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Sonidegib is a Hedgehog signalling pathway inhibitor approved for use in patients with advanced basal cell carcinoma (BCC) not eligible for surgery or radiotherapy. This report describes clinical experience with sonidegib in two patients with locally advanced BCC (one with a tumour adjacent to the right eye and the other with a tumour associated with the left ear) and in one patient with Gorlin syndrome. Two of the patients had recurrent and intractable tumours. Treatment with sonidegib 200 mg/day led to remission in both patients with locally advanced BCC within 7 months and to a reduction in the size and number of lesions after 4 months in the patient with Gorlin syndrome. Adverse effects reported in these patients were cramps, alopecia, ageusia and weight loss, all of which were mild and consistent with the known toxicity profile for sonidegib. Sonidegib has an important role to play in the effective treatment of challenging cases of advanced BCC. In parallel, a need remains to improve management protocols for patients with advanced BCC, particularly through earlier intervention and a multidisciplinary team approach.

Intraoperative identification of parathyroid glands is a tough task for surgeons performing thyroid or parathyroid surgery, because the small size, color and shape of these glands hinder their discrimination from other cervical tissues. In 2011, Paras described the autofluorescence of parathyroid glands, a property that could facilitate their intraoperative identification. Parathyroid glands submitted to a 785 nm laser beam emit fluorescence in the near infrared range, with a peak at 822 nm. As the intrinsic properties of secretory tissues may be affected by the exposure to the near infrared light, a situation that could preclude their intraoperative utilization, the authors compared the structural and ultra-structural patterns of rat’s thyroid and parathyroid glands submitted to irradiation replicating the conditions that allow their intraoperative identification, with those of non irradiated animals. Twenty-four Wistar rats were divided into six groups: animals of Groups 1, 3 and 5 were submitted under general anesthesia to direct irradiation of the cervical area with a 780 nm LED light for 3 minutes through a cervical incision, and animals of Groups 2, 4 and 6 were submitted to cervical dissection without irradiation. Animals of were euthanized immediately (Groups 1 and 2), at Day 30 (Groups 3 and 4) at and at Day 60 (Groups 5 and 6) and thyroid and parathyroid glands were removed: one lobe was prepared for conventional pathological examination and the other lobe for electron microscopy observed by three experienced pathological experts. Twenty-four samples were prepared for conventional histology and there were no alterations reported in any group. Due to technical problems, only 21 samples were observed by electron microscopy and there were no differences in the ultrastructure of parathyroid and thyroid glands, namely the nuclear pattern, mitochondria, endoplasmic reticulum or secretory granules, in any of the groups. These results confirm the innocuity of near infrared irradiation’, allowing its intraoperative utilization.

Abstract Background Intra-operative identification of parathyroid glands is often a challenge for surgeons performing parathyroid or thyroid surgery. Parathyroid glands stimulated by near-infrared light emit autofluorescence, which allows their discrimination from all other tissues in the region, and this may be of value during thyroid and parathyroid surgery. In this study, we present the results of the utilization of a low-cost device developed for the identification of parathyroid glands in surgery for primary hyperparathyroidism. Case presentation In 5 patients operated in our hospital with the diagnosis of primary hyperparathyroidism and non-concordant ultrasonography and Sestamibi scan, we used a 780 nm Light Emitting Diode (LED) to stimulate the cervical area. The resulting autofluorescence was visualized with night vision goggles with a 832 nm filter assembled. In all the five patients, an easily distinguishable nodule was identified and excised, and confirmed as parathyroid adenoma by histological exam. Intra-operative PTH assay showed significant decrease compared with basal values, fulfilling the Miami Criteria for surgical success in use in our institution. Conclusion The utilization of autofluorescence for intra-operative identification of parathyroid glands may have a clinical application in surgery for primary hyperparathyroidism, being of special utility when ultrasonography and Sestamibi Scan are non concordant.

El cáncer de vesícula biliar que se presenta como una colecistitis aguda asociada a hemocolecisto y hemobilia es muy infrecuente. Hasta la fecha hay pocos casos informados en la literatura. Presentamos un caso de carcinoma de vesícula biliar diagnosticado tras colecistectomía de urgencia, realizada por hemobilia y colecistitis aguda por hemocolecisto.

Background: Intraoperative identification of parathyroid glands which remains largely dependent on the surgeon's expertise, is a major challenge in endocrine surgery and the most efficient way to reduce postoperative hypocalcemia and its important morbidity.Since the description on autofluorescence of parathyroid glands by Paras et al. in 2011, other works had confirmed the utility of this property in the identification of the glands but its efficacy in reducing hypocalcemia is not completely stated.In this study we evaluate the utilization of a low-cost device in total thyroidectomy. Methods: In a before and after controlled study we compared patients submitted to total thyroidectomy by the same surgeon in two periods: From January 2017 to February 2018 (visual identification of parathyroid glands) and from February 2018 to December 2019 (with utilization of the near infrared system).Main outcomes included postoperative hypocalcemia and hypoparathyroidism, parathyroid identification and incidental resection. Results: Patients in the study group displayed significantly lower postoperative hypoparathyroidism (p = 0.044). In spite of the reduction observed in study group absolute values of calcium and number of hypocalcemic patients didn't achieve statistical significance. There were no patients with permanent hypocalcemia in study group comparing with 3 in the control group.Number of parathyroid glands identified was significantly higher in study group (p

Metástases cutâneas de neoplasias internas constituem um evento raro, ocorrendo em 0,9% a 4,4% em grandes estudos necrópsicos e atingindo 9% em grandes séries de doentes neoplásicos. Metástases cutâneas de carcinomas da tiróide são ainda mais raros e, entre eles, os de carcinomas foliculares foram mais raramente reportados, mais escassamente do que os de carcinomas papilares ou medulares. Um Eurocaucasiano de 57 A de idade recorreu à consulta por pápula angiomatoide na área parietal do couro cabeludo, com cerca de 4 meses de evolução. O doente tinha sido submetido, 2 anos antes, a tiroidectomia total, complementada com radioterapia e diversos esquemas quimioterapêuticos por um carcinoma metastático de células de Hürthle da tiróide. A biópsia excisional da pápula permitiu estabelecer, com recurso a estudos imuno-histoquímicos, o diagnóstico de metástase cutânea de carcinoma folicular da tiróide. Os gânglios linfáticos, pulmões e os ossos constituem as mais prevalentes localizações à distância das metástases do carcinoma folicular da tiróide. Embora estas neoplasias representem até 12% das neoplasias malignas da tiróide, metástases cutâneas destes tumores têm sido muito raramente reportadas. Estes tumores são habitualmente carcinomas bem diferenciados, com prognóstico favorável a longo termo e caracterizados histologicamente por estruturas foliculares com material colóide e variáveis anaplasia e distorção arquitectural. No caso apresentado merecem destaque a morfologia angiomatoide da lesão metastática, classicamente associada a metástases de tumores de células renais e a alguns casos já relatados de tumores de células de Hürthle, bem como o comportamento agressivo e a evolução fatal verificados. O caso é ilustrado iconograficamente e uma breve revisão da literatura é efectuada.

This paper aims to analyze the thinking of Neder and Cerqueira Filho on Juridical Culture and Religion. The hypothesis is the fact that both authors can be considered outsiders.Se pretende establecer un diálogo con los autores Gizlene Neder y Gisálio Cerqueira Filho, respecto de temas como la Cultura Jurídica y la Religión. Se afirma que los autores trabajan esta temática con un enfoque teórico-metodológico flexible y que, en realidad, son intelectuales outsiders.Pretende-se estabelecer um diálogo com os autores Gizlene Neder e Gisálio Cerqueira Filho a respeito de temas como a Cultura Jurídica e a Religião. Sustenta-se que os autores trabalham esta temática sob um approach teórico-metodológico flexível e que na verdade, são intelectuais outsiders.

Este artigo descreve uma intervenção com economia de fichas numa unidade psiquiátrica de internamentos de longo curso. No documento, referimos detalhadamente sua elaboração e adaptação a 10 sujeitos com múltiplos diagnósticos. A avaliação geral dos participantes da amostra evidencia resultados positivos no aumento de comportamentos adequados e diminuição de comportamentos desadequados. Essa intervenção foi particularmente eficaz na melhoria do comportamento facial e verbal dos participantes. Obtivemos ganhos estatisticamente significativos na redução de comportamentos bizarros, apesar de os índices de deterioração cognitiva serem elevados na maioria dos doentes. Tendo sido a maioria desses estudos implementados já há mais de 40 anos, julgamos importante a comparação de novos estudos com os prévios, dadas as mudanças que se efectuaram entretanto nos recintos hospitalares, bem como nas terapias farmacológicas.

A 2‐year‐old, male, neutered chihuahua was referred to the neurology service with a 3‐week history of progressive weakness of both pelvic limbs. A myelo‐computed tomography and high field magnetic resonance imaging of the thoracolumbar vertebral column identified a large, focal, intradural‐extramedullary mass in the T12–L1 region of the vertebral canal. Histopathological analysis was compatible with a spinal cord nephroblastoma. The dog was treated with toceranib, but was euthanased due to lack of improvement. To the authors' knowledge, this is the first report of a spinal cord nephroblastoma in a chihuahua and the first report that describes the use of toceranib for this tumour type. [ABSTRACT FROM AUTHOR]

Abstract Background Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes. This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation. Methods The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE2-AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a “Living Guideline” process model for the VTE prevention CDS system. Discussion The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics. Trial registration Clinicaltrials.gov – NCT05628207. Prospectively registered 11/28/2022, https://classic.clinicaltrials.gov/ct2/show/NCT05628207 .