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Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

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Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

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Xylella fastidiosa is one of the most important threats to plant health worldwide. This bacterial pathogen has a long history, causing disease in the Americas on a range of agricultural crops and trees, with severe economic repercussions particularly on grapevine and citrus. In Europe, X. fastidiosa was detected for the first time in 2013 in association with a severe disease affecting olive trees in southern Italy. Subsequent mandatory surveys throughout Europe led to discoveries in France and Spain in various host species and environments. Detection of additional introductions of X. fastidiosa continue to be reported from Europe, for example from northern Italy in late 2018. These events are leading to a sea change in research, monitoring and management efforts as exemplified by the articles in this Focus Issue . X. fastidiosa is part of complex pathosystems together with hosts and vectors. Although certain X. fastidiosa subspecies and environments have been well studied, particularly those that pertain to established disease in North and South America, this represents only a fraction of the existing genetic, epidemiological, and ecological diversity. This Focus Issue highlights some of the key challenges that must be overcome to address this new global threat, recent advances in understanding the pathosystem, and steps toward improved disease control. It brings together the broad research themes needed to address the global threat of X. fastidiosa, encompassing topics from host susceptibility and resistance, genome sequencing, detection methods, transmission by vectors, epidemiological drivers, chemical and biological control, to public databases and social sciences. Open communication and collaboration among scientists, stakeholders, and the general public from different parts of the world will pave the path to novel ideas to understand and combat this pathogen.

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Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

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Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

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In the pathosystem of Dalbulus madis (DeLong & Wolcott) (Hemiptera: Cicadellidae), a vector of maize bushy stunt phytoplasma (MBSP), the interactions occurring during the passage, invasion, and multiplication of the phytoplasma inside the vector body have been generalized from other pathosystems, with a poor understanding of the specific interactions. With the aim to understand MBSP movement and potential specific interactions with its vector, D. maidis adults were dissected to obtain the intestine and salivary gland of both infected (acquisition access period=4 d; latent period=23 d) and noninfected individuals. The organs were processed for visualization with transmission electronic microscopy. Images of phytoplasma cells were observed in the alimentary canal, epithelium of the mesenteron, hemocele, and salivary gland of the vector, and were confirmed through observation of similar cells in maize roots with advanced disease symptoms. The study of the MBSP movement within its vector shows novel findings between the synergy of the MBSP phytoplasma and D. maidis.

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Plant viruses can directly influence their insect vectors, and indirectly through their shared host plant, altering their behavior and performance in a mutualistic or rather antagonistic manner. One of the most studied begomovirus, Tomato yellow leaf curl virus (TYLCV), may also facilitate the expansion of its vector, the whitefly Bemisia tabaci (Gennadius). Considering the likely expansion of the disease and its major vector, we studied the direct and the indirect effects of a Mediterranean isolate of this virus (TYLCV-IL) on the biological performance of the Q biotype of B. tabaci. The following parameters were examined: development time and viability of nymphs, sex ratio, fecundity, and fertility and longevity. The results varied from positive to neutral depending on the parameter and the effect studied. TYLCV accelerated nymphal developmental and increased male longevity of B. tabaci when viruliferous insects developed on TYLCV-immune eggplants (direct effects). An indirect, positive effect of TYLCV-infected plants was observed on fecundity of B. tabaci, which laid more eggs on virus-infected than on noninfected tomato plants. Our results show that TYLCV enhances the population increase of its whitefly vector and that there is a high risk of rapid expansion of both the virus and its vector-the MED species of B. tabaci-into new areas when both agents interact together.

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Huanglongbing (HLB) is a severe citrus (Citrus spp.) disease associated with the bacteria genus Candidatus Liberibacter, detected in Brazil in 2004. Another bacterium was found in association with HLB symptoms and characterized as a phytoplasma belonging to the 16SrIX group. The objectives of this study were to identify potential leafhopper vectors of the HLB-associated phytoplasma and their host plants. Leafhoppers were sampled every other week for 12 mo with sticky yellow cards placed at two heights (0.3 and 1.5 m) in the citrus tree canopy and by using a sweep net in the ground vegetation of two sweet orange, Citrus sinensis (L.) Osbeck, groves infected by the HLB-phytoplasma in São Paulo state. Faunistic analyses indicated one Agalliinae (Agallia albidula Uhler) and three Deltocephalinae [Balclutha hebe (Kirkaldy), Planicephalus flavicosta (Stål), and Scaphytopius (Convelinus) marginelineatus (Stål)] species, as the most abundant and frequent leafhoppers (Hemiptera: Cicadellidae). Visual observations indicated an association of leafhopper species with some weeds and the influence of weed species composition on leafhopper abundance in low-lying vegetation. S. marginelineatus and P. flavicosta were more frequent on Sida rhombifolia L. and Althernantera tenella Colla, respectively, whereas A. albidula was observed more often on Conyza bonariensis (L.) Cronq. and B. hebe only occurred on grasses. DNA samples of field-collected S. marginelineatus were positive by polymerase chain reaction and sequencing tests for the presence of the HLB-phytoplasma group, indicating it as a potential vector. The association of leafhoppers with their hosts may be used in deciding which management strategies to adopt against weeds and diseases in citrus orchards.

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Scanning (SEM) and transmission (TEM) electron microscopy were used to elucidate the morphology of the rostrum, as well as the mandibular and maxillary stylets of the psyllid Diaphorina citri, vector of phloem-inhabiting bacteria associated with citrus huanglongbing (HLB) disease. D. citri has a cone-shaped rostrum that extends behind the pair of prothoracic coxae. The stylet bundle comprises a pair of mandibular (Md) and maxillary (Mx) stylets with a mean length of 513.3 µm; when retracted, their proximal portions form a loop and are stored in the crumena (Cr). Serial cross-sections of the rostrum revealed that the mandibles are always projected in front of the maxillary stylets. The two maxillary stylets form the food and salivary canals, with diameters of 0.9 µm and 0.4 µm respectively. These two canals merge at the end of the stylets forming a common duct with a length of 4.3 µm and a mean diameter of 0.9 µm. The acrostyle, a distinct anatomical structure present in the common duct of aphid maxillary stylets, was not observed by TEM in the ultrathin cross-sections of the common duct (CD) of D. citri. This study provides new information on D. citri mouthparts that may help to understand the feeding behaviour of this important vector of HLB-associated bacteria.

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OBJECTIVES: The present study investigated the association between motor activity and severity of depression in 6 depressed adolescent outpatients. METHOD: Motor activity was assessed by actigraphy and the severity of depression was assessed weekly using the CDRS-R. The levels of motor activity were analyzed by considering activity parameters. RESULTS: Among the parameters of motor activity studied, the mean total activity, the mean 24-hour activity levels, the mean waking activity, and the mean activity level between 12:00 and 18:00 h were inversely correlated with severity of depression. The means of the 10 most active hours tended toward a negative correlation with the depressive severity score. CONCLUSION: The results seem to suggest an association between motor activity level and severity of depression in adolescents. Nevertheless, in order to reach a more conclusive understanding, it would be necessary to replicate this study using a larger number of individuals as well as a longer observation period.

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OBJECTIVES: To analyse the activation state and apoptosis of circulating neutrophils in untreated very early rheumatoid arthritis (VERA) and after exposure to low dose corticosteroids and methotrexate (MTX). METHODS: Neutrophils were isolated from the peripheral blood of VERA patients at 3 different times: before any treatment was started, 2 weeks after starting a low dose of prednisone (5-10 mg) and 4 months after reaching more than 20mg/week of MTX. The expression of different activation markers (CD11b, CD64, CD86 and CD69) in freshly isolated neutrophils was analysed by flow cytometry. Apoptosis was measured by the loss of DNA content, which was analysed by flow cytometry using propidium iodide. RESULTS: Compared to neutrophils from healthy controls, we have found a delayed neutrophil apoptosis within 6 h and 22 h of cultured polymorphonuclear leukocytes (PMN) derived from VERA patients without any treatment or treated with corticosteroids. The delay of PMN apoptosis was restored to control levels after treatment with MTX. CONCLUSION: The treatment of VERA patients with corticosteroids did not affect the delay of neutrophil apoptosis. However, delayed apoptosis was restored to control levels after treatment with low dose MTX, which highlights the importance of early RA treatment with MTX.

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The causal agent of diseases in many economically important plants is attributed to the xylem-limited bacterium Xylella fastidiosa. The detection of this plant pathogen has been hampered due to its difficult isolation and slow growth on plates. Nearly complete nucleotide sequences of the 16S rRNA gene and partial sequences of the gyrB gene were determined for 18 strains of X. fastidiosa isolated from different plant hosts. A phylogenetic analysis, based on gyrB, grouped strains in three clusters; grape-isolated strains formed one cluster, citrus-coffee strains formed another cluster, and a third cluster resulted from all other strains. Primer pairs designed for the 16S rRNA and gyrB genes were extensively searched in databases to verify their in silico specificity. Primer pairs were certified with 30 target and 36 nontarget pure cultures of microorganisms, confirming 100% specificity. A multiplex PCR protocol was developed and its sensitivity tested. Sequencing of PCR products confirmed the validity of the multiplex PCR. Xylella fastidiosa was detected in field-collected plants, disease vector insects, and nonsymptomatic but infected plants. Specific detection of X. fastidiosa may facilitate the understanding of its ecological significance and prevention of spread of the disease.

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In Brazil, Xylella fastidiosa is present in citrus (Citrus sinensis), coffee (Coffea arabica), and plum (Prunus sp.) crops, causing the citrus variegated chlorosis (CVC), coffee leaf scorch (CLS), and plum leaf scald (PLS). Also present in these crops and infesting weeds, which ultimately could serve as sources of inoculum for the cultivated trees, are diverse populations of xylem-feeding leafhopper vectors. In order to assess host range of X. fastidiosa among weeds and to better understand their role in epidemics, field surveys, mechanical inoculations, and insect transmission tests were conducted. Polymerase chain reaction (PCR) and culture plating were used to detect the pathogen from plant tissues. X. fastidiosa was detected in 10 out of 23 species of the weed plants sampled in two citrus groves affected by CVC. None of the weed plants showed external symptoms. In the greenhouse, the average percentages of infection on plants mechanically inoculated with the CVC, CLS, and PLS strains of X. fastidiosa were, respectively, 25, 10, 0 in Medicago sativa; 70, 45, 20 in Echinochloa crus-galli; 45, 30, 0 in Brachiaria decumbens; 72, 70, 40 in Brachiaria plantaginea; 13, 10, 0 in Digitaria horizontalis; 31, 30, 0 in Solanum americanum; and 17, 0, 0 in Bidens pilosa. Symptoms were observed only in S. americanum and citrus and only when inoculated with the CVC strain. In insect transmission tests, the grass leafhopper Ferrariana trivittata was first caged on citrus plants showing CVC symptoms and then on healthy citrus and on the four most common weeds. No plants tested positive by PCR or culture, or showed symptoms for at least 4 months after inoculation. The amount of X. fastidiosa cells that may accumulate in weeds inoculated by leafhoppers is probably under insect acquisition thresholds, a factor that would limit their importance to the CVC epidemics, as studies on spatial distribution of diseased citrus trees over time indicate.

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The Fourier spectral analysis of binary time series (or rectangular signals) causes methodological problems, due to the fact that it is based on sinusoidal functions. We propose a new tool for the detection of periodicities in binary time series, focusing on sleep/wake cycles. This methodology is based on a weighted histogram of cycle durations. In this paper, we compare our methodology with the Fourier spectral analysis on the basis of simulated and real binary data sets of various lengths. We also provide an approach to statistical validation of the periodicities determined with our methodology. Furthermore, we analyze the discriminating power of both methods in terms of standard deviation. Our results indicate that the Ciclograma is much more powerful than Fourier analysis when applied on this type of time series.

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Populations of cultivable cells of a citrus variegated chlorosis (CVC) disease strain of Xylella fastidiosa in stems and leaf veins of sweet orange (Citrus sinensis (L.) Osbeck) seedlings were estimated by dilution plating at 1, 2, 4, 8, and 16 weeks after needle inoculation. Cell populations ranged from log 4 to log 5 CFU/g of tissue after 1 week and increased to log 5 to log 7 CFU/g (median log 6) after 8 to 16 weeks. Recovery of greater than log 5 CFU/g from stem nodes distal to the inoculation site indicated systemic movement of the bacteria. Foliar symptoms in inoculated seedlings first appeared after 8 weeks. Population estimates from leaf veins of CVC-affected trees in citrus groves were in the same range but slightly lower (average log 5.8 CFU/g). X. fastidiosa was isolated from citrus more efficiently in periwinkle wilt-GelRite (PWG) and periwinkle wilt (PW) media than in charcoal-yeast extract with ACES buffer (BCYE) medium The relatively lower populations of cultivable cells of X. fastidiosa in citrus with CVC symptoms, compared with those reported in grapevines with Pierce's disease, suggest that most cells of X. fastidiosa within symptomatic citrus may be dead, explaining in part the low rates of vector transmission from citrus to citrus.

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A rare case of infantile myasthenia gravis (congenital type) is reported. The child was 16 months old at the time of the diagnosis, although she presented signs suggestive of the disease since two months earlier. The diagnosis was based solely upon clinical criteria, including immediate response to a therapeutic test with Neostigmine, followed by excellent response to treatment with Mestinon. A review of the different types of myasthenia gravis in infancy is made, with emphasis on the clinical criteria for differential diagnosis of these cases.

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A 20-year-old asymptomatic woman suddenly had complete right ophthalmoplegia associated with right ptosis and impairment of the sensory and motor functions of the right papillary cranial nerve. These symptoms were found to be caused by a chromophobe adenoma of the pituitary gland. Complete resolution of the patient's symptoms followed surgical aspiration of the tumor with subsequent radiation therapy.

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