Percutaneous electrical stimulation for overactive bladder in children: a pilot study.

PURPOSE: The purpose of this was to evaluate the efficacy (tolerance and safety) of once-a-week parasacral percutaneous electrical nerve stimulation (PENS) to treat overactive bladder (OAB) in children. MATERIALS AND METHODS: This is a prospective case series of children aged 4-14 years who underwent PENS for OAB. Acupuncture needles were used bilaterally and symmetrically at S3 for sacral nerve stimulation (Figure). Eighteen children with pure OAB underwent PENS weekly for 20 weeks. Frequency was 10 Hz. Intensity varied up to a maximum of 10 mA, as tolerated by the participant, but without reaching the motor threshold. Pulse width was 600 µs Patients' voiding history was assessed before treatment using a structured questionnaire. The dysfunctional voiding scoring system (DVSS) was used before and after treatment to quantify symptoms of lower urinary tract dysfunction. A visual analog scale (VAS) was used to evaluate treatment outcome. RESULTS: Seven boys and eleven girls (mean age, 7.82 ± 2.45 years) were included. According to the VAS, symptoms were resolved in 66% of patients. Urinary urgency, present in all children at baseline, was resolved in 84% (P = 0.001). The proportion of patients with involuntary loss of urine without urgency decreased from 77% before treatment to 27% (P = 0.04). Urge incontinence resolved in 13 of 16 patients after treatment (P = 0.001). Only one of the 12 children with frequent urination at baseline reported this complaint after treatment (P = 0.04). All cases of recurrent urinary tract infection were resolved (P = 0.001). Regarding nocturnal enuresis, treatment was successful in 9 of 14 children (P = 0.004). DISCUSSION: The theory behind this new method is that when skin impedance is overcome through the use of acupuncture needles and greater proximity is attained between the tip of the electrode and the sacral nerves, a more effective stimulus is achieved, with enough energy to provide the same benefits as parasacral transcutaneous electrical nerve stimulation with the advantage that treatment can be given only once a week. CONCLUSIONS: Percutaneous electrical nerve stimulation seems to be an effective and safe treatment for OAB over the short term. Furthers studies with a control group are needed.

Skeletal anomalies in reared Senegalese sole Solea senegalensis juveniles: a radiographic approach.

Reared Senegalese sole Solea senegalensis Kaup show a high incidence of vertebral anomalies; however, little is known about its skeletal anomaly profile in the later farming phases. The purpose of this study was to provide a detailed description and quantification of the most common skeletal anomalies in reared Senegalese sole in the juvenile stage by means of computed radiography. A total of 374 Senegalese sole were classified according to the external morphology of the fish as normal or altered and then radiographed in latero-lateral and in dorso-ventral projections. Radiographic evaluation of anomalies focused especially on vertebral body anomalies (VBA) and vertebral column deviations (VCD). The 2 orthogonal projections provided a more complete visualization of the skeleton. Approximately 75% of the individuals showed at least 1 anomaly, while VBA and/or VCD were detected in 48.9% of the specimens. Regarding external morphology, 88% of the fish were categorized as normal, although about 72% of these normal fish displayed abnormalities in radiographies. The most frequent anomalies consisted of deformations of the caudal complex plates (hypurals, parhypural and epural), preurals and caudal vertebrae. Scoliosis was the most prevalent among VCD, affecting the caudal area in almost 15% of the individuals. The anomaly profile at the juvenile stages showed some differences compared to what has been reported previously in earlier stages of development. In light of these results, further investigation into the progression of skeletal anomalies over time and the causative factors at later stages is required.

New insight on vertebral anomalies in cultured Senegalese sole (Solea senegalensis, Kaup) at early stages of development.

Senegalese sole (Solea senegalensis, Kaup) is a promising flatfish species in aquaculture. However, skeletal anomalies are still a great concern in sole farming. Investigation of this issue is crucial to improving larval quality and optimizing production. The aim of this study was to thoroughly assess anomalies in the rachis of reared sole at early developmental stages. Sole (n = 507) were sampled at 31 or 32 days after hatching (dah). The specimens were stained with alcian blue and alizarin red and evaluated for the detection of vertebral deformities. Most fish presented 9:34:3 vertebrae in abdominal, caudal and caudal complex regions, respectively. Remarkably, all specimens showed at least one spinal anomaly. Alterations of neural/haemal elements, as well as deformities of hypurals, parhypural and epural, were recurrent. Vertebral body anomalies and/or vertebral column deviations were identified in 52% of the individuals. Vertebral deformations and fusions were common, especially in caudal complex. 'Minor' anomalies were predominant, and some of the detected disorders might be a result of non-/low-pathological processes. These results contribute a new insight into the main skeletal anomalies affecting cultured sole larvae. Further research is required to determine their impact on fish welfare and external appearances at commercial stages.

Estimation of adult patient doses for common diagnostic X-ray examinations in Rio de Janeiro, Brazil.

DoseCal software has been used to evaluate the Entrance Surface Dose (ESD) and Effective Dose (ED) of adult patients undergoing abdomen, cervical spine, chest, lumbar spine and skull diagnostic X-ray examinations in AP, PA and LAT projections. The survey was carried out in nine hospitals in Rio de Janeiro state with a total of 1917 radiographs. The mean values of ESD (mGy) and ED (mSv) were recorded. Although the results obtained are below the international diagnostic reference levels, they present large variations within and between hospitals which reflects the disparity of radiographic techniques used in the examinations. The results were compared with the European Community Reference Levels. Even though in Brazil there are specific legislations on radiation protection and implementation of Quality Assurance Programs (QAPs) in all medical institutions, there is still a need for personnel training and national guidance on good practice for optimization of patients' doses.

Structural and ultrastructural characteristics of the yolk syncytial layer in Prochilodus lineatus (Valenciennes, 1836) (Teleostei; Prochilodontidae).

The yolk syncytial layer (YSL) has been regarded as one of the main obstacles for a successful cryopreservation of fish embryos. The purpose of this study was to identify and characterize the YSL in Prochilodus lineatus, a fish species found in southeastern Brazil and considered a very important fishery resource. Embryos were obtained through artificial breeding by hormonal induction. After fertilization, the eggs were incubated in vertical incubators with a controlled temperature (28 degrees C). Embryos were collected in several periods of development up to hatching and then fixed with 2% glutaraldehyde and 4% paraformaldehyde in 0.1 M sodium phosphate buffer (pH 7.3). Morphological analyses were carried out under either light, transmission or scanning electron microscopy. The formation of the YSL in P. lineatus embryos starts at the end of the cleavage stage (morula), mainly at the margin of the blastoderm, and develops along the embryo finally covering the entire yolk mass (late gastrula) and producing a distinct intermediate zone between the yolk and the endodermal cells. The YSL was characterized by the presence of microvilli on the contact region with the yolk endoderm. A cytoplasmic mass, full of mitochondria, vacuoles, ribosomes, endomembrane nets and euchromatic nuclei, indicated a high metabolic activity. This layer is shown as an interface between the yolk and the embryo cells that, besides sustaining and separating the yolk, acts as a structure that makes it available for the embryo. The structural analyses identified no possible barriers to cryoprotectant penetration.

Prevalence of pulmonary hypertension in systemic sclerosis.

OBJECTIVE: To assess the prevalence of pulmonary arterial hypertension (PAH) in patients with the diagnosis of systemic sclerosis (SSc) followed at a tertiary university service. MATERIAL AND METHODS: Fifty-seven patients with SSc were studied by clinical assessment directed at the cardiopulmonary system, pulmonary function tests and Doppler echocardiography (ECHO). The following criteria were considered for the diagnosis of PAH: pulmonary artery systolic pressure (PASP) > or = 40 mmHg and/or the presence of other direct and indirect signs of PAH detected upon ECHO. RESULTS: Sixteen patients (28%) were diagnosed with PAH upon ECHO, 13 based on PASP > or = 40 mmHg and 3 based on direct and indirect signs of PAH; 8 patients had isolated PAH and 8 had PAH secondary to pulmonary fibrosis. Nine patients showed signs suggestive of cor pulmonale upon ECHO; among these patients, 6 had pressure recordings > or = 40 mmHg and 3 had a PSAP between 35 and 40 mmHg; one patient was asymptomatic and 8 showed signs suggestive of PAH upon clinical examination. Among the clinical and laboratory variables studied, a correlation was only observed between PAH and an elevated erythrocyte sedimentation rate (p = 0.004). CONCLUSIONS: The prevalence of PAH associated with SSc observed in this study was similar to those reported in the literature. However, the cut-off of PSAP measured by ECHO and used for the diagnosis of PAH associated with SSc needs to be revised.

A randomized, multicenter study of G-CSF starting on day +1 vs day +5 after autologous peripheral blood progenitor cell transplantation.

In order to assess the effect of delaying G-CSF administration after autologous peripheral blood progenitor cell (PBPC) transplantation on the duration of neutropenia, 87 patients were randomized to receive G-CSF 5 microg/kg/day starting on day +1 (n = 45) or +5 (n = 42) following PBPC transplantation, until recovery of the neutrophils. The duration of neutropenia (<0.5 x 10(9)/l) was shorter in the day +1 group (7 vs 8 days; P = 0.02), especially in patients receiving melphalan 200 mg/m(2) and CD34(+) cell doses >3.0 x 10(6)/kg. These patients had a later onset of neutropenia after transplant. There were no differences in time to neutrophil and platelet engraftment, or in the incidence of fever and documentation of infection. Although the duration of antibiotic therapy (7 vs 10.5 days; P = 0.01) and time to hospital discharge (13 vs 15 days; P = 0.02) were shorter in the day +1 group, these differences could not be predicted by the day of G-CSF initiation in multivariate analysis. Starting G-CSF on day +1 does not result in faster neutrophil engraftment but in later onset and consequently, slightly shorter duration of neutropenia in patients who receive melphalan 200 mg/m(2) and CD34(+) cell doses >3.0 x 10(6)/kg.

Life-threatening capillary leak syndrome after G-CSF mobilization and collection of peripheral blood progenitor cells for allogeneic transplantation.

We report a case of capillary leak syndrome in a 37-year-old female PBPC donor who received G-CSF 900 microg/day for 4 days and underwent leukapheresis. This lady had remained well and stable despite marked leukocytosis during G-CSF treatment, but developed hypotension during leukapheresis, quickly followed by hypoxemia, ascites, pericardial and pleural effusion, shock, edema, neurologic changes and hepatocellular injury. Upon G-CSF withdrawal, dopamine and crystalloid infusion, methylprednisolone treatment and suspension of apheresis, the clinical situation fully reversed. We hypothesize that leukapheresis, in the presence of marked leukocytosis and high doses of G-CSF, may have triggered neutrophil activation and the release of inflammatory mediators, resulting in tissue damage and systemic manifestations of increased capillary permeability.

Characterization of an amylase produced by a Trichoderma harzianum isolate with antagonistic activity against Crinipellis perniciosa, the causal agent of witches' broom of cocoa.

An isolate of Trichoderma harzianum showing antagonistic activity against Crinipellis perniciosa, the causal agent of the witches' broom disease of cocoa, produces substantial amounts of hydrolytic enzymes. An amylase purified from isolate 1051 had a molecular mass of about 68.7 kDa. Maximal activity against soluble starch was determined at pH 4.0 and 60 degrees C. The K(m) and V(max) values were 3.5 mg ml(-1) and 1.67 mg min(-1) of reducing sugar. The end products were mostly malto-oligosaccharides. The enzyme also hydrolyzed glycogen, amylopectin, maltotriose, and maltotetraose, but not pullulan or cellobiose. Maltose was only barely hydrolyzed. The purified amylase exerted a discrete hydrolytic effect on the C. perniciosa cell wall in vitro as observed by scanning electron microscopic analysis. While Fe(3+), Al(3+), Zn(2+), and Cu(2+) were effective in inhibiting the purified amylase, Mn(2+) considerably enhanced the activity. Ca(2+), Mg(2+), and Co(2+) showed no substantial effect on enzyme activity.

Studies on populations of Lutzomyia longipalpis (Lutz & Neiva, 1912) (Diptera: Psychodidae: Phlebotominae) in Brazil.

Studies were performed on five Brazilian populations of Lutzomyia longipalpis: Salvaterra (PA), São José do Ribamar (MA), Canindé (CE), Natal (RN) and Gruta da Lapinha, Lagoa Santa (MG). No morphological differences were observed that could distinguish between these populations. Homogeneity tests showed that the allopatric populations display a certain heterogeneity and that the sympatric populations, with different patterns of spots, are homogeneous. The Student-Newman-Keuls test, represented by Euler-Venn diagrams, showed a disjunction between the populations from the north/northeast and the one from Gruta da Lapinha. Genetic distances between the four populations (excluding the Canindé population) were within the range of intrapopulational differences. The Gruta da Lapinha population displayed a heterozygotic deficiency that could be a consequence of high levels of inbreeding due to cryptic habits of living in a small cave. These results do not favor the hypothesis of a L. longipalpis species complex in Brazil, and the species should be considered high polymorphic.

Substantive unconscious and adjective unconscious: the contribution of Wilfred Bion.

The author first provides her readers with a brief summary of some of Freud's ideas, as found throughout his work, on the notion of 'unconscious'. The notion of unconscious as noun is contrasted to the idea of unconscious as adjective, this latter being proposed as a quality, or a state, ever temporary, dynamic, and subject to the constant changes going on in the individual's internal psychic world, as well as to external conditions. After presenting some considerations, the author then contrasts the Kleinian model of the mind to the Freudian, and Wilfred Bion's contribution is discussed at some length. Within Bion's conception of psychic functioning, the model of 'dream' is highlighted and, in this regard, clarifications are sought regarding Bion's view of the unconscious. To conclude, a brief and superficial approximation to the work of Carl Jung is touched upon, although the author admits to knowing little of Jung's positions.

[Analysis of adequacy and effectiveness in the use of tocolytics in preterm labor]. / Anlise da adequação e da efetividade do uso de tocolíticos no trabalho de parto prematuro.

The objective of this study was to assess quality of care for premature labor at public maternity facilities in Rio de Janeiro, Brazil, using referents, indicators, and standards of care derived from scientific evidence. The standard utilized in the process analysis for use of betamimetic tocolytics was 100%, considering the related referents. For outcome analysis, the standard applied was the occurrence of premature delivery in 11% of patients within 24 h and in 24% of patients (referent) within 48 h of hospital admission. Use of tocolytics was observed in 18.7% of patients admitted in premature labor. At gestational age from 28 weeks to 33 weeks and 6 days, especially critical for neonatal survival, tocolytics were used in 32.6% of patients. Premature birth occurred in 59% of patients within 24 h and in 64% within 48 h. These outcomes were consistent with the low rate of utilization of tocolytics. Effectiveness of care for preterm labor measured by rate of premature birth was low. Results of the corresponding process and outcomes analysis were consistent.

[The World Health Organization and planning]. / La organización mundial de la salud y la planificación.

The basic concepts, evolution and practice of health planning are described, in the context of WHO role. Special emphasis is given to the Cendes-OPS methodology, to be this procedure a more specific, articulated and implemented widely in the American region. Finally, future projections of these activities are given.

Validation of the psychoanalytic clinical process: the role of dreams.

This paper explores the place of dreams in the validation of the actuality of an evolving psychoanalytic clinical process. The specificity of psychoanalysis, in the author's perspective, consists basically in its being an intersubjective clinical practice; because of this, positivistic notions of validation, such as verification as a search for constancies and regularities, have no proper place here. The shared emotional experience--the intersubjectivity--of the psychoanalytic pair is the place where our method must be validated. Dreams, not only as a solitary intrapsychic production during sleep, but also as narratives made by the analysand within the setting, are an essential part of working through and provide a feasible way to attain some degree of validation of the process. The analysand's narrative of his dreams leads to a 'shared dreaming' in session of the analysand-analyst pair; leaving aside their role as resistance, dreams emerge from emotional experiences as a 'construction of knowledge', as an attempt at symbolic elaboration.

Effect of methionine supplementation to a low-soybean protein diet on liver lipid metabolism.

Female Wistar rats were fed a low-soybean protein (8%) diet supplemented with different concentrations of DL-methionine (0-1.2%) during the lactation period. Diet supplementation with methionine caused a significant increase in rat body weight. The addition of 0.3% DL-methionine to the diet did not cause an increase in liver triacylglycerol concentration in 21-day-old rats, but an increase did occur after the addition of 0.6% DL-methionine to the diet. Supplementation of the diet with DL-methionine did not change liver phospholipid or protein concentrations, nor plasma triacylglycerol levels. Liver lipid synthesis from [1-14C]acetate in 21-day-old rats whose dams had been fed an 8% soybean protein diet supplemented with 1.2% DL-methionine was significantly higher than in the group receiving no DL-methionine supplementation. Hepatic production of CO2 and of water-soluble acid products from [1-14C]palmitate did not differ between groups. Inositol addition to a low-soybean protein diet supplemented with DL-methionine did not change triacylglycerol nor phospholipid levels in the liver.

[Evaluation of the performance of health services]. / Avaliação de desempenho de serviços de saúde.

Recent literature (up to 1988) on health services assessment in general and especially on hospital service assessment is reviewed, with special attention to its conceptual and methodological aspects. The history of this process is also examined, from the first attempts by the American College of Surgeons, through the Joint Commission for Hospital Accreditation activities up to more recent efforts. The Diagnosis Related Group methodology is commented especially, as well as its more recent complement, the severity of illness indicators. Progress made in this field is briefly examined as in the light of the Brazilian situation. The origins of the growing international concern with this field are enumerated: soaring costs of health services; the recent growth in the number of medical malpractice suits; and the sharp increase in the complexity of health services. The sources of information used in the process, such as immediate observation (case-control type studies), medical records, and summary instruments already in use for payment or financial control purposes, are commented on. Mention is made of the deep influences of the assessment process on practice as in the case of the standardization of practices and procedures, staging of the pathological processes, trajectory-type studies; the utilization of tracer situations, and, finally, the most influential on practice of all these assessment instruments: the diagnosis and treatment protocols, already in wide use in some medical fields such as cancer treatment even in developing countries.

Community participation in health activities in an Amazon community of Brazil.

This article describes community participation in a comprehensive eight-year health program at Porto Nacional, a town in Brazils Amazon region. The authors discuss various techniques employed to encourage community participation, indicate methods used to resolve low-key conflicts in a positive manner, describe the major contributions made by community participation in this program, and present a number of conclusions considered applicable to other communities in this part of Brazil.

PIP: Community participation was found to be an important resource for ascertaining and achieving the project health goals of a multiprofessional health team in Porto Nacional, an Amazon community in Brazil's interior. The project was established in 1968 to provide comprehensive, integrated medical care. The health team consisted of 6 physicians (1 sanitarian, 2 surgeons, 2 internists, and 1 pediatrician), 2 social workers, 1 nurse, and 1 educator. The team assumed operating responsibility for the area's health unit and 50 bed hospital, and worked closely with other local health agencies and providers. To attract financial and technical resources, the team founded a non-profit agency, COMSAUDE, to promote health and educational activities. The area's health problems consisted of a predominance of waterborne and foodborne diseases, an infant mortality rate of approximately 70 deaths/1000 live births, high malaria morbidity, tuberculosis, leprosy, cutaneous leishmaniasis, a moderate incidence of Chagas' disease, and extensive infestation of vermin. The local health unit was well-known and accepted in the community which facilitated the team's activities. At the time of the team's arrival, the vermin problem was causing public concern. Work on controlling this problem appeared an appropriate vehicle to achieve the dual objectives of promoting sanitation activities and becoming familiar with and accepted by the community. A combination of home visits and general meetings with institutional and local leaders mobilized a significant segment of the population. Increased cesspool construction resulted. Among the poorest neighborhoods, residents developed an organization to finance the cost of construction materials. Technical assistance from sanitation aides was provided to rural communities. Municipal health boards were organized to assure maximum utilization of visiting physicians, to conduct health surveys, and to oversee the implementation of recommended preventive health measures. A health board of volunteers was initiated in Porto Nacional to identify health related problems and propose solutions within the scope of the local government. The board was responsible for improvements in sanitation at the market place and the organization of trash collection. Health surveys were conducted utilizing students from local schools as interviewers. The surveys increased community awareness of health problems in addition to providing health data. A center for malnourished children was established which served as a recuperation facility for the children and a nutrition and hygiene education center for mothers. A cooperative housing improvement program was initiated. Residents worked Saturdays gathering construction materials and working on neighbors' houses. The sanitation aides assisted in drawing plans and selecting building, cesspool, and well sites. The team participated in educational activities at the schools, including a controversial sex education/marriage preparation course that was ultimately limited to prospective newlyweds. Based on 8 years of program operation, the authors conclude that community participation is an important development resource and that the process of working together is as important as the results achieved.