Mucinose folicular na infância: um diagnóstico raro, mas significante

TCC(graduação) - Universidade Federal de Santa Catarina. Centro de Ciências da Saúde. Medicina.Follicular mucinosis (MF) is a rare cutaneous disease with unclear etiology, it was firstly described by Pinkus et. al. in 1957, who named it mucinous alopecia, referring to a characteristic process of the MF, which leads to alopecia. As this process was not seen on all developments of the disease, in 1959 Jablonska et. al. proposed to name it Follicular mucinosis. Follicular mucinosis is uncommon in children. Using the online searching databases Scielo and PubMed, during the past 10 years, there were found only 16 pediatric case reports about the disease: 3 associated with mycosis fungoides (MFg), 1 about the acneiform presentation of the disease, 9 discussing the primary type, 1 did not specify the diagnosis in the report and 2 were about other presentations of the disease. The main concern of diagnosing a child with MF is whether it is associated with MFg, a cutaneous T-cell lymphoma, that although rare in children, when present is mostly associated with MF. The earlier the diagnosis of MFg is made, the better is the prognosis of the patient. Therefore, it is of great importance that a general practitioner pediatrician can diagnose a case of MF and identify whether it is associated with MFg or other systemic diseases.Mucinose folicular (MF) é uma doença cutânea rara e de etiologia incerta, mas que pode impactar drasticamente a qualidade de vida e o prognóstico dos pacientes. Dessa forma, o presente estudo busca divulgar, no meio científico, uma das possíveis apresentações clínicas da doença, além de reforçar a importância do seu diagnóstico e acompanhamento. A MF foi descrita pela primeira vez por Pinkus et. al. em 1957, que a nomeou Alopecia mucinosa referindo-se a um processo característico da MF, que leva a alopecia. Entretanto, como esse processo não ocorre em todos os casos da doença, em 1959, Jablonska et. al. propôs a alteração do nome para mucinose folicular. A MF é incomum em crianças: usando as bases de dados online da Scielo e do PubMed, foram encontrados apenas 16 relatos de casos pediátricos da doença durante os últimos 10 anos. Entre esses relatos, 3 eram associados à micose fungoide (MFg), 1 sobre a apresentação acneiforme (primária) da doença, 9 discutindo a forma primária clássica da doença, 1 não especificou o diagnóstico no relato e 2 são sobre outras apresentações da doença. A principal preocupação ao fazer um diagnóstico de mucinose folicular é investigar se ele é ou não associado à micose fungoide. A MFg é um linfoma cutâneo de células T, cujo diagnóstico precoce é essencial para um melhor prognóstico do paciente. Apesar de rara em crianças, quando a MFg está presente, é comumente associada a MF. Dessa forma, é de grande importância que um médico generalista consiga identificar um caso de mucinose folicular a fim de dar o encaminhamento necessário ao paciente, excluindo possíveis malignidades associadas

Carcinoma de células ependimárias com metástase renal e pulmonar em equino

Os ependimomas são neoplasias benignas ou malignas de células ependimárias que revestem o plexo coroide, o assoalho dos ventrículos cerebrais e o canal medular. São raros em animais domésticos, mas há relatos em cães e gatos. Neste relato descreve-se um carcinoma metastático de células ependimárias diagnosticado em equino Mangalarga Marchador, com morte decorrente de choque circulatório. Nódulos de superfície levemente rugosa, firme e coloração parda presentes no plexo coroide do IV ventrículo, rim e pulmão foram coletados, fixados em solução de formalina tamponada a 10%. Os fragmentos foram processados com inclusão em parafina e coloração em Hematoxilina/Eosina (HE) e imunomarcados para detecção de GFAP, vimentina e AE1/AE3. Os nódulos do IV ventrículo continham células ependimárias com anisocitose, anisocariose e figuras de mitose. Este padrão celular foi observado no rim e pulmão. Na imunohistoquímica, o nódulo do IV ventrículo foi positivo para GFAP, negativo para vimentina e fortemente positivo para AE1/AE3. No rim e pulmão os fragmentos foram positivos apenas para AE1/AE3. A descrição histopatológica e imunohistoquímica confirmaram diagnóstico do tumor de células ependimárias no IV ventrículo encefálico com metástase renal e pulmonar. Este tumor é considerado raro na espécie equina

Breast Carcinoma with Pulmonary Metastasis in Armadillo (Eupharactus sexcinctus)

Background: Breast neoplasms are among the most common neoplastic conditions affecting domestic animals and are considered the most common type of cancer affecting women, bitches, and cats. However, there are few reports on breast neoplasms in wild animals, and there is no record of their occurrence in armadillos worldwide. Breast neoplasms are hormone-dependent neoplasms that often cause lymph node and pulmonary metastases. The diagnosis is based on the patient’s history, complete physical examination, and complementary tests. Here we report a case of mammary neoplasia with pulmonary metastasis in an armadillo (Euphractus sexcinctus).Case: A senile female armadillo was referred to us for treatment with a history of hyporexia and nodules in both breasts. Ultrasonographic examination revealed a hypoechogenic nodular lesion with a cross-section of approximately 1.3 × 1.4 cm and well-defined borders. The lesion had a circumscribed aspect in the left mammary gland. In the right mammary gland, there was a heterogeneous lesion with cystic formations and anechoic content. Cytopathological examination of the nodules was performed by fine needle aspiration cytology and revealed the presence of epithelial cells with ovoid and aberrant nuclei, anisocariasis, binucleation, coarse chromatin, and a high nucleus to cytoplasm ratio suggestive of carcinoma. The animal had a lean body score due to hyporexia that had evolved to anorexia and was undergoing supportive treatment. Nevertheless, the animal died two months after the cytologic diagnosis. A necropsy was performed. Cutting of the breast nodules revealed a hardened pale yellow material. The animal had pronounced pleural effusion, hemorrhage, and numerous pale yellow nodules of various sizes with firm consistency throughout the lung parenchyma. It also had hepatomegaly and splenomegaly. Fragments of various organs were fixed in 10% buffered formalin, routinely processed, embedded in paraffin, and stained with hematoxylin and eosin. Upon microscopic examination, the mammary nodes demonstrated a proliferation of epithelial cells organized into tubular structures with intraluminal papillary projections. The cells had a polyhedral profile and a high nucleus to cytoplasm ratio, moderately pleomorphic evident nuclei. Some cells had coarse chromatin. We observed moderate anisocytosis and anisocariasis, as well as mitotic figures. In the lungs, nodules with the same microscopic characteristics of the mammary nodes were observed in addition to intense congestion and multifocal hemorrhages.Discussion: This type of mammary carcinoma is considered an invasive neoplasm of ductal origin, and is morphologically characterized by rounded, ovoid, or angulated tubule formations with intraluminal projections. The patient’s prognosis is directly related to the occurrence of vascular invasion and metastasis. If present, these conditions may lead to reduced patient survival. Since the lungs are the most common sites of metastasis, pleural effusion caused by vessel erosion due to the presence of tumors is common and can in most cases lead to respiratory failure and eventually death. In this case, the association between the necropsy findings and the results of the histopathological examination enabled us to classify the carcinoma as one of mammary origin and of the tubulopapillary type with pulmonary metastasis. This is the first report of mammary carcinoma in an armadillo in captivity in the world

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Estrobirulinas e boscalida na qualidade de frutos de melão rendilhado

Until recently, fungicides were used exclusively for disease control; however observations of physiological effects brought a new concept to the use of these products. Strobilurins have positive physiological effects on crop yield, due to the increase of liquid photosynthesis and better hormonal balance. However, boscalid complements the action of these fungicides, applied alternately or together. The aim of this study was to evaluate the effect of strobilurins (azoxystrobin and pyraclostrobin), boscalid and the mixture of these on the physical-chemical quality of net melon fruits (Cucumis melo var. Reticulatus). The experiment was conducted in the municipality of São Manuel (SP), using the hybrid of Cantaloupe M2-308 net melon, the experimental design was in randomized blocks with five replicates. The treatments used were: T1 - control; T2 - azoxystrobin 60g ha-1 of active principle (a.p.); T3 - boscalid 75g ha-1 of the a.p.; T4 - pyraclostrobin 50g ha-1 of the a.p.; T5 - boscalid (37,5g ha-1) of the a.p. + pyraclostrobin (25g ha-1) of the a.p. The first application of the treatments was carried out at fourteen days after the transplanting of the seedlings and the others at seven day intervals, totaling eight applications throughout the cycle. Two fruits of each plot were collected, which were identified for analysis in the laboratory. The following characteristics were evaluated: fresh fruit mass; mesocarp thickness, pulp texture, peel trajectory, pH, titratable acidity, soluble solids and the ratio. The results were submitted to analysis of variance and the averages compared by the Tukey test at 5% probability using the SISVAR program. The fruits of the plants treated with boscalid 75g ha-1 were the ones that showed higher concentration of soluble solids and low titratable acidity, resulting in a better ratio. Despite the lower value, the fruits of the plants treated with pyraclostrobin 50g ha-1 showed a high ratio value, besides presenting higher value for pulp texture. The mixture of boscalid (37.5g ha-1) + pyraclostrobin (25g ha-1) also showed high values of soluble solids which resulted in a good “ratio” value.Os fungicidas até pouco tempo eram utilizados exclusivamente para o controle de doença, no entanto observações de efeitos fisiológicos trouxeram um novo conceito para o uso desses produtos. As estrobilurinas possuem efeitos fisiológicos positivos no rendimento das culturas, devido ao aumento da fotossíntese líquida e melhor balanço hormonal. Já o boscalida complementa a ação desses fungicidas, aplicado alternadamente ou em conjunto. O trabalho teve como objetivo avaliar o efeito da aplicação de estrobilurinas (azoxistrobina e piraclostrobina), boscalida e a mistura destes na qualidade físico-química de frutos de melão rendilhado (Cucumis melo var. reticulatus). O experimento foi conduzido no município de São Manuel (SP), utilizando-se o híbrido de melão rendilhado Cantaloupe M2-308, o delineamento experimental foi em blocos ao acaso com cinco repetições. Os tratamentos utilizados foram: T1 - testemunha; T2 - azoxistrobina 60g ha-1 do princípio ativo (p.a.); T3 - boscalida 75g ha-1 do p.a.; T4 - piraclostrobina 50g ha-1 do p.a.; T5 - boscalida (37,5g ha-1) do p.a. + piraclostrobina (25g ha-1) do p.a. A primeira aplicação dos tratamentos foi realizada aos 14 dias após o transplante das mudas e as demais a intervalos de sete dias, totalizando oito aplicações ao longo do ciclo. Foram colhidos 2 frutos de cada parcela, os quais foram identificados para as análises no laboratório. Foram avaliadas as seguintes características: massa fresca do fruto; espessura do mesocarpo, textura de polpa, rendilhamento da casca, pH, acidez titulável, sólidos solúveis e o “ratio”. Os resultados foram submetidos à análise de variância e as médias comparadas pelo teste Tukey a 5% de probabilidade com auxílio do programa SISVAR. Os frutos provenientes das plantas tratadas com boscalida 75g ha-1 foram os que apresentaram maior concentração de sólidos solúveis e baixa acidez titulável, resultando em melhor “ratio”. Apesar do valor ser menor, os frutos das plantas tratadas com piraclostrobina 50g ha-1 apresentaram alto valor de “ratio”, além de apresentarem maior valor para textura de polpa. A mistura do boscalida (37,5g ha-1) + piraclostrobina (25g ha-1) também apresentou altos valores de sólidos solúveis o que acabou resultando em um bom valor de “ratio”

Extramedullary Plasmacytoma of the Third Eyelid in a Cat

Background: Extramedullary plasmacytoma is a neoplasm originating from plasmacytes with benign behavior, although it can present malignant characteristics such as local invasion and metastases in some cases. Primary extramedullary plasmacytoma in the third eyelid is rare in humans and animals and has not yet been described in cats. Thus, the goal of the present study is to describe the cytological and histopathological findings of an extramedullary plasmacytoma in a cat's third eyelid.Case: A 5-year-old female feline patient with a history of ocular alteration for approximately 30 days was referred to the ophthalmology service. Upon ophthalmic examination of the left eye, an increase in volume with tissue proliferation was identified in the third eyelid's conjunctiva. A collection of material for cytopathological examination was performed. Numerous plasmocytes and atypical lymphocytes with anisocytosis and anisokaryosis were observed, with a possible neoplastic injury being suggested and referred to the patient for surgical removal of the third eyelid. In the histopathological analysis, it was possible to observe several plasma cells and vascular neoformation along the entire conjunctive margin below the epithelium. The glands, serous and mucous, present in the fragment, revealed areas of intervening plasmacytic infiltrate and a large area close to the hyaline cartilage containing intense plasmacytic inflammatory infiltrate with rare neutrophils and macrophages. There was also a structural breakdown of glandular components and lymphocyte cells with mitosis figures and discrete cellular pleomorphism.Discussion: Plasmacytoma is a rare neoplasm in both dogs and cats. The anatomical regions most frequently affected are the digits, lips, and pinna. Concerning the 3rd eyelid tumor involvement, numerous types of neoplasms have been reported in dogs in the veterinary literature, including transmissible venereal tumor, squamous cell carcinoma, and melanocytoma melanoma, lymphoma, plasmacytoma, hemangioma, hemangiosarcoma, mastocytoma, and myoepithelioma. In cats, the third eyelid is the third site most affected by primary tumors. Adult and elderly animals are the most affected; however, an extramedullary plasmacytoma (PEM) has been reported in an eight-month-old male cat's skeletal muscle. Plasmacytoma aspirates, like other round cells, tend to be highly cellular, the cell morphology has a plasmacytoid aspect, resembling mature cells, the cytoplasm is intensely basophilic, and the round nucleus with an eccentric disposition has thin chromatin and indistinct nucleolus. Binucleate and multinucleate cells are common, and the absence of lymphoglandular corpuscles helps differentiate extramedullary plasmacytoma from lymphomas. Histologically, PEM is similar in dogs, humans, and felines, and variations in mature and immature plasma cells can be seen. The diagnosis of extramedullary plasmacytoma is fundamentally histological, and immunohistochemical analysis can also be performed. Surgical excision with safety margins is the primary type of treatment for neoplasms in the 3rd eyelid, being considered an effective method, as seen in this report, during the patient's follow-up for 13 months, no recurrence or metastasis of the neoplasm was seen. When signs of malignant neoplasms are found, it is recommended to evaluate the indication for chemotherapy before surgery and monitor the case after treatment due to recurrence risk