Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study / Disfagia y complicaciones pulmonares en la enfermedad cerebrovascular aguda: estudio observacional retrospectivo

Introduction: Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization. Objectives: This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality. Material and methods: Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions. Results: Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p<0.001), in severe stroke (p<0.001) and in the hemorrhagic subtype (p=0.008). An association was found with dysarthria and aphasia (p=0.003; p=0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p<0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p<0.001). Conclusions: The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.(AU)

Introducción: La disfagia es una complicación frecuente posterior a un evento cerebrovascular, que puede provocar graves secuelas pulmonares. La detección temprana de la disfagia y el riesgo de aspiración puede reducir la morbilidad, la mortalidad y la duración de la hospitalización. Objetivos: Este estudio pretende identificar asociaciones entre la disfagia y la enfermedad cerebrovascular aguda, y evaluar la prevalencia y el impacto de las complicaciones pulmonares en los reingresos y en la mortalidad. Material y método: Estudio observacional retrospectivo basado en 250 historias clínicas de pacientes con enfermedad cerebrovascular aguda: historia clínica, examen neurológico, pruebas de imagen y Gugging Swallowing Screen (GUSS) en las primeras 48h. Los pacientes fueron seguidos durante 3 meses a través de las historias clínicas para estimar la mortalidad a los 3 meses y los reingresos. Resultados: De las 250 historias clínicas analizadas, 102 (40,8%) fueron evaluados por disfagia. La prevalencia de disfagia fue del 32,4%. El riesgo fue mayor en los pacientes de mayor edad (p<0,001), en el ictus grave (p<0,001) y en el subtipo hemorrágico (p=0,008). Se encontró asociación con la disartria y la afasia (p=0,003; p=0,017). Las infecciones del tracto respiratorio se produjeron en el 14,4% de todos los pacientes (grupo GUSS 11,8% vs. grupo sin GUSS 16,2%), y en el 75% de los que tenían disfagia grave (p<0,001). La mortalidad a los 3 meses fue del 24,2% en pacientes disfágicos, especialmente alta en el grupo de disfagia grave (75%; p<0,001). Conclusiones: El tipo de enfermedad cerebrovascular, las puntuaciones NIHSS y GCS, edad, disartria y afasia fueron factores asociados de forma significativa a la disfagia. La prevalencia de infecciones del tracto respiratorio fue mayor en los pacientes sin registro GUSS, y no se observó significación estadística en los reingresos relacionados. La mortalidad a los 3 meses fue superior en el grupo de disfagia grave.(AU)

Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study.

INTRODUCTION: Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization. OBJECTIVES: This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality. MATERIAL AND METHODS: Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions. RESULTS: Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p<0.001), in severe stroke (p<0.001) and in the hemorrhagic subtype (p=0.008). An association was found with dysarthria and aphasia (p=0.003; p=0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p<0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p<0.001). CONCLUSIONS: The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.

The impact of changing the diagnostic algorithm for TB in Manicaland, Zimbabwe.

SETTING: Governmental health facilities performing TB diagnostics in Manicaland, Zimbabwe. OBJECTIVE: To investigate the effect of making Xpert® MTB/RIF the primary TB diagnostic for all patients presenting with presumptive TB on 1) the number of samples investigated for TB, 2) the proportion testing TB-positive, and 3) the proportion of unsuccessful results over time. DESIGN: This retrospective study used data from GeneX-pert downloads, laboratory registers and quality assurance reports between 1 January 2017 and 31 December 2018. RESULTS: The total number of Xpert tests performed in Manicaland increased from 3,967 in the first quarter of 2017 to 7,011 in the last quarter of 2018. Mycobacterium tuberculosis DNA was detected in 4.9-8.6% of the samples investigated using Xpert, with a higher yield in 2017 than in 2018. The overall proportion of unsuccessful Xpert assays due to "no results", errors and invalid results was 6.3%, and highly variable across sites. CONCLUSION: Roll out of more sensitive TB diagnostics does not necessarily result in an increase of microbiologically confirmed TB diagnosis. While the number of samples tested using Xpert increased, the proportion of TB-positive tests decreased. GeneXpert soft- and hardware infrastructure needs to be strengthened to reduce the rate of unsuccessful assays and therefore, costs and staff time.

LIEU: Centres de soins gouvernementaux réalisant des tests diagnostiques de la TB au Manicaland, Zimbabwe. OBJECTIF: Analyser l'effet de l'utilisation du test Xpert® MTB/RIF en tant que test diagnostique principal de la TB chez tous les patients suspects de TB sur 1) le nombre d'échantillons analysés pour TB, 2) la proportion d'échantillons testés positifs à la TB et 3) la proportion de résultats infructueux au fil du temps. MÉTHODE: Cette étude rétrospective a utilisé les données extraites du système GeneXpert, des registres de laboratoire et des rapports d'assurance qualité entre le 1er janvier 2017 et le 31 décembre 2018. RÉSULTATS: Le nombre total de tests Xpert réalisés au Manicaland a augmenté, de 3 967 au premier trimestre 2017 à 7 011 au dernier trimestre 2018. L'ADN de Mycobacterium tuberculosis a été détecté dans 4,9­8,6% des échantillons analysés par test Xpert, avec un rendement plus élevé en 2017 qu'en 2018. La proportion globale de tests Xpert infructueux en raison d'une « absence de résultat ¼, d'erreurs ou de résultats non valides était de 6,3%, avec une forte variation en fonction des sites. CONCLUSION: Le déploiement de tests diagnostiques de la TB plus sensibles n'entraîne pas nécessairement une hausse des diagnostics de TB confirmés microbiologiquement. Alors que le nombre d'échantillons testés par test Xpert a augmenté, la proportion de tests positifs pour la TB a diminué. L'infrastructure du matériel et du logiciel GeneXpert doit être renforcée pour réduire le taux de tests infructueux, et donc les coûts et le temps consacré par le personnel à la réalisation de ces tests.

Secondary dengue infection in immunocompetent murine model leads to heart tissue damage.

Dengue, considered the most important arthropod-borne viral disease affecting humans, is transmitted by the bite of mosquitoes of the genus Aedes and caused by one of the four distinct serotypes of dengue virus (DENV-1, -2, -3 and -4). Infection with one of the four serotypes provides lifelong homotypic immunity. However, immunity against the heterologous serotypes is transient. As a consequence, secondary infection may lead to severer manifestations due to cross-reactivity of antibodies and T-cells. Over 500,000 people are hospitalized every year and around 2,5 million, living in endemic areas, are at risk of infection. Given the background, the development of vaccines and anti-DENV drugs is of the utmost importance, as is the characterization of an animal model for testing them. The purpose of this study was to investigate ultrastructural alterations caused by DENV secondary infection in BALB/c mice heart. To achieve our goal, six BALB/c mice were infected with DENV-1 and, 4 months later, reinfected with DENV-2. Uninfected mice were used as negative controls. Heart samples were collected and processed for ultrastructural and histopathological analysis. Our results showed edema, endothelium activation characterized by the presence of transport vesicles, free platelets in interstitium, mitochondria presenting rarefied matrix and degenerated cristae, and disorganization of muscle fibers. These results point not only to BALB/c mice susceptibility to DENV infection, but also to the fact that, although it is not an often reported occurrence, dengue can lead to heart damage. Keywords: dengue; experimental model; reinfection; BALB/c mice.

Composition of fatty acids, tocopherols, tocotrienols and ß-carotene content in oils of seeds of Brazilian Sapindaceae and Meliaceae species.

This study analyzes the lipid composition and the oxidative stability of oils of Sapindaceae and Meliaceae seeds. The oil content ranged from 14.7% (Guarea guidonia) to 30.1% (Allophylus puberulus and Paullinia elegans). Ten fatty acids were identified in seed oils. Guarea guidonia seeds accumulated mainly oleic (44.9%) and linoleic (24.1%) acid, whereas the unusual gondoic and paullinic acids were identified in A. puberulus (15.8%; 8.9%) and P. elegans (14.4%; 44.2%), respectively. The oil of P. elegans had the highest oxidative stability (16.2 h.). Tocopherol predominated in A. puberulus (10.4 mg/100 g) and tocotrienol predominated in G. guidonea and P. elegans (2.6 mg/100 g). The vitamers α-tocopherol, γ-tocopherol, and γ-tocotrienol were found in the studied oils. ß-carotene was predominantly detected in the oil of A. puberulus seeds (22.4 µg/g). Guarea guidonia seed oil has a high potential in food due to richness in essential fatty acids. In turn, A. puberulus and P. elegans oils could be suggested for other industrial purposes (e.g., biodiesel, varnishes, paints, soaps, or oleochemicals) due to their content of long-chain fatty acids.

Severe asthma in obese patients: Improvement of lung function after treatment with omalizumab.

INTRODUCTION: Asthma and obesity have a considerable impact on public health and their prevalence is increasing. Obesity is a known risk factor for asthma and can make it more difficult to control. Omalizumab is recommended in patients with severe allergic persistent asthma. The aim of this study was to assess the impact of omalizumab treatment in obese asthmatic patients with poorly controlled severe persistent asthma. METHODOLOGY: A non-interventional, prospective study was conducted, in an outpatient asthma clinic. All patients with severe asthma who started treatment with omalizumab were included and followed over 12 months. The study population was divided into two groups (obese and non-obese) for statistical analysis (descriptive and comparative analysis). RESULTS: Thirty-two patients (19 obese) were followed. After 12 months of omalizumab treatment, there was a statistically significant improvement in body mass index, number of exacerbations in the previous year, rescue medication, disease control and lung function, in the whole population. At the end of the study obese patients had a significantly better lung function (FEV1) than non-obese. DISCUSSION: As described in the literature, there was a significant reduction in the number of exacerbations in the previous year, rescue medication and better disease control, in the whole population. In relation to lung function, about which published data are inconsistent, treatment with omalizumab significantly improved it in obese patients. CONCLUSION: Our study showed that omalizumab significantly improved asthma control, reduced rescue medication and asthma exacerbations in all the population; and for the first time showed that obese patients achieved significantly improved lung function.

Role of the impulse oscillometry in the evaluation of tracheal stenosis.

INTRODUCTION AND OBJECTIVES: Tracheal stenosis is a rare and challenging disease. Bronchoscopy is the gold standard for diagnosis and assessment but brings inherent risks. Spirometry is commonly used to access obstructions but is not always feasible due to patient related factors. We therefore considered impulse oscillometry (IOS) as a non-invasive method to quantify airway obstruction and its potential use for diagnosis and follow-up of tracheal stenosis. MATERIALS AND METHODS: Patients with confirmed tracheal stenosis were recruited between January 1st, 2015 and December 31st, 2016. Before bronchoscopy, all subjects underwent IOS and spirometry; for patients submitted to interventional bronchoscopy the same techniques were also performed after the procedure. We assessed the correlation between IOS measurements and airway narrowing as well as between IOS and spirometry values. RESULTS: Twenty-one patients were included. Tracheal narrowing was inversely correlated with X5% (r -0.442, p 0.045) and positively correlated with FEV1/PEF (r 0.467, p 0.033). The stenosis length was inversely correlated with PEF and PEF% (r -0.729, p=0.001 and r -0.707, p=0.002, respectively). There was a strong correlation between spirometric and IOS values. We did not find any significant differences between pre- and post-intervention IOS values for patients assessed after interventional bronchoscopy. CONCLUSIONS: Our study showed a weak correlation between X5% and tracheal narrowing making it unclear whether IOS can be used for physiological assessment of patients with tracheal stenosis. Stenosis length correlated with PEF making it a potential predictor of successful surgical approach. The correlation between IOS and spirometric values makes IOS a potential alternative in patients with suspected tracheal stenosis who are not able to perform spirometry. Larger scale studies should clarify the role of IOS in this pathology.

Endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in non-small cell lung carcinoma.

INTRODUCTION: Lung cancer staging has recently evolved to include endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for nodal assessment. AIM: Evaluate the performance and safety of EBUS-TBNA as a key component of a staging algorithm for non-small cell lung carcinoma (NSCLC) and as a single investigation technique for diagnosis and staging of NSCLC. METHODS: Patients undergoing EBUS-TBNA for NSCLC staging at our institution between April 1, 2010 and December 31, 2014 were consecutively included with prospective data collection. EBUS-TBNA was performed under general anesthesia through a rigid scope. RESULTS: A total of 122 patients, 84.4% males, mean age 64.2 years. Histological type: 78 (63.9%) adenocarcinoma, 33 (27.0%) squamous cell carcinoma, 11 (8.9%) undifferentiated/other NSCLC. A total of 435 lymph node stations were punctured. Median number of nodes per patient was 4. EBUS-TBNA nodal staging: 63 (51.6%) N0; 8 (6.5%) N1; 34 (27.9%) N2, and 17 (13.9%) N3. EBUS-TBNA was the primary diagnostic procedure in 27 (22.1%) patients. EBUS-TBNA NSCLC staging had a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate of 83.3, 100, 100, 86.1, and 91.8%, respectively. No complications were attributable to the procedure. CONCLUSION: A comprehensive lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective. Our EBUS-TBNA performance and safety in this particular setting was in line with previously published reports. Additionally, our study showed that, in selected patients, lung cancer diagnosis and staging are achievable with a single endoscopic technique.

Subclinical pulmonary abnormalities in childhood-onset systemic lupus erythematosus patients.

OBJECTIVE: The aims of this study were to analyze the pulmonary function of childhood-onset systemic lupus erythematosus (cSLE) patients and to identify possible correlations between the high-resolution computed chest tomography (HRCT) score, disease activity, disease cumulative damage, and the participants' quality of life. METHODS: Forty cSLE patients, median age: 14.1 years (range: 7.4-17.9), underwent spirometry and plethysmography. Carbon monoxide diffusing capacity (DLCO), HRCT, disease activity, disease cumulative damage, and quality of life were assessed. RESULTS: Pulmonary abnormalities were evident in 19/40 (47.5%) cSLE patients according to spirometry/DLCO. Forced expired volume in one second (FEV1%) was the parameter most affected (30%). The HRCT showed some abnormality in 22/30 patients (73%), which were minimal in 43%. Signs of airway affects were found in 50%. Twelve patients were hospitalized due to cSLE-related pulmonary complications before the study began (median discharge: 2.1 years earlier). Total lung capacity (TLC%), vital capacity (VC%), forced vital capacity (FVC%), and FEV1% were significantly lower in the group with hospitalization compared to the group without hospitalization (p = 0.0025, p = 0.0022, p = 0.0032, and p = 0.0004, respectively). Of note, DLCO was positively correlated with disease duration (r = +0.4; p = 0.01). The HRCT-score was negatively correlated with FEV1/VC (r = -0.63; p = 0.0002), FEV1 (r = -0.54; p = 0.018), FEF25%-75% (r = -0.67; p < 0.0001), and HRCT-score was positively correlated with resistance (r = +0.49; p = 0.0056). CONCLUSIONS: Almost half of patients with cSLE had subclinical pulmonary abnormalities, especially airway abnormalities. The cSLE-related pulmonary complications seem to determine long-term functional damage.

Surgical treatment of bronchiectasis: A review of 20 years of experience.

BACKGROUND: Bronchiectasis is defined as an abnormal and irreversible dilation and distortion of the bronchi, which has numerous causes. Surgical treatment of this disease is usually reserved for focal disease and when the medical treatment is no longer effective. We report our center experience and outcomes in bronchiectasis surgery during the last 20 years. METHODS: Between 1994 and 2014, sixty-nine patients underwent surgical resection for bronchiectasis. Patient demographics, presenting symptoms, indications for surgical treatment, type of lung resection, morbidity and mortality, as well as clinical follow-up and outcomes were analyzed. RESULTS: From the 69 patients included, 31 (44.9%) were male and 38 (55.1%) were female. Surgery was indicated because of unsuccessful medical therapy in 33 patients (47.8%), haemoptysis in 22 patients (31.9%), nondiagnostic lung mass in 9 patients (13.0%) and lung abscess in 5 patients (7.3%). The surgical procedures were lobectomy in 45 (65.2%) patients, pneumonectomy in 10 (14.5%) patients, bilobectomy in 8 (11.6%) patients, lobectomy plus segmentectomy in 3 (4.3%) patients and only segmentectomy in 3 (4.3%) patients. Morbidity rate was 14.5% and there was no perioperative mortality. The follow-up was possible in 60 patients, with an outcome reported as excellent in 44 (73.3%) patients, as improved in 11 (18.3%) and as unchanged in 5 (8.3%). CONCLUSION: Although the number of patients with bronchiectasis referred for surgical treatment has decreased, pulmonary resection still plays a significant role. Surgical resection of localized bronchiectasis is a safe procedure with proven improvement of quality of life for the majority of patients.

Activation of endogenous angiotensin converting enzyme 2 prevents early injuries induced by hyperglycemia in rat retina

Diabetic retinopathy (DR) is a serious complication of diabetes mellitus that may result in blindness. We evaluated the effects of activation of endogenous angiotensin converting enzyme (ACE) 2 on the early stages of DR. Rats were administered an intravenous injection of streptozotocin to induce hyperglycemia. The ACE2 activator 1-[[2-(dimethylamino) ethyl] amino]-4-(hydroxymethyl)-7-[[(4-methylphenyl) sulfonyl] oxy]-9H-xanthone 9 (XNT) was administered by daily gavage. The death of retinal ganglion cells (RGC) was evaluated in histological sections, and retinal ACE2, caspase-3, and vascular endothelial growth factor (VEGF) expressions were analyzed by immunohistochemistry. XNT treatment increased ACE2 expression in retinas of hyperglycemic (HG) rats (control: 13.81±2.71 area%; HG: 14.29±4.30 area%; HG+XNT: 26.87±1.86 area%; P<0.05). Importantly, ACE2 activation significantly increased the RCG number in comparison with HG animals (control: 553.5±14.29; HG: 530.8±10.3 cells; HG+XNT: 575.3±16.5 cells; P<0.05). This effect was accompanied by a reduction in the expression of caspase-3 in RGC of the HG+XNT group when compared with untreated HG rats (control: 18.74±1.59; HG: 38.39±3.39 area%; HG+XNT: 27.83±2.80 area%; P<0.05). Treatment with XNT did not alter the VEGF expression in HG animals (P>0.05). Altogether, these findings indicate that activation of ACE2 reduced the death of retinal ganglion cells by apoptosis in HG rats.

Activation of endogenous angiotensin converting enzyme 2 prevents early injuries induced by hyperglycemia in rat retina.

Diabetic retinopathy (DR) is a serious complication of diabetes mellitus that may result in blindness. We evaluated the effects of activation of endogenous angiotensin converting enzyme (ACE) 2 on the early stages of DR. Rats were administered an intravenous injection of streptozotocin to induce hyperglycemia. The ACE2 activator 1-[[2-(dimethylamino) ethyl] amino]-4-(hydroxymethyl)-7-[[(4-methylphenyl) sulfonyl] oxy]-9H-xanthone 9 (XNT) was administered by daily gavage. The death of retinal ganglion cells (RGC) was evaluated in histological sections, and retinal ACE2, caspase-3, and vascular endothelial growth factor (VEGF) expressions were analyzed by immunohistochemistry. XNT treatment increased ACE2 expression in retinas of hyperglycemic (HG) rats (control: 13.81±2.71 area%; HG: 14.29±4.30 area%; HG+XNT: 26.87±1.86 area%; P<0.05). Importantly, ACE2 activation significantly increased the RCG number in comparison with HG animals (control: 553.5±14.29; HG: 530.8±10.3 cells; HG+XNT: 575.3±16.5 cells; P<0.05). This effect was accompanied by a reduction in the expression of caspase-3 in RGC of the HG+XNT group when compared with untreated HG rats (control: 18.74±1.59; HG: 38.39±3.39 area%; HG+XNT: 27.83±2.80 area%; P<0.05). Treatment with XNT did not alter the VEGF expression in HG animals (P>0.05). Altogether, these findings indicate that activation of ACE2 reduced the death of retinal ganglion cells by apoptosis in HG rats.

Induction of eosinophil apoptosis by hydrogen peroxide promotes the resolution of allergic inflammation.

Eosinophils are effector cells that have an important role in the pathogenesis of allergic disease. Defective removal of these cells likely leads to chronic inflammatory diseases such as asthma. Thus, there is great interest in understanding the mechanisms responsible for the elimination of eosinophils from inflammatory sites. Previous studies have demonstrated a role for certain mediators and molecular pathways responsible for the survival and death of leukocytes at sites of inflammation. Reactive oxygen species have been described as proinflammatory mediators but their role in the resolution phase of inflammation is poorly understood. The aim of this study was to investigate the effect of reactive oxygen species in the resolution of allergic inflammatory responses. An eosinophilic cell line (Eol-1) was treated with hydrogen peroxide and apoptosis was measured. Allergic inflammation was induced in ovalbumin sensitized and challenged mouse models and reactive oxygen species were administered at the peak of inflammatory cell infiltrate. Inflammatory cell numbers, cytokine and chemokine levels, mucus production, inflammatory cell apoptosis and peribronchiolar matrix deposition was quantified in the lungs. Resistance and elastance were measured at baseline and after aerosolized methacholine. Hydrogen peroxide accelerates resolution of airway inflammation by induction of caspase-dependent apoptosis of eosinophils and decrease remodeling, mucus deposition, inflammatory cytokine production and airway hyperreactivity. Moreover, the inhibition of reactive oxygen species production by apocynin or in gp91(phox-/-) mice prolonged the inflammatory response. Hydrogen peroxide induces Eol-1 apoptosis in vitro and enhances the resolution of inflammation and improves lung function in vivo by inducing caspase-dependent apoptosis of eosinophils.

Case report: A novel TET2 mutation in a patient with refractory cytopenia with multilineage dysplasia.

Myelodysplastic syndrome diagnosis of karyotypically normal patients may be elusive because it relies exclusively on morphological and clinical data. In routine practice, finding of an acquired mutation or a cytogenetic abnormality provides irrefutable evidence of the clonal nature of that disease. Recurrent deletions and somatic mutations in TET2, a gene involved in epigenetic regulation, have been reported in about 20% of adult patients with myelodysplastic syndrome. We report a novel g.95805C>T, nonsense TET2 mutation, leading to a premature stop codon (p.Gln913*), in an adult patient with refractory cytopenia with multilineage dysplasia.

Mercury accumulation and metallothionein expression from aquafeeds by Litopenaeus vannamei Boone, 1931 under intensive aquaculture conditions.

This study describes the accumulation of Hg and metallothionein gene expression in Litopenaeus vannamei Boone, 1931 with aquafeeds as the major source of Hg. Trials were conducted under controlled conditions in experimental tank facilities with high (indoor tanks) and low (outdoor tanks) Hg aquafeeds concentrations. Aquafeeds were the sole source of Hg for the shrimps and concentrations varied from 5.4 to 124 ng.g-1 d.w.. In the three animal fractions analysed; muscle (6,3 - 15,9 ng.g-1); hepatopancreas (5,1 - 22,0 ng.g-1) and exoskeleton (3,0 - 16,2 ng.g-1), Hg concentrations were significantly lower in the outdoor trials submitted to Hg-poor aquafeeds. Maximum shrimp muscle Hg concentrations were low (36.4 ng.g-1 w.w.) relative to maximum permissible concentrations for human consumption and Hg content in muscle and hepatopancreas were significantly correlated with Hg content in aquafeeds. Highest Hg concentrations in the exoskeleton of animals exposed to Hg-richer aquafeed, suggested that a detoxification mechanism is taking place. On the other hand the metallothionein suffered no variation in its relative expression in any of the experiments, meaning that the contact with feed containing the observed Hg concentrations were not sufficient to activate gene transcription. It was not possible, under the experimental design used, to infer Hg effects on the biological performance of the animals.

O grupo como estratégia de sobrevivência: configurações vinculares de crianças na favela / The group while surviving strategy the connecting configurations of children in slums

Esta pesquisa buscou compreender, através do método qualitativo - clínico e da observação participante, as configurações vinculares engendradas por crianças que frequentavam a Escola Comunitária e habitavam a Favela do Pirambu, localizada em Fortaleza, no Ceará. O estudo de seus conteúdos foi baseado na teoria grupanalítica e, mais especificamente, nas idéias winnicotianas concernentes a: a) o grupo como espaço potencial e transacional; b) a tendencia anti-social. O grupo escolar e, de forma mais ampla, o corpo social do Pirambu, onde se estabeleceu o Projeto de Saúde Mental Comunitária 4 Varas, afiguram-se como universos que reativaram âmbitos primordiais do 'holding' materno no que se refere à estrutura física e suporte afetivo. Colegas, professoras e comunitários pareceram ter instigado transicionalidade num espaço que se transmutou em lúdico e terapêutico ao propiciar criação e reciprocidade. Observei que o grupo reconstruiu afetos e preservou para se mesmo uma grata possibilidade humana de restruturação.(AU)

The research seeked to understand, through clinic, qualitative method and participant observation, the link configurations engendered by children, who attended the Communitarian School, and who lived in the slum of Pirambu, located in Fortaleza, Ceará. The study of its contents was based on groupanalysis and more specifically, winncott's ideas concerning to: a) the group as transicional and potential space; and b) the objection-social tendency. The scholar group and the bigger social body of Pirambu, where the Project of Mental Health four sticks were established, shaped, as universes that reactivated primordial ambits of motherly holoding, related to the physics structure and affective support again. Friends, teachers and communitarians apperead to have instigating transition in the space that transformed itself in joyful and therapeutic because it propitates creation and reciprocality. I observed the group reconstructed affections and preservd for itself a grateful human possibility of new restructure.(AU)

O grupo como estratégia de sobrevivência: configurações vinculares de crianças na favela / The group while surviving strategy the connecting configurations of children in slums

Esta pesquisa buscou compreender, através do método qualitativo - clínico e da observação participante, as configurações vinculares engendradas por crianças que frequentavam a Escola Comunitária e habitavam a Favela do Pirambu, localizada em Fortaleza, no Ceará. O estudo de seus conteúdos foi baseado na teoria grupanalítica e, mais especificamente, nas idéias winnicotianas concernentes a: a) o grupo como espaço potencial e transacional; b) a tendencia anti-social. O grupo escolar e, de forma mais ampla, o corpo social do Pirambu, onde se estabeleceu o Projeto de Saúde Mental Comunitária 4 Varas, afiguram-se como universos que reativaram âmbitos primordiais do 'holding' materno no que se refere à estrutura física e suporte afetivo. Colegas, professoras e comunitários pareceram ter instigado transicionalidade num espaço que se transmutou em lúdico e terapêutico ao propiciar criação e reciprocidade. Observei que o grupo reconstruiu afetos e preservou para se mesmo uma grata possibilidade humana de restruturação.

The research seeked to understand, through clinic, qualitative method and participant observation, the link configurations engendered by children, who attended the Communitarian School, and who lived in the slum of Pirambu, located in Fortaleza, Ceará. The study of its contents was based on groupanalysis and more specifically, winncott's ideas concerning to: a) the group as transicional and potential space; and b) the objection-social tendency. The scholar group and the bigger social body of Pirambu, where the Project of Mental Health four sticks were established, shaped, as universes that reactivated primordial ambits of motherly holoding, related to the physics structure and affective support again. Friends, teachers and communitarians apperead to have instigating transition in the space that transformed itself in joyful and therapeutic because it propitates creation and reciprocality. I observed the group reconstructed affections and preservd for itself a grateful human possibility of new restructure.

Unusual foreign body in the esophagus: a challenge for the anesthesiologist.

A foreign body in the esophagus is usually removed by endoscopy. An elder man entered the emergency room dyspneic and dysphagic. A chest X-ray showed that he had a table fork stuck in the upper esophagus. An endoscopist tried to remove it without success. After bilateral block of the superior laryngeal nerve, transtracheal injection, topical anesthesia of the mouth, and sedation, an awake laryngoscopy was carried out. Pushing the laryngoscope into the opening of the esophagus the fork was seen and extracted by the anesthesiologist. This case focuses on the role of the anesthesiologist in the removal of esophageal foreign bodies.