Psychometric Validation of a Hearing Screening Questionnaire for Preschoolers based on language development evaluation by caregivers

INTRODUCTION

This study aimed to validate three age-adjusted versions of a Hearing Screening Questionnaire for Preschoolers, in Brazilian Portuguese, based on parents' perception of their children's hearing and oral language.

METHODS

Psychometric validation was conducted on three questionnaires, each comprising nine items with Yes/No responses. Three items focused on hearing screening at birth, and six assessed hearing and oral language. The study included 152 parents and their children, who attended day care centers in Belo Horizonte, Brazil. The children were categorized into three age bands: 12 to 18 months, 19 to 35 months, and 36 to 48 months. Audiological assessments, including tympanometry, transient-evoked otoacoustic emissions (TOAE) and pure-tone audiometry (when applicable), were performed on the children. In case of abnormal findings in the previous exams, auditory brainstem response (ABR) testing was conducted. Descriptive data, false alarm, and false-negative analyses were carried out.

RESULTS

Considering any type of hearing loss, whether unilateral or bilateral, the questionnaires showed a false-negative rate of 41.17% (7/17 children). However, when considering only bilateral hearing loss, the questionnaire showed a false alarm rate of 31.69% (45/142) and a false-negative rate of 30.0% (3/10). When focusing exclusively on sensorineural hearing loss, the questionnaire identified two children (1.31%), with a false-negative rate of 0% but a false-positive rate of 33.33%.

CONCLUSION

Language-development oriented questionnaires allowed quick screening of potential hearing loss in preschoolers. This study found a robust hit rate with these questionnaires. Their validation signifies a promising and cost-effective tool for conducting hearing screenings in preschool children, especially in nations lacking a comprehensive school screening policy.The validated questionnaire affords an easy-to-apply, low-cost and effective instrument for preschool hearing screening.

Elderly people with human T-cell leukemia virus type 1-associated myelopathy present an early impairment in cognitive skills

BACKGROUND

 Cerebral changes occur in individuals with human T-cell leukemia virus type 1 (HTLV-1)-associated myelopathy (HAM) and seem to predominate in subcortical areas. Little is known about the cognitive decline in the elderly living with HTLV-1.

OBJECTIVE

 To evaluate the cognitive aging of individuals infected with HTLV-1 aged ≥ 50 years.

METHODS

 This is a cross-sectional study of former blood donors infected with HTLV-1 who have been followed in the cohort of the Interdisciplinary Research Group on HTLV-1 since 1997. The groups of study consisted of 79 HTLV-1 infected individuals aged ≥ 50 years, with 41 of them presenting symptomatic HAM and 38 being asymptomatic carriers, and 59 seronegative individuals (controls) aged ≥ 60 years. All were submitted to the P300 electrophysiological test and neuropsychological tests.

RESULTS

 Individuals with HAM presented delayed P300 latency in relation to the other groups, and this latency delay increased progressively with aging. The performance of this group in the neuropsychological tests was also the worst. The HTLV-1- asymptomatic group performance was similar to that of the control group.

CONCLUSIONS

 Individuals with HAM presented cognitive decline that progressed with aging and, although HTLV-1-asymptomatic carriers appear to present cognitive aging similar to that of healthy elderly people, concern about a subclinical cognitive impairment is warranted in this population.

Mapping linear B-cell epitopes of the Tryparedoxin Peroxidase and its implications in the serological diagnosis of tegumentary leishmaniasis

Diagnosis of tegumentary leishmaniasis (TL) is essential to avoid permanent damage and severe functional sequelae and there is an urgent need to discover new antigens. The present study aimed to comprehensively evaluate the potential use of the Tryparedoxin Peroxidase (TryP) as an antigen for serological tests. The proposal integrates data from immunoproteomics with immunoinformatics, in addition to a precise analysis of protein levels in the evolutionary stages of the parasite by flow cytometry. To evaluate the performance in the diagnosis of TL, Enzyme-Linked Immunosorbent Assay (ELISA) assays were performed using the recombinant protein and the respective B-cell epitope, followed by an analysis of the contribution of this peptide in the recognition of the protein by patients, evaluated by serum depletion assays. We showed that the TryP has a linear B-cell epitope with high divergence compared to orthologs from Trypanosoma cruzi and Homo sapiens. The results also show high expression and positive cells for TryP (TryP⁺) in the infective metacyclic promastigotes (MET) and intracellular (24 and 48 hours) stages. From the depletion assays, it was possible to confirm the contribution of the peptide in the specific recognition of the TryP protein by patients with TL (13.7-15.9%). ELISA using the peptide showed high performance in the diagnosis compared to the recombinant TryP (rTryP), Soluble Leishmania braziliensis Antigen (sLba) and Immunofluorescence Assay (IFA) with accuracy of 94.29, 89.29, 65.00 and 37.14%, respectively). We can conclude that the MNEPAPP peptide is a potential antigen for the diagnosis of TL.

Development of an immunogen containing CD4+/CD8+ T-cell epitopes for the prophylaxis of tegumentary leishmaniasis

Abstract

Tegumentary leishmaniasis (TL) is a disease of high severity and incidence in Brazil, and Leishmania braziliensis is its main etiological agent. The inefficiency of control measures, such as high toxicity and costs of current treatments and the lack of effective immunoprophylactic strategies, makes the development of vaccines indispensable and imminent. In this light, the present work developed a gene encoding multiple T-cell (CD4⁺/CD8⁺) epitope, derived from conserved proteins found in Leishmania species and associated with TL, to generate a chimeric protein (rMEP/TL) and compose a vaccine formulation. For this, six T-cell epitopes were selected by immunoinformatics approaches from proteins present in the amastigote stage and associated with host-parasite interactions. The following formulations were then tested in an L. braziliensis murine infection model: rMEP/TL in saline or associated with MPLA-PHAD^®. Our data revealed that, after immunization (three doses; 14-day intervals) and subsequent challenging, rMEP/TL and rMEP/TL + MPLA-vaccinated mice showed an increased production of key immunological biomarkers of protection, such as IgG_2a, IgG_2a/IgG₁, NO, CD4⁺, and CD8⁺ T-cells with IFN-γ and TNF-α production, associated with a reduction in CD4⁺IL-10⁺ and CD8⁺IL-10⁺ T-cells. Vaccines also induced the development of central (CD44^highCD62L^high) and effector (CD44^highCD62L^low) memory of CD4⁺ and CD8⁺ T-cells. These findings, associated with the observation of lower rates of parasite burdens in the vaccinated groups, when compared to the control groups, suggest that immunization with rMEP/TL and, preferably, associated with an adjuvant, may be considered an effective tool to prevent TL.

Key points

• Rational design approaches for vaccine development.

• Central and effector memory of CD4+ and CD8+ T-cells.

• Vaccine comprised of rMEP/TL plus MPLA as an effective tool to prevent TL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00253-022-12033-7.

Impact assessment of different DNA extraction methods for non-invasive molecular diagnosis of tegumentary leishmaniasis

The aim of this study was to evaluate two methods of nucleic acid extraction (spin-column-based method - commercial kit and direct boil - DB) from swab sampling compared to biopsy sampling for the diagnosis of tegumentary leishmaniasis (TL), (cutaneous - CL and mucocutaneous - MCL forms). The impact of these nucleic acid extraction protocols on different types of PCR and LAMP techniques were compared regarding nucleic acid quality, molecular assays accuracy, indirect quantitation, and costs. The evaluated patients were 57 TL cases (36 CL and 21 MCL) and 34 non-cases. Swab samples extracted by the DB method showed a higher DNA degradation rate and worse DNA quality in comparison to the commercial kit. Molecular tests performed on biopsy samples showed identical or higher performance in all analysis, as compared to their own performance on swab samples for TL (CL and MCL). However, only the SSU rRNA TaqMan™ RT-PCR test showed a significant difference between the performance of biopsy and swab samples extracted by commercial kit. The kDNA-cPCR coupled with swab extracted by commercial kit showed the highest accuracy (95.6%) for TL diagnosis. The sensitivity of the LAMP-RT 18S method in swab samples extracted with a commercial kit (82.5%) was close to that found in biopsy samples (86%) for TL diagnosis. The DB extraction method presented the lowest cost. The use of swab as a minimally-invasive sampling method, associated with an efficient nucleic acid extraction protocol, may represent a low-cost alternative for the diagnosis of CL and MCL.

Uso de dispositivos auxiliares da audição e fluência na Libras e na língua oral de estudantes surdos

RESUMO Objetivo: avaliar a relação entre fluência na Libras, fluência na língua oral e o uso de dispositivos auxiliares para audição de estudantes surdos. Métodos: participaram 112 profissionais tradutores, intérpretes ou instrutores de Libras que informaram as características auditivas, fluência na Libras e língua oral dos estudantes acompanhados por eles, matriculados na rede municipal de uma cidade brasileira. A análise da associação entre fluência na Libras, fluência na língua oral, grau da perda auditiva e uso de dispositivo foi realizada por meio do teste qui-quadrado ou teste exato de Fisher, consideraram-se significantes valores de p<0,05. Resultados: as respostas dos profissionais referiram-se a 88% (n=126) do total de estudantes surdos matriculados na rede municipal. A média de idade dos estudantes foi de 13 anos, sendo 72 (57%) meninos, 98 (78%) com perda auditiva severa ou profunda, 57 (45%) usuários de dispositivos eletrônicos auxiliares para audição, 83 (66%) fluentes somente na Libras, 12 (10%) fluentes apenas na língua oral e 18 (14%) fluentes na Libras e língua oral. Estudantes que utilizavam dispositivo auxiliar para audição apresentaram melhor fluência oral (p<0,001). Dos estudantes que apresentavam fluência oral (n=30), 18 (60%) eram fluentes em Libras (p<0,001). Conclusão: a Libras foi a modalidade comunicativa utilizada majoritariamente pelos estudantes surdos, mesmo por aqueles que utilizavam também a língua oral e dispositivos eletrônicos, o que pode indicar mudança de percepção social em relação ao surdo, à sua língua e cultura.

Use of hearing devices and fluency in Brazilian Sign Language and oral language in deaf students

ABSTRACT Purpose: to assess the relationship between deaf students’ fluency in Brazilian Sign Language (BSL) and oral language and hearing aid use. Method: the sample comprised 112 professional BSL translators, interpreters, and instructors. They answered a questionnaire on hearing characteristics and BSL and oral language fluency of students accompanied by them, who attended municipal schools in a Brazilian city. Association analysis between oral language fluency, BSL fluency, the degree of hearing loss, and device use was made with the chi-square test or Fisher’s Exact test. The significance level was set at p<0.05. Results: the professionals’ responses referred to 88% (n = 126) of all deaf students enrolled in municipal schools. The students’ mean age was 13 years; 72 (57%) were males, 98 (78%) had severe or profound hearing loss, 57 (45%) used electronic hearing devices, 83 (66%) were fluent only in BSL, 12 (10%) were fluent only in oral language, and 18 (14%) were fluent in both BSL and oral language. Hearing device use was statistically associated with oral fluency (p < 0.001). Of all students fluent in oral language (n = 30), 18 (60%) were also fluent in BSL (p < 0.001). Conclusion: BSL was the communication modality most used by students, including those who also used oral language and electronic hearing devices. This may indicate a change in the social perception of deaf people, their language, and their culture.

Lian gong as a Therapeutic Treatment Option in Primary Care for Patients with Dizziness: A Randomized Controlled Trial

Introduction  Dizziness is one of the most common reasons for seeking primary health care. Vestibular rehabilitation (VR) is a conventional treatment method for peripheral balance disorders that effectively decreases symptoms. Lian gong [LG] is believed to benefit patients with dizziness and to reduce the impact of the condition on quality of life by stimulating visual fixation, attention, body balance, and neuroplasticity. Objective  The present study aimed to evaluate the effects of LG on the impact of dizziness on quality of life and fear of falling in primary health care patients. Methods  This was a two-arm, parallel randomized clinical trial that included 36 patients with dizziness not caused by central changes. After specific medical evaluations and indications for treatment, the participants were randomly assigned to 3 groups: the LG group ( n  = 11), the VR group ( n  = 11), and the control group ( n  = 14). The interventions were conducted collectively over a period of 12 weeks. Results  Lian gong reduced the influence of dizziness on quality of life in physical (1.8 points, 95% confidence interval [CI]: 0.2-3.4), functional (4.0 points, 95% CI: 2.1-5.9), and emotional domains of quality of life (4.4 points, 95% CI: 1.7-7.2), with no differences compared with VR. There were similar concerns among the groups about the risk of falling. Conclusion  Lian gong was shown to be an effective balance rehabilitation strategy to reduce the impact of dizziness on quality of life, with similar results to those of VR.

Hearing and language screening in preschoolers

ABSTRACT Purpose: to describe the results of preschooler hearing and language screening and the association between them. Methods: a study with 75 children enrolled in preschool. The language was screened with the Behavior Observation Guide for 0-to-6-Year-Old Children. The hearing of children up to 1 year and 11 months old was screened with meatoscopy, acoustic immittance, behavioral hearing assessment, and otoacoustic emissions, while those in the age range 2 years or older were screened with meatoscopy, acoustic immittance, and play pure-tone audiometry. The children who failed the screening were referred for diagnosis. The results of the hearing and language assessments were compared with the McNemar test. Results: of the 75 children screened, 18 (24%) failed the hearing tests and 11 (15%) failed the language test. Hearing impairment was confirmed in 12 (66%) of those referred for diagnosis, and language impairment, in 10 (90%) of them. There was no association between hearing and language impairments (p = 0.230). Conclusion: hearing and language impairments were found in preschoolers. Although they were not associated, they can impact academic performance. This result emphasizes the need for developing strategies to implement preschooler screening programs that include hearing and language.

Vestibular Evoked Myogenic Potential on Ocular, Cervical, and Soleus Muscles to Assess the Extent of Neurological Impairment in HTLV-1 Infection

Introduction: Vestibular Evoked Myogenic Potential (VEMP) can be used to test central vestibular pathways from the midbrain to the lumbar spine, according to the muscle tested.

Purpose: to compare the spinal cord alteration in individuals with HTLV-1-associated myelopathy (HAM) and with HTLV-1-asymptomatic infection using the VEMP recorded from different muscles.

Methods: VEMP was recorded in 90 individuals of whom 30 had HAM, 30 were HTLV-1 asymptomatic carriers, and 30 negative controls. VEMP was recorded in the oculomotor muscle (oVEMP), testing the vestibulo-ocular reflex, and in the cervical muscle (cVEMP) and soleus muscle (sVEMP), testing the vestibulospinal reflex, respectively, in the cervical and in the lumbar spinal level. The type of stimulation was auditory for oVEMP and cVEMP, and galvanic for sVEMP. The compared variables were the latencies of the electrophysiological waves.

Results: HTLV-1-asymptomatic group was similar to the controls regarding oVEMP (p = 0.461), but different regarding cVEMP (p < 0.001) and sVEMP (p < 0.001). HAM group has presented the worst latencies and was different from the HTLV-1-asymptomatic group in the VEMP of all the tested muscles (p < 0.001). The concomitant occurrence of VEMP alterations in the three recorded muscles of the same individual was found in 2 (6.7%) asymptomatic carriers and in 20 (66.7%) patients with HAM (p = 0.001). The analysis of VEMP alteration per group and per muscle has showed that, in HTLV-1-asymptomatic group, oVEMP was altered in 3 (10.0%) individuals, cVEMP in 10 (33.3%) and sVEMP in 13 (43.3%). In HAM group, oVEMP was altered in 23 (76.6%) individuals, cVEMP in 27 (90%), and sVEMP in 30 (100%).

Conclusion: HTLV-1-neurological damage has followed an ascendant progression beginning at the lumbar spine in the stage of a clinically asymptomatic infection, whereas HAM has affected not only the spine, but also the midbrain.

Ocular vestibular evoked myogenic potential (VEMP) reveals mesencephalic HTLV-1-associated neurological disease

Purpose

Vestibular Myogenic Evoked Potential (VEMP) evaluates vestibulo-ocular and vestibulo-collic reflexes involved in the function of the otolithic organs and their afferent pathways. We compared the results of cervical and ocular VEMP in HTLV-1 associated myelopathy (HAM) and HTLV-1-asymptomatic infection.

Participants and methods

This cross-sectional study included 52 HTLV-1-infected individuals (26 HAM and 26 asymptomatic carriers) and 26 seronegative controls. The groups were similar regarding age and gender. Participants underwent simultaneous ocular and cervical VEMP. The stimulus to generate VEMP was a low-frequency tone burst sound tone burst, with an intensity of 120 decibels normalized hearing level, bandpass filter from 10 to 1,500 Hertz (Hz), with 100 stimuli at 500 Hz and 50 milliseconds recording time. The latencies of the electrophysiological waves P13 and N23 for cervical VEMP and N10 and P15 waves for ocular VEMP were compared among the groups. The absence or delay of the electrophysiological waves were considered abnormal results.

Results

Ocular VEMP was similar among the groups for N10 (p = 0.375) and different for P15 (p≤0.001). Cervical VEMP was different for P13 (p = 0.001) and N23 (p = 0.003). About ocular VEMP, in the HTLV-1-asymptomatic group, normal waves were found in 23(88.5%) individuals; in HAM group, normal waves were found in 7(26.9%). About cervical VEMP, 18(69.2%) asymptomatic carriers presented normal waves and only 3(11.5%) patients with HAM presented normal waves. Abnormalities in both VEMPs were found in 1(3.8%) asymptomatic carrier and in 16(61.5%) patients with HAM.

Conclusion

Neurological impairment in HAM was not restricted to the spinal cord. The mesencephalic connections, tested by ocular VEMP, have been also altered. Damage of the oculomotor system, responsible for eye stabilization during head and body movements, may explain why dizziness is such a frequent complaint in HAM.

Intrarater and interrater agreement and reliability of vestibular evoked myogenic potential triggered by galvanic vestibular stimulation (galvanic-VEMP) for HTLV-1 associated myelopathy testing

BACKGROUND

The vestibular evoked myogenic potential triggered by galvanic vestibular stimulation (galvanic-VEMP) has been used to assess the function of the vestibulospinal motor tract and is a candidate biomarker to predict and monitor the human T-cell lymphotropic virus type 1 (HTLV-1) associated myelopathy (HAM). This study determined the agreement and reliability of this exam.

METHODS

Galvanic-VEMP was performed in 96 participants, of which 24 patients presented HAM, 27 HTLV-1-asymptomatic carriers, and 45 HTLV-1-negative asymptomatic controls. Galvanic vestibular stimulation was achieved by passing a binaural and bipolar current at a 2 milliamperes (mA) intensity for 400 milliseconds (ms) between the mastoid processes. Galvanic-VEMP electromyographic wave responses of short latency (SL) and medium latency (ML) were recorded from the gastrocnemius muscle. Intrarater (test-retest) and interrater (two independent examiners) agreement and reliability were assessed by standard error of measurement (SEM), coefficient of repeatability (CR), intraclass correlation coefficient (ICC), and Kappa coefficient.

RESULTS

In the total sample (n = 96), SL and ML medians were 56 ms (IQR 52-66) and 120 ms (IQR 107-130), respectively. The intrarater repeatability measures for SL and ML were, respectively: SEM of 6 and 8 ms; CR of 16 and 22 ms; ICC of 0.80 (p<0.001) and 0.91 (p<0.001); and a Kappa coefficient of 0.53 (p<0.001) and 0.82 (p<0.001). The interrater reproducibility measures for SL and ML were, respectively: SEM of 3 and 10 ms; CR of 8 and 27 ms; ICC of 0.95 (p<0.001) and 0.86 (p<0.001); and a Kappa coefficient of 0.77 (p<0.001) and 0.88 (p<0.001).

CONCLUSION

Galvanic-VEMP is a reliable and reproducible method to define the integrity of the vestibulospinal tract. Longitudinal studies will clarify its validity in the clinical context, aimed at achieving an early diagnosis and the monitoring of HAM.

Screening of hearing in elderly people: assessment of accuracy and reproducibility of the whispered voice test

Given the high prevalence of presbycusis and its detrimental effect on quality of life, screening tests can be useful tools for detecting hearing loss in primary care settings. This study therefore aimed to determine the accuracy and reproducibility of the whispered voice test as a screening method for detecting hearing impairment in older people. This cross-sectional study was carried out with 210 older adults aged between 60 and 97 years who underwent the whispered voice test employing ten different phrases and using audiometry as a reference test. Sensitivity, specificity and positive and negative predictive values were calculated and accuracy was measured by calculating the area under the ROC curve. The test was repeated on 20% of the ears by a second examiner to assess inter-examiner reproducibility (IER). The words and phrases that showed the highest area under the curve (AUC) and IER values were: "shoe" (AUC = 0.918; IER = 0.877), "window" (AUC = 0.917; IER = 0.869), "it looks like it's going to rain" (AUC = 0.911; IER = 0.810), and "the bus is late" (AUC = 0.900; IER = 0.810), demonstrating that the whispered voice test is a useful screening tool for detecting hearing loss among older people. It is proposed that these words and phrases should be incorporated into the whispered voice test protocol.

Vestibular-evoked myogenic potential triggered by galvanic vestibular stimulation may reveal subclinical alterations in human T-cell lymphotropic virus type 1-associated myelopathy

BACKGROUND

Vestibular-evoked myogenic potential triggered by galvanic vestibular stimulation (galvanic-VEMP) evaluates the motor spinal cord and identifies subclinical myelopathies. We used galvanic-VEMP to compare spinal cord function in individuals infected with human T-cell lymphotropic virus type 1 (HTLV-1) from asymptomatic status to HTLV-1-associated myelopathy (HAM).

METHODOLOGY/PRINCIPAL FINDINGS

This cross-sectional study with 122 individuals included 26 HTLV-1-asymptomatic carriers, 26 individuals with possible HAM, 25 individuals with HAM, and 45 HTLV-1-seronegative individuals (controls). The groups were similar regarding gender, age, and height. Galvanic stimuli (duration: 400 ms; intensity: 2 mA) were applied bilaterally to the mastoid processes and VEMP was recorded from the gastrocnemius muscle. The electromyographic parameters investigated were the latency and amplitude of the short-latency (SL) and medium-latency (ML) responses. While SL and ML amplitudes were similar between groups, SL and ML latencies were delayed in the HTLV-1 groups compared to the control group (p<0.001). Using neurological examination as the gold standard, ROC curve showed an area under the curve of 0.83 (p<0.001) for SL and 0.86 (p<0.001) for ML to detect spinal cord injury. Sensibility and specificity were, respectively, 76% and 86% for SL and 79% and 85% for ML. Galvanic-VEMP disclosed alterations that were progressive in HTLV-1-neurological disease, ranging from SL delayed latency in HTLV-1-asymptomatic carriers, SL and ML delayed latency in possible HAM group, to absence of VEMP response in HAM group.

CONCLUSIONS/SIGNIFICANCE

The worse the galvanic-VEMP response, the more severe the myelopathy. Galvanic-VEMP alteration followed a pattern of alteration and may be a prognostic marker of progression from HTLV-1-asymptomatic carrier to HAM.

Increased N200 and P300 latencies in cognitively impaired elderly carrying ApoE ε-4 allele

OBJECTIVE

To compare the results of neuropsychological tests, evoked potentials N200 and P300 and polymorphisms of ApoE and BDNF rs6265 between patients with normal cognition and those with mild cognitive impairment (MCI) and Alzheimer's dementia (AD).

METHODS

This is a cross-sectional study of elderly individuals with normal cognition and those with MCI and AD, who were submitted to evoked potential tests (N200 and P300) by means of hearing stimuli based on the auditory oddball paradigm. Genotyping was obtained by using the real-time PCR technique.

RESULTS

Sixty-five patients were evaluated as follows: 14 controls, 34 with MCI and 17 with AD. N200 latency and P300 latency and amplitude were not associated with MCI and AD diagnosis. Patients with cognitive impairment (MCI or AD) showed increase in the latencies of P300 and N200. BNDF gene was not associated with cognitive impairment.

CONCLUSION

Latencies of N200 and P300 increased in cognitively impaired patients with the presence of ApoE ε-4 allele.

Annexin A1 Is Involved in the Resolution of Inflammatory Responses during Leishmania braziliensis Infection

Leishmaniases are diseases caused by several Leishmania species. Leishmania (Viannia) braziliensis can cause localized cutaneous leishmaniasis (LCL), which heals spontaneously, or mucosal leishmaniasis (ML), characterized by chronic and intense inflammation and scanty parasitism. Annexin A1 (AnxA1) is a protein involved in modulation and resolution of inflammation through multiple mechanisms. In the present study, the role of AnxA1 was investigated in L. braziliensis-infected BALB/c mice. AnxA1 levels increased at the peak of tissue lesion and parasitism in infected mice. AnxA1 increased also after L. braziliensis infection of BALB/c (wild-type [WT]) bone marrow derived macrophages. Despite a lower parasite intake, parasite burden in bone marrow-derived macrophages from AnxA1^-/- mice was similar to WT and associated with an early increase of TNF-α and, later, of IL-10. AnxA1^-/- mice controlled tissue parasitism similarly to WT animals, but they developed significantly larger lesions at later stages of infection, with a more pronounced inflammatory infiltrate and increased specific production of IFN-γ, IL-4, and IL-10. AnxA1^-/- mice also presented higher phosphorylation levels of ERK-1/2 and p65/RelA (NF-κB) and inducible NO synthase expression, suggesting that AnxA1 may be involved in modulation of inflammation in this model of experimental leishmaniasis. Finally, assessment of AnxA1 levels in sera from patients with LCL or ML revealed that ML patients had higher levels of serum AnxA1 than did LCL patients or control subjects. Collectively, these data indicate that AnxA1 is actively expressed during L. braziliensis infection. In the absence of AnxA1, mice are fully able to control parasite replication, but they present more intense inflammatory responses and delayed ability to resolve their lesion size.

Evaluation of a hypothetical protein for serodiagnosis and as a potential marker for post-treatment serological evaluation of tegumentary leishmaniasis patients

The serodiagnosis for tegumentary leishmaniasis (TL) presents problems related to the sensitivity and/or specificity of the tests. In the present study, an enzyme-linked immunosorbent assay (ELISA) technique was used to evaluate the performance from a Leishmania braziliensis hypothetical protein, LbHyM, in an attempt to compare its serological reactivity with a soluble Leishmania antigenic preparation (SLA) for the serodiagnosis of cutaneous (CL) and mucosal (ML) leishmaniasis. LbHyM was predicted to be a kinesin-like protein by bioinformatics tools. Serum samples were collected from both CL and ML patients, as well as from those with Chagas disease and from healthy subjects living in endemic or non-endemic areas of TL. Also, sera were collected from patients before and after the treatments, seeking to evaluate their serological follow-up in relation to the anti-protein and anti-parasite antibody levels. When an ELISA-rLbHyM assay was performed, it proved to be significantly more sensitive than ELISA-L. braziliensis SLA in detecting both CL and ML patients. Also, when using sera from Chagas disease patients, the ELISA-rLbHyM proved to be more specific than ELISA-SLA. The anti-protein and anti-parasite antibody levels were also evaluated 6 months after the treatments, and treated patients showed significantly lower levels of specific-rLbHyM antibodies, when compared to the anti-parasite antibody levels. In conclusion, the ELISA-rLbHyM assay can be considered a confirmatory serological technique for the serodiagnosis of L. braziliensis infection and can also be used in the serological follow-up of treated patients, aiming to correlate the low anti-protein antibody levels with the improvement of the healthy state of the patients.

Electrophysiological analysis shows dizziness as the first symptom in human T cell lymphotropic virus type-associated myelopathy/tropical spastic paraparesis

Dizziness is a symptom in human T cell lymphotropic virus type-associated myelopathy/tropical spastic paraparesis (HAM/TSP) and may occur due to vestibulospinal tract dysfunction. This tract can be assessed by an electrophysiological test called vestibular-evoked myogenic potential (VEMP). The aim was to correlate the result of VEMP generated by acoustic stimuli and dizziness in individuals with human T cell lymphotropic virus type 1 (HTLV-1)-asymptomatic infection and HAM/TSP. VEMP was recorded from the sternocleidomastoid muscle of 60 HTLV-1-negative adults (60±8 years) and 60 individuals infected with HTLV-1, 30 being asymptomatic (59±8 years) and 30 with HAM/TSP (59±8 years). In all groups, 90% of the participants were women. VEMP was generated by acoustic stimuli (short tone bursts), with an intensity of 118 dBHL and band-pass filter from 10 Hz to 1,500 Hz, and presented 200 stimuli at a frequency of 1,000 Hz with a record time of 60 ms. Of 60 HTLV-1-negative individuals, 14 (23%) reported dizziness; VEMP was normal in all. In the HTLV-1-asymptomatic group, 11(37%) complained of dizziness (p=0.31); VEMP was altered in four (40%) subjects with dizziness and in one (5%) without dizziness (p=0.00). In the group with HAM/TSP, dizziness was reported by 17 (57%) subjects (p=0.002); VEMP was altered in 11 (64%) with dizziness and in 5 (38%) without dizziness (p=0.15). Dizziness without an apparent etiology in HTLV-1-asymptomatic carriers deserves attention in terms of a possible subclinical spinal cord involvement that can be clarified through spinal electrophysiological tests. Damage of the vestibulospinal tract seems to occur in the early stages of HAM/TSP.

Vestibular evoked myogenic potential (VEMP) with galvanic stimulation in normal subjects

Introdução

O potencial evocado miogênico vestibular (VEMP) gerado por estimulação galvânica (GVS) reflete uma resposta vestíbulo-espinhal. A resposta obtida no músculo sóleo é bifásica, primeiro com componente de curta latência (CL), em torno de 60 ms, e depois com o de média latência (ML), em torno de 100 ms. O componente de CL associa-se à função otolítica (sáculo e utrículo), e o de ML, aos ductos semicirculares.

Objetivo

Descrever os valores de referência do VEMP com estimulação galvânica em indivíduos normais.

Casuística e método

Forma de estudo transversal; o VEMP foi gerado por GVS de 2 mA/400 ms, aplicada bilateralmente, sob frequência de 5–6 ms. Testou-se resposta no músculo sóleo de 13 sujeitos saudáveis, com idade média de 56 anos. Os sujeitos permaneceram de pé, com cabeça girada contralateral ao GVS aplicado na mastoide. Na configuração catodo direito, anodo esquerda, 30 GVS foi aplicado, seguidos de mais 30 com configuração inversa. Os componentes de CL e de ML da resposta vestibular foram analisados.

Resultado

Os componentes de CL e de ML foram semelhantes em ambas as pernas. O valor médio de CL foi 54 ms, e o de ML, 112 ms.

Conclusão

Os componentes de CL e de ML do VEMP solear foram replicáveis, sendo medidas úteis de função do trato vestíbulo-espinhal.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Incidence of human T cell lymphotropic virus type 1-associated myelopathy/tropical spastic paraparesis in a long-term prospective cohort study of initially asymptomatic individuals in Brazil

The incidence of human T cell lymphotropic virus type 1 (HLTV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is not well defined in the literature. Several studies have reported different incidence rates, and recent publications suggest a higher incidence and prevalence of HAM/TSP. The interdisciplinary HTLV Research Group (GIPH) is a prospective open cohort study of individuals infected with HTLV-1/2. This study describes the demographic data and HAM/TSP incidence rate observed in 181 HTLV-1-seropositive individuals and compares the results with previous reports in the literature. HAM/TSP was diagnosed on the basis of the World Health Organization diagnostic criteria and De Castro-Costa et al. [Proposal for diagnostic criteria of tropical spastic paraparesis/HTLV-I-associated myelopathy (TSP/HAM). AIDS Res Hum Retroviruses 2006;22:931-935]. Seven HAM/TSP incident cases were observed during the follow-up. The HAM/TSP incidence density was 5.3 cases per 1,000 HTLV-1-seropositive cases per year (95% confidence interval: 2.6-10.9), with a mean follow-up of 7±4 years (range: 1 month to 15 years). HAM/TSP was more frequent in women in their 40s and 50s with probable infection via the sexual route. The HAM/TSP incidence density among HTLV-1-seropositive cases observed in the present study is higher than that in previous studies. HAM/TSP may be underdiagnosed in countries like Brazil where HTLV infection is prevalent. Orientation and prevent transmission of HTLV programs are needed. Currently, preventing HTLV-1 transmission is the most effective way to reduce the impact of HAM/TSP on society.

Immunological profile of HTLV-1-infected patients associated with infectious or autoimmune dermatological disorders

In the present study, the frequency, the activation and the cytokine and chemokine profile of HTLV-1 carriers with or without dermatological lesions were thoroughly described and compared. The results indicated that HTLV-1-infected patients with dermatological lesions have distinct frequency and activation status when compared to asymptomatic carriers. Alterations in the CD4(+)HLA-DR(+), CD8(+) T cell, macrophage-like and NKT subsets as well as in the serum chemokines CCL5, CXCL8, CXCL9 and CXCL10 were observed in the HTLV-1-infected group with skin lesions. Additionally, HTLV-1 carriers with dermatological skin lesions showed more frequently high proviral load as compared to asymptomatic carriers. The elevated proviral load in HTLV-1 patients with infectious skin lesions correlated significantly with TNF-α/IL-10 ratio, while the same significant correlation was found for the IL-12/IL-10 ratio and the high proviral load in HTLV-1-infected patients with autoimmune skin lesions. All in all, these results suggest a distinct and unique immunological profile in the peripheral blood of HTLV-1-infected patients with skin disorders, and the different nature of skin lesion observed in these patients may be an outcome of a distinct unbalance of the systemic inflammatory response upon HTLV-1 infection.

Proviral load and the balance of serum cytokines in HTLV-1-asymptomatic infection and in HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP)

This study compared the proviral load and the plasma cytokine profiles (interleukin-IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ) in 87 HTLV-1-infected individuals, including 28 with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), 32 with possible pHAM/TSP and 27 asymptomatic carriers (AC). The control group was composed by 21 HTLV-1-seronegative individuals. Our finding demonstrated that HAM/TSP group presented higher proviral load as compared to all other HTLV-1 groups (p<0.0001). The HAM/TSP group showed higher serum concentration of IL-6 (p=0.0009) as compared to all other groups. Moreover, higher serum concentration of IFN-γ (p=0.0118) and IL-4 (p=0.0166) were observed in HAM/TSP group as compared to the healthy controls. Additionally, the HAM/TSP group also showed higher serum concentration of TNF-α (p=0.0239) and IFN-γ (p=0.0118) as compared to AC. No differences in the serum concentration of IL-2 and IL-10 were observed among the groups. The analysis of cytokine balance demonstrated that HAM/TSP presented higher pro-inflammatory profile with enhanced IFN-γ/IL-10 and IFN-γ/IL-4 ratio as compared to AC and pHAM/TSP. Further analysis pointed out to a positive correlation between the IFN-γ response and the proviral load in AC. Conversely, a negative association between TNF-α and IL-2 with the proviral load was the hallmark of HAM/TSP group. These findings suggested that the proviral load and the pro-inflammatory cytokine profile may be independent events in the peripheral blood of HAM/TSP individuals. The knowledge about the existence of individual virological/immunological behavior upon HTLV-1 infection, may guide to the establishment of more effective therapeutic interventions.

Mucocutaneous Leishmaniasis: clinical markers in presumptive diagnosis

Mucocutaneous Leishmaniasis (ML) can lead to serious sequela; however, early diagnosis can prevent complications.

Aim

To evaluate clinical markers for the early diagnosis of ML.

Materials and Methods

A series study of 21 cases of ML, which were evaluated through clinical interview, nasal endoscopy, biopsy and the Montenegro test.

Results

A skin scar and previous diagnosis of cutaneous leishmaniasis (CL) were reported in 8(38%) patients, and 13(62%) of them denied having had previous CL and had no scar. Nasal/oral symptom onset until the ML diagnosis varied from 5 months to 20 years, mean value of 6 years. In the Montenegro test, the average size of the papule was 14.5 mm, which did not correlate with disease duration (p=0.87). The nose was the most often involved site and the extension of the injured mucosa did not correlate with disease duration. The parasite was found in 2 (9.52%) biopsy specimens.

Conclusions

ML diagnosis was late. Finding the parasite in the mucosa, cutaneous scar and/or previous diagnosis of CL were not clinical markers for ML. ML diagnosis must be based on the Montenegro test, chronic nasal and/or oral discharge and histological findings ruling out other granulomatous diseases.

HTLV-1 associated myelopathy diagnosed during lepromatous leprosy reaction treatment: a case report

Leprosy and human T cell lymphotropic virus type 1 infection are prevalent in Brazil. Coinfection by Mycobacterium leprae and HTLV-1 is reviewed and a case is reported. A 59 year-old woman was followed and HTLV-1 associated myelopathy was diagnosed during leprosy treatment. The clinical and neurological aspects of this unusual association were initially reviewed. Immunological markers and the possible prognoses due to the association of the diseases were discussed. The unexpected association of leprosy and HTLV-1 associated myelopathy may occur in endemic areas and causes difficulties in determining the correct diagnosis and adequate management of the neurological manifestations.

Validade da prova calórica monotermal em comparação à estimulação bitermal

TEMA: a estimulação calórica monotermal tem sido considerada como alternativa à prova calórica bitermal para triagem das assimetrias vestibulares. OBJETIVO: avaliar a confiabilidade da estimulação monotermal em relação à bitermal para o diagnóstico das assimetrias labirínticas. MÉTODO: avaliaram-se 389 resultados de vectoelectronistagmografia realizados entre 1998 e 2007. A estimulação monotermal de 30ºC e 44ºC com pontos de corte de predomínio labiríntico (PL) em 20% e em 25% foi comparada à bitermal com ponto de corte em 25% (padrão ouro). Na análise, interessou encontrar qual foi à prova monotemal (30°C ou 44°C) e com qual ponto de corte (20% ou 25%) que apresentou os valores mais elevados de sensibilidade e especificidade quando comparada à prova bitermal. RESULTADOS: a sensibilidade e especificidade da prova monotermal foram respectivamente de: 84% e 80%, a 30°C com PL em 20%; 78% e 90%, a 30°C com PL em 25%; 81% e 78%, a 44°C com PL em 20%; 76% e 85%, a 44°C com PL em 25%. CONCLUSÃO: a prova monotermal com estimulo a 30°C apresentou valores mais elevados de sensibilidade e especificidade quando comparada a bitermal. Contudo, não se observou diferença significativa em relação aos valores observados com estímulo a 44°C. Em todas as análises, a prova monotermal apresentou a limitação da baixa sensibilidade, de modo que testes alterados pela bitermal podem passar como normais pela prova monoternal. Ao se decidir pela realização da prova monotermal como triagem, deve-se realizá-la em indivíduos com menor probabilidade de estar com doença vestibular, a partir da história clínica.

Myelopathy and adult T-cell leukemia associated with HTLV-1 in a young patient with hearing loss as the initial manifestation of disease

A young male developed hearing loss, vertigo, headache and facial palsy. Neurological examination did not show any abnormalities. Two years later, cervical lymphadenopathy, hepatosplenomegaly and atypical lymphocytes in peripheral blood revealed leukemia. At the same time, acquired ichthyosis was observed. Subsequently, neurological abnormalities revealed myelopathy associated with HTLV-1, due to vertical transmission.

[Presbyvertigo as a cause of dizziness in elderly]

BACKGROUND

dizziness is a frequent complaint in the geriatric population and has a negative impact in the life quality of these individuals.

AIM

to correlate the types of dizziness and alterations in the caloric test and to verify the frequency of presbyvertigo in an elderly population with dizziness.

METHOD

The records of 132 patients aged over 60 and with balance disturbance were reviewed. These patients were evaluated in the Otoneurology Service of the Clinical Hospital of the Federal University of Minas Gerais between the years of 1998 and 2007. The variables considered for analysis were: epidemiologic data, clinical history, associated diseases and the result of the caloric test. Patients with positional and central vertigo were excluded from the analysis.

RESULTS

The research sample consisted of 120 patients, with an average age was of 70 years, being 71% (n=87) of sample women. Vertigo with the duration of a few minutes and of a daily frequency was the most frequent type of dizziness. In relation to the caloric test, normal results were observed in 73% of the sample. Altered results included unilateral weakness (14%), bilateral weakness (10%) and hyperactive caloric response (3%). Correlating the caloric test with the type of dizziness, bilateral weakness was associated with postural instability (p=0.006; IC=2 - 419).

CONCLUSION

dizziness in elderly has many causes. Bilateral weakness of the vestibular function can be related to presbyvertigo and must be considered in aged individuals who present unbalance. Metabolic, psychiatric, disautonomic, orthopedic, visual and proprioceptive disturbances may be the cause of dizziness in aged individuals who present normal vestibular evaluation.

[Vestibular evoked myogenic potential findings on multiple sclerosis]

INTRODUCTION

Vestibular evoked myogenic potential (VEMP) elicited by acoustic stimulation, has been proposed in the assessment of vestibulospinal pathways.

AIM

To research the clinical utility of VEMP on multiple sclerosis (MS).

SUBJECTS AND METHODS

Forty-four individuals were evaluated (30 normal state and 14 had MS). The acoustic stimuli were short tone burst (1 kHz, 118 dBNa, rise-fall 1 ms, plateau 2 ms) presented through a supra-aural earphone. The stimulation rate was 5 stimuli per second.

RESULTS

All the healthy subjects showed a normal VEMP response. In the MS group, abnormal VEMP was recorded among 92.8% of patients and normal in just one case. The P13-N23 increased of prolongation which was the most frequently alteration (57.1%), followed by absence of response among four (28.5%) cases.

CONCLUSION

VEMP was considered a good method of diagnostic support of vestibulospinal tract in cases of MS.

Alterations in early auditory evoked potentials in multiple sclerosis patients

Alterations in early auditory evoked potentials (EAEP) in individuals with demyelinating disease are suggestive of lesions in the brainstem.

AIM

this study aims to evaluate the prevalence of hearing disorders and altered EAEP in multiple sclerosis (MS) patients.

MATERIALS AND METHOD

sixteen female and nine male patients with a defined diagnosis of multiple sclerosis took part in this study. All individuals underwent hearing and EAEP tests. The wave forms were categorized according to Jerger (1986).

RESULTS

fifty EAEP tests were carried out; 70% were classified as type I (normal response) according to Jerger's criteria. Altered EAEP results in at least one ear were classified into types II, III, IV or V according to Jerger. Females accounted for 31.25% of alterations, and males 44.44%, adding up to 36% of all cases.

CONCLUSIONS

these findings stress the importance of looking at EAEP in cases where there is suspicion of demyelinating disease and in patients with a defined diagnosis for MS.

Potencial evocado miogênico vestibular (Vemp): avaliação das respostas em indivíduos normais

TEMA: o Potencial Evocado Miogênico Vestibular (Vemp) é formado por respostas miogênicas ativadas por estimulação sonora de alta intensidade. Essas respostas são registradas por eletromiografia de superfície sobre a musculatura cervical na presença de contração muscular, ativando a mácula, o nervo vestibular inferior e as vias vestíbulo-espinhais descendentes. OBJETIVO: descrever as respostas evocadas do Vemp em uma população normal. MÉTODO: selecionaram-se 30 sujeitos adultos, sendo 13 homens e 17 mulheres, sem queixas otoneurológicas. Utilizou-se 200 estímulos tone burst com freqüência de 1Hz e intensidade de 118dB Na, filtro passa-banda de 10Hz a 1500Hz. Os traçados obtidos foram analisados em relação ao primeiro potencial bifásico composto por P13 e N23. RESULTADOS: não houve diferença estatisticamente significativa entre o lado da estimulação em relação a latência e amplitude, porém foi encontrada diferença estatisticamente significativa em relação à amplitude do potencial entre os sexos. CONCLUSÃO: Vemp demonstrou ser uma ferramenta confiável na avaliação da função vestibular.

Interpretation and use of caloric testing

Caloric testing is an otoneurologic evaluation of the status of the vestibular-ocular reflex; it allows an evaluation of each labyrinth separately. The main aspects on the use and interpretation of caloric testing are reviewed.

Method

A systematic review of papers published in the past one hundred years on caloric testing was undertaken. The inclusion criteria were: cross-sectional, longitudinal, original articles, reviews and meta-analyses. Reviews of patient charts, case reports and editorials were excluded. The key-words were: caloric testing, nystagmus, vestibular system, directional preponderance, labyrinth predominance, monothermal caloric test, ice water caloric testing, Bell´s phenomenon. The databases were: COCHRAINE, MEDLINE, LILACS, CAPES.

Results

Ninety-three of 818 abstracts fulfilled the inclusion criteria. After reading these articles, 55 were selected for this study. These papers discussed the basics of caloric testing, the types of stimulation, the interpretation of results, variables, artifacts, and the monothermal and ice water caloric test.

Final comments

Caloric testing reference values may vary according to each unit; the the cutoff point is defined based on local studies. Attention to the technique is essential to maximize test sensitivity.

Manifestações cutâneas da infecção e das doenças relacionadas ao vírus linfotrópico de células T humanas do tipo 1

O vírus linfotrópico de células T humanas tipo 1 (HTLV-1) é um retrovírus encontrado em todo o mundo e, no Brasil, tem distribuição heterogênea com várias regiões consideradas de alta prevalência. Está relacionado com doenças graves e/ou incapacitantes, como a leucemia/linfoma de células T do adulto, com a doença neurológica conhecida como mielopatia associada ao HTLV-1/paraparesia espástica tropical, com a uveíte associada ao HTLV-1 e com a dermatite infecciosa. O risco para o aparecimento dessas doenças depende, principalmente, de fatores genéticos, da forma como a infecção foi adquirida e da carga proviral. Estima-se que até 10% dos infectados possam desenvolver alguma doença relacionada ao vírus ao longo da vida. O comprometimento da pele tem sido descrito tanto nas doenças relacionadas ao HTLV-1 quanto nos indivíduos portadores assintomáticos. Vários mecanismos são propostos para explicar as lesões da pele, seja pela presença direta do vírus em células, pela imunossupressão ou por resposta inflamatória que a infecção pelo vírus poderia desencadear. Dentre as manifestações dermatológicas mais freqüentes destacam-se a xerose, as dermatofitoses e as infecções bacterianas recorrentes. Neste artigo são revistos os principais aspectos referentes à infecção e às doenças relacionadas ao HTLV- 1, com ênfase na discussão das manifestações dermatológicas observadas nesse contexto.

Otorhinolaryngological and esophageal manifestations of epidermolysis bullosa

Epidermolysis bullosa (EB) is a group of skin diseases with different clinical manifestations and varied inheritance patterns. Blisters may appear spontaneously or following minimal trauma to the skin or mucosa.

Aim

this paper aims to describe the otorhinolaryngological manifestations and esophageal complications related to EB, and the experience in treating patients with esophageal stenosis secondary to this disease.

Materials and method

this descriptive study enrolled 60 patients with EB seen from June 1999 to December 2006 at the Head and Neck Surgery Service of X Hospital, a reference center for EB.

Results

the patients’ mean age was 14.5 years. Twenty-eight (46.6%) were females and 32 (53.4%) were males. Eight (13.4%) were diagnosed with epidermolysis bullosa simplex, while 51 (85%) had epidermolysis bullosa dystrophica; one (1.6%) patient had one acquired EB. Lips, mouth, tongue and ears were the most frequently involved sites (32 patients - 53.3%). Dysphagia was found in 28 patients (46.6%). After esophageal dilatation the symptoms subsided.

Conclusion

EB is a rare disease and patients must be sent for treatment at reference centers. Physicians treating patients for EB must be aware of the measures required to improve the quality of the treatment provided without putting the patients in harm’s way.

[Otoneurological manifestations associated with antiretroviral therapy]

Ototoxicity and antiretroviral therapy seem to be associated. The aim of this study was to evaluate this possible correlation. Evaluations were carried out on 779 medical records from HIV-infected patients who were being regularly followed up, of whom 162 were being treated with antiretroviral therapy and 122 were untreated (controls). The patients undergoing treatment were older (mean: 42 years), had had serological confirmation for longer times (80 months) and had smaller viral loads (P = 0.00). CD4+ was similar between the groups (P = 0.60). In the treated group, three cases (1.8%) of idiopathic hearing loss and two (1.3%) of otosclerosis-related hearing loss were observed, which both started after antiretroviral therapy. No statistical difference relating to idiopathic hearing loss was found between the groups. While descriptive studies consider possible ototoxicity associated with antiretroviral therapy, this possible adverse effect was not related to the antiretroviral therapy in this study. Conversely, otosclerosis might have been correlated with antiretroviral therapy. This issue deserves to be studied.

Interpretação e utilidade da prova calórica

A prova calórica é o teste da avaliação otoneurológica que verifica a integridade do reflexo vestíbulo-ocular e possibilita avaliar cada labirinto separadamente. Os principais aspectos relacionados à realização, interpretação e utilidade da prova calórica foram revistos. MÉTODOS: Realizou-se revisão sistemática sobre as publicações ocorridas nos últimos cem anos sobre o assunto. Incluíram-se artigos originais transversais e longitudinais, de revisão e meta-análise. Excluíram-se revisões de papeleta, relatos de caso e editoriais. Os descritores utilizados foram: prova calórica, nistagmo, sistema vestibular, preponderância direcional, predomínio labiríntico, teste calórico monotermal, teste calórico com água gelada, fenômeno de Bell. Pesquisou-se as bases de dados COCHRAINE, MEDLINE, LILACS, CAPES. RESULTADOS: De 818 resumos de artigos, selecionou-se inicialmente 93 que preenchiam os critérios de inclusão. A leitura dos artigos resultou na seleção final de 55. Na análise dos artigos, enfatizou-se na discussão fundamentos da prova calórica, tipos de estimulação utilizados, prova calórica monotermal e com água gelada, questões relacionadas à interpretação dos resultados, variáveis e artefatos. COMENTÁRIOS FINAIS: os valores de referência utilizados na prova calórica podem variar de serviço para serviço, com ponto de corte definido a partir de estudos locais. Semiotécnica cuidadosa é fundamental para elevar a sensibilidade do exame.

Sensorineural hearing loss in chronic suppurative otitis media with and without cholesteatoma

Sensorineural hearing loss (SNHL) related to chronic suppurative otitis media (CSOM) was studied to clarify the involvement of cholesteatomas in this context. Aim: to evaluate SNHL related to CSOM and its association with cholesteatomas, disease duration and patients’ ages. Methods: Retrospective analysis of 115 patients with CSOM with and without cholesteatoma submitted to surgical treatment. Inclusion criteria were active unilateral disease, normal contralateral ear and age below 60 years. Results: The average age was 26.3 years, 58 males and 57 females. The duration of ear disease was, in average, 12.4 years. The average threshold of hearing was 40 dB in CSOM ear and 22 dB in the normal contralateral ear (P=0.002). CSOM with cholesteatoma occurred in 78 of 115 cases. In the abnormal ear, SNHL was seen in 15 cases, being 6 cases of profound loss, that correlated with adjusted-age (P=0.003) and absence of cholesteatoma (P=0.01), but not with disease duration (P=0.458). Conclusion: SNHL occurred in 13% of the patients with CSOM, and was correlated with older age, but not with the presence of cholesteatoma or longer duration of ear disease.

[Pediatric Otolaryngology at the Public Health System of a city in Southeastern Brazil]

OBJECTIVE

To assess the suitability of referral from primary to secondary care in pediatric Otolaryngology.

METHODS

The study was performed in the city of Belo Horizonte, in the state of Minas Gerais, from March 2004 to May 2005. A total of 408 pre-school children referred from primary care to secondary care in the department of Otolaryngology presenting with otitis, tonsillitis, sinusitis, allergic rhinitis, and tonsillar/adenoidal hypertrophy was assessed. The studied variables were: agreement between diagnoses in primary and secondary care; waiting time for doctor's appointment; follow-up, and professional (pediatrician or family physician) that examined children in primary care. Agreement of diagnoses was assessed using kappa statistics.

RESULTS

Patients were five years old on average, 214 (52.5%) were boys, mean waiting time for appointment was 3.7 months. Diagnoses in primary and secondary care were respectively: otitis (44%, 49%), tonsillar/adenoidal hypertrophy (22%, 33%), tonsillitis (18%, 23%), sinusitis (13%, 21%), allergic rhinitis (3%, 33%). Agreement analysis of kappa was 0.15 for otitis with effusion, 0.35 for recurrent otitis, 0.04 for tonsillar/adenoidal hypertrophy, 0.43 for tonsillitis, 0.05 for allergic rhinitis, and 0.2 for sinusitis. Diagnoses in primary care referred to secondary care were in agreement when given either by pediatrician or family physician.

CONCLUSIONS

Unsuitability of referrals from primary to secondary care in otolaryngology was expressed by the long time waiting for appointments and by the low agreement between diagnoses in different level of care for the same patients. Primary health care could be more efficient if professionals were better qualified in Otolaryngology.

Acuidade no diagnóstico da laringomalácia através da nasofibrolaringoscopia

A laringomalácia é a causa mais comum de estridor na infância. O diagnóstico é estabelecido através do quadro clínico associado aos achados laringoscópicos analisados de forma dinâmica. OBJETIVO: Avaliar a confiabilidade no diagnóstico da laringomalácia através da nasofibrolaringoscopia. Forma de Estudo: Concordância para avaliar a confiabilidade de um teste diagnóstico (clínico). MATERIAL E MÉTODO: Dezoito pacientes com diagnóstico prévio de laringomalácia a partir dos dados clínicos, epidemiológicos e anatômicos foram avaliados. O exame videolaringoscópico desses pacientes foi comparado com relação ao índice de concordância de quatro diferentes examinadores, através da análise cega de um em relação ao exame do outro observador. No protocolo de avaliação, os critérios considerados para o diagnóstico foram: basculamento anterior das aritenóides; epiglote em ômega; pregas ariepiglóticas curtas; basculamento posterior da epiglote; visão ou não da prega vocal; edema da laringe posterior. Os observadores variavam em relação à experiência profissional. Comparou-se a média de concordância de todos os parâmetros considerados. O padrão ouro foi o consenso no exame dos quatro observadores. RESULTADOS: A média de concordância foi de 88,2%. DISCUSSÃO E CONCLUSÃO: A nasofibrolaringoscopia é um método diagnóstico de boa acuidade, uma vez que a experiência do profissional não interferiu no resultado do exame.

Queilite granulomatosa associada à síndrome de Melkersson-Rosenthal

A síndrome de Melkerson-Rosenthal (SMR) caracteriza-se por edema orofacial, paralisia facial recorrente e língua plicada. A tríade completa é incomum, com freqüência variando de 8 a 25%, sendo que a apresentação mais comum é a presença de somente um sintoma. A queixa mais freqüente é o edema facial e/ou no lábio. No presente relato, descreve-se o caso de uma jovem, 17 anos, com edema no lábio persistente e língua plicada devido à SMR. A paciente informou que o edema e as alterações na língua haviam se iniciado há 2 anos. Tratamentos prévios haviam sido realizados, porém sem sucesso. Propôs-se a injeção intralesional de 20mg de triancinolona a cada 15 dias, associada a 5mg ao dia de clofazimine por três meses. O lábio voltou ao seu aspecto normal após quatro infiltrações da medicação. Estudos recentes têm considerado a SMR como uma doença granulomatosa, sendo a fase inicial da apresentação orofacial da Doença de Crohn em alguns pacientes. Assim, pacientes com SMR deveriam ser avaliados e seguidos quanto à presença de sintomas gastroenterológicos. O tratamento com corticosteróides tem se mostrado efetivo em reduzir a tumefação do lábio associada a essa doença. Discute-se características clínicas, tratamento e importância da terapia com corticosteróides na paralisia facial associada à SMR.

Cheilitis granulomatosa associated with melkersson-rosenthal syndrome

Melkersson-Rosenthal syndrome (MRS) consists of persistent or recurrent orofacial edema, relapsing facial palsy and fissured tongue. The complete triad of symptoms is uncommon, varying from 8 to 25%. The presentation of only one symptom is more common. The most frequent complaint is facial edema and enlargement of the lips. We describe a case of a 17-year-old Brazilian girl with limited edema of the lower lip and fissured tongue due to MRS. Her complaints had started two years before. She referred previous clinical treatments without success. We proposed intralesional injection of triamcinolone at 20 mg every 15 days associated with oral clofazimine at 50 mg/day for three months. The lip became normal after four triamcinolone injections. Recent studies have considered MRS a granulomatous disease, and possibly the initial presentation of Crohn's disease in orofacial area of some patients. MRS patients, therefore, should be screened and monitored for gastrointestinal symptoms. Corticosteroid treatment seems to be effective in reducing lip enlargement. We discus the clinical features of this disease, the treatment, and the importance of corticosteroid therapy in cases of MRS-related facial palsy.

Avaliação do efeito da cafeína no teste vestibular

Há controvérsias sobre a interferência da cafeína no teste vestibular. O café é a fonte mais rica em cafeína. Enquanto em alguns serviços os pacientes são orientados a suspender a ingestão de café 24 a 48 horas antes da realização do teste, outros não consideram necessária a suspensão da ingestão dessa bebida. OBJETIVO: Avaliar o efeito da cafeína no resultado do teste vestibular. FORMA DE ESTUDO: clínico com coorte transversal. MATERIAL E MÉTODO: Estudo comparativo, transversal, pareado. O teste vestibular foi realizado em duplicidade, com intervalo máximo de cinco dias entre um e outro exame. No primeiro teste, os pacientes foram orientados a não ingerir café 24 horas antes do exame; no segundo teste, os pacientes foram orientados a beber café como de costume. Todos os participantes tinham indicação clínica de se submeter ao teste vestibular e tinham o hábito de tomar café. RESULTADOS: Participaram do estudo 19 mulheres com idade média de 49,5 anos. O consumo médio de café foi de três xícaras por dia. As queixas de ansiedade e cefaléia foram associadas ao teste realizado com suspensão do café. Não houve diferença estatisticamente significante nos resultados dos exames realizados com e sem ingestão de café. CONCLUSÃO: A ingestão moderada de café não interferiu no resultado do teste vestibular. Considerando ser recomendável que o paciente esteja tranqüilo ao se submeter ao teste vestibular e que a meia-vida da cafeína é de apenas seis horas, sugerimos que a orientação para a suspensão súbita e completa da ingestão moderada de café antes do teste vestibular para os indivíduos habituados à ingestão diária seja reavaliada.

Evaluation of the caffeine effect in the vestibular test

Exist controversy about the interference of the caffeine in the vestibular test. Coffee is the richest source of caffeine. While in some services, the patients were orient to suspend the ingestion of caffeine 24 to 48 hours before the vestibular test, other not consider the suspension of this drink necessary.

Aim

To evaluate the effect of caffeine in the vestibular test result.

Study design

clinical with transversal cohort.

Material and Method

Seccional and matched research. The vestibular test was performed twice in the same patient, with five days interval between the exams. In the first test, the patient did not drink coffee 24 hours before the exam; in the second, the patient drunk coffee as usual. All of the participants had clinical indication for vestibular test and were used to drinking coffee.

Results

Nineteen women, medium age of 49,5 years, participated. The average coffee consumption was three cups per day. The complaints of anxiety and headache were associated with the submission to the vestibular test without coffee. The exams were not statistically different comparing the results of the tests performed with and without the coffee ingestion.

Conclusion

The moderate ingestion of coffee was not shown to interfere in the results of the vestibular test. Considering that it is recommended that the patient be calm to be submitted to the vestibular test and that the half-life of the caffeine is only of six hours, we suggest that the orientation of complete and abrupt drinking coffee suspension of moderate dose before the vestibular test for the individuals used to daily drinking coffee be reevaluated.