Diabetes and necrotizing soft tissue infections-A prospective observational cohort study: Statistical analysis plan.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) are rare but carry a high morbidity and mortality. The multicenter INFECT project aims to improve the understanding of the pathogenesis, clinical characteristics, diagnosis, and prognosis of NSTIs. This article describes the study outline and statistical analyses that will be used. METHODS: Within the framework of INFECT project, patients with NSTI at 5 Scandinavian hospitals are enrolled in a prospective observational cohort study. The goal is to evaluate outcome and characteristics for patients with NSTI and diabetes compared to patients with NSTI without diabetes. The primary outcome is mortality at 90 days after inclusion. Secondary outcomes include days alive and out of ICU and hospital, SAPS II, SOFA score, infectious etiology, amputation, affected body area, and renal replacement therapy. Comparison in mortality between patients with diabetes type 1 and 2 as well as between insulin-treated and non-insulin-treated diabetes patients will be made. Clinical data for diabetic patients with NSTI will be reported. CONCLUSION: The study will provide important data on patients with NSTI and diabetes.

Laying hens behave differently in artificially and naturally sourced ammoniated environments.

Laying hens are chronically exposed to high levels of ammonia (NH3), one of the most abundant aerial pollutants in poultry houses. Tests for aversion to NH3 in laying hens have used artificially sourced NH3/air mixtures (i.e., from a gas cylinder) showing that birds prefer fresh air to NH3. However, artificially sourced NH3/air mixtures may not accurately reflect barn air conditions, where manure emits a variety of gases. Herein, we investigated whether laying hens differentiate between artificially and naturally sourced NH3/air mixtures and how exposure to NH3 affects foraging and aversive behavior. A total of 20 laying hens was exposed to artificially sourced [A] (from an anhydrous NH3 cylinder) and naturally sourced [N] (from conspecific laying hen excreta) gas mixtures. Hens were exposed to A and N mixtures with NH3 concentrations of 25 and 45 ppm, as well as fresh air [FA]. During the experiment, all birds were exposed to each treatment 3 times using a custom-built polycarbonate chamber, containing a foraging area (containing raisins, mealworms, and feed mix) and a gas delivery system. All testing sessions were video recorded, analyzed with INTERACT® software, and subjected to a GLIMMIX procedure in SAS. Our results showed that the laying hens spent less time foraging overall (P < 0.001) and were slower to commence foraging (P = 0.004) in ammoniated environments compared to the fresh air. Laying hens were more likely to forage for a longer time (with fewer interruptions) in N than in A treatments (P < 0.001). Laying hens also reacted with greater aversion towards treatment A compared to treatment N (P < 0.001). These findings suggest that the laying hens of our study preferred fresh to ammoniated air and that they behaved differently in artificially and naturally sourced NH3/air mixtures, possibly due to the presence of familiar stimuli from the excreta. These findings have implications for new developments in methodological approaches for behavioral testing and for recommendations regarding NH3 levels inside poultry barns.

Effects of season and distance during transport on broiler chicken meat.

This research aims to evaluate the microclimate of commercial loads of broiler chickens at different distances in the summer (rainy) and winter (dry) seasons and their effects on meat quality. Twelve broiler loads were monitored with a total of 24 crates per load. Data loggers were used to record temperature and relative humidity. The experiment followed a completely randomized design with 48 treatments in a factorial scheme (2 seasons: rainy and dry) x 2 (distances: short and long) x 12 (positions), with 3 replicates per experimental group. In the rainy season, meat quality was influenced by transport distance. For longer distances, it recorded the highest enthalpy comfort index (ECI), suggesting a tendency of dark, firm, and dry meat (DFD-like) and lower cooking losses (CL). The lowest ECI was recorded during the transport in dry season. Broiler chickens transported and slaughtered in the winter presented meat pH and L* (lightness) classified as "normal," but with higher cooking losses. For the shear force (SF), the seasons and distances had no significant influence on tenderness of the meat. Regarding the crate positioning in the load, no effect was observed during transport on this variable, given the meat quality characteristics of pH, L*, CL, and SF. These results suggest that the distance and the seasons present more influence on broiler meat quality than crate position in the truck.

Heyde syndrome in a 71-year-old man who underwent chest radiotherapy at young age.

We report the case of a 71-year-old man with diagnosis of aortic valve stenosis for ten years, who came to hospital because of breathlessness during the previous two months and recent low intestinal hemorrhage. On admission, laboratory tests and upper gastrointestinal endoscopy and colonoscopy revealed anemia and bleeding cecal angiodysplasia. The echocardiography study showed a severe aortic stenosis. Classical Heyde syndrome is described as the association of aortic stenosis, bleeding gastrointestinal angiodysplasia and secondary anemia. The antecedent of mediastinal radiotherapy for treatment of Hodgkin's disease during his youth, and eventual late cardiac adverse effects that may include aortic or mitral valve disturbances are highlighted. Electrocoagulation with argonium was performed on the sites of active bleeding during the colonoscopy. In sequence, surgical replacement by bioprothesis was done on the aortic valve. The patient remains asymptomatic, under long-term outpatient surveillance, with normal control evaluations. The aim of this case study is to emphasize difficulties related to diagnosis, and to highlight the role of endoscopy and imaging studies to confirm a hypothesis of this underestimated condition.

Two women with cerebral venous thrombosis: oral contraceptives?

Two cases of cerebral venous thrombosis are reported. Patients were apparently healthy 39 and 28-year old females with non-specific presenting features. Image findings were characteristic of cerebral sinus thrombosis. The younger patient received progesterone to treat placental abruption eight years previously; she had cerebral venous thrombosis while using oral contraception. Both patients had used contraceptive pills for a long time. Oral hormonal contraceptives may increase the risk of vascular events, even in people without personal or family history of venous thrombosis. Modern imaging methods have contributed to early diagnosis, but the possibility of under diagnosis still persists. This report aims to increase the awareness of health-workers about cerebral venous thrombosis in women, an entity often misdiagnosed, under diagnosed and under-reported.

Iliopsoas abscess and spondylodiscitis by Staphylococcus aureus: successful clinical treatment.

Although pyogenic abscess of the iliopsoas muscle is considered an uncommon condition, its incidence is on the increase. This abscess may be primary if it occurs without a causal factor; more frequently, it is secondary to gastrointestinal or genitourinary affections, or trauma. The main aetiological agents differ among primary (Staphylococcus aureus) and secondary (Escherichia coli, Klebsiella spp, Streptococcus spp, Bacteroides spp) abscess. We report the case of a 64-year-old man with iliopsoas abscess by S. aureus associated with spondylodiscitis in lumbar vertebrae (L4-L5). Our aim is to emphasize the successful treatment with exclusive intravenous antimicrobials, and highlight the role of control through imaging studies and laboratory tests.

Massive pleural effusion due to metastasis of prostate cancer.

We describe the case of a 72-year old male with pleural effusion associated with prostate cancer. There was a previous history of tobacco smoking (pack/year: 47) and of total prostatectomy followed by external beam radiation therapy seven years previously for prostate cancer. Furthermore, he was submitted to orchiectomy plus non-steroidal anti-androgen blockage, in addition to docetaxel-based chemotherapy and prednisone. After the beginning of chemotherapy, a progressive elevation in prostate specific antigen (PSA) levels was observed. On admission, he presented with fever, weight loss, and respiratory symptoms due to a massive right pleural effusion. Fluid samples obtained by needle aspiration showed haemorrhagic exudates without malignant cells. Pleural metastasis were detected by thorax imaging studies, and biopsy samples revealed prostate adenocarcinoma as the origin of his pleural effusion. Pleural fluid was drained and talc pleurodesis was performed. This report aims to describe the occurrence of massive pleural effusion due to metastasis of prostate cancer and emphasizes the role of pleural biopsy with immunohistochemical studies to characterize this diagnosis.

Quantitative analysis of fibrosis and mast cells in the tongue of chronic chagasic patients: autopsy study.

OBJECTIVE: Recently, an orally transmitted outbreak of Chagas disease was reported in Santa Catarina, Brazil, after ingestion of sugar cane juice (garapa). This disease is caused by Trypanosoma cruzi, a parasite that stimulates the development of chronic inflammatory response, characterized by fibrous connective tissue neoformation (fibrosis). As the density of tissue mast cells (MC) may be an index of fibroblast proliferation and development of local fibrosis, the purpose of this autopsy study was to quantify the fibrosis rate and the number of MC in the tongues of chronic chagasic (CC) patients, compared with a non-chagasic (NC) control group. METHODOLOGY: Twenty-four evaluations, with a quantitative assessment of fibrosis percentage and MC density were performed. RESULTS: The percentage of fibrosis in the tongue was higher among CC than in the control group. In the CC group, a positive and significant correlation was found when the fibrosis rate was compared with the MC density. CONCLUSIONS: These morphometric findings suggest that tongue biopsy may be useful to study specific changes associated with Chagas disease. They also suggest that the systematic analysis of oral cavity, including tongue histopathology changes, could be useful in forensic pathology of the orally acquired chronic Chagas disease.

Clinics in diagnostic imaging (113).

Primary hyperaldosteronism is described in a 27-year-old Brazilian woman from an endemic area of schistosomiasis. She presented with hypokalaemia, cramps and polyuria, refractory hypertension, plasma aldosterone of 40.7 ng/dL and aldosterone/renin activity ratio higher than 100, due to an associated long-standing unsuspected aldosteronoma. Computed tomography showed a well-defined ovoid right adrenal mass, which was subsequently resected and confirmed to be an aldosteronoma. During subsequent follow-up visits, she remained asymptomatic, normokalaemic, and required no antihypertensive drugs. The differential diagnoses of refractory hypertension are discussed.

Widespread hematogenous metastases and Trousseau's syndrome in gastric adenocarcinoma.

A case of widespread hematogenous metastases and Trousseau's syndrome is reported in a 40 year-old white housewife with gastric cancer, presenting subdural hematoma, ecchymoses, epistaxis, stomach and uterine bleeding. After undergoing hematoma drainage, she was unsuccessfully treated with platelets, red blood cells, plasma cryoprecipitate transfusions, and antibiotics. Necropsy disclosed gastric ring-signet adenocarcinoma invading the serous layer, with massive disseminated intravascular coagulation and systemic neoplastic embolism. Multiple old and recent hyaline (rich in fibrin and platelets) microthrombi, and tumor emboli were observed in the bone marrow, meninges, liver, lungs, kidneys, lymph nodes, adrenals, thyroid, heart, pancreas, and ovaries (Krukenberg tumor).

Morphologic and morphometric evaluation of pancreatic islets in chronic Chagas' disease.

PURPOSE: Hyperglycemia and abnormal glucose tolerance tests observed in some patients with chronic Chagas' disease suggest the possibility of morphological changes in pancreatic islets and/or denervation. The purpose of this study was to describe the morphology and morphometry of pancreatic islets in chronic Chagas' disease. METHODS: Morphologic and computerized morphometric studies were performed in fragments of the head, body, and tail regions of the pancreas obtained at necropsies of 8 normal controls and 17 patients with chronic Chagas' disease: 8 with the digestive form (Megas) and 9 with the congestive heart failure form. RESULTS: The Megas group had a larger (p < 0.05) pancreatic islet area in the tail of the pancreas (10649.3 +/- 4408.8 micrometer2) than the normal control (9481.8 +/- 3242.4 micrometer2) and congestive heart failure (9475.1 +/- 2104.9 micrometer2) groups; likewise, the density of the pancreatic islets (PI) was greater (1.2 +/- 0.7 vs. 0.9 +/- 0.6 vs. 1.9 +/- 1.0 PI/mm2, respectively). In the tail region of the pancreas of patients with the Megas form, there was a significant and positive correlation (r = +0.73) between the area and density of pancreatic islets. Discrete fibrosis and leukocytic infiltrates were found in pancreatic ganglia and pancreatic islets of the patients with Chagas' disease. Trypanosoma cruzi nests were not observed in the examined sections. Individuals with the Megas form of Chagas' disease showed increased area and density of pancreatic islets in the tail of the pancreas. CONCLUSION: The observed morphometric and morphologic alterations are consistent with functional changes in the pancreas, including glycemia and insulin disturbances.

[Contribution to the morphologic diagnosis of lung adiaspiromycosis]. / Contribuição ao diagnóstico morfológico da adiaspiromicose pulmonar.

The diagnosis of adiaspiromycosis is usually based on lung sections stained by hematoxylin-eosin, periodic acid Schiff and methenamine silver. Authors describe the fungus aspect examined by mucicarmin, picro-sirius and Congo red methods, including polarized light microscopy. In doubtful cases, these methods could contribute to histopathological diagnosis of Emmonsia parva var crescens.

Pulmonary adiaspiromycosis: report of two cases.

Two cases of human pulmonary adiaspiromycosis are reported. Patients were 29 and 54-year-old males, farm workers, with "grippe-like" symptoms and radiographic findings suggestive of granulomatous interstitial disease. Transthoracoscopic and transbronchial biopsies were performed. Pulmonary function was measured by spirometry. One patient used ketoconazole. Possibility of misdiagnosed pulmonary adiaspiromycosis is emphasized.

Parasitic thyroid nodule in a patient with Hashimoto's chronic thyroiditis.

A case of parasitic thyroid nodule is presented. The patient was a non symptomatic 53-year-old white woman, on irregular course of L-thyroxine to treat hypothyroidism due to Hashimoto's thyroiditis. Without a history of thyroid trauma or surgery, she presented a 1.6 x 0.7 x 0.5cm right pre-laryngeal lymph node-like mass which, on ultrasonography, appeared distinct from the gland. TSH, thyroid peroxidase antibody and thyroglobulin antibody serum levels were elevated and T4-free level was normal. Thyroid and total body 99mTc isonitrile scintiscan showed a topic thyroid without radionuclide uptake in the nodule. Fine-needle aspiration of the nodule showed epithelial cells with nuclear atypia and oncocytic changes plus intense lymphoid infiltration and germinative center formation, simulating lymph node metastasis of papillary thyroid carcinoma. Conventional biopsy revealed a parasitic thyroid nodule with Hashimoto's chronic thyroiditis. Parasitic thyroid nodule must always be remembered so that unnecessary surgical assessment and undesirable sequels may be avoided.

[Iron status, malnutrition and acute phase response in HIV-positive patients]. / Resposta de fase aguda, subnutrição e estado nutricional do ferro em adultos com AIDS.

Nutritional status and some iron metabolism parameters of acute phase response (APR) positive and APR-negative AIDS patients were studied. Twenty-nine AIDS patients were submitted to 24h food intake recall, anthropometry, and albumin, C-reactive protein (CRP), hemoglobin, ferritin, and total iron binding capacity (TIBC) measurements. Infection plus serum CRP > 7 mg/dl were criteria for APR presence. Protein-energy malnutrition (PEM) was ascertained by body mass index (BMI) lower than 18.5 kg/m2 and height-creatinine index (HCI < 70%). PEM (77.8 vs 40%) and pulmonary tuberculosis (44. 4 vs 9.5%) were more frequent in APR-positive patients, which also had lower serum albumin (3.7 +/- 0.9 vs 4.3 +/- 0.9 g/dl), TIBC (165. 8 +/- 110.7 vs 265.9 +/- 74.6 mg/dl) and blood hemoglobin (10.5 +/- 1. 8 vs 12.6 +/- 2.3g/dl). Iron intake was similar between groups; however, serum ferritin levels (median, range) were higher among APR-positive (568, 45.3-1814 vs 246, 18.4-1577 ng/ml) patients. HIV-positive adults with systemic response to invading pathogens showed worse nutritional status than those APR-negative. In APR-positive AIDS patients, anemia appears to be unrelated to recent iron intake.