Crises não epilépticas psicogênicas : delineamento e validação de um instrumento diagnóstico breve

Orientador: Prof. Dr. Hélio Afonso Ghizoni TeiveTese (doutorado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Medicina Interna. Defesa : Curitiba, 03/08/2017Inclui referências : f. 83-90Resumo: JUSTIFICATIVA: crises não epilépticas psicogênicas (CNEPs) são comuns. Contudo, há frequente dificuldade diagnóstica e para condução dos casos. Crises epilépticas (CEs) constituem uma emergência médica e sua abordagem imediata e correta é essencial, particularmente em ambiente de pronto atendimento. Várias situações clínicas podem mimetizar CEs, conduzindo a erros e prescrições inadequadas de fármacos antiepilépticos (FAEs), tanto emergencialmente, quanto em ambiente ambulatorial. CNEPs equivocadamente interpretadas como CEs levam a incrementos em morbidade e custo. Emergencistas, enfermeiros, estudantes de Medicina do último ano, médicos residentes e plantonistas em geral são os primeiros a abordar estes casos e sua impressão inicial é extremamente importante na condução dos mesmos. Nosso estudo aborda a fenomenologia das CNEPs, determina a acurácia diagnóstica para esta condição entre os profissionais citados, propõe e valida um instrumento diagnóstico breve, com base semiológica. MÉTODOS: Este estudo foi concebido em duas partes. Na primeira na fase foram avaliadas CNEPs e CEs para identificação de sinais semiológicos que possibilitassem a discriminação entre estes dois tipos de crises. Estes achados foram comparados com os dados descritos na literatura e foram então separados 6 sinais para compor um instrumento clínico, visando a diferenciação de CNEPs e CEs. Na segunda parte deste estudo, quatro grupos de profissionais (53 enfermeiros, 34 médicos emergencistas, 33 estudantes do último ano de Medicina e 12 residentes de Neurologia) participaram de um curto programa de treinamento, consistindo em uma determinação de acurácia diagnóstica inicial (pré-teste), uma sessão de instrução de 30 minutos, incluindo o instrumento diagnóstico breve e finalmente uma nova determinação de acurácia póstreinamento (pós-teste). As curvas de aprendizagem foram estudadas. RESULTADOS: foram identificados 27 sinais observados nas CNEPs e CEs dos pacientes analisados, todos previamente descritos na literatura. Destes foram separados 6 sinais para compor um instrumento para aplicação clínica. Estes sinais tinham como características o fácil e imediato reconhecimento, dispensando a necessidade de dados da história clínica, testemunhos de circunstantes ou dados sobre a duração da crise. As diferentes categorias de profissionais não mostraram diferenças significativas em sua acurácia diagnóstica para CNEPs ou CEs, ao longo das fases de pré e pós-testes. Entretanto, todos os grupos se beneficiaram significativamente do programa de treinamento apresentado. CONCLUSÕES: os resultados obtidos permitiram identificar sinais clínicos com potencial discriminatório entre CNEPs e CEs e produziram validação para um novo instrumento diagnóstico breve, com fundamentação exclusivamente semiológica. Adicionalmente, nossos resultados demonstram que medidas educativas podem contribuir na identificação de CNEPs por equipes em plantões de emergências médicas, o que poderia melhorar o atendimento primário e reduzir custos e a morbi-letalidade nestes pacientes. PALAVRAS-CHAVE: crises não epilépticas psicogênicas, epilepsia, semiologiaAbstract: RATIONALE: Psychogenic nonepileptic seizures (PNES) are common, often misdiagnosed and poorly approached regarding to treatment. Epileptic seizures (ES) are often seen as a medical emergency and their immediate and accurate recognition is pivotal in providing acute care. A number of clinical situations may mimic ES, potentially leading to misdiagnosis at the emergency room and to inadequate prescription of antiepileptic drugs (AED) in the acute and chronic settings. PNES play a major role in this scenario, leading to delay in the correct diagnosis and consequent increase in treatment morbidity and cost. Emergency physicians, nurse clinicians, senior medical students, medical residents and oncall personnel often conduct the initial assessment of these patients and their impression may be decisive in the prehospital approach to seizures. In our study we evaluate PNES phenomenology and sought to investigate the accuracy of PNES diagnosis among these professionals involved in the initial assistance to patients with ES and PNES. We also proposed and validated a brief diagnostic tool for discrimination between PNES and ES. METHODS: this study was designed with two components to be carried out together. First, we evaluated PNES and ES seeking to identify potential discriminators between these seizures. These findings were compared with the literature and we developed a 6-item diagnostic tool aiming to distinguish PNES from ES. On phase two, 53 registered nurses, 34 emergency physicians, 33 senior year medical students, and 12 neurology residents took a short training program consisting of an initial video-based seizure assessment test (pretest), a 30-minute presentation including the 6-item diagnostic tool and then a videobased reassessment (posttest). Baseline and learning curves were determined. RESULTS: We identified 27 signs listed as potential discriminators between PNES and ES, all previously described in the literature. We then set up a brief diagnostic tool including 6 of these signs. Selection was based on easy and immediate recognition of each sign, not requiring information coming from clinical history, witnesses reports or seizure duration. The distinct professional categories showed no significant differences in their ability to diagnose PNES and ES on both pre and posttests. All groups improved diagnostic skills after the instructional program. CONCLUSIONS: Results aided to determine the best identifiable PNES clinical signs and to provide initial validation to a novel diagnostic instrument. In addition, our results showed that educative measures might help in the identification of PNES by first responders, which may decrease the treatment gap. KEY-WORDS: psychogenic nonepileptic seizures, epilepsy, semiolog

Epilepsia clinicamente refrataria do lobo temporal associada a esclerose mesial temporal : analise dos 20 primeiros casos conduzidos a tratamento cirurgico no Hospital de Clinicas da Univesidade Federal do Parana

Orientador: Lineu Cesar WerneckDissertação (mestrado) - Universidade Federal do Parana, Setor de Ciencias da SaudeResumo: A epilepsia do lobo temporal associada à esclerose mesial temporal (EMT) é atualmente reconhecida como uma síndrome distinta. Apesar de possivelmente traduzir uma das formas mais comuns de epilepsia humana, muitos de seus aspectos permanecem algo obscuros. A incidência, prevalência e mesmo a etiologia da esclerose mesial temporal não são perfeitamente esclarecidas. Por outro lado, tanto a sua apresentação clínica quanto a caracterização via exames complementares são relativamente estereotipadas. O presente estudo teve por objetivos definir o perfil de uma população de pacientes portadores de EMT, atendidos no Hospital de Clínicas da UFPR, bem como avaliar os procedimentos realizados durante a fase de investigação pré-operatória não-invasiva e analisar o seguimento pós-operatório destes pacientes, com ênfase no controle de suas crises epilépticas. Foram estudados os primeiros 20 pacientes consecutivos com estas características, avaliados no Programa de Cirurgia de Epilepsia do Hospital de Clínicas da UFPR, e levantados dados pertinentes à história clínica e exames complementares prévios à admissão no protocolo cirúrgico. Todos os pacientes foram submetidos a monitorização contínua com vídeo-eletrencefalografia, estudos de neuroimagem (ressonância nuclear magnética), avaliação neuropsicológica e teste do amital sódico intracarotídeo (teste de Wada). Todos foram submetidos a lobectomias temporais anteriores, sendo seguidos por uma média de 19.7 meses após a cirurgia. O estudo concluiu que este grupo é composto por pacientes jovens, cujas crises epilépticas (em sua maioria parciais complexas) iniciam-se precocemente na vida e têm um comportamento tipicamente refratário ao tratamento clínico. São pacientes que convivem longos períodos de tempo com sua desordem epiléptica, até o momento em que são referidos a um centro especializado, o que concorre com elevadas taxas de desemprego. O protocolo de avaliação cirúrgica determinou de forma consistente a localização da zona epileptogênica em todos os casos avaliados. Após a cirurgia de epilepsia, a maior parte dos pacientes encontra-se livre de crises e, nos casos cursando com recidivas, a frequência de crises no pós-operatório nunca foi superior àquela verificada previamente à cirurgia. A maior parte dos pacientes mostra-se extremamente satisfeita com o grau de controle de crises obtidos após a cirurgia.Abstract: Temporal lobe epilepsy associated with mesial temporal sclerosis (MTLE) is now generally recognized as a distinct syndrome. It is likely to be the most common form of human epilepsy and yet, it carries many unsolved issues. The incidence and prevalence of MTLE, as well as, the very etiology of mesial temporal sclerosis are largely unknown. On the other hand, both the clinical and laboratorial presentations of this syndrome, on its classic form, are rather stereotyped and easily recognized. The present study aims to define the main features of a MTLE population evaluated at the Clinical Hospital (Federal University of Paraná). It also analyses the various procedures performed during the non-invasive diagnostic phase of the surgical protocol and the post-surgical follow-up of these patients, focusing on their seizure control. The first 20 consecutive patients meeting such criteria were evaluted at the Epilepsy Program, at the Clinical Hospital. The medical records were reviewed and data pertaining to the epilepsy history, as well as, the results on all diagnostic procedures performed on these patients prior to their inclusion on the Epilepsy Program were collected. All patients were subjected to long-term video-eeg monitoring, neuroimaging studies (magnetic ressonance imaging), neuropsychological evaluation and intracarotid sodium amytal test (Wada test). All patients underwent surgery (anterior temporal lobectomies) with a mean post-surgical follow-up of 19.7 months. The study conclusions are the following: the MTLE patients are generally young, with seizures (mostly complex partial seizures) starting early in life. The seizures are typically refractory to clinical treatment. These patients tend to endure long periods of time with their seizure disorder before being referred to a tertiary epilepsy center for surgical evaluation. This aspect, by itself, plays a major role explaining the high unemployment rates found on this population. The surgical protocol consistently localized the epileptogenic zone in all patients. The vast majority of the patients remained seizure-free after surgery. On the esporadic cases of seizure recorrence, the frequency of the episodes has never reached the figures verified previous to the surgery. Almost all patients refer to their current level of seizure control, as extremely satisfactory

Influence of pre-fermentative addition of aqueous solution tannins extracted from oak wood (Quercus petraea) on the composition of Grillo wines

In this research, the chemical characterization of fxed and volatile compounds of two diferent tannins in aqueous solution (Pratiko® L-Harvest and L-Fruit) extracted from oak wood, has been studied. The infuence of the above tannins, at diferent concentrations, on the alcoholic fermentation kinetics and on the composition and sensorial characteristics of a white wine were then evaluated. The wines added tannins in aqueous solution compared to control wines showed signifcant diferences in fxed compounds (colloids, polyphenols and ellagitannins) and volatile compounds (phenolic aldehydes, volatile phenols, furanic and piranic compounds). The diferences of aqueous solution tannins extracted from oak wood were partly due to the drying/maturing and roasting methods used in barrel production. Alcoholic fermentation was partially facilitated by the addition of tannins in aqueous solution. The wines obtained showed a higher content of ethyl esters of medium-chain fatty acids (from 22 to 31%) and, in some cases, higher acetate alcohols (from 15 to 28%), relevant to the olfactory sensations provided to the wines. The tannins added to the must before fermentation also made it possible to obtain an additional supply of polyphenols (from 25 to 85%) able to induce more complex sensory profles in the wines, with increased persistent taste notes

Reciprocal Translocations in Cattle: frequency estimation

Chromosomal anomalies, like Robertsonian and reciprocal translocations represent a big problem in cattle breeding as their presence induces, in the carrier subjects, a well documented fertility reduction. In cattle reciprocal translocations (RCPs, a chromosome abnormality caused by an exchange of material between nonhomologous chromosomes) are considered rare as to date only 19 reciprocal translocations have been described. In cattle it is common knowledge that the Robertsonian translocations represent the most common cytogenetic anomalies, and this is probably due to the existence of the endemic 1;29 Robertsonian translocation. However, these considerations are based on data obtained using techniques that are unable to identify all reciprocal translocations and thus their frequency is clearly underestimated. The purpose of this work is to provide a first realistic estimate of the impact of RCPs in the cattle population studied, trying to eliminate the factors which have caused an underestimation of their frequency so far. We performed this work using a mathematical as well as a simulation approach and, as biological data, we considered the cytogenetic results obtained in the last 15 years. The results obtained show that only 16% of reciprocal translocations can be detected using simple Giemsa techniques and consequently they could be present in no less than 0,14% of cattle subjects, a frequency five times higher than that shown by de novo Robertsonian translocations. This data is useful to open a debate about the need to introduce a more efficient method to identify RCP in cattle

Device migration after endoluminal abdominal aortic aneurysm repair: Analysis of 113 cases with a minimum follow-up period of 2 years

AbstractPurpose: Device migration (DM) has been shown to cause late failure after endoluminal abdominal aortic aneurysm (AAA) repair. To establish the incidence rate and the predictive factors of distal migration of the proximal portion of the endograft, computed tomographic (CT) scans performed at different time intervals during follow-up examination of 113 patients were reviewed. Patients and Methods: Between April 1997 and March 1999, 148 patients underwent endoluminal AAA repair with a modular endograft with infrarenal fixation (Medtronic-AVE AneuRx, Santa Rosa, Calif) at our unit. CT scans performed at 1, 6, and 12 months after surgery and yearly thereafter were prospectively stored in a computer imaging database. Patient demographics, risk factors, operative details, and follow-up events were prospectively collected. No patients were lost to follow-up examination. Twelve patients died within 2 years of surgery, four patients underwent immediate conversion to open repair, and adequate CT measurements were not feasible in 19 cases, which left 113 patients available for a minimum 2-year assessment and 418 CT scan results reviewed. Two vascular surgeons, blinded to patient identity and history with tested interobserver agreement (κ = 0.64), separately reviewed axial reconstructions of CT scans. DM was defined as changes of 10 mm or more in the distance between the lower renal artery and the first visible portion of the endograft at follow-up examination. Ten possible independent predictors of DM were analyzed with multivariate Cox proportional hazards regression model. Results: One AAA rupture, which was successfully treated, occurred at a mean follow-up period of 28 months (range, 24 to 46 months). Seventeen patients (15%) showed DM. Eight patients (47%) with DM underwent reintervention: a proximal cuff was positioned in six patients and late conversion to open repair was performed in two patients. Of the 10 variables analyzed with Cox proportional hazards regression model, AAA neck enlargement of more than 10% after endoluminal repair (hazard ratio, 7.3; confidence interval, 1.8 to 29.2; P =.004) and preoperative AAA diameter of 55 mm or more (hazard ratio, 4.5; confidence interval, 1.2 to 16.7; P =.02) were positive independent predictors of DM. The probability of DM at 36 months was 27% according to life table analysis. Conclusion: DM occurred in a significant portion of our patients, yet aggressive follow-up examination and a high reintervention rate prevented aneurysm-related death. According to our data, dilatation of the infrarenal aortic neck is an important factor that contributes to the distal migration of stent grafts, and patients with large aneurysms are at high risk for DM. (J Vasc Surg 2002;35:229-35.

Assessing the Impact of Water Salinization Stress on Biomass Yield of Cardoon Bio-Energetic Crops through Remote Sensing Techniques

Various species of cultivated thistle, such as Cynara cardunculus L. (cardoon), exhibit interesting features for industrial biomass production as bioenergy crops, given also their advantageous adaptation capacities to typical Mediterranean climate trends, with noticeable resilience to drought and salinization stresses. The in situ hyperspectral reflectance responses of three genotypes of cardoon plants, irrigated with water at different salinity levels, have been tested for assessing the effects on their biophysical parameters, aiming at improving the biomass yield for bioenergy production, minimizing at same time the environmental impacts and the exploitation of soils and waters resources. The leaf and canopy reflectance hyperspectral signatures, acquired at three different growth stages with biometric measurements, were statistically analyzed (ANOVA, Tukey's test, graphs), as noise-resilient spectral indices, sensible to different plant features of interest. Their broadband versions, based on the Landsat 8 OLI and Sentinel 2 MSI satellite sensors, were also evaluated in perspective of operative and extensive remote crop monitoring from space. The results highlighted significant differences in some spectral index responses, related to different cardoon genotypes and water salt concentration. The biometric data supported by red-edge indices modelling evidenced the impact of the highest salt water concentration (200 mM/L) on the plant growth and yield

Museums Virtual Tour: a teaching proposal with research for 5th grade students in a pandemic scenario

This didatic proposal aims to contribute to the scientific literacy of 5th grade students of Elementary School. This is a proposal developed in a pandemic context, using as a pedagogical resource the Virtual Biomes Exhibition, which was presented in Rio de Janeiro in 2012. The methodology is based on the principles of classroom research, through an interdisciplinary and transdisciplinary project, which uses Science and Mathematics Modeling as research and teaching method. The proposal for virtual tour presents a pedagogical alternative in the pandemic context, since it becomes possible to transport knowledge to the digital environment with technological resources, providing access to the collections of several museums worldwide. As an additional contribution, it is intended to contribute to the formation of ethical and critical individuals, who are aware of their rights and duties as citizens.La presente propuesta de enseñanza propone contribuir a la alfabetización científica de los estudiantes de quinto grado de la Escuela Primaria. Se trata de una propuesta elaborada en un contexto de pandemia, utilizando como recurso pedagógico la exposición virtual Biomas, presentada en Río de Janeiro en 2012. Metodológicamente, se fundamenta en los principios de la investigación en el aula, a través de un proyecto interdisciplinario y transdisciplinario, utilizando Modelación en Ciencias y Matemática como método de investigación y enseñanza. Se señala que una propuesta de visitas virtuales en museos se presenta como una alternativa pedagógica en un contexto de una pandemia, ya que, a través de la tecnologia, se transporta el conocimiento presencial al digital, y, de esta forma, se superan barreras, proporcionando acceso a las colecciones de varios museos del mundo. Además, se busca contribuir a la formación de personas éticas, críticas, conocedoras de sus derechos y deberes como ciudadanos.A presente proposta didática, objetiva contribuir para a alfabetização científica dos estudantes do 5º ano dos anos iniciais do Ensino Fundamental. Trata-se de uma proposta elaborada em um contexto pandêmico, utilizando como recurso pedagógico a Mostra virtual Biomas, que foi apresentada no Rio de Janeiro em 2012. Metodologicamente, fundamenta-se nos princípios da pesquisa em sala de aula, por meio de um projeto interdisciplinar e transdisciplinar, utilizando a Modelagem em Ciências e Matemática como método de pesquisa e de ensino. Aponta-se que uma proposta de visitas virtuais em museus se apresenta como uma alternativa pedagógica, em um contexto atravessado por uma pandemia, pois por meio da tecnologia, o conhecimento presencial se transporta ao conhecimento digital, e dessa forma, extrapolam barreiras, fornecendo acesso aos acervos de diversos museus mundiais. Além disso, busca-se contribuir para a formação de indivíduos éticos, críticos e conhecedores dos seus direitos e deveres como cidadão. &nbsp

02/28/1984 - Cager Could Come Up With Upset

We propose the realization of a compact fully-passive biotelemetry tag composed of a high-electron mobility transistor (HEMT) connected to a wireless link. The Gallium Arsenide based gateless HEMT serves both as the environmental sensing element and as the amplitude modulator of the carrier signal received by the antenna. A prototype demonstrator operating in the MHz range has been developed: it consists of an array of transistors with different gate geometries and two spiral loop resonators implementing the wireless link. More specifically, one resonator (Tag-resonator) is connected to the array of transistors, while the other one (Reader-resonator) is connected to a power generator/reader device; the wireless link uses the magnetic coupling between the two resonators. Experimental results demonstrate that the reader-resonator exhibits an intensity modulation of the resonance dip depending on the voltage applied to the HEMT gate. These results will be used as a guideline for the realization of biocompatible sub-millimeter tags operating in the Gigahertz frequency range

The Molecular and Cellular Basis of Tumor Rejection After Vaccination With Mammary Adenocarcinoma Cells Transduced With the MHC Class II Transactivator CIITA

CD8+ T cell responses are major players of tumor eradication in various vaccination protocols. However, an optimal stimulation of CD4+ T helper cells is required for both priming and maintenance of the effector CTL response against the tumor. In this study we show that the murine mammary adenocarcinoma cell line TS/A, a highly malignant MHC-II-negative tumor, is rejected in vivo if genetically engineered to express MHC-II molecules by transfer of the MHC-II transactivator CIITA. TS/ACIITA cells are fully rejected by 93% of the syngeneic recipients and have a significantly lower growth rate in the remaining 7% of animals. Rejection requires CD4+ and CD8+ cells. CD4+ T cells are fundamental in the priming phase, whereas CTLs are the major anti-tumor effectors. All tumor rejecting animals are protected against rechallenge with the parental TS/A tumor. Immunohistochemical data at day 5 post-inoculation showed an higher infiltrate of CD4+ T cells in mice bearing TS/A-CIITA, than in mice bearing the TS/A tumor. Subsequently, from day 7 trough day 10, TS/A-CIITA tumors showed higher number of both CD4+ and CD8+ cells, dendritic cells, together with massive necrosis. The frequency of IFN-αsecreting splenocytes early after inoculations was also assessed by an ex vivo ELISPOT assay. Only the rejecting TS/A-CIITA animals showed an high frequency of IFN-αsecreting cells (between 80 and 120/106 splenocytes). Importantly, CD4 and CD8 depletion experiments revealed that at the time of tumor resolution the major cell population recognizing the TS/A-CIITA cells was of CD4 origin. This is the first example of successful tumor vaccination by genetic transfer of CIITA. These results open the way to a possible use of CIITA for increasing both the inducing and the effector phase of the anti-tumor response. from 2005 International Meeting of The Institute of Human Virology Baltimore, USA, 29 August – 2 September 200

Fatores preditivos de não-adesão à terapia antiretroviral

Cross-sectional study analyzed as case-control to identify risk factors for non-adherence to antiretroviral therapy. We studied 412 out-clinics HIV infected subjects of three public hospitals of Recife, Pernambuco. The objective was to examine the association between non-adherence to the antiretroviral therapy and biological, social-behavior and demographics and economic factors, factors related to the disease and/or treatment, factors related to life habits and depression symptoms. Variables significantly associated with non-adherence to antiretroviral therapy were: time elapsed since HIV diagnosis (p = 0.002), daily dose (p = 0.046), use of alcohol (p = 0.030) and past drug use (p = 0.048), and borderline p-values were found for educational level (p = 0.093) and family monthly income (p = 0.08). In the multivariable analysis, the factors that remained in the final model were family monthly income, time period with HIV infection and use of alcohol. No association was observed between non-adherence to antiretroviral therapy and gender, age, sexual orientation, marital status, educational level and place of residence. Based on our results and the local situation we suggest: assessment of social needs; training of partners and/or families on supporting adherence, creation of "adherence groups" to motivate and to reassure patients on the benefits of treatment; counseling and/or psychotherapy for alcohol drinkers.Estudo transversal com análise tipo caso-controle, que avaliou 412 pacientes de hospitais públicos do Recife - PE, com o objetivo de identificar fatores preditivos de não adesão à terapia antiretroviral. Verificou-se associação entre não adesão à terapia antiretroviral e aspectos biológicos, sócio-comportamentais e demográficos, econômicos, relacionados à doença e ao tratamento, aos hábitos de vida e aos distúrbios do humor. Variáveis com associação estatisticamente significante com não adesão na análise univariada foram: tempo de diagnóstico (p = 0,002), maior número diário de comprimidos (p = 0,046), uso de álcool (p = 0,030) e uso de drogas no passado (p = 0,048). Observou-se associação limítrofe com grau de instrução (p = 0,093) e renda mensal familiar (p = 0,08). Após análise multivariada, permaneceram no modelo final: renda mensal familiar, tempo de diagnóstico e uso de álcool. Não houve associação entre gênero, idade, comportamento sexual, estado civil, grau de instrução, município de residência e não adesão à terapia antiretroviral. Baseados nos nossos resultados e nas características da população estudada sugerimos: valorização das necessidades sociais, sensibilização de parceiros e/ou familiares para estimular a adesão, criação de grupos de adesão para motivar e persuadir os pacientes sobre os benefícios do tratamento, aconselhamento e/ou psicoterapia para alcoolistas