Medical Express

ISSN (print): 2318-8111

ISSN (online): 2358-0429

Issue: 1(6)2014 - 13 Articles


1 - In the December issue of MEDICALEXPRESS

Mauricio Rocha e Silva

MEDICALEXPRESS 2014;1(6):289-290



2 - Clinical and molecular features of uterine sarcomas

Thais Gomes de Almeida; Isabela Werneck da Cunha; Gustavo A R Maciel; Edmund Chada Baracat; Kátia Candido Carvalho

MEDICALEXPRESS 2014;1(6):291-297

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INTRODUCTION: Uterine sarcomas are rare forms of malignant neoplasm, comprising about 3% of all malignant uterine tumors, representing less than 1% of all gynecologic malignancies. Low cure rates often occur due mainly to distant metastases, usually to the lungs. Aggressiveness, high rates of local recurrence, distant metastasis and poor prognosis with overall two-year survival less than 50% are common features of uterine sarcomas. Despite the low prevalence, these tumors are of great interest because of their multiple morphological and clinical features.
OBJECTIVE: This article will be focused on the uterine sarcomas general aspects, etiology, prognosis, treatment and molecular features.
METHOD: This review was performed using the Pubmed database to search for published articles.
RESULTS: Little is known about the etiology of uterine sarcomas. Some studies have demonstrated the association between genetic events involving mutations in genes of the cell cycle and apoptosis and epigenetic in gynecologic sarcomas. Previous studies showed that chromosomal translocations have been identified, resulting in fusion genes that are constitutive and might involve the activation of transcription factors. Advances in molecular techniques have improved the diagnostic possibilities and allowed an improved understanding of the various pathologies.
CONCLUSIONS: There are several factors that make the study of sarcomas a challenging issue, since those tumors are rare and the cell origin of each histologic type is nor well known Thus, molecular study of the events involved in the development of different types of cancer may lead to new strategies used in the diagnosis and treatment of these tumors.

Keywords: uterine sarcoma; molecular features; prognostic factors.

3 - Functional Balance Assessment: review

Angélica Castilho Alonso; Natália Mariana Luna; Felipe Nunes Dionísio; Danielli Souza Speciali; Luiz Eugênio Garcez Leme; Júlia Maria D'Andréa Greve

MEDICALEXPRESS 2014;1(6):298-301

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The aim of this study was to perform a literature review on different methods of postural balance assessment and to provide a theoretical framework for further study of this subject. Medline, PubMed and LILACS databases were used to find currently employed methods which show good reproducibility and reliability. Clinical examination and scale application or force platform testing, each one with their own advantages and limitations, can be used to assess postural balance. There is no common standard. The evaluator should be familiar with all available methods in order to be able to select the most appropriate for his specific requirements.

Keywords: Postural Balance; Evaluation; Geriatric Assessment.

4 - Motor learning through virtual reality in cerebral palsy - a literature review

Thais Massetti; Talita Dias da Silva; Denise Cardoso Ribeiro; Silvia Regina Pinheiro Malheiros; Alessandro Hervaldo Nicolai Ré; Francis Meire Favero; Carlos Bandeira de Mello Monteiro

MEDICALEXPRESS 2014;1(6):302-306

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Cerebral palsy is a well-recognized neurodevelopmental condition beginning in early childhood and persisting throughout life. It is considered the most common non-progressive neurological disease of childhood. Subjects with cerebral palsy present complex motor skill disorders, the primary deficits being abnormal muscle tone that affects posture and movement, alterations of balance and of motor coordination, decrease in strength and loss of selective motor control, with secondary issues of contracture and bone deformity. This population may have difficulties in motor skill learning processes. Skill learning is learning as a result of repeated exposure and practice. Due to the increasing use of virtual reality in rehabilitation and the significance of motor development learning of subjects with cerebral palsy, we have recognized the need for studies in this area. The purpose of this study was to investigate the results of previous studies on motor learning using virtual reality with patients with cerebral palsy. Initially, 40 studies were found, but 30 articles were excluded, as they did not fulfil the inclusion criteria. The data extracted from the ten eligible studies is summarized. The studies showed benefits from the use of virtual reality in children with cerebral palsy in gross motor function and improvements in motor learning with skill transfer to real-life situations. Therefore, virtual reality seems to be a promising resource and a strategic option for care of these children. However, there are few studies about motor learning with virtual reality use. The long term benefits of virtual reality therapy are still unknown.

Keywords: cerebral palsy; virtual reality and motor learning.

5 - Intestinal transplantation: evolution and current status

Jose Renan Cunha-Melo; Guilherme Costa

MEDICALEXPRESS 2014;1(6):307-322

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Despite early disappointments, the three main types of visceral transplantation (isolated intestine, liver intestine, and multivisceral) have evolved into the standard of care for patients with nutritional failure and complex abdominal pathology. Visceral allografts have been assessed in clinical, radiological, endoscopic, and histopathologic studies. Absorptive functions of engrafted intestine have been assessed by body weight, body mass index, and z scores, serum levels of albumin, vitamins, and trace elements, as well as measurements of bone mineral density. Allograft rejection, infection, and renal failure, are the leading causes of death. Additionally, nonfunctional social support and progression of primary disease contribute to mortality rates beyond the five-and ten-year follow-up landmarks. Remote events, including acute rejection, post-transplant lymphoproliferative disorder, and graft-versus-host-disease were significantly higher in pediatric recipients. Adult recipients experience higher incidences of de novo malignancy, primary disease recurrence, and impaired skeletal health. The leading causes of death are graft failure, complications of therapy, post-transplant lymphoproliferative disorder, progression of primary disease, and others, such as substance abuse, suicide and lack of support. Health status was sustained with successful interventions to treat hypertension, diabetes, osteoporosis, and renal failure. In spite of disease recurrence and long-term immunosuppression-related morbidities, the health status of most survivors has been sustained with successful interventions to treat occurring co-morbidities. With continual improvement in early survival and long-term rehabilitative efficacy, visceral transplantation should be considered a better therapeutic option for patients with severe intestinal failure.

Keywords: Intestinal transplantation; Gastrointestinal rehabilitation; Multivisceral transplantation.

6 - Treatment of infantile hemangioma with propranolol

Gian Maria Pacifici

MEDICALEXPRESS 2014;1(6):323-327

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Infantile hemangiomas are proliferative vascular disorders that occur in the pediatric airway, potentially causing airway narrowing and respiratory stress. It appears in 1 out 10 children, more frequently in girls. Hemangiomas are benign tumours that usually appear on the head or neck but may also occur in deep organs. Until recently, the most common medical therapy used was high-dose systemic corticosteroids, which often resulted in significant adverse effects (hypertension, irritability, and Cushing-like conditions). In 2008, propranolol, which was used for treating cardiovascular diseases, was accidentally found to be successful in the treatment of intractable diffuse lymphangiomatosis. Propranolol apparently causes down-regulation of the Raf mutagen-activated protein kinase-signalling pathway, with reduced expression of vascular endothelial growth factor. Propranolol inhibits lymphangiogenesis and reduces lymphatic malformation growth by inhibition of vascular endothelial growth factor. It could have a beneficial effect on lymphatic malformation and in diffuse lymphangiomatosis, and may exert its effects on growing hemangiomas by three different molecular mechanisms: vasodilation, inhibition of angiogenesis and induction of apoptosis. This is a review of the pharmacology of propranolol as it relates to the treatment of hemangiomas.

Keywords: hemangiomas; infants; propranolol.


7 - Effects of massage and compression treatment on performance in three consecutive days

Eiuke Hiruma; Masakazu Umimura; Hisashi Naito; Shizuo Katamoto

MEDICALEXPRESS 2014;1(6):328-335

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OBJECTIVE: To determine the effects of massage treatment plus 24 hours of elastic calf compression on delayed onset of muscle soreness following maximum calf-raise exercises during three consecutive days.
METHODS: Fourteen female students (aged 20-22 yr) who had regularly performed moderate exercise were submitted to maximum calf-raise exercises of 1 movement per 3 seconds till exhaustion. Seven subjects(T-group) received effleurage massage on both calf muscles immediately after the exercise plus 24 hours of elastic calf compression. The other subjects (C-group) received no treatment. We examined creatine-kinase, maximum calf muscle circumference, maximum voluntary isometric muscle contraction, perceived pain, maximum angle of dorsiflexion and one-leg long jumping before and immediately after treatment (T-group) or exercise (C-group) for 3 days of exercise plus 7 days of recovery. Subjects carried a step counter to count the number steps walked each day.
RESULTS: The number of calf-raise repetitions in both groups significantly decreased on days 2 and 3. Creatine kinase increased significantly in the T-group from day two of the exercise period to day five of the recovery period, and was tendentially higher than in the C-group. Maximum calf muscle circumference in T-group was higher post-treatment versus pre-exercise, and significantly higher in the C-group. Perceived pain was significantly lower and one-leg long jumping significantly better (by 5 -10%) in T-group versus C-group.
CONCLUSION: Massage plus elastic calf compression minimizes the change of maximum calf muscle circumference, perceived pain, and one-leg long jumping after maximum calf-raise exercise. Perceived pain correlates with performance.

Keywords: creatine kinase; isometric force; muscle soreness.

8 - Cognitive behavioral therapy treatment for smoking alcoholics in outpatients

Flávia Melo Campos Leite Guimarães; Antonio Egidio Nardi; Adriana Cardoso; Alexandre Martins Valença; Eduardo Guedes da Conceição; Anna Lucia Spear King

MEDICALEXPRESS 2014;1(6):336-340

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OBJECTIVE: Cognitive Behavioral Therapy is a therapy based on cognitive and behavioral techniques: cognitive psychological education, cognitive restructuring, interoceptive exposure, breathing exercises and relaxation, all aiming at behavioral changes. The objective of the study was to determine the effectiveness of a specific model of Cognitive Behavioral Therapy for alcoholic outpatients in the treatment of smoking.
METHOD: Sessions were carried out in two stages: (1) a "stop smoking" stage lasting four weeks, with 3 sessions/ week; (2) a maintenance stage beginning with 2 weeks of a single weekly session, followed by monthly sessions until the end of the one-year treatment.
RESULTS: Forty patients participated in this study, 22 men and 18 women. After a year of treatment, 24 patients had stopped smoking, whereas 16 relapsed during the course of the year; two abandoned treatment. Women showed better results: 77.8% stopped smoking by the end of the treatment, but only 45.4% of the men reached this goal.
CONCLUSION: Patients under treatment for alcoholism submitted to the tobacco treatment program; a majority of them achieved the treatment goal. A growing population of alcoholics and smokers are looking for treatment; this points to the need for a follow-up treatment program for smoking in an Alcoholism Treatment Unit. Cognitive Behavioral Therapy proved to be effective in the treatment of tobacco dependency mainly in women.

Keywords: Addiction; comorbidity; anxiety; withdrawal.

9 - Surgical myocardial revascularization versus stents

Jose Carlos Rossini Iglezias; Alex Chi; Luis Alberto Oliveira Dallan; Luis Felipe Pinho Moreira; Fabio Biscegli Jatene

MEDICALEXPRESS 2014;1(6):341-345

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OBJECTIVES: To compare coronary artery bypass to stenting in our institution, and to compare the studied samples for major adverse cardiac and cerebrovascular outcomes.
METHOD: An observational cohort study. We analyzed 202 patients undergoing coronary artery surgical revascularization versus stenting in our institution between January 17 and July 31, 2009; patients were stratified into: Group G1-STENT, patients who received stents; and Group G2-CABG, patients submitted to coronary artery by-pass grafting. A script containing 62 clinical, hemodynamic and surgical items was used for data collection from medical records.
RESULTS: Women made up a higher percentage of G1-STENT 44% versus 26% in G2-CABG. Diabetics predominated in G2-CABG, 46% versus 29% in G1-STENT. Three or more coronary branches showed a higher percentage in G2-CABG, 55% vs, 9.0%; in G1-STENT, 64% had only one coronary branch involvement. Non-elective procedures were higher for G1-STENT (21% vs. 9%). Worse postoperative renal function occurred in G2-CABG (15% vs. 2%). G1-STENT patients had shorter hospital time. Recurrence of angina was higher in patients in G1-STENT (11% vs. 2%) with no significant difference in hospital mortality. Postoperative quality of life increased from 45% to 55% in G2-CABG.
CONCLUSIONS: Surgical revascularization is the best procedure for patients with multi vessel coronary disease, especially in diabetic patients: it allows a significantly more complete revascularization, reduces the number of readmissions due to cardiac causes, reduces the recurrence of angina and improves quality of life after surgery, with hospital and late mortality rates similar to those obtained through stenting.

Keywords: Coronary Artery Bypass; Coronary Artery Bypass, Off-Pump; Myocardial Revascularization; Stents.

10 - Reversal of the profitability rates of health plans according to age

Vagner Raso; Flávio Alberto Oliva

MEDICALEXPRESS 2014;1(6):346-350

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OBJECTIVE: In this study, we will analyze assistance costs and profitability rates of a private health insurance company.
METHODS: A private health insurance company of an inland city of São Paulo was analyzed. Assistance costs and profitability rates were analyzed in a time interval of seven years according to age and gender. The assistance cost (sum of medical appointments, exams, surgical intervention) was calculated by the absorption counting method, which consists of the analysis of direct and indirect, fixed and variable costs caused by the use of medical and hospital resources. The profitability rate was calculated based on the difference between the premium (monthly fee and co-insurance [20%]) and the cost assistance.
RESULTS: Although the number of users decreases as age increases, costs increase disproportionally. The growth of unitary premiums from the age group of 50 to 59 years contrasts with the unitary results. There is a surplus until the age of 59 years and subsequent deficit from this age on. This deficit progresses according to the age group. In this case, while the first age groups present a balanced unitary profit, there is a growing progression of the unitary cost that causes costs to increase above the premium, especially in individuals over 60 years of age.
CONCLUSION: Our results consistently support the hypothesis of inversion of profitability rates according to age, regardless of the decrease of the number of individuals at the age group of 60 years.

Keywords: Aging; costs; health insurance; profitability.

11 - Responses of the geometric indices of heart rate variability to the active orthostatic test in women

Luiz Carlos de Abreu; Adriano L. Roque; Bianca C.R. de Castro; Ana C. Amorim de Souza; Luiz Carlos M. Vanderlei; Lucas L. Ferreira; Rodrigo D. Raimundo; Fernando L.A. Fonseca; Vitor E. Valenti; José R. Cisternas

MEDICALEXPRESS 2014;1(6):351-355

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OBJECTIVES: The effects of the orthostatic test on the cardiovascular system have been investigated, but there are no data on the behavior of the geometric indices of heart rate variability. We evaluated the effects of the active orthostatic test on the geometric indices of heart rate variability in women.
METHOD: The study was performed on 12 healthy women between ages 18 and 30. For the analysis of heart rate variability, heart rate was recorded beat-to-beat. The RR intervals were transformed into geometric figures, and from these we calculated the triangular index, the triangular interpolation of RR intervals, the SD1, SD2 indexes and the SD1/SD2 ratio, which were obtained from the Poincaré plot. Visual analysis of the plot was also performed. For the test, participants quickly stood up from a seated position in 3 seconds or less, and remained standing still for 15 minutes. Heart rate variability samples were collected at four moments: rest, 0-5 minutes, 5-10 minutes and 10-15 minutes at standing position.
RESULTS: The triangular index, the triangular interpolation of RR intervals, the SD1 and SD2 indices were reduced (p < 0.05) at 10-15 minutes after the volunteers stood up from seated position. The SD1/SD2 ratio was decreased at 0-15 minutes after the subjects changed from seated to orthostatic position.
CONCLUSION: The geometric indices of heart rate variability decreased in response to the active orthostatic test in healthy women.

Keywords: Autonomic Nervous System; Cardiovascular System; Nonlinear Dynamics; Physiology.

12 - Case-control study for clinical findings on intraocular lens opacity

Priscilla de Almeida Jorge; Delano Jorge; Camila Vieira Ventura; Bruna Vieira Ventura; Wagner Lira; Marcelo Carvalho Ventura; Marcony R. Santhiago; Newton Kara-Junior

MEDICALEXPRESS 2014;1(6):356-358

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OBJECTIVE: To evaluate clinical features of patients related to opacification of hydrophilic acrylic intraocular lenses, four years after surgery.
METHODS: We evaluated six cases of late opacification of Ioflex intraocular lenses (case group) compared to 24 patients (control group) with no opacification. Both groups underwent phacoemulsification as a result of a community campaign for underprivileged people. Patients who underwent bilateral cataract surgery had only the right eye included on the study. The patients were submitted to ophthalmic examination, including measurements of corrected distance visual acuity and biomicroscopy slitlamp evaluation. Detailed medical histories were obtained. Surgical details were retrieved.
RESULTS: Systemic arterial hypertension was recorded in 4 patients from the case group and 11 in the control group, with no statistically significant difference between groups. A single patient in the control group had diabetes mellitus, and so was not considered for statistical analysis. No environmental factor could be related. There were no statistically significant differences for mean visual acuity between the groups of patients regarding the evaluation periods. One eye in the control group received an Ioflex intraocular lens with the same lot number as one of the opacified lenses.
CONCLUSION: No clear patient factor could be related to late Ioflex lens opacification.

Keywords: Cataract; intraocular lens; postoperative complications.

13 - Pulse pressure variation patterns in a swine model of hypovolemia under spontaneous breathing vs. invasive positive-pressure ventilation

Mauricio Macário Rocha; José Marconi Almeida de Souza; Angelo Amato Vincenzo de Paola; Antônio Carlos Camargo Carvalho; Adriano Henrique Pereira Barbosa; Guilherme Drummond Fenelon Costa

MEDICALEXPRESS 2014;1(6):359-365

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OBJECTIVE: This study was performed to obtain the title of Master in Medicine, Nov/2012-Jul/2013. Improvement in cardiac output after fluid administration is known as fluid responsiveness. A reliable parameter for its evaluation is pulse pressure variation: it has established its utility in predicting volume responsiveness in mechanically ventilated patients.
METHOD: Pulse pressure variation was analyzed in 10 anesthetized male pigs at four different stages: I) normovolemia and spontaneous breathing; II) hypovolemia and spontaneous breathing; III) hypovolemia under mechanical ventilation; and IV) after volume replacement, under mechanical ventilation. Cardiac output, pulmonary artery occlusion pressure, systolic pressure variation, mean arterial pressure, and heart rate were measured at all stages; red blood cell count was determined at stages I, II, and IV.
RESULTS: Mean pulse pressure variation values during hypovolemia with spontaneous breathing (stage II) were significantly higher than at any other stage. After institution of mechanical ventilation, pulse pressure variation values returned to baseline without fluid administration. The lowest values were achieved after volume replacement.
CONCLUSION: Pulse pressure variation values are higher during spontaneous breathing than during mechanical ventilation. Thus, it may be useful for assessment of fluid volume under these conditions, with baseline values as a starting point to which serial measurements should be compared after institution of specific therapy.

Keywords: pulse pressure variation; hypovolemia; swine model; spontaneous breathing.