Extrinsic compression of the left main coronary artery (LMC) by the pulmonary artery (PA) is a very unusual and poorly understood entity, usually associated with the presence of adult congenital heart disease. We identified 12 patients (age range, 6 months to 55 years) with LMC stenosis (> or = 50%) presumably secondary to compression by a dilated main PA and related to various forms of heart disease (11 congenital, 1 pulmonary hypertension). In all cases, the main PA was dilated with the main PA/aortic root diameter increased (mean, 2.0; normal value, < or = 1.0), and in all but two, PA pressures were increased (> 30 mm Hg systolic). Left coronary trunk stenosis was usually visualized in only one angiographic view (best seen in 45 degrees left anterior oblique, 30 degrees cranial projection). The LMC also appeared to be inferiorly displaced and in close contact with the left aortic sinus (mean angle between sinus and LMC was 23 degrees +/- 13 degrees, a control group was 70 degrees +/- 15 degrees ). In one patient, surgical correction of the dilated PA was associated with a reduction in LMC stenosis from 85% to < 50% and less inferior left main displacement (from 25 degrees to 50 degrees ). Patients with a dilated main PA may exhibit extrinsic LMC compression leading to significant eccentric narrowing and downward displacement of the LMC. In the presence of significant dilatation of the main PA from any etiology, functional and/or anatomic studies should be performed to exclude significant LM obstruction.

The level of knowledge concerning American tegumentary leishmaniasis (ATL) and use of alternative therapies was evaluated in five rural communities in

A melhoria significativa dos cuidados intensivos neonatais causou uma redução na mortalidade em necém-nascidos de risco e, portanto, um aumento de sua morbidade, o que realçou a importância da avaliação do desenvolvimento dessas crianças. Esta revisão de literatura foi desenhada para identificar os principais instrumentos indicados para avaliar o desenvolvimento dos pré-termos. As bases de dados utilizadas foram Medline, Lilacs, Scielo, manuais dos instrumentos e livros na área de Pediatria por apresentarem maiores detalhes sobre os instrumentos e não estabelecer limite de tempo, pois o objetivo da pesquisa foi identificar desde os instrumentos mais antigos até os publicados recentemente. Foram identificados 11 instrumentos de avaliação do desenvolvimento publicados desde 1947 a. O conhecimento dessas escalas e dos testes pode ajudar aos profissionais de saúde e pesquisadores que trabalham com o desenvolvimento de crianças prematuras, pois constituem uma ferramenta adicional durante o processo de avaliação. A escolha do instrumento de avaliação deve ser realizada em acordo com as necessidades de cada criança. Podendo ser utilizados para a triagem, diagnóstico, planejamento e acompanhamento do tratamento.

Visceral leishmaniasis (VL) is endemic in the island of São Luis, State of Maranhão, Brazil. Despite an increase in the number of VL cases, the frequency of the disease is low among pregnant women. We present here the case of a pregnant woman followed up by our group, who was treated with amphotericin B with excellent outcome.

Revista da Sociedade Brasileira de Medicina Tropical 46(6):741-745, Nov-Dec, 2013http://dx.doi.org/10.1590/0037-8682-0203-2013 INTRODUCTION ABSTRACT Introduction:The relationship between severe clinical manifestations of visceral leishmaniasis (VL) and immune response profi les has not yet been clarifi ed, despite numerous studies on the subject. This study aimed to investigate the relationship between cytokine profi les and the presence of immunological markers associated with clinical manifestations and, particularly, signs of severity, as defi ned in a protocol drafted by the Ministry of Health (Brazil). Methods: We conducted a prospective, descriptive study between May 2008 and December 2009. This study was based on an assessment of all pediatric patients with VL who were observed in a reference hospital in Maranhão. Results: Among 27 children, 55.5% presented with more than one sign of severity or warning sign. Patients without signs of severity or warning signs and patients with only one warning sign had the highest interferon-gamma (IFN-γ) levels, although their interleukin 10 (IL-10) levels were also elevated. In contrast, patients with the features of severe disease had the lowest IFN-γ levels. Three patients who presented with more than two signs of severe disease died; these patients had undetectable interleukin 2 (IL-2) and IFN-γ levels and low IL-10 levels, which varied between 0 and 36.8pg/mL. Conclusions: Our results showed that disease severity was associated with low IFN-γ levels and elevated IL-10 levels. However, further studies with larger samples are needed to better characterize the relationship between disease severity and cytokine levels, with the aim of identifying immunological markers of active-disease severity.

The factors determining the development or not of visceral leishmaniasis (VL) have not been completely identified, but a Leishmaniaspecific cellular immune response seems to play a fundamental role in the final control of infection. Few studies are available regarding the production of cytokines in the subclinical form of VL, with only the production of IFN-γ and TNF-α known. The aim of the present study was to identify immunological markers for the oligosymptomatic or subclinical form of VL. A prospective cohort study was conducted on 784 children aged 0 to 5 years from an endemic area in the State of Maranhão, Brazil, between January 1998 and December 2001. During 30 consecutive months of follow-up, 33 children developed the oligosymptomatic form of the disease and 12 the acute form. During the clinical manifestations, serum cytokine levels were determined in 27 oligosymptomatic children and in nine patients with the acute form using a quantitative sandwich enzyme immunoassay. In the subclinical form of VL, variable levels of IL-2 were detected in 52.3% of the children, IL-12 in 85.2%, IFN-γ in 48.1%, IL-10 in 88.9%, and TNF-α in 100.0%, with the last two cytokines showing significantly lower levels than in the acute form. IL-4 was not detected in oligosymptomatic individuals. Multiple discriminant analysis used to determine the profile or combination of cytokines predominating in the subclinical form revealed both a Leishmania resistance (Th1) and susceptibility (Th2) profile. The detection of both Th1 and Th2 cytokine profiles explains the self-limited evolution accompanied by the discrete alterations observed for the subclinical form of VL.

O objetivo do estudo foi caracterizar a cobertura do pré-natal no Estado do Maranhão. Um estudo de base populacional em 30 municípios do Maranhão, com 2.075 mulheres em idade fértil, com gravidez prévia, de julho de 2008 a janeiro de 2009. Os resultados mostraram que as unidades de saúde da família foram responsáveis por 45,9% dos atendimentos de gestantes sendo que 46,8% relataram a realização de seis consultas ou mais de pré-natal durante a última gravidez e 64,6% iniciaram o pré-natal ainda no 1º trimestre. A cobertura do pré-natal foi de 85,6%, no entanto, ao se considerar a cobertura de pré-natal adequado, este foi de 43,4%, de acordo com o preconizado pelo Ministério da Saúde (Brasil). Apesar de uma cobertura de pré-natal acima de 80%, menos da metade é considerada adequada, demonstrando um descompasso na atenção primária com qualidade.

Regulatory T cells (Tregs) are a unique population of CD25+CD4+ T cells that regulate innate and adaptive immune responses and have the ability to control the excessive or misdirected effects of the immune system. This modulation involves different mechanisms, such as the suppression of T cell proliferation and cytokine production, the secretion of suppressive cytokines (IL-10 and TGF-β) and the induction of effector T cell apoptosis in humans with infectious diseases such as Leishmania infections. The aim of this study was to evaluate the expression of Foxp3, IL-10 and TGF-β through immunohistochemistry in 22 skin biopsies of patients with localized cutaneous leishmaniasis (LCL) caused by Leishmania (Viannia) spp. from an endemic area in pre-Amazonian area of Maranhão State, Brazil. The density of these markers was also analyzed according to the species of parasite and the progression of the disease. The cellular density was 234 cells/mm(2) for Foxp3+ cells, 357 cells/mm(2) for TGF-β+ cells and 648 cells/mm(2) for IL-10+ cells in the studied skin lesions. The analysis of the cellular density of these immunological markers in relation to the species of Leishmania demonstrated that lesions caused by L. (V.) braziliensis had a lower density of Foxp3+ cells than lesions caused by L. (Viannia) spp. The expression of IL-10 was also lower in lesions caused by L. (V.) braziliensis. There were no significant differences in TGF-β expression between the two groups. The evaluation of these markers according to the progression of the disease did not reveal any significant differences. These findings suggest that Treg Foxp3+ cells, IL-10, and TGF-β play important roles in the immunopathogenesis of LCL and that these roles differ depending on the causal Leishmania species.