RESUMO
OBJECTIVE: To review the challenges and potential solutions in treatment options for quality migraine care in adult patients who are under or uninsured. BACKGROUND: The Affordable Care Act has improved access to health care for many; however, those who are underserved continue to face treatment disparities and have inadequate access to appropriate migraine management. METHODS: This manuscript is the second of a 2-part narrative review which was performed after a series of discussions within the Underserved Populations in Headache Medicine Special Interest Section meetings of the American Headache Society. Literature was reviewed for key concepts underpinning conceptual boundaries and a broad overview of the subject matter. Published guidelines, state-specific Medicaid websites, headache quality measurement sets, literature review, and expert opinion were used to tailor suggested treatment options and therapeutic strategies. In this second part of our narrative review, we explored migraine care strategies and considerations for underserved and vulnerable adult populations with migraine. RESULTS: Although common, migraine remains untreated, particularly among those of low socioeconomic status. Low socioeconomic status may play an important role in the disease progression, prescription of hazardous medications such as opioids, outcomes, and quality of life of patients with migraine and other headache disorders. There are some evidence-based and guideline supported treatment options available at low cost that include prescription medications and supplements, though approved devices are costly. Resources available online and simple nonpharmacological strategies may be particularly useful in the underserved migraine population. CONCLUSIONS: We identified and discussed migraine treatment barriers that affect underserved populations in the US and summarized practical, cost-effective strategies to surmount them. However, more research is needed to identify the best cost-effective measures for migraine management in underserved and vulnerable patients who are uninsured or underinsured.
Assuntos
Seguro Saúde , Pessoas sem Cobertura de Seguro de Saúde , Transtornos de Enxaqueca/tratamento farmacológico , Transtornos de Enxaqueca/economia , Adulto , Humanos , Estados UnidosRESUMO
OBJECTIVE: To review the scope of the problem facing individuals with migraine who are under- or uninsured. In this first of a 2-part narrative review, we will explore migraine epidemiology and the challenges that face this vulnerable population. BACKGROUND: Implementation of the Affordable Care Act has improved access to health care for many individuals who were previously uninsured, but there are many, particularly those of certain demographics, who are at high risk for worse outcomes. METHODS: A narrative review was performed after a series of discussions within the Underserved Populations in Headache Medicine Special Interest Section meetings of the American Headache Society. Literature was reviewed for key concepts underpinning conceptual boundaries and a broad overview of the subject matter. Published guidelines, state-specific Medicaid websites, headache quality measurement set, literature review, and expert opinion were used to tailor suggested treatment options and therapeutic strategies. RESULTS: Migraine is common, yet remains underdiagnosed and associated with worse outcomes among those of under-represented backgrounds and those who are underinsured or uninsured. Low socioeconomics may play an important role in the disease progression, characteristics, outcome, and quality of life of patients with migraine and other headache disorders. Other barriers to optimal care include time constraints, lack of access to specialty providers, transportation, and financial limitations. CONCLUSION: There are many barriers and challenges that affect people with migraine who are underinsured or uninsured, particularly those of under-represented racial backgrounds and of lower socioeconomic status.
Assuntos
Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Transtornos de Enxaqueca/epidemiologia , Transtornos de Enxaqueca/terapia , Adulto , Humanos , Estados Unidos/epidemiologiaRESUMO
Disease surveillance can be made more effective by either improving disease detection, providing cost savings, or doing both. Currently, cattle herds in low-risk areas (LRAs) for bovine tuberculosis (bTB) in England are tested once every 4 years. In Scotland, the default herd testing frequency is also 4 years, but a risk-based system exempts some herds from testing altogether. To extend this approach to other areas, a bespoke understanding of at-risk herds and how risk-based surveillance can affect bTB detection is required. Here, we use a generalized linear mixed model to inform a Bayesian probabilistic model of freedom from infection and explore risk-based surveillance strategies in LRAs and Scotland. Our analyses show that in both areas the primary herd-level risk factors for bTB infection are the size of the herd and purchasing cattle from high-risk areas of Great Britain and/or Ireland. A risk-based approach can improve the current surveillance system by both increasing detection (9% and 7% fewer latent infections), and reducing testing burden (6% and 26% fewer animal tests) in LRAs and Scotland, respectively. Testing at-risk herds more frequently can also improve the level of detection by identifying more infected cases and reducing the hidden burden of the disease, and reduce surveillance effort by exempting low-risk herds from testing.
Assuntos
Monitoramento Epidemiológico/veterinária , Tuberculose Bovina/epidemiologia , Animais , Bovinos , Inglaterra/epidemiologia , Modelos Logísticos , Modelos Teóricos , Fatores de Risco , Escócia/epidemiologia , Tuberculose Bovina/microbiologiaRESUMO
An area of research that has been recently gaining attention is the relationship between cancer stem cell (CSC) biology and chemo-resistance in colon cancer patients. It is well recognized that tumor initiation, growth, invasion and metastasis are promoted by CSCs. An important reason for the widespread interest in the CSC model is that it can comprehensibly explain essential and poorly understood clinical events, such as therapy resistance, minimal residual disease, and tumor recurrence. This review discusses the recent advances in colon cancer stem cell research, the genes responsible for CSC chemoresistance, and new therapies against CSCs.
RESUMO
A clinical practice guideline on glenohumeral joint osteoarthritis was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists, an occupational therapist, and a physician. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for physical therapist management of glenohumeral joint osteoarthritis. This clinical practice guideline is available in Spanish; see Supplementary Appendix 8.
Assuntos
Osteoartrite , Fisioterapeutas , Articulação do Ombro , Humanos , Osteoartrite/terapia , Modalidades de FisioterapiaRESUMO
BACKGROUND: Cancer treatment has many side effects; therefore, more efficient treatments are needed. Mesenchymal stem cells (MSC) have immunoregulatory properties, tumor site migration and can be genetically modified. Some proteins, such as soluble TRAIL (sTRAIL) and interleukin-12 (IL-12), have shown antitumoral potential, thus its combination in solid tumors could increase their activity. MATERIALS AND METHODS: Lentiviral transduction of bone marrow MSC with green fluorescent protein (GFP) and transgenes (sTRAIL and IL-12) was confirmed by fluorescence microscopy and Western blot. Soluble TRAIL levels were quantified by ELISA. Lymphoma L5178Y cells express a reporter gene (GFP/mCherry), and TRAIL receptor (DR5). RESULTS: An in vivo model showed that combined treatment with MSC expressing sTRAIL+IL-12 or IL-12 alone significantly reduced tumor volume and increased survival in BALB/c mice (p < 0.05) with only one application. However, at the histological level, only MSC expressing IL-12 reduced tumor cell infiltration significantly in the right gastrocnemius compared with the control group (p < 0.05). It presented less tissue dysplasia confirmed by fluorescence and hematoxylin-eosin dye; nevertheless, treatment not inhibited hepatic metastasis. CONCLUSIONS: MSC expressing IL-12, is or combination with BM-MSC expressing sTRAIL represents an antitumor strategy for lymphoma tumors since they increase survival and reduce tumor development. However, the combination did not show significative additive effect. The localized application did not inhibit metastasis but reduced morphological alterations of tissue associated with liver metastasis.
RESUMO
This systematic review and meta-analysis aimed to analyze the effectiveness of maxillary stabilization splint (SS) therapy to reduce headache (HA) intensity and HA frequency in patients with temporomandibular disorders (TMD)-HA comorbidity. Randomized controlled trials (RCTs) using full-arch coverage, hard resin, and maxillary SS therapy were included. Electronic databases, including Cochrane Library, MEDLINE through PubMed, Web of Science, and EMBASE, were searched. The risk of bias was analyzed based on Cochrane's handbook. The search yielded 247 references up to January 28, 2020. Nine RCTs were included at a high risk of bias. The comparison groups included other splints, counseling, jaw exercises, medications, neurologic treatment, and occlusal equilibration. Four studies reported a statistically significant reduction in HA intensity, and five studies reported significant improvement in HA frequency from baseline at 2-12 months in patients with TMD-HA comorbidity treated with a full-arch hard maxillary SS. HA frequency in tension-type HA (TTH) comorbid with TMD diagnoses of myofascial pain (MFP) or capsulitis/synovitis improved significantly with SS than that with full-arch maxillary non-occluding splint (NOS) in two studies. Comparison groups receiving hard partial-arch maxillary splint nociceptive trigeminal inhibition (NTI) showed statistically significant improvements in HA intensity in patients with mixed TMD phenotypes of MFP and disc displacement comorbid with "general HA." Comparison groups receiving partial-arch maxillary resilient/soft splint (Relax) showed significant improvements in both HA intensity and frequency in patients with HA concomitant with MFP. The meta-analysis showed no statistically significant difference in the improvement of pain intensity at 2-3 months with comparison of the splints (partial-arch soft [Relax], hard [NTI], and full-arch NOS) or splint use compliance at 6-12 months with comparison of the splints (partial-arch Relax and full-arch NOS) versus the SS groups in patients with various TMD-HA comorbidities. In conclusion, although SS therapy showed a statistically significant decrease in HA intensity and HA frequency when reported, the evidence quality was low due to the high bias risk and small sample size. Therefore, further studies are required.
RESUMO
INTRODUCTION: The prison environment in Peru is one of the worst in the continent. In situations such as these, where there is considerable stress, many inmates can develop antisocial disorders, especially if they come from a conflictive family setting. OBJECTIVES: To determine the association between family relationships, social environment and features of antisocial personality disorder (ASPD) in the Peruvian prison population in 2016. MATERIAL AND METHOD: Analytical cross-sectional study based on a sub-analysis of the First National Penitentiary Census of Peru in 2016. The sample is the prison population (≥18 years old) that participated in said census, which was carried out in 66 correctional facilities nationwide and reached a coverage of 98.8%. RESULTS: Of the 77,086 prisoners, 76,152 participated in the analysis. The prevalence of antisocial traits was 96% and half of the population met two criteria for the disorder. Independently associated factors were, being male (RPa: 1.35; 1.30-1.40), born outside the capital (RPa: 0.89; 0.88-0, 91), friends in the neighborhood who committed offences (RPa: 1.01; 1.00-1.02) and not living with a father (RPa: 1.00; 1.00-1.01). DISCUSSION: The prevalence of antisocial personality disorder traits in the Peruvian prison population was 96%. We found greater association with the male sex, in those born in Lima and in those who escaped from their home before the age of 15.
Assuntos
Transtorno da Personalidade Antissocial , Prisioneiros , Adolescente , Transtorno da Personalidade Antissocial/epidemiologia , Estudos Transversais , Humanos , Masculino , Peru/epidemiologia , Prisões , Meio SocialRESUMO
OBJECTIVE: To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities. METHODS: An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties. RESULTS: Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities. CONCLUSION: Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.
Assuntos
Transtornos da Cefaleia/terapia , Disparidades em Assistência à Saúde/estatística & dados numéricos , HumanosRESUMO
Colorectal cancer (CRC) is one of the main causes of mortality. Recent studies suggest that cancer stem cells (CSCs) can survive after chemotherapy and promote tumor invasiveness and aggression. According to a higher hierarchy complexity of CSC, different protocols for isolation, expansion, and characterization have been used; however, there are no available resistance biomarkers that allow predicting the clinical response of treatment 5fluorouracil (5FU) and oxaliplatin. Therefore, the primary aim of the present study was to analyze the expression of gene resistance on tumors and CSCderived isolates from patients CRC. In the present study, adenocarcinomas of the colon and rectum (CRAC) were classified based on an in vitro adenosine triphosphatebased chemotherapy response assay, as sensitive and resistant and the percentage of CD24 and CD44 markers are evaluated by immunohistochemistry. To isolate resistant colonCSC, adenocarcinoma tissues resistant to 5FU and oxaliplatin were evaluated. Finally, all samples were sequenced using a custom assay with chemoresistanceassociated genes to find a candidate gene on resistance colonCSC. Results showed that 59% of the CRC tissue analyzed was resistant and had a higher percentage of CD44 and CD24 markers. An association was found in the expression of some genes between the tumorresistant tissue and CSC. Overall, isolates of the CSC population CD44+ resistant to 5FU and oxaliplatin demonstrated different expression profiles; however, the present study was able to identify overexpression of the KRT18 gene, in most of the isolates. In conclusion, the results of the present study showed overexpression of KRT18 in CD44+ cells is associated with chemoresistance to 5FU and oxaliplatin in CRAC.
Assuntos
Neoplasias Colorretais/genética , Neoplasias Colorretais/patologia , Resistencia a Medicamentos Antineoplásicos/genética , Células-Tronco Neoplásicas , Adenocarcinoma/patologia , Adulto , Idoso , Biomarcadores Tumorais/genética , Antígeno CD24 , Feminino , Fluoruracila/farmacologia , Regulação Neoplásica da Expressão Gênica , Humanos , Receptores de Hialuronatos , Imuno-Histoquímica/métodos , Masculino , Pessoa de Meia-Idade , Oxaliplatina/farmacologiaRESUMO
Neurodegeneration associated with pantothenate kinase deficiency is an autosomal recessive condition caused by mutations in the pantothenate kinase 2 gene (PANK2). Clinical characteristics include progressive motor impairment and dementia. Medical treatment is limited and the dystonia tends to be refractory, making stereotactic surgery with placement of deep-brain electrodes an option that is being adopted with greater frequency in these patients. We report the case of a 32-year-old woman with severe dystonia associated with PANK2 protein deficiency. The patient was scheduled for stereotactic bilateral placement of electrodes in the medial globus pallidus, guided by computed tomography and under general anesthesia, to treat the debilitating dystonia and generalized stiffness associated with her condition. Anesthesia was maintained with propofol, rocuronium and remifentanil in perfusion during the intervention, which was uneventful. After the procedure, the patient was transferred to the intensive care unit and sedation was provided with remifentanil to allow slow, gradual emergence from anesthesia. The patient was discharged from hospital after placement of the implanted pulse generator, and subsequent follow-up showed improvement of the dystonia.
Assuntos
Anestesia Intravenosa/métodos , Estimulação Encefálica Profunda , Distúrbios Distônicos/terapia , Rigidez Muscular/terapia , Neurodegeneração Associada a Pantotenato-Quinase/complicações , Adulto , Androstanóis/administração & dosagem , Distúrbios Distônicos/etiologia , Feminino , Globo Pálido , Humanos , Intubação Intratraqueal , Rigidez Muscular/etiologia , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Neurodegeneração Associada a Pantotenato-Quinase/genética , Fosfotransferases (Aceptor do Grupo Álcool)/deficiência , Piperidinas/administração & dosagem , Medicação Pré-Anestésica , Propofol/administração & dosagem , Radiografia Intervencionista , Remifentanil , RocurônioRESUMO
OBJECTIVE: The aim of this study was to describe monitoring, anesthetic management, and risk factors for complications in neuroendoscopic surgery. PATIENTS AND METHODS: Patients who underwent neuroendoscopy between 1994 and 2003 under general anesthesia, with monitoring of intracranial pressure from inside the neuroendoscope, were studied retrospectively. In some patients, the blood flow rate in the middle cerebral artery was monitored using transcranial Doppler ultrasound. Information was collected related to surgical procedure and the development of complications. RESULTS: Of 101 patients included in the study, transcranial Doppler ultrasound images were available for 20. In 75 patients neuroendoscopic intracranial pressure exceeded 20 mm Hg. Forty-five percent of the patients with available transcranial Doppler ultrasound images showed episodes of reduced diastolic flow rate in the middle cerebral artery during ventricular irrigation. Hemodynamic instability was associated with higher neuroendoscopic intracranial pressures (P < .05). An increase of more than 30 mm Hg in neuroendoscopic intracranial pressure was associated with more postoperative complications, the most common of which was delayed awakening. Procedures that were more complicated than a simple ventriculostomy were performed in 58% of the cases. Mean (SD) neuroendoscopic intracranial pressures in such cases were higher (50.5 [30.9] mm Hg vs 31.8 [25.1 mm Hg] in the simpler procedures) and the postoperative complication rate was higher (P = .003). CONCLUSIONS: Neuroendoscopic surgery can causes increases in neuroendoscopic intracranial pressure that are associated with disturbances in cerebral blood flow and complications. This situation demonstrates the importance of monitoring intracranial pressure and cerebral blood flow.
Assuntos
Circulação Cerebrovascular , Recuperação Demorada da Anestesia/etiologia , Hipertensão Intracraniana/diagnóstico , Pressão Intracraniana , Complicações Intraoperatórias/diagnóstico , Manometria/instrumentação , Monitorização Intraoperatória/métodos , Neuroendoscópios , Neuroendoscopia/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos , Adolescente , Adulto , Idoso , Anestesia Geral , Velocidade do Fluxo Sanguíneo , Criança , Pré-Escolar , Recuperação Demorada da Anestesia/prevenção & controle , Desenho de Equipamento , Feminino , Humanos , Lactente , Hipertensão Intracraniana/diagnóstico por imagem , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/prevenção & controle , Complicações Intraoperatórias/diagnóstico por imagem , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Manometria/métodos , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Procedimentos Neurocirúrgicos/instrumentação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Irrigação Terapêutica/efeitos adversos , Ultrassonografia Doppler Transcraniana , Adulto JovemRESUMO
Livestock movements are an important mechanism of infectious disease transmission. Where these are well recorded, network analysis tools have been used to successfully identify system properties, highlight vulnerabilities to transmission, and inform targeted surveillance and control. Here we highlight the main uses of network properties in understanding livestock disease epidemiology and discuss statistical approaches to infer network characteristics from biased or fragmented datasets. We use a 'hurdle model' approach that predicts (i) the probability of movement and (ii) the number of livestock moved to generate synthetic 'complete' networks of movements between administrative wards, exploiting routinely collected government movement permit data from northern Tanzania. We demonstrate that this model captures a significant amount of the observed variation. Combining the cattle movement network with a spatial between-ward contact layer, we create a multiplex, over which we simulated the spread of 'fast' ( R0 = 3) and 'slow' ( R0 = 1.5) pathogens, and assess the effects of random versus targeted disease control interventions (vaccination and movement ban). The targeted interventions substantially outperform those randomly implemented for both fast and slow pathogens. Our findings provide motivation to encourage routine collection and centralization of movement data to construct representative networks. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This theme issue is linked with the earlier issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.
Assuntos
Doenças dos Animais/epidemiologia , Doenças Transmissíveis/veterinária , Países em Desenvolvimento/economia , Gado , Modelos Biológicos , Doenças dos Animais/economia , Animais , Doenças Transmissíveis/economia , Doenças Transmissíveis/epidemiologia , Coleta de Dados , Vigilância da População/métodosRESUMO
Neuraxial techniques are considered safe if certain guidelines are followed, but they are not risk free. We report the case of an 81-year-old woman with an invasive bladder tumor who underwent radical cystectomy with a Bricker-type procedure. General anesthesia was used and epidural analgesia was also provided for surgical and postoperative pain management. Late in the postoperative recovery period a large epidural hematoma was diagnosed based on radiologic signs of spinal cord compression, in the absence of symptoms other than mild and progressive back pain that developed after extubation. The surgeon decided against emergency surgery to reduce compression. Symptoms resolved gradually, and a magnetic resonance image 45 days after discharge confirmed that the hematoma was smaller. In addition to the usual safety recommendations for epidural anesthesia with regard to drugs that alter hemostasis, it is important to bear in mind circumstances that have pharmacokinetic repercussions and that increase risk. Lower back pain can be a warning sign. Some cases may resolve spontaneously.
Assuntos
Anestesia Epidural/efeitos adversos , Hematoma Epidural Espinal/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Idoso de 80 Anos ou mais , Dor nas Costas/etiologia , Cistectomia , Feminino , Hematoma Epidural Espinal/diagnóstico por imagem , Hematoma Epidural Espinal/etiologia , Humanos , Imageamento por Ressonância Magnética , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Punções/efeitos adversos , Radiografia , Compressão da Medula Espinal/etiologia , Neoplasias da Bexiga Urinária/cirurgiaRESUMO
Bovine tuberculosis (bTB) is a chronic zoonosis with major health and economic impact on the cattle industry. Despite extensive control measures in cattle and culling trials in wildlife, the reasons behind the expansion of areas with high incidence of bTB breakdowns in Great Britain remain unexplained. By balancing the importance of cattle movements and local transmission on the observed pattern of cattle outbreaks, we identify areas at elevated risk of infection from specific Mycobacterium bovis genotypes. We show that elevated-risk areas (ERAs) were historically more extensive than previously understood, and that cattle movements alone are insufficient for ERA spread, suggesting the involvement of other factors. For all genotypes, we find that, while the absolute risk of infection is higher in ERAs compared to areas with intermittent risk, the statistically significant risk factors are remarkably similar in both, suggesting that these risk factors can be used to identify incipient ERAs before this is indicated by elevated incidence alone. Our findings identify research priorities for understanding bTB dynamics, improving surveillance and guiding management to prevent further ERA expansion.
Assuntos
Surtos de Doenças/estatística & dados numéricos , Surtos de Doenças/veterinária , Genótipo , Mycobacterium bovis/genética , Tuberculose Bovina/epidemiologia , Tuberculose Bovina/genética , Animais , Bovinos , Incidência , Fatores de Risco , Reino Unido/epidemiologiaRESUMO
OBJECTIVES: To compare the clinical behavior of the disposable Soft Seal laryngeal mask to the behavior of the reusable LMA Classic mask. METHODS: Patients were randomly assigned to 2 groups in which either the LMA Classic or the Soft Seal mask would be used. We assessed time required for positioning and number of attempts, seal pressure, fiberoptic bronchoscopic image, and complications. The masks were inserted by 2 anesthesiologists who were inexperienced in the use of laryngeal masks. We also compared compliance of the cuff in the laboratory. RESULTS: Sixty patients were enrolled. There were no differences in time required for insertion or number of attempts (first-try success, 83%). The mean (SD) seal pressure was greater in the Soft Seal group at 23 (4) cm H2O than in the LMA Classic group at 20 (4) cm H2O. There were no significant differences in the fiberoptic bronchoscopic images, ventilation, incidence of intraoperative complications, presence of blood on the cuff (LMA Classic, 6 out of 30 vs Soft Seal, 11 out of 29), or postoperative sore throat. In 3 patients in the Soft Seal group the laryngeal mask had to be replaced by an orotracheal tube. Cuff compliance in the laboratory was lower for the LMA Classic than for the disposable mask for all sizes assessed. CONCLUSIONS: Although the results suggest that the clinical behavior of the 2 masks is similar, the LMA Classic allowed for effective airway management in all of the cases assigned to it, whereas management was effective in 90% of the cases in which the Soft Seal mask was used. The inflatable cuff of the Soft Seal is more compliant in vitro and it provides a higher airway seal pressure than does the LMA Classic.
Assuntos
Equipamentos Descartáveis , Reutilização de Equipamento , Máscaras Laríngeas , Adulto , Desenho de Equipamento , Feminino , Humanos , Máscaras Laríngeas/efeitos adversos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Transluminal percutaneous carotid angioplasty and stenting (CAS) carries a risk of cerebral ischemia, hemorrhage, or edema due to relative hyperemia and hemodynamic instability during and after the procedure. Noninvasive monitoring of near-infrared regional cerebral oxygen saturation (SrO2) offers an indirect way to estimate cerebral blood flow. OBJECTIVE: To evaluate the behaviour of SrO2 during CAS and the usefulness of this variable for continuous monitoring of cerebral blood flow variation and neurological status. MATERIAL AND METHODS: Prospective study of 25 patients scheduled for unilateral CAS under monitored anesthesia care. SrO, and other hemodynamic and clinical data were recorded. A change in SrO2 (deltaSrO2) of 15% or more in comparison with the baseline value and lasting more than 30 seconds was considered clinically significant. Neurological complications in the first 24 hours were also registered. RESULTS: Baseline SrO, ranged from 51% to 75%. With administration of papaverine SrO2 values increased by a mean (SD) of 5.6% (6%) (P<.05 vs baseline). They decreased during angioplasty, -2.5% (5.7%) (P<.05 vs baseline), increased after 5 minutes, and fell again at 30 minutes to a level 3% (6.54%) above baseline. Two patients showed signs of elevated intracranial pressure after the procedures and also had ASrO2 readings exceeding 15%; measures to lower arterial hypertension reduced SrO2 in these patients. CONCLUSION: High interindividual variability of absolute SrO2 values has been confirmed. SrO, fluctuates with maneuvers that change cerebral blood flow in the same way. Changes can precede the onset of other clinical signs.
Assuntos
Angioplastia com Balão , Artéria Carótida Interna , Estenose das Carótidas/terapia , Circulação Cerebrovascular , Hipóxia Encefálica/prevenção & controle , Monitorização Intraoperatória/métodos , Oximetria/métodos , Oxigênio/sangue , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Idoso , Pressão Sanguínea , Isquemia Encefálica/sangue , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/etiologia , Isquemia Encefálica/prevenção & controle , Estenose das Carótidas/sangue , Feminino , Frequência Cardíaca , Humanos , Hiperemia/sangue , Hiperemia/etiologia , Hipóxia Encefálica/sangue , Hipóxia Encefálica/etiologia , Hipertensão Intracraniana/sangue , Hipertensão Intracraniana/tratamento farmacológico , Hipertensão Intracraniana/etiologia , Complicações Intraoperatórias/sangue , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Oximetria/instrumentação , Papaverina/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho/instrumentação , Vasodilatadores/uso terapêuticoRESUMO
To compare the late neuropsychologic toxicities of CNS prophylaxis in childhood acute lymphoblastic leukemia (ALL), a transversal assessment was performed in two groups of ALL patients and two control groups. The ALL patients had received one of the following CNS prophylaxes: cranial irradiation, 24 Gy and i.t. MTX 10 mg/m2, 6 doses (RT group, n = 25) or i.t. Ara-C 30 mg/m2 and i.t. MTX 10 mg/m2, 10 doses (ChT group, n = 29). The two control groups were: Siblings (Sb, n = 24) and Solid Tumors (ST, n = 22). Intelligence Quotient (IQ), memory, learning, attention and frontal tasks were studied. Comparative analyses between ChT and RT showed no differences in any of the tests. When RT was compared with ST or Sb, RT showed a 10-point lower mean IQ (p greater than 0.05). The results of ChT versus ST or versus Sb were worse in the ChT group. In many tests the differences were statistically significant. Analyses of the 54 ALL patients compared with the 46 controls showed significant differences in all tests except verbal memory and verbal learning. Neuropsychological sequelae of CNS prophylaxis are discussed, and in particular, the role of cranial radiotherapy and i.t. Ara-C. We conclude that prophylactic CNS therapy may cause cognitive dysfunctions.
Assuntos
Neoplasias Encefálicas/prevenção & controle , Encéfalo/efeitos da radiação , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Adolescente , Fatores Etários , Encéfalo/efeitos dos fármacos , Criança , Transtornos Cognitivos/etiologia , Terapia Combinada , Citarabina/efeitos adversos , Feminino , Humanos , Inteligência/efeitos dos fármacos , Inteligência/efeitos da radiação , Masculino , Metotrexato/efeitos adversos , PrognósticoRESUMO
The hypothalamic suprachiasmatic nuclei (SCN) comprise the main site in the brain involved in the control of the homeostatic mechanism which respond to environmental daily light changes. The sympathetic nervous system and hypothalamic releasing or inhibiting factors mediate the SCN control of a number of peripheral organs and tissues. In this work we analyzed the involvement of two environmental light conditions, constant light (LL) and constant dark (DD) for 20 days, on the expression of mRNAs for catecholamines biosynthetic enzymes and neuropeptide Y (NPY) genes in rat superior cervical ganglia (SCG) and adrenal gland. The results of Northern blot analysis show that LL exposure reduces mRNA levels for tyrosine hydroxylase (TH) the rate limiting catecholamine biosynthetic enzyme and also of dopamine beta-hydroxylase (DBH) as well as for NPY in SCG to about half the levels in control animals. In contrast, exposure of the rats to DD did not elicit any change in the SCG. In the adrenal gland, both, LL and DD conditions increased the TH, DBH as well as phenylethanolamine N-methyltransferase (PNMT) mRNA levels. Under the same conditions, adrenal NPY mRNA levels were decreased by either LL or DD. The results show, for the first time, that prolonged changes in environmental light can alter the gene expression of catecholamine biosynthetic enzymes and of NPY. There was differential response in SCG and adrenal gland.
Assuntos
Glândulas Suprarrenais/metabolismo , Catecolaminas/biossíntese , Ritmo Circadiano/genética , Luz , Neuropeptídeo Y/biossíntese , Gânglio Cervical Superior/metabolismo , Adaptação Fisiológica/genética , Glândulas Suprarrenais/citologia , Animais , Catecol O-Metiltransferase/genética , Escuridão , Dopamina beta-Hidroxilase/genética , Regulação para Baixo/genética , Regulação para Baixo/efeitos da radiação , Ambiente Controlado , Masculino , Neuropeptídeo Y/genética , Estimulação Luminosa , RNA Mensageiro/metabolismo , RNA Mensageiro/efeitos da radiação , Ratos , Ratos Wistar , Gânglio Cervical Superior/citologia , Tirosina 3-Mono-Oxigenase/genética , Regulação para Cima/genética , Regulação para Cima/efeitos da radiaçãoRESUMO
OBJECTIVE: To establish nomograms of fetal ear measurements. Newborns with trisomies have smaller ears than the normal population. This observation led us to believe that ear measurements might be useful in the antenatal prediction of fetuses with abnormal karyotypes. METHODS: Fetal ear length and width were obtained ultrasonographically in 124 normal singleton pregnancies between 18-42 weeks' gestation. Regression analyses were used to create the nomograms. RESULTS: Linear relationships were found between ear length and width and gestational age (r = 0.956 and 0.898, respectively). In addition, there were significant correlations between ear measurements and biparietal diameter, head circumference, abdominal circumference, and femur length. The ear width-length ratio and the biparietal diameter-ear length ratio were independent of gestational age. CONCLUSION: These normative data may be helpful in the antenatal prediction of chromosomal abnormalities.