A systematic review of anti-inflammatories for mild to moderate carpal tunnel syndrome

The purpose of this study was to evaluate anti-inflammatory drugs in the medium- and long-term management of mild to moderate carpal tunnel syndrome (CTS). The authors conducted a systematic review of the literature on the effectiveness of steroidal and nonsteroidal anti-inflammatory drugs for mild and moderate cases of CTS. There were included only randomized, double-blind clinical trials. Six publications referring to five trials were included in the review. No study on nonsteroidal anti-inflammatory drugs met our inclusion criteria. Although neurophysiological studies have not shown great differences resulting from the application of corticosteroids, the symptomatic benefit provided by such drugs is clear. In the short term, local infiltration provides better results than systemic administration of corticosteroids. Over a 1-year period, however, this difference does not persist. Further double-blind randomized trials evaluating therapeutic efficacy for a longer follow-up period are required to provide stronger evidence for both steroidal and nonsteroidal anti-inflammatories. © 2009 by Lippincott Williams & Wilkins.

Relações ordinais sob controle contextual em crianças surdas

Dificuldades apresentadas por crianças surdas na aprendizagem da matemática têm conduzido educadores ao desenvolvimento de procedimentos especiais de ensino. O paradigma de equivalência tem sido útil na explicação de comportamentos complexos, como comportamentos conceituais numéricos. Uma expansão desse paradigma envolve a formação de classes de estímulos equivalentes em seqüência. A emergência de novas relações através do responder ordinal já foi documentada em estudos com contingências de reforçamento de três termos. Há necessidade de verificar se esses resultados se mantém estáveis sob contingências de quatro e cinco termos. Três experimentos foram programados com o objetivo de investigar a emergência de relações ordinais com controle discriminativo simples, sob controle condicional (sem e com randomização das tentativas) e sob controle contextual em crianças surdas. No Experimento 1 participaram cinco crianças surdas, matriculadas numa Escola Pública Especializada. Um microcomputador com um software (REL 4.0, utilizado nos Experimentos 1, 2a e 2b e atualizado para a versão 5.0 no Estudo 3) foi utilizado. Nesse estudo foi ensinado aos participantes seqüências de pares de estímulos sobrepostos. Em seguida, foram realizados testes de transitividade e conectividade. Todos os participantes alcançaram o critério de acerto e responderam aos testes. Os resultados replicaram estudos da literatura confirmando a eficiência do procedimento de ensino por sobreposição de estímulos no estabelecimento de relações ordinais. No Experimento 2a, quatro novos participantes e um com história experimental, foram ensinados a selecionar estímulos, aos pares, na ordem crescente na presença da cor verde e na ordem decrescente na presença da cor vermelha. Foram aplicados testes de transitividade e conectividade sob controle condicional. Em seguida foi conduzido um teste de generalização com estímulos do ambiente escolar. Todos os participantes alcançaram o critério de acerto e responderam aos testes de transitividade e conectividade. Nos testes de generalização, três participantes responderam consistentemente aos novos estímulos, um respondeu parcialmente e um não respondeu ao teste. Os resultados corroboraram a eficiência do procedimento de ensino por sobreposição de estímulos sob controle condicional em crianças surdas. O Experimento 2b envolveu os mesmos participantes do Experimento 1 com história experimental e a randomização das tentativas com os estímulos condicionais. Todos os participantes alcançaram o critério de acerto. Nos testes demonstraram um responder consistente com a linha de base. No Experimento 3 participaram três crianças dos Experimento 1 e duas do Experimento 2a, que foram expostas ao procedimento de ensino por pares sobrepostos sob controle contextual de duas formas círculo e triângulo e sob controle condicional das cores verde e vermelha (ex. A1A2, na presença do círculo e da cor verde; ou A2A1, na presença do círculo e da cor vermelha). Todos os participantes alcançaram o critério de acerto e responderam aos testes de transitividade e conectividade. Os resultados indicaram a eficiência do procedimento de ensino por sobreposição de estímulos sob controle contextual, sugerindo que o ensino por contingências de reforçamento simples e sob controle condicional foram pré-requisitos para a emergência de classes ordinais sob controle contextual. Uma extensão deste estudo deve ampliar o número de membros na seqüência e investigar a emergência de novas relações ordinais com seqüências mais longas, e verificar se a ordem de treino em que a seqüência é ensinada interfere sobre o responder ordinal.

Equivalência monetária em crianças surdas

No ensino de habilidades monetárias os procedimentos de escolha com o modelo (MTS) e de escolha com o modelo com resposta construída (CRMTS) têm se mostrado efetivos. Entretanto, há uma controvérsia sobre a importância dos pré-requisitos. O experimento 1 teve por objetivo verificar o efeito de um ensino de MTS e CRMTS sobre a equivalência monetária em crianças surdas com diferentes repertórios matemáticos. Participaram 10 crianças matriculadas em uma Unidade de Ensino Especializada distribuídas em dois grupos experimentais: Crianças com maior repertório matemático (Grupo I) e crianças com menor repertório matemático (Grupo II). As sessões foram realizadas na referida instituição. Um microcomputador foi usado com um software (REL 5.3.3 for Windows). Inicialmente, os participantes foram submetidos a pré-testes e a um pré-treino de identidade. Em seguida, ao ensino de relações condicionais via MTS entre valores monetários em LIBRAS e numerais decimais (AB), valor monetário em LIBRAS e figuras de moedas (AC) e a valor monetário em LIBRAS e figuras de notas (AD), seguidos dos testes de simetria e transitividade. Nos dois grupos, houve emergência de relações para a maioria dos participantes. Posteriormente, houve ensino via CRMTS de figuras de notas e numerais decimais (DB‟), seguido de testes de simetria e transitividade. Nos testes houve variabilidade no responder em ambos os grupos. Pós-testes e testes de manutenção mostraram desempenho consistente com o treino. O experimento 2 teve por objetivo replicar os resultados do experimento 1 verificando se modificações no ensino produziria equivalência monetária. Participaram 3 crianças surdas. O ambiente experimental, materiais e equipamentos foram os mesmos. O procedimento foi similar ao procedimento utilizado no experimento 1, mas com a introdução de algumas fases experimentais: 1) tentativas randomizadas de ensino, ensino de componentes numéricos e pré-treino de CRMTS. Os resultados indicam emergência de relações para os três participantes em MTS e emergência de poucas relações em CRMTS. Em ambos os experimentos a complexidade da tarefa foi uma das possíveis explicações do desempenho e os pré-requisitos não interferiram na a aprendizagem deste tipo de tarefa.

Recuperação acelerada após reparo cirúrgico aberto eletivo do aneurisma da aorta abdominal: revisão sistemática da literatura

Pós-graduação em Anestesiologia - FMB

Placement of dental implants in the maxillary tuberosity: a systematic review

The aim of this systematic review was to identify clinical studies on implants placed in the tuberosity region to determine the survival rate of these implants when compared to implants placed in other regions of the maxilla. A search for data published up until March 2014 was undertaken using the PubMed, Cochrane Library, Embase, and ScienceDirect databases. Eligible studies were selected according to inclusion and exclusion criteria. The first database search revealed 310 titles. After inclusion and exclusion criteria were applied, five studies remained for the detailed analysis. A total of 113 patients were followed for a period of 6-144 months; 289 implants were placed in the patients evaluated. There were eight failures/losses of dental implants in the tuberosity region; the overall survival rate was 94.63% for these implants. In controlled studies, the cumulative survival rates for implants placed in the maxillary tuberosity and other maxillary regions were 96.1% and 95%, respectively. In conclusion, implants placed into the maxillary tuberosity are a predictable alternative for the treatment of patients with insufficient bone volume in the maxillary region. However, randomized trials are needed to assess the effectiveness of this treatment.

Selección del tratamiento farmacológico en el estado de mal epiléptico en niños

The status epilepticus (SE) is characterized by a series of crises which occur without recovery of consciousness or a single seizure lasting more than 30 minutes and can damage the central nervous system and systemic. The duration and frequency of attacks are directly related to patient prognosis. Whether seizures occur often and are longer, increase the risk of neurological and systemic complications. Child population has a higher frequency of seizures and it is associated with a lower threshold of immature brain to trigger these episodes. Aim: To determine the safest drugs prescribed for children in SE, their doses and schedules. A bibliographic survey was performed in electronic databases. Methods: The scientific health descriptors used for search was: “status epilecticus” and “anticonvulsivants” and “child”. Results: This strategy identified 396 manuscripts, of whom four were considered eligible for the study, after the assessment by floating reading and criteria. Of these, two were randomized trials and two descriptive. The studies address the use of oral midazolam, rectal diazepam and intravenous lorazepam. Conclusions: All investigated drugs were effective in treat in status epilepticus. Lorazepam is highlight, since it has fewer secondary effects and, as an alternative to the intravenous, oral midazolam. However, there is a need for further studies to demonstrate the efficacy and safety in the use of drugs in children.

Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

OBJECTIVE: Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS: Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS: Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17+/-6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilar artery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5+/-107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4+/-58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9+/-7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS: Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.

Association Between Use of Lung-Protective Ventilation With Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome A Meta-analysis

Context Lung-protective mechanical ventilation with the use of lower tidal volumes has been found to improve outcomes of patients with acute respiratory distress syndrome (ARDS). It has been suggested that use of lower tidal volumes also benefits patients who do not have ARDS. Objective To determine whether use of lower tidal volumes is associated with improved outcomes of patients receiving ventilation who do not have ARDS. Data Sources MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials up to August 2012. Study Selection Eligible studies evaluated use of lower vs higher tidal volumes in patients without ARDS at onset of mechanical ventilation and reported lung injury development, overall mortality, pulmonary infection, atelectasis, and biochemical alterations. Data Extraction Three reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. Data Synthesis Twenty articles (2822 participants) were included. Meta-analysis using a fixed-effects model showed a decrease in lung injury development (risk ratio [RR], 0.33; 95% CI, 0.23 to 0.47; I-2, 0%; number needed to treat [NNT], 11), and mortality (RR, 0.64; 95% CI, 0.46 to 0.89; I-2, 0%; NNT, 23) in patients receiving ventilation with lower tidal volumes. The results of lung injury development were similar when stratified by the type of study (randomized vs nonrandomized) and were significant only in randomized trials for pulmonary infection and only in nonrandomized trials for mortality. Meta-analysis using a random-effects model showed, in protective ventilation groups, a lower incidence of pulmonary infection (RR, 0.45; 95% CI, 0.22 to 0.92; I-2, 32%; NNT, 26), lower mean (SD) hospital length of stay (6.91 [2.36] vs 8.87 [2.93] days, respectively; standardized mean difference [SMD], 0.51; 95% CI, 0.20 to 0.82; I-2, 75%), higher mean (SD) PaCO2 levels (41.05 [3.79] vs 37.90 [4.19] mm Hg, respectively; SMD, -0.51; 95% CI, -0.70 to -0.32; I-2, 54%), and lower mean (SD) pH values (7.37 [0.03] vs 7.40 [0.04], respectively; SMD, 1.16; 95% CI, 0.31 to 2.02; I-2, 96%) but similar mean (SD) ratios of PaO2 to fraction of inspired oxygen (304.40 [65.7] vs 312.97 [68.13], respectively; SMD, 0.11; 95% CI, -0.06 to 0.27; I-2, 60%). Tidal volume gradients between the 2 groups did not influence significantly the final results. Conclusions Among patients without ARDS, protective ventilation with lower tidal volumes was associated with better clinical outcomes. Some of the limitations of the meta-analysis were the mixed setting of mechanical ventilation (intensive care unit or operating room) and the duration of mechanical ventilation. JAMA. 2012;308(16):1651-1659 www.jama.com

ST Elevation Myocardial Infarction in the elderly

Acute coronary syndromes (ACS) are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials from which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.

Strategies for Multivessel Revascularization in Patients with Diabetes

BACKGROUND In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease. METHODS In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1 +/- 9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03). CONCLUSIONS For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.)

Verlauf und Determinanten der Lebensqualität bei Langzeitüberlebenden nach Prostatakarzinom in Schleswig-Holstein : Ergebnisse einer registerbasierten Kohortenstudie

Durch die ansteigende Inzidenz und niedrige Mortalität steigt die Anzahl der überlebenden Männer nach Prostatakarzinom. Mit einer 5-Jahresprävalenz von 279.000 Männern stellte das Prostatakarzinom im Jahr 2010 den größten Anteil der Krebspatienten. Die absolute 5-Jahres-Überlebensrate liegt bei 78 %. Studien zur Lebensqualität dieser Langzeitüberlebenden (> 5 Jahre nach Diagnosestellung) beschränken sich meist auf bestimmte Therapien, schließen höhere Tumorstadien aus oder untersuchen nur die Wirkung von klinischen Einflussfaktoren. In Schleswig-Holstein wurde im Rahmen der populationsbezogenen OVIS- und CAESAR-Studie die Lebensqualität bei Männern mit bzw. nach Prostatakrebs zu drei Zeitpunkten erhoben (15 Monate, 3 ½ und 7 Jahre nach initialer Diagnose). Für die allgemeine krebsspezifische Lebensqualität (EORTC QLQ-C30) erfolgt eine Beschreibung des Verlaufs sowie ein Vergleich mit Referenzdaten aus der deutschen Allgemeinbevölkerung. Aus der dritten Befragung liegen auch Daten zur prostataspezifischen Lebensqualität (EORTC QLQ-PR25) vor. Mittels multipler linearer Regressionen werden für elf ausgewählte Lebensqualitätsskalen (mögliche Werte 0 bis 100) potenzielle Einflussfaktoren (klinisch, soziodemographisch, Lifestyle) untersucht. Die Lebensqualität der 911 Männer (medianes Alter bei Drittbefragung: 72 Jahre) nimmt im zeitlichen Verlauf nur gering, aber nicht klinisch relevant ab. Es zeigen sich nur geringe Unterschiede zur Lebensqualität der Referenzbevölkerung. Im absoluten Vergleich aller Skalen werden zum Zeitpunkt der Drittbefragung auf den prostataspezifischen Skalen die größten Einschränkungen berichtet. In den berechneten multiplen Regressionen war sieben Jahre nach Diagnose eine Krankheitsprogression auf allen untersuchten Skalen signifikant mit einer geringeren Lebensqualität assoziiert (niedrigster Regressionskoeffizient βadj -13,8, 95 %-CI -18,8; -8,8). Eine Strahlentherapie zeigte auf zehn, eine Hormontherapie auf fünf Skalen einen negativen Einfluss. Ebenfalls auf fünf Skalen war ein höherer Body-Mass-Index ein Prädiktor für eine geringere Lebensqualität. Auf allen Funktionsskalen war ein höherer Sozialstatus mit einer besseren Lebensqualität assoziiert und zeigte tendenziell einen größeren Einfluss als die initiale Therapie. Alleinstehende Männer berichteten eine geringere sexuelle Aktivität (βadj -7,5, 95 %-CI -13,8; -1,2) als Männer in einer Partnerschaft. Neben klinischen Faktoren beeinflussen auch soziodemographische Variablen die Lebensqualität von langzeitüberlebenden Männern nach bzw. mit Prostatakarzinom signifikant. Daher sollten in nicht-randomisierten Studien zum Adjustieren die entsprechenden Variablen (wie z. B. Body-Mass-Index, Sozialstatus, Partnerschaft) mit erhoben werden. Klinisch relevante Veränderungen der allgemeinen krebsspezifischen Lebensqualität finden – wenn überhaupt – innerhalb der ersten 15 Monate nach Diagnosestellung statt. Referenzdaten für die prostataspezifische Lebensqualität der Allgemeinbevölkerung liegen nicht vor. Eine Erhebung dieser scheint sinnvoll, da hier größere Unterschiede im Vergleich beider Gruppen erwartet werden.

Acute basilar artery occlusion in the Basilar Artery International Cooperation Study: does gender matter?

Randomized trials suggested a different benefit of intravenous thrombolysis (IVT) and intra-arterial thrombolysis (IAT) between men and women with anterior circulation stroke because of a worse outcome of women in the control group.

Sonographic follow-up of patients with carpal tunnel syndrome undergoing surgical or nonsurgical treatment: prospective cohort study

Purpose To compare changes in the largest cross-sectional area (CSA) of the median nerve in wrists undergoing surgical decompression with changes in wrists undergoing non-surgical treatment of carpal tunnel syndrome (CTS). Methods This study was a prospective cohort study in 55 consecutive patients with 78 wrists with established CTS, including 60 wrists treated with surgical decompression and 18 wrists with non-surgical treatment. A sonographic examination was scheduled before and 4 months after initiation of treatment. We compared changes in CSA of the median nerve between wrists with surgical treatment and wrists with non-surgical treatment using linear regression models. Results Decreases in CSA of the median nerve were more pronounced in wrists with CTS release than in wrists undergoing nonsurgical treatment (difference in means, 1.0 mm2; 95% confidence interval, 0.3–1.8 mm2). Results were robust to the adjustment for age, gender, and neurological severity at baseline. Among wrists with CTS release, those with postoperative CSA of 10 mm2 or less tended to have better clinical outcomes than those with postoperative CSA of greater than 10 mm2 (p=.055). Postoperative sonographic workup in the 3 patients with unfavorable outcome or recurrence identified likely causes for treatment failure in 2 patients. Conclusions In this observational study, surgical decompression was associated with a greater decrease in median nerve CSA than was nonsurgical treatment. Smaller postoperative CSAs may be associated with better clinical outcomes. Additional randomized trials are necessary to determine the optimal treatment strategy in different subgroups of patients with CTS. Type of study/level of evidence Therapeutic III.

Screening and treatment to prevent sequelae in women with Chlamydia trachomatis genital infection: how much do we know?

Background. An important question for chlamydia control programs is the extent to which finding and treating prevalent, asymptomatic Chlamydia trachomatis genital infection reduces reproductive sequelae in infected women. Methods. We reviewed the literature to critically evaluate evidence on the effect of chlamydia screening on development of sequelae in infected women. Results. Two randomized controlled trials of 1-time screening for chlamydial infection—in a Seattle-area health maintenance organization and a Danish school district—revealed that screening was associated with an ∼50% reduction in the incidence of pelvic inflammatory disease over the following year. However, both of these trials had methodological issues that may have affected the magnitude of observed screening benefits and might limit generalizability to other populations. A large, nonrandomized cohort of chlamydia screening among US Army recruits, although limited by lack of outpatient data, did not find a benefit of similar magnitude to the randomized trials. Methodological limitations restrict valid conclusions about individual benefits of screening using data from historical cohorts and ecological studies. We identified no trials directly evaluating the effect of chlamydia screening on subclinical tubal inflammation or damage, ectopic pregnancy, or tubal factor infertility and no studies addressing the effects of >1 round of screening, the optimal frequency of screening, or the benefits of screening for repeat infections. Conclusions. Additional studies of the effectiveness of chlamydia screening would be valuable; feasible study designs may depend on the degree to which screening programs are already established. In addition, better natural history data on the timing of tubal inflammation and damage after C. trachomatis infection and development of more accurate, noninvasive tools to assess chlamydial sequelae are essential to informing chlamydia control efforts.

Atrial fibrillation in congestive heart failure

Atrial fibrillation (AF) and heart failure (HF) are common and interrelated conditions, each promoting the other, and both associated with increased mortality. HF leads to structural and electrical atrial remodeling, thus creating the basis for the development and perpetuation of AF; and AF may lead to hemodynamic deterioration and the development of tachycardia-mediated cardiomyopathy. Stroke prevention by antithrombotic therapy is crucial in patients with AF and HF. Of the 2 principal therapeutic strategies to treat AF, rate control and rhythm control, neither has been shown to be superior to the other in terms of survival, despite better survival in patients with sinus rhythm compared with those in AF. Antiarrhythmic drug toxicity and poor efficacy are concerns. Catheter ablation of AF can establish sinus rhythm without the risks of antiarrhythmic drug therapy, but has important procedural risks, and data from randomized trials showing a survival benefit of this treatment strategy are still lacking. In intractable cases, ablation of the atrioventricular junction and placement of a permanent pacemaker is a treatment alternative; and biventricular pacing may prevent or reduce the negative consequences of chronic right ventricular pacing.