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Costs of elderly health care in Brazil: challenges and strategies1

Luiz E. Garcez-Leme; Mariana Deckers Leme

MEDICALEXPRESS 2014;1(1):3-8


Suicide among elderly: a systematic review

Verônica de Medeiros Alves; Ana Claudia C. de Ornelas Maia; Antonio Egidio Nardi

MEDICALEXPRESS 2014;1(1):9-13

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This article aimed to perform a systematic review of suicide among the elderly. The literature review was conducted using three databases (SCOPUS, Medline/Pubmed and ISI Web of Science) using the terms suicide and elderly, suicide and older adult and suicide attempt. The publication dates were restricted between 2008 and 2013. Review or theoretical articles were excluded; only epidemiologic studies were selected. A total of 1613 references were found, but only seven met the inclusion criteria, namely articles that assessed the prevalence of suicide in elderly through retrospective cohort studies. The average study period was 7.9 years. The following average annual suicide rates were calculated: Italy (173/cases-year), New York (118.1/cases-year and 51 cases/year - two studies), Ireland (92/cases-year), Finland (12.9/cases-year), Turkey (3.5/cases-year) and England (3/cases-year). All of the studies reported that elderly males had a higher rate of death by suicide compared to elderly females. Hanging, shooting by firearms, drowning and jumping from high places were prevalent suicide methods. Three articles reported that death by suicide was associated with the presence of psychiatric disorders, psychoactive substance use, and physical illnesses, as well as economic and emotional reasons. This review determined that the topic of suicide among the elderly is rarely discussed and that little is known about influences, causes, or prevalence of suicide among the elderly. Moreover, neither the type of health monitoring nor the medications that are used as interventions for eventual suicide victims are commonly reported in elderly populations.

Keywords: Suicide; Elderly; Primary Care.

Hypertonic saline for treatment of shock: have we looked for everything?

Mauricio Rocha e Silva

MEDICALEXPRESS 2014;1(1):14-21

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This review is dedicated to the memory of Luis Poli de Figueiredo, who is responsible for much of what we know about small volume resuscitation. Small volume hypertonic resuscitation was originally based on the concept that a physiologically significant blood volume expansion follows the administration of a comparatively small volume of hypertonic fluid. Because hypertonicity is a physiological vasodilator, its use after severe blood loss induces reperfusion. Previously reported research disclosed a number of additional properties of hypertonic NaCl, amongst them (i) the correction of endothelial and red cell edema with significant consequences in terms of capillary blood flow; (ii) modulation of the immune system, with applications repercussions in the field of sepsis. This review covers developments in this field that occurred from 2005 through 2013. We discuss the discrepancy between animal experiments and human trials, and argue that the basic objective of most multicenter clinical trials may have been based upon a poor strategy.

Keywords: Shock; Hemorrhage; Sepsis Hypertonic saline; Immune circulation.

Is there any correlation between functional and clinical tests in anterior cruciate ligament reconstructed knees after three years?

Ozge Cinar Medeni; Gul Baltaci; Hamza Ozer

MEDICALEXPRESS 2014;1(1):22-26

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OBJECTIVE: Hop and jump tests are frequently used in clinical situations in patients with anterior cruciate ligament injury and reconstruction. We are not aware of any study that analyses correlation of functional tests with clinical tests after three years of reconstruction. The purpose of this study was to analyze the relationship between functional and clinical tests.
METHOD: Twelve male patients with unilateral anterior cruciate ligament reconstruction were assessed. They performed a one-legged hop test and one-legged jump and reach test, to evaluate knee function. Clinical assessments were: (a) instrumental knee laxity measurement, (b) Q angle, (c) knee flexor and (d) extensor muscle strength. To determine the relationship between functional and clinical tests, a correlation analysis was performed by means of the Spearman correlation coefficient. A p value < 0.05 was considered significant.
RESULTS: In anterior cruciate ligament reconstructed vs. healthy knees, hop and jump performance correlated well with muscle strength. Knee laxity did not affect hop and jump performance.
CONCLUSIONS: The correlation of functional and strength tests in each group showed functional performance was restored and was independent of anterior knee laxity three years after reconstruction when compared with the contralateral healthy knee. The single-legged hop test correlated better with knee muscle strength and could give information about muscle strength three years after reconstruction. Q angle and extensor strength must be considered together when evaluating hop performance.

Keywords: Anterior Cruciate Ligament; Knee Recosntruction; Test; Outcome.

Safety and efficacy of hypertonic saline versus isotonic saline solution in off-pump coronary artery bypass grafting

Ricardo de Mola; Jorge Flório; Vanessa R. Pescioto; Douglas Humberto Lovatti; Luis Alberto Oliveira Dallan; Roberto Rocha-e-Silva

MEDICALEXPRESS 2014;1(1):27-30

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OBJECTIVES: Off-pump coronary artery bypass grafting occurrence increases constantly. However transient low cardiac output events occur during this procedure requiring aggressive volume replacement, which may lead to hypervolemia and its complications.
METHOD: This study evaluates the safety and efficacy of a hypertonic-hyperoncotic NaCl solution (6% hydroxyethylamide + 7.5% sodium chloride) versus isotonic saline during the creation of anastomosis in the lateral wall of the left ventricle. In each case, 250 ml of solution was administered from coded bags at the start of the grafting procedure. All staff directly connected with the surgical procedure and post-operative management of patients was blinded to the coding. The primary objective was the determination of post-surgery complications. Secondary objectives were the determination of mean arterial blood pressure and central venous pressure during anastomotic grafting.
RESULTS: Primary objectives showed no difference between hypertonic versus isotonic saline in post-operatory surgery complication. Significant increases of mean arterial pressure and central venous pressure in the Hypertonic Saline group versus normal saline patients during grafting were observed.
CONCLUSION: The use of hypertonic saline during off-pump coronary artery bypass grafting on the lateral posterior wall of the left ventricle led to no complications and improved arterial and central venous pressure, favoring the creation of anastomosis in this wall.

Keywords: cardiac surgery; hypertonic-hyperoncotic solution; cardiopulmonary bypass; off-pump; beating heart.

Depth-scanning confocal Raman for rapid in vivo determination of testosterone concentration profiles in human skin

Marco Antonio Botelho; Stela Julia Guerreiro; Dinalva Brito Queiroz; Gisele Barros; Monaliza Cavalcante; Juliana M. O. Souza; André M. Silva; Telma L. G. Lemos; Lucindo Quintans Jr

MEDICALEXPRESS 2014;1(1):31-35

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OBJECTIVE: The present study aimed to measure in-vivo the depth and the percentage of testosterone in human skin.
METHOD: Two healthy young Brazilian volunteers were evaluated through a Confocal Raman Spectroscopy probe on the right volar forearm. Testosterone spectroscopy of was performed on the Stratum Corneum, Viable Epidermis and Dermis; the percentage concentration of testosterone was compared between the baseline and one hour after local application of a transdermal nanostructured testosterone (5%) formulation.
RESULTS: To the best of our knowledge, this is the first time that the depth and percentage of testosterone has been evaluated non-invasively in-vivo. No adverse events were attributed to this protocol. The method is effective in differentially measuring testosterone in the skin layers.
CONCLUSION: This protocol may serve as a good choice for rapid hormone quantification for forensic or medical purposes.

Keywords: Nanotechnology; Confocal Raman Spectroscopy; Transdermal Delivery; Testosterone; Nanoparticles.

Bixa orellana (annatto) exerts a sustained hypoglycemic effect in experimental diabetes mellitus in rats

Flávio Teles; Felipe Silveira dos Anjos; Tarcilo Machado; Roberta Lima

MEDICALEXPRESS 2014;1(1):36-38

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OBJECTIVE: Bixa orellana (annatto) is a natural pigment and food colorant that has been used for a variety of therapeutic purposes. It has been suggested that annatto could have the property of reducing blood glucose levels. However, most previous studies have demonstrated a hypoglycemic effect in non-diabetic animals. We evaluated the impact of annatto on blood glucose levels in an experimental model of diabetes mellitus.
METHOD: Male Wistar rats were made diabetic by a single dose of60 mg/kg streptozotocin, injected intraperitoneally. One group of diabetic animals was treated with annatto, 540 mg/kg, administered via gavage.
RESULTS: Annatto treated diabetic animals showed significantly lower blood sugar levels than untreated diabetics. The blood glucose curve showed that the hypoglycemic effect of annatto lasted for the twelve hours of evaluation. However, the most significant reduction on blood glucose took place two hours after drug administration. Annatto did not prevent the weight loss that is characteristic of decompensated diabetes mellitus.
CONCLUSION: Annatto has a hypoglycemic property in rats with severe diabetes mellitus. Such an effect had a relatively long duration, but is more pronounced two hours after drug administration.

Keywords: Bixa orellana; Diabetes Mellitus; Rats.

Development of an efficient multiplex semi-nested PCR for convenient use in urine samples for diagnosis of toxoplasmosis

Abbas Ali Eskandarian

MEDICALEXPRESS 2014;1(1):39-42

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BACKGROUND: Toxoplasmosis is a protozoan parasitic infection. The cerebrospinal, ocular and congenital forms of the disease are complicated and life threatening. Diagnosis of toxoplasmosis is difficult due to invasive sample requirement, complications in pathogenesis, immunology, and interpretation of test results. Using urine as a non invasive sample source for molecular diagnosis of toxoplasmosis is the main object of this research. Attempts were made to diagnose toxoplasmosis using polymerase chain reaction (PCR) technique on the parasite's deoxyribonucleic acid (DNA) in urine.
METHODS: Parasite: The Toxoplasma gondii (T. gondii) RH strain was obtained from peritoneal exudates of small white laboratory mice inoculated with 5x105 tachyzoites three days before aspiration. Urine samples with defined numbers of tachyzoites per ml were used as laboratory samples. The target was a 529 bp segment (AF146527 gene bank) of the T. gondii genome with 200-300 repeats as target in PCR. Selected primers were designed on its sequence.
RESULTS: A multiplex semi-nested PCR technique was developed for obtaining a method for precise diagnosis of toxoplasmosis, time and budget saving and to diminish the DNA cross contamination risk. It was sensitive to detect 2 this tachyzoites DNA per final sample.
CONCLUSION: With further development, nested PCR can be a useful and non-invasive method for diagnosis of cerebrospinal, ocular, and congenital toxoplasmosis.

Keywords: Toxoplasmosis; Toxoplasma gondii; Diagnosis; Urine sample; Multiplex; Nested PCR.

Health-related quality of life in adults with attention-deficit and hyperactivity disorder

Maria Aparecida da Silva; Tiffany M. Chaim; Mikael Cavalett; Mauricio H. Serpa; Marcus V. Zanetti; Glauco F. Vieira; Geraldo F. Busatto; Mário R. Louzã

MEDICALEXPRESS 2014;1(1):43-46

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OBJECTIVE: Attention-Deficit and Hyperactivity Disorder is a neurodevelopmental condition that causes substantial deficits in several aspects of human function, resulting in a poor quality of life. However, studies using valid reports to objectively document Quality of Life impairment in never-treated adults with Hyperactivity Disorder Self-Report Scale have, to date, been scarce. The aim of this study was to assess Quality of Life in a clinical sample of treatment-naïve adults with Attention-Deficit and Hyperactivity Disorder in comparison to a healthy control group, and to investigate the relationship between Quality of Life and symptom severity ratings.
METHOD: Symptom severity ratings (assessed using the Attention-Deficit and Hyperactivity Disorder Self-Report Scale) and quality of life measurements using the World Health Organization Quality of Life scale (through WHOQOL-BREF) were obtained from a sample of 46 treatment-naïve adults with Attention-Deficit and Hyperactivity Disorder (mean age=29.3 years) and a group of 28 healthy controls (mean age=28.7 years).
RESULTS: Quality of Life was significantly worse in the Attention-deficit and Hyperactivity Disorder group compared to the healthy controls. The severity of symptoms of hyperactivity (but not of inattention) was negatively correlated with quality of life.
CONCLUSION: The use of a generic Quality of Life tool such as the WHOQOL-BREF allows the detection of lower Quality of Life, vs. healthy controls, in adult Attention-Deficit and Hyperactivity Disorder patients, and highlights the relevance of Quality of Life impairment when planning and monitoring treatment strategies for such a population.

Keywords: Attention-deficit and hyperactivity disorder; Adult; Treatment-naïve; Quality of life.

Use of small volume hypertonic acetate dextran during aortic occlusion in pigs: assessment of blood flow and antioxidant status in tissues

Michael A. Dubick; Luis F. Poli de Figueiredo; George C. Kramer

MEDICALEXPRESS 2014;1(1):47-52

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BACKGROUND: Hypertonic/hyperoncotic fluids may reduce overall fluid requirements and tissue edema, improve perfusion and reduce the incidence of paraplegia associated with aortic cross-clamping and subsequent reperfusion.
OBJECTIVE: We evaluated potential benefits of a hypertonic saline acetate solution on reperfusion injury following ischemia. We examined blood flow and plasma antioxidant status, spinal cord and skeletal muscle above and below the cross-clamp, as well as in the liver and the kidney.
METHOD: The aorta of anesthetized swine (n=5-6/group) was cross-clamped at the level of T9 for 30 min; animals were infused with 4 ml/kg of hypertonic acetate dextran (HAD) or 8.4% NaHCO3 (Control). Pigs were euthanatized 1h later.
RESULTS: As blood flow fell to zero in lower spinal cord and muscle, it doubled in the upper cord and increased 6-fold in upper muscle. Upon reperfusion, blood flow in all regions returned to baseline levels, with no statistical differences between HAD and Controls. Lipid peroxidation in plasma was lower in HAD than Controls. Lower muscle had 41% lower glutathione levels and significantly lower activities of the antioxidant enzymes glutathione peroxidase and reductase, catalase, superoxide dismutase versus upper muscle. The lower spinal cord had 2.5 fold higher malondialdehyde levels and 50% higher catalase activity than upper spinal cord. Within a tissue, any significant differences in antioxidant status or evidence of lipid peroxidation favored HAD over Control.
CONCLUSION: HAD offered only minor advantages over NaHCO3 with respect to blood flow and antioxidant status of spinal cord and muscle following this period of aortic cross-clamping and reperfusion.

Keywords: ischemia/reperfusion; hypertonic saline; blood flow; oxidant stress; swine.

In the April 2014 issue of MedicalExpress

Mauricio Rocha-e-Silva

MEDICALEXPRESS 2014;1(2):53-54


Clinical pharmacology of ibuprofen in preterm infants: A meta-analysis of published data

Gian Maria Pacifici

MEDICALEXPRESS 2014;1(2):55-61

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OBJECTIVES: Ibuprofen is a non-selective anti-inflammatory cyclooxygenase inhibitor drug of the propionic acid class of non-steroidal agents, available without prescription in the USA. In preterm infants, ibuprofen is used to close the Patent Ductus Arteriosus and it was found to be more effective than indomethacin. This metaanalysis determined whether differences exist in the closure rate of Patent Ductus Arteriosus following the oral vs. intravenous ibuprofen administration to preterm infants; it examines metabolism, pharmacokinetics and adverse renal effects of ibuprofen.
METHOD: The bibliographic search was performed using PubMed and EMBASE databases as search engines. In addition, the books "Neofax: a Manual of Drugs Used in the Neonatal Care" by Young and Mangum and the "Neonatal Formulary" were consulted.
RESULTS: Patent Ductus Arteriosus closure was 89% with oral ibuprofen (9 reports) vs. 75% with intravenous ibuprofen (13 reports); p = 0.011. The half-life (t1/2) of ibuprofen is 43.1 and 26.8 hours in infants on the 3rd and 5th day of life, respectively. In adults, the half-life of ibuprofen is 2 hours. The rapid shortening of ibuprofen t1/2 is due to the rapid increase of cytochromes CYP2C9 and CYP2C8 activities, which metabolize ibuprofen and which surge in the liver during the first weeks of life. Ibuprofen reduces the renal glomerular filtration and the sodium tubular transport rates.
CONCLUSION: Oral ibuprofen is more effective than intravenous ibuprofen to close patent ductus arteriosus. Ibuprofen has fewer renal adverse effects than intravenous ibuprofen and has the most favourable risk/benefit ratio.

Keywords: adverse-effects; ibuprofen; metabolism; neonate; pharmacokinetics.

Alteration of vascular permeability in burn injury

Qiaobing Huang; Ming Zhao; Keseng Zhao

MEDICALEXPRESS 2014;1(2):62-76

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Massive burn trauma is characterized by hypovolemic shock induced by the loss of plasma from vessels. The elevation of vascular permeability and the ultimate formation of tissue edema are important events during the development of severe burn injury. The underlying mechanisms involved in the increased permeability include the activation of multiple endothelial signaling pathways and the changes of endothelial structure and functions. This review summarizes some of our recent discoveries in endothelial mechanisms during burninduced vascular hyper-permeability. The emphasis is put on tight junction, adherens junction, and the contraction of endothelial cells. The effects of several protein kinases, including Rho kinase, protein kinase C, and MAPKs are also stressed.

Keywords: Microcirculation; Permeability; Burn.

Emotional memory in patients with agoraphobic panic disorder compared to a control group

Anna Lucia Spear King; Alexandre Valença; Adriana Cardoso; Antonio Egidio Nardi

MEDICALEXPRESS 2014;1(2):81-86

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OBJECTIVES: Rational minds make logical connections between cause and effect, whereas emotional minds make no such distinctions, following instinctive logic. This paper investigates episodic emotional memory in patients with panic disorder with agoraphobia in comparison to a control group.
METHOD: Sixty volunteers, 30 patients with panic disorder with agoraphobia and 30 healthy controls were exposed to the same slideshow of 11 slides, but randomly exposed to two different narrated versions, namely one emotional and one neutral. Each group of 30 participants was randomly subdivided into two subgroups of 15; each subgroup of patients and controls was exposed either to the emotional or to the neutral narrative. One week later patients and controls returned to answer questionnaires about the slides and respective narrated stories.
RESULTS: Panic disorder patients exposed to the emotional content of the story showed a significantly enhanced emotional memory, evidenced by a better recollection of the emotional narration when compared to patients exposed to the neutral version. Compared to controls, panic disorder patients exhibited greater discrepancy between the emotional versus the neutral narrative.
CONCLUSION: Results showed that the panic disorder patients were significantly impacted by the content of the emotional version of the story, with respect to their emotional memory; the same was not observed for the control group exposed to the same emotional version of the story. We conclude that the characteristics of the panic disorder condition had an influence on emotional memory.

Keywords: memory; panic; neuroscience; emotion.

Analysis of velocity and direction of trunk movement in wheelchair basketball athletes

Sileno da Silva Santos; Carlos Bandeira de Mello Monteiro; Bruno Cantelli; Angelica Castilho Alonso; Luis Mochizuki; Alessandro H. Nicolai Ré; Julia Maria D'Andréia Greve

MEDICALEXPRESS 2014;1(2):77-80

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OBJECTIVE: Postural control of the trunk is important to stabilize the entire body and to generate muscle force during sports activities. When the trunk is stable, it is easier and safer to transfer applied forces along the body to perform any motor task because it enhances muscle action and reduces joint loads. Postural control of the trunk is important to stabilize the entire body and to generate muscle force during sports activities. The aim of this study is to verify the velocity and direction of trunk movement in wheelchair basketball athletes.
METHOD: Participants were 26 wheelchair basketball athletes, they were tested on the NeuroCom Balance Master System, protocol: Rhythmic Weight Shift. They were asked to sway the entire body to the right, left, forward and backward. Trials evaluated these movements in low, medium and high velocities.
RESULT: Movement velocity was very significantly affected by task speed and task direction. The highest movement velocity was observed for the fast task and for the left/right direction. There was no interaction between the task and its direction.
CONCLUSION: Wheelchair basketball athletes moved their body faster in the left/right direction. This result suggests that postural control is direction-dependent for the wheelchair-bound individual.

Keywords: basketball; biomechanics; athletes.

Major depression in high-risk obstetric inpatients and outpatients

Thiago Robles Juhas; Gláucia Rosana Guerra Benute; Mara Cristina Souza de Lucia; Rossana Pulcineli Vieira Francisco

MEDICALEXPRESS 2014;1(2):87-90

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OBJECTIVE: To evaluate and compare the presence of major depression in high-risk obstetric patients among ward and ambulatory patients.
METHOD: An exploratory, descriptive, and cross-sectional study was carried out among 542 high-risk pregnant women divided into two groups: 278 were outpatients receiving ambulatory care, and 264 were ward patients. Both attended a public university hospital in the State of São Paulo, Brazil. Major depressive disorder was evaluated using the Brazilian version of the Primary Care Evaluation of Mental Disorders. The Χ2 test was used in the statistical analysis with a level of significance of 5% (p<0.05).
RESULTS: Sixty women (11.0%) were diagnosed with major depression, twenty-five (9%) were outpatients and thirty-five (13%) were ward patients. There was no statistically significant difference between groups with respect to the major depression (p = 0.11). Statistically significant differences were found between outpatients and ward patients as follows: insomnia or hypersomnia (p<0.01); fatigue or loss of energy (p = 0.02); diminished concentration (p<0.01); and restlessness or psychomotor retardation (p<0.01).
CONCLUSIONS: Hospitalization may intensify some depressive symptoms. The high proportion of women with major depression demonstrates the need for access to psychosocial support during the pregnancy period, especially in pregnant women at high-risk.

Keywords: Major Depression; Pregnancy; High-Risk; Hospitalization.

Antinociceptive effects of saccharose and aqueous extract of Cordyline dracaenoides kunth (uvarana) in experimental models after induction of hyperalgesia using capsaicin

Larissa Gulogurski Ribeiro; Ivo Ilvan Kerppers; Isabel de Almeida Paz; Marcos Paulo Polowei Rolão; Thais Barbosa de Oliveira; Camila da Luz Eltchechem; Mário César da Silva Pereira

MEDICALEXPRESS 2014;1(2):91-94

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OBJECTIVE: There is evidence that sweet substances such as saccharose can enhance the analgesic properties of endogenous opioids, leading to pain relief; it is also known that Cordyline dracaenoides Kunt, commonly known as uvarana, is used in folk medicine as an anti-inflammatory and analgesic agent. The aim of the present study was to compare the antinociceptive effects of uvarana aqueous extracts vs. saccharose in rats.
METHOD: Twenty-four Wistar rats were used, divided into two groups of twelve, namely a uvarana and a saccharose group. Capsaicin was used to induce hyperalgesia and the nociceptive threshold was assessed every five minutes for a total of 50 minutes Baseline values were obtained and this was followed by administration of uvarana or saccharose at threedifferent concentrations (100, 250 and 300 g/L) The nociceptive threshold was assessed using the tail flick test.
RESULT: In comparison to baseline values, uvarana and saccharose provoked significant and comparable antinociceptive effects at concentrations of 250 g/L and 300 g/L, respectively.
CONCLUSION: Both substances caused similar antinociceptive effects in comparison to baseline values.

Keywords: analgesia; saccharose; uvarana.

Reliability Index of inter- and intra-rater of manual goniometry and computerized biophotogrammetry to assess the range of motion of internal and external shoulder rotation

Leandro Antonietti; Natalia Luna; Gabriel Nogueira; Ana Ito; Marcelo Santos; Angelica Alonso; Moises Cohen

MEDICALEXPRESS 2014;1(2):95-99

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OBJECTIVES: Measurements of the joint angles of the shoulder complex are important for diagnosis, assessment and monitoring of the treatment progression of movement disorders, provided that they can be seen as valid and reliable. The object of this study was to determine inter- and intra-rater reliability of manual goniometry and computerized biophotogrammetry for the assessment of range of motion of the medial and lateral rotations of the shoulder.
METHODS: Four evaluators (two for goniometry and two for biophotogrammetry) assessed 11 males, 16 - 26 years old, right-handed and with no shoulder anomalies. A universal plastic goniometer was used for the goniometry assessment. The biophotogrammetry assessment involved the use of a digital camera Sony DSC-W1 (5.1Mp), with non-reflective markers placed on the subjects. Photographic frames were analyzed the though the SAPO software (version 0.67). Each evaluator was blinded to data from all other valuators; inter-rater datas were compared. Seven days after the first assessment, all measurements were repeated in order to complete the intra-rater comparison. The Wilcoxon test was used to check statistical significance, the Spearman correlation was calculated and inter-class correlations coefficients were determined.
RESULTS: Inter-class correlations for inter- and intra-rater goniometry results were 0.897 and 0.830 respectively; the corresponding biophotogrammetric values were 0.982 and 0.954, all representing excellent reliability levels.
CONCLUSION: Goniometry and biophotogrammetry are reliable methods for assessment of shoulder rotation; however, biophotogrammetry has been shown to be more reliable.

Keywords: biophotogrammetry; goniometry; reliability; shoulder; joint angles.

Inhalation conscious sedation with nitrous oxide/oxygen in pediatric dentistry

Ana Catarina Barroso Macedo Barbosa; Joana Mourão; Virgínia Milagre; David Casimiro de Andrade; Cristina Areias

MEDICALEXPRESS 2014;1(3):102-104


Clinical pharmacology of analgesics in infants and the pharmacologic management of pain in neonates

Gian Maria Pacifici

MEDICALEXPRESS 2014;1(3):105-115

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OBJECTIVES: The objectives of this study are to describe (1) the clinical pharmacology of analgesics in infants and (2) the pharmacologic management of pain in neonates.
METHODS: The bibliographic search was performed using PubMed and EMBASE databases as search engines.
RESULTS: Opioid analgesics are the most commonly used analgesics for acute pain and they include intravenous morphine (50 to 200 µg/kg), oral methadone (50 to 200 µg/kg), intravenous fentanyl (0.5 to 4 µg/kg), alfentanyl (10 to 20 µg/kg), sufentanil (10 to 15 µg/kg), and remifentanil (5 µg/kg). Fentanyl, alfentanyl, sufentanil and remifentanil are short-action opioid analgesics. Non-opioid analgesics can be used for moderate pain; they include oral paracetamol (acetaminophen, 12 to 15 mg/kg), the intravenous benzodiazepine midazolam (50 to 150 µg/kg) which is not recommended in neonates, intravenous propofol (2.5 mg/kg) which is used for induction of general anaesthesia, and ketamine, (2 mg/kg intravenously or 4 mg/kg intramuscularly) which produces a short-lasting, trance-like state with profound analgesia and amnesia.
CONCLUSION: The use of non-opioid analgesics has increased in the last years for the management of non-acute pain. If prevention or elimination of pain is not possible, a more realistic goal may be to aggressively intervene to minimize pain and its effects.

Keywords: analgesia; analgesics; management of pain; neonate; pain; pharmacokinetics.

Childhood restless legs syndrome

José Carlos Pereira Jr.; Márcia Pradella-Hallinan; Rosana Cardoso Alves

MEDICALEXPRESS 2014;1(3):116-122

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BACKGROUND: The last 20 years witnessed increased medical awareness regarding restless legs syndrome (Willis-Ekbom disease) among adults and children. However, it remains underdiagnosed and undertreated. Diagnosis relies exclusively on the history described by patients in their own words. Children who cannot adequately describe their symptoms represent a difficulty. To circumvent this, probable and possible restless legs syndrome have been instituted as diagnostic alternatives.
OBJECTIVE: This review aims to emphasize to general Pediatricians that among children restless legs syndrome is not only common, but also has the potential to impair the quality of life of affected patients and their caregivers.
METHODS: We performed a search in the database of Medline-PubMed for articles dated from January 1, 2008 to December 31, 2013. Many relevant articles before 2008 were also studied. Key words used were: restless legs syndrome and/or restless legs syndrome children. The Google Scholar database and pages in Portuguese were also investigated. We also searched for the theme in various relevant textbooks. We have added our personal experience to published literature.
CONCLUSION: We observed that restless legs syndrome is common in children, and its diagnosis requires knowledge and intuition on the part of the Pediatrician.

Keywords: Restless legs syndrome; Willis-Ekbom disease; Restless legs syndrome in children.

Effectiveness of sperm washing by discontinuous density gradient centrifugation to remove antibodies bound to the sperm membrane

Danielle Schneider; Cinthia Feijo; Sidney Verza Jr.; Sandro Esteves

MEDICALEXPRESS 2014;1(3):123-126

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OBJECTIVE: We evaluated the effectiveness of sperm washing using the discontinuous two-layer density gradient centrifugation method to remove antisperm antibodies attached to the sperm surface.
METHOD: We prospectively enrolled sixty-six men with unexplained infertility who were seeking evaluation. Each patient delivered one semen specimen for the study. We determined antisperm antibody levels using the direct immunobeads test. Specimens were classified into two groups according to the pre-washing levels of antibody-bound spermatozoa: group 1 (low antisperm antibodies levels, immunobeads test <20%; n = 54), and group 2 (high antisperm antibodies levels, immunobeads test > 20% n = 12). Sperm washing was carried out using the discontinuous two-layer colloidal density gradient centrifugation method. Pre- and post-wash levels of antisperm antibodies were compared in the groups.
RESULTS: The pre- and post-wash percentage of spermatozoa with antisperm antibodies attached to their surface was 11% and 6.5% in group 1 (mean difference = 40% p < 0.01), and 30% and 19.5% in group 2 (mean difference = 36.8% p = 0.02), respectively. The effectiveness of density gradient centrifugation in removing antisperm antibodies was not different between the groups, but individual variations from - 52.3% to - 3.9% were observed.
CONCLUSIONS: Sperm washing by density gradient centrifugation is an overall effective method to remove antibodies bound to sperm membranes, regardless of the levels of antisperm antibodies in the neat semen. Due to an inter-individual variation in the effectiveness of the method, we recommend that each patient be tested before applying sperm washing by density gradient centrifugation in intrauterine insemination.

Keywords: Antibodies; sperm; sperm washing; immunobead test; male infertility

Protective microcirculatory and anti-inflammatory effects of heparin on endotoxemic hamsters

Marcos L. Miranda; Luiz Felipe M. Prota; Maria Júlia B. Silva; Fernando L. Sicuro; Eliane S. Furtado; Ana Olimpia M. T. Santos; Eliete Bouskela

MEDICALEXPRESS 2014;1(3):127-134

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OBJECTIVE: Apart from its anticoagulant properties, heparin has vasodilator and anti-inflammatory effects that could assist in the reversal of septic microcirculatory changes. This paper investigates the effects of heparin on endotoxemia-related microcirculatory changes and compares them to those observed with the use of recombinant human activated protein C.
METHODS: After skinfold chamber implantation procedures and endotoxemia induction by intravenous Escherichia coli lipopolysaccharide administration (2, male golden Syrian hamsters were treated with intravenous unfractionated heparin (0.2 Intravital microscopy of skinfold chamber preparations allowed quantitative analysis of microvascular variables and venular leukocyte rolling and adhesion. Macrohemodynamic parameters were also analyzed. Endotoxemic hamsters treated with recombinant human activated protein C and non-treated animals served as controls.
RESULTS: Heparin decreased lipopolysaccharide-induced leukocyte rolling and arteriolar vasoconstriction; it also increased survival when compared with non-treated animals, while recombinant human activated protein C decreased leukocyte adhesion. Administration of heparin plus recombinant human activated protein C was associated with a significant attenuation of lipopolysaccharide-induced capillary perfusion deficits.
CONCLUSIONS: Heparin yields protective effects on endotoxemic animals' microcirculation. Those benefits were potentiated when heparin was administered in conjunction with recombinant human activated protein C.

Keywords: sepsis; endotoxemia; microcirculation; heparin; recombinant human activated protein C.

Body disabling chronic hemiparesis does not appear to determine differences in the body mass index when compared to able-bodied controls

Paulo Henrique Ferreira de Araujo-Barbosa; Lidiane Teles de Menezes; Abraão Souza Costa; Anderson Castro Mundim; Osmair Gomes de Macedo; Emerson Fachin-Martins

MEDICALEXPRESS 2014;1(3):135-139

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OBJECTIVE: (a) To compare the Body Mass Index between hemiparetic (disabled-bodied) patients vs. matched able-bodied controls, establishing relationships between Body Mass Index and the anthropometric variables (weight and height) used to calculate it; (b) to determine whether the Body Mass Index could be used as a disability indicator.
METHODS: Twenty hemiparetic patients were matched by gender and age to twenty control subjects. All of them were included in procedures to measure the anthropometric parameters used to calculate Body Mass Index. The data were submitted to statistical procedures.
RESULTS: The hemiparetic group did not present significant difference in the Body Mass Index when compared with controls, despite the fact that controls were 5.5 cm taller. From the variables used to calculate Body Mass Index, only weight presented a significant correlation to the index for both groups.
CONCLUSION: Significant differences in the Body Mass Index were not observed between groups. Moreover, for both groups, the index was only associated with body mass. Our results show that Body Mass Index is not a good parameter to establish relationships with disability indicators for disable-bodied patients.

Keywords: stroke; anthropometry; body composition.

YouTube as a source of information for New Delhi Metallo-β-lactamase-1 superbug gene

Sourabh Aggarwal; Harkirat Singh; Navkaran Bajaj; Vishal Sharma

MEDICALEXPRESS 2014;1(3):140-142

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OBJECTIVE: Internet has become an easy source for healthcare information. In recent years, websites like YouTube have become increasingly popular as a source of information. It is necessary to keep in check the information disseminated from these open-access sites to prevent the spread of false information. This study analyzed how information related to the superbug New Delhi Metallo-β-lactamase 1 (NDM1) was portrayed in video clips available on YouTube.
METHODS: YouTube ( was searched on June 22, 2011, using the search terms keywords NDM1, New Delhi beta-metallolactamase, NDM, New Delhi superbug, New Delhi metallolactamase to identify clips related to NDM-1. Videos were classified as useful, misleading and news update. Data analyses were conducted for the duration of videos, number of viewers, and positive and negative rating.
RESULTS: A total of 47 videos were included in this analysis. Twenty-nine videos were classified as news update, 9 videos as useful, and 9 videos as misleading videos. There was no statistically significant difference in the 3 groups regarding duration of videos, number of viewers, and positive and negative rating.
CONCLUSIONS: The results demonstrate that there is a wide variety of information on YouTube regarding NDM-1. The viewers are exposed to the useful videos as much as to misleading videos. As a result, public health professionals should be more vigilant in recognizing videos containing misleading information and physicians should counsel and educate patients against inappropriate use of online videos for medical purposes.

Keywords: Drug resistance; youtube; antibiotic.

Early serum tacrolimus levels predict long-term chronic kidney disease after liver transplantation

Vanessa B. A. Brandão; Luciana C. Faria; Danielle M. Bicalho; Fernando H. Pereira; Agnaldo S. Lima; Teresa C. A. Ferrari

MEDICALEXPRESS 2014;1(3):143-149

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OBJECTIVE: To investigate risk factors for the development of chronic kidney disease and death two years postliver transplantation.
METHOD: Associations between clinical and laboratory parameters and the development of chronic kidney disease and survival two years post-liver transplant were analyzed in a cohort of 148 adult patients with hepatic cirrhosis consecutively submitted to liver transplantation in a referral Brazilian center.
RESULTS: Median age at liver transplantation was 56 (range, 20-73) years, and 105 (70.9%) patients were males. The prevalence of chronic kidney disease at two years post-liver transplantation was: stage 1 or no chronic kidney disease, 27.5%; stage 2, 33.8%; stage 3, 34.6%; stages 4-5, 4.7%. Four variables were independently associated with the stage of chronic kidney disease two years after liver transplantation: (i) age (at liver transplantation), (ii) male gender, (iii) median tacrolimus levels in the first three months post-liver transplantation, and (iv) median of serum creatinine in the first six months post-liver transplantation. Two variables showed independent association with death in two years post-liver transplantation: (i) stay in Intensive Care Unit for three or more days after the liver transplantation surgery and (ii) median of serum creatinine levels in the first six months post-liver transplantation equal or higher than 1.3 mg/dL.
CONCLUSIONS: Administration of the lowest effective dose of tacrolimus and adoption of strategies to spare renal function are important measures to reduce the risk of late chronic kidney disease and death post-liver transplantation especially in high risk patients.

Keywords: Chronic kidney disease; Kidney dysfunction; Liver transplantation; Tacrolimus.

Women respond better to biological therapy in Crohn's Disease

Carlos Henrique Marques dos Santos

MEDICALEXPRESS 2014;1(3):150-152

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OBJECTIVE: Crohn's disease is in itself a major challenge for those treating inflammatory bowel diseases. Those exhibiting the fistulizing form, particularly perianal fistulas, create even more of a challenge, as there is great difficulty in obtaining disease control even using long-term therapeutic advances made in recent years. We evaluated the difference between the gender of patients under biological treatment for Crohn's Disease and perianal fistula.
METHODS: We studied 30 patients with Crohn's Disease with perianal fistula with a mean age of 35 years, from 2000 to 2013. All were naïve to biological agents and received these medications in usual doses and intervals. All were also treated surgically with curettage and placement of seton-stitches prior to the use of biological agents. The results were analyzed statistically by Student's t test, p < 0.05 being considered a significant difference.
RESULTS: Among responders, ten were men and nine were women, with no significant difference between genders in this regard. Among non-responders, eight were men and three were women: thus, significantly more men vs. women were non-responders. In general, 55% of men and 75% of women were responders.
CONCLUSION: Women exhibited a lower failure rate when exposed to biological treatment for perianal fistula in Crohn's Disease when compared to men.

Keywords: Crohn's disease; Infliximab; Adalimumab; perianal fistula; gender.

Cardiovascular responses induced by acute video game boxing performance in healthy women

Luciano Moreira de Souza; Raquel Annoni; Luiz Carlos de Abreu; Vitor E. Valenti; Erica E. Valenti; Fernando R. Oliveira; Rodrigo D. Raimundo; Sidney Benedito Silva

MEDICALEXPRESS 2014;1(3):153-157

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BACKGROUND: Previous studies suggested that some interactive video games induce cardiovascular responses. However, some different styles of video games have not been investigated.
OBJECTIVE: We aimed to evaluate cardiovascular responses induced by video game boxing performance in healthy women.
METHOD: We evaluated ten female sedentary volunteers, aged 20.9 ± 1.4 years, weight 58.7 ± 8.0 kg, height 163.2 ± 5.4cm. All subjects were weighed and measured. Their heart rate, blood pressure and lactate levels were recorded before and after video game performance. The volunteers played a Sony video game (Nintendo® Wii) by using the boxing method, in which all volunteers played for 10 minutes without interruption. At the end of the game the volunteers were reassessed using the same parameters mentioned above.
RESULTS: At the end of the video game boxing performance we observed highly significant increases of lactate production (p < 0.0035) and the double product (heart rate vs. systolic blood pressure) was also higher (p < 0.0001). Both parameters indicate that the performance increased demands of the cardiovascular system.
CONCLUSION: We conclude that a ten-minute video game boxing performance induces cardiovascular responses similar to aerobic exercise. This may be a practical form of exercise, but care should be exercised concerning subjects with cardiovascular disorders.

Keywords: Video Games; Lactic Acid; Physiology, Cardiovascular; Oxygen Consumption.

Psychoeducation improves the quality of life of informal caregivers of Glioblastoma patients

Tatiana Bukstein Vainboim; Maria Helena Pereira Franco; Alessandra Oliveira Ciccone; Flávio Key Miura; Paulo Henrique Pires de Aguiar; Milberto Scaff; Suely Kazue Nagahashi Marie

MEDICALEXPRESS 2014;1(3):158-165

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OBJECTIVE: To evaluate the impact of a psychoeducational program on the quality of life of informal caregivers of Glioblastoma patients.
METHOD: Twenty informal caregivers (test group) were evaluated before and after attending four sessions of psychoeducation and compared to a group of 10 caregivers (control group), who did not attend the sessions, but were also evaluated in two different equivalent time points. The quality of life was evaluated by WHOQOL-BREF questionnaire developed by the World Health Organization, which was applied by the same interviewer to all the participants. At the end of the study, a blinded interviewer who had no previous contact with the participants applied the tool again to check for any interference bias. The Cronbach's alpha coefficient for consistent evaluation, Student's t-test for parametric, and Wilcoxon test for non-parametric data were applied for statistical analysis.
RESULTS: The questionnaire was shown to be a consistent tool to evaluate quality of life. The test group showed significant improvement in the quality of life, especially in the psychological domain. The control group presented deterioration in all WHOQOL-BREF domains.
CONCLUSIONS: The psychoeducational program improved the quality of life of caregivers of Glioblastoma patients, and revealed to be a valuable support program to be implemented in the treatment of this type of cancer.

Keywords: Glioblastoma multiforme; Caregiver; Psychology; Grief; Quality of Life.