Identificação de manifestações de wearing-off (redução do efeito da levodopa) em pacientes com doença de Parkinson utilizando questionário específico e comparação dos resultados com avaliações ambulatoriais de rotina

This study had the objective to verify if the presence of wearing-off phenomenon in patients with Parkinson's disease (PD) could be better identified by the administration of the "Wearing-off Questionnaire Card" (QC). The participant patients were first evaluated by resident doctors in neurology and then invited to answer the QC for detection of motor and nonmotor wearing-off manifestations. Seventy and nine patients were enclosed in the study. The questionnaire revealed that 63 patients (80%) presented wearing-off, whereas the consultation by the resident doctors only identified 33 subjects (41%) with this phenomenon. The motor wearing-off manifestations were more frequent then the nonmotor. We conclude that the administration of the QC in patients with PD may be a useful tool for the diagnosis of wearing-off phenomena.Este estudo teve como objetivo verificar se a presença do fenômeno wearing-off em pacientes com doença de Parkinson pode ser melhor identificada pela aplicação do cartão questionário wearing-off (QC). Os pacientes participantes foram avaliados pelos médicos residentes em neurologia e depois foram convidados a responder as questões do QC para detecção das manifestações motoras e não motoras do wearing-off. O número de pacientes estudados foi de 79. O questionário revelou que 63 pacientes (80%) apresentaram wearing-off, enquanto que a consulta dos residentes identificou apenas 33 indivíduos (41%) com este fenômeno. As manifestações motoras foram mais freqüentes do que as não motoras. Nós concluímos que a aplicação do QC em pacientes com doença de Parkinson pode ser uma ferramenta útil para o diagnostico do fenômeno wearing-off

Efetividade da acupuntura para alívio da dor e ganho funcional em espondilite anquilosante: ensaio clínico controlado e randomizado

Ankylosing Spondylitis (AS) is a chronic disease that leads to musculoskeletal sequelae, functional impairment and pain. In spite of a crescent number of patients seeking acupuncture as an analgesic therapy, only a few studies verified the acupuncture efficacy in controlled trials The objective of this study is to evaluate the effectiveness of acupuncture for spinal pain relief in AS patients. Double-blind randomized placebo-controlled pilot from the Division of Physical Medicine and Rehabilitation, University of Sao Paulo. Ten AS patients suffering from spinal pain were studied to evaluate the effect of ten sessions of classic acupuncture, two times per week, against sham electrical stimulation. Before and after intervention assessment included spinal pain, spinal mobility (Schöber test, Fingers-to-floor distance, Occiput-to-wall distance, and chest expansion), inflammation (BASDAI, acute-phase reactants, number of drugs taken), subjective patient assessment, and function (BASFI).Results: Classic acupuncture was no better than sham electrical stimulation in all outcome measures (p = 0.0625). However, the effect size for pain relief was 2.04 for acupuncture and 1.09 for the sham, both considered comparable with the standard treatments for AS. If evaluated by the Sign test, both acupuncture and sham interventions showed significant results (p = 0.0313). Acupuncture does not seem to be better than sham acupuncture for relieving pain in patients with AS. The relevant response in sham group may provide some evidence of a beneficial, subjective effect as an important component of pain relief in AS patients. The trial is registered under the number ISRCTN02971192 at http://isrctn.orgA espondilite anquilosante (EA) é uma doença inflamatória crônica que acarreta seqüelas osteomusculares, déficit funcional e dor. Apesar do crescente número de pacientes buscando acupuntura como opção terapêutica para analgesia, há poucos trabalhos verificando sua eficácia em ensaios controlados. O objetivo deste estudo é avaliar a eficácia da acupuntura para alívio da dor espinhal em pacientes com EA. Estudo piloto randomizado duplo-cego, placebo-controlado na Divisão de Medicina Física e Reabilitação do Hospital das Clínicas da Universidade de São Paulo. Dez portadores de dor espinhal secundária à EA foram estudados para se verificar o efeito de dez sessões de acupuntura clássica, duas vezes por semana, contra eletroacupuntura placebo. A avaliação da intervenção antes e após incluiu medida da dor espinhal, mobilidade espinhal (teste de Schober, distância dedos-chão, distância occipício-parede e expansibilidade torácica), inflamação (BASDAI, proteínas de fase aguda), avaliação subjetiva do paciente e função (BASFI). Acupuntura clássica não foi melhor que placebo nas medidas de saída. Contudo, o Effect Size para alívio da dor foi 2,04 para acupuntura e 1,09 para placebo, ambos considerados comparáveis aos tratamentos padrão para EA. Pelo teste do Sinal, ambas as intervenções mostraram resultado significante. Acupuntura não é melhor que placebo para o alívio da dor em pacientes com EA. A resposta relevante no grupo placebo fornece evidência do efeito benéfico da relação médico-paciente no alívio da dor em pacientes com EA. O estudo está registrado com o número ISRCTN02971192 em http://isrctn.or

Prognostic values of a combination of intervals between respiratory illness and onset of neurological symptoms and elevated serum IgM titers in Mycoplasma pneumoniae encephalopathy

Background/PurposeTo retrospectively analyze the clinical manifestations of Mycoplasma pneumoniae (M. pneumoniae)-associated encephalopathy in pediatric patients.MethodsPediatric patients with positive serum anti-M. pneumoniae immunoglobulin M (IgM) were enrolled in this study. Clinical signs and symptoms, laboratory data, neuroimaging findings, and electrophysiological data were reviewed.ResultsOf 1000 patients identified, 11 (1.1%; male:female ratio = 7:4) had encephalopathy and were admitted to the pediatric intensive care unit. Clinical presentation included fever, symptoms of respiratory illness, and gastrointestinal upset. Neurological symptoms included altered consciousness, seizures, coma, focal neurological signs, and personality change. Neuroimaging and electroencephalographic findings were non-specific. Specimens of cerebrospinal fluid (CSF) for M. pneumoniae polymerase chain reaction (PCR) were negative. Higher M. pneumoniae IgM titers and longer intervals between respiratory and CNS manifestations were associated with worse outcomes.ConclusionClinical manifestations of M. pneumoniae-associated encephalopathy were variable. Diagnosis of M. pneumoniae encephalopathy should not rely on CSF detection of M. pneumoniae by PCR. M. pneumoniae IgM titers and intervals between respiratory and CNS manifestations might be possibly related to the prognosis of patients with M. pneumoniae-associated encephalopathy

Estimation of energy requirements for mechanically ventilated, critically ill patients using nutritional status

BACKGROUND: There is very little information on what is considered an adequate energy intake for mechanically ventilated, critically ill patients. The purpose of the present study was to determine this energy requirement by making use of patients' nutritional status. METHODS: The study was conducted in a multidisciplinary intensive care unit of Taichung Veterans General Hospital, Taiwan. Patients were hemodynamically stable and not comatose, and were requiring at least 7 days of mechanical ventilation. Fifty-four patients successfully completed this study. The resting energy expenditure was measured using indirect calorimetry. The total energy requirement was considered 120% of the measured energy expenditure. The daily nutrient intake was recorded. Nutritional status was assessed using single and multiple parameters, nitrogen balance, and medical records, and was performed within 24 hours of admission and after 7 days in the intensive care unit. RESULTS: Fifteen patients were being underfed (<90% of total energy requirement), 20 patients were in the appropriate feeding (AF) group (within ± 10% of total energy requirement), and 19 patients received overfeeding (>110% of total energy requirement). Patients in the underfeeding group received only 68.3% of their energy requirement, while the overfeeding group patients received up to 136.5% of their required calories. Only patients in the AF group had a positive nitrogen balance (0.04 ± 5.1) on day 7. AF group patients had a significantly higher Nutritional Risk Index value at day 7 than at day 1. CONCLUSION: AF patients had more improvement in nutritional status than patients in the other feeding groups. To provide at least 120% of the resting energy expenditure seemed adequate to meet the caloric energy needs of hemodynamically stable, mechanically ventilated, critically ill patients

The Volcanic Earthquake Swarm of October 20, 2009 in the Tatun Area of Northern Taiwan

On October 20, 2009, a series of felt earthquakes with local magnitudes ranging from 2.8 - 3.2 occurred in the Tatun volcanic area off the northern tip of Taiwan. Although there was no damage caused by those earthquakes, many residents in the Taipei metropolitan area, particularly for people who live near the Yangminshan National Park, felt strong ground shaking. In order to know what the possible mechanisms were that generated those earthquakes, we carefully examined seismic data recorded by a dense seismic array in the Tatun volcanic area. During the period between October 18 and 22, 2009 we detected at least 202 micro-earthquakes. Most of the earthquakes were relocated using the double-difference method and were clustered in the shallow crust beneath the Dayoukeng area, which is the strongest fumarole in the Tatun volcanic area. Among these earthquakes, 72 focal mechanisms were determined by polarizing the first P-wave motion. Most earthquakes belonged to normal faulting. An extremely high b-value of 2.17 was obtained from those earthquakes. Based on the seismic variations in both the temporary and spatial distribution as well as an extremely high b-value, we conclude that the earthquake sequence on October 20, 2009 was a typically seismic swarm associated with possible active volcanism in the Tatun volcanic area

A importância do tratamento das síndromes dolorosas no traumatismo cranioencefálico

Segundo o modelo do National Center for Medical Rehabilitation Research, a doença crônica (como o traumatismo cranioencefálico) deve ser observada por meio de 5 eixos – a fisiopatologia, a deficiência observável (a hemiparesia), a limitação funcional (incapacidade para tarefa especifica), incapacidade para realização de atividades de vida diária, e limitação social. Levando em conta que tais aspectos sejam interrelacionados, a abordagem interdisciplinar é o método de escolha da prática da Medicina de Reabilitação. O objetivo do presente relato é confirmar a interferência da dor na reabilitação do traumatismo cranioencefálico (TCE), cuja importância muitas vezes é minimizada, apesar de crescentes estudos acerca da etiopatogenia e tratamento da dor no TCE. Foi realizado acompanhamento de uma paciente vítima de TCE na Divisão de Medicina Física do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo em 2002, para quem diversas modalidades analgésicas foram propostas, além da aplicação de questionário funcional e sobre qualidade de vida, com melhora observada em todas as medidas. É necessária análise crítica dos instrumentos de medida de saúde, na medida em que neles se observa alta capacidade para detecção de habilidades motoras e baixa eficiência em detectar melhora da funcionalidade devido aos ganhos nos campos psicoafetivos e sociais, que são diretamente relacionado à experiência dolorosaAccording to National Center for Medical Rehabilitation Research cronic disease model, there are 5 main axes to be on focus during treatment – pathophysiology, impairment, functional limitation, disability and societal limitations. Traumatic brain injury (TBI) is a condition in which patient faces all such problems. Due to great extension of life threaten, interdisciplinary approach is recommended approach. This case report aims to demonstrate the relevance of pain experienced by a TBI survivor and its level of interference during her rehabilitation. She has been treated by Division of Physical Medicine at the Institute of Orthopedics and Traumatology at the University of São Paulo during 2002 who has been submitted to several analgesic procedures. Her follow-up was demonstrated by means of quality of life and functional surveys, with significant improvement of measures. Although recent studies have been focused on pain characteristics in TBI, pain has been neglected among clinical practitioners. Critic analysis is necessary during scales interpretation because a global improvement may be due to psychossocial enhancement which is sometimes directly related to chronic pain

Rehabilitation for traumatic hemipelvectomy

A hemipelvectomia traumática constitui um evento raro, catastrófico, cujos mecanismos de lesão e prognóstico são bem descritos na literatura. O crescente número de acidentes motociclísticos têm elevado a prevalência desta amputação, definindo o grupo de vítimas como jovens do sexo masculino sem comorbidades. Acarreta múltiplas seqüelas físicas, psicológicas e sociais. Através da reabilitação, o paciente poderá recuperar a independência funcional. A protetização é de grande valia, uma vez que os pacientes são jovens e com prognóstico de marcha. Neste relato é apresentado o caso de uma vítima de hemipelvectomia traumática do sexo feminino, que se tornou independente para as atividades da vida diária após processo de reabilitação, que incluiu a prótese, com melhora da qualidade de vida observada sob diversos aspectos. A protetização adequada não devolveu à paciente todas as funções perdidas com a amputação, mas se constituiu em um instrumento capaz de melhorar a qualidade de vida.Traumatic hemipelvectomy is a rare and well described level of amputation. The recent increase in the number of motorcycle traffic accidents has contributed to the growth of the hindquarter amputations. Victims are usually young men without previous diseases. Multiple injuries are expected and lead to physical and psychosocial disabilities, destruction of self-image and loss of independence on activities of daily living (ADL). Early rehabilitation program ables the patient to prevent deformities and to recovering functional abilities. Prosthesis prescription has great value to improve physical conditions. In this report, we present a case of a traumatic hemipelvectomy that happened to a female patient who completely restored independence for ADL and gained quality of life after rehabilitation program. Prosthesis represent a possibility of functional recovery for the amputee although such equipments cannot replace the lost limb during all activities

Efficient Prodrug Activator Gene Therapy by Retroviral Replicating Vectors Prolongs Survival in an Immune-Competent Intracerebral Glioma Model.

Prodrug activator gene therapy mediated by murine leukemia virus (MLV)-based retroviral replicating vectors (RRV) was previously shown to be highly effective in killing glioma cells both in culture and in vivo. To avoid receptor interference and enable dual vector co-infection with MLV-RRV, we have developed another RRV based on gibbon ape leukemia virus (GALV) that also shows robust replicative spread in a wide variety of tumor cells. We evaluated the potential of GALV-based RRV as a cancer therapeutic agent by incorporating yeast cytosine deaminase (CD) and E. coli nitroreductase (NTR) prodrug activator genes into the vector. The expression of CD and NTR genes from GALV-RRV achieved highly efficient delivery of these prodrug activator genes to RG-2 glioma cells, resulting in enhanced cytotoxicity after administering their respective prodrugs 5-fluorocytosine and CB1954 in vitro. In an immune-competent intracerebral RG-2 glioma model, GALV-mediated CD and NTR gene therapy both significantly suppressed tumor growth with CB1954 administration after a single injection of vector supernatant. However, NTR showed greater potency than CD, with control animals receiving GALV-NTR vector alone (i.e., without CB1954 prodrug) showing extensive tumor growth with a median survival time of 17.5 days, while animals receiving GALV-NTR and CB1954 showed significantly prolonged survival with a median survival time of 30 days. In conclusion, GALV-RRV enabled high-efficiency gene transfer and persistent expression of NTR, resulting in efficient cell killing, suppression of tumor growth, and prolonged survival upon CB1954 administration. This validates the use of therapeutic strategies employing this prodrug activator gene to arm GALV-RRV, and opens the door to the possibility of future combination gene therapy with CD-armed MLV-RRV, as the latter vector is currently being evaluated in clinical trials