Majocchi’s Granuloma by Trichophytum rubrum in a kidney transplant patient - A case report

Introduction: Trichophytum rubrum is a filamentous fungus, with worldwide distribution, that usually causes superficial infections of skin and nails, namely tinea pedis, tinea corporis, tinea cruris and onychomycosis. Rarely, severe dermatophytosis can occur, presenting as deep dermatophytosis, Majocchi’s Granuloma or extensive dermatophytosis. Objectives and Methods: Case report of Majocchi’s Granuloma in a kidney transplant patient. Results: A case of a 55-year-old woman who underwent a kidney transplant 7 months before, under immunosuppressive therapy with tacrolimus and mycophenolate mofetil. She attended a Dermatology consultation to clarify skin lesions that appeared 6 months earlier. The skin exam revealed hard and painful plaque lesions on both legs, with an ulcer on the left leg lesion, violaceous papular lesions on the dorsum of the left foot and toes and a hard consistency nodule on the left leg. Some of the toe nails presented dystrophy or onycholysis. The patient denied any previous trauma or contact with plants or soil. Biopsies of lesions of the left leg and foot dorsum where sent for histology and mycological culture and toe nails for mycological culture. The histological examinations showed, in the reticular dermis and reaching the hypodermis, suppurative granulomas with multinucleated giant cells and areas of necrosis. PAS (Periodic Acid- Schiff) and GMS (Grocott’s Methenamine Silver) staining revealed multiple spores and septate hypha within the granulomas but not in the stratum corneum. No remnants of hair follicles where found. Culture of skin biopsies were positive for Tricophytum rubrum but nails´ culture was negative. Identification was further confirmed by sequencing of ITS region of ribosomal DNA (GenBank accession number MK967277). Oral Itraconazole 100mg bid and topic Sertoconazole where initiated. The patient was observed one month after and reported general malaise, tiredness, exertional dyspnea, whitish stools and increased abdominal volume. The physician chose to discontinue itraconazole and initiate oral terbinafine 250mg id. After two months on oral terbinafine, there was regression of the legs´ and left foot lesions with ulcer healing and disappearance of the left leg nodule. Conclusion: Diagnosis of deeper dermatophytosis is difficult, in part because there is no specific clinical presentation and, in many cases, it is even polymorphic. However, especially in patients with immunodeficiency, this hypothesis should be weighed. Confirmation is achieved by finding hyphae compatible with dermatophytes in the dermis and a positive culture for a dermatophyte. Treatment should include systemic antifungal agents, to which topical medication may be associated. Multiple therapeutic regimens have been proposed, but randomized trials or large case series are lacking. Antifungal therapy should be continued until the lesions are completely resolved. Surgical treatment has been reported as an option for highly localized lesions.info:eu-repo/semantics/publishedVersio

Completion problems for real matrices, II

Thirty years ago, G.N. de Oliveira has proposed the following completion problems: Describe the possible characteristic polynomials of [C-ij], i,j is an element of {1, 2}, where C-1,C-1 and C-2,C-2 are square submatrices, when some of the blocks C-ij are fixed and the others vary. Several of these problems remain unsolved. This paper gives the solution, over the field of real numbers, of Oliveira's problem where the blocks C-1,C-1, C-2,C-2 are fixed and the others vary

Analytical model for the development strategy of a low-density territory: The Montesinho Natural Park

Montesinho Natural Park is one of the largest Portuguese natural protected areas, presenting good biodiversity and a cultural heritage with a strong connection to the territory and its people. It constitutes a low-density territory, characterized by a human and social landscape based on community practices, such as joint aid and the community use of goods and means of agricultural production, which have contributed to the construction of the “transmontana” identity and to the richness of the habitats. The promotion of the sustainable development of this low-density rural region demands the understanding of its specificities and an appropriate approach to grasp its challenges and develop effective management tools, allowing to preserve and exploit the region’s potential from various perspectives. The purpose of this article is to develop an analytical model using a literature review and a survey of the region’s specificities. This analytical model intends to provide the basis for designing and assessing sustainable development solutions, increasing local entrepreneurship and community empowerment through regional dynamism, with a focus on environment and heritage preservation, universal tourism accessibility, collective memory and endogenous product development. The suggested model adopts an interdisciplinary perspective and stresses that, in order to ensure that the new initiatives will contribute to the territory’s sustainable development, they should be scrutinized by asking four main questions: Is the initiative promoting the rural development of the territory through the creation of synergies between agroforestry and tourism activities? Is the initiative promoting an inclusive and sustainable tourism that is based on the territory’s resources? Are heritage and collective memory being preserved and valued through the initiative? Is the initiative promoting the empowerment of local communities?info:eu-repo/semantics/publishedVersio

Predictive Response Value of Pre- and Postchemoradiotherapy Variables in Rectal Cancer: An Analysis of Histological Data

Background. Neoadjuvant chemoradiotherapy (nCRT) followed by curative surgery in locally advanced rectal cancer (LARC) improves pelvic disease control. Survival improvement is achieved only if pathological response occurs. Mandard tumor regression grade (TRG) proved to be a valid system to measure nCRT response. Potential predictive factors for Mandard response are analyzed. Materials and Methods. 167 patients with LARC were treated with nCRT and curative surgery. Tumor biopsies and surgical specimens were reviewed and analyzed regarding mitotic count, necrosis, desmoplastic reaction, and inflammatory infiltration grade. Surgical specimens were classified according to Mandard TRG. The patients were divided as "good responders" (Mandard TRG1-2) and "bad responders" (Mandard TRG3-5). According to results from our previous data, good responders have better prognosis than bad responders. We examined predictive factors for Mandard response and performed statistical analysis. Results. In univariate analysis, distance from anal verge and ten other postoperative variables related with nCRT tumor response had predictive value for Mandard response. In multivariable analysis only mitotic count, necrosis, and differentiation grade in surgical specimen had predictive value. Conclusions. There is a lack of clinical and pathological preoperative variables able to predict Mandard response. Only postoperative pathological parameters related with nCRT response have predictive value.info:eu-repo/semantics/publishedVersio

Tumor regression grades: can they influence rectal cancer therapy decision tree?

BACKGROUND: Evaluating impact of tumor regression grade in prognosis of patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS: We identified from our colorectal cancer database 168 patients with LARC who received neoadjuvant therapy followed by complete mesorectum excision surgery between 2003 and 2011: 157 received 5-FU-based chemoradiation (CRT) and 11 short course RT. We excluded 29 patients, the remaining 139 were reassessed for disease recurrence and survival; the slides of surgical specimens were reviewed and classified according to Mandard tumor regression grades (TRG). We compared patients with good response (Mandard TRG1 or TRG2) versus patients with bad response (Mandard TRG3, TRG4, or TRG5). Outcomes evaluated were 5-year overall survival (OS), disease-free survival (DFS), local, distant and mixed recurrence. RESULTS: Mean age was 64.2 years, and median followup was 56 months. No statistically significant survival difference was found when comparing patients with Mandard TRG1 versus Mandard TRG2 (p = .77). Mandard good responders (TRG1 + 2) have significantly better OS and DFS than Mandard bad responders (TRG3 + 4 + 5) (OS p = .013; DFS p = .007). CONCLUSIONS: Mandard good responders had a favorable prognosis. Tumor response (TRG) to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with LAR

Fasting Glucose Metabolism in Pregnancy

The HAPO study found a continuous association between hyperglycemia at 24-32 weeks of gestation, below the diagnostic levels of gestational diabetes mellitus (GDM), and adverse pregnancy outcomes, suggesting the need to reconsider the diagnostic criteria for GDM. Recently, a consensus for diagnosis of diabetes in pregnancy was published, based on the results of the HAPO study. Diagnosing for diabetes is considered already in the first trimester with fasting plasma glucose (FPG), but oral glucose tolerance test is recommended to be performed only at 24-28 weeks of gestation. Identifying all pregnant women at risk for GDM in the first trimester would allow an individualization of obstetric care and establishment of a dietetic and exercise plan since earlier stages of pregnancy with potential benefits for both mother and fetus. The glycemic metabolism varies throughout pregnancy, as insulin resistance increases during pregnancy. However the cut-off values for blood glucose tests in screening and diagnosing GDM are independent of gestational age. The objectives of this study are to verify if the pregnant women with and without GDM diagnosed in the second/third trimester are already different from each other in the first trimester regarding FPG levels and to study the evolution of the FPG throughout pregnancy

Perforated peptic ulcer: main factors of morbidity and mortality.

World J Surg. 2003 Jul;27(7):782-7. Perforated peptic ulcer: main factors of morbidity and mortality. Noguiera C, Silva AS, Santos JN, Silva AG, Ferreira J, Matos E, Vilaça H. Surgery Department, Surgery 1, Hospital Geral de Santo António, Instituto de Ciencias Biomédicas Abel Salazar, Largo do Prof. Abel Salazar, 4099-001 Oporto, Portugal. Abstract It is well stated in the literature that medical treatment for peptic ulcer is based on a combination of proton pump inhibitors (PPIs) and antibiotics to eradicate Helicobacter pylori. This treatment is associated with a high rate of immediate success and a low rate of recurrence at 12 months, although it is not effective in all patients. Peptic ulcer (PU) perforation is a serious problem that leads to high complication and mortality rates. Surgical treatment, with its various possibilities, constitutes the ideal treatment. Surgical intervention in these cases, however, can be directed to treating the perforation alone, or it can offer definitive treatment of the ulcer itself. With the hope of establishing why such complications and mortality were seen in the patients in our hospital population, we gathered the facts about PU perforations and the types of surgery performed. We studied 210 consecutive patients (150 men, 60 women) who had undergone surgery at our hospital because of perforation between January 1, 1990 and December 31, 2000. The patients' median age was 53.0 +/- 20.6 years (men 47.7 +/- 17.3 years; women 66.3 +/- 22.0 years). Altogether, 86 patients had significant associated illnesses, 62 were admitted more than 24 hours after the perforation, and 25 were admitted in shock. We performed resections in 10 patients; 88 patients were treated by suturing the perforation with or without a patch of epiploon; and 112 underwent a troncular vagotomy with drainage (VT + Dr). A total of 21 patients died (10%). Significant risk factors that led to complications were identified by statistical studies. They were a perforation that had been present more than 24 hours, the coexistence of significant associated illnesses, and resection surgery. The significant risk factors that led to death were the presence of shock at admission, the coexistence of significant illnesses, and resection surgery. There was no statistically significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery (VT + Dr). PMID: 14509505 [PubMed - indexed for MEDLINE

Early gastric cancer: ten years of experience

World J Surg. 2002 Mar;26(3):330-4. Epub 2001 Dec 21. Early gastric cancer: ten years of experience. Nogueira C, Silva AS, Santos JN, Silva AG, Ferreira J, Matos E, Vilaça H. Surgery Department, Surgery 1, Hospital Geral de Santo António, Largo Prof. Abel Salazar, 4000 Oporto, Portugal. [email protected] Abstract Gastric cancer is a disease in which the main treatment is surgical extirpation. The modifications introduced in the surgical treatment over the last decades were accompanied by a clear increase of survival, which reaches global values of 61% at 5 years in Japan. One of the reasons that contribute to this improvement is early diagnosis of the lesions. In the period between January 1, 1990 and December 31, 1999 662 patients with gastric adenocarcinoma were treated in the Service of Surgery 1 of our hospital; 110 were refused surgical treatment. Of the resected patients, 91 (21.4%) were classified as early gastric cancer according to the definition of the Japanese Society of Digestive Endoscopy. There were 30 women and 61 men, with a median age of 60.2 +/- 15 years; 3 patients had a preoperative diagnosis of gastric ulcer; 2 others were operated without recent histology; and 1 patient was urgently resected for a bleeding ulcer. In all the remaining patients biopsy confirmed the presence of cancer (89%) or serious dysplasia (4.6%). The lesions had been distributed essentially in the medium 1/3 (48.3%) and distal 1/3 of the stomach. Subtotal gastrectomy was accomplished in 48 patients, total gastrectomy in 40, total desgastrogastrectomy in 3, and in 9 patients the surgery involved the spleen (8 patients) and the spleen and tail of the pancreas in 1 patient. Lymphadenectomy was not performed in 5 patients, lymph nodes by the first lymph node barrier were removed in 25 patients and by the second barrier in 61 patients (67%). Median tumor size was 26 +/- 1.8 mm. The lesion reached the mucosa in 46 patients and the mucosa and submucosa in 45. In 6 patients the removed lymph nodes were microscopically invaded (6.7%). Five patients died (5.7%). The median follow-up of the patients is 41 +/- 26 months; 7 patients died (8.1%) during this period; 4 died unequivocally of disease progression. The median survival of patients was 85% at 5 years and 80% at 10 years. In our series, survival was affected by the presence of invaded lymph nodes, not by the penetration in depth of the lesion or the size of the tumor. PMID: 11865370 [PubMed - indexed for MEDLINE