A First Sign Not to be Missed: Cutaneous Metastasis from Breast Cancer

Cutaneous metastasis has a frequency of 1 to 10% among all metastatic cancer forms and breast cancer accounts for 30% of all cases. We report the case of a 73-year-old woman who presented with 4 skin lesions distributed across the upper trunk and abdomen; these had developed over a period of 12 months. Over the previous 6 months she had also developed anorexia, asthenia and weight loss. Upon investigation, a nodular mass was found in the left breast. Skin and breast mass biopsy were performed. Histology confirmed the diagnosis: infiltrating lobular breast cancer with cutaneous metastasis. The patient underwent hormonal treatment, mastectomy and radiotherapy.

In rare cases, cutaneous metastasis appears as the first clinical manifestation of breast cancer. It is therefore crucial for patients and health professionals alike to be aware of new skin lesions. Cutaneous metastasis is a diagnostic sign of cancer that, it must be emphasised, is not restricted exclusively to later forms of the disease.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

P724 The mysteries of sinus of Valsalva

Sinus of Valsalva aneurysms are a rare pathology that can be clinically silent during years and/or become suddenly symptomatic. We described 3 cases with different clinical presentation, complications and surgical treatment.

A 26-year-old male, competitive cyclist was admitted with a 1.5 month history of fatigue, palpitations, and nocturnal cough and sweating. At physical examination he was apyretic, blood pressure 157/49mmHg and radial pulse 96 bpm; jugular vein engorgement and continuous heart murmur, were noticed. Blood samples only revealed a mild raised BNP. EKG showed sinus tachycardia and right intraventricular conduction delay and the transthoracic echocardiography (TTE) revealed high velocity systolic-diastolic shunt (image) between a non-dilated right coronary sinus (RCS) and the right atrium (RA); moderate left ventricle dilation, severe right atrium and mild right ventricle enlargement with mild pulmonary hypertension and normal biventricular systolic function. He was referred to angioCT that showed a large communication between a non-dilated RCS and RA with signs of right ventricular overload. He was submitted to surgery, where ruptured aneurysm sac was found. Fistula closure, aneurysm sac suture and tricuspid annuloplasty were performed.

A 45-year-old male asymptomatic, with no relevant medical background went to a Cardiology consultation after detection of a holossistolic murmur in the physical exam. EKG showed sinus rhythm arrhythmia with a nonspecific intraventricular conduction delay and the TTE revealed a communication between a dilated noncoronary sinus (NCS) and RA; the biventricular systolic function was normal. He was referred to angioCT which confirmed the diagnosis. He was submitted to surgery where an exeresis and closure of the fistula was performed.

A 38-year-old male with no relevant medical background was admitted to emergence room for an intermittent anterior thoracic pain radiating to the neck (2 days of evolution). The EKG showed sinus tachycardia, incomplete right bundle branch block and the high-sensitivity troponin assays were negative. The TTE revealed severe sinus of Valsalva aneurysm, particularly of the NCS with mild aortic regurgitation. The patient performed transesophageal echocardiography and angioCT which excluded an acute aortic syndrome. He was oriented to surgery where a contained rupture of the RCS and a non-visualization of the ostium right coronary artery were detected, suggesting an intimal dissection. The patient was submitted to Bentall procedure and a bypass with internal mammary artery to right coronary artery.

In spite of the unclear etiology, all the cases had a good clinical and echocardiographic evolution at follow-up. The difficulty in making a timely diagnosis is related to the variability of clinical presentation and the need of high clinical suspicion. Echocardiography and angioTC have demonstrated its value, in providing a prompt diagnosis and appropriate management guidance.

Abstract P724 Figure. Ruptured aneurysm sac and fistula

Listeria monocytogenes as a Cause of Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis is a common and often serious complication of long standing ascites in the presence of advanced liver disease. We report a case of a 74-year-old woman with alcoholic cirrhosis admitted to our emergency department with a 1-week history of diffuse abdominal pain and increased abdominal perimeter. On physical examination, she had a significant abdominal distention and a positive fluid wave consistent with ascites. A diagnosis of spontaneous bacterial peritonitis was made and empiric therapy with ceftriaxone was started but the patient’s condition worsened. Four days later Listeria monocytogenes was detected in peritoneal fluid culture and ampicillin was initiated according to in vitro sensibility test. The patient completed 14 days of treatment with clinical and laboratory improvement. Listeria is an uncommon cause of spontaneous bacterial peritonitis. Clinicians should be aware of the uncommon agents of spontaneous bacterial peritonitis, mainly when there is not a proper response to therapy.

Vasculitis and Steroid Psychosis: A Case Report and Review of Literature

Corticosteroids have become the cornerstone of therapy for many pathologies such as vasculitis. Steroid psychosis is a known complication of corticosteroids therapy, although infrequent. We describe a case of psychosis secondary to corticosteroids in a 69-year-old man with large-vessel vasculitis without previous history of psychiatric pathology. He was diagnosed with large-vessel vasculitis and the treatment started with prednisone 1 mg/kg/day. One week later, the patient presented with behavior change: emotional lability, disorientation and aggressiveness. The symptoms worsened for hallucinatory activity and cognitive deficit. After exclusion of other causes, the diagnosis of psychosis secondary to corticosteroids was assumed. It was decided to wean corticosteroids and start new therapy with methotrexate and tocilizumab and introduction of antipsychotic therapy. The patient had a good outcome with disease remission and had no further neuropsychiatric symptomatology. Systemic corticosteroids are widely used, sometimes with a low concern of its potential adverse effects. So it is important that physicians are aware of the potential for their adverse effects and the need to monitor disease activity and drug toxicity.

Amniotic fluid lactic acid and matrix metalloproteinase-8 levels at the time of fetal surgery for a spine defect: association with subsequent preterm prelabour rupture of membranes

OBJECTIVE

In utero fetal surgery to correct incomplete closure of the spinal cord lessens the extent of permanent damage but is associated with preterm prelabour rupture of membranes (PPROM). We determined whether compounds in amniotic fluid collected at the time of surgery predicted subsequent development of PPROM.

DESIGN

Prospective study.

SETTING

Hospitals in Sao Paulo, Brazil.

POPULATION

Twenty-four consecutive pregnant women at 24-26 weeks of gestation seen between February and October 2017 with a singleton pregnancy underwent in utero surgery to correct an open spinal defect in their fetus.

METHODS

Amniotic fluid was tested for lactic acid, matrix metalloproteinase 2 (MMP-2), MMP-8, MMP-9 and interleukin-6 (IL-6) by enzyme-linked immunosorbent assay. Clinical data were collected after completion of all laboratory studies.

MAIN OUTCOME MEASURE

Amniotic fluid concentration of compounds in women with or without PPROM.

RESULTS

Preterm prelabour rupture of membranes occurred in seven (29.2%) women. There were no differences in maternal age, gravidity, parity, race, history of caesarean sections or fetal gender between women with or without PPROM. Length of surgery, days of wound healing and length of hospital stay were also indistinguishable. The median concentrations of MMP-8 (1.7 versus 0.6 ng/ml; P = 0.0041) and lactic acid (7.1 versus 5.9 mm; P = 0.0181) were higher in women with PPROM. The amniotic fluid MMP-8 level was also negatively correlated with gestational age at delivery (Spearman r = -0.4217, P = 0.0319).

CONCLUSION

Differences in susceptibility to develop PPROM are present before fetal surgery. An increase in anaerobic glycolysis, evidenced by the intra-amniotic lactic acid level, may enhance MMP-8 production and weaken maternal and fetal membranes.

TWEETABLE ABSTRACT

Matrix metalloproteinase-8 and lactic acid in amniotic fluid predict preterm prelabour rupture of membranes.

Structural and molecular study of the supraspinatus muscle of modern humans (Homo sapiens) and common chimpanzees (Pan troglodytes)

OBJECTIVES

To analyze the muscle architecture and the expression pattern of the myosin heavy chain (MyHC) isoforms in the supraspinatus of Pan troglodytes and Homo sapiens in order to identify differences related to their different types of locomotion.

MATERIALS AND METHODS

We have analyzed nine supraspinatus muscles of Pan troglodytes and ten of Homo sapiens. For each sample, we have recorded the muscle fascicle length (MFL), the pennation angle, and the physiological cross-sectional area (PCSA). In the same samples, by real-time quantitative polymerase chain reaction, we have assessed the percentages of expression of the MyHC-I, MyHC-IIa, and MyHC-IIx isoforms.

RESULTS

The mean MFL of the supraspinatus was longer (p = 0.001) and the PCSA was lower (p < 0.001) in Homo sapiens than in Pan troglodytes. Although the percentage of expression of MyHC-IIa was lower in Homo sapiens than in Pan troglodytes (p = 0.035), the combination of MyHC-IIa and MyHC-IIx was expressed at a similar percentage in the two species.

DISCUSSION

The longer MFL in the human supraspinatus is associated with a faster contractile velocity, which reflects the primary function of the upper limbs in Homo sapiens-the precise manipulation of objects-an adaptation to bipedal locomotion. In contrast, the larger PCSA in Pan troglodytes is related to the important role of the supraspinatus in stabilizing the glenohumeral joint during the support phase of knuckle-walking. These functional differences of the supraspinatus in the two species are not reflected in differences in the expression of the MyHC isoforms.

Psychophysiological Reactivity in Couples During a Marital Interaction Task

The ability to regulate our own physiological arousal when dealing with the emotional expression of our partner is crucial for satisfactory and stable intimate relationships. In previous physiological studies of marital interactions, researchers have found greater levels of psychophysiological arousal for members of the couple in conflictual interactions in comparison with positive interactions. Past researchers have established that intense and prolonged autonomic and neuroendocrine arousal during marital conflict can have negative consequences for mental and physical health. In this study we examined the physiological reactivity, as measured by skin conductance level, heart rate and cortisol levels, from both partners during a couple's interaction task consisting of a structured conversation about positive and negative aspects of their relationship. Participants were thirty-two heterosexual couples (N = 64) in a committed monogamous relationship with a minimum duration of one year. We found higher heart rate and cortisol levels during negative interaction condition when compared with the positive condition. Skin conductance was higher in the positive interaction condition, when compared with the negative interaction condition. In addition, we found a significant negative association between heart rate variability and autonomic arousal evoked by the interaction task. The implications of these findings for the effects of marital strain on health as well as for the design of risk-reducing interventions, namely biofeedback are discussed.

[Perineal Groove: A Rare Congenital Anomaly]

Perineal groove is a rare congenital anorectal malformation, with incidence yet undetermined. It is almost exclusive to the female newborn and its embryogenic origin remains uncertain. We present a case-report of a newborn girl that was discharged from the nursery without complications. At her first appointment at primary care we noted a wet sulcus connecting the posterior vaginal commissure and the anus. This case report emphasizes the rarity of the perineal groove and the importance of a good quality history and physical examination at primary care.

Facial biometry of Amazon indigenous people of the Xingu River - Perspectives on genetic and environmental contributions to variation in human facial morphology

OBJECTIVE

To evaluate facial morphology of non-mixed indigenous people living in the Xingu region. Studies on these populations report that the total genetic diversity is as high as that observed for other continental populations. On the other hand, eating habits are different between indigenous and urban population, as indigenous people still have traditional habits.

SETTING AND SAMPLE POPULATION

The sample consisted of 106 indigenous subjects, in permanent dentition stage, belonging to four groups: Arara-Laranjal (n = 35), Arara-Iriri (n = 20), Xikrin-Kaiapó (n = 24), and Assurini (n = 27).

MATERIAL AND METHODS

Standardized facial photographs were obtained, and fourteen measurements were analyzed. Intra- and intergroup homogeneities were examined by discriminant analysis, followed by anova and Kruskal-Wallis tests. Sexual dimorphism to each village was analyzed by Student's t-test or Mann-Whitney test, at p < 0.05.

RESULTS

Significant facial differences were found between male and female, indicating that sex data should not be grouped for intergroup comparison. Discriminant analysis showed a large intergroup heterogeneity, while an intragroup homogeneity was found, especially for females. It was also observed that some morphological features of the face are specific to some villages, regardless of ethnicity.

CONCLUSIONS

Facial morphological characteristics were strongly different among groups, even comparing villages from the same ethnicity. Furthermore, a low diversity within groups was observed. Our findings, supported by previous reports on genetics and eating habits in these populations, reinforce the role of the genetic determination on craniofacial morphology.

Serving the underserved: Communication activities conducted at home with children of the autism spectrum

The increase in prevalence of Autism Spectrum Disorders (ASD) demands that new strategies for delivering speech-language therapy services to them are tested and improved. Including families and familiar situations may be a way to provide more intensive stimulation. The aim of this study was to identify strategies to stimulate communication development of children with ASD that can be suggested to parents and followed-up systematically. Participants were 67 children with diagnosis within the autism spectrum that attended weekly speech-language therapy at a specialized service of a large university in São Paulo (Brazil). The study was conducted in four phases: planning of activities; four face-to-face meetings with the parents to suggest and discuss activities that should be conducted at home daily; during six weeks the parents continued to conduct the proposed activities at home, with systematic weekly follow-up by the child's therapist finally, individual the parents reported their impressions about the proposal and the outcomes regarding their child's development during individual interviews. Activities involved the main areas of disorders in ASD. They suggested that the parents used familiar situations as opportunities for games and plays involving language, cognitive and social demands. Parents reported difficulties in implementing the proposed routine of playing with their child for at least a few minutes every day. They mentioned “lack of time” and “being tired” as the main reasons for it. Nevertheless they all reported that they were more able to understand their child's needs and demands and that their child responded well to the suggestions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Leaf Fluctuating Asymmetry and Herbivory of Tibouchina heteromalla in Restored and Natural Environments

Fluctuating asymmetry (FA) is a parameter to measure developmental stability in plants, which can be altered by disturbances, pollution, and biotic factors such as herbivory. We evaluated the effects of environmental stress and herbivory on the FA levels in individuals of Tibouchina heteromalla (Melastomataceae) that occur in natural and undergoing restoration areas in rupestrian grasslands at Serra do Cipó, Brasil. Individuals were collected and measured in seven restored and five natural areas, totalizing 240 individuals. We found that individuals in restored areas had greater leaf area, higher levels of insect herbivory and FA compared to individuals that occurred in natural areas. In both environments, the proportion of individuals with leaf damage caused by herbivory was higher than the proportion of undamaged individuals. In addition, FA was positively correlated with herbivory and total leaf area in both restored and natural areas. These results suggest that more favorable conditions in the restored areas enhanced leaf growth, resulting in higher FA.