Rat Bite Fever: A Case Report and Review of the Literature.

Cases of rat-bite fever (RBF) were reported in the literature for more than 2000 years. Not until recently, however, were attempts made to differentiate between RBF and Streptobacillus moniliformis septic arthritis, 2 arguably different clinical entities. There are limited data regarding S moniliformis septic arthritis and the features that distinguish it from RBF, and most conclude that although clinically disparate diseases, it is difficult to differentiate between them. We report a case of a 17-year-old girl who presented with S moniliformis bacteremia and symptoms that spanned both RBF and S moniliformis septic arthritis. This case emphasizes the difficulty in differentiating the 2 clinical entities and the importance of early diagnosis, proper clinical suspicion, and prompt treatment to achieve positive outcomes.

What do medical students think about their quality of life? A qualitative study.

BACKGROUND: Medical education can affect medical students' physical and mental health as well as their quality of life. The aim of this study was to assess medical students' perceptions of their quality of life and its relationship with medical education. METHODS: First- to sixth-year students from six Brazilian medical schools were interviewed using focus groups to explore what medical student's lives are like, factors related to increases and decreases of their quality of life during medical school, and how they deal with the difficulties in their training. RESULTS: Students reported a variety of difficulties and crises during medical school. Factors that were reported to decrease their quality of life included competition, unprepared teachers, excessive activities, and medical school schedules that demanded exclusive dedication. Contact with pain, death and suffering and harsh social realities influence their quality of life, as well as frustrations with the program and insecurity regarding their professional future. The scarcity of time for studying, leisure activities, relationships, and rest was considered the main factor of influence. Among factors that increase quality of life are good teachers, classes with good didactic approaches, active learning methodologies, contact with patients, and efficient time management. Students also reported that meaningful relationships with family members, friends, or teachers increase their quality of life. CONCLUSION: Quality of teachers, curricula, healthy lifestyles related to eating habits, sleep, and physical activity modify medical students' quality of life. Lack of time due to medical school obligations was a major impact factor. Students affirm their quality of life is influenced by their medical school experiences, but they also reframe their difficulties, herein represented by their poor quality of life, understood as necessary and inherent to the process of becoming doctors.

Randomised controlled trial comparing the clinical effectiveness of mouthwashes based on essential oils, chlorhexidine, hydrogen peroxide and prebiotic in gingivitis treatment.

AIM: The present clinical study aimed to investigate the clinical efficacy of 5 types of mouthwash based on different active substances. MATERIALS AND METHODS: The study included 180 patients divided into 6 groups of 30 patients, each group rinsing with one of the following types of mouthwash based on: essential oils, combination of essential oils and 0.12% chlorhexidine, hydrogen peroxide (0.8%), prebiotic, 0.2% chlorhexidine, and placebo. All participants underwent professional mechanical plaque removal after which they were instructed to rinse with 15 ml mouthwash 2 times a day for 21 days. During the study period, patients were monitored at days 0, 14, and 21, examining oral hygiene index, gingival index, bleeding index, and presence of side effects. RESULTS: Gingival index, bleeding index, and oral hygiene index were reduced statistically significantly in all treatment groups. Adjunctive use of mouthwashes demonstrated better clinical effectiveness compared to mechanical plaque control (and placebo mouthwash). The gingival index and the plaque index were reduced most significantly in the group using mouthwash with hydrogen peroxide. The bleeding index decrease was most significant in the group using 0.2% chlorhexidine. CONCLUSIONS: All tested mouthwashes demonstrated significant clinical effectiveness in different degrees in gingivitis treatment. New formulas with prebiotic and combination of essential oils and chlorhexidine indicate promising effectiveness.

CD43 regulates the threshold for T cell activation by targeting Cbl functions.

T cell (TC) activation requires the coordinated signaling of the T cell receptor (TCR) and coreceptor molecules, allowing TCs to respond to lower degrees of TCR occupancy. Coreceptor molecules set the threshold for TC activation by controlling different regulatory signaling loops. The Cbl family members prevent undesired activation of T cells by regulating TCR signals. In this report, we show that TC prestimulation by the CD43 coreceptor molecule before TCR engagement inhibits TCR-dependent c-Cbl tyrosine phosphorylation, c-Cbl interaction with the adapter molecule Crk-L and promotes Cbl-b degradation in a PKCθ-dependent manner. Consequently, the prolonged tyrosine phosphorylation and delayed degradation of ZAP-70 and of the ζ chain lead to enhanced mitogen-activated protein kinase activation and robust TC response. These data indicates that CD43-mediated signals lower the threshold for TC activation by restricting the c-Cbl and Cbl-b inhibitory effects on TCR signaling. In addition to the strength and duration of intracellular signals, our data underscore temporality with which certain molecules are engaged as yet another mechanism to fine tune TC signal quality, and ultimately immune function.

Pathogenesis of the erythroid failure in Diamond Blackfan anaemia.

Diamond Blackfan anaemia (DBA) is a severe congenital failure of erythropoiesis. Despite mutations in one of several ribosome protein genes, including RPS19, the cause of the erythroid specificity is still a mystery. We hypothesized that, because the chromatin of late erythroid cells becomes condensed and transcriptionally inactive prior to enucleation, the rapidly proliferating immature cells require very high ribosome synthetic rates. RNA biogenesis was measured in primary mouse fetal liver erythroid progenitor cells; during the first 24 h, cell number increased three to fourfold while, remarkably, RNA content increased sixfold, suggesting an accumulation of an excess of ribosomes during early erythropoiesis. Retrovirus infected siRNA RPS19 knockdown cells showed reduced proliferation but normal differentiation, and cell cycle analysis showed a G1/S phase delay. p53 protein was increased in the knockdown cells, and the mRNA level for p21, a transcriptional target of p53, was increased. Furthermore, we show that RPS19 knockdown decreased MYB protein, and Kit mRNA was reduced, as was the amount of cell surface KIT protein. Thus, in this small hairpin RNA murine model of DBA, RPS19 insufficient erythroid cells may proliferate poorly because of p53-mediated cell cycle arrest, and also because of decreased expression of the key erythroid signalling protein KIT.

Clinical tolerance in large field radiotherapy--the knowledge gained over the last ten years.

Malignant disorders are still far from being successfully managed in spite of the apparent progress achieved by surgical treatment, high energy radiotherapy (RT) and chemotherapy (CHT). They keep being the second most frequent cause of lethal outcomes both in Bulgaria and in most countries of the world. One of the promising approaches to increasing the efficaciousness of treatment is development and use of methods that are in full accord with the modern requirements of a complex therapy. Over the last fifty years, large field radiation techniques, applied as systemic therapy in oncology, have been investigated and established. These techniques show the transition in oncology to using actively various variants of large field radiotherapy (LFR), the "heavy artillery" of oncoradiologic practice, as an alternative or adjunct therapy to chemotherapy (CHT). In the present paper we review the current knowledge in the field and present the clinical experience accumulated over the last ten years with respect to clinical tolerance in the major large-field radiotherapy techniques--total body irradiation, half body irradiation, whole abdominal irradiation, total and partial lymphoid irradiation. Described in detail are the contemporary knowledge about clinical and hematologic tolerance in total body irradiation as part of the myelo- and nonmyeloablative conditioning regimens as well as in half body irradiation as a systemic therapy in oncology. We also present the amassed experience in clinical tolerance in partial body irradiation in the form of whole abdominal and total or partial lymphoid irradiation. Another point worth noting based again on the experience gained over the last ten years is that for LFR we need to develop a radiotherapy technique that is designed carefully to achieve an optimal therapeutic effect that should include the disease control, good clinical tolerance and reduction of post-radiotherapy sequelae.

Violence against women by their intimate partner and common mental disorders.

The World Health Organization considers gender violence a cause of anxiety, depression and suicidal thoughts among women. This study investigated the association between violence committed against women by their intimate partners, defined by psychologically, physically and sexually abusive acts, and common mental disorders, assessed by using the Self Reporting Questionnaire (SRQ-20). A population-based household survey was carried out among women aged 15-49 years in two sites: São Paulo, the largest Brazilian city, and Zona da Mata of Pernambuco, a region with both urban and rural areas in the Northeast of the country. A large proportion of women reported violence (50.7%). The most frequent forms were psychological violence alone (18.8%) or accompanied by physical violence (16.0%). The prevalence of mental disorders was 49.0% among women who reported any type of violence and 19.6% among those who did not report violence (p<0.0001). After adjustment for demographic and socioeconomic characteristics, the nature of the relationship, stressful life events and social support, all the forms of violence studied, with the exception of sexual violence alone or accompanied by either physical or psychological violence (p=0.09), were significantly associated with mental disorders: physical violence alone (OR1.91; CI 95%1.2-3.0), psychological violence alone (OR 2.00; CI 95% 1.5-2.6), sexual violence alone or accompanied by either physical or psychological violence (OR1.80; CI95% 0.9-3.6), both psychological and physical violence (OR 2.56; CI 95% 1.9-3.5) and all three forms of violence (OR 2.68; CI 95% 1.8-4.0). This is the first population-based study on the association between intimate partner violence and mental health in Brazil. It contributes to the existing body of research and confirms that violence, frequently experienced by women in the country, is associated with mental disorders. Policies and strategies aimed at reducing gender-based violence are necessary for preventing and reducing anxiety and depression among women.

Tailoring Drug Release Properties by Gradual Changes in the Particle Engineering of Polysaccharide Chitosan Based Powders.

Chitosan is a natural copolymer generally available in pharmaceutical and food powders associated with drugs, vitamins, and nutraceuticals. This study focused on monitoring the effect of the morphology and structural features of the chitosan particles for controlling the release profile of the active pharmaceutical ingredient (API) propranolol hydrochloride. Chitosan with distinct molecular mass (low and medium) were used in the formulations as crystalline and irregular particles from commercial raw material, or as spherical, uniform, and amorphous spray-dried particles. The API⁻copolymer interactions were assessed when adding the drug before (drug-loaded particles) or after the spray drying (only mixed with blank particles). The formulations were further compared with physical mixtures of the API with chitin and microcrystalline cellulose. The scanning electron microscopy (SEM) images, surface area, particle size measurements, X-ray diffraction (XRD) analysis and drug loading have supported the drug release behavior. The statistical analysis of experimental data demonstrated that it was possible to control the drug release behavior (immediate or slow drug release) from chitosan powders using different types of particles.

Designing structural features of novel benznidazole-loaded cationic nanoparticles for inducing slow drug release and improvement of biological efficacy.

Several polymers have been investigated for producing cationic nanocarriers due to their ability to cross biological barriers. Polycations such as copolymers of polymethylmethacrylate are highlighted due to their biocompatibility and low toxicity. The purpose of this study was to produce small and narrow-sized cationic nanoparticles able to overcome cell membranes and improve the biological activity of benznidazole (BNZ) in normal and cancer cells. The effect of composition and procedure parameters of the used emulsification-solvent evaporation method were controlled for this purpose. The experimental approach included particle size, polydispersity index, zeta potential, atomic force microscopy (AFM), attenuated total reflectance Fourier transforms infrared spectroscopy (ATR- FTIR), drug loading efficiency, and physical stability assays. Spherical and stable (over six weeks) sub 150nm cationic nanoparticles were optimized, with the encapsulation efficiency >80%. The used drug/copolymer ratio modulated the slow drug release, which was adjusted by the parabolic diffusion mathematical model. In addition, the ability of the cationic nanoparticles improve the BNZ uptake in the normal kidney cells (HEK 293) and the human colorectal cancer cells (HT 29) demonstrate that this novel BNZ-loaded cationic has great potential as a chemotherapeutic application of benznidazole.

Mitral balloon valvuloplasty by Inoue technique without echocardiographic standby.

Mitral balloon valvuloplasty (MBV) by Inoue technique was performed in 85 patients with symptomatic rheumatic mitral stenosis (MS). Twenty-eight patients were male and 57 patients were female. The age range was nine to 59 years (mean 28). All patients were subjected to echocardiographic and Doppler examinations before and one day after the procedure. The first 57 patients were subjected to exercise tolerance tests (ETT) a few days before and a few days after the procedure. An echocardiographic score was measured regarding valve thickening, leaflet mobility, degree of calcification and the severity of involvement of subvalvular apparatus. The mitral valve area (MVA) increased from 0.9 +/- 0.2 cm2 to 1.9 +/- 0.45 cm2, (P<0.0001). The mitral gradient (MG) decreased from 20 +/- 5.8 mm/Hg to 5.05 +/-+ 3.2 mm/Hg (P<0.0001). Mean left atrial pressure (LAP) dropped from 25.85 +/- 8.4 mm/Hg to 11.05 +/- 5.4 mm/Hg (P<0.0001). Exercise tolerance test (ETT) increased from 5.59 +/- 1.3 to 11.75 +/- 1.48 min. (P<0.0001). Complications included severe mitral regurgitation (MR) in two patients (2.3%). In the first 57 patients, mild left-to-right shunt measured by green dye dilution technique had occurred in 40% of patients. In conclusion, MBV by Inoue balloon is a good alternative to surgical commissurotomy and echocardiographic standby is very helpful when it is available. However, MBV can be safely performed if echocardiography is inaccessible.

Intimate partner violence among undergraduate students of two universities of the state of Sao Paulo, Brazil.

INTRODUCTION: The prevalence of violence in intimate relationships, suffered or perpetrated, was estimated among undergraduate students, be it physical, psychological and sexual, describing the overlap between them. This is an original study and there is scarce literature on this matter in Brazil. Men and women were investigated and some issues on gender violence were discussed. METHODS: The study is part of the multicenter survey "International Study of Violence in Dating - IDVS" conducted in 2002 - 2003, using its standardized instrument. A total of 362 students, from two universities in the state of São Paulo, one public and one private, answered the self-reported questionnaire, being 37% male and 63% female, mean age of 20 years old. Suffered and perpetrated intimate partner violence during life was examined. RESULTS: Among all interviewees, 75.9% suffered and 76.4% perpetrated some kind of violence throughout life. Psychological violence was the most prevalent type, followed by sexual violence, both suffered and perpetrated. The great superposition between suffered and perpetrated violence (83.9%) reflects the reciprocity of aggression, with no observed difference between men and women. The results of this study are consistent with previous literature on dating violence, which shows high prevalence of suffered and perpetrated violence, besides reciprocity for both men and women. CONCLUSIONS: Intervention actions at this stage of intimate relationships may potentially impact on subsequent marital partnership situations.

Intimate partner violence among undergraduate students of two universities of the state of Sao Paulo, Brazil / Violencia por parceiro intimo entre estudantes de duas universidades do Estado de Sao Paulo, Brasil

INTRODUCTION: The prevalence of violence in intimate relationships, suffered or perpetrated, was estimated among undergraduate students, be it physical, psychological and sexual, describing the overlap between them. This is an original study and there is scarce literature on this matter in Brazil. Men and women were investigated and some issues on gender violence were discussed. METHODS: The study is part of the multicenter survey "International Study of Violence in Dating - IDVS" conducted in 2002 - 2003, using its standardized instrument. A total of 362 students, from two universities in the state of São Paulo, one public and one private, answered the self-reported questionnaire, being 37% male and 63% female, mean age of 20 years old. Suffered and perpetrated intimate partner violence during life was examined. RESULTS: Among all interviewees, 75.9% suffered and 76.4% perpetrated some kind of violence throughout life. Psychological violence was the most prevalent type, followed by sexual violence, both suffered and perpetrated. The great superposition between suffered and perpetrated violence (83.9%) reflects the reciprocity of aggression, with no observed difference between men and women. The results of this study are consistent with previous literature on dating violence, which shows high prevalence of suffered and perpetrated violence, besides reciprocity for both men and women. CONCLUSIONS: Intervention actions at this stage of intimate relationships may potentially impact on subsequent marital partnership situations. .

INTRODUÇÃO: Foram estimados entre universitários a prevalência da violência em relacionamentos íntimos, sofrida ou perpetrada, para os tipos físico, psicológico e sexual, descrevendo-se as sobreposições entre eles. Estudo original com rara produção no Brasil. Foram pesquisados homens e mulheres, com discussão de algumas questões da violência de gênero. MÉTODO: O estudo faz parte de pesquisa multicêntrica "Estudo Internacional de Violência no Namoro - IDVS", realizada em 2002 - 2003, usando seu instrumento padronizado. O questionário foi auto-aplicado em 362 alunos de duas universidades, uma pública e outra privada, do Estado de São Paulo, sendo 37% do sexo masculino e 63% do feminino, com idade mediana de 20 anos. Foram descritas as violências sofridas por e perpetradas na vida contra parceiros íntimos. RESULTADOS: Entre todos os entrevistados, 75,9% sofreram e 76,4% perpetraram algum tipo de violência na vida. O tipo de violência mais prevalente, tanto sofrida como perpetrada, foi a psicológica, seguida da sexual. A grande sobreposição entre violências sofridas e perpetradas (83,9%) reflete a reciprocidade das agressões, sem diferença entre homens e mulheres. Os resultados do presente estudo estão em consonância com a literatura que analisa a violência no namoro, com alta prevalência de violências sofridas e perpetradas, além da reciprocidade tanto para homens como para mulheres. CONCLUSÕES: Ações de intervenção nesta fase dos relacionamentos íntimos podem potencialmente repercutir em situações posteriores de parceria conjugal. .

Comparison of two approaches to observation therapy for acute otitis media in the emergency department.

OBJECTIVE: This study compared parental adherence to delayed antibiotic therapy for acute otitis media with and without a written prescription in a pediatric emergency department. PATIENTS AND METHODS: Children aged 2 to 12 years who met criteria for delayed antibiotic treatment were randomly assigned to observation therapy with or without a prescription. Patients randomly assigned to observation therapy without prescription were instructed to seek follow-up care if symptoms persisted for 2 to 3 days. Patients assigned to observation therapy with a prescription were discharged with an antibiotic prescription, and instructed to fill it if their child's symptoms persisted 2 to 3 days. A research assistant who was blinded to group assignment called parents 7 to 10 days after the visit to assess adherence to observation therapy. RESULTS: Of 117 children assigned to the observation therapy group, 100 completed follow-up; of 115 assigned to the observation therapy with a prescription group, 106 completed follow-up. In the observation therapy group, 87 parents reported no antibiotic use within the 3-day observation period compared with 66 parents in the prescription group. During the entire study period, 81% of the observation therapy group reported no use of antibiotics compared with 53% in the prescription group. These groups did not differ in satisfaction with the visit; 91% and 95% were very or extremely satisfied, respectively. No complications were reported. CONCLUSIONS: Observation therapy with and without a prescription were both well accepted by parents of children diagnosed with acute otitis media in an urban pediatric emergency department. Adherence to delayed antibiotic therapy was better for those not offered a prescription. These data suggest that, in the pediatric emergency department setting, observation therapy reduces antibiotic use without compromising satisfaction with the visit.

Ribosomal protein S24 gene is mutated in Diamond-Blackfan anemia.

Diamond-Blackfan anemia (DBA) is a rare congenital red-cell aplasia characterized by anemia, bone-marrow erythroblastopenia, and congenital anomalies and is associated with heterozygous mutations in the ribosomal protein (RP) S19 gene (RPS19) in approximately 25% of probands. We report identification of de novo nonsense and splice-site mutations in another RP, RPS24 (encoded by RPS24 [10q22-q23]) in approximately 2% of RPS19 mutation-negative probands. This finding strongly suggests that DBA is a disorder of ribosome synthesis and that mutations in other RP or associated genes that lead to disrupted ribosomal biogenesis and/or function may also cause DBA.

O trabalho médico: questoes acerca da autonomia profissional / Work in medicine: some issues concerning professional autonomy

Analisa algumas questoes da prática médica relacionadas com a autonomia técnica que caracteriza a açäo profissional. Aponta a existência simultânea do lado científico e do lado empírico-pragmático da medicina, mais conhecido como a arte médica; ou a complexidade de sua açäo, pelas incertezas que cercam o julgamento clínico, conjugado à racionalidade tecnológica que rege a aplicaçäo de suas ciências e historicamente busca ser soberana. Define o trabalho em medicina como uma estrutura sob tensäo, examinando a repercussäo desta condiçäo nas auto-representaçoes dos médicos acerca de si mesmos como agentes do trabalho e sujeitos da açäo.

A autonomia e o trabalho em medicina / Autonomy and work in medicine

Discute a autonomia no trabalho médico como decorrente de dois momentos essenciais: como trabalho social, que consome e produz bens e serviços, reproduzindo o modo de produçäo dominante e valores decorrentes; e como serviço, onde esta autonomia, relativizada pela sua realidade de trabalho social, manifesta-se em atributos adquiridos pelo trabalho médico (independência técnica e auto-regulaçäo) via monopólio da aplicaçäo da ciência às necessidades individuais percebidas como relativas à saúde. Estes produtos cristalizam-se na relaçäo médico-paciente, o que realça as incertezas que cercam tal relaçäo e as necessidades a ela transferidas. A partir desta compreensäo do trabalho médico e sua condiçäo de exercício autônomo discutem-se alguns quadros teóricos que, relacionados ao estudo do trabalho e/ou dos serviços contemporâneos na sociedade, permitem abordagens mais adequadas e epistemologicamente mais profícuas na pesquisa científica que o toma por objeto.

Violência contra mulheres: interfaces com a Saúde / Violence against women: interfaces with Health care

Este ensaio procurará tratar do tema violência sob o recorte da violência contra mulheres. Discute a precedência histórica da tomada da violência contra a mulher como questäo do Direito e objeto da justiça, traçando paralelos na emergência do problema como questäo de Saúde e alvo da Saúde Pública e das práticas médico-sanitárias.

A violência contra mulheres: demandas espontâneas e busca ativa em unidade básica de saúde / Violence against women: spontaneous demands v. screening in healthcare centers

Avalia a emergência de demandas refiridas à violência por parte das usuárias de uma unidade básica da rede pública, contrastando-se a demanda espontânea com a busca ativa de casos. Realiza um primeiro estudo por técnicas de observação participante, seguida de estudo de prontuário, com 142 mulheres sendo acompanhadas. Num segundo estudo, em uma amostra de 322 usuárias, aplicou-se entrevista. Em atividades grupais foram observados relatos espontâneos e nos prontuários médicos registros de demandas espontâneas; o mesmo não ocorreu em consultas individuais. A entrevista detectou uma prevalência de casos muito maior. A possibilidade de detecção de casos, seu acolhimento e algumas respostas do serviço, requer especificidade de abordagem e cuidados próprios para que a violência contra mulheres possa emergir como parte da demanda usual na saúde