Comprehensive assessment of executive functioning following childhood severe traumatic brain injury: clinical utility of the child executive functions battery.

Objectives: To perform a detailed description of executive functioning following moderate-to-severe childhood traumatic brain injury (TBI), and to study demographic and severity factors influencing outcome. Methods: A convenience sample of children/adolescents aged 7-16 years, referred to a rehabilitation department after a TBI (n = 43), was compared to normative data using a newly developed neuropsychological test battery (Child Executive Functions Battery-CEF-B) and the BRIEF. Results: Performance in the TBI group was significantly impaired in most of the CEF-B subtests, with moderate to large effect sizes. Regarding everyday life, patients were significantly impaired in most BRIEF clinical scales, either in parent or in teacher reports. Univariate correlations in the TBI group did not yield significant correlations between the CEF-B and socio-economic status, TBI severity, age at injury, or time since injury. Conclusion: Executive functioning is severely altered following moderate-to-severe childhood TBI and is best assessed using a combination of developmentally appropriate neuropsychological tests and behavioral ratings to provide a comprehensive understanding of children's executive functions.

Hypoparathyroidism and Fahr's syndrome: case series / Hipoparatireoidismo e síndrome de Fahr: série de casos

Abstract Hypoparathyroidism (HP) is a rare metabolic disorder and causes hypocalcemia because parathyroid hormone secretion is inadequate to mobilize calcium from bone and reabsorb calcium from kidney and gut. Anterior neck surgery is the most common cause of acquired HP and autoimmune HP is the next most common form in adults. The duration, severity, and rate of development of hypocalcemia determine the clinical presentation. A variety of organs can be affected by calcification, more frequently kidneys, but also joints, eyes, skin, vasculature, and other organ systems and, although rarely seen, intracerebral calcifications. We report four cases of bilateral basal ganglia calcifications (BGC) also known as Fahr's syndrome related to hypoparathyroidism. Fahr's syndrome is characterized by bilateral symmetrical calcification of areas of the brain that control movements including basal ganglia, thalamus, and others; it is a rare inherited or sporadic neurological disorder with a prevalence of less than 1/1.000.000. Main symptoms related to bilateral BGC include extra-pyramidal and cerebellar disorders, cognitive impairment, epileptic seizures, and psychiatric changes. BGC has been established as a possible outcome of HP. Its prevalence, demonstrated in the HP cohorts, varied significantly from 12 up to 74%. Currently, computed tomography (CT) is the most valuable method for diagnosis. The treatment include symptomatic support and identification of causes, but there is no specific treatment limiting the progression of calcification in the basal ganglia. Especially in HP, an early treatment can prevent calcification and neurophysiological disorders.

Resumo O hipoparatireoidismo (HP) é um distúrbio metabólico raro e causa hipocalcemia, pois a secreção do paratormônio é inadequada para mobilizar o cálcio dos ossos e reabsorver o cálcio dos rins e intestino. A cirurgia cervical anterior é a causa mais comum de HP adquirido. O HP autoimune é a segunda causa mais comum em adultos. A duração, gravidade e taxa de desenvolvimento da hipocalcemia determinam a apresentação clínica. Diversos órgãos podem ser afetados pela calcificação, mais frequentemente os rins, mas também articulações, olhos, pele, vasculatura e outros órgãos e, embora raramente vista, calcificações intracerebrais. Relatamos quatro casos de calcificações dos gânglios da base (CGB) bilaterais, também conhecidas como síndrome de Fahr relacionadas ao hipoparatireoidismo. A síndrome de Fahr é caracterizada pela calcificação bilateral simétrica de áreas do cérebro que controlam os movimentos incluindo os gânglios da base, tálamo e outros; é um distúrbio neurológico raro, hereditário ou esporádico, com uma prevalência 1/1.000.000. Os principais sintomas relacionados à CGB bilateral incluem distúrbios extrapiramidais e cerebelares, comprometimento cognitivo, convulsões e alterações psiquiátricas. A CGB foi estabelecida como uma possível consequência do HP. Sua prevalência, demonstrada nas coortes de HP, variou significativamente de 12 a 74%. Atualmente, a tomografia computadorizada (TC) é o método mais valioso para o diagnóstico. O tratamento inclui suporte sintomático e identificação de causas, mas não há tratamento específico limitando a progressão da calcificação nos gânglios da base. Especialmente no HP, um tratamento precoce pode prevenir calcificações e distúrbios neurofisiológicos.

Development of inhibition and working memory in school-age Moroccan children.

Studies regarding executive functions (EFs) in children rarely focus on populations of North Africa countries. In this context, this research aimed to adapt EFs tests to the Moroccan context and provide preliminary normative data on the development of inhibitory control and working memory (WM). In addition, the executive performance of school-age Moroccan children was examined, as well as the effects of gender, parents' education level and multilingualism. The sample included 115 children at age 7 to 12 from Fes city. Results showed that the translation and adaptation steps were sufficient for the cross-cultural adaptation of the tasks. In addition, an overall effect of age on inhibition and WM performances was found, whereas gender and parents' education level showed non-significant effects. Multilingualism effects had a partial positive influence on EFs, with improved scores on a few executive tasks for multilingual children compared to their bilingual peers. Overall, results suggest that EFs in school-age Moroccan children operate on relatively homogeneous development trajectories, marked by improvements that differ according to tasks. As neuropsychological tools and normative data are still lacking in Morocco, this study helps better understand EFs development of children in this country.

Assessing executive functions in Brazilian children: A critical review of available tools.

The goal of this review is to perform a critical analysis of the instruments used to assess executive functions (EFs) in preschool and school-age children in Brazil. We identified 37 assessment measures through a systematic review. Some performance-based tests for assessing working memory and inhibition were identified. However, there is a lack of rating measures and instruments to assess flexibility and planning in clinical practice. We observed regional differences in the performance of EFs measures. One possible explanation may be the use of normative samples from more highly-developed regions to characterize performance in less-developed regions. However, there may be alternative explanations, such as variations in the exposure to testing and the adequacy of test materials in different regions. Joint efforts among research groups should be encouraged in order to obtain normative references that are more representative of the socio-cultural diversity of the country. This improvement is essential to better understand the typical and atypical development of EFs and how the peculiarities of each country's context and culture can impact its trajectory.

Hypoparathyroidism and Fahr's syndrome: case series.

Hypoparathyroidism (HP) is a rare metabolic disorder and causes hypocalcemia because parathyroid hormone secretion is inadequate to mobilize calcium from bone and reabsorb calcium from kidney and gut. Anterior neck surgery is the most common cause of acquired HP and autoimmune HP is the next most common form in adults. The duration, severity, and rate of development of hypocalcemia determine the clinical presentation. A variety of organs can be affected by calcification, more frequently kidneys, but also joints, eyes, skin, vasculature, and other organ systems and, although rarely seen, intracerebral calcifications. We report four cases of bilateral basal ganglia calcifications (BGC) also known as Fahr's syndrome related to hypoparathyroidism. Fahr's syndrome is characterized by bilateral symmetrical calcification of areas of the brain that control movements including basal ganglia, thalamus, and others; it is a rare inherited or sporadic neurological disorder with a prevalence of less than 1/1.000.000. Main symptoms related to bilateral BGC include extra-pyramidal and cerebellar disorders, cognitive impairment, epileptic seizures, and psychiatric changes. BGC has been established as a possible outcome of HP. Its prevalence, demonstrated in the HP cohorts, varied significantly from 12 up to 74%. Currently, computed tomography (CT) is the most valuable method for diagnosis. The treatment include symptomatic support and identification of causes, but there is no specific treatment limiting the progression of calcification in the basal ganglia. Especially in HP, an early treatment can prevent calcification and neurophysiological disorders.

Age-related changes of cognitive flexibility and planning skills in school-age Moroccan children.

North African countries such as Morocco are scarcely the focus of neuropsychological studies, although the role of culture in cognition processes is widely recognized. Currently, studies on flexibility and planning skills in the Moroccan context are still lacking and there are no adapted tools to assess these functions in the country. In this scenario, this study aimed to adapt the Child Executive Functions Battery (CEF-B) tasks and the playing cards task of the Behavioral Assessment of the Dysexecutive Syndrome for Children (BADS-C) to Morocco and provide preliminary normative data on the development of flexibility and planning. In addition, this study proposed to examine the effects of gender, parents' education level and multilingualism on executive development. To this end, six tasks of the CEF-B were adapted through a translation and back-translation process and administered to 115 children aged 7-12 years. Results showed that the adopted procedure was sufficient for the cross-cultural adaptation of the tasks. Analyses showed a continuous increase with age on executive performance in most of the variables. However, gender and parents' level of education showed mostly non-significant effects. On the other hand, a significant effect of multilingualism was found on the two analyzed functions, with better results for multilingual children if compared to their bilingual peers. In general, results suggest that the identified pattern of development is consistent with international studies. Although normative data on executive functions are still lacking in Morocco, this unprecedented study will help better understand their development in this context.

Development of executive functions in Lebanese children.

The current study focused on adapting EF tests for children to the Arabic language and examine the developmental trajectories of a sample of school-aged Lebanese children in four domains of EF (inhibition, flexibility, working memory, and planning). It also focused on examining the effects of gender and parental education level on EF performance. The study population included 100 Lebanese children aged from 6 to 12-years old who were grouped and comparable for age, gender, and parental level of education. Results revealed a main effect of age and level of education of parents while the effect of gender was non-significant.

Pieces of evidences of reliability of the Brazilian version of the Child Executive Functions Battery (CEF-B).

Executive dysfunctions are central symptoms in different neurological, developmental, and context-related conditions. The assessment of these functions is then essential in neuropsychological pediatric clinical practice. Given the need for reliable and valid evaluation batteries for clinical practice in Brazil, this study aimed to present the pieces of evidences of reliability of the Child Executive Functions Battery (CEF-B). A total of 230 Brazilian children with typical development aged between 7 and 12 years participated in the study. Internal consistency was determined by the split-half method, Cronbach's α, and Ω. In addition, measurements of test-retest reliability and intraclass coefficient were also performed. Retest indicators were mostly weak and moderate (between .43 and .75). Overvall, coefficients show a satisfactory internal consistency reliability for planning and inhibition measures (between .72 and .92). Considering the measures of WM, results were also satisfactory for both α and Ω indexes. This study revealed that the CEF-B has satisfactory internal consistency reliability coefficients. However, several tests have shown low reliability assessed through the test-retest method. In general, findings reveal interesting pieces of initial evidence of reliability of the Brazilian version. The methodological approach could be improved in future studies by including children with executive disorders.

Telemedicine in long-term elderly care facilities as "social accountability" in the context of Covid-19 / Telemedicina nas instituições de longa permanência para idosos como social accountability no contexto da Covid-19

Abstract: Introduction: The World Health Organization defined the compulsory need to redirect all educational, research and public health service activities of medical schools to meet all priority health needs, attributing to them this social responsibility role. Due to the emergency situation in the public health system caused by the COVID-19 pandemic, as a measure of social accountability, remote medical care services and online education were adopted in order to continue following the curricular program and to provide assistance to local city governments. Experience report: Two months before graduation, medical students followed-up on the monitoring of residents and COVID-19 healthcare professionals of forty-three ILPIs (Long-Term Elderly Care Facilities) in the city of Sao Jose do Rio Preto, state of Sao Paulo, Brazil. The medical students made daily telephone calls to all these ILPI units, requesting information, generally from the head nurses and owners, about the main COVID-19 symptoms that were detected in the residents and employees of these facilities. All the collected information was discussed daily with the teacher in charge of mentoring the program, fed into an online database and into a work schedule chart, then relayed to the local Municipal Health Secretariat. A COVID-19 contingency plan was devised by the team, authorized by the Local Health Secretariat and then presented to the ILPIs, aiming to offer them the best guidance throughout the pandemic. Discussion: the COVID-19 pandemic revealed the Health Education System's fragilities, limitations and capacity to adapt to this crisis, thus largely contributing to improving the training of new medical doctors. During the program, medical students faced many challenges, especially regarding the difficulty to contact some ILPIs by telephone, omitted or erroneous information provided by employees in these facilities and delays in reporting suspected cases. In spite of this scenario, daily contact with these facilities allowed the team to identify the ILPIs that were more adequately prepared and the ones that needed auditing and further supervision. Also, this daily contact established a bond between the team and the ILPIs. Conclusion: During the pandemic, it was possible to perform actions according to the logic of social accountability, demonstrating that remote online medical practice is a tool capable of both maintaining interns in contact with the practical aspects of medical care and providing medical assistance to the community and to the local government.

Resumo: Introdução: A Organização Mundial da Saúde definiu a obrigatoriedade do direcionamento das atividades de educação, pesquisa e serviços para atender às preocupações prioritárias de saúde como responsabilidade social das escolas médicas. Considerando a emergência em saúde pública em decorrência da Covid-19, decidiu-se utilizar a telemedicina e implementar o ensino remoto para continuar a programação curricular e prestar apoio à gestão municipal a partir do pressuposto da social accountability. Relato de experiência: A dois meses do fim da graduação, discentes de Medicina acompanharam as 43 instituições de longa permanência para idosos (Ilpis) - públicas e privadas - do município de São José do Rio Preto com o intuito de monitorar residentes e funcionários em relação à Covid-19. Por meio de ligações diárias para as Ilpis, eles solicitaram ao representante de cada unidade, geralmente enfermeiro responsável, ou ao proprietário do estabelecimento informações sobre os principais sintomas da Covid-19 detectados nos moradores e funcionários das instituições. Cotidianamente, essas informações eram registradas numa plataforma on-line, na planilha de organização do trabalho, e depois relatadas para a Secretaria Municipal de Saúde (SMS) e discutidas com o professor responsável pela mentoria. Um plano de contingência para a Covid-19 foi elaborado pela equipe, autorizado pela SMS e repassado às Ilpis, para orientá-las durante a pandemia. Discussão: A Covid-19 apontou as fragilidades, as limitações e a capacidade de adaptação do sistema educacional de saúde, o que possibilitou o aprimoramento da formação dos novos médicos. Durante o monitoramento, os discentes encontraram diversos desafios: dificuldade no contato telefônico com algumas Ilpis, informações omitidas ou fornecidas de forma equivocada pelos funcionários e atrasos na comunicação de casos suspeitos. Contudo, o contato diário permitiu reconhecer as Ilpis que se apresentavam mais adequadas e as que necessitavam de investigação e orientação, criando vínculo com as Ilpis. Conclusão: Durante a pandemia, foi possível realizar ações na lógica da social accountability, evidenciando que o teleatendimento é uma ferramenta que, ao mesmo tempo que mantém os internos nos cenários de práticas, presta assistência à comunidade e à gestão municipal durante a pandemia.

Developmental dyslexia and executive functions: evidence on main evaluation methods / Dislexia do desenvolvimento e funções executivas: evidências sobre os principais métodos de avaliação / Dislexia del desarrollo y funciones ejecutivas: evidencias sobre los principales métodos de evaluación

In recent years, a growing number of studies have been associating Developmental dyslexia (DD) with alterations in executive functions (EF). However, the literature still hasn't reached a consensus on this subject. This study objective was to carry out a systematic literature review of the most explored functions and neuropsychological instruments for the assessment of EF on children and teenagers with DD, between the years of 2007 and 2017. Seventy-one different instruments for the assessment of EF in individuals with DD were mapped. The most used tests were the Digit Span Task, the Stroop Test and the Tower of London. The most studied EF was working memory. It was concluded that the recent interest in this research field, the wide variety of instruments employed and of EF models adopted hamper the establishment of a consensus on the influence of the diverse aspects of EF on DD.

Nos últimos anos, crescente número de estudos tem associado à Dislexia do Desenvolvimento (DD) a alterações em funções executivas (FE). No entanto, a literatura ainda não apresenta consenso quanto a esta questão. Este estudo teve como objetivo realizar revisão sistemática da literatura, investigando os instrumentos e as funções neuropsicológicas mais exploradas para avaliar as FE em crianças e adolescentes com DD, entre os anos de 2007 e 2017. Foram mapeados 71 instrumentos para avaliar FE em indivíduos com DD. Os testes mais utilizados foram o Digit Span Task, o Stroop Test e o Tower of London. A FE mais estudada foi a memória de trabalho. Conclui-se que o recente interesse neste campo de pesquisa, a grande variedade de instrumentos empregados e de modelos de FE adotados dificulta o estabelecimento de um consenso sobre a influência dos diversos aspectos das FE na DD.

En los últimos años, un creciente número de estudios asocian la dislexia del desarrollo (DD) a alteraciones en las funciones ejecutivas (FE). Sin embargo, la literatura aún no ha llegado a un consenso sobre este tema. El objetivo de este estudio fue realizar una revisión sistemática de la literatura de las funciones más exploradas y los instrumentos neuropsicológicos más utilizados para la evaluación de las FE en niños y adolescentes con DD, entre los años de 2007 y 2017. Fueron mapeados 71 instrumentos diferentes para la evaluación de EF en individuos con DD. Las pruebas más utilizadas fueron la Tarea de Digit Span, la Prueba de Stroop y la Torre de Londres. La FE más estudiada fue la memoria de trabajo. Se concluyó que el reciente interés en este campo de investigación, la gran variedad de instrumentos empleados y de modelos de FE adoptados dificultan el establecimiento de un consenso sobre la influencia de los diversos aspectos de las EF en la DD.

Developmental Profile of Executive Functioning in School-Age Children From Northeast Brazil.

The development of executive functions (EF) is recognizably correlated to culture, contextual and social factors. However, studies considering all the basic EF are still scarce in Brazil, most notably in the Northeast region, which is known for its social inequality and economic gap. This study aimed to analyze the developmental trajectories and structure of four EF, namely inhibition, flexibility, working memory and planning. In addition, the potential effects of socioeconomic status (SES) and gender were examined. The sample included 230 Brazilian children between 7-12 years old, homogeneously distributed by age, gender and type of school. The EF were assessed through the Brazilian version of the Child Executive Functions Battery (CEF-B). A global effect of age was found for most of the EF measures evaluated. Gender effect was mostly non-significant, except for 4 of the 12 tasks. There was a significant SES effect on 8 tasks, all in favor of private school children. Exploratory factorial and correlation analysis showed a 4-factor EF structure, corroborating the theoretical distribution considered in the CEF-B. A developmental progression is evident in the results for all of the EF measures evaluated. While gender had little influence on EF, SES seems to significantly impact the development of EF. As normative data are still lacking in Northeast Brazil, this study may help to understand EF development trajectories and provide tools for neuropsychological evaluation.

Dialogia e insight: narrativas de pais e filhos sobre o transtorno de asperger / Dialogismo y insigth: narrativas de padres y hijos sobre el trastorno de asperger / Dialogism and insight: parents and children narratives about asperger disorder

Resumo O presente estudo objetivou investigar os processos de insight em sujeitos com Transtorno de Asperger (TA). Entende-se por insight o conhecimento do próprio diagnóstico e os sentidos construídos a partir deste. O desenvolvimento doinsight é aqui compreendido não como função restrita à vida mental pessoal, mas como fenômeno intersubjetivo, forjado nas relações sociais. O arcabouço teórico que subsidia a presente pesquisa é a perspectiva genética de desenvolvimento avançada pela psicologia histórico-cultural. Para tanto, foram propostas a três díades de pais e adolescentes diagnosticados com TA duas tarefas de produção narrativa que investigaram aspectos relacionados às experiências Asperger. Os resultados sugerem que a característica central dos processos de insight no TA pode ser descrita como disrupção na transição do modo monológico para o modo dialógico de pensamento. Acredita-se que os resultados aqui encontrados contribuem para a compreensão da singularidade e eventicidade da existência e da experiência subjetiva.

Resumen El presente estudio tuvo como objetivo investigar los procesos de insight en sujetos con trastorno de Asperger (TA). Insight significa el conocimiento del diagnóstico mismo y los significados construidos a partir de él. El desarrollo del insight se entiende aquí no como una función restringida a la vida mental personal, sino como un fenómeno intersubjetivo, forjado en las relaciones sociales. El marco teórico que sustenta esta investigación es la perspectiva genética del desarrollo que adelanta la psicología histórico-cultural. Para ello, a tres díadas de padres y adolescentes diagnosticados de TA se les ofrecieron dos tareas de producción narrativa que investigaban aspectos relacionados con las experiencias de Asperger. Los resultados sugieren que la característica central de los procesos de insight en TA puede describirse como una interrupción en la transición del modo de pensamiento monológico al dialógico. Se cree que los resultados encontrados aquí contribuyen a la comprensión de la singularidad y la eventualidad de la existencia y la experiencia subjetiva.

Abstract The present article aimed to investigate insight processes in people with Asperger disorder. Insight is understood as the knowledge of one's own diagnosis and the senses built from it. The insight development is understood here not as a function of personal psychological life, but as an intersubjective phenomenon, forged in social relations. The theoretical framework that subsidizes this research is the genetic perspective of development advanced by cultural-historical psychology. For this purpose, two tasks of narrative production were proposed to three dyads of parents and teenagers with AD, which investigated aspects related to Asperger experiences. The results suggest that the central characteristic of insight processes in AD can be described as a disruption in the transition of a thinking monologic mode to a thinking dialogic mode. It is believed that the results here found contribute to the comprehension of singularity and occurrence of subjective experience and existence.

Cross-cultural adaptation of the Childhood Executive Functions Battery (CEF-B) to brazilian portuguese / Adaptação Transcultural do Protocolo FEC - funções executivas em crianças para o português brasileiro / Adaptación Transcultural del Protocolo FEN - funciones ejecutivas en niños para el portugués brasileño

This study aimed to describe the processes of translation and cross-cultural adaptation to Brazilian Portuguese of the Childhood Executive Functions Battery (CEF-B), designed to evaluate executive functions in children and adolescents from 6 to 16 years of age. Six steps were carried out to ensure the quality of the processes: 1) instrument translation into the new language; 2) synthesis of the translated versions; 3) evaluation of the synthesized version by experts; 4) evaluation by the target population; 5) back-translation and 6) pilot study. We sought to ensure the translation and adaptation properties of the CEF-B in terms of semantic, idiomatic, experiential and cultural equivalence between the instructions in the original language and the target language. Results showed preliminary evidence of cultural adequacy and a satisfactory comprehension of the instrument instructions by the target population. (AU)

Este estudo objetiva descrever os procedimentos de tradução e adaptação transcultural para o português brasileiro do Protocolo Funções Executivas em Crianças (FEC), voltado para a avaliação das funções executivas de crianças e adolescentes de 6 a 16 anos. Para garantir a qualidade do processo, foram realizadas seis etapas: 1) tradução do instrumento do idioma de origem para o idioma-alvo; 2) síntese das versões traduzidas; 3) avaliação por experts; 4) avaliação pelo público-alvo; 5) tradução reversa e 6) estudo piloto. Buscou-se assegurar as propriedades da tradução e adaptação do protocolo FEC, em termos de equivalência semântica, idiomática, experiencial e cultural entre as instruções no idioma original e no idioma-alvo. Os resultados apontaram evidências iniciais de adequação cultural e boa compreensão das instruções do instrumento pelo público-alvo. (AU)

Este estudio objetiva describir los procedimientos de traducción y adaptación transcultural del protocolo Funciones Ejecutivas en Niños (FEN) para el portugués brasileño, dirigido a la evaluación de las funciones ejecutivas de los niños y adolescentes de 6 a 16 años. Para garantizar la calidad del proceso, se realizaron 6 etapas: 1) traducción del instrumento del idioma de origen al idioma de destino; 2) síntesis de las versiones traducidas; 3) evaluación por expertos; 4) evaluación por el público objetivo; 5) traducción inversa y 6) estudio piloto. Se buscó garantizar las propiedades de la traducción y adaptación del protocolo FEN, en términos de equivalencia semántica, idiomática, experiencial y cultural entre las instrucciones en el idioma original y en el idioma de destino. Los resultados apuntaron evidencias iniciales de adecuación cultural y buena comprensión de las instrucciones del instrumento por el público objetivo. (AU)

Renal histological findings in a patient with acute renal injury associated with purpura fulminans: a case report / Achados histológicos renais em paciente com injúria renal aguda associada à purpura fulminans: relato de caso

ABSTRACT Introduction: Purpura fulminans (PF) is a rapid progressive thrombotic disease in which hemorrhagic infarction of the skin and disseminated intravascular coagulation (DIC) occurs. It can potentially cause acute kidney injury (AKI). However, there is no description in the medical literature of renal histological findings of PF. Case report: A 20-year-old female patient, previously healthy, was admitted to the emergency department (ED) with odynophagia, fever, generalized myalgia and anuria, which evolved with the appearance of purpuric plaques on the face and limbs. She required dialysis on admission. Laboratorial tests showed anemia, leukocytosis, thrombocytopenia, and elevation of lactic dehydrogenase (LDH). The purpuric lesions became bullous with ruptures and then necrotic and erosive, reaching the dermis, subcutaneous tissue and musculature, until bone exposure. There was no improvement with initial antibiotic therapy aimed at the treatment of meningococcemia. Thrombotic microangiopathy (TMA) and PF were then suspected. The patient remained in daily dialysis, requiring plasmapheresis. After sustained improvement of the thrombocytopenia, she underwent renal biopsy, which was not compatible with TMA, characterizing possible PF. A complete recovery of the renal function was achieved and cutaneous sequels were treated with grafts. Conclusion: When thrombotic and hemorrhagic phenomena overlap, obtaining a renal biopsy can be difficult. However, in the presented case, the biopsy allowed the exclusion of AKI caused by TMA, presenting for the first time, histological findings compatible with PF.

RESUMO Introdução: Purpura Fulminans (PF) é uma doença trombótica de rápida progressão, com infarto hemorrágico da pele e coagulação intravascular disseminada (CIVD). É potencialmente causadora de injúria renal aguda (IRA). Porém, não há descrição na literatura médica dos achados histológicos renais causados por PF. Relato de caso: Mulher, 20 anos, previamente hígida, hospitalizada por odinofagia, febre, mialgia generalizada e anúria, evoluiu com aparecimento de placas purpúricas em face e membros. Necessitou de hemodiálise (HD) já na admissão. Exames laboratoriais mostravam anemia, leucocitose, plaquetopenia e elevação de desidrogenase lática. As lesões purpúricas tornaram-se bolhosas com rompimento e progressão para necrose, se aprofundaram, atingindo derme, subcutâneo e musculatura, até a exposição óssea. Não houve melhora com antibioticoterapia inicial voltada para tratamento de meningococemia. Suspeitou-se, então, de microangiopatia trombótica (MAT) e PF. A paciente permaneceu em HD diária e necessitou também de plasmaférese, após melhora sustentada da plaquetopenia, foi submetida à biópsia renal, que não foi compatível com MAT, possivelmente caracterizando PF. Houve recuperação completa da função renal e as sequelas cutâneas foram tratadas com enxerto. Conclusão: Em casos nos quais os fenômenos trombóticos e hemorrágicos se sobrepõem, a obtenção da biópsia renal se torna difícil. Neste caso, a biópsia permitiu excluir IRA causada por MAT e mostrar, pela primeira vez, achados compatíveis com PF.

Renal histological findings in a patient with acute renal injury associated with purpura fulminans: a case report.

INTRODUCTION: Purpura fulminans (PF) is a rapid progressive thrombotic disease in which hemorrhagic infarction of the skin and disseminated intravascular coagulation (DIC) occurs. It can potentially cause acute kidney injury (AKI). However, there is no description in the medical literature of renal histological findings of PF. CASE REPORT: A 20-year-old female patient, previously healthy, was admitted to the emergency department (ED) with odynophagia, fever, generalized myalgia and anuria, which evolved with the appearance of purpuric plaques on the face and limbs. She required dialysis on admission. Laboratorial tests showed anemia, leukocytosis, thrombocytopenia, and elevation of lactic dehydrogenase (LDH). The purpuric lesions became bullous with ruptures and then necrotic and erosive, reaching the dermis, subcutaneous tissue and musculature, until bone exposure. There was no improvement with initial antibiotic therapy aimed at the treatment of meningococcemia. Thrombotic microangiopathy (TMA) and PF were then suspected. The patient remained in daily dialysis, requiring plasmapheresis. After sustained improvement of the thrombocytopenia, she underwent renal biopsy, which was not compatible with TMA, characterizing possible PF. A complete recovery of the renal function was achieved and cutaneous sequels were treated with grafts. CONCLUSION: When thrombotic and hemorrhagic phenomena overlap, obtaining a renal biopsy can be difficult. However, in the presented case, the biopsy allowed the exclusion of AKI caused by TMA, presenting for the first time, histological findings compatible with PF.

Reversal of uremic tumoral calcinosis by optimization of clinical treatment of bone and mineral metabolism disorder.

Tumoral calcinosis is an uncommon type of extraosseous calcification characterized by large rubbery or cystic masses containing calcium-phosphate deposits. The condition prevails in the periarticular tissue with preservation of osteoarticular structures. Elevated calcium-phosphorus products and severe secondary hyperparathyroidism are present in most patients with uremic tumoral calcionosis (UTC). Case report of an obese secondary to chronic glomerulonephritis, undergoing continuous ambulatory peritoneal dialysis (CAPD) reported the appearance of painless tumors in the medial surface of fifth finger and left arm. Tumoral calcinosis was confirmed by left biceps biopsy. Poor adherence to CAPD. The patient was transferred to the "tidal" modality of peritoneal dialysis and after was treated by hemodialysis, despite the persistence of severe hyperparathyroidism progressive reduction of UTC until near to its complete disappearance. Nowadays, one year after patient received deceased-donor kidney transplantation, he presents with an improvement in secondary hyperparathyroidism. UTC should be included in the elucidation of periarticular calcification of every patient on dialysis. Relevant laboratory findings such as secondary hyperparathyroidism and elevated calcium- phosphorus products in the presence of periarticular calcification should draw attention to the diagnosis of UTC.

Reversal of uremic tumoral calcinosis by optimization of clinical treatment of bone and mineral metabolism disorder / Reversão da calcinose tumoral urêmica pela otimização do tratamento clínico da desordem do metabolismo ósseo e mineral

Abstract Tumoral calcinosis is an uncommon type of extraosseous calcification characterized by large rubbery or cystic masses containing calcium-phosphate deposits. The condition prevails in the periarticular tissue with preservation of osteoarticular structures. Elevated calcium-phosphorus products and severe secondary hyperparathyroidism are present in most patients with uremic tumoral calcionosis (UTC). Case report of an obese secondary to chronic glomerulonephritis, undergoing continuous ambulatory peritoneal dialysis (CAPD) reported the appearance of painless tumors in the medial surface of fifth finger and left arm. Tumoral calcinosis was confirmed by left biceps biopsy. Poor adherence to CAPD. The patient was transferred to the "tidal" modality of peritoneal dialysis and after was treated by hemodialysis, despite the persistence of severe hyperparathyroidism progressive reduction of UTC until near to its complete disappearance. Nowadays, one year after patient received deceased-donor kidney transplantation, he presents with an improvement in secondary hyperparathyroidism. UTC should be included in the elucidation of periarticular calcification of every patient on dialysis. Relevant laboratory findings such as secondary hyperparathyroidism and elevated calcium- phosphorus products in the presence of periarticular calcification should draw attention to the diagnosis of UTC.

Resumo A calcinose tumoral é um tipo raro de calcificação extraóssea caracterizada por grandes massas císticas e elásticas contendo depósitos de fosfato de cálcio. A condição é mais prevalente no tecido periarticular e preserva estruturas osteoarticulares. A elevação do produtos cálcio-fósforo e o hiperparatireoidismo secundário grave estão presentes na maioria dos pacientes com calcinose tumoral urêmica (UTC). O relato de caso em questão refere-se a um homem de 22 anos, branco, obeso, com doença renal crônica secundária à glomerulonefrite crônica, em diálise peritoneal ambulatorial contínua (CAPD), que apresentou aparecimento de tumores indolores na face medial do quinto quirodáctilio e braço esquerdo. A calcinose tumoral foi confirmada por biópsia do bíceps esquerdo. O paciente apresentava baixa adesão à CAPD. Foi transferido para a modalidade de diálise peritoneal e depois iniciou tratamento por hemodiálise. Apesar da persistência do hiperparatireoidismo grave, houve redução progressiva da UTC, com resolução próxima do seu desaparecimento completo. Há 1 ano o paciente foi submetido a transplante renal, doador falecido, e apresentou melhora do hiperparatiroidismo secundário. A UTC deve ser incluída na elucidação de calcificação periarticular de pacientes em diálise. Os achados laboratoriais relevantes, tais como hiperparatiroidismo secundário e elevação dos produtos cálcio-fósforo na presença de calcificação periarticular, devem chamar a atenção para o diagnóstico da UTC.

Desempenho intelectual pós tratamento de câncer: um estudo com crianças / Intellectual outcome after cancer treatment: a study with children

Na atualidade cresce a preocupação com a neurotoxicidade do tratamento antineoplásico e o neurodesenvolvimento. O objetivo deste estudo foi comparar o impacto da modalidade de tratamento sobre a capacidade intelectiva de 22 sobreviventes de Tumores de Fossa Posterior e Leucemia Linfóide Aguda com idades entre seis e 14 anos. Participantes com astrocitoma foram submetidos à cirurgia; aqueles com meduloblastoma à cirurgia, à quimioterapia sistêmica e à radioterapia de crânio e neuroeixo (54Gy) e; aqueles com LLA à quimioterapia sistêmica e intratecal. Apenas os participantes com astrocitoma obtiveram desempenho dentro do esperado. Observou-se contrastes estatisticamente significativos entre os grupos, notadamente entre as crianças com meduloblastoma e as demais nos escores não verbais. Sugere-se que a combinação cirurgia, quimioterapia sistêmica e radioterapia potencializou as sequelas cognitivas, e reforça-se a hipótese de que a radioterapia acarreta danos à substância branca. A quimioterapia intratecal associada à sistêmica promoveu impactos significativos sobre o funcionamento executivo.

Concerns about the neurotoxicity of antineoplastic treatment and neurodevelopment are increasing nowadays. The aim of this study was to compare the impact of treatment modality on intellectual functioning of 22 survivors of Posterior Fossa Tumors and Acute Lymphoblastic Leukemia aged from six to 14 years. The astrocytoma group underwent surgery; the medulloblastoma group underwent surgery, systemic chemotherapy, and cranial and neuraxis radiation (54Gy); the LLA group underwent systemic and intrathecal chemotherapy. Only the astrocytoma group obtained average performance. Significant contrasts were obtained between groups, especially among the medulloblastoma group and others in non-verbal scores. Results suggest that the combination of surgery, radiotherapy and systemic chemotherapy increase the cognitive sequelae and enhance the hypothesis that radiation damages white matter. The association between intrathecal and systemic chemotherapy leads to significant impact on executive functioning.

Contribuição do meio midiático para a promoção da saúde cardiovascular / Contribución de los medios de comunicación para promover la salud cardiovascular / Contribution of the media to promote cardiovascular health

Objective: to analyze the contribution of the media for promoting cardiovascular health. Method: case study, qualitative, theoretically based on the method of Paulo Freire for reasoning and data analysis. There search was conducted using as a scenario the "Bem Estar" TV program of “Rede Globo”, in the episodes whose thematic was cardiovascular disease. Results: there was a concern of the program to involve participants in the educational process, ensuring, in a mediated way, their involvement in the educational process. However, there are limitations to the adoption of a model of liberating education as proposed by Paulo Freire. Another finding was the absence of nursing professionals as collaborators. Conclusion: the study allowed the expansion of knowledge about a subject not explored by Nursing, reaffirming the importance of more qualified professionals related to participation in the educational act.

Objetivo: analisar a contribuição do meio midiático para a promoção da saúde cardiovascular. Método: estudo de caso, de caráter qualitativo, tendo como referencial teórico o método de Paulo Freire para fundamentação e análise dos dados. A pesquisa foi desenvolvida utilizando-se como cenário o Programa Bem-Estar, veiculado pela Rede Globo, nos episódios cuja temática era o adoecimento cardiovascular. Resultados: verificou-se a preocupação do programa em envolver os participantes no processo educacional, garantindo, de forma mediada, seu envolvimento no processo educativo. Porém, existem limitações para a adoção de um modelo de educação libertadora como o proposto por Paulo Freire. Outra constatação foi a ausência de profissionais da enfermagem como colaboradores. Conclusão: o estudo permitiu a ampliação do conhecimento acerca de uma temática ainda pouco explorada pela Enfermagem, reafirmando a importância da participação de profissionais mais capacitados quanto ao ato educativo.

Objetivo: analizar la contribución de los medios de comunicación para la promoción de la salud cardiovascular. Método: estudio de caso, basado en teoría de Paulo Freire para el razonamiento y el análisis de dados. La investigación se realizó utilizando como escenario el Programa “Bem Estar” de la Rede Globo, episodios cuyo tema fue la enfermedad cardiovascular. Resultados: hubo una preocupación del programa para involucrar a los participantes en el proceso educativo, asegurando su participación en el proceso educativo. Hay limitaciones a la adopción de un modelo de educación liberadora en la forma propuesta por Paulo Freire. Otro hallazgo fue la ausencia de profesionales de enfermería como colaboradores. Conclusión: el estudio permitió la expansión del conocimiento sobre un tema no explorado por la Enfermería, reafirmando la importancia de los profesionales más cualificados a participar en proceso educativo.

Dor neuropática orofacial associada à instalação de implantes / Neuropathic orofacial pain associated with implant surgery – literature review

Esta revisão de literatura avaliou a relação entre as dores neuropáticas orofaciais e as lesões neuronais associadas à instalação de implantes dentários, tendo como foco os aspectos clínicos, preventivos e suas opções terapêuticas. Material e métodos: uma revisão de literatura foi realizada tendo como referência as bases de dados PubMed e SciELO. Apenas estudos clínicos publicados entre os anos de 1993 e 2013 foram analisados. Resultados: as ferramentas de busca permitiram a seleção de 18 trabalhos, sendo: seis relatos de casos clínicos, sete estudos observacionais, um ensaio clínico randomizado e quatro revisões da literatura. Grande parte dos trabalhos revelou que as lesões neuronais relacionadas às cirurgias para instalação de implantes são de caráter transitório. Conclusão: o reconhecimento precoce dos sinais e sintomas de lesões neuronais, bem como o acompanhamento do progresso na regeneração nervosa, representam boas práticas clínicas que devem ser aplicadas com o objetivo de evitar a cronificação da lesão...

This literature review evaluated the relationship between neuropathic orofacial pain and the nerve injury associated with dental implants replacement, focusing in the clinical, prevention and management aspects. Material and methods: PubMed and SciELO database were analyzed in this literature review. We considered only clinical studies published between 1993 and 2013. Results: we selected and included 18 articles of which, six were case reports, seven were observational studies, um randomized controlled trial and 4 literature reviews. Most of the articles highlighted the transitory nature of the neuronal damage associated with dental implants replacement. Conclusion: the early recognition of signs and symptoms of neuronal damage, as well as the follow-up during the healing period are good clinical practices and should be endorsed in order to avoid chronifi cation...