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Clinics, Volume: 64, Número: 11, Publicado: 2009
  • In the november 2009 issue of Clinics Editorial

    Rocha-e-Silva, Mauricio
  • Pemphigoid gestationis: clinical and laboratory evaluation Clinical Sciences

    Cobo, Marina Flangini; Santi, Claudia Giuli; Maruta, Celina Wakisaka; Aoki, Valéria

    Resumo em Inglês:

    INTRODUCTION: Pemphigoid gestationis, also known as herpes gestationis, is a rare autoimmune blistering disease associated with pregnancy. It usually occurs during the second or third trimester, but it may be present at any stage of pregnancy or the puerperium. The clinical, histologic, and immunopathological features of pemphigoid gestationis are similar to those of the pemphigoid group of disorders. METHODS: We hereby report seven patients who were diagnosed with pemphigoid gestationis and followed at the Autoimmune Blistering Disease Clinic in the Department of Dermatology of the University of Sao Paulo Medical School between 1996 and 2008. DISCUSSION: Demographic and clinical findings, such as median age, sites of involvement, and gestational age of onset of our patients, coincide with those described in previous reports. The majority of patients (85%) exhibited complement C3 or C3 and immunoglobulin G (IgG) deposition along the basement membrane zone (BMZ) on immunofluorescence. Herpes gestationis factor (HG) factor was postitive in four out of six patients (67%), and three out of five patients recognized the bullous pemphigoid recombinant antigen (BP180) by ELISA. CONCLUSION: This study revealed a good outcome of the newborns from pemphigoid gestationis affected mothers, based on the absence of pemphigoid gestationis cutaneous lesions, mean birth weight, and normal Apgar scores and gestational age at birth.
  • Incidence of histological prostatitis and its correlation with PSA density Clinical Sciences

    Piovesan, Affonso Celso; Freire, Geraldo de Campos; Torricelli, Fabio César Miranda; Cordeiro, Paulo; Yamada, Renato; Srougi, Miguel

    Resumo em Inglês:

    OBJECTIVE: The aim of this study was to determine the incidence of asymptomatic, histologically proven prostatitis in men with symptoms of benign prostate hyperplasia and to observe the correlation between asymptomatic prostatitis and prostate specific antigen (PSA) density. INTRODUCTION: The incidence of type IV prostatitis is unknown. There is a tendency to correlate the presence of inflammatory prostatitis with an elevation of PSA. MATERIALS AND METHODS: From August 2000 to January 2006, 183 patients who underwent surgical treatment for benign prostate hyperplasia as a result of obstructive or irritative symptoms were prospectively studied. In accordance with the histology findings, these patients were divided into two groups: group I included patients with the presence of histological prostatitis and group II included patients with the absence of histological prostatitis. The mean PSA densities were compared. RESULTS: Histological evidence of prostatitis was observed in 145 patients. In this group, the mean PSA density was 0.136 ± 0.095. In 38 cases, there was no evidence of inflammation upon histological examination of the surgical samples. In these 38 cases, the mean PSA density was 0.126 ± 0.129. No statistically significant differences were detected between the two groups; the p-value is 0.124. CONCLUSION: Abnormal PSA density should not be attributed to the inflammatory prostatitis process.
  • A higher meal frequency may be associated with diminished weight loss after bariatric surgery Clinical Sciences

    Ribeiro, Angela Gadelha; Costa, Maria José de Carvalho; Faintuch, Joel; Dias, Maria Carolina Gonçalves

    Resumo em Inglês:

    OBJECTIVE: This study aimed to investigate the relationship between meal frequency, the occurrence of vomiting and weight loss among patients submitted to Roux-en-Y gastric bypass up to 9 months after surgery. METHODS: Female patients (n = 80) were followed at 3-month intervals for 9 months. Weight, BMI, 24-hour dietary recall, drug consumption and vomiting episodes were recorded and compared with nutritional outcome. RESULTS: The BMI values at 3, 6 and 9 months were 45.1 ± 9.7, 39.9 ± 7.6 and 35.4 ± 8.2 kg/m², respectively. The corresponding choleric intakes were 535.6 ± 295.7, 677.1 ± 314.7 and 828.6 ± 398.2 kcal/day, and the numbers of daily meals were 5.0 ± 2.5, 4.7 ± 1.8 and 4.9 ± 1.0, respectively. The peak of vomiting episodes occurred within 6 months; however, patients tolerated this complication despite its high prevalence. A significant negative correlation between weight loss and diet fractioning, but not vomiting, was observed throughout the entire postoperative period (P = 0.001). CONCLUSIONS: 1) Frequent small meals were associated with a reduction in weight loss after gastric bypass and a decrease in vomiting episodes at 6 months, and 2) vomiting did not interfere with nutritional outcome. Unless required because of vomiting or other reasons, multiple small meals may not be advantageous after such intervention.
  • Neoadjuvant chemoradiation therapy for soft tissue sarcomas of the extremities Clinical Sciences

    Aguiar Junior, Samuel; Ferreira, Fábio de Oliveira; Rossi, Benedito Mauro; Santos, Érika Maria Monteiro; Salvajoli, João Victor; Lopes, Ademar

    Resumo em Inglês:

    INTRODUCTION AND OBJECTIVE: Neoadjuvant and adjuvant therapies for soft tissue sarcomas of the extremities are still controversial. The aim of this study was to analyze the results of a protocol of neoadjuvant chemoradiation therapy for extremity sarcomas. METHODS: A retrospective analysis was carried out in a consecutive series of 49 adult patients with advanced extremity soft tissue sarcomas that could not be resected with adequate margins during the primary resection. All patients were treated with a protocol of preoperative radiation therapy at a total dose of 30 Gy, concomitant with doxorubicin (60 mg/m²) chemotherapy. The main endpoints assessed were local recurrence-free survival, metastasis-free survival and overall survival. The median follow-up time was 32.1 months. RESULTS: The five-year local recurrence-free survival, metastasis-free survival and overall survival rates were 81.5%, 46.7% and 58.3%, respectively. For high-grade tumors, the five-year metastasis-free and overall survival rates were only 36.3% and 41.2%, respectively. Severe wound complications were observed in 41.8% of the patients who underwent surgery. These complications precluded adjuvant chemotherapy in 73.7% (14/19) of the patients eligible to receive it. CONCLUSIONS: In this study, neoadjuvant chemoradiation therapy was associated with a good local control rate, but the distant relapse-free rate and overall survival rate were still poor. The high rate of wound complications modified the planning of adjuvant treatment in most patients.
  • Influence of the ageing process on the resistive and reactive properties of the respiratory system Clinical Sciences

    Tramont, Caio Vinicius Villalón e; Faria, Alvaro Camilo Dias; Lopes, Agnaldo José; Jansen, José Manoel; Melo, Pedro Lopes de

    Resumo em Inglês:

    INTRODUCTION: In an increasingly old society, the study of the respiratory system changes and new techniques dedicated to older patients are of interest in physiologic studies as well as in the diagnosis of respiratory diseases. OBJECTIVES: (1) To investigate the impact of ageing on the resistive and reactive properties of the respiratory system, and (2) to compare the easiness of accomplishment of spirometry and forced oscillation for assessing lung function. METHODS: We conducted a cross-sectional study in which forced oscillation was used to investigate respiratory system resistive and reactive properties, while spirometry was used as a reference test to evaluate 80 normal subjects aged between 20 and 86 years. A questionnaire was used to evaluate the easiness of accomplishment of spirometry and forced oscillation. RESULTS: There was a significant increase in the respiratory system resonance frequency (p<0.003) and a reduction in the mean reactance (p<0.004) with increasing age. Respiratory system resistance and dynamic compliance were not related to the ageing process. The easiness of accomplishment of forced oscillation measurements was greater than that of spirometry. This result was particularly relevant in subjects over 70 years old (p<0.05). CONCLUSIONS: Respiratory system resistance and dynamic compliance are not modified with ageing. On the other hand, respiratory system homogeneity decreases during the ageing process. Forced oscillation is easy to perform and provides information complementary to spirometry. This technique may be a promising alternative and/or complement to other conventional exams used to evaluate older people who are unable to adequately perform spirometric tests.
  • Sexual harassment in the physician-patient interaction: analysis of charges against doctors in the state of São Paulo Clinical Sciences

    Cohen, Claudio; Kelian, Rogério L'Abbate; Oliveira, Reinaldo Ayer; Gobbetti, Gisele Joana; Massad, Eduardo

    Resumo em Inglês:

    OBJECTIVE: This research intends to discuss sexual harassment within the doctor-patient relationship based on four parameters: doctor's characteristics, accuser's characteristics, accusation characteristics, and the evaluation by the Medicine Council of São Paulo. METHOD: It is a descriptive, quantitative approach using a retrospective documental analysis. Studied subjects were doctors who were allegedly engaged in sexual harassment. This analysis considered all accusations made from January 2000 to December 2005 (n=150). RESULTS: For this type of sexual abuse, there was a prevalence of male professionals (96.6%) who committed abuse against female patients (90.3%) during adulthood (77.7%). The mean age of the accused was 46.87 years, ranging from 30-76 years, concentrated between 46-75 years. The intrinsic difficulty of understanding sexual harassment by a professional constrained ethical evaluation of the cases, with 24.1% of the cases being considered proceeding charges by the professional council. When the cases were recognized as proceeding, they were either filed (88.2%) or were considered to be ethical infringement (11.8%) becoming Professional Ethical Process (PEP). In the majority of proceeding cases (87%), there was a Police Occurrence Report enclosed. DISCUSSION AND CONCLUSION: The incidence of sexual abuse by professionals was independent of education, as the accused professionals came from a large variety of medical colleges, without significant differences related to institution. The predominance of accusations against older professionals may occur due to the frail personality structure that allows professional acting out. Objective evidence is very important in ethical evaluations compared to psychological and subjective evidence.
  • Acute application of bilevel positive airway pressure influences the cardiac autonomic nervous system Clinical Sciences

    Pantoni, Camila Bianca Falasco; Mendes, Renata Gonçalves; Thommazo, Luciana Di; Catai, Aparecida Maria; Sampaio, Luciana Maria Malosá; Borghi-Silva, Audrey

    Resumo em Inglês:

    INTRODUCTION: Noninvasive positive pressure has been used to treat several diseases. However, the physiological response of the cardiac autonomic system during bilevel positive airway pressure (Bilevel) remains unclear. OBJECTIVE: The aim of this study was to evaluate the heart rate variability (HRV) during Bilevel in young healthy subjects. METHODS: Twenty men underwent 10-minute R-R interval recordings during sham ventilation (SV), Bilevel of 8-15 cmH2O and Bilevel of 13-20 cmH2O. The HRV was analyzed by means of the parallel R-R interval (mean R-Ri), the standard deviation of all R-Ri (SDNN), the root mean square of the squares of the differences between successive R-Ri (rMSSD), the number of successive R-Ri pairs that differ by more than 50 milliseconds (NN50), the percentage of successive R-Ri that differ by more than 50 milliseconds (pNN50), the low frequency (LF), the high frequency (HF) and SD1 and SD2. Additionally, physiological variables, including blood pressure, breathing frequency and end tidal CO2, were collected. Repeated-measures ANOVA and Pearson correlation were used to assess the differences between the three studied conditions and the relationships between the delta of Bilevel at 13-20 cmH2O and sham ventilation of the HRV indexes and the physiological variables, respectively. RESULTS: The R-Ri mean, rMSSD, NN50, pNN50 and SD1 were reduced during Bilevel of 13-20 cmH2O as compared to SV. An R-Ri mean reduction was also observed in Bilevel of 13-20 cmH2O compared to 8-15 cmH2O. Both the R-Ri mean and HF were reduced during Bilevel of 8-15 cmH2O as compared to SV, while the LF increased during application of Bilevel of 8-15 cmH2O as compared to SV. The delta (between Bilevel at 13-20 cmH2O and sham ventilation) of ETCO2 correlated positively with LF, HF, the LF/HF ratio, SDNN, rMSSD and SD1. Acute application of Bilevel was able to alter the cardiac autonomic nervous system, resulting in a reduction in parasympathetic activity and an increase in sympathetic activity and higher level of positive pressure can cause a greater influence on the cardiovascular and respiratory system.
  • Glucose homeostasis and weight loss in morbidly obese patients undergoing banded sleeve gastrectomy: a prospective clinical study Clinical Sciences

    Miguel, Gustavo Peixoto Soares; Azevedo, Joao Luiz Moreira Coutinho; Gicovate Neto, Carlos; Moreira, Cora Lavigne Castelo Branco; Viana, Elaine Cristina; Carvalho, Perseu Seixas

    Resumo em Inglês:

    OBJECTIVE: To assess glucose homeostasis and weight loss in morbidly obese patients undergoing Silastic® ring sleeve gastrectomy. METHODS: This was a prospective clinical study. Thirty-three female patients with a mean body mass index (BMI) of 42.33 ± 1.50 kg/m² (range: 40-45 kg/m²), a mean age of 36.7 ± 9.4 years and a mean waist circumference of 118.7 ± 5.98 cm were included in this study. Type 2 diabetes mellitus was observed in 11 patients (33.3%), and glucose intolerance was observed in 4 patients (12.1%). Mean plasma fasting glucose levels were 109.77 ± 44.19 mg/dl (75-320) in the preoperative period. All Silastic® ring sleeve gastrectomy procedures were performed by the same surgical team using the same anesthetic technique. The patients were monitored for at least 12 months after surgery. RESULTS: The mean weight of the patients decreased from 107.69 ± 6.57 kg to 70.52 ± 9.36 kg (p < 0.001), the mean BMI decreased to 27.4 ± 2.42 kg/m² (p < 0.001), and the mean waist circumference decreased to 89.87 cm ± 6.66 (p < 0.001) in the postoperative period. Excess BMI loss was 86.5 ± 14.2%. Fasting glucose levels were reduced to 80.94 ± 6.3 mg/dl (p < 0.001). Remission of diabetes and glucose intolerance was observed in all patients. CONCLUSION: Silastic® ring sleeve gastrectomy was effective in promoting weight loss, waist circumference reduction and control of glucose homeostasis in morbidly obese patients.
  • Lung morphometry, collagen and elastin content: changes after hyperoxic exposure in preterm rabbits Clinical Sciences

    Mascaretti, Renata Suman; Mataloun, Marta Maria Galli Bozzo; Dolhnikoff, Marisa; Rebello, Celso Moura

    Resumo em Inglês:

    INTRODUCTION: Elastic and collagen fiber deposition increases throughout normal lung development, and this fiber network significantly changes when development of the lung is disturbed. In preterm rats and lambs, prolonged hyperoxic exposure is associated with impaired alveolization and causes significant changes in the deposition and structure of elastic fibers. OBJECTIVES: To evaluate the effects of hyperoxic exposure on elastic and collagen fiber deposition in the lung interstitial matrix and in alveolarization in preterm rabbits. METHODS: After c-section, 28-day preterm New-Zealand-White rabbits were randomized into 2 study groups, according to the oxygen exposure, namely: Room air (oxygen = 21%) or Oxygen (oxygen > 95%). The animals were killed on day 11 and their lungs were analyzed for the alveolar size (Lm), the internal surface area (ISA), the alveoli number, and the density and distribution of collagen and elastic fibers. RESULTS: An increase in the Lm and a decrease in the alveoli number were observed among rabbits that were exposed to hyperoxia with no differences regarding the ISA. No difference in the density of elastic fibers was observed after oxygen exposure, however there were fewer collagen fibers and an evident disorganization of fiber deposition. DISCUSSION: This model reproduces anatomo-pathological injuries representing the arrest of normal alveolar development and lung architecture disorganization by just a prolonged exposition to oxygen. CONCLUSIONS: In the preterm rabbit, prolonged oxygen exposure impaired alveolization and also lowered the proportion of collagen fibers, with an evident fiber network disorganization.
  • Effect of renal embolization with trisacryl and PAVc Clinical Sciences

    Barbosa, Leandro de Assis; Caldas, Jose Guilherme Mendes Pereira; Conti, Mario Luiz; Malheiros, Denise Maria Avancini Costa; Ramos Jr., Francisco Ferreira

    Resumo em Inglês:

    OBJECTIVES: Evaluate the degree of vascular occlusion, vascular recanalization, and necrosis of the vascular wall caused by polyvinyl alcohol-covered polyvinyl acetate (PVAc) particles compared to trisacryl particles after renal embolization. METHODS: Seventy-nine female albino New Zealand rabbits underwent arterial catheterization of the right kidney. Thirty-three animals were embolized with trisacryl particles, thirty-one with PVAc particles, and fifteen were kept as controls. Four animals were excluded (three trisacryl and one PVAc) due to early death. Five subgroups of six animals were created. The animals in the different groups were sacrificed either 48 hours, 5 days, 10 days, 30 days, or 90 days after embolization. The control group was divided into subgroups of three animals each and kept for the same periods of time. The kidneys were dyed with hematoxylin-eosin and Masson's trichrome and then examined using optical microscopy. RESULTS: There were significant differences in the degree of vascular occlusion caused by the trisacryl and the PVAc particles between the five-day and the ten-day groups. Additional differences were noted between the five-day and 48-hour groups in regard to the amount of necrosis. For both findings, the PVAc group members showed adequate tissue reaction (ischemia and volumetric reduction) and less recanalization than those treated with trisacryl. CONCLUSION: The use of PVAc as an embolization material exhibited an adequate tissue reaction (ischemia and volumetric reduction), more expressive vascular occlusion and necrosis, and less recanalization than the trisacryl material.
  • Fresh soy oil protects against vascular changes in an estrogen-deficient rat model: an electron microscopy study Clinical Sciences

    Adam, Siti Khadijah; Das, Srijit; Othman, Faizah; Jaarin, Kamsiah

    Resumo em Inglês:

    OBJECTIVE: To observe the effects of consuming repeatedly heated soy oil on the aortic tissues of estrogen-deficient rats. METHODS: Thirty female Sprague Dawley rats (200- 250 g) were divided equally into five groups. One group served as the normal control (NC) group. The four treated groups were ovariectomized and were fed as follows: 2% cholesterol diet (OVXC); 2% cholesterol diet + fresh soy oil (FSO); 2% cholesterol diet + once-heated soy oil (1HSO); and 2% cholesterol diet + five-times-heated soy oil (5HSO). After four months, the rats were sacrificed, and the aortic tissues were obtained for histological studies. RESULTS: After four months of feeding, the NC, FSO and 1HSO groups had a lower body weight gain compared to the OVXC and 5HSO groups. The tunica intima/media ratio in the 5HSO group was significantly thicker (p < 0.05) compared to the NC, OVXC and FSO groups. Electron microscopy showed that endothelial cells were normally shaped in the FSO and NC groups but irregular in the 1HSO and 5HSO groups. A greater number of collagen fibers and vacuoles were observed in the 5HSO group compared to the other treatment groups. CONCLUSIONS: Fresh soy oil offered protection in the estrogen-deficient state, as these rats had similar features to those of the NC group. The damage to the tunica intima and the increase in the ratio of tunica intima/media thickness showed the deleterious effect of consuming repeatedly heated soy oil in castrated female rats.
  • Anterior hepatic transection for caudate lobectomy Review

    Chaib, Eleazar; Ribeiro Jr, Marcelo A F; Souza, Yngrid Ellyn Dias Maciel de; D'Albuquerque, Luiz Augusto C

    Resumo em Inglês:

    Resection of the caudate lobe (segment I- dorsal sector, segment IX- right paracaval region, or both) is often technically difficult due to the lobe's location deep in the hepatic parenchyma and because it is adjacent to the major hepatic vessels (e.g., the left and middle hepatic veins). A literature search was conducted using Ovid MEDLINE for the terms "caudate lobectomy" and "anterior hepatic transection" (AHT) covering 1992 to 2007. AHT was used in 110 caudate lobectomies that are discussed in this review. Isolated caudate lobectomy was performed on 28 (25.4%) patients, with 11 case (11%) associated with hepatectomy, while 1 (0.9%) was associated with anterior segmentectomy. Complete caudate lobectomy was performed on 82 (74.5%) patients. Hepatocellular carcinoma was observed in 106 (96.3%) patients, while 1 (0.9%) had hemangioma and 3 (2.7%) had metastatic caudate tumors. AHT was used in 108 (98.1%) caudate resections, while AHT associated with a right-sided approach was performed in 2 (1.8%) cases. AHT is recommended for tumors located in the paracaval portion of the caudate lobe (segment IX). AHT is usually a safe and potentially curative surgical option.
  • Sacral stress fracture in a runner: a case report Letter To The Editors

    Rodrigues, Luciano Miller Reis; Ueno, Fabrício Hidetoshi; Valesin Filho, Edgar Santiago; Fujiki, Edison Noboru; Milani, Carlo
  • Spontaneous resolution of a caseous calcification of the mitral annulus Letter To The Editors

    Correale, Michele; Deluca, Giovanni; Ieva, Riccardo; Biase, Matteo Di
  • An anomaly of flexor muscles of the fifth (little) finger of the hand: an anatomical case report Letter To The Editors

    Yilmaz, Ali; Bozer, Cüneyt; Uluçam, Enis; Taşkinalp, Oğuz
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