Contractions of specific abdominal muscles in postural tasks are affected by respiratory maneuvers

The influence of respiratory activity of the abdominal muscles on their reaction time in a postural task was evaluated. The electromyographic (EMG) onsets of the abdominal muscles and deltoid were evaluated in response to shoulder flexion initiated by a visual stimulus occurring at random throughout the respiratory cycle. Increased activity of the abdominal muscles was produced by inspiratory loading, forced expiration below functional residual capacity, and a static glottis-closed expulsive maneuver. During quiet breathing, the latency between activation of the abdominal muscles and deltoid was not influenced by the respiratory cycle. When respiratory activity of the abdominal muscles increased, the EMG onset of transversus abdominis and internal oblique, relative to deltoid, was significantly earlier for movements beginning in expiration, compared with inspiration [by 97-107 ms (P < 0.01) and 64-90 ms (P < 0.01), respectively]. However, the onset of transversus abdominis EMG was delayed by 31-54 ms (P < 0.01) when movement was performed during a static expulsive effort, compared with quiet respiration. Thus changes occur in early anticipatory contraction of transversus abdominis during respiratory tasks but they cannot be explained simply by existing activation of the motoneuron pool.

The IgM anti-desmoglein 1 response distinguishes Brazilian pemphigus foliaceus (Fogo selvagem) from other forms of pemphigus

Fogo selvagern (FS) and pemphigus foliaceus (PF) possess pathogenic IgG anti-desmoglein 1-(Dsg1) autoantibodies. Although PF occurs sporadically, FS is endemic in Limao Verde (LV), Brazil (3.4% prevalence). IgM anti-Dsg1 were detected in 58% FS LV patients (n=31), 19% of FS patients from Hospital-Campo Grande (n=57), 19% from Hospital-Goiania (n=42), 12% from Hospital-Sao Paulo (n=56), 10% of PF patients from United States (n=20), and 0% of PF patients from Japan (n=20). Pemphigus vulgaris (n=40, USA and Japan), bullous pemphigoid (n=40, USA), and healthy donors (n=55, USA) showed negligible percentages of positive sera. High percentages of positive IgM anti-Dsg1 were found in healthy donors from four rural Amerindian populations (42% of 243) as compared with urban donors (14% of 81; P<0.001). More than 50% of healthy donors from LV (n=99, age 5-20 years) possess IgM anti-Dsg1 across ages, whereas IgG-anti-Dsg1 was detected in 2.9% (age 5-10 years), 7.3% (age 11-15 years), and 29% of donors above age 16. IgM anti-Dsg1 epitopes are Ca2+ and carbohydrate-independent. We propose that IgM anti-Dsg1 are common in FS patients in their native environment and uncommon in other pemphigus phenotypes and in FS patients who migrate to urban hospitals. Recurrent environmental antigenic exposure may lead to IgM and IgG responses that trigger TS.

Visuospatial attention disturbance in Duchenne muscular dystrophy

AIM The cognitive deficits present in the Duchenne muscular dystrophy (DMD) are not yet well characterized. Attention, considered to be the brain mechanism responsible for the selection of sensory stimuli, could be disturbed in DMD, contributing, at least partially, to the observed global cognitive deficit. The aim of this study was to investigate attentional function in individuals with DMD. METHOD Twenty-five males (mean age 12y; SD 2y 2mo) with DMD and 25 healthy males (mean age 12y; SD 2y) were tested in a visuospatial task (Posner computerized test). They were instructed to respond as quickly as possible to a lateralized visual target stimulus with the ipsilateral hand. Their attention was automatically orientated by a peripheral prime stimulus or, alternatively, voluntarily orientated by a central spatially informative cue. RESULTS The main result obtained was that the attentional effect (sum of the benefit and the cost of attention) did not differ between the two groups in the case of automatic attention (p=0.846) but was much larger for individuals with DMD than for comparison individuals in the case of voluntary attention (p < 0.001). INTERPRETATION The large voluntary attentional effect exhibited by the participants with DMD seems similar to that of younger children, suggesting that the disease is associated with delayed maturation of voluntary attention mechanisms.

Spirometric Function Improves in the Morbidly Obese After 1-Year Post-surgery

Obesity can negatively affect pulmonary function tests, with or without clinical symptoms, but the impact of bariatric weight loss is still debated. Aiming to document such profile in a consecutive homogeneous population, a prospective cohort study was undertaken. Sixty-one patients (100% females, age 40 +/- 8 years, BMI 49 +/- 5 kg/m(2) and without respiratory disease) were enrolled. Spirometric analysis was carried out to compare preoperative respiratory pattern with outcome after 6 and 12 months. Variables included vital capacity (VC), expiratory reserve volume (ERV), forced expiratory volume (1 s) (FEV1), FEV1/FVC ratio and maximum voluntary ventilation (MVV). Correlation of results with weight loss was examined. The following initial variables exhibited significant difference when compared to the 12-month postoperative control: FVC (P = 0.0308), FEV1/FVC (P = 0.1998), MVV (P = 0.0004) and ERV (P = 0.2124). Recovery of FVC and FEV1/FVC occurred earlier by 6 months. The most seriously depressed preoperative finding was ERV, which even after 1 year still remained inadequate. (1) Pulmonary limitations were diagnosed in approximately one third of the population. (2) Changes were demonstrated for FVC, FEV1/FVC, ERV and MVV. (3) FEV1 and FEV1/FVC were acceptable due to the absence of an obstructive pattern. (4) Two variables increased by 6 months (FEV1/FVC and ERV), whereas recovery for others was confirmed after 1 year. (5) The only exception was ERV which continued below the acceptable range.

Relationship between limb movement speed and associated contraction of the trunk muscles

Rapid shoulder movement is preceded by contraction of the abdominal muscles to prepare the body for the expected disturbance to postural equilibrium and spinal stability provoked by the reactive forces resulting from the movement. The magnitude of the reactive forces is proportional to the inertia of the limb. The aim of the study was to investigate if changes in the reaction time latency of the abdominal muscles was associated with variation in the magnitude of the reactive forces resulting from variation in limb speed. Fifteen participants performed shoulder flexion at three different speeds (fast, natural and slow). The onset of EMG of the abdominal muscles, erector spinae and anterior deltoid (AD) was recorded using a combination of fine-wire and surface electrodes. Mean and peak velocity was recorded for each limb movement speed for five participants. The onset of transversus abdominis (TrA) EMG preceded the onset of AD in only the fast movement condition. No significant difference in reaction time latency was recorded between the fast and natural speed conditions for all muscles. The reaction time of each of the abdominal muscles relative to AD was significantly delayed with the slow movement compared to the other two speeds. The results indicate that the reaction time latency of the trunk muscles is influenced by limb inertia only with limb movement below a threshold velocity.

Prospective evaluation of EUS versus CT scan for staging of ampullary cancer

Background: Malignancies of the biliary and pancreatic systems are associated with a poor prognosis. However, ampullary cancer carries a better prognosis and is often diagnosed when curative treatment is still possible. Accurate staging is important for the determination of the most appropriate treatment option. Objectives: (1) To determine the test performance characteristics of EUS and CT in loco-regional staging of ampullary neoplasms, and (2) to determine the impact of CT scan results on the test performance characteristics of EUS. Design and Setting: Prospective single-arm intervention study performed in 2 academic hospitals. Results and Main Outcome Measurements: Thirty-seven patients were screened and 33 staged with EUS and CT A total of 27 patients (13 men; mean age, 69.5 years; mean serum bilirubin level, 12.6 mg/dL) with locally advanced disease completed the protocol with EUS and CT and underwent surgical resection. Tumor classifications were as follows: 2 patients (7.4%), T1 tumors; 13 patients (48.1%), T2 tumors; and 12 patients (44.4%), T3 tumors, as per surgical pathology. Seventeen tumors (62.9%) were classified as NO and 10 (37.1%) as NI. The difference in proportion of correct tumor (74.1% vs 51.8%; P =.15, 95% CI, -0.06-0-50) and lymph node (81.4% vs; 55.5%; P =.07, 95% Cl, -0.01-0.53) staging by EUS and CT, respectively, was not statistically significantly different. However, the strength of tumor (kappa 0.51 vs 0.11) and nodal (kappa 0.59 vs 0.05) agreement with pathology was statistically significantly higher for EUS than for CT (P <.05). EUS was more sensitive and specific than CT for tumor and nodal staging, and the association of CT to EUS data did not improve the final test accuracy Limitation: Low number of T1 tumors. Conclusions: EUS is in accurate diagnostic test and exhibits a high level of agreement with surgical pathology. CT findings do not improve the test performance characteristics of EUS. Therefore, the evaluation for metastatic disease should not be compromised by CT protocols that aim to perform tumor and nodal staging. Further studies to determine the role of specialized CT protocols in patients with ampullary malignancies are needed. (Gastrointest Endosc 2009;70:290-6.)

Reprocessing and reuse of single-use medical devices used during hemodynamic procedures in Brazil: A widespread and largely overlooked problem

Background. Several medical devices used during hemodynamic procedures, particularly angiographic diagnostic and therapeutic cardiac catheters, are manufactured for single use only. However, reprocessing and reuse of these devices has been reported, to determine the frequency of reuse and reprocessing of single-use medical devices used during hemodynamic procedures in Brazil and to evaluate how reprocessing is performed. Design. National survey, conducted from December 1999 to July 2001. Methods. Most of the institutions affiliated with the Brazilian Society of Hemodynamic and Interventional Cardiology were surveyed by use of a questionnaire sent in the mail. Results. The questionnaire response rate was 50% (119 of 240 institutions). Of the 119 institutions that responded, 116 (97%) reported reuse of single-use devices used during hemodynamic procedures, and only 26 (22%) reported use of a standardized reprocessing protocol. Cleaning, flushing, rinsing, drying, sterilizing and packaging methods varied greatly and were mostly inadequate. Criteria for discarding reused devices varied widely. Of the 119 institutions that responded, 80 (67%) reported having a surveillance system for adverse events associated with the reuse of medical devices, although most of these institutions did not routinely review the data, and only 38 (32%) described a training program for the personnel who reprocessed single-use devices. Conclusions. The reuse of single-use devices used during hemodynamic procedures was very frequent in hospitals in Brazil. Basic guidance on how to reuse and reprocess single-use medical devices is urgently needed, because, despite the lack of studies to support reusing and reprocessing single-use medical devices, such devices are necessary in limited-resource areas in which these practices are current.

Prevalence of, and risk factors for Kaposi`s sarcoma-associated herpesvirus infection among blood donors in Brazil: A multi-center serosurvey

Kaposi`s sarcoma-associated herpesvirus (KSHV) is endemic in the Amazon and rare in southern regions of Brazil. However, geographical distribution and epidemiological correlates of infection in this large country are still poorly defined. To estimate the seroprevalence of, and risk factors for, KSHV infection in Brazil, a multi-center study was conducted among 3,493 first-time voluntary unpaid blood donors from Salvador, Sao Paulo and Manaus. Antibodies against KSHV were detected using a whole-virus ELISA validated prior to the serosurvey. Antibodies against the latency-associated nuclear antigen (LANA) were detected by immuno-fluorescence assay (IFA) among ELISA-positive sera and a random sample of ELISA-negative sera. Overall, seroprevalence of KSHV by whole-virus ELISA was 21.7% (95% confidence interval (Cl): 20-23.4%) in men and 31.7% (95% Cl: 29-34.3%) in women (P<0.0001). KSHV antibodies were detected by IFA-LANA in 3% (95% Cl: 2-4.3%) of 867 ELISA-positive samples and in none of 365 randomly selected ELISA-negative samples. In multivariate analysis, KSHV seroprevalence by whole-virus ELISA was independently associated with female sex (odds ratio [OR] = 1.6, 95% Cl: 1.4-1.9); residence in the Amazon (OR = 1.4, 95% Cl: 1.2-1.8; compared to Salvador); Caucasian ethnicity (OR = 1.3, 95% Cl: 1.1-1.6) and herpes simplex virus type 2 (HSV-2) infection (OR = 1.3, 95% Cl: 1.1-1.6). KSHV seroprevalence did not significantly increase with age, nor was it associated with self-reported sexual behavior. KSHV seroprevalence is high among Brazilian blood donors, particularly from the Amazon region. This study supports the co-existence of sexual and non-sexual routes of KSHV transmission in this population.

Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp.

Background: There has been an increase in worldwide infections caused by carbapenem-resistant Acinetobacter. This poses a therapeutic challenge as few treatment options are available. Objectives: The aim of this study was to evaluate the efficacy and safety of polymyxins and ampicillin/sulbactam for treating infections caused by carbapenem-resistant Acinetobacter spp. and to evaluate prognostic factors. Methods: This was a retrospective review of patients from two teaching hospitals who had nosocomial infections caused by carbapenem-resistant Acinetobacter spp. from 1996 to 2004. Diagnosis of infection was based on CDC criteria plus the isolation of Acinetobacter from a usually sterile site or from bronchoalveolar lavage. Urinary tract infections were not included. Data on demographic and clinical features and treatment were collected from medical records. Prognostic factors associated with two outcomes (mortality during treatment and in-hospital mortality) were evaluated. Results: Eighty-two patients received polymyxins and 85 were treated with ampicillin/sulbactam. Multiple logistic regression analysis revealed that independent predictors of mortality during treatment were treatment with polymyxins, higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score, septic shock, delay in starting treatment and renal failure. On multivariate analysis, prognostic factors for in-hospital mortality were older age, septic shock and higher APACHE II score. Conclusions: This is the first study comparing current therapeutic options for infections due to carbapenem-resistant Acinetobacter. The most important finding of the present study is that ampicillin/sulbactam appears to be more efficacious than polymyxins, which was an independent factor associated with mortality during treatment.

Seven-year trend analysis of nosocomial candidemia and antifungal (fluconazole and caspofungin) use in Intensive Care Units at a Brazilian University Hospital

Candidemia is associated with high morbidity and mortality resulting in significant increases in the length of patients` hospitalization and in healthcare costs. Critically ill patients are at particular risk for candidemia because of their debilitated condition and frequent need for invasive procedures. The aim of this study was to characterize the incidence and epidemiology of candidemia over a seven-year period in intensive care units (ICUs) and the use of fluconazole and caspofungin in a large university-affiliated hospital. All cases of candidemia were identified by surveillance, using the Centers for Diseases Control and Prevention criteria. Demographic variables, use of antifungal (fluconazole and caspofungin) and patient outcomes were evaluated. The 2 test for linear trend was employed to evaluate the distribution of Candida spp. and the use of fluconazole and caspofungin by defined daily dose (DDD) per 1,000 patients-days during the study period. One hundred and eight episodes of candidemia were identified. The overall incidence of candidemia (P=0.20) and incidence of non-Candida albicans Candida infections (P=0.32) remained stable over the study period and ranged from 0.3-0.9 episodes per 1,000 catheter-days and 0.39-0.83 episodes per 1,000 patients-days. However, the use of fluconazole and caspofungin increased significantly (P0.001). While there were no reports of the use of fluconazole for prophylaxis in 1999, its use for this purpose increased from 3% in 2000 to 7.0% (P=0.07) in 2006. C. albicans was the most frequent specie isolated and burns and cancer were the most frequent underlying conditions. The overall mortality was 76%. There was no difference between C. albicans and non-C. albicans Candida infections when the crude and 14-day mortality rates were compared. Our data demonstrated that C. albicans is still the most frequent species causing candidemia in our intensive care units. Our rates of candidemia are lower than those reported from the region and similar to American and European hospitals. Although the incidence of blood stream infections (BSI) and candidemia remained stable, the use of fluconazole and caspofungin increased significantly over the years included in this study but had no impact on the incidence of infections caused by non-C. albicans Candida species.

Evaluation of interventions to reduce catheter-associated bloodstream infection: Continuous tailored education versus one basic lecture

Background: This study evaluated the impact of 2 models of educational intervention on rates of central venous catheter-associated bloodstream infections (CVC-BSIs). Methods: This was a prospective observational study conducted between January 2005 and June 2007 in 2 medical intensive care units (designated ICU A and ICU B) in a large teaching hospital. The study was divided into in 3 periods: baseline (only rates were evaluated), preintervention (questionnaire to evaluate knowledge of health care workers [HCWs] and observation of CVC care in both ICUs), and intervention (in ICU A, tailored, continuous intervention; in ICU B, a single lecture). The preintervention and intervention periods for each ICU were compared. Results: During the preintervention period, 940 CVC-days were evaluated in ICUA and 843 CVC-days were evaluated in ICU B. During the intervention period, 2175 CVC-days were evaluated in ICUA and 1694 CVC-days were evaluated in ICU B. Questions regarding CVC insertion, disinfection during catheter manipulation, and use of an alcohol-based product during dressing application were answered correctly by 70%-100% HCWs. Nevertheless, HCWs` adherence to these practices in the preintervention period was low for CVC handling and dressing, hand hygiene (6%-35%), and catheter hub disinfection (45%-68%). During the intervention period, HCWs` adherence to hand hygiene was 48%-98%, and adherence to hub disinfection was 82%-97%. CVC-BSI rates declined in both units. In ICUA, this decrease was progressive and sustained, from 12CVC-BSIs/1000 CVC-days at baseline to 0 after 9 months. In ICU B, the rate initially dropped from 16.2 to 0 CVC-BSIs/1000 CVC-days, but then increased to 13.7 CVC-BSIs/1000 CVC-days. Conclusion: Personal customized, continuous intervention seems to develop a ""culture of prevention"" and is more effective than single intervention, leading to a sustained reduction of infection rates.

Molecular basis of infantile reversible cytochrome c oxidase deficiency myopathy

Childhood-onset mitochondrial encephalomyopathies are usually severe, relentlessly progressive conditions that have a fatal outcome. However, a puzzling infantile disorder, long known as `benign cytochrome c oxidase deficiency myopathy` is an exception because it shows spontaneous recovery if infants survive the first months of life. Current investigations cannot distinguish those with a good prognosis from those with terminal disease, making it very difficult to decide when to continue intensive supportive care. Here we define the principal molecular basis of the disorder by identifying a maternally inherited, homoplasmic m.14674T > C mt-tRNA(Glu) mutation in 17 patients from 12 families. Our results provide functional evidence for the pathogenicity of the mutation and show that tissue-specific mechanisms downstream of tRNA(Glu) may explain the spontaneous recovery. This study provides the rationale for a simple genetic test to identify infants with mitochondrial myopathy and good prognosis.

Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle after spinal cord injury

Objective To study increases in electromyographic (EMG) response from the right and left rectus femoris muscles of individuals with long-term cervical spinal cord injuries after EMG biofeedback treatment. Design Repeated measure trials compared EMG responses before and after biofeedback treatment in patients with spinal cord injuries. Main outcome measures The Neuroeducator was used to analyse and provide feedback of the EMG signal and to measure EMG response. Setting Department of Traumatic Orthopaedics, School of Medicine, University of Sao Paulo, Brazil. Participants Twenty subjects (three men and 17 women), between 21 and 49 years of age, with incomplete spinal cord injury at level C6 or higher (range C2 to C6). Of these subjects, 10 received their spinal cord injuries from motor vehicle accidents, one from a gunshot, five from diving, three from falls and one from spinal disc herniation. Results Significant differences were found in the EMG response of the right rectus femoris muscle between pre-initial (T1), post-initial (T2) and additional (T3) biofeedback treatment with the subjects in a sitting position [mean (standard deviation) T1: 26 mu V (29); T2: 67 mu V (50); T3: 77 mu V (62)]. The mean differences and 95% confidence intervals for these comparisons were as follows: T1 to T2, -40.7 (-53.1 to -29.4); T2 to T3, -9.6 (-26.1 to 2.3). Similar differences were found for the left leg in a sitting position and for both legs in the sit-to-stand condition. Conclusions The EMG responses obtained in this study showed that treatment involving EMG biofeedback significantly increased voluntary EMG responses from right and left rectus femoris muscles in individuals with spinal cord injuries. (C) 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Health technology diffusion in developing countries: a case study of CT scanners in Brazil

Background The development of products and services for health care systems is one of the most important phenomena to have occurred in the field of health care over the last 50 years. It generates significant commercial, medical and social results. Although much has been done to understand how health technologies are adopted and regulated in developed countries, little attention has been paid to the situation in low- and middle-income countries (LMICs). Here we examine the institutional environment in which decisions are made regarding the adoption of expensive medical devices into the Brazilian health care system. Methods We used a case study strategy to address our research question. The empirical work relied on in-depth interviews (N = 16) with representatives of a wide range of actors and stakeholders that participate in the process of diffusion of CT (computerized tomography) scanners in Brazil, including manufacturers, health care organizations, medical specialty societies, health insurance companies, regulatory agencies and the Ministry of Health. Results The adoption of CT scanners is not determined by health policy makers or third-party payers of public and private sectors. Instead, decisions are primarily made by administrators of individual hospitals and clinics, strongly influenced by both physicians and sales representatives of the medical industry who act as change agents. Because this process is not properly regulated by public authorities, health care organizations are free to decide whether, when and how they will adopt a particular technology. Conclusions Our study identifies problems in how health care systems in LMICs adopt new, expensive medical technologies, and suggests that a set of innovative approaches and policy instruments are needed in order to balance the institutional and professional desire to practise a modern and expensive medicine in a context of health inequalities and basic health needs.

The awareness of chronic fatigue syndrome: A comparative study in Brazil and the United Kingdom

Objective: While in many Western affluent countries there is widespread awareness of chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), little is known about the awareness of CFS/ME in low- and middle-income countries. We compared the awareness of CFS in Brazil and the United Kingdom. Methods: Recognition and knowledge of CFS were assessed among 120 Brazilian specialist doctors in two major university hospitals using a typical case vignette of CFS. We also surveyed 3914 and 2435 consecutive attenders in Brazilian and British primary care clinics, respectively, concerning their awareness of CFS. Results: When given a typical case vignette of CFS, only 30.8% [95% confidence interval (CI), 22.7-39.9%] of Brazilian specialist doctors mentioned chronic fatigue or CFS as a possible diagnosis, a proportion substantially lower than that observed in Western affluent countries. Similarly, only 16.2% (95% CI, 15.1-17.4%) of Brazilian primary care attenders were aware of CFS, in contrast to 55.1% (95% CI, 53.1-57.1%) of their British counterparts (P <.001). This difference remained highly significant after controlling for patients` sociodemographic and socioeconomic characteristics (P <.001). Conclusions: The awareness of CFS was substantially lower in Brazil than the United Kingdom. The observed difference may influence patients` help-seeking behavior and both doctors` and patients` beliefs and attitudes in relation to fatigue-related syndromes. Attempts to promote the awareness of CFS should be considered in Brazil, but careful plans are required to ensure the delivery of sound evidence-based information. (c) 2008 Elsevier Inc. All rights reserved.