Lumbosacral pain in a patient with psoriatic arthritis: when the rheumatic disease is innocent.

Lumbar pain is a very common symptom that derives from benign musculoskeletal conditions, rheumatic inflammatory diseases, neoplasms, and referred and/or nociplastic pain. A 70-year-old man with psoriatic arthritis presented with early-onset lumbosacral pain without evident red flags. Symptomatic treatment was unhelpful. Radiographic imaging showed subtle signs of a disease that could easily be missed. Magnetic resonance imaging revealed a massive prostatic malignancy with bone (sacral and iliopubic) metastasis. Awareness must be given not to disregard every lumbar pain as part of the preexisting rheumatic inflammatory disease (spondyloarthropathy in this case) or a common muscle/ligament/articular disarrangement. Persistence of pain, albeit not inflam-matory nor sharp in nature, despite adequate treatment might be just as important as an acute red flag and requires proper follow-up.

"A case of vanishing bone disease complicated by chylothorax- diagnosis and treatment".

A 16-year old girl with Gorham-Stout disease is presented. She had progressive replacement of the bones of her left arm and shoulder girdle by fibroadipose tissue and numerous proliferated, non-neoplastic, lymphatic channels. The clinico-pathologic features of this condition are discussed, as are its possible complications and available therapeutic modalities.

Accuracy of cold sensibility testing on teeth with full-coverage restorations: a clinical study.

AIM: This clinical study evaluated the reliability of the 1,1,1,2-tetrafluoroethane (Endo Ice) cold test to determine the pulpal diagnosis of teeth with full-coverage restorations (FCR). The effect of several variables on its reliability was also investigated. METHODOLOGY: Data collected from 825 patients treated in the Advanced Education Program in Endodontics at the University of Iowa, USA were analysed. The experimental group included 425 teeth with FCR, whilst the control group consisted of 400 teeth with natural crowns (NC). The pulp sensibility test results, tooth type, tooth number, type of crown, age, gender, presence or absence of caries and recent use of analgesics were recorded. Bivariate analyses were performed to assess the variables associated with the accuracy of dental pulp sensibility tests for either teeth with crowns or teeth without crowns using chi-square tests, Fisher's exact tests, Cochran-Mantel-Haenszel tests, and the Wilcoxon rank-sum tests. A P-value of less than 0.05 was used as a criterion for statistical significance, and a P-value in 0.05 < P < 0.10 was used as a criterion for marginal relevance. RESULTS: The sensibility test results for FCR teeth had an accuracy of 0.866; sensitivity of 0.835; specificity of 0.879; a positive predictive value of 0.746; and a negative predictive value of 0.926. The data indicated a significant difference in the accuracy of pulp sensibility test results between the experimental and control groups (P < 0.001). Although the cold test in FCR teeth still had high accuracy, teeth with NC were significantly more likely to have true-positive and true-negative results (91.5% NC vs. 86.6% FCR, P = 0.024). No significant differences between FCR and NC were found concerning gender, tooth type, type of crown, the presence of abutment and recent use of analgesic (P > 0.05). CONCLUSION: Pulp sensibility cold testing with 1,1,1,2-tetrafluoroethane (TFE) on teeth with FCR was less accurate than on teeth without full-coverage crowns. However, the use of TFE cold testing is still a relevant and reliable diagnostic tool, particularly for teeth with a pulpal diagnosis of symptomatic irreversible pulpitis. Clinicians should routinely carry out cold pulp sensibility testing on teeth when making a pulpal diagnosis.

Leucine metabolites do not induce changes in phase angle, bioimpedance vector analysis patterns, and strength in resistance trained men.

We aimed to assess the effects of off-the-shelf leucine metabolite supplements on phase angle (PhA), bioimpedance vector analysis (BIVA) patterns and strength during an 8-week resistance training protocol. Fifty-three male participants were allocated into 4 groups: α-hydroxyisocaproic acid (n = 12, age = 30.9 ± 9.3 years), ß-hydroxy-ß-methylbutyrate free acid (n = 12, age = 31.0 ± 9.3 years), calcium ß-hydroxy-ß-methylbutyrate (n = 15, age = 32.1 ± 5.2 years) or placebo (n = 14, age = 28.9 ± 6.6 years). Bioimpedance parameters and 1-repetition maximum (1RM) for back squat and bench press were assessed at baseline and at the end of weeks 4 and 8. Additionally, fat-free mass and fat mass were evaluated by dual-energy X-ray absorptiometry. No statistically group by time interactions were found, even adjusting for age. PhA and vector did not change over the training period, while time-dependent increases were observed for 1RM back squat and 1RM bench press. A direct association was observed between PhA and 1RM bench press changes (whole sample), while PhA and strength were correlated throughout the study, even when adjusting for fat-free mass and percentage of fat mass. Leucine metabolites have no effect on PhA, BIVA patterns or strength during an 8-week resistance training program, in resistance trained subjects. The trial was registered at ClincicalTrials.gov: NCT03511092. Novelty: Supplementation with leucine metabolites is not a supplementation strategy that improves bioelectrical phase angle, cellular health, and strength after an 8-week resistance training program. When consuming a high protein diet, none of the α-hydroxyisocaproic acid, ß-hydroxy-ß-methylbutyrate free acid, and calcium ß-hydroxy-ß-methylbutyrate metabolites resulted in an ergogenic effect in resistance trained men.

Unilateral accumbal dopamine depletion affects decision-making in a side-specific manner.

Mechanisms underlying affective and cognitive deficits in Parkinson's disease (PD) remain less studied than motor symptoms. Nucleus accumbens (NAc) is affected in PD and due to its well-known involvement in motivation is an interesting target in this context. Furthermore, PD is frequently asymmetrical, with side-specific deficits aligning with evidences of accumbal laterality. We therefore used a 6-hydroxydopamine (6-OHDA) model to study the role of left and right NAc dopamine depletion in a battery of behavioral tasks. 2 months old male rats were used in all experiments. Habitual-based and goal-directed decision-making, impulsivity, anxiety- and depressive-like behavior and motor performance were tested 3 weeks after left (6-OHDA L) or right (6-OHDA R) NAc lesion was induced. Upon contingency degradation, 6-OHDA R decrease their lever press rate less than Sham and 6-OHDA L, indicating an impairment in the shift from habit-based to goal-directed strategies. On the other hand, 6-OHDA L lesions lead to increased rates of premature responding when delays where increased in the variable delay-to-signal test. Importantly, in both paradigms task acquisition was similar between groups. In the same line we found no differences in the amount of sugared pellets eaten when freely available as well as in both general and fine motor behaviors. In conclusion, left and right NAc play distinct roles in the contingency degradation and impulsivity. More studies are needed to understand the mechanisms behind this functional lateralization and its implications for PD patients.

Validation of NoSAS (Neck, Obesity, Snoring, Age, Sex) score as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic.

INTRODUCTION: Screening methods have become increasingly important due to the growing number of patients suspected of having obstructive sleep apnea (OSA) being referred to sleep clinics. The Lausanne NoSAS (Neck circumference, Obesity, Snoring, Age, Sex) score test is a simple, efficient, and easily employed tool enabling identification of individuals at risk for the disease. The score ranges from 0 to 17 and the patient has a high probability of OSA if they have a NoSAS score of 8 or higher. OBJECTIVES: To evaluate the performance of the NoSAS score as a screening tool for the diagnosis of OSA in a sleep clinic. METHODS: Prospectively, for 12 months, we included all the patients referred by primary care physicians to our sleep unit for clinical evaluation who had undergone in-lab polysomnography (PSG) and completed the NoSAS score. This test assigns 4 points for a neck circumference of more than 40cm, 3 points for a body-mass index of 25kg/m2 to less than 30kg/m2 or 5 points for having a body-mass index of 30kg/m2 or more, 2 points for snoring, 4 points for being older than 55 years of age and 2 points for being male. RESULTS: Of the 294 patients, 70.7% were male, aged 53.5±12.1 years, with a neck circumference of 41.0±3.6cm and a BMI of 30.8±5.1kg/m2. OSA was present in 84.0% of the patients, 34.8% with moderate OSA and 36.4% severe OSA. Using the NoSAS model for the prediction of all OSA, moderate/severe OSA and severe OSA, the area under the ROC (Receiver Operating Characteristic) was 0.770 (IC95%: (0.703; 0.837), p<0.001), 0.746 (IC95%: (0.691; 0.802), p<0.001) and 0.686 (IC95%: (0.622; 0.749), p<0.001), respectively, thus confirming the diagnostic ability of the NoSAS model. With a NoSAS score ≥7, the sensitivity and positive predictive value (PPV) were 94.3% and 87.6% for all OSA, 94.9% and 62.8% for moderate/severe OSA and 100% and 33.8% for severe OSA, respectively. With the same cut-off, the negative predictive value (NPV) for moderate/severe and severe OSA were 67.9% and 100%, respectively. Each increase in the NoSAS score was associated with an increase in the probability of OSA, reaching a 97% OSA probability for a score of 17. CONCLUSIONS: The NoSAS score showed high sensitivity and PPV for OSA with specificity and diagnostic accuracy steadily increasing with higher scores. Furthermore, a low score showed high predictive value for the exclusion of moderate/severe OSA. Overall, our results suggest that, in primary care, this score can be a powerful tool for stratifying and prioritizing patients in the diagnosis of OSA. Nevertheless, more studies are needed to evaluate the efficacy of this score in hospital health care, in younger populations, with a predominance of female and non-obese individuals or in cardiovascular disease.

Radiation therapy facility risk analysis in Brazil with SEVRRA software.

Risk assessment deals with processes, accident-initiating events, barriers and risk ratings to unveil the fragility and weakness of some processes; within this study, specifically related to radiation therapy facilities. Barriers are technical or organizational safety measures put in place to avoid, prevent, detect, control, reduce or mitigate the consequences of an accident once an initiating event has occurred. In this work, radiological risk analysis was performed for a set of 20 Brazilian radiotherapy facilities making use of the freeware sevrra risk-management software. The objective of this study was to define parameters that could be useful in creating an overall risk profile. This profile would be helpful for establishing priorities for decision making and support a risk-informed regulatory process. The most relevant missing barriers in facilities were identified according to three parameters: the 'importance index', 'impacted facilities index' and the 'barrier-effectiveness index'. Barriers such as 'in vivo dosimetry in the first treatment session', 'weekly in vivo dosimetry to detect errors in the dose delivering process', 'annual external audit for the control of reference dose rate' and 'independent verification of calibration by various medical physicists with a different dosimetry equipment' were found to be the most effective in reducing the risk level of the facilities. The present investigation reinforces the need to strengthen the mechanisms that guarantee the effectiveness of such barriers in radiation therapy procedures.

Sporadic Abdominal Wall Desmoid type Fibromatosis: treatment paradigm after thirty two years.

BACKGROUND: Desmoid-type fibromatosis is a benign mesenchymal neoplastic process. It exhibits an uncertain growth pattern and high recurrence rate. Previously radical surgical resection was the mainstay of treatment, but recently more surgeons are opting for conservative management with observation ("wait and see" policy). The authors intend to evaluate different therapeutic modalities and oncological outcomes for abdominal wall desmoid tumors. METHODS: We performed a retrospective study of patients who underwent surgical, hormonal or chemotherapy treatment for abdominal wall desmoid tumors between 1982 to 2014 at two institutions affiliated with the University of São Paulo, Brazil. RESULTS: In the study period, 32 patients were included. Twenty-seven patients had surgery upfront. Of those, 89% were women with a median age of 33 years. Mean tumor size was 10 cm. Pathology confirmed free margins in 92% of resections. Tumor recurrence rate was 11%, with median relapse-free survival being 24 months. Multivariate analysis showed that positive final margins (p < 0.001) and positive frozen section (p = 0.001) were independent predictors of recurrence. For the 5 patients who underwent pharmacological therapy, median age was 33 years and median tumor diameter before treatment was 13 cm. Four patients exhibited partial response by Response Evaluation Criteria in Solid Tumors (RECIST). The single patient who did not respond to RECIST underwent radiotherapy. CONCLUSION: Desmoid tumor treatment has been evolving over the past decade towards a more conservative approach. Pharmacological treatment may result in tumor size regression. When surgical excision is indicated, positive margins represent an important prognostic factor for local tumor recurrence.

Ion chambers compliance results of Brazilian radiation therapy facilities.

The Brazilian Nuclear Energy Commission (cnen) has been making a constant effort to keep up to date with international standards and national needs to strengthen the status of radiological protection of the country. The guidelines related to radiation therapy facilities have been revised in the last five years in order to take into consideration the most relevant aspects of the growing technology as well as to mitigate the accidents or incidents observed in practice. Hence, clinical dosimeters have gained special importance in this matter. In the present work, we discuss the effectiveness of regulation and inspections to the enforcement of instrument calibration accuracy for the improvement of patient dosimetry and quality control. As a result, we observed that the number of calibrated instruments, mainly well chambers, is increasing each year. The same behavior is observed for instruments employed in technologically advanced radiation treatments such as intensity modulated radiotherapy, volumetric therapy and stereotatic radiosurgery. We ascribe this behavior to the new regulation.

Genetic parameters and selection of soybean lines based on selection indexes.

Defining selection criteria is important to obtain promising genotypes in a breeding program. The objective of this study was to estimate genetic parameters for agronomic traits and to perform soybean line selection using selection indices. The experiment was conducted at an experimental area located at Capim Branco farm, belonging to the Federal University of Uberlândia. A total of 37 soybean genotypes were evaluated in randomized complete block design with three replicates, in which twelve agronomic traits were evaluated. Analysis of variance, the Scott-Knott test at the 1 and 5% level of probability, and selection index analyses were performed. There was genetic variability for all agronomic traits, with medium to high levels of genotype determination coefficient. Twelve lines with a total cycle up to 110 days were observed and grouped with the cultivars MSOY 6101 and UFUS 7910. Three lines, UFUS FG 03, UFUS FG 20, and UFUS FG 31, were highlighted regarding grain yield with higher values than the national average of 3072 kg/ha. The direct selection enabled the highest trait individual gains. The Williams (1962) index and the Smith (1936) and Hazel (1943) index presented the highest selection gain for the grain yield character. The genotype-ideotype distance index and the index of the sum of ranks of Mulamba and Mock (1978) presented higher values of total selection gain. The lines UFUS FG 12, UFUS FG 14, UFUS FG 18, UFUS FG 25, and UFUS FG 31 were distinguished as superior genotypes by direct selection methods and selection indexes.

Titration with automatic continuous positive airway pressure in obstructive sleep apnea.

BACKGROUND AND OBJECTIVE: Autotitrating positive airway pressure (APAP) is an accepted titration method to determine the optimal positive airway pressure (PAP), for the treatment of obstructive sleep apnea (OSA). The required duration of APAP monitoring to determine a fixed continuous positive airway pressure level still remains to be established. We aimed to evaluate the variation in PAP level, delivered by APAP devices, at different periods of treatment, to determine the APAP treatment duration required to reach an effective and stable PAP level. METHODS: A cross-sectional study of 62 patients newly diagnosed with OSA were evaluated after 3 months of APAP therapy. APAP data corresponding to the first day (D1), first week (W1), seventh week (W7) and twelfth week (W12) under APAP therapy was collected. For the analysis of the pressure behaviour, the difference of P95th pressure level between W12 and W7 (P W12-W7), W12 and W1 (P W12-W1) and W12 and D1 (P W12-D1) was calculated. RESULTS: There was a high correlation in P95th pressure level between D1 and W12 (r=0.771; p>0.0001), W1 and W12 (r=0.817; p>0.0001), and W7 and W12 (r=0.926; p>0.0001). This correlation progressively increased with APAP use. A significance difference was found in concordance between P W12-W7 and P W12-D1 (p=0.046) within the pressure range ±2cmH2O. However there was no significant difference in concordance between P W12-W7 and P W12-W1. CONCLUSIONS: One week of APAP therapy seems sufficient to determine an effective and stable PAP level, within the pressure range ±2cmH2O.

Old and new challenges in Parkinson's disease therapeutics.

Parkinson's disease (PD) is a neurodegenerative disorder characterized by the degeneration of dopaminergic neurons and/or loss od neuronal projections, in several dopaminergic networks. Current treatments for idiopathic PD rely mainly on the use of pharmacologic agents to improve motor symptomatology of PD patients. Nevertheless, so far PD remains an incurable disease. Therefore, it is of utmost importance to establish new therapeutic strategies for PD treatment. Over the last 20 years, several molecular, gene and cell/stem-cell therapeutic approaches have been developed with the aim of counteracting or retarding PD progression. The scope of this review is to provide an overview of PD related therapies and major breakthroughs achieved within this field. In order to do so, this review will start by focusing on PD characterization and current treatment options covering thereafter molecular, gene and cell/stem cell-based therapies that are currently being studied in animal models of PD or have recently been tested in clinical trials. Among stem cell-based therapies, those using MSCs as possible disease modifying agents for PD therapy and, specifically, the MSCs secretome contribution to meet the clinical challenge of counteracting or retarding PD progression, will be more deeply explored.

Abdominal wall reconstruction after desmoid type fibromatosis radical resection: Case series from a single institution and review of the literature.

BACKGROUND: Abdominal wall desmoid type fibromatosis management has been changing over recent years, from an aggressive approach towards a more conservative one. When radical resection is indicated, the surgical team faces the challenge of abdominal wall reconstruction, for which optimal technique is still debated. The present study reports the experience from a single center with abdominal closures after desmoid type fibromatosis resection. MATERIAL AND METHODS: Retrospective analysis of patients who underwent abdominal wall closure after sporadic abdominal desmoid type fibromatosis radical resection from 1982 to 2013. RESULTS: Twenty-seven patients were included, mean tumor diameter was 10 + 5.3 cm, and the main choice of abdominal wall reconstruction was midline closure with anterior rectus sheath relaxing incisions and polypropylene onlay mesh (74% of the cases). Only 7% of the cases required more complex procedures for skin closure. Mean follow-up was 5 years and 89% remained disease-free. No grade 4 or 5 complications were observed. CONCLUSION: High midline fascial closure rate can be achieved after resection of abdominal wall desmoid tumor using relaxing incisions and mesh, with low complication rate.

Factors affecting the incidence of early endoscopic recurrence after ileocolonic resection for Crohn's disease: a multicentre observational study.

AIM: Early endoscopic recurrence is frequently observed in patients following resection for Crohn's disease (CD). However, factors affecting the incidence of an early postoperative endoscopic recurrence (EPER) have not been fully determined. The aim of this study was to evaluate risk factors for EPER after ileocolonic resection for CD. METHOD: This was a retrospective, international multicentre study, in which 127 patients with a first ileocolonoscopy conducted between 6 and 12 months after ileocolonic resection for CD were included. Endoscopic recurrence was defined as a Rutgeerts score of ≥ i2. The following variables were investigated as potential risk factors for EPER: gender, age at surgery, location and behaviour of CD, smoking, concomitant perianal lesions, preoperative use of steroids, immunomodulators and biologics, previous resection, blood transfusion, surgical procedure (open vs laparoscopic approach), length of resected bowel, type of anastomosis (side-to-side vs end-to-end), postoperative complications, granuloma and postoperative biological therapy. Variables related to the patient, disease and surgical procedure were investigated as potential risk factors for EPER, with univariate and multivariate (logistic regression) analyses. RESULTS: 43/127 (34%) patients had EPER at the time of the first postoperative ileocolonoscopy. In univariate analysis, only preoperative steroid use was significantly associated with a higher rate of EPER [21/45 patients (47%) on steroids and 22/82 patients (27%) without steroids (P = 0.04)]. In multivariate analysis, only preoperative steroid use was a significant independent risk factor for EPER (odds ratio 3.28, 95% confidence interval: 1.30-8.28; P = 0.01). CONCLUSIONS: This study found that only preoperative steroid use was a significant risk factor for EPER after ileocolonic resection for CD. Prospective studies are necessary to evaluate precisely the impact of perioperative medications on EPER rates.

Influence of Different ECM-Like Hydrogels on Neurite Outgrowth Induced by Adipose Tissue-Derived Stem Cells.

Mesenchymal stem cells (MSCs) have been proposed for spinal cord injury (SCI) applications due to their capacity to secrete growth factors and vesicles-secretome-that impacts important phenomena in SCI regeneration. To improve MSC survival into SCI sites, hydrogels have been used as transplantation vehicles. Herein, we hypothesized if different hydrogels could interact differently with adipose tissue-derived MSCs (ASCs). The efficacy of three natural hydrogels, gellan gum (functionalized with a fibronectin peptide), collagen, and a hydrogel rich in laminin epitopes (NVR-gel) in promoting neuritogenesis (alone and cocultured with ASCs), was evaluated in the present study. Their impact on ASC survival, metabolic activity, and gene expression was also evaluated. Our results indicated that all hydrogels supported ASC survival and viability, being this more evident for the functionalized GG hydrogels. Moreover, the presence of different ECM-derived biological cues within the hydrogels appears to differently affect the mRNA levels of growth factors involved in neuronal survival, differentiation, and axonal outgrowth. All the hydrogel-based systems supported axonal growth mediated by ASCs, but this effect was more robust in functionalized GG. The data herein presented highlights the importance of biological cues within hydrogel-based biomaterials as possible modulators of ASC secretome and its effects for SCI applications.

Using artificial neural networks to select upright cowpea (Vigna unguiculata) genotypes with high productivity and phenotypic stability.

Cowpea (Vigna unguiculata) is grown in three Brazilian regions: the Midwest, North, and Northeast, and is consumed by people on low incomes. It is important to investigate the genotype x environment (GE) interaction to provide accurate recommendations for farmers. The aim of this study was to identify cowpea genotypes with high adaptability and phenotypic stability for growing in the Brazilian Cerrado, and to compare the use of artificial neural networks with the Eberhart and Russell (1966) method. Six trials with upright cowpea genotypes were conducted in 2005 and 2006 in the States of Mato Grosso do Sul and Mato Grosso. The data were subjected to adaptability and stability analysis by the Eberhart and Russell (1966) method and artificial neural networks. The genotypes MNC99-537F-4 and EVX91-2E-2 provided grain yields above the overall environment means, and exhibited high stability according to both methods. Genotype IT93K-93-10 was the most suitable for unfavorable environments. There was a high correlation between the results of both methods in terms of classifying the genotypes by their adaptability and stability. Therefore, this new approach would be effective in quantifying the GE interaction in upright cowpea breeding programs.