Search

OBJECTIVE: To evaluate is serial measurements of respiratory rate (frequency to tidal volume, f/VT) may predict extubation failure (EF) from mechanical ventilation in patients following a successful spontaneous breathing trial (SBT) with first measurement of f/V(T) < or = 105. DESIGN: Prospective cohort study. SETTING: Two medical-surgical intensive care units. PATIENTS: Seventy-three patients ventilated for more than 48 hours after successful SBT were extubated and followed up for postextubation respiratory distress during 48 hours. RESULTS: Extubation failure occurred in 16 (21.9%) of 73 patients. Factors such as age, sex, Apache II score, days on mechanical ventilation, respiratory failure cause, and hemodynamic or ventilatory parameters did not predict EF. Patients were evaluated during 120 minutes of SBT, and f/V(T) was measured at the 1st minute (f/V(T-1)), 30th minute (f/V(T-30)), and 120th minute (f/V(T-120)). The f/V(T-30) increased as compared with f/V(T-1) (79 +/- 24 vs 68 +/- 30, P = .01) but did not differ from f/V(T-120) (79 +/- 44 vs 81 +/- 42, P = .79). The f/V(T-1) was lower in successful extubation (ES) as compared with EF patients (62 +/- 29 vs 82 +/- 15, P = .01), and this difference was unchanged during the trial (f/V(T-30): ES [63 +/- 22] vs EF [85 +/- 24], P = .02; and f/V(T-120): ES [65 +/- 26] vs EF [88 +/- 20], P = .01)]. CONCLUSIONS: Serial f/V(T) measurements during 120 minutes of SBT were unable to detect EF in patients following a successful SBT with initial f/V(T) lower than 105. © 2008 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

Background: Therapeutic exercise has been considered a useful tool to rehabilitate shoulder pain, namely through its influence on scapular dynamics. Accordingly, the effectiveness of scapular therapeutic exercise needs to be explored. The present study aims to evaluate the effectiveness of scapular therapeutic exercises in shoulder pain and to identify the most effective exercise type (focal or multijoint) and ways of delivering them (as dose and progression)., Methods: Search was conducted at EMBASE, Cochrane Library, MEDLINE via PubMed, Web of Science, PEDro (Physiotherapy Evidence Database), and trial registration databases. The meta-analysis considered randomized controlled/crossover trials that compared the effect of scapular exercises against other types of intervention in the shoulder pain, shoulder function, scapular motion, and/or muscular activity. The risk of bias was assessed through the PEDro scale., Results: From the 8318 records identified, 8 (high to low risk of bias- scoring from 4 to 8 on the PEDro scale) were included. The overall data, before sensitivity analysis, indicated that the scapular therapeutic exercises are: a) more effective than comparators in improving shoulder function (standardized mean difference [SMD] = 0.52 [95% Cl: 0.05, 0.99], P  = .03, I 2  = 76%); and b) as effective as comparators in reducing shoulder pain (SMD = 0.32 [95% Cl: -0.09, 0.73], P  = .13, I 2  = 70%). Subgroup analysis revealed that scapular exercises are more effective in improving shoulder function when the program duration is equal to or higher than 6 weeks (SMD = 0.43 [95% Cl: 0.09, 0.76] P  = .01, I 2  = 21%) and/or when the maximum number of exercise repetitions per session is lower than 30 (SMD = 0.79 [95% Cl: 0.15, 1.42], P  = .01, I 2  = 77%). Only 1 study considered scapular motion as an outcome measure, revealing therapeutic exercise effectiveness to improve scapular range of motion., Conclusions: Intervention programs involving scapular therapeutic exercises are effective in improving shoulder function, presenting benefits when performed for 6 or more weeks and/or when used up to a maximum of 30 repetitions per exercise, per session., (© 2024 The Authors.)

The epidemiological demands of aging point to the need for characterizing older adults regarding health and disability. This systematic review aims to summarize the indicators (instruments) identifying different components of disability as a result of aging exposition in community-dwelling older adults, considering the International Classification of Functioning, Disability, and Health framework. Taking the PRISMA 2020 recommendations as a reference, studies with community-dwelling older adults, reporting the development and/or age disability modifications were included. Two reviewers analyzed the observational studies searched in the MEDLINE, CINAHL, Web of Science, Scopus, and Embase databases. Of the 137 potentially eligible studies, 49 were included in this review. Several indicators (instruments) demonstrated older adults' disabilities according to the different domains of the ICF. Objective measures assessed Body Structures, Body Functions, and Environmental Factors and included handgrip strength (dynamometry, n = 8), cognitive function (Mini-Mental State examination, n = 7), gait speed (walk test, n = 6), and endurance (Chair stand-test, n = 4). Self-reported measures assessed Activities and Participation, but not the Body Structures, and included the basic and instrumental activities of daily living (ADL) (the Katz Index of ADL, n = 4 studies, the Lawton and Brody Instrumental ADL, n = 4 studies). The summary of the measures gathered can guide researchers and health professionals to select indicators (instruments) to assess and monitor older adults' disabilities resulting from aging exposition, to support the development of new wearables, and to provide improvements to the existing ones, allowing the tailored assessment of different health and disability dimensions.

The past two decades have been marked by a global spread of bacterial resistance to β-lactam drugs and carbapenems derivatives are the ultimate treatment against multidrug-resistant bacteria. β-lactamase expression is related to resistance which demands the development of bacterial resistance blockers. Drug inhibitor combinations of serine-β-lactamase and β-lactam were successful employed in therapy despite their inactivity against New Delhi metallo-beta-lactamase (NDM). Until now, few compounds are active against NDM-producing bacteria and no specific inhibitors are available yet. The rational strategy for NDM inhibitors development starts with in vitro assays aiming to seek compounds that could act synergistically with β-lactam antibiotics. Thus, eight thiosemicarbazone derivatives were synthesized and investigated for their ability to reverse the resistant phenotype in NDM in Enterobacter cloacae . Phenotypic screening indicated that four isatin-beta-thiosemicarbazones showed Fractional Inhibitory Concentration (FIC) ≤ 250   µM in the presence of meropenem (4 µg/mL). The most promising compound (FIC= 31.25 µM) also presented synergistic effect (FICI = 0.34). Docking and molecular dynamics studies on NDM-thiosemicarbazone complex suggested that 2,3-dihydro-1 H -indol-2-one subunit interacts with catalytic zinc and interacted through hydrogen bonds with Asp124 acting like a carboxylic acid bioisostere. Additionally, thiosemicarbazone tautomer with oxidized sulfur (thione) seems to act as a spacer rather than zinc chelator, and the aromatic moieties are stabilized by pi-pi and cation-pi interactions with His189 and Lys221 residues. Our results addressed some thiosemicarbazone structural changes to increase its biological activity against NDM and highlight its scaffold as promising alternatives to treat bacterial resistance.Communicated by Ramaswamy H. Sarma.

PrEP users are under high risk for bacterial sexually transmitted infections (STI), including those caused by Treponema pallidum (Tp), Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng). Ct and Ng screening at multiple anatomic sites may improve the diagnostic sensitivity among high-risk populations. We analyzed the prevalence and incidence of Ct, Ng, and Tp and investigated predictors of bacterial STI occurrence between January 2018 and November 2019 in a retrospective cohort of PrEP users in Sao Paulo, Brazil. We describe the frequency and percentage of Ct/Ng per anatomical site and calculate the percentage of missed diagnosis if molecular testing were applied only in symptomatic patients, or only in urine samples. Patients underwent syphilis testing every 3-4 months and Ct/Ng testing every 6 months. We included 413 PrEP users with a median age of 31 years. At baseline, 25% had a positive treponemal test and 7% had active syphilis; Ct and Ng were more frequently detected in the oropharynx and anus (6.4-6.9%) than in urine samples (0.7-2.6%). Twelve months after the onset of PrEP, the incidence of Tp, Ct and Ng was, respectively, 13.4%, 11.4% and 8.9%. During follow-up, 23 out of 33 Ct/Ng cases (69%, 95% CI 51-84) would have been missed if oropharynx and anus samples had not been tested. In addition, if only symptomatic cases had been tested, 30 out of 33 Ct/Ng cases (90%, 95% CI 75-98) would have been missed. Participants with incident STI had a higher baseline number of sexual partners and a longer follow-up. Our study reinforces that active and frequent screening for STI is a powerful strategy to improve the diagnostic sensitivity.

This paper presents a novel coupling between a four-phase electroextraction (EE) system and paper spray mass spectrometry (PS-MS) for the extraction, pre-concentration, and direct analysis of target compounds in different samples. The approach, EE-PS-MS, is based on the sorption of analytes directly on the tip of a triangular-shaped chromatographic paper, with subsequent prompt analysis by PS-MS. Thus, no off-line extraction step is required before the PS analysis, improving the protocol efficiency and reducing the analysis time. In addition to functioning as a porous material to absorb the target compounds, the chromatographic paper also served as the support for one of the aqueous phases of the optimized four-phase electroextraction system. Extraction conditions, such as the composition of the donor and organic phases, applied electric potential, and extraction time, were optimized. Three different applications, involving biofluid, food, and water quality analysis, were evaluated as a proof-of-concept. These applications involved the determination of (i) cocaine and lidocaine in saliva, (ii) malachite green in tap water, and (iii) bisphenol A (BPA) in red wine. When compared with direct PS-MS, the novel EE-PS-MS protocol improved the sensitivities by factors ranging from 14 to 110, depending on the analyte and the sample. The electroextraction procedures were performed on a laboratory-built 66-well plate, which offered the functionality of simultaneous sample handling and, most importantly, improved analytical throughput.

A porous and hydrophilic sorbent material was used in an extraction system, assisted by electric fields, for the extraction of cocaine in saliva and subsequent determination by ultra-high-performance liquid chromatography associated with sequential triple quadrupole mass spectrometry (UHPLC-MS/MS). The cellulose-based material was characterized by scanning electron microscopy, infrared spectroscopy, thermogravimetric analysis, and X-ray diffraction. The time and voltage variables applied in the extraction process were investigated through a Doehlert experimental design, and with the best conditions found (35min and 300 V) some validation parameters were evaluated. The established working range was 1-100 μg L -1 (R 2  > 0.99), and the detection and quantification limits determined were 0.3 and 0.8 μg L -1 , respectively. Recoveries from 80 to 115% and coefficient of variation ≤15 and 16% for intra-day and inter-day assays, respectively, were obtained for sample concentrations of LOQ, 5, 25, and 75 μg L -1 , indicating satisfactory accuracy and precision for the proposed method. In addition, the method presented no matrix effect, and the extraction efficiency was between 56 and 70%. The results showed that the material used has adequate physicochemical characteristics and can be applied as a sorbent and electrolyte support in multiphase extractions using electric fields., (Copyright © 2019 Elsevier B.V. All rights reserved.)

In this work, cellulose cone tips were used as a hydrophilic sorbent supporting an aqueous electrolyte solution in a four-phase electric-field-assisted extraction. The wetted tips were immersed in an immiscible organic phase, acting as a filter to extract analytes present in an aqueous sample. Simultaneous four-phase extractions were carried out under the influence of an electric field using a 66-well plate constructed with inexpensive and readily available laboratory materials. Several parameters that control the electric resistivity of the system were evaluated, and the cone tips provided reproducible and stable electric current during application of electric potential difference. In a final application, a cationic dye and its metabolite, crystal and leuco crystal violet, were extracted from spiked fish extracts and quantified by a digital image analysis method. The method presented a linear range of 2-100 ng mL -1 ( r > 0.999), limit of detection of 1.37 ng mL -1 , inter- (3 consecutive days) and intraday precision determined for 4 concentration levels ( n = 6, each) were lower than 29% and mean recoveries for these concentrations ranging from 95% to 115%. The results demonstrated that the 66-well plate provides a stable, reproducible, and simple way to conduct extractions of ionic compounds from complex aqueous matrixes. The effectiveness of the low-cost cellulose cone tips used as a solid fourth phase also confirmed that it can easily overcome many drawbacks of similar liquid-liquid-liquid approaches.

We evaluated the effects of chronic oral supplementation with l-glutamine and l-alanine in their free form or as the dipeptide l-alanyl-l-glutamine (DIP) on muscle damage, inflammation and cytoprotection, in rats submitted to progressive resistance exercise (RE). Wistar rats (n 8/group) were submitted to 8-week RE, which consisted of climbing a ladder with progressive loads. In the final 21 d before euthanasia, supplements were delivered in a 4 % solution in drinking water. Glutamine, creatine kinase (CK), lactate dehydrogenase (LDH), TNF-α, specific IL (IL-1β, IL-6 and IL-10) and monocyte chemoattractant protein-1 (MCP-1) levels were evaluated in plasma. The concentrations of glutamine, TNF-α, IL-6 and IL-10, as well as NF-κB activation, were determined in extensor digitorum longus (EDL) skeletal muscle. HSP70 level was assayed in EDL and peripheral blood mononuclear cells (PBMC). RE reduced glutamine concentration in plasma and EDL (P<0·05 v. sedentary group). However, l-glutamine supplements (l-alanine plus l-glutamine (GLN+ALA) and DIP groups) restored glutamine levels in plasma (by 40 and 58 %, respectively) and muscle (by 93 and 105 %, respectively). GLN+ALA and DIP groups also exhibited increased level of HSP70 in EDL and PBMC, consistent with the reduction of NF-κB p65 activation and cytokines in EDL. Muscle protection was also indicated by attenuation in plasma levels of CK, LDH, TNF-α and IL-1β, as well as an increase in IL-6, IL-10 and MCP-1. Our study demonstrates that chronic oral l-glutamine treatment (given with l-alanine or as dipeptide) following progressive RE induces cyprotective effects mediated by HSP70-associated responses to muscle damage and inflammation.

In this study we investigated the chronic effects of oral l-glutamine and l-alanine supplementation, either in their free or dipeptide form, on glutamine-glutathione (GLN-GSH) axis and cytoprotection mediated by HSP-27 in rats submitted to resistance exercise (RE). Forty Wistar rats were distributed into 5 groups: sedentary; trained (CTRL); and trained supplemented with l-alanyl-l-glutamine, l-glutamine and l-alanine in their free form (GLN+ALA), or free l-alanine (ALA). All trained animals were submitted to a 6-week ladder-climbing protocol. Supplementations were offered in a 4% drinking water solution for 21 days prior to euthanasia. Plasma glutamine, creatine kinase (CK), myoglobin (MYO), and erythrocyte concentration of reduced GSH and glutathione disulfide (GSSG) were measured. In tibialis anterior skeletal muscle, GLN-GSH axis, thiobarbituric acid reactive substances (TBARS), and the expression of heat shock factor 1 (HSF-1), 27-kDa heat shock protein (HSP-27), and glutamine synthetase were determined. In CRTL animals, high-intensity RE reduced muscle glutamine levels and increased GSSG/GSH rate and TBARS, as well as augmented plasma CK and MYO levels. Conversely, l-glutamine-supplemented animals showed an increase in plasma and muscle levels of glutamine, with a reduction in GSSG/GSH rate, TBARS, and CK. Free l-alanine administration increased plasma glutamine concentration and lowered muscle TBARS. HSF-1 and HSP-27 were high in all supplemented groups when compared with CTRL (p < 0.05). The results presented herein demonstrate that l-glutamine supplemented with l-alanine, in both a free or dipeptide form, improve the GLN-GSH axis and promote cytoprotective effects in rats submitted to high-intensity RE training.

Kocuria rosea belongs to genus Kocuria (Micrococcaceae family, suborder Micrococcineae, order Actinomycetales) that includes about 11 species of bacteria. Usually, Kocuria sp are commensal organisms that colonize oropharynx, skin and mucous membrane; Kocuria sp infections have been described in the last decade commonly affecting immunocompromised patients, using intravenous catheter or peritoneal dialysis. These patients had mainly bacteremia/recurrent sepsis. We hereby describe the case of a 10-year-old girl, immunocompetent, who had endocarditis/sepsis by K. rosea which was identified in five different blood cultures by Vitek 2 ID-GPC card (BioMérieux, France). Negative HIV serology, blood count within normal range of leukocytes/neutrophils and lymphocytes, normal fractions of the complement, normal level of immunoglobulins for the age; lymphocyte immunophenotyping was also within the expected values. Thymus image was normal at chest MRI. No catheters were required. Identification of K. rosea was essential to this case, allowing the differentiation of coagulase-negative staphylococci and use of an effective antibiotic treatment. Careful laboratory analysis of Gram-positive blood-born infections may reveal more cases of Kocuria sp infections in immunocompetent patients, which may collaborate for a better understanding, prevention and early treatment of these infections in pediatrics., (Copyright © 2014 Elsevier Editora Ltda. All rights reserved.)

Introduction: American tegumentary leishmaniasis (ATL) can affect the skin or mucosa (mucocutaneous leishmaniasis - MCL) including the oral cavity. MCL oral lesions are often confused with other oral diseases, delaying diagnosis and specific treatment, and increasing the likelihood of sequelae. Thus, increasing the knowledge of the evolution of ATL oral lesions can facilitate its early diagnosis improving the prognosis of healing., Objectives: Evaluate the frequency of ATL oral lesion and describe its clinical, laboratory and therapeutic peculiarities., Methods: A descriptive transversal study was carried out, using data from medical records of 206 patients with MCL examined at the outpatient clinics-IPEC-Fiocruz between 1989 and 2013. Proportions were calculated for the categorical variables and the association among them was assessed by the Pearson's chi-square test. Measures of central tendency and dispersion were used for the continuous variables and their differences were assessed by both parametric (t test) and non parametric (Mann-Whitney) tests. P-values <0.05 were considered as significant., Results: The most affected site was the nose, followed by the mouth, pharynx and larynx. Seventy eight (37.9%) have oral lesions and the disease presented a lower median of the evolution time than in other mucous sites as well as an increased time to heal. The presence of oral lesion was associated with: the presence of lesions in the other three mucosal sites; a smaller median of the leishmanin skin test values; a longer healing time of the mucosal lesions; a higher recurrence frequency; and a smaller frequency of treatment finishing and healing. When the oral lesion was isolated, it was associated with an age 20 years lower than when the oral lesion was associated with other mucosal sites., Conclusion: Considering the worst therapy results associated with the presence of oral lesions, we suggest that lesions in this location represent a factor of worse prognosis for MCL.

Introduction: Pentavalent antimonials are the first drug of choice in the treatment of tegumentary leishmaniasis. Data on ototoxicity related with such drugs is scarcely available in literature, leading us to develop a study on cochleovestibular functions., Case Report: A case of a tegumentary leishmaniasis patient, a 78-year-old man who presented a substantial increase in auditory threshold with tinnitus and severe rotatory dizziness during the treatment with meglumine antimoniate, is reported. These symptoms worsened in two weeks after treatment was interrupted., Conclusion: Dizziness and tinnitus had already been related to meglumine antimoniate. However, this is the first well documented case of cochlear-vestibular toxicity related to meglumine antimoniate.

Background: Persistent pulmonary air leak is the most frequent complication after lung resection, resulting in an increase in postoperative morbidity and mortality. We evaluated the viability, integration, and efficacy of a free peritoneal fat graft as a method for controlling air leak in normal and emphysematous rat lungs., Methods: Sixty Wistar rats were divided into two groups: elastase-produced lung emphysema (n=30) and control (normal) lungs (n=30). Pulmonary air leak was produced by puncture of the right lower lobe, and aerostasis was attempted by means of intrapulmonary injection of autologous free peritoneal fat graft. Rats in each group (n=6) were randomly allocated to subgroups and were sacrificed at 7, 14, 21, 30, and 60 days. Then, lungs were removed for histology, morphometry, vessel identification and counting, and immunohistochemistry for caspase 3, vascular endothelial growth factor, and factor VIII., Results: Tissue integration of the free fat grafts was found in all animals in both groups. Vessels stained with India ink inside the fat grafts were present at all assessment periods in both groups. Vascular endothelial growth factor expression was significantly higher in all periods in the emphysema group compared with normal lungs (p<0.001). There was a significant increase in caspase 3 expression in the emphysema group at 7, 21, 30, and 60 days (p<0.001). Factor VIII showed a significant increase (p<0.001) at 30 and 60 days in emphysematous lungs., Conclusions: The use of free peritoneal fat graft was able to control the air leaks in normal and emphysematous rat lungs, with persisting graft viability for as long as 60 days after implantation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To assess interobserver agreement between thoracic radiologists, radiology residents, and emergency physicians in diagnosing pulmonary embolism (PE)., Materials and Methods: Emergency physicians, radiology residents, and thoracic radiologists evaluated 123 computed tomography pulmonary angiography images. Interobserver agreement was analysed using kappa statistics., Results: Very good agreements were observed between thoracic radiologists and radiology residents (0.81 and 0.82). Fair and moderate agreements (0.39 and 0.42) were demonstrated between emergency physicians and thoracic radiologists., Conclusions: Important differences in interobserver agreement were found, with emergency physicians tending to overdiagnose PE., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The aim of the present study was to determine the effects of oral supplementation with L-glutamine plus L-alanine (GLN+ALA), both in the free form and L-alanyl-L-glutamine dipeptide (DIP) in endotoxemic mice., Methods: B6.129 F2/J mice were subjected to endotoxemia (Escherichia coli lipopolysaccharide [LPS], 5 mg/kg, LPS group) and orally supplemented for 48 h with either L-glutamine (1 g/kg) plus L-alanine (0.61 g/kg) (GLN+ALA-LPS group) or 1.49 g/kg DIP (DIP-LPS group). Plasma glutamine, cytokines, and lymphocyte proliferation were measured. Liver and skeletal muscle glutamine, glutathione (GSH), oxidized GSH (GSSG), tissue lipoperoxidation (TBARS), and nuclear factor (NF)-κB-interleukin-1 receptor-associated kinase 1 (IRAK1)-Myeloid differentiation primary response gene 88 pathway also were determined., Results: Endotoxemia depleted plasma (by 71%), muscle (by 44%), and liver (by 49%) glutamine concentrations (relative to the control group), which were restored in both GLN+ALA-LPS and DIP-LPS groups (P < 0.05). Supplemented groups reestablished GSH content, intracellular redox status (GSSG/GSH ratio), and TBARS concentration in muscle and liver (P < 0.05). T- and B-lymphocyte proliferation increased in supplemented groups compared with controls and LPS group (P < 0.05). Tumor necrosis factor-α, interleukin (IL)-6, IL-1 β, and IL-10 increased in LPS group but were attenuated by the supplements (P < 0.05). Endotoxemic mice exhibited higher muscle gene expression of components of the NF-κB pathway, with the phosphorylation of IκB kinase-α/β. These returned to basal levels (relative to the control group) in both GLN+ALA-LPS and DIP-LPS groups (P < 0.05). Higher mRNA of IRAK1 and MyD88 were observed in muscle of LPS group compared with the control and supplemented groups (P < 0.05)., Conclusion: Oral supplementations with GLN+ALA or DIP are effective in attenuating oxidative stress and the proinflammatory responses induced by endotoxemia in mice., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aims: We hypothesized that oral l-glutamine supplementations could attenuate muscle damage and oxidative stress, mediated by glutathione (GSH) in high-intensity aerobic exercise by increasing the 70-kDa heat shock proteins (HSP70) and heat shock factor 1 (HSF1)., Main Methods: Adult male Wistar rats were 8-week trained (60-min/day, 5 days/week) on a treadmill. During the last 21 days, the animals were supplemented with either l-alanyl-l-glutamine dipeptide (1.5 g/kg, DIP) or a solution containing the amino acids l-glutamine (1g/kg) and l-alanine (0.67 g/kg) in their free form (GLN+ALA) or water (controls)., Key Findings: Plasma from both DIP- and GLN+ALA-treated animals showed higher l-glutamine concentrations and reduced ammonium, malondialdehyde, myoglobin and creatine kinase activity. In the soleus and gastrocnemius muscle of both supplemented groups, l-glutamine and GSH contents were increased and GSH disulfide (GSSG) to GSH ratio was attenuated (p<0.001). In the soleus muscle, cytosolic and nuclear HSP70 and HSF1 were increased by DIP supplementation. GLN+ALA group exhibited higher HSP70 (only in the nucleus) and HSF1 (cytosol and nucleus). In the gastrocnemius muscle, both supplementations were able to increase cytosolic HSP70 and cytosolic and nuclear HSF1., Significance: In trained rats, oral supplementation with DIP or GLN+ALA solution increased the expression of muscle HSP70, favored muscle l-glutamine/GSH status and improved redox defenses, which attenuate markers of muscle damage, thus improving the beneficial effects of high-intensity exercise training., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Bacteriocins are antibacterial, proteinaceous substances that mediate microbial dynamics. Bacteriocin production is a highly disseminated property among all major lineages of bacteria, including Shigella. In this paper, we addressed the purification and characterisation of a bacteriocin produced by a Shigella sonnei strain (SS9) isolated from a child with acute diarrhoea. The substance was purified through ammonium-sulphate precipitation and sequential steps of chromatography. The intracellular fraction obtained at 75% ammonium sulphate maintained activity following exposure to pH values from 1-11 and storage at -80ºC for more than two years and was inactivated by high temperatures and proteases. The molecular mass of the purified bacteriocin was determined by mass spectrometry to be 18.56 kDa. The N-terminal sequence of the bacteriocin did not match any other antibacterial proteins described. A putative new bacteriocin produced by S. sonnei has been detected. This bacteriocin may represent a newly described protein or a previously described protein with a newly detected function. Considering that SS9 expresses antagonism against other diarrhoeagenic bacteria, the bacteriocin may contribute to S. sonnei virulence and is potentially applicable to either preventing or controlling diarrhoeal disease.

Introduction: We analyzed the vertical and monthly distributions of culicid species in the gallery forest of Brasília National Park, with an emphasis on the potential vectors of yellow fever (YF)., Methods: Between September 2010 and August 2011, mosquitoes were captured on the ground and in the canopy of the forest for five consecutive days per month, from nine to 15 hours. The mosquitoes were examined to verify natural infection with flaviviruses by isolation in Aedes albopictus Skuse, 1864 cells followed by indirect immunofluorescence., Results: We identified 2,677 culicids distributed in 29 species. Most of the mosquitoes were captured at ground level (69%) during the rainy season (86%). The most abundant species were Sabethes (Sabethes) albiprivus Theobald, 1903; Limatus durhamii Theobald, 1901; Haemagogus (Conopostegus) leucocelaenus Dyar & Shannon, 1924; Haemagogus (Haemagogus) janthinomys Dyar, 1921; Aedes (Ochlerotatus) scapularis Rondani, 1848; Psorophora (Janthinosoma) ferox Von Humboldt, 1819; and Aedes (Ochlerotatus) serratus Theobald, 1901. Limatus durhamii, Limatus durhamii, Psorophora ferox, Aedes scapularis and Aedes serratus showed significant differences (p<0.05) in their habitat use. Limatus durhamii was found more often in the canopy, unlike the other species. During the rainy season, the most abundant species were Sa. albiprivus, Haemagogus leucocelaenus and Limatus durhamii. During the dry season, the potential YF vectors exhibited a very low frequency and abundance, except Aedes scapularis and Aedes serratus. No flavivirus was detected in the 2,677 examined mosquitoes., Conclusions: We recommend continued and systematic entomological monitoring in areas vulnerable to the transmission of YF in the Federal District of Brazil.

We evaluated the effectiveness and safety of intralesional meglumine antimoniate (MA) in 24 not submitted to previous treatment patients with cutaneous leishmaniasis (CL) and with contraindication to systemic therapy. Each treatment consisted of one to four intralesional applications of MA at 15-day intervals. Patients' age ranged from 3 to 90 years; fourteen were females. Intralesional treatment in the absence of any relevant toxicity was successful in 20 (83.3%) patients. Three patients required additional treatment with amphotericin B and one required systemic MA. None of the patients developed mucosal lesions when followed up to 60 months. Intralesional MA is an effective and less toxic alternative treatment of patients with CL and contraindication to systemic therapy.

Background: Lung transplantation (LT) has been established as a current therapy for selected patients with end-stage lung disease. Different prognostic factors have been reported by transplant centers. The objective of this study is to report our recent results with LT and to search for prognostic factors., Methods: We performed a retrospective analysis of 130 patients who underwent LT at our institution from January 2004 to July 2009. Donor, recipient, intraoperative, and postoperative variables were collected., Results: The mean age was 53.14 years (ranging from 8 to 72 years) and 80 (61.5%) were male. The main causes of end-stage respiratory disease were pulmonary fibrosis 53 (40.7%) and chronic obstructive pulmonary disease 52 (40%). The actuarial 1-year survival was 67.7%. Variables correlated with survival were age (P=0.004), distance in the 6-min walk test (P=0.007), coronary heart disease (P=0.001), cardiopulmonary bypass (P=0.02), intraoperative transfusion of red blood cells (P=0.016), increasing central venous pressure at 24th postoperative hour (P=0.001), increasing pulmonary capillary wedge pressure at 24th postoperative hour (P=0.01); length of intubation (P<0.01), reintubation (P=0.001), length of intensive care unit stay (P<0.001), abdominal complication (P=0.003), acute renal failure requiring dialysis (P<0.001), native lung hyperinflation (P=0.02), and acute rejection in the first month (P=0.03). In multivariate analysis, only dialysis (P=0.004, hazards ratio [HR] 2.68), length of intubation (P=0.004, HR 1.002 for each hour), and reintubation (P=0.003, HR 2.88) proved to be independent predictors., Conclusion: Analysis of variables in our cohort highlighted dialysis, longer mechanical ventilation requirement, and reintubation as independent prognostic factors in LT.

Antifungal proteins and peptides, essential compounds for plant defense, have been isolated from several tissues of various plants. These proteins could be used as a natural alternative to control phytopathogenic fungi. In this report a heterodimeric antifungal protein named Pa-AFP1, showing higher identity with the 2S albumin family, was purified by using 70-100% ammonium sulfate saturation and further purification steps such as anionic exchange Q-Sepharose chromatography associated with HPLC reversed-phase C4 chromatography. Analysis by Tricine-SDS-PAGE revealed two peptidic molecular masses of approximately 4500 Da and 7000 Da, in the presence of β-mercaptoethanol, while by removing the reducing agent a single protein with molecular mass of about 11,500 Da was obtained. Moreover, dimer mass was confirmed by MALDI-TOF analyses (11,569.76 Da). The antifungal protein, named Pa-AFP1, efficiently inhibited the growth of filamentous fungi Colletotrichum gloeosporioides, and was added to a short list of 2S albumins with antimicrobial properties. Otherwise, this same peptide showed no activity toward bacteria and yeasts. In summary, this compound could be used in the future to develop biotechnological products for the control of phytopathogenic fungi., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: We wanted to compare the variability in the longitudinal emphysema index (EI) measurements that were computed with standard and high resolution (HR) reconstruction algorithms (RAs)., Materials and Methods: We performed a retrospective review of 475 patients who underwent CT for surveillance of lung nodules. From this cohort, 50 patients (28 male) were included in the study. For these patients, the baseline and follow-up scans were acquired on the same multidetector CT scanner and using the same acquisition protocol. The CT scans were reconstructed with HR and standard RAs. We determined the difference in the EI between CT1 and CT2 for the HR and standard RAs, and we compared the variance of these differences., Results: The mean of the variation of the total lung volume was 0.14 L (standard deviation [SD] = 0.13 L) for the standard RA and 0.16 L (SD = 0.15 L) for the HR RA. These differences were not significant. For the standard RA, the mean variation was 0.13% (SD = 0.44%) for EI -970 and 0.4% (SD = 0.88%) for EI -950; for the HR RA, the mean variation was 1.9% (SD = 2.2%) for EI -970 and 3.6% (SD = 3.7%) for EI -950. These differences were significant., Conclusion: Using an HR RA appears to increase the variability of the CT measurements of the EI.

Heavy agricultural losses are closely related to attacks by insect-pests and phytopathogens such as bacteria and fungi. Among them, the fungus Botrytis cinerea can cause gray mold in more than 200 different species of plants, and is considered a challenging problem for agribusiness. Fungicides are commonly used to control this pathogen because they are fast-working and easy to apply. However, the continuous use of fungicides may promote the selection of resistant fungi and can also cause profound contamination in ecosystems. Aiming to find alternative strategies to solve these problems, several studies have focused on searching for plant proteins and peptides with antifungal activities (AFPs). With this in mind, this report shows the isolation and characterization of two novels antifungal proteins from flowers of rosemary pepper (Lippia sidoides Cham.) with 10 and 15 kDa. Isolation was performed by using an Octyl-Sepharose hydrophobic column. In vitro bioassays indicated that isolated proteins were able to inhibit B. cinerea development, but were not effective against all bacteria tested. Moreover, N-termini sequences indicate that both proteins showed sequence homology with NBS-LRR R proteins with a lower molecular mass, suggesting possible protein fragmentation. Data reported here could help in the development of biotechnological products for crop protection against phytopathogenic fungi in the near future.

Objectives: To evaluate dysphonia in patients treated for laryngeal tuberculosis, and to assess the effect of speech therapy on patients' vocal quality., Materials and Methods: Seven of 23 patients with a confirmed diagnosis of laryngeal tuberculosis, treated at the Evandro Chagas Institute of Clinical Research, Oswaldo Cruz Foundation, underwent speech therapy for six months. These seven patients were evaluated by videolaryngoscopy and vocal acoustic analysis, before, during and after a course of speech therapy., Results: The 23 patients with laryngeal tuberculosis comprised five women and 18 men, with ages ranging from 25 to 83 years (mean 41.3 years). Dysphonia was present in 91.3 per cent of these laryngeal tuberculosis patients, being present as the first symptom in 82.6 per cent. In laryngeal tuberculosis patients with dysphonia, laryngeal tuberculosis treatment resulted in dysphonia resolution in only 15.8 per cent. After speech therapy, dysphonia patients had better vocal quality, as demonstrated by statistical analysis of jitter, shimmer, fundamental frequency variability, maximum phonation time, and the ratio between maximum phonation time for voiceless and voiced fricative sounds., Conclusions: Following treatment of laryngeal tuberculosis, the incidence of dysphonia was very high. Speech therapy improved patients' vocal quality.

Objective: To evaluate dizziness in patients receiving meglumine antimoniate for the treatment of mucosal leishmaniasis., Materials and Methods: We retrospectively studied 127 patients treated at the Laboratory of Leishmaniasis Surveillance, Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, between 1 January 1989 and 31 December 2004., Results: A low dose of meglumine antimoniate (5 mg/kg/day) was used in 86.6 per cent of patients; a dose of 10 mg/kg/day or higher was used in 13.4 per cent of patients. Dizziness was reported by 4.7 per cent of patients. The adjusted odds ratios were 7.37 for dizziness in female patients, 4.9 for dizziness in patients aged 60 years or older, and 7.77 for dizziness in the presence of elevated serum lipase., Conclusion: We suggest that dizziness may be a side effect of meglumine antimoniate, particularly in elderly individuals, in females and in patients with elevated serum lipase.

Drug-induced lung diseases are a frequent cause of morbidity. Diffuse pulmonary haemorrhage is an uncommon complication of drug therapy, and is a potentially life-threatening situation. We report the high-resolution CT and clinical findings of a 32-year-old man with diffuse pulmonary haemorrhage induced by ketorolac tromethamine.

There are many candidate genes for chronic obstructive pulmonary disease (COPD). One such candidate is the group of genes that code for matrix metalloproteinases (MMPs), which play an essential role in tissue remodeling and repair associated with COPD. We tested the hypothesis that polymorphic variation in MMP genes influences the risk of developing COPD by examining functional polymorphisms in the promoters of MMP-3, MMP-9 and MMP-12 genes in 111 COPD patients and 101 controls. The -1171 5A/6A MMP-3, -1562 C/T MMP-9 and -82 A/G MMP-12 polymorphisms were analyzed by polymerase chain reaction, followed by restriction digestion. No significant differences were observed in allele and genotype frequencies between COPD patients and controls. Haplotype analysis also did not reveal differences between COPD patients and controls. We found that MMP polymorphisms had no significant impact on the risk of developing COPD in this Brazilian sample.

Peripheral bronchial carcinoids are uncommon. Their presentation as synchronous tumors is rare and limited to anecdotal cases.We report the case of a 62-year-old female with the radiological finding of multiple bilateral nodular lesions. Bilateral sequential thoracotomies were performed and all three nodules were treated by sublobar resections. Pathological examination revealed all specimens to be carcinoid tumors and subsequent investigation confirmed the lung as the primary site. A review of previous cases of multiple carcinoids is presented and the particularities of their management are discussed.

Flowers represent a relatively unexplored source of antimicrobial peptides of biotechnological potential. This review focuses on flower-derived defense peptide classes with inhibitory activity towards plant pathogens. Small cationic peptides display diverse activities, including inhibition of digestive enzymes and bacterial and/or fungal inhibition. Considerable research is ongoing in this area, with natural crop plant defense potentially improved through the application of transgenic technologies. In this report, comparisons were made of peptide tertiary structures isolated from diverse flower species. A summary is provided of molecular interactions between flower peptides and pathogens, which include the role of membrane proteins and lipids. Research on these peptides is contributing to our understanding of pathogen resistance mechanisms, which will, given the perspectives for plant genetic modification, contribute long term to plant genetic improvement for increased resistance to diverse pathogens.

It is established that there is an increase in soft tissue of the clubbed digits as demonstrated on previous histopathological examinations. In the present study, the nail bed thickness was assessed and measured on plain radiographs of index fingers in two groups of patients: one group with lung disease and fingers clubbing and one group of normal controls. A vertical x-ray beam was used with a focus-film distance of 1.0 m, with the index finger placed in lateral view directly over the film, without anti-diffusion grid. Three investigators, blinded to prevent bias measured the thickness of soft tissues between the nail root and the terminal phalanx on the radiographs. This method was used to evaluate a group of 85 clinically clubbed (hyponychial angle > 192.0 degrees) adult patients with lung disease and a control group of a 100 normal adult individuals with no clubbing (hyponychial angle < 188.0 degrees). The mean nail bed thickness in the patients with clubbing (n = 85) was 3.88 +/- 0.55 mm (3.00-5.50 mm). In comparison, in the normal subjects (n = 100), the mean was 2.38 +/- 0.27 mm (1.75-3.10 mm), revealing a significant difference (P < 0.001). Only two normal individuals presented nail bed thickness >or=3.0 mm. A good interobserver agreement on the measurements was found (P > 0.900). The radiographic evaluation of the nail bed thickness was easily performed, with good interobserver concordance. It is possible to distinguish between clubbed from nonclubbed fingers, in vivo, using plain radiograph., ((c) 2008 Wiley-Liss, Inc.)

Research on the germinal center has tried to unravel the mechanisms that control its dynamics. In this study we focus on the termination of the germinal center reaction, which is still an open problem. We propose two hypothetical biological mechanisms that may be responsible for the control of germinal center dynamics and analyze them through mathematical models. The first one is based on the differentiation of follicular dendritic cells and/or T cells. Interaction of these cells in the differentiated state with germinal center B cells would promote B cell differentiation into memory B cells and Ab-forming cells, ending the germinal center reaction. The second mechanism applies only to a scenario without recycling and consists of the decay of a hypothetical proliferation signal for centroblasts that limits the number of cell divisions. Each of the models makes predictions that can be experimentally tested.

Mathematical models have been used to study different aspects of the germinal centre reaction, in particular, affinity maturation of antibodies and the hypothesis of recycling. So far, interpretation of several theoretical and experimental results has pointed to the existence of recycling. However, theoretical models have seldom been compared with experimental data from specific immune responses and the potential relevance of recycling in the germinal centre is still an open problem. In this article, we propose a model without recycling that takes into account selection mechanisms that were previously uncovered experimentally. We apply the model to several experimental systems that use different Ag and compare the results with experimental data of affinity maturation whenever available. The results obtained for a primary immune response to the hapten (4-hydroxy-3-nitrophenyl)-acetyl show that recycling is not a necessary mechanism to achieve the level of affinity maturation observed in germinal centre reactions. Similar levels of affinity maturation are obtained for other responses, although for antibodies involving several affinity-enhancing mutations the affinity maturation obtained with the model is much lower. Interpretation of these results and consequences towards the concept of recycling are discussed.

We report a rare case of chronic disseminated histoplasmosis with several ulcerated lesions in the oral cavity in an alcoholic patient without human immunodeficiency virus infection, with no detectable signs and symptoms of systemic disease or extraoral manifestations. Histopathological analysis revealed chronic inflammatory process with granulomas containing Histoplasma-like organisms. The isolation of Histoplasma capsulatum provided the definitive diagnosis. Treatment with itraconazole resulted in complete remission of oral lesions. As far we aware, this is the second case report of oral histoplasmosis in an HIV negative patient described in Brazil.

Objective: To analyze tests used in routine clinical practice for the diagnosis of myocardial ischemia to predict the development of cardiac events in type 2 diabetic patients., Methods: The occurrence of cardiac events (new myocardial infarct, myocardial re-vascularization procedures, congestive heart failure, acute pulmonary edema, sudden death, and death after myocardial infarction or pulmonary edema) were prospectively assessed in a cohort of 135 type 2 diabetic patients after up to seven years of follow-up. At baseline, coronary artery disease was assessed by the WHO cardiovascular questionnaire, resting electrocardiogram, and stress myocardial scintigraphy., Results: Forty-eight cardiac events were observed in 41 patients (10.5 events/100 patients-year). In a Cox's proportional-hazard model only the presence of symptoms of coronary artery disease on the WHO cardiovascular questionnaire alone (RR = 2.13, 95% CI 1.11-4.07, P= 0.022) or in combination with abnormalities on resting ECG (RR= 2.03, 95% CI 1.05-3.92, P= 0.034) or on myocardial scintigraphy (RR= 1.89, 95% CI 1.001-3.57, P= 0.050) predicted cardiac events, adjusted for fasting plasma glucose, mean blood pressure, body mass index, peripheral vascular disease and diabetic nephropathy., Conclusion: The WHO cardiovascular questionnaire, a simple tool for the diagnosis of coronary artery disease, is a significant predictor of cardiac events in type 2 diabetic patients.

Unlabelled: Leprosy is an infectious condition that has a chronic evolution caused by the Mycobacterium leprae. It very often attacks the nasal cavities mucosa independent of its clinical form, even before skin lesions or lesions to other parts of the body arise, in the presence or not of clinical complaints., Aim: To show the efficiency of nasal endoscopy to identify endonasal mucosa lesions and the importance of the Otorhinolaryngologist in the diagnosis and follow-up of Leprosy patients., Study Design: Clinical history study., Material and Method: A historic study was performed with 173 patient's records without previous treatment from 1990 to 2000 at the Otorhinolaryngology Services, Instituto de Pesquisas Clinicas Hospital Evandro Chagas, Fiocruz., Results: All of the patients showed nasal lesions, 121 with and 52 without clinical complaints., Discussion: Nasal cavities endoscopy exam enabled early identification of the mucosa alteration in Leprosy patients as well as how to identify the evolution of the lesions. This type of exam also helps to establish local treatment., Conclusion: The evaluation and follow-up of Leprosy patients by the Otorhinolaryngologist in a multidisciplinary team are justified and offer the patient early diagnosis and specific treatment.

We retrospectively analyzed a series of 151 cases of cutaneous leishmaniasis treated between 1967 and 1982. One-hundred-and-thirty-nine (92%) patients presented with active lesions and were treated with daily doses of meglumine antimoniate: 81 adults received a 5-ml vial IM and 58 children received 1 to 5 ml. Forty-five (32.4%) patients underwent continuous treatment with meglumine antimoniate for 25 to 116 days without rest intervals, and 94 (67.6%) intermittent treatment with 2 to 5 series of meglumine antimoniate. Intermittent series could include schedules of daily IM applications for 10 to 25 days each and intervals varying from 10 to 60 days. Antimony dose was calculated for 66 (47.5%) patients and ranged from 3.9 to 28.7 Sb5+/kg/day. Of these, 35 patients received > or =10 mg and 31 patients < 10 mg Sb5+/kg/day. Median time of healing was longer for lesions on the legs and feet -- 67.5 days versus 48.7 days (p < 0.001) for other sites. However, there were no significant differences in the median time of healing between adults and children, intermittent and continuous regimens or high and low antimony doses. Fifty-one patients were reassessed 5 to 14 years after treatment and showed no evidence of disease. These results support further investigation (clinical trials) on treatment using low doses of antimony.

Background: Tegumentary leishmaniasis and leprosy display similar spectra of disease phenotypes, which are dependent on cell-mediated immunity to specific antigens. Diffuse cutaneous leishmaniasis and lepromatous leprosy represent the anergic end of the spectrum, whereas mucocutaneous leishmaniasis and tuberculoid leprosy are associated with marked antigen-specific cellular immune response., Methods: We characterized and compared the cell-mediated response to Leishmania and Mycobacterium leprae antigens in a patient with an intriguing association of mucocutaneous leishmaniasis with lepromatous leprosy, which are at opposite ends of the immunopathological spectra of these diseases. This was done by performance of skin tests and by assessment of the cell proliferation and cytokine production of peripheral blood mononuclear cells (PBMCs)., Results: Strong skin-test reactions and PBMC proliferation were observed in response to Leishmania antigens but not to M. leprae antigens. The stimulation of PBMCs with Leishmania and M. leprae antigens induced comparable levels of tumor necrosis factor- alpha , interleukin-5, and interleukin-10. However, the interferon- gamma response to Leishmania antigens was remarkably high, and that to M. leprae antigens was almost nil., Conclusions: We found that concomitant leprosy and tegumentary leishmaniasis can produce opposite polar forms associated, respectively, with absent or exaggerated cell-mediated immune responses to each pathogen. This suggests that independent mechanisms influence the clinical outcome of each infection. Moreover, interferon- gamma appears to play a major role in the clinical expression of these intracellular infections.

Exposure to stress induces a cluster of physiological and behavioral changes in an effort to maintain the homeostasis of the organism. Long-term exposure to stress, however, has detrimental effects on several cell functions such as the impairment of antioxidant defenses leading to oxidative damage. Oxidative stress is a central feature of many diseases. The lungs are particularly susceptible to lesions by free radicals and pulmonary antioxidant defenses are extensively distributed and include both enzymatic and non-enzymatic systems. The aim of the present study was to determine lipid peroxidation and total radical-trapping potential (TRAP) changes in lungs of rats submitted to different models of chronic stress. Adult male Wistar rats weighing 180-230 g were submitted to different stressors (variable stress, N = 7) or repeated restraint stress for 15 (N = 10) or 40 days (N = 6) and compared to control groups (N = 10 each). Lipid peroxidation levels were assessed by thiobarbituric acid reactive substances (TBARS), and TRAP was measured by the decrease in luminescence using the 2-2'-azo-bis(2-amidinopropane)-luminol system. Chronic variable stress induced a 51% increase in oxidative stress in lungs (control group: 0.037 +/- 0.002; variable stress: 0.056 +/- 0.007, P < 0.01). No difference in TBARS was observed after chronic restraint stress, but a significant 57% increase in TRAP was presented by the group repeatedly restrained for 15 days (control group: 2.48 +/- 0.42; stressed: 3.65 +/- 0.16, P < 0.05). We conclude that different stressors induce different effects on the oxidative status of the organism.

Drawing from four sixteenth-century sources, the article reports some apparent incidents of American Tegumentary Leishmaniasis within the territory of the Andes. Reinterpretation of these sources affords a look at the longstanding issue of the origin of espundia,or mucosal Leishmaniasis (ML). The study reinforces the hypothesis that ML originated in the western Amazon region, from there climbing into the high forests and later into hot inter-Andean lands via Bolivia's and Peru's borders with Brazil, above al through human migration. dating to archeological times, this process intensified during the Inca period under the social policies of the mitmaq or mitimaes. These events transpired within the historical and social context of the fall of the Inca Empire and the advent of Spanish colonization.

Systematic examination of the upper respiratory and digestive tracts (URDT) was performed in a group of 80 paracoccidioidomycosis (PCM) patients submitted to post-treatment follow-up ranging from 8 months to 17 years. Mucosae of the URDT had been involved prior to specific treatment in 74 patients, distributed as follows: oropharynx, 50 (41 alone, 7 in association with the larynx, and 2 with the nasal mucosa); larynx, 30 (23 alone and 7 in association); and nasal mucosa, 3 (1 alone and 2 in association). Inactive lesions were observed in all the 50 patients with lesions of the oropharynx, 3 of whom with deforming scars (1 with retraction of the tongue and 2 with narrowing of the oral orifice). One case presented a destructive lesion, with perfuration of the palate. Of the other 46 cases, examination showed nacreous white striated scars which were nearly imperceptible in some cases and in others displayed partial retraction of anatomical structures without any alteration of their features. Patients presented a high rate of missing teeth. In 3 patients with involvement of the nasal mucosa, none of whom presented active PCM lesions, 2 still had nasal voices. In 30 patients with lesions of the larynx, 1 suffered a relapse of PCM and 2 developed epidermoid carcinoma. Of the other 27 cases, none of whom had active PCM lesions, 15 presented dysphonia, 3 were tracheotomized, and 9 were asymptomatic.