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.

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.

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.

In vitro study of enamel erosion caused by soft drinks and lemon juice in deciduous teeth analysed by stereomicroscopy and scanning electron microscopy.

The erosion caused in vitro by cola-type and guaraná-type beverages (the latter is a soft drink sold in Brazil), and a canned lemon juice on the enamel of human deciduous teeth was analyzed. Morphological analysis of affected enamel was done using stereomicroscopy and scanning electron microscopy (SEM). The harmful effect of all test products on deciduous enamel was clearly demonstrated. Stereomicroscopy showed loss of gloss and an alteration in normal color of enamel, with irregular loss of dental tissue in variable degrees. Such a loss became more serious as the time of incubation increased. Different degrees of solubilization of enamel prisms were demonstrated by SEM, affecting initially the sheaths and the heads of prisms and later their tails. Areas of erosion increased in proportion to the time of incubation. All the products showed a great erosive potential on human deciduous dental enamel.

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.

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.

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.

Septicemia em crianca: analise de 102 casos. / Septicemia in children: analysis of 102 cases

Os autores analisam 102 casos de criancas internadas no Instituto da Crianca com o diagnostico de septicemia, com base em dados clinicos e laboratoriais (hemoculturas positivas). Foram avaliados os seguintes parametros clinicos: sexo, idade, estado nutricional, internacao previa e evolucao. Em relacao a etiologia, destaca-se a alta incidencia de Salmonella sp (57,8%). O antibiograma foi avaliado para S. aureus e Salmonella sp: os achados diferem dos existentes na literatura

Insuficiencia renal aguda, em malaria por Plasmodium falciparum. / Acute kidney failure in malaria due to Plasmodium falciparum

Entre janeiro de 1977 a abril de 1982 foram internados no Instituto de Medicina Tropical de Manaus (I.M.T.M.) 1.429 pacientes com malaria por Plasmadium falciparum. Destes, 37 (2,58%) desenvolveram insuficiencia renal aguda (IRA) com creatinina serica superior a 3 mg%, sendo que 30 (81,08%) eram primo-infectados.No grupo que desenvolveu IRA o periodo entre o inicio dos sintomas e a internacao hospitalar foi de 9,00 +/- 4,87 dias (2-30) e que foi maior quando comparado com um grupo controle (p < 0,01). A ureia serica de internacao foi de 155,24 +/- 67,36 mg% (29-266) e a creatinina de 5,89 +/- 3,88 mg% (0,9-22,5). A mortalidade foi de 11 (29,72%) pacientes, sendo mais frequente no grupo em que a creatinina serica foi superior a 7 mg% (P < 0,1). Dialise peritoneal (DP) foi realizada em 11 pacientes e destes 6 (54,54%) morreram. Dos 26 restantes, que nao fizeram DP, 5 (19, 23%) foram a obito (p < 0,05). Nao observamos tendencias a hiperpotassemia. Edema cerebral pulmonar agudo foi a principal causa de obito