Allopurinol-Induced Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a rare and life-threatening cutaneous disease, frequently triggered by drugs. Allopurinol is one of the most frequent drugs associated with TEN, which implies detachment of a significant amount of the body surface area (BSA) and has a high morbidity and mortality associated with it. We present the case of a 68-year-old female with a recent diagnosis of hyperuricemia who started treatment with allopurinol. A week later, she presented to the emergency department with an extensive maculopapular exanthema with blisters and skin detachment. After the exclusion of other etiologies, the diagnosis of allopurinol-induced TEN was made, with 35% of BSA involvement. Due to the severity of the clinical condition, she was admitted to intensive care and treated with corticoids that had no response. So, she was started on immunoglobulins and transferred to a burn unit. She developed sepsis with multiorgan failure and required supportive treatment. She was discharged after a month, and physical rehabilitation was needed. This clinical case highlights the severity of allopurinol hypersensitivity that may happen and the importance of an accurate diagnosis and treatment for this rare disease.

Visual Thinking Strategies in medical education: a systematic review

BACKGROUND

Arts-based pedagogical tools have been increasingly incorporated into medical education. Visual Thinking Strategies (VTS) is a research-based, constructivist teaching methodology that aims to improve visual literacy, critical thinking, and communication skills through the process of investigating works of art. Harvard Medical School pioneered the application of VTS within medical education in 2004. While there are several studies investigating the use of VTS, there is a need to systematically assess the different programs that exist for medical education and their efficacy in improving relevant clinical skills. This systematic review aims to critically analyse the available evidence of the effectiveness of VTS in medical education to guide future research and provide a framework to adapt medical curricula.

METHODS

A systematic search of PubMed, PsycINFO, and Cochrane CENTRAL databases (through November 2022) was conducted to identify studies of VTS-based interventions in undergraduate and postgraduate medical education. Two reviewers independently screened citations for inclusion criteria, extracted data, and assessed risk of bias. The extracted data was then narratively synthesized.

RESULTS

Of 5759 unique citations, 10 studies met the inclusion criteria. After reference review, one additional study was included. Therefore, 11 studies were included in our review. Of these, eight reported VTS-based interventions for undergraduate medical students and three reported interventions in residency training, specifically in dermatology and ophthalmology. The main goal of most studies was to increase observational or visual diagnostic skills. Three of the studies in undergraduate medical education and two in postgraduate achieved a statistically significant improvement in observational skills in post-course evaluations. Some studies reported increased tolerance for ambiguity and empathy.

CONCLUSIONS

Although the studies varied considerably in study design, learning objectives, and outcomes, findings consistently indicate that the VTS approach can serve as a vehicle to develop crucial clinical competencies, encouraging more in-depth visual analysis that could be applied when observing a patient. Despite some limitations of the included studies (lack of control groups, self-selection bias, or non-standard outcome measures), the results of this review provide support for greater inclusion of VTS training in the medical curriculum.

DOEGE-POTTER SYNDROME BY PLEURAL SOLITARY FIBROUS TUMOR

Solitary fibrous tumor of the pleura (SFTP) is a rare neoplasm that accounts for less than 5% of all pleural tumors. We present the case of a 73-year-old man with a history of recurrent episodes of severe hypoglycemia secondary to a large malignant SFTP. This paraneoplastic manifestation of SFTP occurs in less than 5% of cases and is referred to as Doege-Potter syndrome. Although rare, this is an important and reversible cause of hypoglycemia, which is resolved by complete surgical resection of the tumor. We describe the pathogenesis, diagnosis, and treatment of Doege-Potter syndrome. Key imaging findings and pathologic correlation are shown.

Two Rare Entities in One Patient: Mucinous Tubular and Spindle Cell Carcinoma of the Kidney and Peritoneal Adenomyomas

Mucinous tubular and spindle cell carcinoma of the kidney is a rare subtype of renal cell carcinoma, that is believed to portend a favorable prognosis. Adenomyomas are benign tumors that typically arise from the myometrium. Extrauterine adenomyomas are extremely rare, with only a few cases reported in the literature. Here, we present an unusual case of a 46-year-old woman, with an incidentally detected bulky interpolar left kidney mass measuring 12 cm and multiple lobulated coalescent peritoneal nodules in the large epiploon suspicious for peritoneal carcinomatosis. A biopsy of the lesions revealed a mucinous tubular and spindle cell carcinoma of the kidney and extrauterine adenomyomas of the peritoneum. A left radical nephrectomy was performed and long-term hormone therapy with gonadotropin-releasing hormone agonists was prescribed. The purpose of this article is to focus on these two rare lesions, review the current literature, illustrate their key imaging findings along with pathologic correlation, as well as to discuss the differential diagnosis and clinical management.

Social stress in adolescents induces depression and brain-region-specific modulation of the transcription factor MAX

MAX is a conserved constitutive small phosphoprotein from a network of transcription factors that are extensively studied in tumorigenesis and whose functions affect cell proliferation, differentiation and death. Inspired by its higher expression during development and in regions involved in emotional behaviors, we hypothesized its involvement in cerebral changes caused by early-life stress. We studied the effects of repeated social stress during adolescence on behaviors and on MAX and its putative partner MYC. Thirty-day-old C57BL/6 male mice underwent brief daily social defeat stress from an adult aggressor for 21 days. Following social stress episodes and housing in social groups after each defeat, adolescent mice exhibit depressive-like, but not anxiety-like behaviors and show higher MAX nuclear immunoreactivity in hippocampal (HC) but not prefrontal cortical (PFC) neurons. Conversely, MAX immunoreactivity is lower in the striatum (ST) of defeated adolescents. The positive correlation between MAX and MYC levels in the PFC revealed disruptions in both the HC and ST. The changes in MAX protein levels are not due to differential gene expression or protein degradation in those regions, suggesting that posttranscriptional modifications occurred. These findings indicate that repeated, brief social defeat in adolescent male mice, combined with group housing, is a useful protocol to study a subtype of depression that is dissociated from generalized (non-social) anxiety. To our knowledge, this is the first report of an association between dysregulation of the MAX-MYC network in the brain and a behavior, suggesting a novel approach for exploiting the neuroplasticity associated with depression.

A survey of tick-borne pathogens in dogs and their ticks in the Pantanal biome, Brazil

Tick and blood samples collected from domestic dogs in the Brazilian Pantanal were tested by molecular methods for the presence of tick-borne protozoa and bacteria. Among 320 sampled dogs, 3.13% were infected by Babesia vogeli (Piroplasmida: Babesiidae), 8.75% by Hepatozoon canis (Eucoccidiorida: Hepatozoidae), 7.19% by Anaplasma platys (Rickettsiales: Anaplasmataceae), and 0.94% by an unclassified Anaplasma sp. In three tick species collected from dogs, the following tick-borne agents were detected: (a) B. vogeli, An. platys and Ehrlichia canis (Rickettsiales: Anaplasmataceae), infecting Rhipicephalus sanguineus sensu lato (Ixodida: Ixodidae) ticks; (b) H. canis, an unclassified Anaplasma sp. and Rickettsia amblyommii (Rickettsiales: Rickettsiaceae), infecting Amblyomma cajennense sensu lato (Ixodida: Ixodidae) ticks, and (c) Rickettsia sp. strain Atlantic rainforest, an emerging human pathogen, infecting Amblyomma ovale ticks. Molecular analysis, based on a mitochondrial gene, revealed that the Am. cajennense s.l. ticks of the present study corresponded to Amblyomma sculptum, a member of the Am. cajennense species complex, and that Rh. sanguineus s.l. belonged to the tropical lineage. Whereas dogs are exposed to a number of tick-borne bacterial and protozoan agents in the Pantanal biome, humans are potentially exposed to infection by spotted fever group rickettsiae (e.g. R. amblyommii and Rickettsia sp. strain Atlantic rainforest) because both Am. sculptum and Am. ovale are among the most important human-biting ticks in Brazil.

Reconstruction of magnetic source images using the Wiener filter and a multichannel magnetic imaging system

A system for imaging magnetic surfaces using a magnetoresistive sensor array is developed. The experimental setup is composed of a linear array of 12 sensors uniformly spaced, with sensitivity of 150 pT*Hz(-1/2) at 1 Hz, and it is able to scan an area of (16 × 18) cm(2) from a separation of 0.8 cm of the sources with a resolution of 0.3 cm. Moreover, the point spread function of the multi-sensor system is also studied, in order to characterize its transference function and to improve the quality in the restoration of images. Furthermore, the images are generated by mapping the response of the sensors due to the presence of phantoms constructed of iron oxide, which are magnetized by a pulse of 80 mT. The magnetized phantoms are linearly scanned through the sensor array and the remanent magnetic field is acquired and displayed in gray levels using a PC. The images of the magnetic sources are reconstructed using two-dimensional generalized parametric Wiener filtering. Our results exhibit a very good capability to determine the spatial distribution of magnetic field sources, which produce magnetic fields of low intensity.

On-pump versus off-pump coronary-artery bypass surgery: a meta-analysis

There are controversies about the possible benefits of off pump coronary artery bypass grafting (OPCABG) compared to on-pump coronary artery bypass grafting (ONCABG). For a better perspective on this important issue, we performed a meta-analysis of randomized controlled trials, comparing the two techniques. The objective of this study was to verify which technique applied in Coronary Artery Bypass Surgery, OPCABG or ONCABG, provides better results through a meta-analysis of published randomized trials comparing the two techniques. We carried out a computer-based literature search in PubMed, Embase, B-on and Science Direct from March 2009 to January 2010. The studies covered were recovered according to predetermined criteria. A systematic review of randomized clinical trials was performed in order to evaluate the differences between the two revascularization techniques (OPCABG versus ONCABG) regarding mortality and morbidity. Selected studies did not include patients at high risk and long-term longitudinal evaluations. The meta-analysis focused on nine randomized clinical trials, corresponding to a total of 75,086 patients, and compared OPCABG to ONCABG. Regarding mortality, a reduction of 18% in the risk of cardiovascular mortality (OR: 0.82, 95%CI: 0.70 to 0.98, p = 0.03) and 27% in the risk of stroke postoperatively (OR: 0.73, 95%CI: 0.63 to 0.85, p = 0.0001) were observed, both in favor of OPCABG. Concerning the occurrence of complications associated with the procedure, no significant differences were found between the two surgical techniques, particularly with regard to the occurrence of kidney complications (OR: 0.97, 95%CI: 0.84-1.14, p = 0, 74) and sepsis (OR 0.98, 95%CI: 0.64-1.51, p = 0.93, respectively). Off-pump CABG significantly reduces the occurrence of major cardiovascular events (mortality and CVA) compared to on-pump CABG surgery.

Coinfections of Rickettsia slovaca and Rickettsia helvetica with Borrelia lusitaniae in ticks collected in a Safari Park, Portugal

Borrelia and Rickettsia bacteria are the most important tick-borne agents causing disease in Portugal. Identification and characterization of these circulating agents, mainly in recreational areas, is crucial for the development of preventive measures in response to the gradually increasing exposure of humans to tick vectors. A total of 677 questing ticks including Dermacentor marginatus, Rhipicephalus sanguineus, Ixodes ricinus, Hyalomma lusitanicum, H. marginatum, and Haemaphysalis punctata were collected in a Safari Park in Alentejo, Portugal, to investigate the prevalences of infection and characterize Borrelia and Rickettsia species. From a total of 371 ticks tested by PCR for Borrelia burgdorferi sensu lato (s.l.), of which 247 were tested for Rickettsia, an infection prevalence of 18.3% was found for B. lusitaniae and 55.1% for Rickettsia spp. Sequence analysis of positive amplicons identified the presence of B. lusitaniae (18.3%), R. monacensis strain IRS3 (51.7%), and R. helvetica (48.3%) in I. ricinus. R. slovaca (41.5%), R. raoultii (58.5%), and also B. lusitaniae (21%) were identified in D. marginatus ticks. One (5.9%) H. lusitanicum was infected with B. lusitaniae, and R. massiliae was found in one Rhipicephalus sanguineus. Coinfection was found in 7 (20%) I. ricinus and 34 (23.3%) D. marginatus ticks. We report, for the first time, simultaneous infection with R. helvetica and B. lusitaniae and also R. slovaca, the agent of TIBOLA/DEBONEL, with B. lusitaniae. Additionally, 6 isolates of B. lusitaniae were established, and isolates of Rickettsia were also obtained for the detected species using tick macerates cultured in mammalian and mosquito cell lines. This report describes the detection and isolation of tick-borne agents from a Portuguese Safari Park, highlighting the increased likelihood of infection with multiple agents to potential visitors or staff.

[High blood pressure prevalence in Oporto sedentary and regular exercise practicing people]

INTRODUCTION

The association between the lack of exercise and prevalence of high blood pressure (HBP) is a well known fact. The non-pharmacological treatment for HBP includes regular aerobic exercise practicing.

METHODS

A total of 900 individuals, aged above 40, resident in Oporto, representing the 15 parishes of the city, were approached to answer a questionnaire about exercise habits and diagnosis of HBP. The exercise practitioner was defined as the one who practices aerobic exercise for a minimal period of 30 minutes at least 3 times a week. For data analysis non-parametric tests (Pearson's Chi-Square) were used through the Statistical Package for the Social Sciences (SPSS) software.

RESULTS

The HBP prevalence in the sample was 39.67% (Confidence Interval (IC) 95%, 36,46% to 42,87%). The HBP prevalence in the exercise practitioners was inferior to the one of the non-practitioners (13,78% vs 25,89%, p < 0,001). This result is valid to the male 33,5% vs 51,6%, p < 0,001) and female population (27,1% vs 51,9%, p < 0,001), as well as to the population without the most frequent HBP-related comorbidities (21,8% vs 44,6%, p < 0,001).

CONCLUSIONS

The HBP prevalence in the population resident in Oporto city is higher in the non-practitioners of regular exercise. The HBP prevalence, in both sexes, is higher in the non-practitioners of exercise. Finally, we can also conclude that the studied comorbidities don't bias the obtained results because the group of individuals who don't have them the HBP prevalence is still higher in the group of sedentary.

Hepatitis B vaccine in infants: a randomized controlled trial comparing gluteal versus anterolateral thigh muscle administration

A significantly diminished antibody response to hepatitis B vaccine has been demonstrated in adults when the buttock is used as the injection site. However, in Brazil, the buttock continues to be recommended as site of injection for intramuscular administration of vaccines in infants. In this age group, there are no controlled studies evaluating the immunogenicity of the hepatitis B vaccine when administered at this site. In the present study, 258 infants were randomized to receive the hepatitis B vaccine either in the buttock (n = 123) or in the anterolateral thigh muscle (n = 135). The immunization schedule consisted of three doses of hepatitis B vaccine (Engerix Bregister mark or target, 10 microg) at 2, 4 and 9 months of age. There were no significant differences in the proportion of seroconversion (99.3% x 99.2%), or in the geometric mean titer of ELISA anti-HBs (1,862.1 x 1,229.0 mIU/mL) between the two groups. This study demonstrates that a satisfactory serological response can be obtained when the hepatitis B vaccine is administered intramuscularly into the buttock.

Differential localization of acetylcholinesterase in relation to pre- and postsynaptic nicotinic receptors in the chick brain

Immunofluorescence and confocal microscopy were combined to study the distribution of acetylcholinesterase in relation to the localization of the beta2 subunit of the nicotinic acetylcholine receptors in the chick brain. In several areas where the beta2 subunit is recognizably part of presynaptic receptors, the localization of acetylcholinesterase appeared not to overlap the localization of beta2. On the other hand, acetylcholinesterase and the beta2 subunit exhibited a strictly matching localization in areas where postsynaptic nicotinic receptors are known to be present. These data may represent a morphological substrate for possible differential actions of acetylcholinesterase at presynaptic and postsynaptic nicotinic sites.

Elimination of biliary stones through the urinary tract: a complication of the laparoscopic cholecystectomy

The introduction and popularization of laparoscopic cholecystectomy has been accompanied with a considerable increase in perforation of gallbladder during this procedure (10% - 32%), with the occurrence of intraperitoneal bile spillage and the consequent increase in the incidence of lost gallstones (0.2% - 20%). Recently the complications associated with these stones have been documented in the literature. We report a rare complication occurring in an 81-year-old woman who underwent laparoscopic cholecystectomy and developed cutaneous fistula to the umbilicus and elimination of biliary stones through the urinary tract. During the cholecystectomy, the gall bladder was perforated, and bile and gallstones were spilled into the peritoneal cavity. Two months after the initial procedure there was exteriorization of fistula through the umbilicus, with intermittent elimination of biliary stones. After eleven months, acute urinary retention occurred due to biliary stones in the bladder, which were removed by cystoscopy. We conclude that efforts should be concentrated on avoiding the spillage of stones during the surgery, and that no rules exist for indicating a laparotomy simply to retrieve these lost gallstones.