Role of dermatologists in leprosy elimination and post-elimination era: the Brazilian contribution

Dermatologists in Brazil have always been involved in care of leprosy patients, and have been alternating with public health physicians in the management of control policies. It is worth mentioning that Fernando Terra, founder of the Brazilian Society of Dermatology (BSD) in 1912, established the position of intern dermatologist at the Hospital dos Lizaros, in Rio de Janeiro, in 1913 (Souza-Araújo, 1952; Oliveira, 1991). In 1920, the dermatologist Eduardo Rabello formulated the first national public policy on the control of leprosy in the country, which was called 'Inspection of Prophylaxis of Leprosy and Venereal Diseases'. His son was an enthusiast of dermatological research and his main legacy was the polarity concept of leprosy (Rabelo, 1937). However, from 1930 to 1985, the public health physicians were in charge of the political guidelines that represented the period of establishing the vertical programmatic structure, with compulsory isolation of patients (1933-1962). Moreover, the federal states coordinated the control actions, based on the leprosy prophylaxis campaign. The dermatologists resumed the conduction of the control process in 1986, when multi-drug therapy (MDT) was implemented in the country, and in 1991, when decentralization of public healthcare services to the municipal level took place. In 2003 again, the dermatologists were no longer in control of the national policy. However, active dermatologists have acted in Brazilian references on diagnosis and treatment of Hansen's disease, at municipal, state and national levels. It is true that dermatologists have been getting away from leprosy control actions. And one could ask: who will replace this specialist? In the 'post-elimination' era, when the public primary healthcare technicians no longer consider leprosy of much significance, the knowledge of the expert in this disease and its differential diagnoses will be crucial.     

Portal triad clamping (TC) or hepatic vascular exclusion (VE) for major liver resection after prolonged neoadjuvant chemotherapy? A case-matched study in 60 patients

BACKGROUND: Prolonged systemic preoperative chemotherapy induces pathologic changes in liver parenchyma. The consequences of vascular occlusion on liver submitted to prolonged preoperative systemic chemotherapy are not known. The aim of this case-matched study was to assess which method of vascular occlusion is most appropriate for major liver resection in patients who have undergone prolonged preoperative systemic chemotherapy. METHODS: Among 305 patients who had liver resection for colorectal metastases from 1998 to 2003, 28 underwent major liver resections under portal triad clamping after more than 6 cycles of preoperative chemotherapy (TC group). These 28 patients were compared with 32 patients matched for age, sex, ASA status, number of liver metastases, type of liver resection, and type of preoperative chemotherapy, but who had major liver resection under hepatic vascular exclusion after more than 6 cycles of preoperative chemotherapy (VE group). RESULTS: There was no postoperative mortality. The morbidity rate was 18% after TC and 43% after VE (P = 0.044). Pulmonary complication rate was greater after VE (31% vs 3%, P = 0.017). The transfusion rate was 50% in the TC group and 40% in the VE group (P = 0.482). Postoperative changes of liver function tests were comparable in the two groups except for the prothrombin time, which was more prolonged from day 1 (P = 0.003) to day 5 (P = 0.04) after VE. CONCLUSION: Vascular occlusion can be used with no mortality and acceptable morbidity for major liver resection after prolonged preoperative chemotherapy. TC should be preferred to VE, permitted by the location of the neoplasm.     

Human alpha rhythms during visual delayed choice reaction time tasks: a magnetoencephalography study

Magnetoencephalography (MEG) includes fast and comfortable recording procedures very suitable for the neurophysiological study of cognitive functions in aged people. In this exploratory MEG study in normal young adults, we tested whether very simple short-term memory (STM) demands induce visible changes in amplitude and latency of surface alpha rhythms. Two delayed response tasks were used. In the STM condition, a simple cue stimulus (one bit) was memorized along a brief delay period (3.5-5.5 s). In the control (no short-term memory; NSTM) condition, the cue stimulus remained available along the delay period. To make extremely simple the tasks, the explicit demand was visuospatial but the retention could be also based on phonological and somatomotor coding. Compared to the control condition, the amplitude of the alpha 1 (6-8 Hz) ERD decreased in the left hemisphere, whereas the amplitude of the alpha 2 (8-10 Hz) and alpha 3 (10-12 Hz) event-related desynchronization (ERD) increased in right and left parietal areas, respectively. Furthermore, the latency of the alpha ERD peak was slightly but significantly (P < 0.05) later in STM compared to control condition. In conclusion, whole-head MEG technology and very simple STM demands revealed significant changes of human neuromagnetic alpha rhythms in normal young adults.     

Primary glomerular diseases in Brazil (1979-1999): is the frequency of focal and segmental glomerulosclerosis increasing?

AIMS: Different patterns of glomerulonephritis (GN) are reported from all over the world and the occurrence of primary GN is changing in the course of time. We report the frequencies of primary GN in a major teaching hospital in Brazil, from 1979-1999. METHODS: The case files of renal biopsies of primary GN were reviewed. The included patients were > 14 years of age, with native kidneys, and the specimens were examined with at least light and immunofluorescence microscopy. We excluded biopsy results of patients with any kind of known secondary glomerular involvement. Differences in proportions of diagnoses between the periods over time were evaluated using Chi-square test for trend. RESULTS: We considered 943 patients for the analysis. Focal and segmental glomerulosclerosis (FSGS) was the most common lesion (n = 279), followed by membranous GN (n = 140), membranoproliferative type I GN (n = 109) and IgA nephropathy (n = 109). FSGS (32.1%) was the most frequent diagnosis among nephrotic patients whereas IgAN (29.4%) predominated in non-nephrotic ones. The occurrence of FSGS increased from the earlier to the later periods: 22.3% (1979-1983), 23.7% (1984-1988), 35.7% (1989-1993), 33.9% (1994-1999), p < 0.05. The increase in frequency of FSGS was proportionally higher in non-nephrotic patients and FSGS became as common as IgA nephropathy in this group (31.6% and 28.0%, respectively) from 1994-1999. CONCLUSIONS: FSGS was the most common pattern of primary glomerulonephritis and its relative frequency seems to be increasing in biopsied patients over time. The reasons for this behavior are unclear and warrant further investigations.     

Cardiorespiratory reflex effects induced by intravenous administration of ethanol in rats

Intravenous administration of a bolus of ethanol (40 mg/100 g b.w.) to rats induced bradycardia, hypotension and apnea. Bradycardia was dose dependent (r = -0.78, p less than 0.001). Acute bilateral vagotomy blocked bradycardia and hypotension. Apnea, however, persisted in all cases but was of short duration and occurred after a significant delay as compared to an untreated group. Atropine (0.1 mg/100 g b.w.) and hexamethonium (0.75 mg/100 g b.w.) blocked bradycardia and early hypotension. Pretreatment with reserpine (0.25 mg/100 g b.w. IP 24 and 48 hours before the experiment) significantly increased bradycardia induced by ethanol as compared to untreated animals. In rats pretreated with reserpine and vagotomized, IV ethanol did not induce bradycardia, early hypotension or apnea. A bolus of ethanol (20 mg/100 g b.w.) given directly into the left ventricle did not induce reflex changes in heart rate or respiration, while the same dose of alcohol given IV decreased heart rate by 53 +/- 8.9%. Thus, the ethanol effect seems to be initiated in pulmonary J receptors. Bradycardia appeared to be mediated both by increase in vagal tone, and to a lesser extent, by sympathetic withdrawal. Hypotension was due mainly to bradycardia, and apnea might be caused by a dual mechanism, reflex (early) and direct on the respiratory center (late).     

Assaults on psychiatrists by patients.

The authors describe the results of a survey of 115 psychiatrists regarding assaults by patients. Forty-eight psychiatrists stated that they had been assaulted; a total of 68 assaults was reported. Psychiatrists were most often assaulted in the early stages of their career or while they were working in high-risk settings such as prisons or emergency rooms. Many reported retrospectively that they might have had a role in provoking the assault and that they could have anticipated it. The authors believe that psychiatrists avoid dealing with the issue of violence by patients for a variety of reasons, and they recommend that clinicians learn techniques for managing potentially assaultive patients.     

Influences of changes in calcium concentration and verapamil on the cardiac depressant effect of ethanol in cat papillary muscle.

1. In isolated cat heart papillary muscle electrically driven at a constant rate the depressant effects of increasing concentrations of ethanol on peak tension developed (PTD) was studied in Ringer-Locke solution with different calcium concentrations and with the addition of verapamil. 2. Ethanol induced a concentration dependent decrease in PTD that was significantly greater for each concentration of ethanol in hypocalcic medium (1.1 mM) than in normocalcic medium (2.2 mM). 3. In normocalcic (2.2 mM) medium, verapamil (5.1 x 10(-4) mM) plus ethanol (48.6 and 97.2 mM) produced a decrease in PTD to values significantly greater than those obtained by the addition of ethanol and verapamil alone. Therefore a potentiation of the effects of ethanol by verapamil was observed when both drugs act simultaneously. 4. In hypercalcic medium (4.4 mM), verapamil plus ethanol (48.6 and 97.2 mM) produced a slight decrease in PTD that was significantly less than that observed in normocalcic and hypocalcic mediums. 5. In hypocalcic medium (1.1 mM) verapamil plus ethanol (48.6 and 97.2 mM) produced a decrease in PTD that was of the same relative magnitude (%) as that observed in normocalcic medium. However no potentiation of the combined effects of verapamil plus ethanol was observed in hypocalcic medium.