How a discerning cytological examination can aid in the diagnosis of infectious diseases: case reports.

Infections caused by uncommon and resistant pathogens in unusual sites have been increasingly reported in medical literature. We describe four cases of rare cytological findings and clinical impact for patients. In the first case, Aspergillus sp and Pneumocystis jirovecii were observed in the bronchoalveolar lavage of a patient with severe systemic lupus. In the second and third cases, we describe the presence of Trichomonas sp and Strongyloides sp larvae in samples of pleural and peritoneal fluid, respectively. The fourth report is about a patient with a wrist subcutaneous nodule whose synovial aspiration and cytology revealed the presence of brown septate hyphae. The early identification of the infectious agent in the cytological examination was essential for the introduction and/or re-adaptation of therapy in the four cases described. Patients in this report were immunocompromised with severe comorbidities, conditions often associated with unfavorable clinical outcomes.

How a discerning cytological examination can aid in the diagnosis of infectious diseases: case reports

Infections caused by uncommon and resistant pathogens in unusual sites have been increasingly reported in medical literature. We describe four cases of rare cytological findings and clinical impact for patients. In the first case, Aspergillus sp and Pneumocystis jirovecii were observed in the bronchoalveolar lavage of a patient with severe systemic lupus. In the second and third cases, we describe the presence of Trichomonas sp and Strongyloides sp larvae in samples of pleural and peritoneal fluid, respectively. The fourth report is about a patient with a wrist subcutaneous nodule whose synovial aspiration and cytology revealed the presence of brown septate hyphae. The early identification of the infectious agent in the cytological examination was essential for the introduction and/or re-adaptation of therapy in the four cases described. Patients in this report were immunocompromised with severe comorbidities, conditions often associated with unfavorable clinical outcomes.

Diagnostic performance of the Xpert Carba-R™ assay directly from rectal swabs for active surveillance of carbapenemase-producing organisms in the largest Brazilian University Hospital.

BACKGROUND: The global spread of carbapenemase-producing organisms (CPO) has been considered by international health authorities as a critical public health concern. Brazil has a high CPO prevalence according to distinct publications but many routine microbiology laboratories have only phenotypic resources to evaluate this epidemiological situation, which is time-consuming and detects only carbapenem-resistant isolates missing CPO susceptible expressing a slightly decreased susceptibility. New molecular platforms can detect CPO faster but a local evaluation is essential. AIM: To evaluate the performance of CPO detection direct from rectal swabs with the Xpert Carba-R™ assay (Cepheid, Sunnyvale, CA) in the largest Brazilian University Hospital. METHODS: A prospective diagnostic accuracy study of CPO was performed with the collection of rectal swabs from patients admitted into the Intensive Care Unit (ICU) and into the Emergency Department (ED) between April and July 2016. The Xpert Carba-R™ assay results were compared with carbapenem-resistant Enterobacterales (CRE) surveillance cultures plus in-house PCR carbapenemase detection (reference method). In case of discordant results between methods, additional tests were performed. The limit of detection (LoD) for the CRE culture and the Xpert Carba-R™ assay were performed with contrived isolates of known carbapenemases genes. RESULTS: A total of 921 clinical rectal swabs were analyzed being 21% (196/921) from the ICU and 79% (725/921) from the ED. Overall, the Xpert Carba-R™ assay detected 9.9% (91/921) of CPOs being 9.5% (87/921) positive only for blaKPC and 0.4% (4/921) positive only for blaNDM. The reference method detected 9.1% (84/921) CPO being 77 (8.4%) blaKPC, 5 blaVIM (0.5%) and 2 blaNDM (0.2%). No IMP or OXA-48 like gene was detected. Overall, twelve samples, 1.3% (10 blaKPC, 2 blaNDM) were Xpert Carba-R™ positive but negative by the reference method. Five isolates (0.5%) were positive for blaVIM only by in-house PCR and confirmed to be blaVIM-2 by DNA sequencing. The Kappa value, sensitivity, specificity, positive/negative predictive values and accuracy of the Xpert Carba-R™ assay were; 0.893 (95% confidence interval [CI], 0.842-0.944), 94% (86.7-98.0), 98.6% (97.5-99.3), 86.8% (78.1-93.0), 99.4% (98.6-99.8) and 98.2% (97.3-99.1), respectively. The LoD for blaKPC of the Xpert Carba-R™ assay and the CRE cultures were 101 CFU/swab. CONCLUSION: The Xpert Carba-R™ assay is an accurate test to detect CPO directly from the rectal swabs with significant lower turnaround time (TAT) when compared to the reference method (CRE culture plus in-house PCR). Xpert Carba-R™ may, therefore, be regarded as a good and fast epidemiological tool.

Species distribution and antifungal susceptibility of 358 Trichosporon clinical isolates collected in 24 medical centres.

OBJECTIVES: To provide species distribution and antifungal susceptibility profiles of 358 Trichosporon clinical isolates collected from 24 tertiary-care hospitals. METHODS: Species identification was performed by sequencing the IGS1 region of rDNA. Antifungal susceptibility testing for amphotericin B, fluconazole, voriconazole and posaconazole followed the Clinical and Laboratory Standards Institute reference method. Tentative epidemiologic cutoff values (97.5% ECVs) of antifungals for Trichosporon asahii were also calculated. RESULTS: Isolates were cultured mostly from urine (155/358, 43.3%) and blood (82/358, 23%) samples. Trichosporon asahii was the most common species (273/358, 76.3%), followed by T. inkin (35/358, 9.7%). Isolation of non-T. asahii species increased substantially over the last 11 years [11/77 (14.2%) from 1997 to 2007 vs. 74/281, (26.3%) from 2008 to 2018, p0.03]. Antifungal susceptibility testing showed high amphotericin B minimum inhibitory concentrations against Trichosporon isolates, with higher values for T. faecale. The ECV for amphotericin B and T. asahii was set at 4 µg/mL. Among the triazole derivatives, fluconazole was the least active drug. The ECVs for fluconazole and posaconazole against T. asahii were set at 8 and 0.5 µg/mL, respectively. Voriconazole showed the strongest in vitro activity against the Trichosporon isolates; its ECV for T. asahii was set at 0.25 µg/mL after 48 hours' incubation. CONCLUSIONS: Trichosporon species diversity has increased over the years in human samples, and antifungal susceptibility profiles were species specific. Trichosporon asahii antifungal ECVs were proposed, which may be helpful to guide antifungal therapy.

Sexualidade e saúde mental: uma revisão integrativa / Sexuality and mental health: an integrative review

Objetivo: conhecer a produção científica brasileira acerca da sexualidade de pessoas com transtornos mentais. Métodos: revisão integrativa realizada através de uma busca das produções científicas dos últimos dez anos na Biblioteca Virtual em Saúde, no período de janeiro a março de 2016. Foram obtidos 1.721 artigos e após a seleção foram incluídos seis estudos. Resultados: agrupou-se os resultados em duas principais categorias. Com relação à visão dos profissionais foi observada a fragilidade das equipes de saúde para lidarem com questões relacionadas à sexualidade das pessoas com transtorno mental. Além disso, notou-se a presença de preconceitos, tabus e a negação da existência da sexualidade não patológica nestas pessoas. Considerações Finais: considera-se imprescindível a sensibilização dos profissionais, para que as pessoas com transtornos mentais assumam o protagonismo da própria vida e vivam sua sexualidade.

Objective: to know Brazilian scientific production about the sexuality of people with mentaldisorders. Methods: integrative review carried out through a search of the scientific productions ofthe last ten years in the Virtual Health Library, from January to March, 2016. There were obtained1,721 articles and six studies were included after the selection. Results: the results were groupedinto two main categories. Regarding the professionals' view, the fragility of the health teams to dealwith issues related to the sexuality of people with mental disorders was observed. In addition, itwas noted the presence of prejudices, taboos and the denial of non-pathological sexuality in thesepeople. Final Considerations: it is considered essential to raise the awareness of professionals, sothat people with mental disorders are protagonists of their lives and their sexuality.

Candida and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer.

Critically ill patients and patients with haematological cancer are HIV-negative populations at high risk of invasive fungal infections. In intensive-care units, candidaemia and intra-abdominal candidiasis predominate, but aspergillosis has emerged as a lethal, under-recognised cause of pneumonia. In patients with haematological malignancies or who have undergone stem-cell transplantations, pulmonary disease due to aspergillus and other mould diseases predominate. In this Series paper, we provide an update on risk assessment, new diagnostic strategies, and therapeutic approaches. New concepts have emerged for use of risk prediction rules and an evidence base now exists for inclusion of biomarkers (eg, galactomannan, 1,3-ß-D-glucan, and PCR assays for Aspergillus spp) into early diagnostic and therapeutic strategies. Imaging techniques remain helpful for early diagnosis of pulmonary mould diseases, with PET techniques offering potential improvements in diagnostic specificity and evaluation of clinical response. Echinocandins and triazoles have been validated extensively for prophylaxis, empirical therapy, and targeted therapy, but an increase in intrinsically resistant fungi and emergence of secondary resistance as a result of drug-induced selection pressure are of major concern. Echinocandins remain a major component of treatment of invasive candidiasis and new triazoles are the best alternative for prophylaxis and therapy of invasive aspergillosis.

Parâmetros nutricionais e padrões nictemeral do comportamento ingestivo de cordeiros Somalis Brasileira alimentados com diferentes níveis de energia metabolizável / Nutritional parameters and nycterohemeral patterns of ingestive behavior of Brazilian Somali lambs fed different levels of metabolizable energy

O presente estudo foi conduzido para determinar o consumo e a digestibilidade dos nutrientes, bem como o comportamento ingestivo de cordeiros Somalis Brasileira, alimentados com diferentes níveis de energia metabolizável (EM). Foram utilizados 40 animais, não castrados, com peso vivo médio de 13,47±1,76kg. Os animais foram distribuídos em delineamento em blocos ao acaso, com cinco dietas com diferentes níveis de energia metabolizável (1,18; 2,07; 2,25; 2,42 e 2,69Mcal/kg de MS). O consumo de MS, PB, FDN, CF (g/dia), MS (g/kg0,75) e FDN (%PC e g/kg0,75) apresentaram efeito quadrático (P<0,05), assim como os coeficientes de digestibilidade (P<0,05) da PB, da FDN e dos CF. Foi averiguado efeito linear crescente (P<0,05) para digestibilidade da MS, da MO e dos CNF com o aumento da EM na dieta. Os tempos de alimentação e ócio (h/dia) foram influenciados pelos níveis de energia (P<0,05), e as eficiências de alimentação e ruminação (g FDN/h) apresentaram efeito quadrático (P<0,05). Conclui-se que o aumento dos níveis de EM das rações influencia o consumo e a digestibilidade dos nutrientes, bem como o comportamento ingestivo de cordeiros Somalis Brasileira...

The study was conducted to determine the intake, nutrient digestibility and ingestive behavior of Brazilian Somali lambs fed different levels of metabolizable energy (ME). Forty non-castrated Brazilian Somali lambs with average weight of 13.47±1.76kg were used. The animals were assigned to a randomized block design with eight replications per block and five diets with increasing metabolizable energy (1.18, 2.07, 2.25, 2.42 and 2.69 Mcal/kg DM). The quadratic effect (P<0.05) of the ME level was determined for DM, CP, NDF and FC (g/day) and DM (g/kg0,75) and NDF(%PC and g/kg0,75) intake, as well as the digestibility coefficients (P<0.05) for CP, NDF and CF. A linear effect (P<0.05) was observed for digestibility of DM, OM and NFC with the increase of ME in the diet. Eating and idle results (hours/day) were influenced by the energy levels (P<0.05) and efficiencies of feeding and rumination (g NDF/h) showed a quadratic effect (P<0.05). It is concluded that the increase of ME levels in the diet influences intatke, nutrient digestibility and ingestive behavior of Brazilian Somali lambs...

Invasive Trichosporon infection in solid organ transplant patients: a report of two cases identified using IGS1 ribosomal DNA sequencing and a review of the literature.

Trichosporon species are rare etiologic agents of invasive fungal infection in solid organ transplant (SOT) recipients. We report 2 well-documented cases of Trichosporon inkin invasive infection in SOT patients. We also conducted a detailed literature review of Trichosporon species infections in this susceptible population. We gathered a total of 13 cases of Trichosporon species infections. Any type of organ transplantation can be complicated by Trichosporon infection. Bloodstream infections and disseminated infections were the most common clinical presentations. Liver recipients with bloodstream or disseminated infections had poor prognoses. Although the most common species was formerly called Trichosporon beigelii, this species name should no longer be used because of the changes in the taxonomy of this genus resulting from the advent of molecular approaches, which were also used to identify the strains isolated from our patients. Antifungal susceptibility testing highlights the possibility of multidrug resistance. Indeed, Trichosporon has to be considered in cases of breakthrough infection or treatment failure under echinocandins or amphotericin therapy. Voriconazole seems to be the best treatment option.

Usefulness of matrix-assisted laser desorption ionisation-time-of-flight mass spectrometry for identifying clinical Trichosporon isolates.

Trichosporon spp. have recently emerged as significant human pathogens. Identification of these species is important, both for epidemiological purposes and for therapeutic management, but conventional identification based on biochemical traits is hindered by the lack of updates to the species databases provided by the different commercial systems. In this study, 93 strains, or isolates, belonging to 16 Trichosporon species were subjected to both molecular identification using IGS1 gene sequencing and matrix-assisted laser desorption ionisation-time-of-flight (MALDI-TOF) analysis. Our results confirmed the limits of biochemical systems for identifying Trichosporon species, because only 27 (36%) of the isolates were correctly identified using them. Different protein extraction procedures were evaluated, revealing that incubation for 30 min with 70% formic acid yields the spectra with the highest scores. Among the six different reference spectra databases that were tested, a specific one composed of 18 reference strains plus seven clinical isolates allowed the correct identification of 67 of the 68 clinical isolates (98.5%). Although until recently it has been less widely applied to the basidiomycetous fungi, MALDI-TOF appears to be a valuable tool for identifying clinical Trichosporon isolates at the species level.

Effects of cold water immersion and active recovery on post-exercise heart rate variability.

The aim of the present study was to investigate the potential benefits of cold water immersion (CWI) and active recovery (AR) on blood lactate concentration ([Lac]) and heart rate variability (HRV) indices following high-intensity exercise. 20 male subjects were recruited. On the first visit, an incremental test was performed to determine maximal oxygen consumption and the associated speed (MAS). The remaining 3 visits for the performance of constant velocity exhaustive tests at MAS and different recovery methods (6 min) were separated by 7-day intervals [randomized: CWI, AR or passive recovery (PR)]. The CWI and AR lowered [Lac] (p<0.05) at 11, 13 and 15 min after exercise cessation in comparison to PR. There was a 'time' and 'recovery mode' interaction for 2 HRV indices: standard deviation of normal R-R intervals (SDNN) (partial eta squared=0.114) and natural log of low-frequency power density (lnLF) (partial eta squared=0.090). CWI presented significantly higher SDNN compared to PR at 15 min of recovery (p<0.05). In addition, greater SDNN values were found in CWI vs. AR during the application of recovery interventions, and at 30 and 75 min post-exercise (p<0.05 for all differences). The lnLF during the recovery interventions and at 75 min post-exercise was greater using CWI compared with AR (p<0.05). For square root of the mean of the sum of the squares of differences between adjacent R-R intervals (RMSSD) and natural log of high-frequency power density (lnHF), a moderate effect size was found between CWI and PR during the recovery interventions and at 15 min post-exercise. Our findings show that AR and CWI offer benefits regarding the removal of [Lac] following high-intensity exercise. While limited, CWI results in some improvement in post-exercise cardiac autonomic regulation compared to AR and PR. Further, AR is not recommended if the aim is to accelerate the parasympathetic reactivation.

Assessment of using digital manipulation tools for diagnosing mandibular radiolucent lesions.

OBJECTIVE: The purpose of this study was to analyse the use of digital tools for image enhancement of mandibular radiolucent lesions and the effects of this manipulation on the percentage of correct radiographic diagnoses. METHODS: 24 panoramic radiographs exhibiting radiolucent lesions were selected, digitized and evaluated by non-experts (undergraduate and newly graduated practitioners) and by professional experts in oral diagnosis. The percentages of correct and incorrect diagnoses, according to the use of brightness/contrast, sharpness, inversion, highlight and zoom tools, were compared. All dental professionals made their evaluations without (T1) and with (T2) a list of radiographic diagnostic parameters. RESULTS: Digital tools were used with low frequency mainly in T2. The most preferred tool was sharpness (45.2%). In the expert group, the percentage of correct diagnoses did not change when any of the digital tools were used. For the non-expert group, there was an increase in the frequency of correct diagnoses when brightness/contrast was used in T2 (p=0.008) and when brightness/contrast and sharpness were not used in T1 (p=0.027). The use or non-use of brightness/contrast, zoom and sharpness showed moderate agreement in the group of experts [kappa agreement coefficient (κ) = 0.514, 0.425 and 0.335, respectively]. For the non-expert group there was slight agreement for all the tools used (κ ≤ 0.237). CONCLUSIONS: Consulting the list of radiographic parameters before image manipulation reduced the frequency of tool use in both groups of examiners. Consulting the radiographic parameters with the use of some digital tools was important for improving correct diagnosis only in the group of non-expert examiners.

Digestibilidade aparente da dieta com capim-elefante ensilado com diferentes aditivos / Apparent digestibility of diet with elephant grass ensiled with different additives

Foram estudados os efeitos da adição de 15 por cento de diferentes aditivos - casca de café, farelo de cacau e farelo de mandioca - à forragem verde de capim-elefante (peso/peso), no momento da ensilagem, sobre a digestibilidade aparente de dietas. Foram usados 20 ovinos machos, não castrados, com média de 22,27±3,24kg de peso corporal, em um delineamento inteiramente ao acaso, com quatro tratamentos e cinco repetições. Os tratamentos foram: T1 = capim-elefante ensilado sem aditivo; T2 = capim-elefante ensilado com 15 por cento de casca de café; T3 = capim-elefante ensilado com 15 por cento de farelo de cacau; T4 = capim-elefante ensilado com 15 por cento de farelo de mandioca. Os animais receberam dieta isoproteica (10 por cento de proteína bruta) em proporção de 60 por cento de volumoso e 40 por cento de concentrado, na base da matéria seca. Utilizou-se o método de coleta total de fezes durante sete dias. Os coeficientes de digestibilidade aparente da matéria seca, proteína bruta, fibra em detergente neutro e fibra em detergente ácido e de digestibilidade verdadeira da proteína bruta foram maiores no capim-elefante ensilado sem aditivo. O coeficiente de digestibilidade do extrato etéreo foi mais alto na silagem sem aditivo e na silagem com farelo de cacau. Os coeficientes de digestibilidade da matéria orgânica e dos carboidratos totais foram mais elevados na silagem sem aditivo e na silagem com farelo de mandioca. Os maiores valores de nutrientes digestíveis totais foram observados nas dietas que continham silagem sem aditivo e silagem com farelo de mandioca. A silagem de capim-elefante com 15 por cento de farelo de mandioca, bem como a silagem sem aditivo apresentaram melhor digestibilidade dos nutrientes.

The effects of adding 15 percent of different additives (coffee hulls, cocoa meal and, cassava meal) to green elephant grass forage (weight/weight) at the time of ensiling on the apparent digestibility of diets were studied using 20 male sheep in a completely randomized design, with four treatments and five replications. The treatments were: T1 = elephant grass ensiled without additive; T2 = elephant grass ensiled with 15 percent coffee hulls; T3 = elephant grass ensiled with 15 percent cocoa meal; and T4 = elephant grass ensiled with 15 percent cassava meal. The animals were fed isonitrogen diet (10 percent crude protein) in 60 percent roughage and 40 percent concentrate rate, on dry matter basis. Total feces collection method was used for seven days. The apparent digestibility coefficients of dry matter, crude protein, neutral detergent fiber, and acid detergent fiber and the true digestibility coefficient of crude protein were higher in elephant grass ensiled without additive. The ether extract digestibility coefficient was higher in the silages without additive and with cocoa meal. The digestibility coefficients of organic matter and total carbohydrates were higher in the silage without additive and in the silage with cassava meal. The highest values of total digestible nutrients were observed in diets containing silages without additive and with cassava meal. The elephant grass silage with 15 percent cassava meal, together with the silage without additive, showed better nutrients digestibility.

Gene flow from transgenic to nontransgenic soybean plants in the Cerrado region of Brazil.

Evaluation of transgenic crops under field conditions is a fundamental step for the production of genetically engineered varieties. In order to determine if there is pollen dispersal from transgenic to nontransgenic soybean plants, a field release experiment was conducted in the Cerrado region of Brazil. Nontransgenic plants were cultivated in plots surrounding Roundup Ready transgenic plants carrying the cp4 epsps gene, which confers herbicide tolerance against glyphosate herbicide, and pollen dispersal was evaluated by checking for the dominant gene. The percentage of cross-pollination was calculated as a fraction of herbicide-tolerant and -nontolerant plants. The greatest amount of transgenic pollen dispersion was observed in the first row, located at one meter from the central (transgenic) plot, with a 0.52% average frequency. The frequency of pollen dispersion decreased to 0.12% in row 2, reaching 0% when the plants were up to 10 m distance from the central plot. Under these conditions pollen flow was higher for a short distance. This fact suggests that the management necessary to avoid cross-pollination from transgenic to nontransgenic plants in the seed production fields should be similar to the procedures currently utilized to produce commercial seeds.

Total agenesis of the left pericardium.

This is the report of a 46-year-old patient with the preoperative diagnosis of an atrial septal defect (ASD) of the ostium secudum type. After sternectomy, partial agenesis of the left pericardium was diagnosed. It is our opinion that, if the radiographic picture is suggestive of this entity, a clinical search for cardiopulmonary anomalies should be performed, because the majority of these associated anomalies can and should be surgically corrected.

Surgical revascularization of posterior coronary arteries without cardiopulmonary bypass.

OBJECTIVE: To assess the results observed during the early postoperative period in patients who had the posterior coronary arteries revascularized without cardiopulmonary bypass (CPB), in regard to the following parameters: age, sex, bypass grafts types, morbidity and mortality. METHODS: From January 1995 to June 1998, 673 patients underwent myocardial revascularization (MR). Of this total, 607 (90.20%) MR procedures were performed without CPB. The posterior coronary arteries (PCA) were revascularized in 298 (44.27%) patients, 280 (93.95%) without CPB. The age of the patients ranged from 37 to 88 years (mean, 61 years). The male gender predominated, with 198 men (70.7%). The revascularization of the posterior coronary arteries had the following distribution: diagonalis artery (31 patients, 10%); marginal branches of the circumflex artery (243 patients, 78.7%); posterior ventricular artery (4 patients, 1.3%); and posterior descending artery (31 patients, 10%). RESULTS: Procedure-related complications without death occurred in 7 cases, giving a morbidity of 2.5%. There were 11 deaths in the early postoperative period (mortality of 3.9%). CONCLUSION: Similarly to the anterior coronary arteries, the posterior coronary arteries may benefit from myocardial revascularization without CPB.

Saphenous nerve entrapment manifested as proximal cruralgia.

A 16 year old boy had continuous pain in the right testis, groin, and the medial aspect of the thigh and knee for 16 months. The onset of symptoms was acute and pain distribution included a retrograde area in relation to the entrapment site. Tinel's sign was the clue for diagnosis. Diagnosis was confirmed at operation and division of the aponeurosis of Hunter's canal relieved the symptoms for three days. A second surgical exploration, proximal to the former one, was performed after five months. The right femoral nerve was found normal. This new operation was therapeutically ineffective. Causes of pain distribution and relapsed pain are discussed. The relapse was attributed to myofascial pain syndrome. This diagnosis should be considered independently of the correct treatment of the primary lesion.

Comunicaçäo direta entre a artéria pulmonar direita e o átrio esquerdo: relato de caso / Direct communication of the right pulmonary artery and the left atrium: a case report

Uma criança de 7 anos de idade portadora de comunicaçäo direta da artéria pulmonar direita com o átrio esquerdo, com cianose intensa, foi operada com sucesso. Foi feita revisäo dos 20 casos até agora publicados, com especial atençäo no diagnóstico, tipos anatômicos e resultado cirúrgico