Disturbed by a sandfly: visceral leishmaniasis in ileal Crohn´s disease under combined immunosuppression.

This case reports illustrates a 44-year-old Caucasian male with ileal Crohn´s disease under combined immunosuppression that first presented with unspecific constitutional symptoms, newly pancytopenia and elevated inflammatory markers. The infectious screening was negative except for an ileal abscess that resolved with conservative antibiotic therapy. Due to concerns for lymphoproliferative disease in a patient under anti-TNF and azathioprine, a myelogram was performed that ruled out dysplastic changes. After abscess resolution the symptoms relapsed with evening fever, nocturnal sudoresis and worsen pancytopenia. A more thorough work-up was performed with bone marrow and ileal biopsies that demonstrated numerous intra-and-extracellular leishmania amastigote forms, which confirmed the diagnosis of visceral leishmaniasis infiltrating the small bowel. The patient recovered after adequate treatment and withheld of immunosuppression during follow-up.

Metastatic pituitary neuroendocrine neoplasms: A case report of a malignant prolactinoma.

We report a rare clinical case of a malignant prolactinoma in which the exponential increase of prolactin levels with minimal tumor growth and no response to treatment led to diagnosis of abdominal, thoracic, and vertebral metastases.

Balance between maternal antiviral response and placental transfer of protection in gestational SARS-CoV-2 infection.

The intricate interplay between maternal immune response to SARS-CoV-2 and the transfer of protective factors to the fetus remains unclear. By analyzing mother-neonate dyads from second and third trimester SARS-CoV-2 infections, our study shows that neutralizing antibodies (NAbs) are infrequently detected in cord blood. We uncovered that this is due to impaired IgG-NAb placental transfer in symptomatic infection and to the predominance of maternal SARS-CoV-2 NAbs of the IgA and IgM isotypes, which are prevented from crossing the placenta. Crucially, the balance between maternal antiviral response and transplacental transfer of IgG-NAbs appears to hinge on IL-6 and IL-10 produced in response to SARS-CoV-2 infection. In addition, asymptomatic maternal infection was associated with expansion of anti-SARS-CoV-2 IgM and NK cell frequency. Our findings identify a protective role for IgA/IgM-NAbs in gestational SARS-CoV-2 infection and open the possibility that the maternal immune response to SARS-CoV-2 infection might benefit the neonate in 2 ways, first by skewing maternal immune response toward immediate viral clearance, and second by endowing the neonate with protective mechanisms to curtail horizontal viral transmission in the critical postnatal period, via the priming of IgA/IgM-NAbs to be transferred by the breast milk and via NK cell expansion in the neonate.

Cerebral Toxoplasmosis as an Uncommon Complication of Biologic Therapy for Rheumatoid Arthritis: Case Report and Review of the Literature.

Toxoplasmosis is one of the most common opportunistic infections, mainly reported in patients with acquired immunodeficiency syndrome (AIDS). Patients with rheumatoid arthritis (RA) have also been linked to reactivation of toxoplasmosis due to immunosuppressive treatment, although biologic drugs have seldom been implicated. We present a case of cerebral toxoplasmosis in a 62-year-old female patient with RA after initiation of biologic therapy (adalimumab). The patient had detectable serum IgG antibodies to toxoplasma gondii, was also on chronic treatment with other non-biologic drugs and presented with worsening disorientation, unsteady gait and left hemiparesis. Imaging studies showed a space-occupying lesion in the right basal ganglia with ring-enhancement. Brain biopsy confirmed the diagnosis of toxoplasmosis and the patient was treated with pyrimethamine and sulfadiazine for 6 weeks, showing complete recovery on follow-up. A review of the literature yielded other four case reports of cerebral toxoplasmosis implying biologic drugs; however, data concerning toxoplasmosis serologic testing, prophylaxis and treatment in these patients are lacking. Each case must be carefully evaluated prior to treatment and a high-index of suspicion in seropositive patients is warranted. Since the use of biologic drugs is increasing, further research is needed to establish practical guidelines for seropositive patients receiving immunosuppressive treatment.

Pituitary metastasis as the first manifestation of lung carcinoma.

Pituitary metastases are rare. Clinical presentation could range from asymptomatic to panhypopituitarism or local symptoms. We present a case report of a 43-year-old male patient with a new onset headache, visual disturbances, and panhypopituitarism. The investigation led to the diagnosis of pituitary metastasis as the first manifestation of underlying lung cancer.

Code of practice for medical autopsies: a minimum standard position paper for pathology departments performing medical (hospital) autopsies in adults.

The medical autopsy (also called hospital or clinical autopsy) is a highly specialised medical procedure, which requires professional expertise and suitably equipped facilities. To ensure high standards of performance, the Working Group of Autopsy Pathology of the European Society of Pathology (ESP) suggests a code of practice as a minimum standard for centres performing medical autopsies. The proposed standards exclusively address autopsies in adults, and not forensic autopsies, perinatal/or paediatric examinations. Minimum standards for organisation, standard of premises, and staffing conditions, as well as minimum requirements for level of expertise of the postmortem performing specialists, documentation, and turnaround times of the medical procedure, are presented. Medical autopsies should be performed by specialists in pathology, or by trainees under the supervision of such specialists. To maintain the required level of expertise, autopsies should be performed regularly and in a number that ensures the maintenance of good practice of all participating physicians. A minimum number of autopsies per dedicated pathologist in a centre should be at least 50, or as an average, at least one autopsy per working week. Forensic autopsies, but not paediatric/perinatal autopsies may be included in this number. Turnaround time for final reports should not exceed 3 weeks (14 working days) for autopsies without fixation of brain/spinal cord or other time-consuming additional examinations, and 6 weeks (30 working days) for those with fixation of brain/spinal cord or additional examinations.

Case report: Rare convexity meningeal chondroma mimicking a meningioma.

BACKGROUND: Intracranial chondromas account for 0.2-0.3% of all intracranial neoplastic lesions and less than a quarter arise in the convexity or falx. Despite its benign nature, exceedingly rare malignant transformations exist. The misdiagnosis with meningiomas is frequent and may be related with chondromas' similar insidious clinical presentation and imaging features. Standalone surgery is advised and complete resection provides the definitive treatment. CASE DESCRIPTION: A 44-year-old female presents with insidious headache, visual disturbances, and papilledema. The imaging studies were compatible with frontal parasagittal meningioma. Surgery revealed a meningeal based mass, mostly avascular and with a well-demarked surgical plane from the brain parenchyma. Complete resection with meningeal margins was achieved and the histopathologic examination revealed a chondroma. The patient symptoms subsided and no surgical complications existed. CONCLUSION: Intracranial convexity chondromas constitute a rare differential diagnosis for meningiomas. The present case reinforces the current scarce data and serves as reminder for clinicians diagnosing and treating intracranial tumors.

BD-2 and BD-3 increase skin flap survival in a model of ischemia and Pseudomonas aeruginosa infection.

The main aim of this work was to study the usefulness of human ß-defensins 2 (BD-2) and 3 (BD-3), which are part of the innate immune system, in the treatment of infected ischemic skin flaps. We investigated the effect of transducing rat ischemic skin flaps with lentiviral vectors encoding human BD-2, BD-3, or both BD-2 and BD-3, to increase flap survival in the context of a P. aeruginosa infection associated with a foreign body. The secondary endpoints assessed were: bacterial counts, and biofilm formation on the surface of the foreign body. A local ischemic environment was created by producing arterialized venous flaps in the left epigastric region of rats. Flaps were intentionally infected by placing underneath them two catheters with 105 CFU of P. aeruginosa before the surgical wounds were hermetically closed. Flap biopsies were performed 3 and 7 days post-operatively, and the specimens submitted to immunohistochemical analysis for BD-2 and BD-3, as well as to bacterial quantification. Subsequently, the catheter segments were analyzed with scanning electron microscopy (SEM). Flaps transduced with BD-2 and BD-3 showed expression of these defensins and presented increased flap survival. Rats transduced with BD-3 presented a net reduction in the number of P. aeruginosa on the surface of the foreign body and lesser biofilm formation.

Simultaneous Supratentorial and Infratentorial Pilocytic Astrocytomas in an Adult Patient with Concurrent Neurofibromatosis Type 1 and HIV Infection.

BACKGROUND: Neurofibromatosis type 1 (NF1) has been identified as a predisposing factor in the development of pilocytic astrocytoma (PA), a common benign central nervous system tumor. Although this is a common association, simultaneous development of multiple lesions is an infrequent finding, especially in nonoptic and hypothalamic locations. CASE DESCRIPTION: A 41-year-old female patient with NF1 and uncontrolled human immunodeficiency virus (HIV) type 1 infection presented with a first generalized seizure and associated headache and ataxia. Imaging studies revealed 2 large intra-axial PAs, nodular-cystic in the supratentorial compartment and solid in the infratentorial compartment. Both lesions were treated by gross total resection in 2 surgeries performed 1 week apart. Despite their different imaging patterns, the tumors were histologically and genetically identical. CONCLUSIONS: We present a unique case involving 2 histologically and genetically identical PAs occurring simultaneously in supratentorial and infratentorial locations. We suggest that an intrinsic predisposition to tumor development in patients with NF1 might have been enhanced by the HIV-related immunosuppression in this case. Strict oncologic surveillance is essential in patients with a tumor predisposition syndrome combined with immunosuppression.

A dissecação como ferramenta pedagógica no ensino da Anatomia em Portugal / Dissection as a pedagogical tool in anatomy teaching in Portugal / La disecación como herramienta pedagógica en la enseñanza de la Anatomía en Portugal

Ao longo da História, a importância da utilização de cadáveres humanos para o ensino e investigação não tem sido consensual. No passado, a obtenção dos cadáveres indispensáveis ao ensino passou pelo recurso a cadáveres de reclusos, de não reclamados e ao roubo e/ou compra. Para além da inadmissibilidade ética e jurídica destas soluções, estas revelaram-se insuficientes para as necessidades das escolas médicas. Nas últimas décadas, a consciência global da legitimidade da doação de cadáveres foi-se intensificando, considerando-se, hoje, a forma digna de colmatar essa falta. Neste artigo realizou-se uma revisão da literatura com o objetivo de se fazer uma resenha histórica, jurídica e pedagógica sobre a importância da utilização de cadáveres humanos no ensino da Anatomia Humana nos cursos de Medicina, incluindo em Portugal, nomeadamente pelo recurso à dissecação cadavérica em complementaridade com outras ferramentas pedagógicas.

Over the course of history, there has not been any consensus regarding the importance of using human cadavers for educational and research purposes. In the past, to obtain the cadavers essential for teaching, it was necessary not only to use cadavers of the condemned and those not claimed by their families, but also to steal and/or purchase corpses. These solutions, besides being ethically and legally inadmissible, always proved to be insufficient for the needs of medical schools. Over the last few decades, global awareness of the legitimacy of cadaver donation has gradually increased, and this is considered today to be the dignified way to fill this need. This article presents a historical, legal and pedagogical review of the literature on the importance of using of human cadavers in the teaching of human anatomy in medical schools, including in Portugal, especially the role of cadaveric dissection complementarily with other teaching tools.

A lo largo de la historia, la importancia de la utilización de cadáveres humanos para la enseñanza y la investigación no ha sido un consenso. En el pasado, la obtención de los cadáveres indispensables para la enseñanza contaba con el recurso de cadáveres de presos, de no reclamados y del robo/compra de ellos. Más allá de la inadmisibilidad ética y jurídica de estas soluciones, ellas se mostraron insuficientes para las necesidades de las escuelas médicas. En las últimas décadas, la conciencia global de la legitimidad de la donación de cadáveres se fue intensificando, considerándose hoy día una forma digna de suplir esa falta. En este artículo se realizó una revisión de la literatura con el objetivo de hacer una reseña histórica, jurídica y pedagógica sobre la importancia de la utilización de cadáveres humanos en la enseñanza de Anatomía Humana en los cursos de Medicina, incluyendo en Portugal principalmente el recursos para la disecación cadavérica en complemento con otras herramientas pedagógicas.

Satisfação dos utentes face à prestação de cuidados de saúde / User satisfaction with health care delivery

Introdução ­ A prestação de cuidados de saúde de qualidade é uma questão actual e cada vez mais premente, sendo entendida como uma necessidade intrínseca aos próprios serviços, uma vez que estes existem para servir os utentes. Em consequência, é fundamental ir de encontro às suas necessidades, expectativas e conseguir um elevado grau de satisfação dos mesmos com os cuidados. Com a realização deste trabalho pretendemos: descrever as características sócio-demográficas e clínicas da amostra em estudo; determinar a satisfação dos utentes face à prestação de cuidados de saúde, no serviço de Ortopedia da ULSG; identificar as variáveis que mais influenciam a satisfação dos doentes com os cuidados recebidos; e contribuir para a reflexão sobre a problemática. Métodos ­ Conceptualizámos um estudo transversal, descritivo-correlacional, de natureza quantitativa. Recorremos a uma amostra não probabilística por conveniência, constituída por 52 indivíduos, na sua maioria mulheres, com idades compreendidas entre os 22 e os 89 anos (x=61,56; Dp=18,74). O instrumento de colheita de dados incorporou uma ficha de caracterização sóciodemográfia e clínica, o questionário EQ-5D para avaliação da qualidade de vida e o questionário INPATSAT32, da European Organization for Research and Treatment of Cancer, para a mensuração da percepção dos cuidados recebidos. Resultados ­ Os receptores de cuidados caracterizaram a sua qualidade de vida como mediana (56,56), sendo que 44,2% apresentam alguns problemas em deambular e 38,5% em lavar-se/despir-se, 40,4% no desempenho das actividades habituais, 61,5% apresentam dores/mal-estar moderados e 50% estão moderadamente ansiosos/deprimidos. A satisfação dos utentes face à prestação de cuidados de saúde apresenta um efeito significativo apenas quando cruzados com os grupos etários 60-79 e 80-99. Verificámos que os mais velhos apresentam melhor percepção sobre os cuidados, isto para as dimensões dos cuidados médicos (p=0.015) e dos cuidados de enfermagem (p=0.015). Constatámos também a existência de relação entre a satisfação e os dias de internamento, sendo muito significativa na correlação com cuidados da equipa médica (p=0.002) e com a satisfação global (p=0.004), sendo menos significativa a correlação com a organização dos serviços (p=0,040). Na sua globalidade os indivíduos da amostra referem-se menos satisfeitos com a disponibilidade e a informação fornecida, contrariamente às competências técnicas e interpessoais. O pior item de avaliação é a acessibilidade/acessos (38,5). Na avaliação global sobre os cuidados de saúde recebidos, verificamos um score de 65,4. O grupo profissional dos enfermeiros é o que tem melhor avaliação (68). Conclusões ­ A qualidade dos cuidados de saúde implica conhecer o grau de satisfação dos utentes e o sentimento de bem-estar da comunidade em geral. A satisfação com os cuidados é uma componente central na avaliação da qualidade dos cuidados de saúde na perspectiva do utilizador.

Introduction-The health care quality management is a topical issue and increasingly urgent and is viewed as an intrinsic services necessity, since they exist to serve the users. It is therefore essential to meet users needs, expectations and a high degree of satisfaction. With this work we intend to: describe the socio-demographic and clinical sample under study; evaluate the satisfaction with health care services of Orthopaedics ULSG; identify the variables that most influence patient satisfaction with the care received and contribute to the debate on the issue. Methods ­ We conceptualized a cross-sectional descriptive, correlational, quantitative study. We use a non-probabilistic convenience sample consisting of 52 individuals, mostly women, aged between 22 and 89 years (x = 61.56, SD = 18.74). The data collection instrument incorporated a socio-demographic and clinical, the EQ-5D questionnaire for assessing quality of life and IN-PATSAT32 questionnaire (the European Organization for Research and Treatment of Cancer), to measure the perception of care received. Results - The health care receivers characterized the quality of life as median (56.56), 44.2% had some problems in walking, 38.5% in washing and undressing, 40.4% in performance of usual activities, 61.5% had pain/discomfort and 50% are moderately anxious/depressed. The satisfaction with health care revealed a significant effect only when crossed with the age groups 60-79 and 80-99. We found that older people have a better perception of care, for the dimensions of care (p=0.015) and nursing care (p=0.015). We also noted the existence of a relevant relationship between satisfaction and hospital days, a marked significant correlation with the medical care team (p = 0.002) and overall satisfaction (p = 0.004), and a less significant correlation with the organization of services (p = 0.040). In general individuals in the sample refer less satisfied with the availability and the information provided, contrary to the technical and interpersonal skills. The worst grade item is affordability/access (38.5). In the overall evaluation of health care received, we found a score of 65.4. The professional group of nurses was better scored (68). Conclusions - The quality of health care means knowing the degree of user satisfaction and sense of well-being of the community in general. Satisfaction with care is a central component in assessing the quality of health care from the user perspective.