Munchausen by proxy syndrome mimicking childhood-onset systemic lupus erythematosus.

Childhood-onset systemic lupus erythematosus (cSLE) is a chronic inflammatory multisystem autoimmune disease that requires multiple differential diagnoses. Munchausen by proxy syndrome (MBPS) is a form of child abuse, where a caregiver intentionally creates a medical history and induces or fabricates signs or disease in a patient. To our knowledge, there is no case report of MBPS mimicking cSLE diagnosis. We reported herein a 9-year-old male patient, with a history of multiple hospitalizations due to seizures with altered levels of consciousness. The mother reported malar rash, photosensitivity, alopecia, arthralgia, arterial hypertension, macroscopic hematuria, seizure and positive antinuclear antibodies. In the other service, he was treated with intravenous methylprednisolone, prednisone and mycophenolate mofetil. At 8 years and 8 months, he was admitted to our tertiary center with history of fever and macroscopic hematuria. Laboratory examinations were normal, including negative for antinuclear antibodies, anti-double stranded DNA, anticardiolipin, anti-Ro/SSA, anti-La/SSB, anti-RNP and anti-Sm antibodies. Multiple urine cultures revealed the presence of Enterococcus faecium, Acinetobacter sp., Stenotrophomonas maltophilia and Serratia marcescens, without any association with pyuria. At 8 years and 9 months, he was readmitted at emergency room with history of severe fever, headache, vomiting, photophobia, phonophobia and dizziness. The physical examination showed agitation, confusion, ataxic gait, slurred speech, horizontal nystagmus, painful facial expressions, tachycardia and weight loss. Brain magnetic resonance angiography and cerebrospinal fluid analysis were normal. During hospitalization, he had an acute episode of epistaxis and otalgia with excoriation in the auditory canal. At that moment, the suspicion of MBPS mimicking cSLE was raised and phenytoin intoxication was confirmed (peak phenytoin concentration was 45.4 mcg/mL, therapeutic range 10-20 mcg/mL). The mother and the patient were immediately separated, and she was replaced by another legal guardian. One week later, the neurological and other signs and symptoms were completely resolved. The child was placed under paternal custody with a court order and moved to another state. After that, the mother reported phenytoin use for her child and was referred to psychiatric follow-up. In conclusion, the first case of MBPS mimicking cSLE, resulting in multiple unnecessary examinations and treatments with delayed diagnosis was reported.

Prevalence and predictive factors of moderate/severe liver steatosis in chronic hepatitis C (CHC) infected patients evaluated with controlled attenuation parameter (CAP).

A novel controlled attenuation parameter (CAP) using FibroScan® has been developed for assessment of liver steatosis. The aim was to evaluate the frequency and associated factors for moderate/severe steatosis evaluated by CAP in CHC patients submitted to transient elastography (TE) by FibroScan® . CHC patients underwent TE with CAP evaluation. The classification of steatosis was defined as: CAP < 222 dB/m  =  S0; CAP ≥ 222 dB/m and <233dB/m  =  S1; ≥233 dB/m < 290dB/m  =  S2 and >= 290 dB/m  =  S3. The prevalence of moderate/severe steatosis (CAP ≥ S2) and the related independent factors were identified by a logistic regression analysis. A significance level of 5% was adopted. 1104 CHC patients, 85% genotype-1 were included (mean age 55 ± 11 years; 46% male, mean BMI 25 ± 4 Kg/m2 ). Systemic arterial hypertension and type 2 diabetes mellitus prevalences were 39% and 17%, respectively. Liver stiffness measurement ≥ 9.5 kPa was observed in 39% of patients and steatosis was identified in 50% (S1 = 7%, S2 = 28% and S3 = 15%). The variables independently associated with moderate/severe steatosis were: male gender (OR=1.35; P = .037; 95% CI:1.01-1.81); systemic arterial hypertension (OR=1.57; P = .002; 95% CI:1.17-2.10) and BMI (OR=1.17; P < .01;95% CI:1.12-1.22). In conclusion, when CAP was adopted as a tool to detect steatosis, genotype 1 CHC patients presented a high prevalence of moderate/advanced steatosis. In these patients, liver steatosis was associated mostly to metabolic factors (arterial hypertension and high BMI).

Application of a central composite design to evaluate the influence of colouring agents in lipstick formulation.

OBJECTIVES: The aim of this study was to evaluate by central composite design the influence of colouring agents in lipstick colour, expressed by L*, a*, b* parameters (CIELab system) where L* indicates lightness, and a* and b* are the chromaticity coordinates. The a* indicates colour direction from red to green and b* from yellow to blue. METHODS: Lipsticks were formulated as described by (Recent Adv. Prosp. Potent Med. Plants, 2009 and 39). The combined effect of three variables (dye, pigment and opacifier) was evaluated by different formulations in a central composite design. Colour parameters (L*, a*, b*) were analysed by reflectance spectrophotometry. Lipsticks were characterized by visual analyses and melting point. RESULTS: All formulations were integrate and homogeneous. The pigments and dye do not influence in colour transfer neither in melting point of lipsticks. On the other hand, results indicated that variables studied show influence only in parameter b*, whereas for L* and a* values there was no significant difference (P < 0.05). CONCLUSION: It was possible to verify that only the colour parameter b* was influenced by the variation in colouring agent's concentrations in lipstick formulation, leading to the production of the colour ranging between violet and light red. Such results are useful for developing new lipstick formulations to obtain the desired colour in the final product.

Novel controlled attenuation parameter for noninvasive assessment of steatosis using Fibroscan(®): validation in chronic hepatitis C.

A novel controlled attenuation parameter (CAP) has been developed for Fibroscan(®) to assess liver steatosis, simultaneously with liver stiffness measurement (LSM). We assessed CAP diagnostic accuracy in a large cohort of patients with chronic hepatitis C (CHC) virus. A total of 615 patients with CHC, who underwent both Fibroscan(®) and liver biopsy, were analysed. Fibrosis was graded using METAVIR score. Steatosis was categorized by visual assessment as S(0) : steatosis in <10% of hepatocytes, S(1) : 11-33%, S(2) : 34-66% and S(3) : 67-100%. Performances of CAP and liver stiffness were determined using receiver operating characteristic (ROC) curve analysis and cross-validated using the bootstrap method. The Obuchowski measure was used to assess overall accuracy of CAP and to differentiate between steatosis grades. In multivariate analysis, CAP was related to steatosis (P < 10(-15) ) independently of fibrosis stage (which was related to LSM). The areas under ROC curves using CAP to detect steatosis were 0.80 (95% CI, 0.75-0.84) for S ≥ S(1) , 0.86 (0.81-0.92) for S ≥ S(2) and 0.88 (0.73-1) S = S(3) . CAP exhibited a good ability to differentiate steatosis grades (Obuchowski measure = 0.92). Performance of LSM for fibrosis assessment confirmed results from previous studies. CAP is a novel tool to assess the degree of steatosis and both fibrosis and steatosis can be evaluated noninvasively during the same procedure using Fibroscan(®) , in patients with CHC.

Insulin resistance and geographical origin: major predictors of liver fibrosis and response to peginterferon and ribavirin in HCV-4.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) genotype 4 (HCV-4) is increasing in prevalence in Western countries. However, little is known about the severity of the disease and response to treatment. The aim of this study was to assess the predictors (logistic regression) of severe fibrosis (METAVIR score F3-F4), and sustained virological response (SVR) to peginterferon and ribavirin in 226 consecutive HCV-4 patients (Egyptians 40%, Europeans 35% and Africans 24%). PATIENTS AND METHODS: Insulin resistance was assessed using the homeostasis model (HOMA-IR). Serum HCV-RNA level (bDNA) and subtypes of HCV (LiPA) were determined for all patients. RESULTS: Insulin resistance (HOMA-IR >3) was present in 105 patients (46%), and was associated with: age >45 years (OR, 2.614; 95% CI, 1.316 to 5.194), body mass index (BMI) >25 kg/m(2) (OR, 2.105; 95% CI, 1.048 to 4.229), serum HCV-RNA >800 000 IU/ml (OR, 3.143; 95% CI, 1.503 to 6.574), severe fibrosis (OR, 2.657; 95% CI, 1.214 to 5.818), and steatosis >30% (OR, 2.488; 95% CI, 1.105 to 5.602). Severe fibrosis was present in 67 patients (29%) and was associated with Egyptian origin (OR, 5.872; 95% CI, 2.747 to 12.553), excessive alcohol intake (OR, 5.311; 95% CI, 1.287 to 21.924), and HOMA-IR >3 (OR, 3.864; 95% CI, 1.859 to 8.034). 108 patients received a 48 week course of peginterferon plus ribavirin. SVR (undetectable serum HCV-RNA (TMA) 24 weeks after treatment stopping) was achieved in 59 patients (55%) and was associated with Egyptian origin (OR, 13.119; 95% CI, 3.089 to 55.706), HOMA-IR <2 (OR, 5.314; 95% CI, 1.953 to 14.459), and non-severe fibrosis (OR, 8.059; 95% CI, 2.512 to 25.855). CONCLUSION: Insulin resistance and geographical origin are major predictors of liver fibrosis and response to peginterferon and ribavirin in HCV-4 patients. Insulin resistance is frequently encountered in these patients, and correlated independently with serum HCV-RNA.

Relationship between ecological condition and ecosystem services in European rivers, lakes and coastal waters.

We quantify main ecosystem services (i.e. the contribution of ecosystems to human well-being) provided by rivers, lakes, coastal waters and connected ecosystems (riparian areas and floodplains) in Europe, including water provisioning, water purification, erosion prevention, flood protection, coastal protection, and recreation. We show European maps of ecosystem service capacity, flow (actual use), sustainability and efficiency. Then we explore the relationship between the services and the ecosystem condition at the European scale, considering the ecological status of aquatic ecosystems, reported under the EU Water Framework Directive, as a measure of the ecosystem integrity and biodiversity. Our results indicate that a higher delivery of the regulating and cultural ecosystem services analysed is mostly correlated with better conditions of aquatic ecosystems. Conversely, the use of provisioning services can result in pressures on the ecosystem. This suggests the importance of maintaining good ecological condition of aquatic ecosystems to ensure the delivery of ecosystem services in the future. These results at the continental scale, although limited to the ecosystem services under analysis, might be relevant to consider when investing in the protection and restoration of aquatic ecosystems called for by the current EU water policy and Biodiversity Strategy and by the United Nations Sustainable Development Goals.

Impact of controlled attenuation parameter on detecting fibrosis using liver stiffness measurement.

BACKGROUND: Liver fibrosis is often accompanied by steatosis, particularly in patients with non-alcoholic fatty liver disease (NAFLD), and its non-invasive characterisation is of utmost importance. Vibration-controlled transient elastography is the non-invasive method of choice; however, recent research suggests that steatosis may influence its diagnostic performance. Controlled Attenuation Parameter (CAP) added to transient elastography enables simultaneous assessment of steatosis and fibrosis. AIM: To determine how to use CAP in interpreting liver stiffness measurements. METHODS: This is a secondary analysis of data from an individual patient data meta-analysis on CAP. The main exclusion criteria for the current analysis were unknown aetiology, unreliable elastography measurement and data already used for the same research question. Aetiology-specific liver stiffness measurement cut-offs were determined and used to estimate positive and negative predictive values (PPV/NPV) with logistic regression as functions of CAP. RESULTS: Two thousand and fifty eight patients fulfilled the inclusion criteria (37% women, 18% NAFLD/NASH, 42% HBV, 40% HCV, 51% significant fibrosis ≥ F2). Youden optimised cut-offs were only sufficient for ruling out cirrhosis (NPV of 98%). With sensitivity and specificity-optimised cut-offs, NPV for ruling out significant fibrosis was moderate (70%) and could be improved slightly through consideration of CAP. PPV for significant fibrosis and cirrhosis were 68% and 55% respectively, despite specificity-optimised cut-offs for cirrhosis. CONCLUSIONS: Liver stiffness measurement values below aetiology-specific cut-offs are very useful for ruling out cirrhosis, and to a lesser extent for ruling out significant fibrosis. In the case of the latter, Controlled Attenuation Parameter can improve interpretation slightly. Even if cut-offs are very high, liver stiffness measurements are not very reliable for ruling in fibrosis or cirrhosis.

The water quality of the Ria de Aveiro lagoon, Portugal: from the observations to the implementation of a numerical model.

Ria de Aveiro is a very important area of the Portuguese coast, which has been under an increasing anthropogenic pressure for several decades and, contributes to the degradation of the lagoon's water quality. This work presents both a characterisation of the water quality of the Ria de Aveiro lagoon, using physical, chemical and biological experimental data, and an implementation of a numerical model for the water quality of the lagoon. The ultimate goal is to obtain an accurate numerical model able to simulate major water quality features of the lagoon under the influence of different forcing conditions. Data analysis reveals good correlations between the salinity and almost all the water quality variables as well as between the different variables. The maximum biochemical oxygen demand concentration (BOD) depends on the light intensity, the temperature and the river inputs. The main vulnerable areas of the lagoon, from the water quality point of view, seem to be the far end of the main channels, where low dissolved oxygen concentration (DO) and high BOD concentrations are observed. The numerical model of the Ria de Aveiro has reproduced both winter-spring and spring-summer events related to the lagoon water quality as well as its main pattern. Both data and modelling results show that the BOD5 concentrations (where the subscript '5' means that the BOD measurements were conducted for five days, without inhibitor of nitrification) are driven by the river influence, during the winter-spring period, and by the biological activity during the spring-summer period. The DO concentrations show high values in the spring-summer period and smaller concentrations in the winter-spring period at the far end of the lagoon. The application of the model to the study of scenarios has demonstrated the role of nutrients and light in the phytoplankton growth, the relationship between DO and phytoplankton concentrations, as well as the effect of the BOD degradation in the ammonia (NH4) regeneration.

The Tetrahymena chaperonin subunit CCT eta gene is coexpressed with CCT gamma gene during cilia biogenesis and cell sexual reproduction.

We report here the cloning and the characterization of the T. pyriformis CCT eta gene (TpCCT eta) and also a partial sequence of the corresponding T. thermophila gene (TtCCT eta). The TpCCt eta gene encodes a protein sharing a 60.3% identity with the mouse CCT eta. We have studied the expression of these genes in Tetrahymena exponentially growing cells, cells regenerating their cilia for different periods and during different stages of the cell sexual reproduction. These genes have similar patterns of expression to those of the previously identified TpCCt gamma gene. Indeed, the Tetrahymena CCT eta and CCT gamma genes are up-regulated at 60-120 min of cilia recovery, and in conjugation when vegetative growth was resumed and cell division took place. Our results seem to indicate that both CCT subunits play an important role in the biogenesis of the newly synthesized cilia of Tetrahymena and during its cell division.

Microsurgical anatomy of the temporal lobe: part 1: mesial temporal lobe anatomy and its vascular relationships as applied to amygdalohippocampectomy.

OBJECTIVE: We review the anatomy of the mesial temporal lobe region, establishing the relationships among the intraventricular, extraventricular, and surrounding vascular structures and their angiographic characterization. We also demonstrate the clinical application of these anatomic landmarks in an anatomic temporal lobectomy plus amygdalohippocampectomy. METHODS: Fifty-two adult cadaveric hemispheres and 12 adult cadaveric heads were studied, using a magnification ranging from 3x to 40x, after perfusion of the arteries and veins with colored latex. RESULTS: The intraventricular elements are the hippocampus, fimbria, amygdala, and choroidal fissure; the extraventricular elements are the uncus and parahippocampal and dentate gyri. The uncus has an anterior segment, an apex, and a posterior segment that has an inferior and a posteromedial surface; the uncus is related medially to cisternal elements and laterally to intraventricular elements. The anterior segment is related to the proximal sylvian fissure, internal carotid artery, proximal M1 segment of the middle cerebral artery, proximal cisternal anterior choroidal artery, and amygdala. The apex is related to the oculomotor nerve, uncal recess, and amygdala; the posteromedial surface is related to the P2A segment of the posterior cerebral artery inferiorly, to the distal cisternal anterior choroidal artery superiorly, and to the head of the hippocampus and amygdala intraventricularly. The choroidal fissure is located between the thalamus and fimbria; it begins at the inferior choroidal point behind the head of the hippocampus and constitutes the medial wall of the posterior two-thirds of the temporal horn. CONCLUSION: Not only is the knowledge of these relations useful to angiographically characterize the mesial temporal region, but it has also proven to be of extreme value during microsurgeries involving this region.

Endoscopic foraminotomy using MED system in cadaveric specimens.

STUDY DESIGN: Four cadavers had cervical foraminotomies performed at noncontiguous levels using either the standard open technique or the microendoscopic technique. OBJECTIVES: To evaluate the feasibility of using a minimally invasive technique for posterior decompression of cervical disc disease. SUMMARY OF BACKGROUND DATA: Even though the anterior approach is more commonly performed for the treatment of cervical disc disease, the posterior approach has distinct advantages in selected cases of foraminal stenosis and posterolateral disc herniation. Current technique, however, requires extensive muscle dissection, and is, therefore, subject to significant morbidity. METHODS: Each of four cadavers had posterior cervical foraminotomies performed using either the MICROENDOSCOPIC (MED) technique, or the standard open technique. Three noncontiguous levels were decompressed using one technique, and the other technique was used for the adjacent contralateral decompression. Each specimen was then evaluated with postoperative myelogram/CT and open dissection. Laminotomy size, length of root decompressed, and percentage of facet removed were measured. RESULTS: Average vertical diameter decompression and percentage of facet removed were significantly greater for the MED technique than for the open technique. Transverse diameter of the laminotomy area and the average length of decompressed root were not significantly different between the techniques. CONCLUSION: Posterior cervical foraminotomy, using the microendoscopic technique, is technically feasible and may be applicable to the treatment of foraminal stenosis and laterally located cervical disc herniation. Studies in live animals are currently examining techniques for hemostasis.

Numerical analysis of a dental implant system preloaded with a washer.

Gold screw loosening is a problem that frequently affects dental implants. The application of a preload has been the main means of preventing loosening. However, this measure has not been able to eliminate its occurrence. In this study the effect of a washer in a Brånemark-type implant on the loosening conditions of the retaining screw was investigated using a finite element simulation. The simulation indicated that a washer may significantly increase the tolerance of a screw against loosening. This is accomplished by increasing the tolerance of the implant against deformation. The addition of a customized washer to a dental implant system may offer a very simple and inexpensive solution for the persistent problem of screw loosening.

Relationship between apparent optical properties and photosynthetic pigments in the sub-alpine Lake Iseo.

The aim of the present study was the evaluation of methods for estimating the content of bio-physical parameters in lake water on the basis of spectral reflectance measured above water surface, in particular the estimation of chlorophyll-a (chl-a) concentrations. Data sets considered refer to some sampling point located in the sub-alpine meso-eutrophic Lake Iseo, surveyed six times over the period March-July and once in November 1998, as these months were very important for the characterization of the springtime algal bloom, which affect the lake waters yearly. At each point station, limnological observations (chlorophyll, total suspended solids, Secchi disk depth) were conducted simultaneously with optical measurements. The latter consisted of water leaving radiance measured by means of a spectroradiometer above the water surface; moreover, a standard reflector radiance was also measured to obtain the water reflectance. Reflectance spectra were transformed according to two well-documented models and correlated to water quality parameters, to investigate their performances as retrieval algorithms under different conditions and referring to different analytical methods. Results outline the sensitivity of the models to chl-a concentrations, different phytoplankton composition, and the sampling depth.

Clinical and laboratory techniques for repair of fractured porcelain in fixed prostheses: a case report.

A technique used to repair the abutment tooth of a fixed partial metal-ceramic prosthesis is described. This prosthesis extended from the maxillary central incisor to the left canine. The whole porcelain facial aspect of the central incisor had been fractured. Following a reduction of the metallic structure, a single porcelain crown was bonded to that area. The repair was quick, less expensive and less difficult than removal of the prosthesis and fabrication of a replacement, and provided excellent esthetic and functional results.

Coronal fracture with invasion of the biologic width: a case report.

To repair a coronal fracture with invasion of the biologic width, flap surgery with osteotomy and osteoplasty localized on the fractured tooth was performed, and the crown was reattached to the tooth remnant with a composite resin system. Results after 6 years revealed optimal periodontal health and reasonable esthetics.

The use of natural teeth to make removable partial prostheses and complete prostheses: case reports.

Human natural teeth were used in manufacturing two complete prostheses and two partial removable dentures in three patients. All four prostheses continue to function satisfactorily. The practitioner, by utilizing the patient's natural teeth in preference to artificial teeth, achieves an excellent means of solving the patient's esthetic problems.

Towards good ecological status of surface waters in Europe--interpretation and harmonisation of the concept.

The Water Framework Directive (WFD) is a new legislative framework to manage, use, protect, and restore surface water and groundwater resources and coastal waters in the European Union (EU). The aim is to ensure sustainable water management and to reach good water quality by 2015. The assessment of the ecological status and setting of the practical management goals require several steps. The process has started with the characterisation of the river basins including identification of surface water bodies and types, and identification of significant anthropogenic pressures and impacts. The water bodies will be classified in five quality classes (high, good, moderate, poor, bad) based on the Ecological Quality Ratio, which is a ratio between reference conditions and measured status of the biological quality elements. The normative criteria for high, good and moderate ecological status described in the WFD need to be made operational because those will be used to set the practical quality targets for surface water management. National ecological assessment systems and classifications will be harmonised through the WFD intercalibration exercise in order to ensure an equal level of ambition in achieving good surface waters status all over Europe.

Risk factors and outcome in 100 patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Clinical and surgical outcome of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm were assessed in comparison to pre-operative data and risk factors such as previous medical history, clinical presenting condition, CT findings and site of bleeding. METHODS: We evaluated 100 consecutive patients with aneurysmal SAH. Gender, color, history of hypertension, smoking habit, site and size of aneurysm, admittance and before surgery Hunt Hess scale, need for cerebro-spinal fluid shunt, presence of complications during the surgical procedure, Glasgow Outcome Scale, presence of vasospasm and of rebleeding were assessed and these data matched to outcome. For statistical analysis, we applied the chi-squared test or Fisher's test using the pondered kappa coefficient. Kruskal-Wallis test was used for comparison of continue variables. Tendency of proportion was analyzed through Cochran-Armitage test. Significance level adopted was 5%. RESULTS: Patients studied were mainly white, female, without previous history of hypertension and non-smokers. Upon hospital admittance, grade 2 of Hunt-Hess scale was most frequently observed (34%), while grade 3 of Fisher scale was the most prevalent. Single aneurysms were most frequent at anterior circulation, between 12 and 24 mm. The most frequent Glasgow Outcome Scale observed was 5 (60%). Hunt Hess upon the moment of surgery and presence of complications during surgical procedure showed positive correlation with clinical outcome (p=0.00002 and p=0.001, respectively). Other variables were not significantly correlated to prognosis. Tendency of proportion was observed between Hunt-Hess scale and Fisher scale. CONCLUSION: Among variables such as epidemiological data, previous medical history and presenting conditions of patients with ruptured aneurysms, the Hunt-Hess scale upon the moment of surgery and the presence of surgical adversities are statistically related to degree of disability.

Dental erosion: diagnostic-based noninvasive treatment.

Lesions that result from dental erosion can be difficult to recognize--particularly when abrasion and attrition are also present. Consequently, dental erosion is often misdiagnosed and mistreated by radical restorative modalities that compromise the vitality of the pulp. This article provides clinicians with knowledge concerning the diagnosis of the complex lesions of dental wear and demonstrates the conservative treatment of this condition. Two cases that exhibit marked tooth wear in anterior teeth and their subsequent restoration utilizing occlusal principles and composite resin are presented.