High prevalence of ST121 in community-associated methicillin-susceptible Staphylococcus aureus lineages responsible for skin and soft tissue infections in Portuguese children.

In order to evaluate the incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Portugal, we analyzed a collection of 38 S. aureus isolates recovered from 30 children attending the pediatric emergency department of a central hospital in Lisbon due to skin and soft tissue infections. Molecular characterization identified seven clonal lineages among the 35 methicillin-susceptible S. aureus (MSSA) isolates, of which the major lineage PFGE A/t159/ST121 included 63% of the isolates. The three MRSA isolates belonged to the Pediatric clone PFGE D/t535/ST5-IV (n = 2) and to the European CA-MRSA clone PFGE G/t044/ST80-IVc (n = 1). All isolates harbored several virulence factors, namely, leukocidins. Panton-Valentine leukocidin (PVL) was produced by isolates from five MSSA lineages and by the ST80 MRSA. Of interest, this is the first reported isolation of CA-MRSA ST80 in Portugal.

Mola hidatiforme completa prévia coexistente com feto vivo numa gravidez gemelar bicoriónica / Complete hydatiform mole with coexisting live fetus in dichorionic twin gestation

A existência de uma mola hidatiforme completa coexistentecom feto vivo, numa gravidez gemelar, é uma entidaderara. A atitude clínica constitui um desafio uma vez que amanutenção da gravidez de modo a alcançar a viabilidadefetal pode associar-se a potenciais complicações fetais e/oumaternas graves, tais como hemorragia vaginal, pré-eclâmpsia,morte fetal, prematuridade e risco aumentado de doençatrofoblástica persistente, condicionando um verdadeirodilema clínico, mãe/feto.Os autores descrevem o caso de uma mulher de 35 anos,admitida às 24 semanas de gestação por hemorragia vaginalpersistente numa gravidez gemelar bicoriónica, com umadas placentas com feto normal e outra placenta prévia total,compatível com mola hidatiforme completa. Apresentava,concomitantemente, hipertiroidismo subclínico. A gravidezfoi vigiada com atitude expectante até às 27 semanas degestação, altura em que após episódio grave de hemorragiavaginal, realizou-se cesariana com extracção de nado vivocom 947 g. Os níveis séricos da subunidade β da hormonagonadotrofina coriónica humana (β-hGC) negativaram nadécima quarta semana após o parto.A clínica, os níveis séricos de β-hGC e as imagens ecográficassugeriram o diagnóstico de mola hidatiforme completa,os quais foram corroborados pelos estudos citogenéticos (AU)

A twin pregnancy with a coexisting complete hydatiformmole and a healthy fetus is a rare event. The ma-Casos clínicosMola hidatiforme completa préviacoexistente com feto vivo numagravidez gemelar bicoriónica1 Serviço de Medicina Materno Fetal2 Centro de Diagnóstico Pré-Natal3 Serviço de Anatomia PatológicaMaternidade Dr. Alfredo da CostaLisboa (Portugal)4 Unidade de CitogenéticaDepartamento de Genética HumanaInstituto Nacional de Saúde Dr. Ricardo Jorge, INSA, I.PLisboa (Portugal)T. Sardinha1A. I. Machado1E. Dias1L. Martins2I. Biscaia3H. Correia4F. Serrano1J. Correia2A. Campos1nagement is challenging because although the fetus maybe viable, maintaining the pregnancy is associated withpotentially serious maternal and fetal complications, likevaginal bleeding, pre-eclampsia, preterm delivery, fetaldeath and an increased risk of persistent gestational trophoblasticdisease, which leads us to a clear mother versusfetus clinical dilemma.We describe a case of a 35-year-old woman who wasadmitted for persistent vaginal bleeding in a 24 weeks bichorionictwin pregnancy, one placenta with a normal fetusand the other, a complete placenta praevia,compatible with a complete hydatiform mole. She alsopresented subclinical hyperthyroidism. The pregnancywas managed conservatively until 27 weeks gestationwhen, following an episode of major antepartum haemorrhage,a 947-g live was delivered by Caesarean Section.Serum human chorionic gonadotrophin β-subunit(β-hCG) concentrations returned to baseline fourteen weeksfollowing delivery.The clinical, the serum β-hCG concentrations and theultrasound suggested the diagnosis of a complete hydatiformmole but it was the cytogenetic studies that confirmed it (AU)

Tumor anexial fetal / Fetal adnexal tumor

Os tumores anexiais fetais são uma patologia pouco frequente. A realização de ecografia obstétrica por rotina veio permitir não só a sua detecção precoce como um aparente aumento da sua incidência nas últimas duas décadas. Os autores descrevem o caso clínico de uma primigesta saudável de 33 anos de idade, cuja gravidez teve uma evolução normal até ao terceiro trimestre. Em ecografia obstétrica de rotina foi detectada formação quística com aparente sede anexial direita, com 40 mm de maiores diâmetros, bem delimitada, avascular, com ecos difusos no seu interior e finas septações. Rins fetais sem alterações ecográficas. Realizou controlos ecográficos semanais até ao parto, não se tendo verificado aumento das dimensões nem alterações das características da neoformação. Parto por cesariana às 38 semanas de gestação, por apresentação pélvica. Exame objectivo da recém-nascida normal. Confirmação do diagnóstico pré-natal em ecografia abdomino- pélvica realizada no período neonatal precoce. Marcadores tumorais negativos. Por aumento das dimensões da neoformação para 60 mm ( em ecografia realizada na primeira semana de vida), a recém-nascida foi submetida a intervenção cirúrgica – quistectomia direita–, ao 15º dia de vida. O diagnóstico anatomo- patológico foi de “quisto ovárico simples (provavelmente folicular), com necrose e sem achados epiteliais específicos”. Apesar dos avanços em ecografia fetal, o diagnóstico pré-natal dos quistos anexiais - que é ecográfico - coloca um dilema terapêutico, na medida em que a história natural desta entidade nosológica não é ainda bem conhecida

Fetal adnexal tumors are an infrequent pathology.Obstetric routine ultrasound has made possible not onlyits earlier detection but also an apparent increase of its incidence in the last two decades.The authors describe a case report of an healthy 33years old primigravid whose pregnancy had no complications until the third trimester. In a routine ultrasonographic examination a cystic tumor was detected which origin was apparently the right adnexa. Its diameter was 40 mm and it was well delimitated, avascular, with diffuse echos in its interior and smooth septations. The fetal kidneys were normal.Weekly obstetric ultrasonographic examinationswere made until the day of birth and no increase of thetumor´s dimensions or any modification concerning itsgeneral aspect were verified.A cesarean section was made at 38th week because ofbreech presentation. The newborn had a normal physicalexam.The prenatal diagnosis was confirmed with an abdomino-pelvic ultrasonographic examination made on theneonatal period. The tumoral markers were negative.As an increase in the dimensions of the tumor (to 60 mm)was found in the second ultrasonographic examination (done on the first week of life), the newborn underwent surgery –right cystectomy–, on the 15th day of life. The anatomo-pathological diagnosis was of “simple ovarian cyst (probably follicular in origin), with necrosis and no specific epithelial characteristics (absence of identifiable lining cells)”.Although there have been advances in obstetric andfetal ultrasound, the prenatal diagnosis of adnexal cysts- which is made by ultrasound -, poses a therapeutic dilemma, because the natural history of these lesions is not well known

Hemorrhoids.

Technologic advances have contributed to numerous diverse approaches to the management of hemorrhoid disease over the past centuries. Better understanding of the pathophysiology and anatomy of the anal canal has also added to the increased success in the treatment of hemorrhoids. This article reviews the clinical and pathological aspects of hemorrhoid disease, emphasizing new therapeutic modalities.

Membrane-type 1 matrix metalloproteinase mRNA expression in colorectal cancer.

PURPOSE: Membrane-type matrix metalloproteinases are recently described proteolytic enzymes belonging to the matrix metalloproteinase family. Initial studies have indicated that membrane-type matrix metalloproteinases are involved in tumor invasion and metastasis. Membrane-type 1 matrix metalloproteinase is the first membrane-type matrix metalloproteinase to be described. The aim of this study was to investigate the expression of membrane-type 1 matrix metalloproteinase mRNA in colorectal cancer. METHODS: Samples were collected from surgical specimens of patients with colorectal adenocarcinoma and were immediately frozen in liquid nitrogen and stored at -80 degrees C until processed. Both normal and cancer tissue was taken from each patient. TNM stage, tumor differentiation, mucin production, and vascular invasion were assessed. Northern blotting was used to quantify membrane-type 1 matrix metalloproteinase mRNA levels in the samples using a membrane-type 1 matrix metalloproteinase cDNA clone. X-ray film images were digitized and densitometry was used to quantify bands. All samples were normalized against 18S rRNA levels. Results are expressed as the ratio of cancer to normal tissue levels. Statistical analysis was performed using analysis of variance, with P < 0.05 accepted as the level of significance. RESULTS: A total of 32 samples were prospectively analyzed. The correlation between TNM stage and increased expression of membrane-type 1 matrix metalloproteinase mRNA in cancer tissue over normal tissue is expressed in the mean ratio of cancer to normal tissue expression for Stages I through IV, respectively: 1.4 +/- 0.2 (12 patients); 4.1 +/- 2.6 (8 patients); 3.4 +/- 3 (7 patients); and 4.5 +/- 5 (5 patients). Stage I is significantly different from Stages II and IV (P < 0.05). These preliminary results show an overall increasing trend in membrane-type 1 matrix metalloproteinase expression with increasing tumor stage. However, there was no correlation between membrane-type 1 matrix metalloproteinase expression and mucin production, degree of tumor differentiation, or vascular invasion. CONCLUSION: Preliminary results indicate that membrane-type 1 matrix metalloproteinase levels correlate with increasing tumor stage.

Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) after controlled bowel injuries in a rabbit model.

PURPOSE: Patients in whom enterolysis is performed are at high risk for recurrence of adhesions and for injury during adhesiolysis. Therefore, the aim of this study was to assess the safety of sodium hyaluronate-based bioresorbable membrane (Seprafilm) after myotomy and enterotomy. METHODS: A total of 60 rabbits underwent laparotomy with equal distribution to one of three groups: creation of either three repaired, or three unrepaired myotomies, or three repaired enterotomies. Thus, a total of 180 defects were created in the same anatomic positions. One-half of the animals in each group had the surface of the myotomies or enterotomies covered by Seprafilm. Fourteen days later, after complete absorption of Seprafilm, the presence of intra-abdominal abscess, adhesions, and the integrity of the suture line were evaluated by a surgeon blinded to the use of Seprafilm and by a standard radiographic isobaric contrast study. Statistical analysis was done by use of Fisher's exact test; significance was set at P < 0.05. RESULTS: The incidence of adhesions in the repaired myotomy group were 2 (6.6 percent) and 9 (30 percent) in the Seprafilm and control (nonSeprafilm) groups, respectively (P < 0.05); in the unrepaired myotomy group, 2 (6.6 percent) and 10 (33 percent) in the Seprafilm and control groups, respectively (P < 0.05); and in the enterotomy group, 28 (94 percent) and 29 (97 percent) in the Seprafilm and control groups, respectively (P = not significant). A single phlegmon occurred in the myotomy group at a Seprafilm site (1.6 (1/60) vs. 0 percent, P = not significant). There were no leaks in this group. In the enterotomy group, the incidence of phlegmons was 33 percent (10/30) in the Seprafilm group, whereas it was 27 percent (8/30) in the nonSeprafilm group (P = not significant). The incidence of leaks was 6.6 (2/30) and 10 percent (3/30) in the Seprafilm and nonSeprafilm group, respectively (P = not significant). CONCLUSION: The use of Seprafilm at the sites of myotomies significantly reduced the incidence of adhesions. Effectiveness at the enterotomy site may have been attenuated by a greater inflammatory response. Importantly, Seprafilm did not increase septic mortality in any group.

Colonoscopy in octogenarians: a review of 428 cases.

Studies on the use of colonoscopy in the octogenarian are few. Therefore this study evaluated the results and cost-effectiveness of colonoscopy in octogenarians. A total of 403 patients 80 years of age or older who underwent colonoscopy from May 1994 to May 1996 were reviewed (median 84, range 80-95). Parameters evaluated were indications for colonoscopy, significant endoscopic findings (biopsy-confirmed adenocarcinoma and adenomatous polyps >/=1 cm), complications, colonoscopy completion rate, and mean charge per procedure. Postpolypectomy bleeding occurred in one patient. The cecal intubation rate was 94%. The calculated cost per procedure was U.S. $2,342. Indications for colonoscopy/number of cancers detected include: change in bowel habits, 78/2; blood/hemoccult positive, 69/8; abdominal pain, 12/0; constipation, 9/0; diarrhea, 8/0; surveillance for history of polyps, 159/3; surveillance for history of cancer, 51/1; cancer or polyp on sigmoidoscopy, 42/4. The cancer detection rate in patients with bleeding was 11.5%, compared with 1. 9% for all other symptoms. Colonoscopy can be safely performed in the octogenarian population. Our data suggest that more stringent selection criteria for colonoscopy in the octogenarian could result in significant cost savings.

The influence of cigarette smoking on cytokine levels in patients with inflammatory bowel disease.

Anecdotal reports suggest that smoking may be beneficial for patients with inflammatory bowel disease (IBD) as nicotine may act through inflammatory mediators within the colonic mucosa. Furthermore, there is increasing evidence that cytokines play a pathologic role in IBD. Our aim was to determine the effects of cigarette smoking on cytokine levels in the colonic mucosa of patients with and without IBD. Mucosal biopsies were obtained from 10 patients with Crohn's disease (CD), 10 with ulcerative colitis (UC), and 10 healthy controls. Five of 10 patients in each of the three groups were smokers and five were nonsmokers. Concentrations of interleukin (IL)-1beta, IL-2, IL-6, and IL-8 were determined using enzyme-linked immunosorbent assay (ELISA). Cytokine levels of smokers were compared with nonsmokers in each group and with controls. Results were analyzed using the Mann-Whitney test; significance was set at p<0.05. The concentration of IL-8 was significantly higher in healthy controls who smoke compared with nonsmokers and significantly reduced in smokers with CD compared with nonsmokers with CD. Moreover, concentrations of IL-1beta and IL-8 were significantly reduced in smokers with UC compared with nonsmokers with UC. Smokers had significantly elevated levels of IL-8 in the colonic mucosa. Smokers with IBD had a significant reduction in cytokine levels; specifically, IL-1beta and IL-8 for patients with UC and IL-8 for patients with CD. Further studies are warranted to determine if this reduction in cytokine levels is histologically and clinically significant.

Laparoscopy for inflammatory bowel disease: pros and cons.

The role of laparoscopic surgery in the treatment of colorectal malignancies is still under investigation, although it can offer significant benefits to many patients with inflammatory bowel disease (IBD). The aim of this study was to assess the pros and cons of the laparoscopic management of IBD. Data were obtained from a review of the literature published since 1992, when the first report of laparoscopic surgery for IBD appeared in print. From 1992 to 1997 several series of laparoscopic colorectal surgery for the management of IBD have been reported. A close evaluation of these studies revealed that laparoscopy in patients with terminal ileal Crohn's disease or anal Crohn's disease in need of fecal diversion offers significant advantages compared to laparotomy, including decreased pain, length of hospitalization, and disability. An additional bonus is improved cosmesis and a reduction in symptomatic postoperative adhesions. These many benefits can be achieved without any increase in morbidity or expense. Conversely, the use of this technology for restorative proctocolectomy in patients with mucosal ulcerative colitis is associated with a longer operative time and an increased incidence of both intra- and postoperative complications compared to laparotomy. Laparoscopic colorectal surgery can thus be advantageous for treatment of terminal ileal Crohn's disease but cannot be routinely justified for the treatment of mucosal ulcerative colitis.

Efficiency and productivity of a sheathed fiberoptic sigmoidoscope compared with a conventional sigmoidoscope.

PURPOSE: The aim of this study was to measure and compare time and productivity between a new sheathed flexible sigmoidoscope and a traditional fiberoptic flexible sigmoidoscope relative to labor and cost analysis. METHODS: Two flexible sigmoidoscopes, the Vision Sciences sigmoidoscope using a protective sheath covering requiring removal and replacement between procedures and a conventional flexible sigmoidoscope requiring meticulous cleaning using a washer and high-level disinfection, were compared. Sigmoidoscope preparation was defined as the average time between the procedures (reprocessing, start to finish) and was measured by an independent nonmedical timekeeper JG). The parameter recorded was scope reprocessing time. RESULTS: Ten procedures were performed using the sheathed flexible sigmoidoscope system compared with nine using a conventional sigmoidoscope. Scope performance and endoscopic visualization for both systems were comparable. The average reprocessing time was 46.8 minutes for the conventional sigmoidoscope vs. 4.9 minutes for the sheathed sigmoidoscope (P < 0.0001). The average time saved was 9.5 times greater with the sheathed flexible sigmoidoscope system than with the conventional sigmoidoscope. CONCLUSION: The almost tenfold difference in the time saved using the sheathed flexible sigmoidoscope system represents increased productivity and potentially decreased overall labor cost. By reducing endoscope turnover time, this new sheathed system can reduce or even eliminate the need for backup endoscopes and endoscope washers and potentially allow better use of nursing staff.

[Effectiveness of the yellow fever vaccine 17D: an epidemiologic evaluation in health services]. / Efetividade da vacina antiamarílica 17D: uma avaliação epidemiológica em serviços de saúde.

The purpose of this study was to evaluate the efficacy of the 17D yellow fever vaccine in the conditions under which it is used in public health services. In 1989, a nonconcurrent prospective study was carried out in Bocaiúva, Minas Gerais State, Brazil, 6 months after mass vaccination of the population. The study population was made up of first-grade students from all the schools in Bocaiúva. The exposed group consisted of a simple random sample of vaccinated students (n = 173) and the unexposed group consisted of all those who had not been vaccinated (n = 55). Serum samples were examined with the neutralization test in mice; these tests were conducted blind, that is, the examiner did not know the vaccination status of the subject. The serology results were as follows: of those vaccinated, 75% were seropositive, 17% were seronegative, and 7% showed an inconclusive result; in the unvaccinated children, these results were 9%, 87%, and 4%, respectively. The age-adjusted seropositivity ratio between vaccinated and unvaccinated children was 7.6 (95% CI: 3.4 to 16.7). The proportion of seropositivity attributable to vaccination, adjusted for age, was 86.8% (95% CI: 70.6 to 94.0). The results showed that the efficacy of the vaccine, defined by means of seropositivity for the virus, was below the levels expected for the 17D vaccine. This may have been due to operational failures in the conservation or application of the vaccine. The results point to the need for routine systematic evaluations by the health services after mass utilization of the vaccine.