Publications by authors named "Ricardo Mendes Pereira"

33 Publications

Two-year history of lymphadenopathy and fever caused by Bartonella henselae in a child.

Rev Inst Med Trop Sao Paulo 2022 16;64:e15. Epub 2022 Feb 16.

Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, São Paulo, Brazil.

We report the case of a 6-year-old boy that presented with enlarged lymph nodes on his neck. He complained of tiredness and discouragement, which worsened during feverish periods. There were no relevant laboratory test abnormalities and serological tests were not reactive. Bartonella henselae DNA was detected by species-specific nested polymerase chain reaction. After treatment, the patient progressed with no fever or lymphadenopathy. Bartonellosis is a group of infectious diseases caused by bacteria of the genus Bartonella. This case report is a useful reminder to clinicians that long-term fever of unknown origin can be related to B. henselae infection, even if the specific serology is not reactive.
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http://dx.doi.org/10.1590/S1678-9946202264015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8853666PMC
February 2022

Reproducibility of MRI Features of Uterine Leiomyomas: A Study on Interobserver Agreement and Inter-Method Agreement With Surgery.

Can Assoc Radiol J 2022 May 16;73(2):337-345. Epub 2021 Aug 16.

Department of Diagnostic Imaging, Hospital São Paulo, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Purpose: To evaluate interobserver agreement in the interpretation of different MRI features of uterine leiomyomas (UL) according to observers' experience, and to assess the inter-method reproducibility (MRI versus surgery) regarding the International Federation of Gynecology and Obstetrics (FIGO) classification.

Methods: Retrospective study including UL patients who underwent MRI and surgical treatment. Four blinded observers (2 >10 years of experience) assessed UL regarding dimensions and volume; inner and outer mantles; FIGO classification; vascularization; degeneration; and diffusion-weighted imaging features. Uterine dimensions and volume were calculated. FIGO classification as ascertained by observers was compared to surgical findings. Intraclass correlation coefficient (ICC) estimates were used for interobserver comparison of numerical variables, and kappa statistic for categorical variables.

Results: Thirty-five patients (26y-73y) with 61 UL were included in the interobserver analyses, and 31 patients (54 UL) had available data allowing retrospective surgical FIGO classification for assessment of inter-method reproducibility. Both groups of observers had good to excellent agreement in assessing UL (ICC = 0.980-0.994) and uterine volumes (ICC = 0.857-0.914), mantles measurement (ICC = 0.797-0.920), and apparent diffusion coefficient calculation (ICC = 0.787-0.883). There was substantial agreement for both groups regarding FIGO classification (κ = 0.645-0.767). Vascularization, degeneration and restricted diffusion had lower agreement, varying from reasonable to moderate. Inter-method agreement was reasonable (κ = 0.341-0.395).

Conclusions: Interobserver agreement of MRI for UL was higher for quantitative than qualitative features, with a little impact of observers' experience for most features. MRI agreement with surgery was reasonable. Further efforts should be taken to improve interobserver and inter-method reproducibility for MRI in this scenario.
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http://dx.doi.org/10.1177/08465371211038546DOI Listing
May 2022

Hysterosalpingography using Magnetic Resonance Imaging for infertility patients.

JBRA Assist Reprod 2021 07 21;25(3):403-411. Epub 2021 Jul 21.

Baby Center - Center for Reproductive Medicine, São Paulo, Brazil.

Objective: Some studies have shown that it is possible to evaluate tubal permeability through MRI. Our aim is to perform a prospective study and to perform a comprehensive review in the literature regarding HSG-MRI.

Methods: We carried out a PUBMED search using the following keywords: hysterosalpingogram, hysterosalpingography, magnetic resonance imaging and MRI. As inclusion criteria, we included only papers published in English, and exams ran on humans. We also conducted a prospective inclusion of patients who had visited a human reproduction clinic between May/2017 and April/2019 for laboratory image diagnoses using HSG-MRI.

Results: Following the inclusion and exclusion criteria, we included seven original papers. Review papers and those written in a language other than English, were excluded. Between the period of May/2017 and April/2019, we selected ten patients for our study. The average exam duration was 30 minutes. Cervical catheterization was possible in all cases. There were no major complications. We highlight that in 8/9 of patients, we could directly visualize uterine tubes with contrast (excluding one patient with bilateral tubal ligation).

Conclusions: Our initial experience with HSG-MRI shows promise. We demonstrated an optimized protocol for conducting an HSG-MRI (with excellent image quality). HSG-MRI had some advantages, such as not using ionized radiation, less pain and being able to analyze pelvic anatomy. Patients referred for a pelvic MRI as part of a more detailed investigation into infertility can also benefit from undergoing a simultaneous HSG using MRI.
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http://dx.doi.org/10.5935/1518-0557.20210002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312299PMC
July 2021

Epidemiology of Ocular Trauma in a Pediatric Referral Unit, Sao Paulo, Brazil.

Indian Pediatr 2021 Jun 26;58(6):589-590. Epub 2020 Dec 26.

Department of Pediatrics, School of Medical Sciences, University of Campinas, Tessália Vieira de Camargo, 126, Barão Geraldo, Cidade Universitária Zeferino Vaz, Campinas, São Paulo, Brazil.

We performed a retrospective study of hospital records of children younger than 14 years with ocular trauma seen at our center in Sao Paulo, Brazil, between 2011 and 2012. From the total number of cases, 224 (89.2%) could be easily avoided. Accidents occurred with 5 children under 1 year of age; with one baby as young as 2 months. Also, there was a higher prevalence of ocular trauma in 2-to-6-year-old male patients, mainly caused by accidents resulting from the patient's own actions and occurred at home, usually in the presence of an adult. The average time (range) between the accident and seeking medical care was 17.4 hours (10 minutes to 14 days). There is a need to educate parents for preventing ocular trauma.
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June 2021

CLINICAL, DEMOGRAPHIC, ANATOMOPATHOLOGICAL, AND MOLECULAR FINDINGS IN PATIENTS WITH MEDULLOBLASTOMA TREATED IN A SINGLE HEALTH FACILITY.

Rev Paul Pediatr 2020 16;39:e2019298. Epub 2020 Nov 16.

Universidade Estadual de Campinas, Campinas, SP, Brazil.

Objective: To describe the clinical, demographic, anatomopathological, molecular, and survival characteristics of patients with medulloblastoma.

Methods: Retrospective study based on patient information obtained from the review of medical records. Overall and event-free survival were analyzed using the Kaplan-Meier estimator, and the curves were compared by the log-rank test.

Results: Among the patients investigated, 70 were male (66%), and age at diagnosis ranged from 2 months to 22 years. The most frequent signs and symptoms were headache (80.8%) and vomiting (75.8%). Regarding treatment, most patients (63.2%) underwent complete surgical resection, with a predominance of classic histology (63.2%). The 5-year overall survival rate was 67.9%, and the 10-year rate was 64.2%. Patients with molecular profile characteristic of the wingless (WNT) subgroup had a better prognosis, with 5-year overall survival of 75%.

Conclusions: The clinical, demographic, anatomopathological, and molecular characteristics of patients with medulloblastoma described in the present study were mostly similar to those reported in the literature. Patients submitted to complete tumor resection had better clinical outcomes than those who underwent incomplete resection/biopsy. Patients classified as high-risk showed worse overall and event-free survival than those in the standard-risk group, and the presence of metastasis at diagnosis was associated with recurrence.
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http://dx.doi.org/10.1590/1984-0462/2021/39/2019298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669220PMC
August 2021

Association between IL-27 and Tr1 cells in severe form of paracoccidioidomycosis.

Cytokine 2020 03 2;127:154962. Epub 2020 Jan 2.

Department of Clinical Pathology, Faculty of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil. Electronic address:

Interleukin-27, a cytokine of the IL-12 family, is secreted by antigen-presenting cells such as macrophages and dendritic cells (DCs). Recent studies suggest an anti-inflammatory role for IL-27 by inducing IL-10 producing Tr1 cells capable of inhibiting Th1 and Th17 type responses. Our study aimed to investigate the involvement of IL-27 and Tr1 cells in the immunomodulation of paracoccidioidomycosis (PCM), the most prevalent systemic mycosis in Brazil. The presence of IL-27 was evaluated in serum and biopsies of patients with PCM by ELISA, immunohistochemistry, and immunofluorescence. The presence of Tr1 in peripheral blood was analyzed by flow cytometry. In vitro assays were performed to verify the ability of P. brasiliensis yeast to induce IL-27 production by DCs and macrophages, as well as the polarization of lymphocytes to the Tr1 phenotype. Patients with the acute form and severe chronic form, the most severe and disseminated forms of PCM, presented higher serum concentrations of IL-27 and higher percentage of Tr1 cells compared to patients with mild chronic form. IL-27 was also detected in lesions of patients with PCM and associated with DCs and macrophages. P. brasiliensis Pb18 yeasts were able to induce IL-27 production by both DCs and macrophages. We found that DCs pulsed with Pb18 were able to induce Tr1 lymphocytes in vitro. Our data suggest that IL-27 and Tr1 cells could contribute to the deficient immune response to P. brasiliensis that leads to severe and disseminated forms of the disease.
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http://dx.doi.org/10.1016/j.cyto.2019.154962DOI Listing
March 2020

Acute-subacute paracoccidioidomycosis: A paediatric cohort of 141 patients, exploring clinical characteristics, laboratorial analysis and developing a non-survival predictor.

Mycoses 2019 Nov 4;62(11):999-1005. Epub 2019 Sep 4.

The State University of Campinas - Unicamp, Campinas, SP, Brasil.

The acute-subacute form of paracoccidioidomycosis (PCM) is a severe systemic mycosis that affects children and adolescents from endemic regions, leading to generalised lymphadenopathy, fever, weight loss, anaemia, eosinophilia, hypoalbuminemia and hypergammaglobulinemia. The objective of this study is to describe the clinical and laboratorial characteristics of acute-subacute PCM, to determine a mortality risk factor and to propose a test for non-survival hazard related to the disease. Children and adolescents diagnosed with PCM, under 15 years were included in the study. Their epidemiological, clinical and laboratorial data were obtained from the hospital records. Descriptive analysis, comparison of means, univariate logistic regression, multivariate logistic regression and a ROC curve were performed in order to identify significant information (P < .05). Through a period of 38 years, 141 children and adolescents were diagnosed with acute-subacute PCM. The main antifungal agent used for the treatment was sulfamethoxazole-trimethoprim (SMX-TMP). The complication rate was 17%, the relapse rate was 7.8% and the mortality rate was 5.7%. A low albumin dosage was identified as a predictor factor for mortality. The cut-off for serum albumin was 2.18 g/dL, above which, the survival rate is 99.1%. Thus, simple clinical and laboratorial examinations may lead to the diagnosis of acute-subacute PCM, and the beginning of the treatment is encouraged even before the isolation of the fungus in biological samples, preventing unfavourable outcomes. Patients with an albumin dosage ≤ 2.18g/dL must receive special attention, preferably hospitalised, during the first four weeks of treatment for presenting an elevated mortality hazard.
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http://dx.doi.org/10.1111/myc.12984DOI Listing
November 2019

Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions.

Eur J Pediatr 2019 Sep 16;178(9):1369-1377. Epub 2019 Jul 16.

Pediatric Intensive Care Unit, Department of Pediatrics, State University of Campinas (UNICAMP), 1000, Hermantino Coelho St., Campinas, SP, 13087-500, Brazil.

The objective of this study was to evaluate the interoperator agreement of lung ultrasonography (LUS) on specific thoracic regions in children diagnosed with pneumonia and to compare the findings of the LUS with the chest X-ray. Participants admitted to the ward or PICU underwent LUS examinations performed by an expert and a novice operator. A total of 261 thoracic regions in 23 patients were evaluated. Median age and weight of participants were 30 months and 11.6 kg, respectively. A substantial overall agreement between operators was found for normal lung tissue (κ = 0.615, 95% confidence interval (95% CI) = 0.516-0.715) and for consolidations (κ = 0.635, 95% CI = 0.532-0.738). For B-lines, a moderate agreement was observed (κ = 0.573, 95% CI = 0.475-0.671). An almost perfect agreement was found for pleural effusion (κ = 0.868, 95% CI = 0.754-0.982). The diagnosis of consolidations by LUS showed a high sensitivity (93% for both operators) but a low specificity (14% for expert and 25% for novice operator). While intubated patients presented significantly more consolidations, nonintubated patients presented more normal ultrasound patterns.Conclusion: Even when performed by operators with very distinct degrees of experience, LUS had a good interoperator reliability for detecting sonographic patterns on specific thoracic regions. What is Known: • Lung ultrasound is feasible, safe, and highly accurate for the diagnosis of pneumonia in children; however, it does not allow global visualization of the thorax in a single moment as in chest X-rays, and, similar to the stethoscope, partial thorax assessments must be performed sequentially. What is New: • This is the first study evaluating the agreement of LUS on specific thoracic regions between operators with distinct degrees of experience performing the sonograms. • There is a good agreement between an expert operator and a novice operator who underwent a brief theoretical-practical training program on LUS.
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http://dx.doi.org/10.1007/s00431-019-03428-2DOI Listing
September 2019

Septic arthritis caused by Salmonella enterica serotype Rubislaw: A case report.

Rev Soc Bras Med Trop 2019 01 17;52:e20180253. Epub 2019 Jan 17.

Departamento de Pediatria, Faculdade de Ciências Médicas da Universidade Estadual de Campinas, Campinas, SP, Brasil.

An eleven-year-old boy presented with fever and hip pain, with limited mobility of the right side of the hip. Computed tomography scan revealed an increased volume of the right coxo-femoral joint, requiring surgical drainage of purulent secretion, from which Salmonella enterica was isolated. After four weeks of treatment with third-generation cephalosporin, he was discharged with a favorable evolution. Invasive disease caused by Salmonella spp represents a small proportion of salmonellosis cases, although it is responsible for greater rates of hospitalization, morbidity and mortality. Children under 5 years, elders over 60 years and immunodeficient patients have greater risk for invasive salmonellosis.
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http://dx.doi.org/10.1590/0037-8682-0253-2018DOI Listing
January 2019

INVASIVE NON-TYPE B HAEMOPHILUS INFLUENZAE DISEASE: REPORT OF EIGHT CASES.

Rev Paul Pediatr 2019 Apr-Jun;37(2):156-160. Epub 2019 Jan 7.

Universidade Estadual de Campinas, Campinas, SP, Brazil.

Objective: To describe eight cases of invasive non-type b Haemophilus influenzae disease in children admitted to Hospital de Clínicas of Universidade Estadual de Campinas.

Cases Description: In 2015, there were eight cases of invasive non-type b H. influenzae disease. We tested the ampicillin sensitivity and beta-lactamase production of the strains identified and performed the genotyping. Molecular typing was determined by Pulsed-Field Gel Electrophoresis. Four patients were diagnosed with bacteremia; in two cases, H. influenzae was detected in the pleural fluid, and two patients had meningitis. Patients with comorbidities represented 37.5% of cases. Except for the strain of one patient - not sent to the reference laboratory -, all were ampicillin-sensitive and non-beta-lactamase-producing. Genotyping identified four non-capsular, one type c, and two type a strains. Molecular typing ruled out nosocomial transmission since all serotypes were distinct regarding genotype.

Comments: The rise in cases of invasive non-type b H. influenzae infection was real. There was no nosocomial transmission, and we found no justification for the increase. These data indicate the need for surveillance to correctly diagnose, monitor, and understand the spectrum of non-type b H. influenzae disease.
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http://dx.doi.org/10.1590/1984-0462/;2019;37;2;00006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6651304PMC
January 2020

[Brazilian guidelines for the clinical management of paracoccidioidomycosis].

Epidemiol Serv Saude 2018 08 16;27(spe):e0500001. Epub 2018 Aug 16.

Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brasil.

Paracoccidioidomycosis is a systemic fungal disease associated with agricultural activities. Its incidence and prevalence are underestimated because of the lack of reporting in several Brazilian states. If paracoccidiodomycosis is not diagnosed and treated early and adequately, endemic fungal infection may result in serious sequelae. In addition to the Paracoccidioides brasiliensis (P. brasiliensis) complex, the appearance of a new species, Paracoccidioides lutzii (P. lutzii), in Rondônia state, where the disease has reached epidemic levels, and in the country's Midwest region and Pará state, are challenges to diagnosis and to the urgent availability of antigens that are reactive with patients' sera. These guidelines aim to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. The guidelines provide data on etiology, epidemiology, immunopathogenesis, diagnosis, treatment and sequelae, with emphasis on diagnosis and treatment, as well as current recommendations and challenges in this field of knowledge.
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http://dx.doi.org/10.5123/S1679-49742018000500001DOI Listing
August 2018

LATE DIAGNOSIS OF CONGENITAL SYPHILIS: A RECURRING REALITY IN WOMEN AND CHILDREN HEALTH CARE IN BRAZIL.

Rev Paul Pediatr 2018 Jul-Sep;36(3):376-381. Epub 2018 Jul 26.

Universidade Estadual de Campinas, São Paulo, Brasil.

Objective: To describe a case of congenital syphilis with a late diagnosis and identify missed opportunities at diverse phases/levels of healthcare, which led to late diagnosis.

Case Description: Boy, 34 days of life, referred from a basic healthcare unit to a tertiary hospital due to enlarged abdominal volume and progressive jaundice for 2 weeks, fecal hypocholia, hepatosplenomegaly, anemia, low platelet count and elevated liver enzymes. At physical examination, the infant presented with erythematous-exfoliative lesions on the palms and soles, macular rash in the inguinal region, ascitis, palpable liver 5 cm below the right costal margin and a palpable spleen 3 cm from the left costal margin. Infant serology: reactive CMIA (chemiluminescent microparticle immunoassay), VDRL (Venereal Diseases Research Laboratory) 1:1024 and reactive TPHA (Treponema pallidum Hemagglutination). Maternal serology: reactive CMIA and TPHA, VDRL 1:256. Radiography of the long bones showed symmetric periostitis, periosteal thickening, and lucent bands in the femur, humerus, ulna and tibia. After treatment with crystalline penicillin, the infant showed clinical and laboratory improvement, receiving hospital discharge at the 18th hospitalization day.

Comments: This case shows that congenital syphilis is occasionally diagnosed late as a result of failed strategies to prevent this disease, both in the basic and secondary/tertiary levels of care. The application of interventions recommended by the Ministry of Health and identification of the situation in which there is ineffective implementation of these measures are important to assess routine care in all levels of healthcare and diverse units responsible for newborn and infant health care.
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http://dx.doi.org/10.1590/1984-0462/;2018;36;3;00011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202887PMC
May 2019

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial.

Arch Dis Child 2018 10 4;103(10):952-956. Epub 2018 Apr 4.

Deparment of Pediatrics, University of Campinas (UNICAMP), Campinas, Brazil.

Objective: We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians.

Design: Randomised controlled trial.

Setting: A paediatric intensive care unit of a teaching hospital.

Patients: 80 children (aged 28 days to <14 years).

Interventions: Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique.

Main Outcome Measures: Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications.

Results: We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all).

Conclusions: Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience.

Trial Registration Number: RBR-4t35tk.
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http://dx.doi.org/10.1136/archdischild-2017-314568DOI Listing
October 2018

TUBERCULOSIS IN PEDIATRIC PATIENTS: HOW HAS THE DIAGNOSIS BEEN MADE?

Rev Paul Pediatr 2017 Apr-Jun;35(2):165-170. Epub 2017 May 15.

Departamento de Pediatria da Faculdade de Ciências Médicas da Unicamp, Campinas, SP, Brasil.

Objective: To describe clinical, radiological, epidemiological, and microbiological characteristics of pediatric patients with diagnosis of tuberculosis in a period of 15 years.

Methods: Retrospective study including children and adolescents younger than 18 years diagnosed with tuberculosis in the Clinical Hospital of the Universidade Estadual de Campinas in São Paulo State, Brazil. Active tuberculosis was defined by the identification of Mycobacterium tuberculosis in culture, microscopy, or histopathological examination. Children with positive clinical history and radiological tests who had been exposed to sick adults or with positive tuberculin skin test were also considered as having active tuberculosis. Statistical analysis compared the data obtained from children younger and older than 10 years of age, since they present a disease pattern more similar to adults.

Results: There were 145 identified cases, 61.4% in patients under 10 years of age. The main symptoms reported were coughing (55.9%) and fever (46.9%), and the variables of fever, coughing, weight-loss, and pain were significantly influenced by age, with a higher frequency in older children. Diagnosis was confirmed by culture, microscopy, or histopathology in 67.6% of the cases. The other cases (32.4%) had the diagnosis of tuberculosis based on clinical, radiological, and epidemiological characteristics, as well as tuberculin skin test. The positivity for culture, microscopy, and tuberculin skin test was, respectively, 65.8, 35.7, and 72.3%. History of contact with a sick adult was confirmed in 37.2%, without influence of age.

Conclusions: Diagnosis of tuberculosis in children is still a challenge, since all the confirmation tests have low positivity. These results demonstrate the need for new diagnostic methods and improved strategies for searching sick contacts.
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http://dx.doi.org/10.1590/1984-0462/;2017;35;2;00004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496715PMC
July 2018

Brazilian guidelines for the clinical management of paracoccidioidomycosis.

Rev Soc Bras Med Trop 2017 Sep-Oct;50(5):715-740. Epub 2017 Jul 12.

Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.

Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis ( P. brasiliensis ) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii ( P. lutzii ), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.
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http://dx.doi.org/10.1590/0037-8682-0230-2017DOI Listing
December 2017

Functional and phenotypic evaluation of eosinophils from patients with the acute form of paracoccidioidomycosis.

PLoS Negl Trop Dis 2017 May 10;11(5):e0005601. Epub 2017 May 10.

Department of Clinical Pathology, Faculty of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil.

Background: Eosinophilia is a typical finding of the acute/juvenile form of paracoccidioidomycosis (PCM), a systemic mycosis endemic in Latin America. This clinical form is characterized by depressed cellular immune response and production of Th2 cytokines. Moreover, it has been shown that the increased number of eosinophils in peripheral blood of patients returns to normal values after antifungal treatment. However, the role of eosinophils in PCM has never been evaluated. This study aimed to assess the phenotypic and functional characteristics of eosinophils in PCM.

Methods/principal Findings: In 15 patients with the acute form of the disease, we detected expression of MBP, CCL5 (RANTES) and CCL11 (eotaxin) in biopsies of lymph nodes and liver. In addition, there were higher levels of chemokines and granule proteins in the peripheral blood of patients compared to controls. Isolation of eosinophils from blood revealed a higher frequency of CD69+ and TLR2+ eosinophils in patients compared to controls, and a lower population of CD80+ cells. We also evaluated the fungicidal capacity of eosinophils in vitro. Our results revealed that eosinophils from PCM patients and controls exhibit similar ability to kill P. brasiliensis yeast cells, although eosinophils of patients were less responsive to IL-5 stimulation than controls.

Conclusion/principal Findings: In conclusion, we suggest that eosinophils might play a role in the host response to fungi and in the pathophysiology of PCM by inducing an intense and systemic inflammatory response in the initial phase of the infection.
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http://dx.doi.org/10.1371/journal.pntd.0005601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439957PMC
May 2017

Bilateral spontaneous chylothorax after severe vomiting in children.

Rev Paul Pediatr 2016 Dec 16;34(4):518-521. Epub 2016 Apr 16.

Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil.

Objective: To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting.

Case Description: Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings.

Comments: Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.
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http://dx.doi.org/10.1016/j.rpped.2016.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5176075PMC
December 2016

The relationship among HOXA10, estrogen receptor α, progesterone receptor, and progesterone receptor B proteins in rectosigmoid endometriosis: a tissue microarray study.

Reprod Sci 2015 Jan 11;22(1):31-7. Epub 2014 Sep 11.

Department of Gynecology, São Paulo University School of Medicine, Sao Paulo, Brazil.

Background: Very few studies have evaluated the expression of homeobox A10 (HOXA10) and steroid (estrogen and progesterone) receptors exclusively in deep endometriosis. Conclusions drawn from studies evaluating peritoneal and ovarian endometriosis are usually generalized to explain the pathogenesis of the disease as a whole. We aimed to evaluate the expression of HOXA10, estrogen receptor α (ER-α), progesterone receptor (PR), and PR-B in rectosigmoid endometriosis (RE), a typical model of deep disease.

Methods: We used RE samples from 18 consecutive patients to construct tissue microarray blocks. Nine patients each were operated during the proliferative and secretory phases of the menstrual cycle. We quantified the expressions of proteins by immunohistochemistry using the modified Allred score.

Result: The HOXA10 was expressed in the stroma of nodules during the secretory phase in 5 of the 18 patients. Expression of ER-α (in 16 of 18 patients), PR (in 17 of 18 patients), and PR-B (17 of 18 patients) was moderate to strong in the glands and stroma of nodules during both phases. Expression of both PR (P = .023) and PR-B (P = .024) was significantly greater during the secretory phase.

Conclusion: The HOXA10 is expressed in RE, where it likely imparts the de novo identity of endometriotic lesions. The ER-α, PR, and PR-B are strongly expressed in RE, which differs from previous studies investigating peritoneal and ovarian lesions. This suggests different routes of pathogenesis for each of the 3 types of endometriosis.
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http://dx.doi.org/10.1177/1933719114549846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527422PMC
January 2015

Reexpansion pulmonary edema in children.

Rev Paul Pediatr 2013 Sep;31(3):411-5

Unicamp, Faculdade de Ciências Médicas, Departamento de Pediatria, CampinasSP, Brasil.

OBJECTIVE To present a case of a patient with clinical and radiological features of reexpansion pulmonary edema, a rare and potentially fatal disease. CASE DESCRIPTION An 11-year-old boy presenting fever, clinical signs and radiological features of large pleural effusion initially treated as a parapneumonic process. Due to clinical deterioration he underwent tube thoracostomy, with evacuation of 3,000 mL of fluid; he shortly presented acute respiratory insufficiency and needed mechanical ventilation. He had an atypical evolution (extubated twice with no satisfactory response). Computerized tomography findings matched those of reexpansion edema. He recovered satisfactorily after intensive care, and pleural tuberculosis was diagnosed afterwards. COMMENTS Despite its rareness in the pediatric population (only five case reports gathered), the knowledge of this pathology and its prevention is very important, due to high mortality rates. It is recommended, among other measures, slow evacuation of the pleural effusion, not removing more than 1,500 mL of fluid at once.
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http://dx.doi.org/10.1590/S0103-05822013000300021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182965PMC
September 2013

Hepatic involvement in paediatric patients with paracoccidioidomycosis: a histological study.

Histopathology 2014 Jan 1;64(2):256-62. Epub 2013 Oct 1.

Center for Investigation in Pediatrics, UNICAMP School of Medicine, Campinas, Brazil.

Aim: Paracoccidioidomycosis is a systemic mycosis that is endemic to certain countries in Latin America. This study aimed to describe the histological features of liver involvement in patients with paracoccidioidomycosis aged <16 years of age who were treated between 1980 and 2010, with a diagnosis that was confirmed by detection of the fungus by pathological examination.

Methods And Results: Liver tissue was obtained from one necropsy and 12 biopsies. Throughout 2007, biopsies were taken from patients with persistent jaundice or portal hypertension, after which biopsies became indicated due to elevated aminotransferase and low albumin levels. Using haematoxylin and eosin (H&E), Masson's trichrome and immunohistochemical (CK7 and CK19) staining, we noted degenerative alterations in bile duct cells and inflammatory injury to the bile ducts in 10 biopsies. Using immunohistochemistry for CK7 and CK19, we observed ductal proliferation in all 12 samples.

Conclusions: Bile duct injuries by inflammatory cells might explain the predominant increase in canalicular enzymes; immunohistochemistry is more sensitive in demonstrating ductular reactions and might show changes that are not apparent on H&E staining.
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http://dx.doi.org/10.1111/his.12244DOI Listing
January 2014

Hepatic involvement in pediatric patients with paracoccidioidomycosis: a clinical and laboratory study.

Mycopathologia 2013 Oct 6;176(3-4):279-86. Epub 2013 Aug 6.

Center for Investigation in Pediatrics, UNICAMP School of Medicine, Campinas, São Paulo, Brazil,

The liver is one of the organs most affected by paracoccidioidomycosis, a systemic mycosis endemic in some Latin American countries. The majority of articles focused on adult populations and failed to describe any detailed experience of liver abnormalities in pediatric patients. Therefore, the aim of this study was to describe the frequency and characteristics of liver involvement in children with paracoccidioidomycosis. This study comprised 102 patients less than 16 years of age (median 104.3 months) diagnosed with paracoccidioidomycosis from 1980 to 2010. Diagnosis was established by the identification of fungus. Forty-one patients had liver involvement. The main clinical features were generalized lymph node enlargement (39/41), weight loss (34/41) and fever 32/41). Approximately, one-third of the patients had jaundice. Patients with hepatic involvement were younger. A predominant elevation of canalicular enzymes occurred. There was a statistically significant difference in albumin (p < 0.001) and hemoglobin (p = 0.002) values between patients with and without liver involvement, and the lowest values were found in the former group. Cutoff levels of albumin (<3.05 g/dL) and hemoglobin (<9.2 g/dL) can be used to infer hepatic involvement. Hypoalbuminemia (median 2.4 g/dl) is more severe in patients with hepatic involvement and may indicate a worse liver function or complication of the disease (intestinal lymphangiectasia). Deaths (6) occurred only among patients with liver involvement. Particular clinical and laboratory characteristics are present in pediatric patients with hepatic involvement. Younger patients and those with severe hypoalbuminemia are more likely to present liver involvement by Paracoccidioides brasiliensis.
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http://dx.doi.org/10.1007/s11046-013-9682-8DOI Listing
October 2013

Neuroparacoccidioidomycosis (NPCM): magnetic resonance imaging (MRI) findings.

Mycopathologia 2013 Feb 11;175(1-2):181-6. Epub 2012 Dec 11.

Departamento de Radiologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Rua Tessália Vieira de Camargo, 126 CP: 6111, 13083-887, Cidade Universitária Zeferino Vaz Campinas, SP, Brazil.

Objective: To describe the magnetic resonance imaging (MRI) patterns of the central nervous system (CNS) involvement by neuroparacoccidioidomycosis (NPCM).

Methods: Between January 1999 and March 2011, a review of MRI data analysis from 8 cases of NPCM was performed. The following MRI characteristics were examined by an experienced neuroradiologist: topography of lesions, aspects on T1- and T2-weighted images (WI), contrast enhancement, diffusion and spectroscopy.

Results: All patients had evidence of paracoccidioidomycosis infection outside the nervous system. Regarding CNS involvement, five patients had only supratentorial lesions; three had infra- and supratentorial ones. Meningeal extension occurred in three patients. The lesions were predominantly hyperintense on T1WI. At T2WI, a hypointense component was present in five cases as well as a perilesional abnormal white matter. A ring-enhancement pattern was seen in five cases. Spectroscopy was performed in three patients and showed an increased lipid peak in all of them. In one case, there was also an increased choline peak.

Conclusion: NPCM is rare, and MRI may help its differentiation from other inflammatory lesions. However, the presence of active infection outside CNS and some imaging characteristics should point to this diagnosis.
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http://dx.doi.org/10.1007/s11046-012-9607-yDOI Listing
February 2013

Factors associated with complications of community-acquired pneumonia in preschool children.

J Bras Pneumol 2012 Sep-Oct;38(5):614-21

Unicamp, State University at Campinas – Campinas, Brazil.

Objective: To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP).

Methods: This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed.

Results: Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001).

Conclusions: Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.
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http://dx.doi.org/10.1590/s1806-37132012000500011DOI Listing
December 2013

Leiomyomatosis peritonealis disseminata associated with endometriosis and multiple uterus-like mass: report of two cases.

Clin Med Insights Case Rep 2012 21;5:63-8. Epub 2012 May 21.

Department of Pathology, Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP), Brazil.

Leiomyomatosis peritonealis disseminate (LPD) is a rare benign disease of unknown etiology of women in reproductive age. A few reported cases of association with endometriosis have been described suggesting a possible origin from submesothelial multipotential cells. We present two cases of LPD associated with endometriosis expressing smooth muscle metaplasia, and some of the nodules with aspects of uterus-like mass. Laparoscopy, gross findings, and the pathological and immunohistochemical study of the surgical specimens were described. Our findings suggest an endometriotic origin for the LPD and indicate that the therapeutic approach might contemplate the surgical reduction of the nodules and endometriosis treatment.
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http://dx.doi.org/10.4137/CCRep.S9530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364027PMC
August 2012

Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy.

Radiographics 2011 Jul-Aug;31(4):E77-100

Department of Diagnostic Imaging, Fleury Medicina e Saúde, São Paulo 01333-910, Brazil.

Endometriosis is a common multifocal gynecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. It may occur as invasive peritoneal fibrotic nodules and adhesions or as ovarian cysts with hemorrhagic content. Although findings at physical examination may be suggestive, imaging is necessary for definitive diagnosis, patient counseling, and treatment planning. The imaging techniques that are most useful for preoperative disease mapping are transvaginal ultrasonography (US) after bowel preparation, and magnetic resonance (MR) imaging. Initial transvaginal US is a reliable technique for detecting rectosigmoid endometriotic lesions. MR imaging is indicated as a complementary examination in complex cases of endometriosis with extensive adhesions and ureteral involvement. Peritoneal endometriotic implants are typically hypoechoic on transvaginal US images and demonstrate low signal intensity on T2-weighted MR images. Endometriotic implants most commonly are found in retrocervical and rectosigmoid sites, followed by the vagina, bladder, and ureters. Cysts with low-level internal echoes and echogenic peripheral foci at transvaginal US are suggestive of endometriomas. MR imaging has high specificity for identifying endometriomas, which are characterized by high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. Correlation of the radiologic imaging features of endometriotic lesions with their laparoscopic appearances may help improve individual proficiency in the radiologic diagnosis of endometriosis.
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http://dx.doi.org/10.1148/rg.314105193DOI Listing
March 2012

Transvaginal US after bowel preparation for deeply infiltrating endometriosis: protocol, imaging appearances, and laparoscopic correlation.

Radiographics 2010 Sep;30(5):1235-49

Department of Diagnostic Imaging, Fleury Medicina e Saúde, Rua Cincinato Braga, São Paulo, Brazil.

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.
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http://dx.doi.org/10.1148/rg.305095221DOI Listing
September 2010

The feasibility of laparoscopic bowel resection performed by a gynaecologist to treat endometriosis.

Curr Opin Obstet Gynecol 2010 Aug;22(4):344-53

Huntington Reproductive Medicine Center, São Paulo, São Paulo, São Paulo, Brazil.

Purpose Of Review: Intestinal endometriosis is commonly diagnosed in the setting of deeply infiltrating endometriosis. A multidisciplinary team that includes gynaecologists and general surgeons traditionally performs laparoscopic bowel resections for symptomatic patients. Recently, Pereira et al. has published the results of a series of patients who underwent laparoscopic bowel resection for endometriosis performed by a team of gynaecologic surgeons, after a period of experimental training with animals and joining participation with general surgeons in the first cases. It is suggested that gynaecologic surgeons may be able to perform laparoscopic bowel resections for endometriosis, if properly trained, although the results may not be reproducible.

Recent Findings: A review of recent literature related to laparoscopic bowel resections for endometriosis showed that the learning curve and experience of the surgeon may be the most important predictive factors for the effectiveness of the procedure. Results concerning major operative complications and clinical remission were considered satisfactory in both single and multidisciplinary approaches, that is, laparoscopic bowel resections performed by gynaecologic and colorectal surgeons. Protective colostomies or ileostomies could not reduce the rate of rectovaginal fistulae in multidisciplinary experiences.

Summary: The single-surgeon model approach in laparoscopic excision of endometriosis that includes bowel resection may provide advantages for both the patients and healthcare system. The best model should be decided on the maximum benefit of the patient.
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http://dx.doi.org/10.1097/GCO.0b013e32833beae0DOI Listing
August 2010

Successful interval laparoscopic transabdominal cervicoisthmic cerclage preceding twin gestation: a case report.

J Minim Invasive Gynecol 2009 Sep-Oct;16(5):634-8

Huntington Reproductive Medicine Centre, São Paulo, Brazil.

Laparoscopic transabdominal cervicoisthmic cerclage (LTCC) is an alternative, less-morbid option to the traditional transabdominal cerclage, indicated for patients with cervical incompetence. Experience with the technique is based on case reports and a few case series. Considering LTCC for twin gestations, reports are very scarce and are derived from LTCC performed during pregnancy. We report the case of a 36-year-old patient, gravida 1, para 0, aborta 1, who underwent interval LTCC after a previous failed transvaginal emergency cerclage performed in the second trimester. Hysteroscopic metroplasty was concomitantly performed for an incomplete septate uterus. The procedure lasted 100 minutes, with an estimated blood loss of 50 mL. The patient was discharged home on the second postoperative day. The patient became pregnant with twins 3 months after the procedure after undergoing in vitro fertilization. The gestational course was uneventful, and the patient delivered 2 healthy neonates at 38 weeks gestation by elective cesarean section. The cerclage tape was left in situ. Minor modifications of the previously reported techniques included use of a laparoscopic Deschamps needle for placing the cotton cardiac tape used as suture material. Vessels in the cervical transverse cervical ligament were exposed before cerclage tape application. To our knowledge, this is the first report of interval LTCC preceding a twin gestation.
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http://dx.doi.org/10.1016/j.jmig.2009.05.011DOI Listing
December 2009

Should the gynecologist perform laparoscopic bowel resection to treat endometriosis? Results over 7 years in 168 patients.

J Minim Invasive Gynecol 2009 Jul-Aug;16(4):472-9

Huntington Reproductive Medicine Centre, São Paulo, Brazil.

Study Objective: To assess the feasibility and safety of laparoscopic bowel resections for endometriosis performed by gynecologic surgeons.

Design: Retrospective cohort study (Canadian Task Force Classification II-3).

Setting: Fertility and pelvic surgery clinics.

Patients: One hundred sixty-eight women (age 21-53 years) with symptoms including pelvic pain, infertility, or both with 252 bowel endometriotic lesions underwent laparoscopic bowel resection performed by gynecologic surgeons between May 2000 and January 2008.

Interventions: Laparoscopic procedures for excision of several endometriotic nodes and lesions included shaving resection (LscShR), discoid resection (LscDR), segmental resection (LscSgR), terminal ileal resection (LscIR), partial cecal resection (LscCR), and appendectomy (LscAp).

Measurements And Main Results: The 168 patients underwent 172 laparoscopic bowel resections (4 patients were operated on twice) by the same surgeon. Lesions were distributed as follows: 133 (79%) in the rectum, 61 (24%) in the sigmoid colon, 47 (19%) in the appendix, 5 (2%) in the terminal ileum, 3 (1%) in the descending colon, and 3 (1%) in the cecum. At surgeon discretion, 12 lesions were not resected. A total of 216 bowel procedures were necessary to remove the 240 lesions include shaving resection in 22 patients (10%), discoid resection in 52 (24%), segmental resection in 92 (42%), terminal ileal resection in 2 (1%), partial cecal resection in 1 (0.6), and appendectomy in 47 (22%). Major complications occurred in 13 patients (7.6%) and included rectovaginal fistula in 3 patients (1.7%), rectosigmoid anastomosis dehiscence and bowel occlusion in 1 patient each (0.6%), and persistent bowel dysfunction in 4 patients (2.3%). These results are comparable to those reported in the literature to date. Complete relief of symptoms (measured using the Visick scale) was noted in patients with dysmenorrhea (59%), dyspareunia (75%), noncyclic pelvic pain (90%), pain on defecation (100%), constipation (83%), and cyclic rectal bleeding (100%).

Conclusion: Surgery to treat bowel endometriosis can be safely and efficiently performed by the gynecologic pelvic surgeon. Meticulous training and a multidisciplinary approach to comprehensive operative care are necessary. These findings can be validated by prospective collaborative studies and reports from other surgeons.
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http://dx.doi.org/10.1016/j.jmig.2009.04.004DOI Listing
October 2009
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