Multidrug-resistant tuberculosis: case reports study in a central state of Brazil

Multidrug-resistant tuberculosis (MDR-TB) is an emerging and worrisome health problem that threatens tuberculosis (TB) control worldwide. The clinical management of MDR-TB is a complex issue associated with the use of multiple drugs for a long period, usually accompanied by side effects and high costs. The objective of this work was to relate cases of MDR-TB occurring in Goiás, a central state of Brazil. We related five cases of MDR-TB, three women and two men. All were pulmonary cases. Three were in their second treatment and two in their first treatment. Surgical pulmonary resection was performed in one case. One death occurred. Lack of adherence, gastric intolerance to anti-TB drugs and poor clinical management were the main aspects related to the emergent resistance. A revision of the main clinical aspects of this disease was performed.     

Lower Leg Anterior and Lateral Intracompartmental Pressure Changes Before and After Classic Versus Skate Nordic Rollerskiing

Context

Chronic exertional compartment syndrome (CECS) is a debilitating condition resulting in loss of function and a decrease in athletic performance. Cases of CECS are increasing among Nordic skiers; therefore, analysis of intracompartmental pressures (ICPs) before and after Nordic skiing is warranted.

Objective

To determine if lower leg anterior and lateral ICPs and subjective lower leg pain levels increased after a 20-minute Nordic rollerskiing time trial and to examine if differences existed between postexercise ICPs for the 2 Nordic rollerskiing techniques, classic and skate.

Design

Crossover study.

Setting

Outdoor paved loop.

Patients or Other Participants

Seven healthy Division I Nordic skiers (3 men, 4 women; age = 22.71 ± 1.38 y, height = 175.36 ± 6.33 cm, mass = 70.71 ± 6.58 kg).

Intervention(s)

Participants completed two 20-minute rollerskiing time trials using the classic and skate technique in random order. The time trials were completed 7 days apart. Anterior and lateral ICPs and lower leg pain scores were obtained at baseline and at minutes 1 and 5 after rollerskiing.

Main Outcome Measure(s)

Anterior and lateral ICPs (mm Hg) were measured using a Stryker Quic STIC handheld monitor. Subjective measures of lower leg pain were recorded using the 11-point Numeric Rating Scale.

Results

Increases in both anterior (P = .000) and lateral compartment (P = .002) ICPs were observed, regardless of rollerskiing technique used. Subjective lower leg pain increased after the classic technique for the men from baseline to 1 minute postexercise and after the skate technique for the women. Significant 3-way interactions (technique × time × sex) were observed for the anterior (P = .002) and lateral (P = .009) compartment ICPs and lower leg pain (P = .005).

Conclusions

Postexercise anterior and lateral ICPs increased compared with preexercise ICPs after both classic and skate rollerskiing techniques. Lower leg pain is a primary symptom of CECS. The subjective lower leg pain 11-point Numeric Rating Scale results indicate that increases in lower leg ICPs sustained during Nordic rollerskiing may increase discomfort during activity. Our results therefore suggest that Nordic rollerskiing contributes to increases in ICPs, which may lead to the development of CECS.Key Words: chronic exertional compartment syndrome, compartment syndrome, anterior compartment, lower leg pain Nordic skiing

Key Points

• The exact cause of chronic exertional compartment syndrome is currently unknown.
• The diagnosis of chronic exertional compartment syndrome is increasing within the competitive Nordic skiing population.
• Increases in anterior and lateral intracompartmental pressures were observed after a 20-minute time trial using either the classic or skating Nordic rollerskiing technique.

Chronic exertional compartment syndrome (CECS) is a debilitating condition resulting in loss of function and a decrease in athletic performance. In general, a compartment syndrome occurs when the circulation and function of tissues within a closed space are compromised by increased pressure within that space.¹ An increase in tissue pressure within an enclosed space can threaten perfusion and tissue viability. In the case of CECS, this increase in tissue pressure within the confined space is reversible and will decrease after exercise ceases.² Common symptoms of CECS in the lower leg include burning, aching, paresthesia, weakness, and an inability to dorsiflex the foot. These symptoms are detrimental to performance and, if left untreated, have the potential to end an athlete''s career. Chronic exertional compartment syndrome has been reported among runners, cyclists, and military personnel.³ Recently, increasing anecdotal evidence of CECS among competitive Nordic skiers has been shown; however, no researchers have examined the relationship between Nordic skiing and intracompartmental pressures (ICPs).Rollerskiing is a typical dry-land method of Nordic ski training and may be performed using either the classic or the skate technique. Rollerskis are shortened Nordic skis with 1 wheel at each end designed to be used on smooth indoor or outdoor surfaces. Classic rollerskiing uses the same kick-and-glide motion as on snow. Classic rollerskis have wider wheels than skate rollerskis. A ratchet mechanism on 1 wheel only rolls forward, providing unidirectional travel and limiting negative gain. Skate rollerskiing uses the same lateral leg push as on snow. Skate rollerskis have narrower wheels, similar to in-line skates, and both wheels roll freely in either direction. For both techniques, boots and bindings are the same as those used for Nordic skiing on the snow.Anecdotally, some athletes complain that they experience more lower leg pain during classic rollerskiing than classic snow skiing, which could be attributed to the weight of the ski (approximately 2.5 kg per pair of classic rollerskis compared with approximately 1.18 kg per pair of classic snow skis). More recent anecdotal evidence has suggested that any increased pressure observed during the classic rollerskiing technique may be attributed to the quality of the rollerski wheels and the skier''s effort needed to maintain forward tracking and control of the ski while in motion. This suggestion is similar to anecdotal reports of increased lower leg pain while skate skiing in icy conditions, when one must sustain muscular contractions in the lower leg and foot to maintain control of the ski.It is unknown whether Nordic skiing causes chronic increases in anterior and lateral ICPs, which may contribute to the development of CECS. Combined with a thorough history and clinical examination, ICP testing is the gold standard used to diagnose CECS.⁴ In this study, if anterior and lateral ICPs increased during Nordic rollerskiing, the findings could point to Nordic rollerskiing as a possible contributor in the development of CECS. Coaches, athletes, and health care personnel may then seek modified skiing techniques and equipment to avoid increased ICPs during Nordic rollerskiing.The purpose of our study was to determine if ICPs of the anterior and lateral lower leg compartments increased among collegiate Nordic skiers after a 20-minute rollerskiing time trial. We also aimed to determine whether postexercise ICPs differed for the classic rollerskiing technique versus the skate rollerskiing technique. We hypothesized that the ICPs of both the anterior and lateral lower leg compartments would increase among collegiate Nordic skiers after the 20-minute time trial. We also hypothesized that postexercise anterior and lateral ICPs would be higher after the skate rollerskiing technique than the classic rollerskiing technique. Significant results will allow physicians, athletic trainers, coaches, and athletes to better understand CECS and the Nordic skiing population, which may lead to modified training methods or injury-prevention practices for both symptomatic and asymptomatic skiers.     

Biological,psychological and social processes that explain celebrities’ influence on patients’ health-related behaviors

Background

Celebrities can have substantial influence as medical advisors. However, their impact on public health is equivocal: depending on the advice’s validity and applicability, celebrity engagements can benefit or hinder efforts to educate patients on evidence-based practices and improve their health literacy. This meta-narrative analysis synthesizes multiple disciplinary insights explaining the influence celebrities have on people’s health-related behaviors.

Methods

Systematic searches of electronic databases BusinessSource Complete, Communication & Mass Media Complete, Humanities Abstracts, ProQuest Political Science, PsycINFO, PubMed, and Sociology Abstracts were conducted. Retrieved articles were used to inform a conceptual analysis of the possible processes accounting for the substantial influence celebrities may have as medical advisors.

Results

Fourteen mechanisms of celebrity influence were identified. According to the economics literature, celebrities distinguish endorsed items from competitors and can catalyze herd behavior. Marketing studies tell us that celebrities’ characteristics are transferred to endorsed products, and that the most successful celebrity advisors are those viewed as credible, a perception they can create with their success. Neuroscience research supports these explanations, finding that celebrity endorsements activate brain regions involved in making positive associations, building trust and encoding memories. The psychology literature tells us that celebrity advice conditions people to react positively toward it. People are also inclined to follow celebrities if the advice matches their self-conceptions or if not following it would generate cognitive dissonance. Sociology explains how celebrities’ advice spreads through social networks, how their influence is a manifestation of people’s desire to acquire celebrities’ social capital, and how they affect the ways people acquire and interpret health information.

Conclusion

There are clear and deeply rooted biological, psychological and social processes that explain how celebrities influence people’s health behaviors. With a better understanding of this phenomenon, medical professionals can work to ensure that it is harnessed for good rather than abused for harm. Physicians can discuss with their patients the validity of celebrity advice and share more credible sources of health information. Public health practitioners can debunk celebrities offering unsubstantiated advice or receiving inappropriate financial compensation, and should collaborate with well-meaning celebrities, leveraging their influence to disseminate medical practices of demonstrated benefit.

Electronic supplementary material

The online version of this article (doi:10.1186/2049-3258-73-3) contains supplementary material, which is available to authorized users.     

The spectrum of computerized tomography (CT) findings in central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii in immunocompetent children

Cranial CT scans of eleven immunocompetent children with central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii were retrospectively reviewed. These children had an average age of 8.8 years and positive culture for C. n. var. gattii in cerebrospinal fluid. The most common signs and symptoms were headache, fever, nuchal rigidity, nausea and vomiting. No normal cranial CT was detected in any patient. Hypodense nodules were observed in all patients. The remaining scan abnormalities were as follows: nine had diffuse atrophy, six had hydrocephalus, and five had hydrocephalus coexistent with diffuse atrophy.     

A new method of evaluating attachment representations in young school-age children: The Manchester Child Attachment Story Task

We describe a new instrument, using a doll-play vignette completion method, which applies concepts and methodologies from infant and adult attachment research to enable identification and detailed classification of internal representations of attachment relationships in young school-age children. Validation of the Manchester Child Attachment Story Task (MCAST) in a normal population (N = 53) shows good interrater reliability and content validity. Patterns of attachment representation identified show stability over time. Comparisons are made with existing methodologies, and potential applications of the instrument and directions for future research are discussed.     

Can only histological evaluation determine the allocation of ECD kidneys?

Introduction

There is a recent debate on the "transplantability" of ECD (Expanded Criteria Donors) kidneys and the selection criteria used to allocate them to single or double transplantation. Remuzzi et al. have defined a protocol incorporating pre-transplant donor biopsy to guide the use of older donor organs. They allocated organs as single or double transplants on the basis of histological findings. We aim to show the pros and cons of the only histological evaluation in the allocation of ECD kidneys, to compare the different experiences in United States and Europe and thus to discuss whether this tool should be used alone or included in a comprehensive clinical and histopathological evaluation.

Discussion

In the United States many Authors stated that the biopsy actually increases the percentage of kidney discarded and they raised questions about the importance of the biopsy in evaluating ECD kidneys for transplantation. On the other hand, the experiences of the majority of european transplant centers showed that allocating kidneys as single or dual transplant based on biopsy findings may achieve good graft and patient outcomes.Moreover, the experience of some centers as ours showed that kidneys allocated as DKT (Dual Kidney Transplant) on the basis of Remuzzi’s score could have been suitable for single transplantation suggesting the need of an adjustment of the Remuzzi Score System. Many Authors, who are in favor of histological evaluation, actually believe that a comprehensive clinical and histopathological assessment before transplantation remains necessary.

Summary

We lack precise national- or international-based selection criteria to guide clinicians. An adjustment of the Remuzzi Score System could be taken into consideration such as narrowing the indication for DKT from those ECD kidneys with higher scores and including the histological evaluation in a multifactor score.