Impact of cancer-related symptom synergisms on health-related quality of life and performance status

To identify the impact of multiple symptoms and their co-occurrence on health-related quality of life (HRQOL) dimensions and performance status (PS), 115 outpatients with cancer, who were not receiving active cancer treatment and were recruited from, a university hospital in Sao Paulo, Brazil completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30, the Beck Depression Inventory, and the Brief Pain Inventory. Karnofsky Performance Status scores also were completed. Application of TwoStep Cluster analysis resulted in two distinct patient subgroups based on 113 patient experiences with pain, depression, fatigue, insomnia, constipation, lack of appetite, dyspnea, nausea, vomiting, and diarrhea. One group had multiple and severe symptom subgroup and another had Less symptoms and with lower severity. Multiple and severe symptoms had worse PS, role functioning, and physical, emotional, cognitive, social, and overall HRQOL. Multiple and severe symptom subgroup was also six times as likely as lower severity to have poor role functioning;five times more likely to have poor emotional;four times more likely to have poor PS, physical, and overall HRQOL, and three times as likely to have poor cognitive and social HRQOL, independent of gender, age, level of education, and economic condition. Classification and Regression Tree analyses were undertaken to identify which co-occurring symptoms would best determine reduction in HRQOL and PS. Pain and fatigue were identified as indicators of reduction on physical HRQOL and PS. Fatigue and insomnia were associated with reduction in cognitive; depression and pain in social; and fatigue and constipation in role functioning. Only depression was associated with reduction in overall HRQOL. These data demonstrate that there is a synergic effect among distinct cancer symptoms that result in reduction in HRQOL dimensions and PS.

Stroke prevalence in a poor neighbourhood of Sao Paulo, Brazil: applying a stroke symptom questionnaire

Background Brazil has one of the highest stroke mortality rates in the world, these rates are most endemic in the poor. We verified the prevalence of stroke in a deprived neighbourhood in the city of Sao Paulo, Brazil and compared it with other surveys worldwide. Methods A questionnaire with six questions concerning limb and facial weakness, articulation, sensory disturbances, impaired vision, and past diagnosis of stroke was completed door-to-door in a well-defined area of 15 000 people. Questionnaires were considered positive when a participant answered two or more questions about stroke symptoms or the presence of stroke being confirmed by a physician, or at least three questions in the positive, even if not confirmed by a doctor. Results Of the 4496 individuals over 35-years old living in the area, 243 initially screened positive for stroke. The age-adjusted prevalence rate for men was 4 center dot 6% (95% confidence interval 3 center dot 5-5 center dot 7). For women, the prevalence rate was 6 center dot 5% (95% confidence interval 5 center dot 5-7 center dot 5); when considering only one question, the rate was 4 center dot 8% (95% confidence interval 3 center dot 9-5 center dot 7). The most commonly reported symptoms were limb weakness and sensory disturbances. Hypertension and heart disease were the conditions most commonly associated with previous stroke. Conclusion Stroke prevalence rates were higher in this poor neighbourhood compared with other surveys.

Cross-cultural adaptation and validation of a Quality of Life questionnaire: The Nasal Obstruction Symptom Evaluation questionnaire

Background:The Nasal Obstruction Symptom Evaluation (NOSE) instrument is a disease-specific questionnaire for assessing the outcome of an intervention in nasal obstruction in trials. This instrument is only available in the English language and cross-culturally valid questionnaires are very important for all research, including nasal obstruction. The aim of the current study was to reproduce the cross-cultural adaptation process for the NOSE questionnaire in the Portuguese language (NOSE-p). Methodology: Cross-cultural adaptation and validation of the instrument were divided into two stages. Stage I involved four bilingual professionals, an expert committee and the author of the original instrument. In Stage 2, the NOSE-p was tested on 33 patients undergoing septoplasty for internal consistency, test-retest reliability, construct validity. discriminant validity, criterion validity, and response sensitivity. Results: The cross-cultural adaptation process was completed and the NOSE-p was demonstrated to be a valid instrument with satisfactory construct validity. It showed an adequate internal consistency reliability and adequate test-retest reliability. It could discriminate between patients with and without nasal obstruction and it has a high response sensitivity to change. Conclusions: The cross-cultural adaptation and validation process demonstrated to be valid and the NOSE-p proved to be applicable in Brazil.

Suicidality in Obsessive-Compulsive Disorder: Prevalence and Relation to Symptom Dimensions and Comorbid Conditions

Background: Suicidal thoughts and behaviors, also known as suicidality, are a fairly neglected area of study in patients with obsessive-compulsive disorder (OCD). Objective: To evaluate several aspects of suicidality in a large multicenter sample of OCD patients and to compare those with and without suicidal ideation, plans, and attempts according to demographic and clinical variables, including symptom dimensions and comorbid disorders. Method: This cross-sectional study included 582 outpatients with primary OCD (DSM-IV) recruited between August 2003 and March 2008 from 7 centers of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. The following assessment instruments were used: the Yale-Brown Obsessive Compulsive Scale, the Dimensional Yale-Brown Obsessive Compulsive Scale, the Beck Depression and Anxiety Inventories, the Structured Clinical Interview for DSM-IV Axis I Disorders, and 6 specific questions to investigate suicidality. After univariate analyses, logistic regression analyses were performed to adjust the associations between the dependent and explanatory variables for possible confounders. Results: Thirty-six percent of the patients reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide, and 10% presented current suicidal thoughts. In the logistic regression, only lifetime major depressive disorder and posttraumatic stress disorder (PTSD) remained independently associated with all aspects of suicidal behaviors. The sexual/religious dimension and comorbid substance use disorders remained associated with suicidal thoughts and plans, while impulse-control disorders were associated with current suicidal thoughts and with suicide plans and attempts. Conclusions: The risk of suicidal behaviors must be carefully investigated in OCD patients, particularly those with symptoms of the sexual/religious dimension and comorbid major depressive disorder, PTSD, substance use disorders, and impulse-control disorders. J Clin Psychiatry 2011;72(1):17-26 (C) Copyright 2011 Physicians Postgraduate Press, Inc.

Association between symptom severity and internal capsule volume in obsessive-compulsive disorder

Neurobiological models support an involvement of white matter tracts in the pathophysiology of obsessive-compulsive disorder (OCD), but there has been little systematic evaluation of white matter volumes in OCD using magnetic resonance imaging (MRI). We investigated potential differences in the volume of the cingulum bundle (CB) and anterior limb of internal capsule (ALIC) in OCD patients (n = 19) relative to asymptomatic control subjects (n = 15). White matter volumes were assessed using a 1.5T MRI scanner. Between-group comparisons were carried out after spatial normalization and image segmentation using optimized voxel-based morphometry. Correlations between regional white matter volumes in OCD subjects and symptom severity ratings were also investigated. We found significant global white matter reductions in OCD patients compared to control subjects. The voxel-based search for regional abnormalities (with covariance for total white matter volumes) showed no specific white matter volume deficits in brain portions predicted a priori to be affected in OCD (CB and ALIC). However, large clusters of significant positive correlation with OCD severity scores were found bilaterally on the ALIC. These findings provide evidence of OCD-related ALIC abnormalities and suggest a connectivity dysfunction within frontal-striatal-thalamic-cortical circuits. Further studies are warranted to better define the role of such white matter alterations in the pathophysiology of OCD, and may provide clues for a more effectively targeting of neurosurgical treatments for OCD. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Case Series: Sensory Intolerance as a Primary Symptom of Pediatric OCD

Introduction. Marked intolerance or intrusive re-experiencing of ordinary sensory stimuli that in turn drive functionally impairing compulsive behaviors are occasionally seen in voting children with OCD. Methods. We describe a number of children with DSM-IV OCD ascertained from of family genetic study of pediatric OCD, whose intolerance: of ordinary sensory stimuli created significant subjective distress and time-consuming ritualistic behavior that was clinically impairing. Results. In each case these sensory symptoms were the primary presenting symptoms and were experienced in the absence of intrusive thoughts, images, or ideas associated with ""conventional"" OCD symptoms. Conclusions. These symptoms suggest abnormalities in sensory processing and integration in at least a subset of OCD patients. Recognition of these sensory symptoms and sensory-driven behaviors as part of the broad phenotypic Variation in children with OCD could help clinicians more easily identify OCD patients and,facilitate treatment.

Homeopathic practice in Intensive Care Units: objective semiology, symptom selection and a series of sepsis cases

Homeopathy has been used for more than two hundred years to treat chronic disease using various approaches in a wide range of diseases. However, for acute disease and critical illness, application has been limited by inadequate training of homeopathic physicians and the small number of pertinent clinical studies. In view of the difficulty of practising homeopathy in Intensive Care Units (ICU), a protocol was developed to facilitate description of objective homeopathic symptoms with a ranking of symptoms appropriate for these situations (Protocol for Objective Homeopathic Semiology). Examples of favorable results with individualized homeopathic treatments for a series of cases of Systemic Inflammatory Response Syndrome (sepsis) are described. Homeopathy (2008) 97, 206-213.

Brain structure and symptom dimension relationships in obsessive-compulsive disorder: A voxel-based morphometry study

Background: Obsessive-compulsive disorder (OCD) is a clinically heterogenous disorder characterized by temporally stable symptom dimensions. Past inconsistent results from structural neuroimaging studies of OCD may have resulted from the effects of these specific symptom dimensions as well as other socio-demographic and clinical variables upon gray matter (GM) volume. Methods: GM volume was measured in 25 adult OCD patients and 20 adult healthy controls using voxel-based morphometry (VBM), controlling for age and total brain GM volume. Univariate and multivariate regression analyses were carried out between regions of GM difference and age, age of onset, medication load, OCD severity, depression severity, and separate symptom dimension scores. Results: Significant GM volumetric differences in OCD patients relative to controls were found in dorsal cortical regions, including bilateral BA6, BA46, BA9 and right BA8 (controls > patients), and bilateral midbrain (patients > controls). Stepwise regression analyses revealed highly significant relationships between greater total OCD symptom severity and smaller GM volumes in dorsal cortical regions and larger GM volumes in bilateral midbrain. Greater age was independently associated with smaller GM volumes in right BA6, left BA9, left BA46 and larger GM volumes in right midbrain. Greater washing symptom severity was independently associated with smaller GM volume in right BA6, while there was a trend association between greater hoarding symptom severity and lower GM volume in left BA6. Limitations: The sample was relatively small to examine the relationship between symptom scores and GM volumes. Multiple patients were taking medication and had comorbid disorders. Conclusions: These analyses suggest dorsal prefrontal cortical and bilateral midbrain GM abnormalities in OCD that appear to be primarily driven by the effects of total OCD symptom severity. The results regarding the relationship between GM volumes and symptom dimension scores require examination in larger samples. (C) 2008 Elsevier B.V. All rights reserved.

Relationship among eccentric hip and knee torques, symptom severity and functional capacity in females with patellofemoral pain syndrome

Objective: To determine the relationships between eccentric hip and knee torques, symptom severity and functional capacity in females with patellofemoral pain syndrome (PFPS). Design: Within-subject correlational study. Setting: University biomechanics laboratory. Participants: 10 females diagnosed with PFPS. Main outcome measures: Eccentric strength of the hip abductors and lateral rotators, and knee extensors were assessed using an isokinetic dynamometer. A 10-cm visual analog scale was used to determine usual knee pain in the last week. The Anterior Knee Pain Scale (AKPS) was used to determine the functional capacity of the patients. Results: The study found that the greater the eccentric knee extensor and hip lateral rotator torques, the higher the functional capacity of the patients (p = 0.02, r = 0.72; p = 0.02, r = 0.72). It was also shown that the greater hip lateral rotator torque, the less the usual pain reported in the last week (p = 0.004, r = -0.84). Despite the lack of statistical significance (p = 0.11), it was also found a modest negative relationship between the eccentric knee extensor torque and the usual pain reported in the last week (r = -0.56) that was considered clinically meaningful (d = 1.4). Conclusions: This study showed that eccentric knee extensor and hip lateral rotator torques were associated with functional capacity and pain level in females with PFPS. Further investigations should be carried out to verify the effects of an intervention program focused on the eccentric action of these muscles with respect to the symptoms in patients with PFPS. (C) 2011 Elsevier Ltd. All rights reserved.

Segmental LeFort I osteotomy for treatment of a class III malocclusion with temporomandibular disorder

This article reports the case of a 19-year-old young man with Class III malocclusion and posterior crossbite with concerns about temporomandibular disorder (TMD), esthetics and functional problems. Surgical-orthodontic treatment was carried out by decompensation of the mandibular incisors and segmentation of the maxilla in 4 pieces, which allowed expansion and advancement. Remission of the signs and symptoms occurred after surgical-orthodontic intervention. The maxillary dental arch presented normal transverse dimension. Satisfactory static and functional occlusion and esthetic results were achieved and remained stable. Three years after the surgical-orthodontic treatment, no TMD sign or symptom was observed and the occlusal results had not changed. When vertical or horizontal movements of the maxilla in the presence of moderate maxillary constriction are necessary, segmental LeFort I osteotomy can be an important part of treatment planning.

Systemic treatment in severe cases of recurrent aphthous stomatitis: an open trial

PURPOSE: This study aimed to evaluate the efficacy of the systemic drugs thalidomide, dapsone, colchicine, and pentoxifylline in the treatment of severe manifestations of RAS. METHODS: An open, 4-year clinical trial was carried out for 21 consecutive patients with severe RAS. Initially, patients were given a 2-week course of prednisone to bring them to a baseline status. Simultaneously, one of the four test drugs was assigned to each patient to be taken for a period of 6 months. During the course of the trial, patients were switched to one of the other three drugs whenever side effects or a lack of satisfactory results occurred, and the 6-month limit of the treatment was then reset. RESULTS: The most efficient and best-tolerated drug was thalidomide, which was administered to a total of eight patients and resulted in complete remission in seven (87.5%). Dapsone was prescribed for a total of nine patients, of whom eight (89%) showed improvement in their symptoms, while five showed complete remission. Colchicine was administered to a total of ten patients, with benefits observed in nine (90%), of whom four showed complete remission. Pentoxyfilline was administered to a total of five patients, with benefits observed in three (60%), of whom one patient showed complete remission. CONCLUSION: The therapeutic methods used in this trial provided significant symptom relief. Patients experienced relapses of the lesions; however, this occurred after withdrawal of their medication during the follow-up period.

Osteochondroma of the temporomandibular joint: a case report

Osteochondroma of the mandibular condyle has been found in the oral and maxillofacial region rarely. This paper describes a case of osteochondroma of the mandibular condyle in a 20-year-old woman, who was referred to our service with facial asymmetry, prognathic deviation of chin, cross-bite to the contralateral side, changes in condylar morphology, limited mouth opening, and malocclusion. Computed tomography (CT) was performed for better evaluation to the pathological conditions on the temporomandibular joint. Based on the clinical examination, patient history, and complementary exams, the hypothesis of osteochondroma was established. Condylectomy was performed using a preauricular approach with total removal of the lesion. After 3 years of postoperative follow up and orthodontic therapy, the patient is symptom-free, and has normal mouth opening with no deviation in the opening pattern.

Tratamento farmacológico da DPOC

Aproximadamente sete milhões de brasileiros acima de 40 anos são acometidos pela DPOC. Nos últimos anos, importantes avanços foram registrados no campo do tratamento medicamentoso dessa condição. Foi realizada uma revisão sistemática incluindo artigos originais sobre tratamento farmacológico da DPOC publicados entre 2005 e 2009, indexados em bases de dados nacionais e internacionais e escritos em inglês, espanhol ou português. Artigos com tamanho amostral menor de 100 indivíduos foram excluídos. Os desfechos sintomas, função pulmonar, qualidade de vida, exacerbações, mortalidade e efeitos adversos foram pesquisados. Os artigos foram classificados segundo o critério da Global Initiative for Chronic Obstructive Lung Disease para nível de evidência científica (grau de recomendação A, B e C). Dos 84 artigos selecionados, 40 (47,6%), 18 (21,4%) e 26 (31,0%) foram classificados com graus A, B e C, respectivamente. Das 420 análises oriundas desses artigos, 236 referiam-se à comparação de fármacos contra placebo nos diversos desfechos estudados. Dessas 236 análises, os fármacos mais frequentemente estudados foram anticolinérgicos de longa duração, a combinação β2-agonistas de longa duração + corticosteroides inalatórios e corticosteroides inalatórios isolados em 66, 48 e 42 análises, respectivamente. Nas mesmas análises, os desfechos função pulmonar, efeitos adversos e sintomas geraram 58, 54 e 35 análises, respectivamente. A maioria dos estudos mostrou que os medicamentos aliviaram os sintomas, melhoraram a qualidade de vida, a função pulmonar e preveniram as exacerbações. Poucos estudos contemplaram o desfecho mortalidade, e o papel do tratamento medicamentoso nesse desfecho ainda não está completamente definido. Os fármacos estudados são seguros no manejo da DPOC, com poucos efeitos adversos.

Ressecções eletiva e de urgência para tratamento de neoplasia maligna do cólon em hospital universitário: estudo de 66 casos

O câncer de cólon é uma doença de alta prevalência e mortalidade, cujo tratamento baseia-se na ressecção cirúrgica. A possibilidade de cura aumenta com o diagnóstico precoce, daí a importância dos programas de rastreamento populacional do câncer colorretal. O presente estudo analisou, retrospectivamente, 66 pacientes submetidos a ressecções do cólon por neoplasia em um período de 58 meses no Hospital Universitário da Universidade de São Paulo. Os pacientes foram divididos em dois grupos: grupo 1, submetidos a cirurgia eletiva (28 pacientes), e grupo 2, submetidos a cirurgia de urgência (38 pacientes). Os grupos foram comparados com relação às variáveis sexo, idade, apresentação clínica, aspectos da técnica cirúrgica, sítio anatômico da lesão, estádio patológico, taxas de complicações, permanência hospitalar pós-operatória e óbitos na internação. Verificou-se no presente estudo que a idade entre os grupos foi semelhante. Houve uma predominância do sexo masculino entre os pacientes operados de urgência. No grupo de cirurgia eletiva, o principal sintoma foi a hematoquezia, enquanto os operados na urgência, tinham como principal queixa dor abdominal. A grande maioria dos pacientes, no momento da cirurgia, apresentava-se sintomática há meses. Os pacientes operados na urgência apresentaram mais tumores pT4 e os operados eletivamente apresentaram mais neoplasias em estádio I. Em ambos os grupos, o caráter oncológico dos procedimentos foi preservado, bem como foi alto o índice de anastomoses primárias (81,8%). As taxas de complicações pós-operatórias, o tempo de permanência hospitalar pós-operatório e a mortalidade foram semelhantes.

Evolucionismo e genética do transtorno de estresse pós-traumático

Os autores discutem, a partir do conceito evolutivo, como a resposta de estresse, nas suas possibilidades de fuga e luta e de imobilidade tônica, pode levar a uma nova compreensão etiológica do transtorno de estresse pós-traumático. Através da análise dos agrupamentos de sintomas desse diagnóstico - revivência, evitação e hiperexcitação -, procuram correlacionar os achados neurobiológicos e evolutivos. As descobertas atuais sobre a genética do transtorno de estresse pós-traumático são resumidas e colocadas nessa perspectiva evolutiva, dentro de conceitos que possibilitam o entendimento da interação gene/ambiente, como a epigenética. Propõem que a pesquisa dos fatores de risco do transtorno de estresse pós-traumático deva ser investigada do ponto de vista fatorial, onde a somatória destes aumenta o risco de desenvolvimento do quadro, não sendo possível a procura da causa do transtorno de forma única. A pesquisa de genes candidatos no transtorno de estresse pós-traumático deve levar em consideração todos os sistemas associados aos processos de respostas ao estresse, sistemas dos eixos hipotálamo-hipofisário-adrenal e simpático, mecanismos de aprendizado, formação de memórias declarativas, de extinção e esquecimento, da neurogênese e da apoptose, que envolvem vários sistemas de neurotransmissores, neuropeptídeos e neuro-hormônios.