Análise biomecânica da marcha e funcionalidade em crianças com Paralisia Cerebral: efeito da intervenção da fisioterapia com facilitação em tapete rolante

Introdução: As crianças com Paralisia Cerebral evidenciam frequentemente alterações da sua funcionalidade global, evidenciadas nomeadamente na marcha. Diferentes protocolos de facilitação da marcha em tapete rolante têm vindo a ser alvo de estudos no sentido de clarificar a sua eficácia nesta população. Estes sugerem uma evolução positiva dos diferentes aspectos estudados (funcionalidade global, resistência cardiorespiratória, componentes da marcha), contudo utilizam diferentes metodologias e especificidades do protocolo, não existindo consenso acerca das melhores condições de utilização. Objectivo(s): O presente trabalho teve como objectivo principal avaliar o efeito da aplicação de um protocolo de marcha em tapete rolante (PMTR) em crianças com Paralisia Cerebral (PC) espástica, nos parâmetros biomecânicos da mesma e funcionalidade global. Métodos: Participaram no estudo 9 crianças com PC do tipo diplégico e hemiplégico inscritos na Associação de Paralisia Cerebral de Braga (APCB), com idades compreendidas entre os 3 e os 8 anos de idade. Cada criança foi avaliada antes e após a aplicação do PMTR, através da análise biomecânica da marcha (dinamometria e electromiografia de superfície), bem como da aplicação do teste de medida da função motora (TMFM). A amostra foi dividida em dois grupos – grupo sujeito ao protocolo de marcha em tapete rolante (GPMTR) (n=5) e grupo controlo (GC) (n=4). O protocolo em tapete rolante foi incluído nas sessões de intervenção de fisioterapia, com uma frequência semanal de 2 a 3 vezes por semana, durante um período de 10 semanas consecutivas, após o qual foram repetidas as avaliações iniciais. Resultados: A análise dos resultados permitiu verificar evoluções no GPMTR ao nível do score total da TMFM e especialmente na dimensão E, o que revelou melhorias significativas da funcionalidade motora global neste grupo. Verificaram-se ainda, em termos eletromiográficos um melhor padrão de recrutamento muscular, bem como, no que se refere à análise dinamométrica, evoluções positivas, na componente vertical das forças de reacção do solo.Conclusão: O presente estudo parece sugerir que a inclusão da facilitação da marcha em tapete rolante no plano de intervenção pode contribuir para uma melhoria nos parâmetros biomecânicos da marcha e funcionalidade global de crianças com Paralisia Cerebral do tipo diplégico e hemiplégico, com idades compreendidas entre os 3 e os 8 anos.

HIV AND HCV COINFECTION: PREVALENCE, ASSOCIATED FACTORS AND GENOTYPE CHARACTERIZATION IN THE MIDWEST REGION OF BRAZIL

A cross-sectional study on prevalence, associated factors and genotype distribution of HCV infection was conducted among 848 HIV-infected patients recruited at reference centers in the Midwest Region of Brazil. The prevalence rate of HIV-HCV coinfection was 6.9% (95% CI: 5.2 to 8.6). In multivariable analysis, increasing age, use of illicit drugs (injection and non-injection), a history of blood transfusion before 1994, and the absence of a steady partnership were significant independent associated factors for HIV-HCV coinfection. The phylogenetic analysis based on the NS5B region revealed the presence of two major circulating genotypes of HCV: genotypes 1 (58.3%) and 3 (41.7%). The prevalence of HIV-HCV coinfection was lower than those reported in studies conducted with HIV-infected patients in different regions of Brazil, due to the fact that illicit drug use is not a frequent mode of HIV transmission in this region of Brazil. Serologic screening of HIV-patients for HCV before initiating antiretroviral treatment, a comprehensive identification of associated factors, and the implementation of effective harm reduction programs are highly recommended to provide useful information for treatment and to prevent HCV coinfection in these patients.

The HIF1A Functional Genetic Polymorphism at Locus +1772 Associates with Progression to Metastatic Prostate Cancer and Refractoriness to Hormonal Castration

The hypoxia inducible factor 1 alpha (HIF1a) is a key regulator of tumour cell response to hypoxia, orchestrating mechanisms known to be involved in cancer aggressiveness and metastatic behaviour. In this study we sought to evaluate the association of a functional genetic polymorphism in HIF1A with overall and metastatic prostate cancer (PCa) risk and with response to androgen deprivation therapy (ADT). The HIF1A +1772 C>T (rs11549465) polymorphism was genotyped, using DNA isolated from peripheral blood, in 1490 male subjects (754 with prostate cancer and 736 controls cancer-free) through Real-Time PCR. A nested group of cancer patients who were eligible for androgen deprivation therapy was followed up. Univariate and multivariate models were used to analyse the response to hormonal treatment and the risk for developing distant metastasis. Age-adjusted odds ratios were calculated to evaluate prostate cancer risk. Our results showed that patients under ADT carrying the HIF1A +1772 T-allele have increased risk for developing distant metastasis (OR, 2.0; 95%CI, 1.1-3.9) and an independent 6-fold increased risk for resistance to ADT after multivariate analysis (OR, 6.0; 95%CI, 2.2-16.8). This polymorphism was not associated with increased risk for being diagnosed with prostate cancer (OR, 0.9; 95%CI, 0.7-1.2). The HIF1A +1772 genetic polymorphism predicts a more aggressive prostate cancer behaviour, supporting the involvement of HIF1a in prostate cancer biological progression and ADT resistance. Molecular profiles using hypoxia markers may help predict clinically relevant prostate cancer and response to ADT.

LACK OF ASSOCIATION BETWEEN HERPESVIRUS DETECTION IN SALIVA AND GINGIVITIS IN HIV‑INFECTED CHILDREN

The aims of this study were to compare the detection of human herpesviruses (HHVs) in the saliva of HIV-infected and healthy control children, and to evaluate associations between viral infection and gingivitis and immunodeficiency. Saliva samples were collected from 48 HIV-infected and 48 healthy control children. Clinical and laboratory data were collected during dental visits and from medical records. A trained dentist determined gingival indices and extension of gingivitis. Saliva samples were tested for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), varicella zoster virus (VZV), Epstein-Barr virus (EBV), and cytomegalovirus (CMV) by nested polymerase chain reaction assays. Thirty-five HIV-infected and 16 control children had gingivitis. Seventeen (35.4%) HIV-infected children and 13 (27%) control children were positive for HHVs. CMV was the most commonly detected HHV in both groups (HIV-infected, 25%; control, 12.5%), followed by HSV-1 (6.2% in both groups) and HSV-2 (HIV-infected, 4.2%; control, 8.3%). The presence of HHVs in saliva was not associated with the presence of gingivitis in HIV-1-infected children (p = 0.104) or healthy control children (p = 0.251), or with immunosuppression in HIV-infected individuals (p = 0.447). Gingivitis was correlated with HIV infection (p = 0.0001). These results suggest that asymptomatic salivary detection of HHVs is common in HIV-infected and healthy children, and that it is not associated with gingivitis.

Evidence for Nevirapine Bioactivation in Man: Searching for the First Step in the Mechanism of Nevirapine Toxicity

Despite its efficacy, including in the prevention of vertical transmission, the antiretroviral nevirapine is associated with severe idiosyncratic hepatotoxicity and skin rash. The mechanisms underlying nevirapine toxicity are not fully understood, but drug bioactivation to reactive metabolites capable of forming stable protein adducts is thought to be involved. This hypothesis is based on the paradigm that drug reactive metabolites have the potential to bind to self-proteins, which results in drug-modified proteins being perceived as foreign by the immune system. The aim of the present work was to identify hemoglobin adducts in HIV patients as biomarkers of nevirapine haptenation upon bioactivation. The ultimate goal is to develop diagnostic methods for predicting the onset of nevirapine-induced toxic reactions. All included subjects were adults on nevirapine-containing antiretroviral therapy for at least 1month. The protocol received prior approval from the Hospital Ethics Committees and patients gave their written informed consent. Nevirapine-derived adducts with the N-terminal valine of hemoglobin were analyzed by an established liquid chromatography-electrospray ionization-tandem mass spectrometry method and characterized on the basis of retention time and mass spectrometric fragmentation pattern by comparison with adduct standards prepared synthetically. The nevirapine adducts were detected in 12/13 patient samples, and quantified in 11/12 samples (2.58±0.8 fmol/g of hemoglobin). This work represents the first evidence of nevirapine-protein adduct formation in man and confirms the ability of nevirapine to modify self-proteins, thus providing clues to the molecular mechanisms underlying nevirapine toxicity. Moreover, the possibility of assessing nevirapine-protein adduct levels has the potential to become useful for predicting the onset of nevirapine-induced adverse reactions.

The HIF1A Functional Genetic Polymorphism at Locus +1772 Associates with Progression to Metastatic Prostate Cancer and Refractoriness to Hormonal Castration

The hypoxia inducible factor 1 alpha (HIF1a) is a key regulator of tumour cell response to hypoxia, orchestrating mechanisms known to be involved in cancer aggressiveness and metastatic behaviour. In this study we sought to evaluate the association of a functional genetic polymorphism in HIF1A with overall and metastatic prostate cancer (PCa) risk and with response to androgen deprivation therapy (ADT). The HIF1A +1772 C>T (rs11549465) polymorphism was genotyped, using DNA isolated from peripheral blood, in 1490 male subjects (754 with prostate cancer and 736 controls cancer-free) through Real-Time PCR. A nested group of cancer patients who were eligible for androgen deprivation therapy was followed up. Univariate and multivariate models were used to analyse the response to hormonal treatment and the risk for developing distant metastasis. Age-adjusted odds ratios were calculated to evaluate prostate cancer risk. Our results showed that patients under ADT carrying the HIF1A +1772 T-allele have increased risk for developing distant metastasis (OR, 2.0; 95%CI, 1.1-3.9) and an independent 6-fold increased risk for resistance to ADT after multivariate analysis (OR, 6.0; 95%CI, 2.2-16.8). This polymorphism was not associated with increased risk for being diagnosed with prostate cancer (OR, 0.9; 95%CI, 0.7-1.2). The HIF1A +1772 genetic polymorphism predicts a more aggressive prostate cancer behaviour, supporting the involvement of HIF1a in prostate cancer biological progression and ADT resistance. Molecular profiles using hypoxia markers may help predict clinically relevant prostate cancer and response to ADT.

Invasive Assessment of the Coronary Microcirculation Using the Index of Microcirculatory Resistance: Description and Validation of an Animal Model

INTRODUCTION: The index of microcirculatory resistance (IMR) enables/provides quantitative, invasive, and real-time assessment of coronary microcirculation status. AIMS: The primary aim of this study was to validate the assessment of IMR in a large animal model, and the secondary aim was to compare two doses of intracoronary papaverine, 5 and 10 mg, for induction of maximal hyperemia and its evolution over time. METHODS: Measurements of IMR were performed in eight pigs. Mean distal pressure (Pd) and mean transit time (Tmn) were measured at rest and at maximal hyperemia induced with intracoronary papaverine, 5 and 10 mg, and after 2, 5, 8 and 10 minutes. Disruption of the microcirculation was achieved by selective injection of 40-μm microspheres via a microcatheter in the left anterior descending artery. RESULTS: In each animal 14 IMR measurements were made. There were no differences between the two doses of papaverine regarding Pd response and IMR values - 11 ± 4.5 U with 5 mg and 10.6 ± 3 U with 10 mg (p=0.612). The evolution of IMR over time was also similar with the two doses, with significant differences from resting values disappearing after five minutes of intracoronary papaverine administration. IMR increased with disrupted microcirculation in all animals (41 ± 16 U, p=0.001). CONCLUSIONS: IMR provides invasive and real-time assessment of coronary microcirculation. Disruption of the microvascular bed is associated with a significant increase in IMR. A 5-mg dose of intracoronary papaverine is as effective as a 10-mg dose in inducing maximal hyperemia. After five minutes of papaverine administration there is no significant difference from resting hemodynamic status.

Contraceptive Choices Pre and Post Pregnancy in Adolescence

STUDY OBJECTIVE: The main aim of this study is to evaluate the impact of adolescent pregnancy in the future contraceptive choices. A secondary aim is to verify whether these choices differ from those made after an abortion. DESIGN: Retrospective study. SETTING:Adolescent Unit of a tertiary care center. PARTICIPANTS:212 pregnant teenagers. INTERVENTIONS: Medical records review. MAIN OUTCOME MEASURES:Intended pregnancy rate and contraceptive methods used before and after pregnancy. For contraceptive choices after pregnancy we considered: Group 1 - teenagers who continued their pregnancy to delivery (n = 106) and Group 2 - the same number of adolescents who chose to terminate their pregnancy. RESULTS: The intended pregnancy rate was 14.2%. Prior to a pregnancy continued to delivery, the most widely used contraceptive method was the male condom (50.9%), followed by oral combined contraceptives (28.3%); 18.9% of adolescents were not using any contraceptive method. After pregnancy, contraceptive implant was chosen by 70.8% of subjects (P < .001) and the oral combined contraceptives remained the second most frequent option (17.9%, P = .058). Comparing these results with Group 2, we found that the outcome of the pregnancy was the main factor in the choices that were made. Thus, after a pregnancy continued to delivery, adolescents prefer the use of LARC [78.4% vs 40.5%, OR: 5,958 - 95% (2.914-12.181), P < .001)], especially contraceptive implants [70.8% vs 38.7%, OR: 4.371 - 95% (2.224-8.591), P < .001], to oral combined contraceptives [17.9% vs 57.5%, OR: 0.118 - 95% CI (0.054-0.258), P < .001]. CONCLUSION:Adolescent pregnancy and its outcome constitute a factor of change in future contraceptive choice.

Avaliação terapêutica do hycanthone em pacientes com período de infecção esquistossomótica conhecido

Neste trabalho são estudados 28 pacientes com período de infecção esquistossomótica conhecido, e que foram tratados com hycanthone, (2,5 mg/kg, dose única, i.m.) em diferentes épocas após o contágio. Através do exame coprológico quantitativo (método de Kato), demonstra-se que a cura parasitológica é menor nos pacientes com infecção recente. De fato, de 15 pacientes tratados, 2 a 8 meses após o contágio, apenas 6 (40,0%) curaram-se. Enquanto que nos pacientes com infecção em tôrno de 1 ano, 84,7% deixaram de eliminar ovos pelas fezes. Mesmo assim, nos pacientes com infecção recente, o tratamento produziu uma acentuada redução no número de ovos de S. mansoni.

Phacoemulsification Versus Peripheral Iridotomy in the Management of Chronic Primary Angle Closure: Long-Term Follow-Up

Primary angle closure occurs as a result of crowded anterior segment anatomy, causing appositional contact between the peripheral iris and trabecular meshwork, thereby obstructing aqueous outflow. Several studies highlight the role of the crystalline lens in its pathogenesis. The objective of this work is to compare the long-term efficacy of phacoemulsification versus laser peripheral iridotomy (LPI) in the management of chronic primary angle closure (CPAC). Prospective case-control study with 30 eyes of 30 patients randomly divided in two groups: 15 eyes in the LPI group and 15 eyes in the IOL group. Patients in the LPI group underwent LPI using argon and Nd:YAG laser. Patients in the IOL group underwent phacoemulsification with posterior chamber intraocular lens (IOL) implantation. Examinations before and after the procedure included gonioscopy, Goldmann applanation tonometry, and anterior chamber evaluation using the Pentacam rotating Scheimpflug camera. The mean follow-up time was 31.13 ± 4.97 months. There was a statistically significant reduction in the intraocular pressure (IOP) and number of anti-glaucoma medications (p < 0.01) only in the IOL group. Anterior chamber depth, angle, and volume were all higher in the IOL group (p < 0.01) at the end of the follow-up period. Phacoemulsification with posterior chamber IOL implantation results in a higher anterior chamber depth, angle, and volume, when compared to LPI. Consequently, phacoemulsification has greater efficacy in lowering IOP and preventing its long-term increase in patients with CPAC and cataract.

Adenocarcinoma of the Ileum: A Rare and Challenging Entity

INTRODUCTION: Primary small bowel malignancy is unusual and accounts for 1-3% of all gastrointestinal tract neoplasms. Adenocarcinoma is one of the most common histologic types, but its frequency decreases with more distal locations. Its clinical presentation is nonspecific and is usually associated with advanced disease, which contributes to delayed diagnosis. PRESENTATION OF CASE: A 66-year-old woman was admitted to the hospital with a 6-day history of progressively worsening abdominal pain localized in the right lower quadrant, nausea, and vomiting. Investigation revealed an inflammatory appendiceal tumor. The patient underwent surgery and an unexpected tumor involving the distal ileal segment and ileocecal appendix was found. Right radical hemicolectomy with en bloc resection of the distal ileum was performed. Histopathological examination revealed adenocarcinoma of the ileum. DISCUSSION: This rare entity is associated with a nonspecific clinical presentation that contributes to delayed diagnosis and treatment, and consequently to a worse prognosis. Approximately half of the cases are only diagnosed at surgery. Primary treatment consists of wide resection with locoregional lymphadenectomy. The role of adjuvant chemotherapy has yet to be determined. CONCLUSION: This case demonstrates an unusual condition characterized by late and challenging diagnosis. We highlight the importance of an earlier diagnosis and optimal treatment for improved patient outcomes.

Hérnia Diafragmática Congénita. Casuística de 10 Anos

Os autores fizeram a revisão dos casos de hérnia diafragmática congénita admitidos na Unidade de Cuidados Intensivos Neonatais do Hospital de Dona Estefânia de Janeiro de 1984 a Dezembro de 1993 (10 anos). Neste período foram internados 53 recém-nascidos (RN) com hérnia diafragmática congénita tipo Bochdalek. A pesquisa incidiu sobre os índices de gravidade clínicos, radiológico, ventilatório, de oxigenação e mortalidade. Em 54,7% dos RN houve asfixia neonatal. A dificuldade respiratória teve início antes das 6 horas de vida em 43 dos RN (81.1%), mas o início dos sintomas foi imediato em 31. A hérnia localizava-se à esquerda em 77.4% dos casos. Em 5 casos não foi possível a correcção cirúrgia do defeito diafragmático. A mortalidade global foi 47.2%. Dos 48 RN operados faleceram 20 (41.7%). Em todas as crianças que faleceram, excepto numa, houve início imediato dos sintomas. A mortalidade dos RN com índice radiológico >6 foi de 81.5%. O índice ventilatório >1000 e o índice de oxigenação >40 tiveram valor preditivo de morte (mortalidade de 100% em ambos os casos). Nesta casuística, os achados que melhor se correlacionaram com o prognóstico foram: início imediato dos sintomas, I.R. >6, I.V.> 1000 e I.O.> 40.

Encefalite Crónica a Enterovírus num Doente com Agamaglobulinémia Congénita Ligada ao Cromossoma X

Os autores apresentam um caso clínico de encefalite crónica a enterovírus num rapaz de 9 anos com agamaglobulinémia congénita ligada ao cromossoma X (doença de Bruton). Apesar da terapêutica intraventricular com doses elevadas de gamaglobulina, registou-se uma progressão da doença com deterioração neurológica maciça e morte. Discutem-se os aspectos diagnósticos e terapêuticos desta situação.