Avaliação da eficácia do laser erbium-doped yttrium aluminium garnet (Er:YAG) associado ao esmalte de amorolfina no tratamento da onicomicose : estudo pareado e randomizado

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Ciências da Saúde, Programa de Pós-Graduação em Ciências da Saúde, 2013.Introdução: A onicomicose acomete cerca de 10% da população global, sendo desafiador seu manejo, já que o tratamento é prolongado, tem alto custo e apresenta risco de toxicidade sistêmica. Ainda, o diagnóstico da doença é dificultado pela baixa sensibilidade e acurácia dos exames. As altas taxas de falência terapêutica, recidiva e reinfecção são fatores diretamente ligados à baixa penetração e à dificuldade de manutenção de níveis adequados da droga no sítio da infecção. Por conseguinte, métodos diagnósticos mais acessíveis e de fácil execução, bem como, novas técnicas, instrumentos ou tecnologias que colaborem para a melhoria do tratamento são desejáveis. Objetivos: Avaliar o uso da dermatoscopia no diagnóstico da DSLO, através da análise da frequência dos sinais dermatoscópicos; e sobretudo, avaliar a eficácia do uso do LASER (Light Amplification by Stimulated Emission of Radiation)de Er:YAG em associação ao esmalte de amorolfina a 5% no tratamento da onicomicose subungueal distal lateral (DSLO). Metodologia: Trata-se de estudo transversal descritivo da frequência dos sinais dermatoscópicos em casos de DSLO; e de ensaio clínico aberto, controlado e randomizado, visando o estudo da associação do LASER de Er:YAG com o esmalte de amorolfina 5% no tratamento de casos de DSLO. Pacientes com diagnóstico clínico e micológico de DSLO, por fungos dermatófitos, foram objetos dos estudos. Para o estudo transversal, achados/sinais dermatoscópicos de unidades ungueais com a doença foram categorizados e analisados quanto sua sensibilidade. Para o ensaio clínico, unidades ungueais foram agrupadas aos pares, quanto à similaridade de alterações patológicas, e então randomizadas para o grupo de intervenção (L+A) ou grupo controle (A), para receber sessão única de ablação fracionada com o LASER de Er:YAG e posterior aplicação semanal do esmalte de amorolfina 5% (L+A) ou apenas ao uso semanal do esmalte de amorolfina 5% (A). Ao final de 6 meses, as variáveis cura micológica, melhora clínica/dermatoscópica e cura global foram avaliadas através do teste exato de Liddell. Resultados: Nove pacientes do sexo feminino (idade, 54,6±10,6 anos) participaram do estudo, com um total de 46 unidades acometidas por DSLO. A avaliação dermatoscópica das unidades ungueais demostrou a onicólise (n=46, 100%), borda espiculada proximal à área de onicólise (n=42, 91,3%), hiperceratose subungueal (n=41, 89,1%), opacidades ungueais e discromias (n=40, 86,9%), descamação periungueal (n=34,73,9%) e estrias longitudinais (n=30, 65,2%) como os achados mais frequentes na DSLO. Quando aos achados do ensaio clínico, não houve diferença estatística nos índices de cura micológica (p>0,99), ou cura global (p=0,68) entre os grupos de intervenção (L+A) e o grupo controle (A). Conclusões: Os sinais dermatoscópicos foram de fácil identificação na DSLO usando magnificações convencionais (10X), e devem ter seus valores, nos diversos tipos de onicomicose, melhor determinados. Por outro lado, para a presente amostra e período de segmento de 6 meses, o LASER de Er:YAG não se mostrou efetivo no aumento da eficácia do tratamento tópico com esmalte de amorolfina 5%. Entretanto, o grande número de unidades ungueais com melhora clínica e avaliação micológica negativa, porém sem alcançar critérios de cura, aponta para a necessidade de estudos mais longos, visando excluir a interferência da baixa velocidade de crescimento das unhas na análise das variáveis. ______________________________________________________________________________________ ABSTRACTBackground: Onychomycosis affects about 10% of the population around the world. It presents a challenging management given its long-term and expansive treatment. The diagnosis is often difficult due to the low sensibility and accuracy of the widely available tests. Otherwise, high rates of failure regarding treatment, relapses and reinfection, seem to be closely linked to the low penetration of drugs to the nail plate, as well as, to the difficulty in keeping effective drug concentration on infection site. Thereby, new tests, more accessible and effective, and also new techniques, instruments or technologies which could enhance therapeutic success are willing.Objectives: To evaluate the value of onychoscopy in the diagnosis of DSLO, by means of the frequency of dermoscopic finds; and specially,to evaluate the use of Er:YAGLASER(Light Amplification by Stimulated Emission of Radiation) in association with 5% amorolfine nail lacquer in the treatment of subungual distal lateral type onychomycosis (DSLO).Patients and Methods: Both a transversal descriptive study, about the frequency of dermoscopic finds in DSLO, and an opened, controlled and randomized clinical trial, aimed at evaluating the combination of Er:YAGLASER plus amorolfine nail lacquer in the treatment of DSLO, have been developed. Patients with clinical diagnosis of DSLO, caused by dermatophyteswere recruited to the study. A transversal evaluation involved the analysisof dermoscopic findsin ungual units with DSLO, by means of its sensibility on disease diagnosis. The clinical trial required ungual units with DSLO to be grouped in pairs, in accordance with damage grades. Nails were then randomized into one of study groups, in which the L+A group (investigation) was submitted to a single session of Er:YAG fractionated ablation of affected area, followed by weekly use of 5% amorolfine nail lacquer, and the A group (control) received only weekly application of amorolfine. After 6 months follow-up, ungual units were tested for micologycal cure, clinical and dermoscopic improvement and global cure, being pair-matched data analyzed by Liddell’s exact test. Results: Nine female patients with mean age of 54,6±10,6 years with a total of 46 ungual units with DSLO were studied. Dermoscopic exam of nails showed onycholysis (n=46, 100%), “spikes” signal (n=42, 91,3%), subungual hyperkeratosis (n=41, 89.1%), discoloration/ungual opacities (n=40, 84.5%), perungual desquamation (n=34, 73.9%) and longitudinal streaks (n=30, 65,2%) as the main signs found in DSLO. On the other hand, results from clinical trial did not show statistical differences regarding mycological cure (p>0,99) or global cure (p=0,68) between L+A or A groups. Conclusions: Dermoscopic signs were of easy identification in DSLO using regular magnification (10X), although their role in the diagnosis of different types of onychomycosis must be better determined. On the other hand, assuming the sample studied and the follow-up period of 6 months, Er:YAG LASER did not show to improve the efficacy provided by topical treatment with 5% amorolfine nail lacquer in cases of DLSO. Although, the great number of nails which reached mycological cure and also showed at least partial improvementpoints out to the possibility of bias effect of slowly growing nails on the results of global cure analysis

Leishmaniose recidiva cútis

Paciente do sexo masculino, 18 anos. Dois anos após tratamento insuficiente para leishmaniose tegumentar americana, apresentou, na mesma localização, lesão formada por cicatriz atrófica central e nódulos verrucosos na periferia. Era imunocompetente, hígido e negava qualquer trauma local. O diagnóstico de leishmaniose recidiva cutis foi feito através de cultura do aspirado da lesão. Realizou tratamento com N-metilglucamina (20mgSbV/kg/dia) associado à pentoxifilina (1200mg/dia) durante 30 dias alcançando cura clínica. Os casos semelhantes requerem atenção diferenciada pela dificuldade ao tratamento.We present a case of an 18-year-old male patient who, after two years of inappropriate treatment for cutaneous leishmaniasis, began to show nodules arising at the edges of the former healing scar. He was immune competent and denied any trauma. The diagnosis of recurrent cutaneous leishmaniasis was made following positive culture of aspirate samples. The patient was treated with N-methylglucamine associated with pentoxifylline for 30 days. Similar cases require special attention mainly because of the challenges imposed by treatment

Complementary exams in the diagnosis of american tegumentary leishmaniasis

The diagnosis of American Tegumentary Leishmaniasis is a difficult but essential task when considering the high toxicity profile of the drugs available. Since the discovery of its etiologic agent, numerous diagnostic tests have been developed. None of the tests available today can be considered as the gold standard, since they do not add enough accuracy for the disease detection. Good epidemiological and clinical knowledge of the disease are fundamental precepts of the dermatology practice and precede the rational use of existing diagnostic tests. In this article we aim, through extensive literature review, to recall fundamental concepts of any diagnostic test. Subsequently, based on this information, we will weave important comments about the characteristics of existing diagnostic tests, including immunological tests such as Montenegro's skin test, serology and detection of parasites by direct examination, culture or histopathology. Finally we will discuss the new technologies and options for the diagnosis of Cutaneous Leishmaniasis. The molecular biology technique is considered a promising tool, promoting the rapid identification of the species involved. We also aim to educate dermatologists about a disease with high morbidity and assist in its difficult recognition

Infection of the lymphatic system by Aureobasidium pullulans in a patient with erythema nodosum leprosum

Aureobasidium pullulans is a causal agent of phaeohyphomycosis, occasionally found in men and animals. As an agent of different opportunistic fungal processes, it may cause fungemia, systemic infections and abscesses in different viscera. This paper aims to report a case of a patient with infection of the lymphatic system by A. pullulans. A 23-year-old patient being treated for erythema nodosum leprosum presented a 60-day complaint of daily fever, hoarseness, odynophagia and weight loss. Laboratory tests showed pancytopenia with severe neutropenia, cervical adenomegaly and solid contrast uptake lesion in the oropharyngeal region. Due to neutropenia and sepsis the patient was initially treated with cefepime and vancomycin, but there was no clinical improvement. Lymph node puncture-aspiration showed yeast-form fungus identified as A. pullulans by sequencing ITS region. The patient was treated with amphotericin B deoxycholate, leading to complete recovery of bone marrow function and regression of adenomegaly and the oropharyngeal lesion

Associação VACTERL: Relato De Caso

BACKGROUND: VACTERL association is established by the appearance of congenital malformations: vertebral defects, anal atresia, tracheoesophageal fistula with or without esophageal atresia, limb dysplasia, renal dysplasia and heart diseases. CASE REPORT: pediatric patient, 4 years old, female, brown, natural and resident of country town of the state of Maranhão. Mother without prenatal achievement. Born vaginally. She presented anorectal malformation from birth, underwent a double mouth colostomy and, after an interval of time, reconstruction of intestinal transit and successive anal dilatations. In the investigation of other congenital anomalies, ultrasonography of the kidneys and urinary tracts, magnetic resonance imaging of the neuroaxis and radiography of the right upper limb and echocardiography were requested. Besides the anorectal anomaly, vestibular fistula, right unilateral renal agenesis, spina bífida L5, right radial agenesis and ventricular septal defect were also observed. With these data in hand, the VACTERL syndrome was characterized. CONCLUSIONS: The association of VACTERL highlights a set of malformations with diverse clinical presentation that brings great burden to the patients and shows the importance of early prenatal and neonatal diagnosis, since the conduct to be taken after birth will be defined based on severity of anomalies, showing to be always an important topic of discussion among clinicians, pediatricians and surgeons.INTRODUÇÃO: A associação VACTERL é estabelecida amiúde pelo aparecimeto de pelo menos três das seguintes malformações congênitas:  defeitos vertebrais, atresia anal, fístula traqueoesofágica com ou sem atresia de esôfago, displasia em membros, displasia renal e cardiopatias. RELATO DE CASO: paciente pediátrica, 4 anos, feminino, parda, natural e residente de uma cidade do interior do estado do Maranhão. Mãe não realizou pré-Natal. Nascida de parto vaginal. Apresentou malformação anorretal desde o nascimento, passou por realização de colostomia de dupla boca e, após um intervalo de tempo, reconstrução de trânsito intestinal e sucessivas dilatações anal. Na investigação de outras anomalias congênitas foi solicitado ultrassonografia de rins e vias urinárias, ressonância magnética de neuroeixo e radiografia de membro superior direito e ecocardiograma. Ao diagnóstico evidenciou-se, além da anomalia anorretal, fístula uretrovaginal e retovaginal, agenesia renal unilateral direita, espinha bífida em L5, deformidade em antebraço direito e comunicação interventricular. Com esses dados em mãos, foi caracterizado a síndrome VACTERL. CONSIDERAÇÕES FINAIS: a associação de VACTERL ressalta um conjunto de malformações com apresentação clínica diversa que traz grande ônus aos portadores e mostra a importância do diagnóstico pré-natal e neonatal precoce, visto que a conduta a ser tomada após o nascimento será definida com base na gravidade das anomalias, mostrando ser sempre um tópico importante de discussão entre clínicos, pediatras e cirurgiões

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear understanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5,6,7 vast areas of the tropics remain understudied.8,9,10,11 In the American tropics, Amazonia stands out as the world's most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepresented in biodiversity databases.13,14,15 To worsen this situation, human-induced modifications16,17 may eliminate pieces of the Amazon's biodiversity puzzle before we can use them to understand how ecological communities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple organism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region's vulnerability to environmental change. 15%–18% of the most neglected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lost

Audiometric comparison in children with vent tub

Introduction: Otitis media with effusion (OME) is one of the most common diseases in the childhood. Clinical manifestations vary from speech damage to learning deficit. The diagnosis must be made, mainly, through the physical exam and tympanometry. The treatment of OME may be clinical or surgical, with a vent tube. Objective: To evaluate the follow-up of patients with OME submitted to the placing of vent tube and compare the pre- and postoperative audiometric findings. Method: Children with OME and failure in the clinical treatment were submitted to tympanometry and placing of vent tube. The audiometry obtained in the postoperative period was compared with that requested during follow-up, between six and twelve months after surgery, subsequent to the tube extrusion. Results: The Speech Recognition Threshold exceeded an average value of 28.75 dB to 13 dB. Conclusions: The children submitted to the placement of the vent tube presented a significant audiometric improvement after the surgery. Since the data in this study were obtained from objective exams, we believe this is an excellent way to evaluate the surgical results of patients submitted to the placement of the vent tube