was answered by the owners with information about gender, age, deworming, diarrhea, water source, food, place of residence and contact with other animals. From those samples, 40 were positive for G. duodenalis. Good quality of the SSU rRNA gene by nPCR were obtained from two samples. For the first time, we report the occurrence of G. duodenalis assemblage A on pet rabbits in Brazil.

Simultaneous reconstruction of both medial and lateral collateral ligament complexes for recurrent instability of elbow dislocation: a case report.

The late sequela of a simple elbow dislocation includes loss of motion or recurrent instability. This case report involves a patient with a 4-year history of recurrent elbow instability following multiple closed traumatic posterior elbow dislocation, who underwent the simultaneous reconstruction of both medial and lateral collateral ligament complexes, for both varus and valgus instability. The patient was informed and consented that data concerning his case would be submitted for publication.

Atypically Located Solitary Neurofibroma of the Ulnar Nerve as Inaugural Presentation of a New Genetic Variant of Neurofibromatosis Type 1: A Case Report.

We report the case of a 34-year-old woman with hypothenar pain due to a solitary neurofibroma (NF) of the ulnar nerve, with an extrafascicular location, outside Guyon canal, with no clinical evidence of associated neurologic impairment, who was successfully treated with surgical resection. The identification of this isolated tumor led to the diagnosis of a new genetic variant of neurofibromatosis type 1 after genome sequencing. At the 1-year follow-up, the patient remains asymptomatic without recurrence or other peripheral nerve sheath tumors. A solitary NF of a deep-seated nerve is extremely rare, especially in the context of neurofibromatosis type 1. To our knowledge, there are no reports of a NF of the ulnar nerve with an extraneural location. In the presence of a solitary NF related to a deep-seated peripheral nerve, neurofibromatosis type 1 should always be excluded.

Ulnar Shortening Osteotomy: Our Experience.

Objective The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p < 0.05), there was a decrease in quick-DASH (64 to 28, p < 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion ( p = 0.2), and of 5.5° for supination ( p = 0.3), as well as decreasing grip strength to about 86% on the contralateral side ( p = 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm ( p < 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.

Automated Diagnosis of Canine Gastrointestinal Parasites Using Image Analysis.

Because canine intestinal parasites are considered cosmopolitan, they carry significant zoonotic potential to public health. These etiological agents are routinely diagnosed using microscopic examination commonly used because of its low cost, simple execution, and direct evidence. However, there are reports in the literature on the poor performance of this test due to low to moderate sensitivity resulting from frequent errors, procedures and interpretation. Therefore, to improve the diagnostic efficiency of microscopic examination in veterinary medicine, we developed and evaluated a unique new protocol. This system was tested in a study involving four genera of highly prevalent canine intestinal parasites in an endemic region in São Paulo state, Brazil. Fecal samples from 104 animals were collected for this research. The new protocol had a significantly higher (p < 0.0001) number of positive cases on image data, including parasites and impurities, and was elaborate to test them with the TF-GII/Dog technique, with a moderate agreement and Kappa index of 0.7636. We concluded that the new Prototic Coproparasitological Test for Dogs (PC-Test Dog) allowed a better visualization of the parasitic structures and showed a favorable result for the diagnosis of intestinal parasites in dogs.

Acute mononeuropathy in a child with newly diagnosed type 1 diabetes mellitus.

INTRODUCTION: Neuropathy is a frequent complication of diabetes mellitus (DM), increasing with the duration of the disease, poor glycemic control and advanced age. Acute presentation of a neuropathy in the setting of a newly diagnosed type 1 DM is rare and holds a diagnostic challenge. CASE REPORT: A 10-year-old girl, presented at the emergency service with complaints of polydipsia, polyuria, asthenia and weight lost over the last 15 days, accompanied by difficulties in flexing the right foot, during the previous week. The patient denied any pain, paresthesias, or altered sensibility. There was no fever documented, or recent infectious intercurrence or trauma. On physical examination, she was conscious, collaborative and space and time-orientated, had a diminished strength in the right foot, namely in the dorsiflexion, conditioning a steppage gait ipsilateral. Hyperalgesia was felt in the dorsum of the right feet to the ankle. DM type 1 was diagnosed based on serum glucose of 629 mg/dL and mild ketoacidosis. Investigation for infectious, immune and nutritional aetiologies for the mononeuropathy was negative. Electrophysiological study was suggestive of a lesion of the peroneal nerve on the popliteal cesspit, but was not conclusive. The patient started physiotherapy during her hospital stay and exhibited a slight improvement in the dorsiflexion of the foot. Four months later she was asymptomatic and with good glycaemic control. CONCLUSION: Diabetic neuropathy is a heterogeneous group that still lacks adequate comprehension. Its approach is empirical and demands exclusion of other etiologies. A definitive diagnosis is not always possible and sometimes is retrospective.

Ulnar Shortening Osteotomy: Our Experience / Osteotomias de encurtamento da ulna: A nossa experiência

Abstract Objective The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p< 0.05), there was a decrease in quick-DASH (64 to 28, p< 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion (p= 0.2), and of 5.5° for supination (p= 0.3), as well as decreasing grip strength to about 86% on the contralateral side (p= 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm (p< 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.

Resumo Objetivo O objetivo do presente estudo foi avaliar os resultados clínicos e radiográficos da nossa casuística relativamente a osteotomias de encurtamento da ulna, bem como rever sumariamente a patologia, as indicações e as opções cirúrgicas do conflito ulnocárpico. Métodos Realizamos uma análise retrospectiva de pacientes consecutivos que foram tratados com osteotomia de encurtamento da ulna entre janeiro de 2012 e junho de 2017 no nosso hospital. Avaliamos clinicamente a dor, amplitude articular, força da garra e resultados funcionais recorrendo ao questionário quick-DASH. Medimos radiograficamente a variância ulnar pré- e pós-operatória e o encurtamento realizado. Resultados Identificamos oito pacientes operados, tendo sido possível avaliar sete destes. Nesta população, obtivemos uma diminuição da dor (escala analógica visual [VAS, na sigla em inglês] de 7 para 2.6, p< 0,05), uma diminuição do quick-DASH (64 para 28, p< 0,05) e constatamos uma diminuição da amplitude articular ∼ 7° para a flexão (p= 0.2), de 5.5° para a supinação (p = 0,3), bem como diminuição da força da garra para cerca de 86% do lado contralateral (p = 0,07). A variância ulnar foi alterada de uma média de + 5.5 mm para −1.1 mm (p < 0,05). Dois em 8 pacientes (25%) apresentaram sintomatologia relacionada com a placa, sendo que um deles foi submetido a nova intervenção para extração do material. Conclusões A osteotomia de encurtamento da ulna é um procedimento cirúrgico eficaz, tanto no tratamento do conflito ulnocárpico, como na descarga da ulna. Os resultados apresentados vão ao encontro aos demais publicados na literatura, tendo-se obtido bons resultados clínicos e radiográficos.

Proximal row carpectomy with allograft scaffold interposition arthroplasty.

The authors present a solution for motion preservation in severe wrist arthritis with intercarpal involvement. Acellular dermal allograft is used as an interposition arthroplasty in these situations, rather than local tissue flaps such as previously described. Proximal row carpectomy has been shown to be one of the most successful procedures to correct chronic destructive arthritis in the wrist, keeping useful motion. Traditionally, a contraindication for proximal row carpectomy includes an arthritis that invades the lunate-capitate joint. The authors describe a technique to extend the traditional indications by covering the eroded articular surfaces with dermal allograft scaffold.

Indicadores de salud. Perspectiva actual

Los inicadores son instrumentos de análisis de situaciones, que por su propia complejidad, necesitan de una estrategia eficaz. Desde tiempos remotos han sido utilizados, y en el campo de la salud y actualmente cobran un especial interés, en cuanto el diseño de estrategias concretas, con metas mensurables y comparables. El presente trabajo da una panorámica de estos útiles instrumentos