Medical Express

ISSN (print): 2318-8111

ISSN (online): 2358-0429

Issue: 1(5)2014 - 13 Articles


1 - The October issue of MedicalExpress

Mauricio Rocha-e-Silva

MEDICALEXPRESS 2014;1(5):219



2 - Prognostic factors in patients with breast cancer metastasis in the femur treated surgically

Guilherme Grisi Mouraria; Silvia Raquel Frick Matte; Carlos Hideo Hanasilo; Maria Julia Rosso de Carvalho; Mauricio Etchebehere

MEDICALEXPRESS 2014;1(5):221-226

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BACKGROUND: Breast carcinoma is a common malignancy in the developed world. Late diagnosis of the disease is associated with bone metastasis. The femur is commonly affected. Prognostic factors of mortality in patients with bone metastases originating from cancers in general have been reported. However, there is no specific report of prognostic factors in relation to breast cancer metastasis in the surgically treated femur. The determination of prognostic factors in patients with bone metastasis can assist in therapeutic decisions.
OBJECTIVE: To determine clinical and orthopedic factors related to mortality in patients with breast cancer and metastases to the femur treated surgically.
METHOD: This was a retrospective study and included 41 patients undergoing surgical treatment of femoral metastases. We analyzed the following variables: (i) number and location of bone metastases, (ii) visceral metastases, (iii) presence of pathological fracture, (iv) fixation method, and (v) laboratory tests. These factors were correlated with mortality using Cox Multivariate Logistic regression and Kaplan-Meier curves.
RESULTS: There was a high prevalence of multiple metastases associated with pathological fractures at the time of surgery. Mortality was high and early. Subtrochanteric location, the presence of fractures, anemia, and alterations in renal function were associated with higher mortality. The fixation method, the number of bone metastases, and the presence of metastasis in other organs did not affect mortality.
CONCLUSIONS: Breast cancer with metastasis to the femur is an advanced disease with early mortality. Clinical and orthopedic factors should be considered. Surgery is recommended when lesions occur, regardless of the type of implant used.

Keywords: Breast Cancer; Femur Metastasis; Prognosis; Mortality.

3 - High intensity exercise training worsens alveolar destruction in pulmonary emphysema rats

Viviani Barnabé; Fernanda D.T. Lopes; Beatriz M. Saraiva-Romanholo; Clarice O. Rosa; Rogerio Pazetti; Vitor E. Valenti; Milton de Arruda Martins

MEDICALEXPRESS 2014;1(5):227-232

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OBJECTIVE: Investigation of standard intensities of physical exercise is important to better comprehend and develop rehabilitation programs for emphysema. We aimed to evaluate the effects of different intensities (moderate and high-intensity) of physical exercise on the development of a protease-induced (papain intratracheal instillation) emphysema in rats.
METHODS: Male Wistar rats were randomly separated into five groups that received intratracheal instillation of papain solution or vehicle: (i) papain high intensity exercise, (ii) papain moderate exercise, (iii) saline high intensity exercise, (iv) saline sedentary and (v) papain sedentary. Forty days after intratracheal instillation, the exercise groups were submitted to an exercise-training protocol on a treadmill during 10 weeks, 5 days/week, at 0.9 km/h (Papain and saline high exercise), or at 0.6 km/h (papain moderate exercise).We measured respiratory system elastance and resistance, the collagen fiber lung parenchyma, and the pulmonary mean linear intercept.
RESULTS: All animal groups that received papain instillation presented higher alveolar wall destruction compared to animals that received only saline solution. The papain high intensity exercise group presented higher values of mean linear intercept compared to emphysema groups that were trained at a moderate intensity or not submitted to exercise.
CONCLUSION: High intensity exercise training worsened alveolar destruction in an experimental model of emphysema in rats when compared to moderate intensity exercise, or to no exercise.

Keywords: Emphysema; Pulmonary Disease; Chronic Obstructive; Exercise; Rats.

4 - Yoga Relaxation (savasana) decreases cardiac sympathovagal balance in hypertensive patients

Danilo F Santaella; Geraldo Lorenzi-Filho; Marcos R Rodrigues; Taís Tinucci; Ana Paula Malinauskas; Décio Mion-Júnior; Nicola Montano; Cláudia LM Forjaz

MEDICALEXPRESS 2014;1(5):233-238

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OBJECTIVE: Although relaxation is recommended as complementary therapy for hypertension, its post-intervention cardiovascular autonomic effects are unclear. The objective of this research was to investigate the effects of savasana relaxation on cardiovascular autonomic modulation in hypertensive patients.
METHODS: This randomized controlled trial was performed at the Hemodynamic Laboratory of the Physical Education School of the University of São Paulo/Brazil. Sixteen hypertensive (6-women) and 14 normotensive patients (6-women) non-obese subjects participated in 2 random sessions: savasana relaxation and control. Patients remained supine for 55 min after interventions. Electrocardiogram, beat-to-beat blood pressure and respiration were acquired during and after interventions for posterior autoregressive spectral analysis of the R-R interval and blood pressure variability.
RESULTS: Hypertensive and normotensive patients presented similar cardiac autonomic modulation responses during and after experimental sessions. During relaxation, low frequency and sympathovagal balance were significantly lower in the Relaxation sessions than during supine rest in the Control sessions. Fifteen minutes after interventions, low frequency and sympathovagal balance were still lower in Relaxation than in Control, and remained lower for 35 min; at 55 min, the variables were similar between sessions. Systolic blood pressure variability did not differ among sessions.
CONCLUSIONS: Savasana Relaxation decreases cardiac sympathetic autonomic modulation after its performance in hypertensive patients; this reduction lasts at least 35 minutes and is not blunted in hypertensive patients when compared to normotensive controls. Thus, savasana relaxation has positive effects on cardiac autonomic modulation of hypertensive patients, and may be included as a strategy for the non-drug treatment of hypertension.

Keywords: Heart rate variability; Hatha Yoga; Hypertension.

5 - The prevalence of mitochondrial DNA mutations in Leigh syndrome in a Brazilian series

Suely Kazue Nagahashi Marie; Sueli Mieko Oba-Shinjo; Maria Joaquina Marques-Dias; Sergio Rosemberg; Fernando Kok; Umbertina Conti Reed

MEDICALEXPRESS 2014;1(5):239-242

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OBJECTIVE: To determine the prevalence of mitochondrial DNA (mtDNA) mutations in cases with findings compatible with the diagnosis of Leigh syndrome in a Brazilian Neurological Service, and to compare those findings between the patients presenting or not these mutations.
METHOD: We analyzed six mtDNA point mutations (T8993G, T8993C, T8851C, G1644T, T9176C, and T3308C) by PCR and endonuclease digestion in 32 patients with presumptive diagnosis of Leigh syndrome, according to distribution across different age ranges.
RESULTS: We found two patients, in the subgroup under 4 years of age, presenting T8993G and T8993C mutations. Their clinical symptoms and neuroimaging findings were similar when compared to those patients not harboring these mutations.
CONCLUSION: As the molecular confirmation is pivotal for both the precise genetic counselling and therapeutic guidance, we emphasise the benefit of screening for mtDNA mutation in Leigh syndrome patients under 4 years old. Mitochondrial whole genome and whole exome analysis by next-generation sequencing technology maybe a future alternative for molecular diagnosis of this extensive genetic heterogeneous syndrome.

Keywords: Leigh's syndrome; T8993G; T8993C; maternal inheritance; earlyinfantile.


6 - Clinical pharmacology of caffeine citrate in preterm infants

Gian Maria Pacifici

MEDICALEXPRESS 2014;1(5):243-250

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BACKGROUND: Apnea of prematurity consists in 15 to 20 sec. of breathing cessation and is the most important disorder in the control of breathing in preterm infants. It is treated with caffeine citrate.
OBJECTIVES: The objectives of this article are to review: (1) the mechanisms of action, (2) the effects, (3) the metabolism, (4) the pharmacokinetics, and (5) the adverse effects of caffeine citrate in preterms.
METHODS: The bibliographic search was performed using PubMed and EMBASE databases as search engines and April 2014 was the cutoff point.
RESULTS: Caffeine citrate is a stimulant of the respiratory and central nervous systems. It binds competitively to the receptors for adenosine A1 and A2A, causing inhibition. Caffeine increases respiratory rate and minute volume, stimulates respiratory centers, and increases pulmonary blood flow and the sensitivity of central medullary areas to hypercapnia. Orally administered caffeine citrate is rapidly and completely absorbed. It is N-demethylated by CYP1A2 and is N-acetylated by N-acetyltransferase. The half-life of caffeine citrate is 100 hours at birth and 5 hours at a gestational age >29 weeks. There is a remarkable shortening of the half-life during neonatal maturation. Adverse effects of caffeine are usually mild, and include restlessness, vomiting, and functional cardiac symptoms.
CONCLUSIONS: Caffeine citrate is the drug of choice for the treatment of apnea of prematurity. It is an easy drug to use. Administered orally or intravenously once a day, it does not require monitoring of serum concentrations and has few side effects.

Keywords: caffeine citrate; metabolism; neonate; pharmacodynamics; pharmacokinetics.

7 - Clinical and therapeutic controversies on subclinical hyperthyroidism

Fernanda Salles; Daniela Salles

MEDICALEXPRESS 2014;1(5):251-256

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Subclinical hyperthyroidism is defined as low or undetectable serum thyrotropin concentration in the presence of levels of free thriiodothyronine and thyroxine within the reference range. Despite the conflicting results from many observational studies, this thyroid disorder has been associated with an increased risk of developing atrial fibrillation, left ventricular hypertrophy, increased heart rate and diastolic function impairment. In addition, a relation between subclinical hyperthyroidism, skeletal disorders and cognitive changes has been reported. Treatment of subclinical hyperthyroidism remains controversial, given the lack of prospective randomized studies showing clinical benefits with restoration of the euthyroid state. Nevertheless, this review recommends the treatment of subclinical hyperthyroidism to individuals aged over 65, postmenopausal women, patients with cardiac risk factors, heart disease, osteoporosis or hyperthyroidism symptoms, whenever TSH is persistently suppressed(<0.1 mU/L). When TSH is between 0.1 - 0.5 mU/L, treatment should be considered for individuals over age 65, patients with heart disease or hyperthyroidism symptoms.

Keywords: Subclinical hyperthyroidism; atrial fibrillation; bone mineral density; management.


8 - Adding triamcinolone to viscosupplementation: one year outcome of randomized trial

Gustavo Constantino Campos; Marcelo Issao Hissadomi; Renato Frucchi; Thiago Pasqualin; Marcia Uchôa de Rezende

MEDICALEXPRESS 2014;1(5):257-261

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OBJECTIVE: This is an extended follow-up of a randomized controlled trial to evaluate if the addition of triamcinolone to viscosupplementation could alter one-year pain and function of viscosupplementation alone. This is a Level I Therapeutic study (See Guidelines for Authors for a complete description of levels of evidence).
METHODS: In a previously reported study we prospectively enrolled 104 patients with knee osteoarthritis and randomized them to receive either a single intra-articular injection (6 mL) of hylan GF-20 (Group viscosupplementation [Group VS]), or a single intra-articular injection of hylan GF-20 (6 mL) and 1 mL (20 mg) of triamcinolone hexacetonide (Group VS + T). Visual Analogue Scale, WOMACTM, and Lequesne questionnaires were completed at baseline, at weeks 1, 4, 12, 24. At the one-year follow-up point, all patients were recruited and reassessed.
RESULTS: At one year, the effects of treatment observed in the previous periods were present, with no differences between groups; only the Group receiving hylan + triamcinolone hexacetonide still showed a difference from baseline in the Visual Analogue Scale questionnaire.
CONCLUSIONS: The addition of triamcinolone hexacetonide improves first-week symptoms and functional scores of viscosupplementation and does not alter its adverse effects. There might be benefits for the one-year pain results.

Keywords: viscosupplementation; osteoarthritis; intraarticular injection; triamcinolone.


9 - Low dose of green tea catechins improves endothelial function and vascular smooth muscle cell reactivity in obese women

Daniel Alexandre Bottino; Débora Cherfan Goulart Nogueira; Ana Cláudia Lourenço; Vanessa Silveira Fortes; Andresa A. Berretta; Eliete Bouskela

MEDICALEXPRESS 2014;1(5):262-267

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BACKGROUND: The high prevalence of obesity in the world is associated with several health problems, with endothelial dysfunction figuring as a frequent feature. We investigated whether low dose consumption of green tea extract (catechins < 200 mg/day) could modify endothelial function, lipid profile, fasting glucose and insulin, post load plasma glucose, inflammatory/oxidative stress biomarkers and blood pressure in obese women.
METHODS: Sixteen obese women with body mass index (BMI) between 30 and 40 Kg/m2, mean age 38 [33-40] years, consumed 600 ml green tea (3 × 200 ml) per day, containing 153.3 mg of catechins and 72.5 mg of caffeine, during three months. Endothelial function was evaluated through venous occlusion plethysmography by increment of peak forearm blood flow (FBF), after 5 min ischemia, during the reactive hyperemia response/baseline FBF. Endothelium-independent vasodilation was analyzed through peak FBF after 0.4 mg sublingual nitroglycerin/baseline FBF.
RESULTS: After 3 months, this consumption of green tea reduced BMI from 34.02 to 33.13, and diastolic blood pressure by 4 mmHg. The reactive hyperemia response/baseline FBF improved by 27%, and the endothelium-independent vasodilation by 12%. The blood biochemical profile, where all parameters were within the normal range, remained unaltered.
CONCLUSIONS: A low dose of green tea ameliorated the endothelial dysfunction present in obesity, indicating that its consumption should be encouraged in these patients, because endothelial dysfunction is an early marker of atherosclerosis.

Keywords: Obesity; green tea; microcirculation; venous occlusion plethysmography; endothelial function.

10 - Antinociceptive action of light emitting diode in an experimental model with hyperalgesia by capsaicin

Ivo Ilvan Kerppers; Isabel de Almeida Paz; Juliana Aparecida Wosch Pires; Larissa Gulogurski Ribeiro; Marcos Paulo Polowei Rolão; Meiriélly Furmann; Thais Barbosa de Oliveira; Camila da Luz Eltchechem; Mario César da Silva Pereira; Andersom Ricardo Fréz

MEDICALEXPRESS 2014;1(5):268-270

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OBJECTIVE: To assess the antinociceptive effect of a light emitting diode (LED) in the acute phase of pain induced by capsaicin.
METHOD: Twelve Wistar rats were used, divided into a control and an experimental group. The pain process was induced in both groups by applying 50 microliters of a 2% capsaicin solution in the plantar region of the right hind limb. In the experimental group, a single application of LED 627nm (70mw, 7 Joules/cm2 dose) was also applied. Nociception was assessed 30 minutes and 24 hours after LED application using a digital analgesymeter (Von Frey).
RESULTS: Twenty four hours after irradiation, an increase in the nociceptive threshold was observed in the LED group in comparison to the 30 min level, as well as in the inter-group comparison.
CONCLUSIONS: The use of LED can be considered as a non-invasive analgesic method as it increases of the nociceptive threshold 24 hours after pain is induced.

Keywords: Light Emitting Diode; nociception; pain measurement.

11 - Delayed Gastric Emptying of Semi-solid diets in Patients with Chagasic Megaesophagus

Decio Chinzon;Tomas Navarro-Rodriguez; Karine Dal-Paz; Ricardo Anuar Dib; Joaquim Prado Pinto de Moraes-Filho

MEDICALEXPRESS 2014;1(5):271-274

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OBJECTIVE: To measure the time to gastric emptying of a semi-solid diet in individuals with Chagasic megaesophagus, in comparison with a non-Chagasic control group.
METHOD: The time to gastric emptying of a semi-solid diet was assessed via ultrasonography in 28 patients with Chagasic megaesophagus (grades I, II, and III) and compared to that of a control group (n = 15). After measurement of antral diameter under fasting conditions, 400mL of a semi-solid diet were administered and consecutive measurements were performed every 30 min.
RESULTS: The duration of dysphagia was significantly lower in patients with megaesophagus grade I than in those with grades II or III. The time to gastric emptying was significantly increased in the megaesophagus group compared to the control group. The means of antral areas measured under fasting conditions and after maximal antral distension did not differ between the megaesophagus and control groups.
CONCLUSION: The time to gastric emptying of a semi-solid diet was significantly greater in patients with Chagasic megaesophagus than in controls. The delay did not depend on the extent of dilatation of the megaesophagus or the duration of dysphagia.

Keywords: Gastric emptying; Chagasic megaesophagus; Dysphagia.


12 - Clinical pharmacology of dobutamine and dopamine in preterm neonates

Gian Maria Pacifici

MEDICALEXPRESS 2014;1(5):275-283

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Dobutamine is a β1 selective stimulant. β Receptor agonists are used to stimulate the rate and the force of cardiac contraction. The chronotropic effect is useful for the treatment of arrhythmias whereas the inotropic effect is useful to augment the myocardial contractility. Dobutamine is about four times as potent as dopamine in stimulating myocardial contractility in low concentrations and increases left ventricular output in the hypotensive preterm infants. Dobutamine possesses a center of asymmetry. The (-)-isomer of dobutamine is a potent agonist of α1 receptors and is capable of causing marked pressor responses. In contrast, (+)-dobutamine is a potent α1 receptor antagonist which can block the effects of (-)-dobutamine. Dobutamine is relatively cardioselective at dosages used in clinical practice with its main action being on β1-adrenergic receptors. Dobutamine and dopamine undergo intense metabolism in neonates where they are conjugated with sulphate and O-methylated. The clearance and the half-life of dobutamine and dopamine range over one order of magnitude in neonates. Dopamine is widely used to increase blood pressure, cardiac output, urine output and peripheral perfusion in neonates with shock and cardiac failure. Dopamine is more effective than dobutamine in the short-term treatment of systemic hypotension in preterm infants. High doses of dopamine cause vasoconstriction, increase systemic vascular resistance, and, eventually, decrease renal blood flow. Treatment with dobutamine is associated with a significantly greater increase in left ventricular output in the single study reporting that outcome. Dobutamine is indicated for the short-term treatment of cardiac decompensation.

Keywords: dobutamine; dopamine; hypotension; metabolism; neonate; pharmacokinetics.

13 - Influence of resistance training on cardiac autonomic modulation: literature review

Marianne Penachini da Costa de Rezende Barbosa; Anne Kastelianne França da Silva; Aline Fernanda Barbosa Bernardo; Naiara Maria de Souza; Jayme Neto Junior; Carlos Marcelo Pastre; Luiz Carlos Marques Vanderlei

MEDICALEXPRESS 2014;1(5):284-288

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Among the benefits provided by resistance training, its influence on cardiac autonomic modulation draws attention, given the importance of the autonomic nervous system in the control of the internal functions of the body. The objective of this narrative review was to gather information about the effects of resistance training on autonomic modulation in healthy young adults, assessed through heart rate variability. This search was performed in May 2013 in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO) and Literature and Latin American and Caribbean Health Sciences (LILACS), with articles published between January 2003 and March 2013. The keywords used were: "resistance training," "lifting," "exercise therapy" crossreferenced with "autonomic nervous system" and "parasympathetic nervous system" and also the term "heart rate variability". Of the 1,940 titles found, 3 complete articles were selected to compose the review. Data were analyzed qualitatively. The analysis of these studies suggests that resistance training can change the heart rate variability indices in the population of healthy young adults and that this change is due to increased vagal activity, provided by the practice of this type of training.

Keywords: Resistance training; Exercise therapy; Autonomic nervous system; Parasympathetic nervous system.