ABSTRACT Food allergies are the leading cause of anaphylaxis in children. Cofactors, such as exercise and non-steroidal anti-inflammatory drugs, may influence the occurrence and severity of allergic reactions to food. However, despite their relevance, the underlying mechanisms of cofactor-enhanced food allergies remain poorly understood. We report the case of a 12-year-old girl with mitochondrial DNA depletion syndrome who was referred to an allergy appointment due to suspected ibuprofen hypersensitivity. Detailed anamnesis, laboratory assessment, and negative drug challenge results excluded this diagnosis; however, continued follow-up revealed a crucial pattern on patient reactions that led to the diagnosis of a cofactor-enhanced food allergy with the presumed involvement of soy storage proteins and non-steroidal anti-inflammatory drugs. Our purpose was to highlight the non-negligible role of cofactors in food allergies and the importance of early identification. Moreover, to underscore the relevance of maintaining patient follow-up, as new information may arise and redirect the diagnosis.

ABSTRACT Kabuki syndrome is a rare congenital malformation with typical facial features, skeletal anomalies, delayed neuropsychomotor development and growth, and cardiac, genitourinary, gastrointestinal, endocrine, and dental anomalies. One of the main differential diagnoses is CHARGE syndrome, standing for and characterized by Coloboma of the eye, Heart defects, Atresia of the nasal choanae, Restricted intellectual development, Genitourinary malformations, and Ear anomalies. Because these syndromes have similar characteristics, distinguishing them may be challenging. A 24-year-old male patient admitted with reduced renal function had a previous phenotype-based diagnosis of CHARGE syndrome based on many characteristic clinical features. The unveiling of a hypocalcemic crisis diagnosed as primary hypoparathyroidism at the age of 15 years, which did not fit into that diagnosis, led the nephrologist to request a genetic test, which evidenced a missense variant of uncertain significance in exon 38 of the KMT2D gene. This phenotype further suggested Kabuki syndrome, ruling out CHARGE. The present report highlights the importance of genetic testing and discusses phenotype-genotype correlations, which ultimately showed that specific variants in exon 38 rendered a form of Kabuki syndrome distinct from the typical one.

ABSTRACT Introduction: The COVID-19 pandemic necessitated a shift from in-person to remote learning, including team-based learning activities. Many studies have explored several aspects of team-based learning; however, there is still a lack of knowledge regarding the factors affecting students’ attitudes and performance. Objective: To evaluate the impact of the COVID-19 pandemic on medical students’ performance in individual readiness assurance tests during team-based learning activities, given that their grades were excluded from the final course grades. Methods: We compared the number of team-based learning applications, student absences, and individual readiness assurance tests grades of medical undergraduate students in three different scenarios: Group 1, in-person individual readiness assurance tests before the pandemic; Group 2, remote individual readiness assurance tests during the lockdown period when their grades were excluded from the final grade calculation; and Group 3, in-person individual readiness assurance tests during the pandemic after lockdown restrictions eased. Results: Remote team-based learning led to significantly lower grades than in-person evaluations. Moreover, the number of students with failing or insufficient grades (below seven) increased during the remote learning period, when their grades were excluded from the final grade calculation, compared to in-person individual readiness assurance tests before the pandemic. Furthermore, absenteeism was higher when the online strategy was applied. Conclusion: We observed lower academic performance by medical students during remote team-based learning sessions, likely owing to the exclusion of individual readiness assurance tests grades from the final course grade calculations during the COVID-19 pandemic.

ABSTRACT Objective: Compare alcohol-based hand sanitizer use in intensive care units in a municipality in São Paulo state, before and during the coronavirus pandemic. Methods: Analytical retrospective study using indirect documentation, with data obtained from a notification spreadsheet for epidemiological indicators of healthcare-associated infection in the state. Data on monthly alcohol-based sanitizer use were collected from the intensive care units of public and private general hospitals of the municipality. Analysis was conducted using descriptive statistics and graphically with run charts. The Mann-Whitney test was applied to compare the median consumption of public and private hospitals, at a 5% significance level. Results: Adult, neonatal and pediatric intensive care units showed median increases in hand sanitizer use of 34.03 to 57.64, 31.53 to 48.66 and 34.38 to 60.35mL/patient-day, respectively. Private hospitals showed greater hand sanitizer use in the adult and pediatric intensive care units compared to public institutions. Conclusion: The pandemic contributed to increasing hand sanitizer use in municipal intensive care units, but there is still room for improvement. More effort is needed to ensure that hand sanitizer use remains high.

ABSTRACT Schizophrenia diagnostics have evolved to adapt to clinical needs and scientific advances, and the current denominations emerged at the beginning of the twentieth century. Most problems arise while integrating clinical experiences, based on historical psychopathological descriptions, with emerging translational neuroscience research. This study aimed to evaluate the state-of-the-art critics of the current schizophrenia concept and their recommendations for new concepts. We performed a narrative review of the literature and searched for studies published in English in PubMed in the last 2 years which discussed the diagnosis of schizophrenia. Two authors independently selected the studies after analyzing the abstracts. Subsequently, studies were selected for this review by consensus. Twenty-six studies were selected, and all authors, except two, had restrictions on the current categorical model for the diagnosis of schizophrenia owing to the heterogeneity of symptomatology and high frequency of comorbidity. Eight studies proposed changes to the concept of schizophrenia. The central proposition was to adopt psychotic syndrome as a core feature instead of the current concept of schizophrenia. We synthesize these proposals using psychosis as a spectrum that includes schizophrenia as a more severe case at the end of the spectrum.

ABSTRACT Objective Patients with American Tegumentary Leishmaniasis often experience malnutrition, weight loss, and dehydration; however, their eating profile and the degree of interference of disease manifestations on food intake is not well understood. Therefore, this study aimed to evaluate the nutritional profile and food intake of patients with American Tegumentary Leishmaniasis before treatment initiation. Methods This was a cross-sectional study of adult and older patients with cutaneous and mucosal leishmaniasis treated at a reference center between 2011 and 2017. A nutritional consultation was conducted to collect anthropometric, biochemical, and dietary intake data (24-h dietary recalls), which were assessed for adequacy. Results Sixty-two patients were included, with a median age of 47.5 (35.0-60.5) years, 82.3% being men, and 59.7% presenting the cutaneous form of the disease. Approximately half of the participants (51.6%) were overweight; however, most had an inadequate intake of selenium (93.5%), calcium (91.9%), magnesium (83.9%), and fiber (66.1%). Patients with mucosal leishmaniasis showed greater nutritional impairment (lower body weight, arm muscle circumference, and serum albumin levels), which was associated with older age and symptoms such as odynophagia, dysphagia, and nasal obstruction, and insufficient zinc intake than those with cutaneous leishmaniasis (p<0.05). Conclusion Patients with mucosal leishmaniasis had greater nutritional impairment leading to reduced dietary intake and inadequate intake of micronutrients, which can negatively interfere with disease prognosis and prolong the healing process. Consequently, nutrient supplementation, a nutritional intervention, could increase the effectiveness of American Tegumentary Leishmaniasis treatment, by ensuring a good nutritional status, which is essential for tissue recovery.

ABSTRACT Dengue, a vector-borne acute febrile illness caused by members of the Flavivirus genus, has dramatically increased its occurrence worldwide. Neurological complications of dengue range from 2.63 to 40%, and subarachnoid hemorrhage is a rare, but significant manifestation. Hemophagocytic lymphohistiocytosis is a life-threatening hyperinflammatory syndrome, sometimes secondary to infections such as dengue. This report presents a rare case of severe dengue with subarachnoid hemorrhage and hemophagocytic lymphohistiocytosis. A 19-year-old male presented with a 7-day history of fever and myalgia, followed by severe headache and vomiting. Initial examination revealed high fever, hepatosplenomegaly, and pancytopenia. Lumbar puncture confirmed via computed tomography showed a Fisher Grade 2 subarachnoid hemorrhage with a small aneurysm at the junction of the left anterior coronary and anterior communicating arteries. Secondary hemophagocytic lymphohistiocytosis was diagnosed based on the criteria from 2004, with elevated inflammatory markers, hypertriglyceridemia, and hyperferritinemia. The patient was treated conservatively with intravenous fluids, osmotic diuretics, antiepileptics, steroids, and nimodipine. The patient showed clinical improvement and was discharged on the 11th day. Isolated subarachnoid hemorrhage is rare in dengue. The hyperinflammatory state in hemophagocytic lymphohistiocytosis, which is often overlooked due to nonspecific symptoms, can lead to aneurysm formation and rupture. Persistent fever, cytopenia, and hyperferritinemia should raise suspicion of hemophagocytic lymphohistiocytosis in cases of severe dengue with neurological complications. In patients with severe dengue and intracranial hemorrhage, clinicians should remain cautious for hemophagocytic lymphohistiocytosis to reduce the associated morbidity and mortality.

ABSTRACT Objective: Endometriosis is characterized by the presence of glandular tissue or endometrial stroma outside the uterus. This study aimed to determine the prevalence of symptomatic deep endometriosis and the clinical factors associated with this condition in women of reproductive age. Methods: A descriptive prevalence study combined with a cross-sectional observational study was conducted between 2017 and 2021 at a public primary care outpatient clinic in Brazil. Women of reproductive age with at least one of the following symptoms were included in the study: deep dyspareunia, dysmenorrhea, chronic pelvic pain, intestinal or urinary symptoms during the menstrual cycle, or infertility. A sample size calculation indicated that an estimated sample of 269 patients was required for the study. Qualitative variables are described as absolute and relative frequencies, while quantitative variables are expressed as medians and quartiles. Factors associated with endometriosis were analyzed using logistic regression and multiple models. Results: Data from 1,445 patients were considered. Among these, 92 were diagnosed with deep endometriosis, resulting in a prevalence of 6.4% (95%CI= 5.2-7.7) and 34.2% among women with pelvic pain (95%CI= 28.8-40.1). Women with palpable posterior cul-de-sac nodules (0R= 3.58, 95%CI= 1.68-7.63, p = 0.001) or a retroverted uterus (0R= 2.36, 95%CI= 1.28-4.37, p = 0.006) were more likely to have endometriosis. Conclusion: Using real-world data, the prevalence of deep endometriosis was found to be 6.4% in women of reproductive age and 34.2% in those with pelvic pain. The primary clinical variables associated with endometriosis are palpable posterior cul-de-sac nodules and a retroverted uterus.

ABSTRACT Objective: The aim of this study was to investigate the effects of saliva, human colostrum, and 3'-sialyllactose on the initial adhesion and biofilm formation of Candida albicans in vitro. Methods: Colostrum and saliva samples were collected from 30 postpartum mothers and newborns, respectively. An 18h culture of C. albicans was treated with colostrum, 3'-sialyllactose, saliva, or a combination of colostrum and saliva at three different time points: before, during, and 24h after C. albicans inoculation. Biofilm assays were conducted in sterile 96-well flat-bottom microtiter plates for 24h. Biofilms were fixed, washed, stained with crystal violet, and extracted. Absorbance was measured to evaluate biofilm biomass. Results: The combined application of colostrum and saliva before and after microbial inoculation did not differ from the control biofilms (p<0.05). In contrast, the combined application of colostrum and saliva during C. albicans application resulted in a higher biomass than the control (p<0.05). Saliva alone decreased the biofilm biomass (p<0.05), and the application of 3'-sialyllactose reduced biofilm formation regardless of the timing of application (p<0.05). Conclusion: Saliva contributed to the proliferation of biofilms, while colostrum did not prevent initial adhesion but influenced biofilm accumulation and development. In contrast, 3'-sialyllactose significantly decreased biofilm formation at all application times. These findings underscore the importance of colostrum as a potent oral antimicrobial biofluid.

ABSTRACT Objective: To compare the effectiveness and safety of phacoviscocanalostomy and phacotrabeculectomy in treating combined glaucoma and cataracts. Methods: A systematic review and meta-analysis were conducted following the PRISMA guidelines. The PubMed, Web of Science, Cochrane, and Embase databases were searched for randomized controlled trials or observational studies comparing phacotrabeculectomy to phacoviscocanalostomy in patients with glaucoma and cataracts. Statistical analysis was used to compare the efficacy (intraocular pressure reduction, mean deviation of the visual field, and failure rates) and safety (general complication rate and rates of hyphema, hypotony, perforation, and intraocular pressure spikes) between the two procedures. Results: The study included 331 eyes from one randomized controlled trial and two non-randomized controlled trials, with 154 undergoing phacoviscocanalostomy and 177 undergoing phacotrabeculectomy. The results indicated no significant differences in surgical failure rates, mean deviation of the visual field, and intraocular pressure at one, three, six, and twelve months between the phacoviscocanalostomy and phacotrabeculectomy groups. Furthermore, although the overall complication rate between the two procedures showed no difference, the rate of intraocular pressure spikes was higher in patients who underwent phacoviscocanalostomy. Conclusion: Phacotrabeculectomy and phacoviscocanalostomy are effective treatments for glaucoma and cataracts. Prospero database registration: (www.crd.york.ac.uk/prospero) under ID CRD42024502391.