Effect of Splinting on Orthodontic Mini-Implant Tipping and Bone Histomorphometric Parameters: An In Vivo Animal Model Study.

This study aimed to address the stability of orthodontic mini-implants submitted to an immediate orthodontic functional load, in splinted or unsplinted conditions, further characterizing the histomorphometric parameters of the neighboring bone tissue, in an in vivo experimental model. Mini-implants (1.4 × 6.0 mm) were placed in the proximal tibia of New Zealand White rabbits and immediately loaded with a 150 g force. Tissue healing was characterized within 8 weeks. Microtomography was used to assess the mini-implants' tipping and bone histomorphometric indexes. Loaded implants were evaluated in splinted and unsplinted conditions, with data being compared to that of unloaded mini-implants with the Kruskal-Wallis nonparametric test, followed by Dunn's multiple comparison tests. The splinting of mini-implants submitted to immediate orthodontic loading significantly reduced the tipping to levels similar to those of unloaded mini-implants. Immediate loading further increased the histomorphometric indexes associated with bone formation at the peri-implant region, in both splinted and unsplinted conditions, with no significant differences between the tension and compression regions. Accordingly, within this experimental setting, splinting was found to lessen tipping and mini-implants' displacement, without affecting the increased bone formation at the peri-implant region, induced by a functional orthodontic load.

Lane-Hamilton Syndrome in an Adult With Down Syndrome: A Case Report.

The Lane-Hamilton syndrome (LHS) is an extremely rare association between celiac disease (CD) and idiopathic pulmonary hemosiderosis (IPH), with only a few cases reported in the literature. The authors report a case of a 32-year-old man with Down syndrome who presented to the emergency department with a history of hemoptysis and chronic diarrhea. The complementary investigation revealed iron deficiency anemia and features suggestive of diffuse alveolar hemorrhage on computed tomography (CT) scan of the chest. After excluding all competing diagnosis, the IPH diagnosis was made. The biopsy of the small intestine confirmed CD and the diagnosis of LHS was established. A gluten-free diet and steroids were given to the patient with a very good clinical response. Since there is an established association between IPH and CD, if the diagnosis of IPH is made, it's recommended to screen for CD even in patients without gastrointestinal symptoms.

Upper Extremity Deep Vein Thrombosis as the Tip of the Iceberg: Case Report and Review of Literature.

Unprovoked venous thromboembolism (VTE) may be the earliest manifestation of cancer. According to recent studies, approximately 5% of patients with unprovoked VTE will be diagnosed with cancer within the first year of follow-up. Although screening extensively at the time of VTE diagnosis is attractive for clinicians, current clinical guidance documents suggest only a limited cancer screening strategy. The authors describe a rare case of Krukenberg tumor of the ovary arising from a primary gastric adenocarcinoma whose first sign was an unprovoked venous thrombosis of the upper extremity.

Pleural Mesothelioma: A Rapid Evolution of an Indolent Disease.

Mesothelioma is a rare and insidious neoplasm and is characterized by its highly malignant and aggressive nature. The most common etiology is asbestos exposure, but there are some reports without known asbestos exposure and other factors leading to malignant pleural mesothelioma (MPM). Here, we present the case of a 58-year-old woman with pleuritic chest pain, dyspnea, and fever on presentation to the emergency department (ED), which caused several admissions to the ED in 20 days. The patient was then admitted to the internal medicine department with a diagnosis of community-acquired pneumonia with parapneumonic effusion. During hospitalization, a positron emission tomography (PET) scan, thoracic computed tomography (CT), and pleural biopsy were performed and a final diagnosis of malignant epithelioid pleural mesothelioma was made. Six weeks after the onset of symptoms, the patient presented with an exponential disease progression, dying two months after the diagnosis, despite the initiation of chemotherapy. MPM remains a diagnostic and therapeutic challenge with a very poor prognosis. However, studies show that mesothelioma patients who undergo treatment live at least twice as long as patients who do not receive treatment. This case report is particularly significant because, although it was epithelioid mesothelioma, multiple solid masses were noted on CT and the patient exhibited rapid disease progression, dying a few weeks after starting treatment.

Not a stroke? A Pituitary Macroadenoma with an unusual presentation / ¿No es una trombosis cerebral? Un macroadenoma hipofisario con una presentación inusua

We present the case of a 66 year-old male, no medical history, presenting with facial palsy, dysphagia and right hemiparesis and hemihypostesia.Neurological examination also showed left eye ptosis. Stroke was first suspected. In head-CT and angio-CT scans image compatible with macroadenoma are seen. These kind of neurological defficits are not usual with theses lesions which present with headache and visual disturbances.Stroke diagnosis and treatment should be prompt. This shoudl’t however mislead us to be precipitous and ignore differencial diagnosis. Pituitarymacroadenomas usually present with headaches and visual disturbances but this is not always the case as this report shows us. (AU)

Fahr’s Syndrome – A Case Report / Síndrome de Fahr: un caso clínico

Fahr’s syndrome is an uncommon neurodegenerative disorder, characterized by bilateral and extensive deposition of calcium in the basal ganglia.We present the case of a 66-year-old female presented to the Emergency Department with (a sudden and) intense holocranial headache accompanied by nausea. She also reported paresthesias of the hands and feet with several years of evolution, mnesic changes and periods of uninhibited behavior. Head CT revealed extensive and bilateral calcifications of the basal ganglia, cerebellum and frontal region and the analytical findings showed a severe hypocalcemia. She begun replacement with intravenous and oral calcium. An improvement of signs and symptoms were observed during the hospitalization.Although rare, Fahr’s syndrome must be kept in mind and appropriate treatment should be aplied in order to stop it’s progression and improve the clinic symptoms and signs. (AU)

Non-HIV Associated Kaposi’s Sarcoma: A case report / Sarcoma de Kaposi no asociado a VIH: un caso clínico

Kaposi sarcoma (KS), first described in 1872, is an angioproliferative neoplasm that often presents with red-purple macules in the skin. This report is of a case ofclassic/iatrogenic form of KS in a 79-year-old male, that had a prolonged hospitalization due to surgical complications. After discharge, he presented a red-purple macule. A biopsy was made and KS was confirmed. He was HIV negative. The patient did not require any other treatment asides from the total removal of thelesion. Kaposi’s sarcoma is an uncommon disease, still very associated with HIV. This case demonstrates the importance of recognition of KS in non-HIV patients.There are four types of Kaposi’s sarcoma and the importance of its recognition in non-HIV patients. (AU)

Systemic Bacillus Calmette-Guérin (BCG) Infection With Renal Involvement: A Rare Complication of BCG Immunotherapy.

Intravesical instillation of bacillus Calmette-Guérin (BCG) is the adjuvant therapy for superficial urothelial carcinoma of the bladder with the lowest recurrence rates and is well tolerated with minor and self-limiting adverse effects. Serious complications, such as systemic BCG infection, are uncommon as the diagnosis is difficult and, in the majority of cases, Mycobacterium bovis cannot be isolated. We describe a case of a man who presented with prolonged fever associated with polyuria, dysuria, anorexia, and significant weight loss, refractory to several courses of appropriate antibiotic therapy. After an exhaustive investigation, the underlying diagnosis of systemic BCG infection with renal involvement was considered. Antituberculosis treatment resulted in a marked clinical and radiological recovery, supporting this diagnosis.

Primary Biliary Cholangitis Overlap With Autoimmune Hepatitis? A Case Report.

Primary biliary cholangitis (PBC) is a chronic, autoimmune cholestatic disease, characterized by inflammation of the small and medium-sized bile ducts, which can lead to cirrhosis. Two to nineteen percent of patients with PBC have been reported to have features that overlap with autoimmune hepatitis (AIH). We report a case of a 39-year-old man with changes in liver biochemistry, with 6 years of asymptomatic evolution, whose diagnostic investigation determined the diagnosis of PBC, however with some features of AIH.

Kluver-Bucy Syndrome: A Rare Complication of Herpes Simplex Encephalitis.

Kluver-Bucy syndrome (KBS) is a characterized by a group of cognitive dysfunctions that include hypersexuality, placidity, hyperorality, memory deficits and hypermetamorphosis. This syndrome is often seen in pathological states that destroy the temporal lobes, normally bilaterally. Herpes simplex encephalitis (HSE) is one of the causes of KBS, as the herpes virus can cause dysfunction/destruction of the temporal lobes. KBS is a very rare syndrome, with just a few cases described in the literature. We present the case of a 21-year-old-man who was diagnosis with KBS after HSE. LEARNING POINTS: Kluver-Bucy syndrome (KBS) should be kept in mind in patients with visual agnosia, hypermetamorphosis, memory disturbances, hypersexuality and placidity.Neurological causes of KBS should be treated quickly.Treatment of KBS is still very challenging.

A Rare Case of Second-degree Atrioventricular Block and Takotsubo Syndrome.

BACKGROUND: Takotsubo cardiomyopathy is characterized by transient left systolic dysfunction that can mimic acute myocardial infarction. Atrioventricular (AV) block associated with Takotsubo is rare, but a few cases have been reported in recent years. METHODS: We present the case of a 77-year-old woman presenting with second-degree AV and Takotsubo syndrome. RESULTS: The diagnosis of Takotsubo syndrome was based on echocardiogram changes and the absence of coronary artery obstruction on coronary angiography. CONCLUSIONS: We describe a patient with a diagnosis of Takotsubo syndrome and AV conduction defect. These conditions rarely occur simultaneous, but when they do, a dilemma arises regarding pacemaker implantation. LEARNING POINTS: Takotsubo syndrome is a rare disorder that can mimic acute myocardial infarction.Takotsubo syndrome normally resolves by itself, but the associated arrhythmias may need treatment and pacemaker implantation.The timing of pacemaker implantation has to be evaluated on a case-by-case basis.

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity.

INTRODUCTION: Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon. METHODS: Two cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses. RESULTS: In the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions. CONCLUSION: In the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.

Fístula arteriovenosa para hemodiálise: da pré-construção à primeira punção: o papel do enfermeiro especialista no follow up / Arteriovenous fistula for hemodialysis: from pre-construction to the first puncture: the role of specialist nurses in follow-up

Este documento permitirá o leitor acompanhar o mestrando no seu percurso académico relativo aos ensinos clínicos, nas diferentes unidades de saúde da especialidade Nefrológica. Serão descritas as atividades relacionadas à aquisição e desenvolvimento de competências comuns e específicas do enfermeiro especialista contempladas pela Ordem dos Enfermeiros, (2010; 2011) e as que são definidas pela European Dialysis & Transplant Nurses Association/European Renal Care Association ­ EDTNA/ERCA (Chamney, 2007). Será redigida uma reflexão sustentada pelos níveis de aquisição de competências do modelo de Dreyfus, aplicado por Benner (2001) à prática de enfermagem. Evidenciando, conforme os descritores de Dublin, uma prática reflexiva, com capacidade de articulação do conhecimento nos vários contextos multidisciplinares e suportada em elementos de investigação. De acordo com o projeto de estágio, elaborado na fase preparatória, este relatório cumprirá o seu objetivo relativamente ao tema em estudo "Da pré-construção à primeira punção: O papel do Enfermeiro Especialista no follow up da fistula arteriovenosa para Hemodiálise", através de uma revisão scoping. Mapeando evidência científica que sustente a importância do follow up, numa consulta de enfermagem de acessos vasculares. Neste sentido, dos artigos selecionados organizamse duas grandes áreas relativas ao papel do enfermeiro, as competências teórico-práticas, e o apoio-educação ao utente durante os diferentes momentos do acesso arteriovenoso. O enfermeiro especialista deve ser capaz de dinamizar na sua unidade de saúde, aspetos formativos que viabilizem a aquisição de competências teórico-práticas, e permitir que estas se desenvolvam ao longo da sua experiência clínica, numa perspetiva contínua de partilha de conhecimentos entre a equipa de enfermagem e o utente. Estes conhecimentos teóricos e competências práticas permitem cuidados de enfermagem direcionados para o utente com fistula arteriovenosa, garantindo assim cuidados qualificados. No respeitante ao apoio-educação ao utente, duas áreas de atenção "vigilância do acesso" e "capacitação do autocuidado", foram identificadas (Sousa, Apóstolo, Figueiredo, Martins & Dias, 2013). A primeira área engloba os cuidados de enfermagem no período pré e pós construção da fístula arteriovenosa. A área "capacitação do autocuidado" engloba 4 dimensões: cuidados antecipatórios na preparação da fístula arteriovenosa; cuidados nas 48 horas após a construção da fístula arteriovenosa; cuidados específicos com o processo de maturação da fístula arteriovenosa e cuidados específicos em programa regular de hemodiálise (Sousa et al 2013). As quatro dimensões referidas, e a Teoria do Défice de Autocuidado de Enfermagem, de Orem (2001), formam deste modo, um suporte orientador para o enfermeiro relativo à conceção e aplicação de um plano de intervenções para a consulta de enfermagem de acessos vasculares, durante os diferentes momentos da fístula arteriovenosa. Através das suas três teorias, a Teoria do Autocuidado, a Teoria do Défice de Autocuidado e a Teoria dos Sistemas de Enfermagem, a sua aplicabilidade neste contexto é manifesta, na medida em que permite diagnosticar o défice de conhecimento relativamente à fistula arteriovenosa, capacitando o utente para dar resposta ao requisito de autocuidado do acesso, através do sistema apoio-educação. Assim, o envolvimento efetivo do utente, desde a pré-construção até à primeira punção do acesso, comprometerá o mesmo à execução do autocuidado, diminuindo a ansiedade (Mollaoglu, Tuncay, Fertelli & Yürügen, 2012) e beneficiando de um processo de coping positivo (Romyn, Rush & Hole, 2015), aquando da primeira punção. É então, importante manter o suporte de apoio-educação ao utente regularmente, uma vez que favorece a intervenção precoce à fístula arteriovenosa, durante o processo de follow up.

This document will allow the reader to accompany the student in her academic path related to clinical teaching, in the different Nephrology health units. The activities related to the acquisition and development of common and specific skills of the specialist nurse are contemplated by the Nurses Order, (2010; 2011) and defined by the European Dialysis & Transplant Nurses Association / European Renal Care Association - EDTNA / ERCA (Chamney, 2007). A reflection based on the levels of skills acquisition of the Dreyfus model, applied by Benner (2001) to nursing practice, will be written, evidencing, according to Dublin's descriptors, a reflexive practice, with the ability to articulate knowledge in the various multidisciplinary contexts and supported by research elements. According to the internship project, prepared in the preparatory phase, this report will fulfill its objective regarding the topic under study "From pre-construction to the first puncture: The role of the Specialist Nurse in the follow up of the arteriovenous fistula for Hemodialysis", through a scoping review. Mapping scientific evidence to support the importance of follow up, in a vascular consultation nursing consultation. In this sense, the selected articles organize two major areas related to the role of the nurse, the theoretical-practical skills, and the support-education to the user during the different moments of the arteriovenous access. The specialist nurse must be able to dynamize, in health unit, training aspects that enable the acquisition of theoretical and practical skills, and allow them to develop throughout his clinical experience, in a continuous perspective of knowledge sharing among the team of nursing and the user. This theoretical knowledge and practical skills allow nursing care directed at the user with arteriovenous fistula, thus guaranteeing qualified care. Regarding user education support, two areas of attention "access surveillance" and "self-care training" were identified (Sousa, Apóstolo, Figueiredo, Martins & Dias, 2013). The first area encompasses nursing care in the pre and post-construction period of arteriovenous fistula. The area "training self-care" encompasses 4 dimensions: anticipatory care in the preparation of arteriovenous fistula; care within 48 hours after the construction of the arteriovenous fistula; specific care with the arteriovenous fistula maturation process and specific care in a regular hemodialysis program (Sousa et al 2013). The four dimensions mentioned, and Orem's Nursing Self-Care Deficit Theory (2001), thus form a guiding support for nurses regarding the design and application of an intervention plan for the vascular access nursing consultation, during the different moments of the arteriovenous fistula. Through its three theories, the Self-Care Theory, the Self-Care Deficit Theory and the Nursing Systems Theory, its applicability in this context is manifested, as it allows the diagnosis of the knowledge deficit in relation to the arteriovenous fistula, enabling to respond to the self-care requirement, through the support-education system. Thus, the effective involvement of the patient, from the pre-construction to the first puncture, will compromise to perform self-care, reducing anxiety (Mollaoglu, Tuncay, Fertelli & Yürügen, 2012) and benefiting from a positive coping process (Romyn, Rush & Hole, 2015), in the first puncture. It is therefore important to maintain support-education support to the patient regularly, since it favors early intervention for arteriovenous fistula, during the follow up process.