Low-level laser therapy for pain relief after episiotomy: a double-blind randomised clinical trial

Aims and objectives. To evaluate the effectiveness of a low-level laser therapy for pain relief in the perineum following episiotomy during childbirth. Background. Laser irradiation is a painless and non-invasive therapy for perineal pain treatment and its effects have been investigated in several studies, with no clear conclusion on its effectiveness. Design. A double-blind randomised controlled clinical trial. Method. One hundred and fourteen women who underwent right mediolateral episiotomies during vaginal birth in an in-hospital birthing centre in Sao Paulo, Brazil and reported pain =3 on a numeric scale (010) were randomised into three groups of 38 women each: two experimental groups (treated with red and infrared laser) and a control group. The experimental groups were treated with laser applied at three points directly on the episiotomy after suturing in a single session between 656 hours postpartum. We used a diode laser with wavelengths of 660 nm (red laser) and 780 nm (infrared laser). The control group participants underwent all laser procedures, excluding the emission of irradiation. The participants and the pain scores evaluator were blinded to the type of intervention. The perineal pain scores were assessed at three time points: before, immediately after and 30 minutes after low-level laser therapy. Results. The comparison of perineal pain between the three groups showed no significant differences in the three evaluations (p = 0.445), indicating that the results obtained in the groups treated with low-level laser therapy were equivalent to the control group. Conclusions. Low-level laser therapy did not decrease the intensity of perineal pain reported by women who underwent right mediolateral episiotomy. Relevance to clinical practice. The effect of laser in perineal pain relief was not demonstrated in this study. The dosage may not have been sufficient to provide relief from perineal pain after episiotomy during a vaginal birth.

The implementation of the Medical Regulation Office and Mobile Emergency Attendance System and its impact on the gravity profile of non-traumatic afflictions treated in a University Hospital: a research study

Abstract Background The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital. Methods The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined. Results From 1996 to 2001, the mean age increased from 49 ± 0.9 to 52 ± 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 ± 0.5 to 14.8 ± 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department. Conclusion The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.

Apolipoprotein E mRNA expression in mononuclear cells from normolipidemic and hypercholesterolemic individuals treated with atorvastatin

Abstract Background Apolipoprotein E (apoE) is a key component of the lipid metabolism. Polymorphisms at the apoE gene (APOE) have been associated with cardiovascular disease, lipid levels and lipid-lowering response to statins. We evaluated the effects on APOE expression of hypercholesterolemia, APOE ε2/ε3/ε4 genotypes and atorvastatin treatment in Brazilian individuals. The relationship of APOE genotypes and plasma lipids and atorvastatin response was also tested in this population. Methods APOE ε2/ε3/ε4 and plasma lipids were evaluated in 181 normolipidemic (NL) and 181 hypercholesterolemic (HC) subjects. HC individuals with indication for lowering-cholesterol treatment (n = 141) were treated with atorvastatin (10 mg/day/4-weeks). APOE genotypes and APOE mRNA in peripheral blood mononuclear cells (PBMC) were analyzed by TaqMan real time PCR. Results HC had lower APOE expression than NL group (p < 0.05) and individuals with low APOE expression showed higher plasma total and LDL cholesterol and apoB, as well as higher apoAI (p < 0.05). Individuals carrying ε2 allele have reduced risk for hypercholesterolemia (OR: 0.27, 95% I.C.: 0.08-0.85, p < 0.05) and NL ε2 carriers had lower total and LDL cholesterol and apoB levels, and higher HDL cholesterol than non-carriers (p < 0.05). APOE genotypes did not affect APOE expression and atorvastatin response. Atorvastatin treatment do not modify APOE expression, however those individuals without LDL cholesterol goal achievement after atorvastatin treatment according to the IV Brazilian Guidelines for Dyslipidemia and Atherosclerosis Prevention had lower APOE expression than patients with desirable response after the treatment (p < 0.05). Conclusions APOE expression in PBMC is modulated by hypercholesterolemia and the APOE mRNA level regulates the plasma lipid profile. Moreover the expression profile is not modulated neither by atorvastatin nor APOE genotypes. In our population, APOE ε2 allele confers protection against hypercholesterolemia and a less atherogenic lipid profile. Moreover, low APOE expression after treatment of patients with poor response suggests a possible role of APOE level in atorvastatin response.

Impact of urban atmospheric environment on hospital admissions in the elderly

OBJECTIVE: To analyze the impact of intra-urban atmospheric conditions on circulatory and respiratory diseases in elder adults. METHODS: Cross-sectional study based on data from 33,212 hospital admissions in adults over 60 years in the city of São Paulo, southeastern Brazil, from 2003 to 2007. The association between atmospheric variables from Congonhas airport and bioclimatic index, Physiological Equivalent Temperature, was analyzed according to the district's socioenvironmental profile. Descriptive statistical analysis and regression models were used. RESULTS: There was an increase in hospital admissions due to circulatory diseases as average and lowest temperatures decreased. The likelihood of being admitted to the hospital increased by 12% with 1ºC decrease in the bioclimatic index and with 1ºC increase in the highest temperatures in the group with lower socioenvironmental conditions. The risk of admission due to respiratory diseases increased with inadequate air quality in districts with higher socioenvironmental conditions. CONCLUSIONS: The associations between morbidity and climate variables and the comfort index varied in different groups and diseases. Lower and higher temperatures increased the risk of hospital admission in the elderly. Districts with lower socioenvironmental conditions showed greater adverse health impacts.

Bedeutung endogener Faktoren für Steady-State-Level und Reparatur oxidativer DNA-Modifikationen in Säugerzellen

Die endogene Bildung reaktiver Sauerstoffspezies (ROS) - wie beispielsweise Hydroxyl-Radikale, Superoxid-Radikalanionen, Wasserstoffperoxid und Singulett-Sauerstoff - bei essentiellen Stoffwechselreaktionen in allen aeroben Lebewesen stellt eine potentielle Gefahr für die Integrität der DNA in jeder Zelle dar. ROS generieren in der DNA unter anderem oxidative DNA-Modifikationen (zum größten Teil wahrscheinlich 8-Hydroxyguanin (8-oxoG)), welche wiederum zu einem Teil zu Mutationen führen.In dieser Arbeit wurden Untersuchungen vorgenommen, in welchem Ausmaß zum einen die Steady-State-Level oxidativer DNA-Schäden in Säugerzellen zum anderen die Reparaturgeschwindig-keiten solcher DNA-Modifikationen durch verschiedene endogene Faktoren beeinflußt werden.Im Mittelpunkt der Arbeit stand dabei die Charakterisierung der 8-Hydroxyguaninglykosylase der Säugerzellen. Sie ist das Produkt des OGG1-Gens, das erst 1997 kloniert wurde. In transfizierten Zellinien konnte durch eine konstitutive Überexpression des menschlichen OGG1-Gens demonstriert werden, daß die Reparatur von induzierten oxidativen Basenmodifikationen bis zu dreifach beschleunigt wird und daß eine Korrelation zwischen dem Grad der Überexpression und der Reparaturrate besteht. Dagegen waren die Steady-State-Level der oxidativen DNA-Schäden durch die Überexpression unbeeinflußt. Sowohl bei den spontanen Mutationsraten als auch bei den durch oxidative Schädigungen induzierten Mutationsfrequenzen konnte keine Erniedrigung bedingt durch die hOGG1-Überexpression beobachtet werden.Weitere Untersuchungen zur Bedeutung von Ogg1-Protein konnten in Mäusezellen durchgeführt werden, in denen das OGG1-homologe Mäusegen, mOGG1, homozygot inaktiviert (mOGG1(-/-)) worden war. Hierbei konnte gezeigt werden, daß in den mOGG1-defizienten Zellen im Vergleich zu den entsprechenden Wildtyp-Zellen (mOGG1(+/+)) eine Reparatur induzierter oxidativer Basenmodifikationen erst nach 8 h einsetzt, während in den Kontrollzellen schon nach 3-4 h 50 % der Modifikationen repariert waren. Die Steady-State-Level oxidativer Modifikationen in mOGG1(-/-)-Zellen waren in immortalisierten, schnell proliferierenden Mäusefibroblasten nur um den Faktor 1.4, in primären Mäusehepatocyten jedoch um den Faktor 2.5 gegenüber den Wildtyp-Zellen erhöht.Inwieweit das menschliche Reparaturprotein Xrcc1 (X-ray repair cross complementing group 1) auch an der Prozessierung oxidativer DNA-Modifikationen beteiligt ist, und ob dabei möglicherweise eine Interaktion mit Ogg1 vorliegt, wurde in der XRCC1-defizienten CHO-Zellinie EM9 untersucht. Dabei wurde ermittelt, daß weder die Steady-State-Level noch die Reparaturkinetiken der oxidativen Basenmodifikationen durch die XRCC1-Defizienz beeinflußt werden. Aufgrund weiterer Ergebnisse kann jedoch nicht ausgeschlossen werden, daß das Xrcc1-Protein zumindest am Ligationsschritt während der Reparatur oxidativer DNA-Schäden beteiligt ist.In einem weiteren Schwerpunkt der Arbeit wurde untersucht, ob Unterschiede im Steady-State-Level in Abhängigkeit von Organ-, Gewebe- und Zelltyp auftreten. Dazu wurden Untersuchungen in Bronchialkarzinom-Zellinien verschiedener Subtypen durchgeführt. Des weiteren wurde zur Frage der Zelltyp-Abhängigkeit in der menschlichen Zellinie HL60 der Einfluß des Zelldifferenzierungsstadiums auf die Steady-State-Level untersucht.

Kalorimetrische Tieftemperaturdetektoren für niederenergetische (E 1 MeV/amu) Schwerionen und ihr erster Einsatz in der Beschleuniger-Massenspektrometrie zur Spurenanalyse von 236 U

Im Rahmen der vorliegenden Arbeit wurden zum ersten Mal kalorimetrische Tieftemperatur-Detektoren in der Beschleuniger-Massenspektrometrie (Accelerator Mass Spectrometry AMS), einer Standard-Methode zur Bestimmung kleinster Isotopenverhältnisse, eingesetzt, um das Isotopenverhältnis von 236U zu 238U zu bestimmen. Das Uran-Isotop 236U entsteht in der Neutroneneinfang-Reaktion 235U(n,gamma)236U und kann daher als Monitor-Nuklid für Neutronenflüsse verwendet werden. Die Detektoren bestehen aus einem Saphir-Absorber, auf den ein supraleitender Aluminium-Film aufgedampft ist, der als Thermistor dient. Ein energetisches Schwerion deponiert seine kinetische Energie als Wärme im Absorber, dessen Temperaturänderung durch die Widerstandsänderung des Supraleiters nachgewiesen wird. Mit solchen Detektoren konnte in vorhergehenden Experimenten bei GSI in einem Energiebereich von E = 5 - 300 MeV/amu für eine Vielzahl von Ionen von Neon bis Uran eine relative Energieauflösung von (1 - 4) E-3 erreicht werden. Der für die Beschleuniger-Massenspektrometrie typische Energiebereich liegt bei E = 0.1 - 1 MeV/amu. Im ersten Schritt wurde daher die systematische Untersuchung der Detektoreigenschaften auf diesen Energiebereich ausgedehnt. Diese Untersuchungen sowie die AMS-Messungen wurden am Tandem-Beschleuniger VERA des Instituts für Isotopenforschung und Kernphysik der Universität Wien durchgeführt. In einem Energiebereich von 10 - 60 MeV konnte für verschiedene Ionen (13C, 197Au, 238U) zunächst eine relative Energieauflösung von DeltaE/E = 7 E-3 erreicht werden. Dies übertrifft die Auflösung konventioneller Ionisations-Detektoren um ca. eine Größenordnung. Durch eine Verbesserung thermischer und elektronischer Rauschbeiträge konnte in einem zweiten Experiment für Uran der Energie 17 MeV die Auflösung auf DeltaE/E = 4.6 E-3 verbessert werden. Die Energie-Response des Detektors war linear über den gesamten beobachteten Energiebereich und unabhängig von der Ionenmasse; bis auf ein Niveau von 0.1 % wurde kein Pulshöhendefekt beobachtet. Diese Ergebnisse zeigen, daß solche Detektoren ein wertvolles Werkzeug in der Schwerionenphysik im Bereich relativ niedriger Ionenenergien darstellen. Mit der erreichten Energieauflösung war es möglich, für mehrere Proben aus natürlichem Uran das Isotopenverhältnis 236U/238U zu bestimmen: Um einen Material-Standard für Uran in der AMS zu etablieren, wurde das Isotopenverhältnis 236U/238U für zwei Proben aus der Mine ''K.u.K. Joachimsthal'' möglichst präzise bestimmt. Die Ergebnisse in der vorliegenden Arbeit stimmen gut mit früheren Messungen überein, die mit einem konventionellen Detektorsystem durchgeführt wurden. Sowohl der statistische als auch der systematische Fehler konnten deutlich reduziert werden. Für eine weitere Probe, extrahiert aus dem Wasser einer Uran-haltigen Quelle in Bad Gastein, wurde ein Isotopenverhältnis von 6.1 E-12 gemessen. Dies stellt das kleinste bislang für 236U/238U gemessene Isotopenverhältnis dar und bedeutet eine Steigerung der Sensitivität um eine Größenordnung. Die erreichte Energieauflösung ermöglicht es außerdem, die Detektoren zur direkten Massenidentifikation von schweren Ionen mittels einer kombinierten Energie-Flugzeit-Messung einzusetzen. In ersten Test-Messungen im Rahmen der vorliegenden Arbeit wurde eine Massenauflösung von DeltaM/M = (8.5 - 11.0) E-3 erreicht. In einem ersten Test für den Einsatz dieser Detektoren zum Nachweis sog. ''superschwerer Elemente (Z >= 112)'' erlaubte der große dynamische Bereich, die Reaktionsprodukte und ihre nachfolgenden Alpha-Zerfälle mit hoher Energieauflösung simultan und zeitaufgelöst nachzuweisen.

Identification of adequate neurally adjusted ventilatory assist (NAVA) during systematic increases in the NAVA level

Neurally adjusted ventilatory assist (NAVA) delivers airway pressure (P(aw)) in proportion to the electrical activity of the diaphragm (EAdi) using an adjustable proportionality constant (NAVA level, cm·H(2)O/μV). During systematic increases in the NAVA level, feedback-controlled down-regulation of the EAdi results in a characteristic two-phased response in P(aw) and tidal volume (Vt). The transition from the 1st to the 2nd response phase allows identification of adequate unloading of the respiratory muscles with NAVA (NAVA(AL)). We aimed to develop and validate a mathematical algorithm to identify NAVA(AL). P(aw), Vt, and EAdi were recorded while systematically increasing the NAVA level in 19 adult patients. In a multistep approach, inspiratory P(aw) peaks were first identified by dividing the EAdi into inspiratory portions using Gaussian mixture modeling. Two polynomials were then fitted onto the curves of both P(aw) peaks and Vt. The beginning of the P(aw) and Vt plateaus, and thus NAVA(AL), was identified at the minimum of squared polynomial derivative and polynomial fitting errors. A graphical user interface was developed in the Matlab computing environment. Median NAVA(AL) visually estimated by 18 independent physicians was 2.7 (range 0.4 to 5.8) cm·H(2)O/μV and identified by our model was 2.6 (range 0.6 to 5.0) cm·H(2)O/μV. NAVA(AL) identified by our model was below the range of visually estimated NAVA(AL) in two instances and was above in one instance. We conclude that our model identifies NAVA(AL) in most instances with acceptable accuracy for application in clinical routine and research.

Protein level expression of Toll-like receptors 2, 4 and 9 in renal disease

Toll-like receptors (TLR) recognize a variety of ligands, including pathogen-associated molecular patterns and link innate and adaptive immunity. Individual receptors can be up-regulated during infection and inflammation. We examined the expression of selected TLRs at the protein level in various types of renal disease.

Non-fatal cardiovascular outcome in patients with posttraumatic stress symptoms caused by myocardial infarction

Objectives Posttraumatic stress disorder (PTSD) prospectively increases the risk of incident cardiovascular disease (CVD) independent of other risk factors in otherwise healthy individuals. Between 10% and 20% of patients develop PTSD related to the traumatic experience of myocardial infarction (MI). We investigated the hypothesis that PTSD symptoms caused by MI predict adverse cardiovascular outcome. Methods We studied 297 patients (61 ± 10 years, 83% men) who self-rated PTSD symptoms attributable to a previous index MI. Non-fatal CVD-related hospital readmissions (i.e. recurrent MI, elective and non-elective intracoronary stenting, bypass surgery, pacemaker implantation, cardiac arrhythmia, cerebrovascular event) were assessed at follow-up. Cox proportional hazard models controlled for demographic factors, coronary heart disease severity, major CVD risk factors, cardiac medication, and mental health treatment. Results Forty-three patients (14.5%) experienced an adverse event during a mean follow-up of 2.8 years (range 1.3–3.8). A 10 point higher level in the PTSD symptom score (mean 8.8 ± 9.0, range 0–47) revealed a hazard ratio (HR) of 1.42 (95% CI 1.07–1.88) for a CVD-related hospital readmission in the fully adjusted model. A similarly increased risk (HR 1.45, 95% CI 1.07–1.97) emerged for patients with a major or unscheduled CVD-related readmission (i.e. when excluding patients with elective stenting). Conclusions Elevated levels of PTSD symptoms caused by MI may adversely impact non-fatal cardiovascular outcome in post-MI patients independent of other important prognostic factors. The possible importance of PTSD symptoms as a novel prognostic psychosocial risk factor in post-MI patients warrants further study.

Health-related quality of life anticipated with different management strategies for febrile neutropenia in adult cancer patients

PURPOSE: To describe anticipated health-related quality of life (HRQL) for different hypothetical strategies of febrile neutropenia (FN) management in adult cancer patients. METHODS: Seventy-eight adult cancer patients were enrolled. Our study considered four different hypothetical treatment strategies for FN: (1) entire inpatient management with intravenous (IV) antibiotics; (2) oral treatment at home after an initial observation in hospital with IV antibiotics; (3) entire outpatient management with IV antibiotics; and (4) entire outpatient management with oral antibiotics. Initially, patients were asked to rank the different treatment strategies for FN based on their personal preference. Subsequently, HRQL was rated using visual analog scale (VAS), time trade-off (TTO), and willingness-to-pay (WTP). RESULTS: Seventy-five percent of all respondents preferred an outpatient strategy for FN (36% oral, 21% intravenous, 18% early discharge). Further, outpatient strategies were associated with higher mean VAS scores (possible range 0-10) (oral: 6.1 (standard deviation (SD) 3.1); intravenous: 6.2 (SD 2.2); early discharge: 5.7 (SD 2.1)) as compared to inpatient care (5.3 (SD 2.9)). On the aggregate level, patients were willing to give up between 9 and 10 weeks of their life (TTO; corresponding to <1% of remaining life expectancy) and to pay between $255 and $327 Canadian dollars (WTP) to avoid treatment in hospital. CONCLUSIONS: Our study indicates that the majority of adult cancer patients would prefer an outpatient strategy for FN. However, patients' preferences vary substantially at the individual level. Implementation of outpatient strategies into routine clinical practice should consider this variability.

Differential patterns of multisensory interactions in core and belt areas of human auditory cortex

The auditory cortex is anatomically segregated into a central core and a peripheral belt region, which exhibit differences in preference to bandpassed noise and in temporal patterns of response to acoustic stimuli. While it has been shown that visual stimuli can modify response magnitude in auditory cortex, little is known about differential patterns of multisensory interactions in core and belt. Here, we used functional magnetic resonance imaging and examined the influence of a short visual stimulus presented prior to acoustic stimulation on the spatial pattern of blood oxygen level-dependent signal response in auditory cortex. Consistent with crossmodal inhibition, the light produced a suppression of signal response in a cortical region corresponding to the core. In the surrounding areas corresponding to the belt regions, however, we found an inverse modulation with an increasing signal in centrifugal direction. Our data suggest that crossmodal effects are differentially modulated according to the hierarchical core-belt organization of auditory cortex.