Stafne's bone defect: a systematic review

BACKGROUND

This systematic review integrated the available data published in the literature on Stafne's bone defect (SBD), considering the clinical, imaging and histopathological results.

MATERIAL AND METHODS

An electronic search was undertaken in six databases. Eligibility criteria were: articles in English, Spanish, and Portuguese describing case reports or case series of SBD, reported up to September/2021. Risk of bias was assessed using the Joanna Briggs Institute tool.

RESULTS

A total of 98 articles were retrieved, involving 465 individuals with SBD and were included for quantitative analysis. Mean age was 52.78 years (range: 11-89 years), with male predilection (n=374/80.85%). Radiographs were the most frequent imagiological exams (n=298/64.09%), followed by computed tomography (n=98/21.08%). SBD was more prevalent in the posterior mandible (n=361/93.77%) as a hypodense radiolucent lesion (n=250/77.40%). Mean size was 1.58 cm (range: 0.3-.8.0 cm). Two-hundred-and-two lesions (97.37%) were unilocular and 126 (91.97%) were classified as well-defined. Clinical symptoms were reported in 73 cases, while 68 cases (93.15%) were asymptomatic. Only 34 cases (12.32%) were submitted to histopathological examination. Mean follow-up time was 26.42 ±25.39 months.

CONCLUSIONS

SBD is more frequent in male patients in the fifth and sixth decade of life. Classic SBD is radiographically characterized as a single, unilocular and well-defined lesion in the posterior region of the jaw with a radiolucent/hypodense appearance.

Predominance of SARS-CoV-2 P.1 (Gamma) lineage inducing the recent COVID-19 wave in southern Brazil and the finding of an additional S: D614A mutation

Recently, the highest wave of SARS-CoV-2 epidemic occurred since the beginning of the pandemic in Brazil was registered in Rio Grande do Sul (RS) State, Southern Brazil, considering the number of cases, deaths and hospitalization per day caused by COVID-19. In this study we described which lineages were circulating in the first quarter of 2021 in Southern Brazil to better understand the viral factors involved in the health crisis caused by SARS-CoV-2 in the region, searching also for possible additional SARS-CoV-2 sequence mutations. A total of 70 positive SARS-CoV-2 samples collected between January 28th, 2021 until April 23rd, 2021, were selected to sequencing. Whole genome sequencing of 70 SARS-CoV-2 samples showed a predominance of Gamma lineage (67%, 47/70), followed by P.2 lineage (27%, 19/70) and B.1.1.28 (6%, 4/70). Two Gamma lineage consensus sequences presented a new S:D614A mutation. Newly mutations could be emerging due the quick SARS-CoV-2 spreading. Thus, the greater understanding about immune protection and variants vigilance is essential to the better management of the health SARS-CoV-2 crisis.

Reinfection cases by closely related SARS-CoV-2 lineages in Southern Brazil

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the pandemic that started in late 2019 and still affects people's lives all over the world. Lack of protective immunity after primary infection has been involved with reported reinfection cases by SARS-CoV-2. In this study, we described two cases of reinfection caused by non-VOC (Variants of Concern) strains in southern Brazil, being one patient a healthcare worker. The four samples previously positive for SARS-CoV-2 by real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) were sequenced by a high-performance platform and the genomic analysis confirmed that lineages responsible for infections were B.1.91 and B.1.1.33 (patient 1), and B.1.1.33 and B.1.1.28 (patient 2). The interval between the two positive RT-qPCR for patients 1 and 2 was 45 and 61 days, respectively. This data shows that patients may be reinfected even by very closely related SARS-CoV-2 lineages.

Early detection of SARS-CoV-2 P.1 variant in Southern Brazil and reinfection of the same patient by P.2

Multiple variants of the Severe Acute Respiratory Syndrome coronavirus 2 virus (SARS-CoV-2) have been constantly reported across the world. The B.1.1.28 lineage has been evolving in Brazil since February 2020 and originated the P.1 variant of concern (VOC), recently named as the Gamma variant by the newly WHO nomenclature proposal, and P.2 as a variant of interest (VOI). Here we describe an early case of P.1 primary infection in Southern Brazil in late November 2020, soon after the emergence of the variant in Manaus, Northern Brazil. The same male patient was reinfected by another B.1.1.28 variant, namely P.2, in March, 2021. The genomic analysis confirmed genetically significant differences between the two viruses recovered in both infections, the P.1 lineage in the first episode and P.2 in the reinfection. Due the very early detection of P.1, we have also investigated the circulation of P.1 in the same region by differential RT-qPCR, showing that this was an isolated case of P.1 at the time of detection, and this variant has disseminated and became prominent from late January to the end of March, 2021. SARS-CoV-2 recent reports of reinfection have raised critical questions on whether and how well a first infection protects against reinfection.

Outcome of temporary tracheostomy tube-placement following surgery for brachycephalic obstructive airway syndrome in 42 dogs

OBJECTIVES

To describe the use, complications and outcome of temporary tracheostomy tube placement as part of the management of acute upper airway obstruction in the postoperative period following multi-level airway surgery in patients with brachycephalic obstructive airway syndrome.

MATERIALS AND METHODS

Retrospective review of records of dogs surgically treated for brachycephalic obstructive airway syndrome that had a temporary tracheostomy tube placed in the postoperative period.

RESULTS

Forty-two dogs were included. Median duration of temporary tracheostomy tube placement was 2 days (range 1 to 7). The major complication rate was 83.3%, minor complication rate was 71.4%, resulting in an overall postoperative complication rate of 95.2%. The most common postoperative complications were tracheostomy tube obstruction (32/42), cough (25/42) and tracheostomy tube dislodgement (16/42). Temporary tracheostomy tube management was classified as successful in 97.6%. Dyspnoea was the most common clinical sign in the short-term postoperative follow-up period, while dyspnoea and increased upper respiratory tract noise were the most common clinical sign in the long term. The median duration of follow-up was 251 days.

CLINICAL SIGNIFICANCE

In an appropriate clinical setting, placement of temporary tracheostomy tubes following multi-level airway surgery for brachycephalic obstructive airway syndrome is a useful strategy to manage postoperative airway obstruction, carrying a low mortality rate, and with a complication rate similar to that found in previous reports.

The importance of bioceramics and computed tomography in the late clinical management of a horizontal root fracture: A case report

Root fractures resulting from dental trauma involve dentin, cementum and pulp. The present study aimed to demonstrate the importance of cone-beam computed tomography (CBTC) and bioceramics in the correct planning and intervention of a horizontal root fracture case in tooth 11 with late treatment in an 18-year-old patient. Clinical and radiographic examinations revealed tooth displacement, pain on vertical percussion and images suggestive of a horizontal root fracture. Pulp necrosis was diagnosed and CBTC was requested for treatment planning. Subsequently, endodontic treatment was performed using a bioceramic apical plug. A 2-year follow-up indicated the absence of root resorption and normal periodontal and periapical tissues. It was concluded that endodontic treatment associated with the use of bioceramics and the aid of CBTC is an effective therapeutic option in cases of permanent horizontal root fractures.

Key words:Bioceramics, Cone-beam computed tomography, dental Injuries, root fracture.

Significant bone loss after stopping long-term denosumab treatment: a post FREEDOM study

We evaluate 38 elderly women who had received long-term denosumab treatment after stopping the drug. Taking into account the gain during treatment and the loss after stopping treatment, they lost 35.5% of the total gain in the spine, 44.6% of the total gain in the femoral neck, and 103.3% in the total hip.

INTRODUCTION

Denosumab (DMAb) is a soluble inhibitor of the receptor activator of nuclear factor-kappaB ligand (RANKL) and, therefore, does not incorporate into the bone matrix. Consistently, DMAb discontinuation is associated with reversal of the effects attained with treatment.

PURPOSE

The aim of this study is to assess changes in BMD after a year of discontinuation of DMAb in a group of postmenopausal women treated with DMAb for 7 or 10 years. Secondly, is to evaluate the occurrence of fragility fractures.

METHODS

Women who had participated in the FREEDOM study and its extension were invited to participate in this follow-up study. BMD at LS and hip and spine X-rays were obtained. Results were compared to the last value obtained while in treatment to assess changes after discontinuation.

RESULTS

Thirty-eight women, mean age: 81 ± 3.4 years completed study procedures; none had received bisphosphonates after stopping DMAb. Mean gap time between DMAb last dose and the follow-up visit was 17 months (range 16-20 months). Bone mineral density (BMD) decreased significantly in all regions: - 8.1% in LS, - 6% in FN, and - 8.4% in TH. Five (5/38, 13.15%) patients had a fragility fracture, one suffered a wrist fracture, and four experienced vertebral fractures. Three patients suffered one vertebral fracture and one of them had two vertebral fractures. Laboratory results showed the following mean values: CTX = 996 ± 307 pg/ml (normal values 550 ± 226 pg/ml); osteocalcin = 55.2 ± 18.6 ng/ml (normal value 42 ng/ml); and 25 OH vitamin D = 23.7 ± 6.9 ng/ml.

CONCLUSION

Our results describe the rapid bone loss occurring after cessation of denosumab treatment. Further studies are needed to assess if patients have a higher risk of fracture after stopping DMAb and if so, which patients have the highest risk, and assess the role of transitioning to bisphosphonates in the long term.

Comparison between avian pathogenic (APEC) and avian faecal (AFEC) Escherichia coli isolated from different regions in Brazil

Detection and analysis of virulence-associated genes (VAGs) of avian pathogenic Escherichia coli (APEC) may be helpful to distinguish pathogenic from commensal faecal strains (AFEC). The aim of this study was to characterise 120 isolates of avian Escherichia coli, comprising 91 APEC (from diseased birds) and 29 AFEC (from healthy chickens), collected in Brazil. Phylogenetic analysis and in vivo pathogenicity testing was performed on 38 VAGs. The VAGs iucD, iutA, iroN, fepC, ompT, cvi and hlyF were statistically associated with medium and high pathogenicity (MP/HP) strains. A minimal group of seven VAGs may be required to accurately discriminate pathogenic and non-pathogenic avian strains of E. coli in Brazil.

Donor-derived Trypanosoma cruzi infection in solid organ recipients in the United States, 2001-2011

Although Trypanosoma cruzi, the parasite that causes Chagas disease, can be transmitted via organ transplantation, liver and kidney transplantation from infected donors may be feasible. We describe the outcomes of 32 transplant recipients who received organs from 14 T. cruzi seropositive donors in the United States from 2001 to 2011. Transmission was confirmed in 9 recipients from 6 donors, including 3 of 4 (75%) heart transplant recipients, 2 of 10 (20%) liver recipients and 2 of 15 (13%) kidney recipients. Recommended monitoring posttransplant consisted of regular testing by PCR, hemoculture, and serology. Thirteen recipients had no or incomplete monitoring; transmission was confirmed in five of these recipients. Four of the five recipients had symptomatic disease and all four died although death was directly related to Chagas disease in only one. Nineteen recipients had partial or complete monitoring for T. cruzi infection with weekly testing by PCR, hemoculture and serology; transmission was confirmed in 4 of 19 recipients with no cases of symptomatic disease. Our results suggest that liver and kidney transplantation from T. cruzi seropositive donors may be feasible when the recommended monitoring schedule for T. cruzi infection is followed and prompt therapy with benznidazole can be administered.

Evaluation of bone microarchitecture by high-resolution peripheral quantitative computed tomography (HR-pQCT) in hemodialysis patients

Hemodialyzed patients have decreased bone strength not completely characterized. We evaluated bone microarchitecture in hemodialysis patients and compared it to that of subjects without renal disease by high-resolution peripheral quantitative computed tomography (HR-pQCT). Hemodialysis patients have a marked decreased in cortical density, thickness, and area with significant reduction in trabecular parameters that correlated with the severity of secondary hyperparathyroidism only in women.

INTRODUCTION

Although fracture risk is greatly increased in dialysis patients, the corresponding decreased in bone strength has not been completely characterized.

METHODS

We evaluated volumetric bone mineral density (vBMD) and bone microstructure by HR-pQCT at the distal radius and tibia in 50 hemodialyzed (HD) patients (30 females, mean age 53.2 ± 6 years and 20 males, mean age 59.1 ± 11 years) and 50 sex- and age-matched controls.

RESULTS

At the distal radius HD, women showed a 29% reduction in total and trabecular density and trabecular bone volume fraction (p < 0.0001) compared to controls. Trabecular number was reduced by 25% (p < 0.0001), while trabecular separation was increased by 51%. Cortical thickness (-40%, p < 0.0001) and cortical area (-42%, p < 0.0001) were the parameters most reduced, while compact density was the parameter least reduced (-15%, p < 0.0001). Similar findings were found at the tibia. In HD men, HR-pQCT at the distal radius and tibia showed a reduction in volumetric density and microstructure parameters to a lesser extent than in women. In the hemodialyzed group, cortical thickness at the radius was negatively correlated with age both in women and men. At the distal radius and tibia, we found significant negative correlations between Log iPTH and total alkaline phosphatase with cortical vBMD(r = -0.48, p < 0.01; r = -0.69, p < 0.001), thickness (-0.37, p < 0.05; r = -0.60, p < 0.001), and area ((r = -0.43, p = 0.02; r = -0.65, p < 0.001) but only in women.

CONCLUSION

We conclude that hemodialysis patients have a marked decreased in cortical density, thickness, and area with significant reduction in trabecular parameters that correlated with the severity of secondary hyperparathyroidism only in women.

Comportamento de células do sistema imune frente ao desafio com Salmonella Enteritidis em aves tratadas e não tratadas com ácidos orgânicos

A Salmonelose é uma importante zoonose, considerada a principal causa de infecções bacterianas, sendo associada ao consumo de produtos avícolas. Como alternativa de controle, ácidos orgânicos têm sido amplamente usados. No entanto, pouco se conhece sobre o estado imunológico de aves de produção, e uma avaliação deste status é necessária para proteger frente a enfermidades e para garantir à aplicação segura de agentes terapêuticos ou imunização profilática. Este trabalho teve como objetivo verificar o comportamento do sistema imunológico das aves previamente infectadas com Salmonella Enteritidis (SE) tratadas com um composto de ácidos orgânicos em diferentes concentrações administrado via água e ração comparando com as aves infectadas e não tratadas. Foram inoculados 120 frangos de corte com 1mL de SE, via oral, na concentração de 1,0 x 108 UFC/mL, no 1º e 2º dia de idade, divididos em seis tratamentos com duas repetições, utilizando 200, 400, 500 e 1000ppm do ácido orgânico. Aos 35 dias de vida das aves, foram coletados, de todos os grupos, alíquotas de sangue de 3mL em tubo contendo EDTA para a avaliação das células imunes através de citometria de fluxo. Foram analisadas as porcentagens circulantes de células CD4+, CD8β+, MHC I+, MHC II+, TCRVβ1+, TCRVβ2+ e CD28+. Para análise microbiológica foram coletadas tonsilas cecais destas aves. Observou-se com esse estudo que os ácidos orgânicos nas dosagens 1000ppm na água e 500ppm na ração durante, dois e sete dias respectivamente antes do abate, foram eficazes na redução da infecção por SE em frangos de corte, comprovadas pelo método microbiológico e demonstradas através do comportamento das células do sistema imune. No presente estudo as aves infectadas apresentaram uma proporção menor de células T auxiliares circulantes quando comparadas às aves infectadas, mas tratadas com o AO ou com o grupo não infectado. A mesma tendência pode ser observada para as células CD28+, TCRVβ1+ e MHC IIbright+, e, com menor resolução, para CD8β+.

Avaliação da resistência do cascudinho (Alphitobius diaperinus) (Panzer) (Coleoptera: Tenebrionidae) a diferentes temperaturas

Alphitobius diaperinus, conhecido como cascudinho, é encontrado abundantemente nas instalações avícolas, e acarreta prejuízos zootécnicos e sanitários na avicultura industrial mundialmente. As formas de controle deste besouro estão baseadas exclusivamente no uso de inseticidas para os quais já existem vários relatos de populações resistentes forçando o emprego de métodos alternativos como o controle biológico, interferindo no ciclo de vida do inseto. Este estudo avaliou, em condições de laboratório, a mortalidade de larvas e adultos de A. diaperinus frente a diferentes temperaturas de aquecimento (45º, 50º, 55º e 60º C) e resfriamento (-10º, -13º e -18º C), na presença de maravalha (PM) e ausência de maravalha (AM), através do tempo letal de 100% dos insetos (TL100) em minutos em cada temperatura. A TL100 de larvas e adultos em 45º C foi de 36 e 38 AM e 42 e 57 PM, em 50º C foram 15 e 11 AM e 19 e 16 PM, para 55º C foi de 8 e 9 AM e 12 PM e em 60º C foi de 5 e 6 AM e 11 e 9 PM. Já em -10º C variou de 57 e 60 AM e 70 e 75 PM, em -13º C levou 52 e 55 AM e 60 e 64 PM e em -18º C levou 42 e 43 AM e 51 e 52 PM. Em todas as temperaturas avaliadas houve mortalidade dos insetos em tempo consideravelmente rápido e métodos de controle, através da temperatura, devem levar em consideração esses pontos para referência.

One hundred pancreas transplants performed in a Brazilian institution

After decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for selected patients with type 1 diabetes mellitus. Between January 2001 and January 2008, 100 patients underwent pancreatic transplantation at our center: 88 simultaneous pancreas-kidney transplantation and 12 pancreas transplantations alone. Pancreas graft management of the exocrine drainage technique involved enteric drainage in 8 (all simultaneous pancreas-kidney) and the bladder in 92 cases. The recipient systemic venous system was used for the pancreas graft venous effluent in all cases. Our overall results have shown that the number of functioning pancreatic grafts was 64 of 100. Graft losses were: rejection (n = 8), venous thrombosis (n = 9), arterial thrombosis (n = 1), or surgical complications such as anastomotic leak (n = 3), perigraft infection (n = 10), pancreatitis of the graft (n = 5). Most cases of pancreatitis (80%) had preservation times exceeding 18 hours. Despite surgical and immunosuppressive complications, our impression was that pancreas transplantation was a highly effective therapy for diabetes mellitus. After 7 years of the program and 100 transplantations, we believe that there is a major role for transplantation in diabetes management.

Calcium hydroxide barrier over the apical root-end of a type III dens invaginatus after endodontic and surgical treatment

AIM

To report the simultaneous endodontic and surgical treatment of a tooth associated with Oehlers type III dens invaginatus and a persistent periapical lesion, which comprised root-end resection, root-end filling and application of a calcium hydroxide barrier placed on the resected dentine surface.

SUMMARY

Three root canals were identified in a tooth with a type III dens invaginatus, which presented with a necrotic pulp, wide foraminal opening and extensive periapical lesion, and with a previous history of acute abscess, intracanal exudate and fistula. After root canal preparation followed by intracanal application of calcium hydroxide pastes, the clinical-pathological status persisted. After periapical curettage and root-end resection, the root canals were filled, followed by root-end filling with Sealer 26 mixed with zinc oxide powder to a clay-like consistency. Calcium hydroxide paste was then applied over the exposed dentinal surface forming a covering over the root apex. At the 20-month follow-up examination the patient had no symptoms and no fistula; advanced periapical bone repair was obvious on the radiograph.

KEY LEARNING POINTS

Because of the variable morphology and extent of invagination, type III dens invaginatus represents a challenge for conventional treatment, often leading to the need for a surgical approach. Sealer 26 thickened with zinc oxide powder provided satisfactory clinical properties for use as a root-end filling material. Application of a calcium hydroxide barrier over the resected root-end is a potential treatment option to encourage tissue repair.

Intraabdominal Bleeding Following Simultaneous Pancreas-Kidney Transplantation Treated With Angiographic Embolization

Significant early bleeding is one of the surgical complications following simultaneous pancreas-kidney transplantation that has historically shaped the procedure. The consequence, exploratory laparotomy, carries high morbidity levels and elevated costs for the health system. Angiographic intervention is already a common procedure for the treatment of late, but not early, vascular complications. We describe a case of an early vascular complication that was successfully treated with angiographic embolization in a to simultaneous pancreas-kidney transplant patient.

Genome-wide scan for visceral leishmaniasis susceptibility genes in Brazil

A genome-wide scan was conducted for visceral leishmaniasis (VL) in Brazil. Initially, 405 markers were typed in 22 multicase pedigrees (28 nuclear families; 174 individuals; 66 affected). Non-parametric multipoint analysis detected nine chromosomal regions with provisional evidence (logarithm of the odds (LOD) scores 0.95-1.66; 0.003<P<0.018) for linkage. To confirm linkage, 132 individuals (43 affected) from 19 independently ascertained families were genotyped across these regions. Three regions (6q27, 7q11.22 and 17q11.2-q21.3) retained evidence (LOD scores 1.08, 1.34, 1.14; P=0.013, 0.007, 0.011) for linkage. To determine which genes contribute to linkage at 17q11.2-q21.3, 80 single nucleotide polymorphisms were genotyped in 98 nuclear families with 183 affected individuals. Family-based association test analysis indicated associations at two chemokine genes, CCL1 and CCL16, that lie 1.6 Mb apart, show some extended linkage disequilibrium with each other, but each lie within different clusters of candidate CCL genes. Multiple genes may therefore contribute to the linkage peak for VL at 17q12.

Nonsurgical treatment of extensive cyst-like periapical lesion of endodontic origin

AIM

To report the repair of an extensive periapical lesion of endodontic origin, following nonsurgical treatment.

SUMMARY

Clinical and radiographic examination revealed an extensive periapical lesion related to tooth 22, extending from the distal surface of tooth 21 to the mesial surface of 26. The patient reported a previous history of dental trauma involving this quadrant and had been under orthodontic treatment for a year. Intraoral examination revealed an asymptomatic bony hard swelling, mainly confined to the palate. During root canal exploration irregular walls associated with 3 mm of apical calcification were noted. After apical patency was obtained 1 mL of bloody serous exudate was drained. Intracanal aspiration provided a further 2 mL of yellow serous exudate. Following biomechanical preparation, a dressing of calcium hydroxide with anaesthetic solution was applied and replaced four times over a period of 12 months. The clinical-pathological picture demonstrated resolution of the lesion during this period of time. The 14-month clinical and radiographic examinations revealed normal bony contour and a significant resolution of the maxillary radiolucency.

KEY LEARNING POINTS

Periapical lesions of endodontic origin may develop asymptomatically and become large. Proper biomechanical preparation followed by calcium hydroxide medication renewed periodically represents a nonsurgical approach to resolve extensive inflammatory periapical lesions.

Genome-wide scans for leprosy and tuberculosis susceptibility genes in Brazilians

Genome-wide scans were conducted for tuberculosis and leprosy per se in Brazil. At stage 1, 405 markers (10 cM map) were typed in 16 (178 individuals) tuberculosis and 21 (173 individuals) leprosy families. Nonparametric multipoint analysis detected 8 and 9 chromosomal regions respectively with provisional evidence (P<0.05) for linkage. At stage 2, 58 markers from positive regions were typed in a second set of 22 (176 individuals) tuberculosis families, with 22 additional markers typed in all families; 42 positive markers in 50 (192 individuals) new leprosy families, and 30 additional markers in all families. Three regions (10q26.13, 11q12.3, 20p12.1) retained suggestive evidence (peak LOD scores 1.31, 1.85, 1.78; P=0.007, 0.0018, 0.0021) for linkage to tuberculosis, 3 regions (6p21.32, 17q22, 20p13) to leprosy (HLA-DQA, 3.23, P=5.8 x 10(-5); D17S1868, 2.38, P=0.0005; D20S889, 1.51, P=0.004). The peak at D20S889 for leprosy is 3.5 Mb distal to that reported at D20S115 for leprosy in India. (151 words).

Evidence for a cluster of genes on chromosome 17q11–q21 controlling susceptibility to tuberculosis and leprosy in Brazilians

The region of conserved synteny on mouse chromosome 11/human 17q11-q21 is known to carry a susceptibility gene(s) for intramacrophage pathogens. The region is rich in candidates including NOS2A, CCL2/MCP-1, CCL3/MIP-1alpha, CCL4/MIP-1beta, CCL5/RANTES, CCR7, STAT3 and STAT5A/5B. To examine the region in man, we studied 92 multicase tuberculosis (627 individuals) and 72 multicase leprosy (372 individuals) families from Brazil. Multipoint nonparametric analysis (ALLEGRO) using 16 microsatellites shows two peaks of linkage for leprosy at D17S250 (Z(lr) score 2.34; P=0.01) and D17S1795 (Z(lr) 2.67; P=0.004) and a single peak for tuberculosis at D17S250 (Z(lr) 2.04; P=0.02). Combined analysis shows significant linkage (peak Z(lr) 3.38) at D17S250, equivalent to an allele sharing LOD score 2.48 (P=0.0004). To determine whether one or multiple genes contribute, 49 informative single nucleotide polymorphisms were typed in candidate genes. Family-based allelic association testing that was robust to family clustering demonstrated significant associations with tuberculosis susceptibility at four loci separated by intervals (NOS2A-8.4 Mb-CCL18-32.3 kb-CCL4-6.04 Mb-STAT5B) up to several Mb. Stepwise conditional logistic regression analysis using a case/pseudo-control data set showed that the four genes contributed separate main effects, consistent with a cluster of susceptibility genes across 17q11.2.

Genetic analysis of multicase families of visceral leishmaniasis in northeastern Brazil: no major role for class II or class III regions of HLA

Familial aggregation, high relative risk to siblings, and segregation analysis, suggest genetic control of visceral leishmaniasis in Brazil. Class II gene effects in mice, and high circulating tumour necrosis factor alpha in humans, provide reasons to target HLA. Fifteen polymorphic markers across 1.03 Mb (DQB1 to TNFa) were genotyped (87 multicase families; 638 individuals). Model-based parametric analyses using single-point combined segregation and linkage in COMDS, or multi-point linkage in ALLEGRO, failed to detect linkage. Model-free nonparametric affected sibling pair (SPLINK) or NPL(all) score (ALLEGRO) analyses also failed to detect linkage. Information content mapping confirmed sufficient marker information to detect linkage. Analysis of simulated data sets demonstrated that these families had 100% power to detect NPL(all) scores of 5 to 6 (>LOD4; P < 0.00001) over the range (7% to 61%) of age-related penetrances for a disease susceptibility gene. The extended transmission disequilibrium test (TDT) showed no consistent allelic associations between disease and the 15 loci. TDT also failed to detect significant associations between extended haplotypes and disease, consistent with failure to detect significant linkage disequilibrium across the region. Linkage disequilibrium between adjacent groups of markers (HLADQ/DR; 82-1/82-3/-238bpTNFA; LTA/62/TNFa) was not accompanied by significant global haplotype TDT associations with disease. The data suggest that class II/III regions of HLA do not contain major disease gene(s) for visceral leishmaniasis in Brazil.

Emergence of black moulds in fungal disease: epidemiology and therapy

Black moulds are a heterogeneous group of darkly pigmented (dematiaceous) fungi, widely distributed in the environment, that occasionally cause infection in humans. The clinical spectrum of infection includes mycetomas, chromoblastomycosis, sinusitis, and superficial, cutaneous, subcutaneous and systemic phaeohyphomycosis. During the last 2 years, there have been reports of infection caused by black moulds in previously healthy individuals and in immunocompromised patients, including an outbreak of fungemia in hospitalized patients. Molecular analysis of strains obtained from patients and from the environment has suggested a common nosocomial source. In addition, data on antifungal susceptibility tests have become available. Surgical excision and antifungal therapy (usually itraconazole) remain the standard treatment for these infections.

Application of the IDSA guidelines for the use of antimicrobial agents in neutropenic patients: impact on reducing the use of glycopeptides

We evaluated the impact of applying the Infectious Diseases Society of America guidelines for febrile neutropenic patients in reducing the use of glycopeptides. Forty-five prior episodes of febrile neutropenia were compared to 97 episodes seen after application of the guidelines. Glycopeptide use was reduced from 73% to 43% of episodes (P=.0008), without changes in outcome.

Association and linkage of leprosy phenotypes with HLA class II and tumour necrosis factor genes

Previous analyses indicate major gene control of susceptibility to leprosy per se and the HLA class II region has been implicated in determining susceptibility and control of clinical phenotype. Segregation analysis using data from 76 Brazilian leprosy multi-case pedigrees (1166 individuals) supported a two locus model as the best fit: a recessive major gene and a recessive modifier gene(s) (single locus vs two locus model, P = 0.0007). Combined segregation and linkage analysis to the major locus, showed strong linkage to HLA class II (HLA-DQB1 P = 0.000002, HLA-DQA1 P = 0.000002, HLA-DRB1 P = 0.0000003) and tumour necrosis factor genes (TNF P = 0.00002, LTA P = 0.003). Extended transmission disequilibrium testing, using multiple affected family members, demonstrated that the common allele TNF*1 of the -308 promoter region polymorphism showed linkage and/or association with disease per se, at a high level of significance (P < 0.0001). Two locus transmission disequilibrium testing suggested susceptibility (TNF*1/LTA*2) and protective (TNF*2/LTA*2) haplotypes in the class iii region. Taken together the segregation and HLA analyses suggest the possibility of more than one susceptibility locus in the MHC.

Genetic epidemiology of visceral leishmaniasis in northeastern Brazil

Familial clustering of disease, racial differences in asymptomatic:disease ratios, and studies of mice all point to a genetic component for disease susceptibility in visceral leishmaniasis. Analysis of 87 multi-case pedigrees (824 individuals; 138 nuclear families) from a region of northeastern Brazil endemic for Leishmania chagasi demonstrates a high relative risk ratio (lambda(2S) = 34) to further siblings of affected sibling pairs. Complex segregation analysis using POINTER and COMDS show that all single locus models, as well as polygenic and multifactorial models, provide a significantly (P < 0.001) better fit to the data than a sporadic model. Of the genetic models, the general single locus model was not significantly different from additive or dominant single locus models, all of which gave a gene frequency for the putative disease susceptibility allele of approximately 0.002. The general single locus model was strongly favored (P < 0.001) over a recessive single gene model. Using POINTER, polygenic and multifactorial models were clearly rejected (P < 0.001 in all cases) in favor of the general single locus model. Using COMDS, the analysis was extended to consider two locus models. Results under a general two-locus model did not differ significantly from the dominant, additive, or general single locus models. Under this model, one locus was estimated at a gene frequency of 0.0017, i.e., in the same range as the disease susceptibility locus for the most favored single gene models, with the second locus at a much lower frequency of 0.0002. Hence, the data support the hypothesis that a single major gene may be important in determining disease susceptibility in this population. To identify the gene(s) involved, a genome scan with replication using two subsets of these larger pedigrees with power to detect linkage is in progress.

Nosocomial fungemia due to Exophiala jeanselmei var. jeanselmei and a Rhinocladiella species: newly described causes of bloodstream infection

Fungi have become increasingly important causes of nosocomial bloodstream infections. The major cause of nosocomial fungemia has been Candida spp, but increasingly molds and other yeasts have caused disease. Exophiala jeanselmei and members of the genus Rhinocladiella are dematiaceous moulds, which have been infrequently associated with systemic infection and have not been described as causes of fungemia. In this paper, the occurrence of 23 cases of fungemia due to these organisms over a 10-month period is reported and the clinical characteristics of patients and outcomes are described. The majority of patients were immunosuppressed; 21 of 23 (91%) had received blood products and 78% had a central venous catheter. All patients had at least one manifestation of fever, but only one patient had signs or symptoms suggesting deep-seated infection. Antifungal therapy was given to 19 of the 23 patients; of those who did not receive therapy, 3 died prior to the culture result and 1 had been discharged without therapy. Antifungal susceptibility of the organisms showed activity of amphotericin B, itraconazole, and the new triazole antifungals voriconazole and posaconazole. E. jeanselmei and Rhinocladiella species are potential causes of nosocomial fungemia and may be associated with systemic infection.

Evaluation of intraocular pressure in eyes of clinically normal llamas and alpacas

OBJECTIVE

To estimate intraocular pressure (IOP) in eyes of healthy camelids, using applanation tonometry.

ANIMALS

The eyes of 34 camelids (16 llamas [Lama glamal and 18 alpacas [L. pacos]) that did not have major abnormalities of the ocular surface or intraocular abnormalities.

PROCEDURE

Tonometry measurements were obtained from each eye 3 times during a 24-hour period. Each measurement was the mean of several corneal applanations obtained by use of an applanation tonometer. Data were analyzed, using an ANOVA for a repeated-measures design.

RESULTS

Mean (+/- SEM) IOP of llamas and alpacas was 13.10+/-0.35 and 14.85+/-0.45 mm Hg, respectively. Range of IOP was 7 to 18 mm Hg for llamas and 11 to 21 mm Hg for alpacas. Mean IOP of llamas was significantly less than the mean IOP of alpacas. Significant differences in IOP were not detected between the right and left eye of animals. Significant differences in IOP were not attributed to sex, age, or time of measurement within llamas or alpacas.

CONCLUSIONS AND CLINICAL RELEVANCE

Establishing the mean and range of IOP of clinically normal llamas and alpacas provides a frame of reference that is important for use in a complete ophthalmic examination of camelids, which can assist clinicians in the diagnosis of glaucoma and uveitis. Reasons for the difference in mean IOP between llamas and alpacas are unknown. Although the difference may be unimportant clinically, this finding reiterates the fact that caution must be used when extrapolating IOP among species.

Precision synchronous polarimeter with linear response for the measurement of small rotation angles

A synchronous polarimeter was set up for the measurement of small rotation angles of the polarization plane of light. The polarimeter is based on a polarizer-Faraday modulator-analyzer structure with a synchronous detection scheme, which produces a linear system response. The theoretical background is studied, and the system performance is investigated experimentally. We achieved an accuracy of the order of 10(-4) deg, or 5 mg/dl of glucose in a 1-cm light path.

A double-blind, randomized, placebo-controlled trial of itraconazole capsules as antifungal prophylaxis for neutropenic patients

To evaluate the efficacy of itraconazole capsules in prophylaxis for fungal infections in neutropenic patients, we conducted a prospective, double-blind, placebo-controlled, randomized trial. Patients with hematologic malignancies or those who received autologous bone marrow transplants were assigned either a regimen of itraconazole (100 mg orally twice daily; n=104) or of placebo (n=106). Overall, fungal infections (superficial or systemic) occurred more frequently in the placebo group (15% vs. 6%; P=.03). There were no differences in the empirical use of amphotericin B or systemic fungal infections. Among patients with neutropenia that was profound (<100 neutrophils/mm3) and prolonged (for at least 7 days), those receiving itraconazole used less empirical amphotericin B (22% vs. 61%; P=.0001) and developed fewer systemic fungal infections (6% vs. 19%; P=.04). For patients with profound and prolonged neutropenia, itraconazole capsules at the dosage of 100 mg every 12 h reduce the frequency of systemic fungal infections and the use of empirical amphotericin B.