Dissertações e Teses

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Achados fonoaudiológicos na avaliação do sistema estomatognático em pacientes com doença do refluxo gastroesofágico
(Faculdade Ciências Médicas de Minas Gerais, 2017-04-26) Silva, Ana Paula Ferreira Opaso Alvarez Antonucci e; Almeida, Alessandra Maciel; Passos, Maria do Carmo Friche
Backgrounds: There is some evidence that a portion of patients with Gastroesophageal Reflux Disease present alterations in the stomatognathic system that justify the mainly atypical symptomatology. Objectives: To evaluate the stomatognathic system in adult patients with GERD and verify the association of disorders of the stomatognathic system and esophageal and extraesophageal symptoms. Methods: A total of 40 patients, aged over 18 years with a confirmed diagnosis of GERD by the gastroenterologist, were selected. All patients answered a questionnaire prepared by the researchers and underwent an evaluation of the stomatognathic system performed by the speech pathologist. The findings of the speech-language pathologist evaluation were correlated with those obtained in the self-evaluation of the patient. Results: The sample was predominantly female (60%), mean age of 48.2 years. Most of the patients performed physical activities (62.5%), 37.5% gained weight in the last six months. More than half of the patients (55%) have comorbidities, and hypertension is the most prevalent. In the evaluation of the stomatognathic system, 40% had decreased tone and mobility of the orofacial musculature. It was found that 57.5% of the patients presented adequate chewing according to the audiologist's evaluation and in the self-assessment, 65.1% of the diagnoses were concordant. Of these, 72.5% stated that they did not present noises / cracks in the temporomandibular joint during mastication, however in the expert's evaluation this number was 65.5%. Of the 11 patients who reported noises / snags in the temporomandibular joint during chewing, only 4 (36.4%) presented concordant results with the audiologist's evaluation. Also, 52.5% of the patients had a preference for crushing food, 20% of which used prostheses and 30% had dental flaws. Conclusion: The majority of patients diagnosed with gastroesophageal reflux disease present orofacial muscular hypotonia, which can lead to ineffective chewing, causing a disorder in the digestive process and may induce or aggravate the symptoms of gastroesophageal reflux disease.
Como os pacientes com melanoma morrem: estudo transversal sobre a percepção entre os cuidadores sobre os últimos 30 dias do final da vida
(Faculdade Ciências Médicas de Minas Gerais, 2017-09-25) Parreiras, Fernanda Cardoso; Wainstein, Ana Paula Drummond Lage; Wainstein, Alberto Julius Alves
Introduction: Melanoma is the skin cancer with the worst prognosis and is responsible for most of the skin cancer-related deaths. Even with the innovations of target immunotherapies and therapies, most patients with metastatic melanoma still evolve to death. So knowing the conditions in which advanced melanoma patients live at their end of life is important in helping doctors determine better control of symptoms and improve the quality of death of these patients. Objective: To evaluate the symptoms in the period before death and to identify the place where it occurred, the caregiver's opinion about the ideal environment for death and end-of-life care. METHOD: This was a retrospective cross-sectional study that used secondary data (review of medical records of 818 patients with melanoma) and interviews with caregivers between 2015 and 2016. Among 66 confirmed deaths, 32 patients were effectively included in the study, and the signs and symptoms were evaluated. most prevalent symptoms 1 month, 1 week and on the day of death. Results: Pain (40.63%) was the most disturbing symptom for patients. Digestive symptoms such as nausea, vomiting and weight loss were very prevalent and cumulative from the 30th day of death. Complaints of limitation for ambulation, personal hygiene and depression also showed high prevalence from 30 days before death. In the week prior to death these symptoms were more prevalent showing inadequate control, however, on the day of death there was no significant change. The majority of patients died in the hospital (84.38%) and, according to caregivers, this is the best place to provide better conditions and control of symptoms. Conclusion: Controlling the most prevalent symptoms improves the quality of death of patients. It highlights the importance of accessing their conditions and preferences, especially the place where they wish to die, and thus, plan a treatment according to their needs.
Alta associação entre síndrome do intestino irritável e transtornos psiquiátricos em Belo Horizonte-MG
(Faculdade Ciências Médicas de Minas Gerais, 2017-10-06) Oliveira Sobrinho, Ismael Gomes de; Almeida, Alessandra Maciel; Passos, Maria do Carmo Friche
Introduction Irritable Bowel Syndrome (IBS) is a functional intestinal disorder that affects about 11% of the world population and is really associated to psychological stress and psychiatric comorbidities. According to the medical literature the prevalence of IBS in psychiatric patients is significantly higher than in the general population, and the epidemiological data are analyzed together, once they bring significant impacts on quality of life and high direct and indirect costs. There are few studies that evaluate the prevalence of IBS in psychiatric patients, and there is no study in the Brazilian population. Objective: To investigate the prevalence of IBS in patients diagnosed with depression, generalized anxiety disorder and panic disorder in a psychiatry service. Materials and Methods: One hundred and eighty-seven patients, aged between 18 and 65 years of age, treated in a psychiatry clinical of Belo Horizonte/Brazil, agreed documentally to participate in the study. They first responded to a structured questionnaire containing demographic and health data and subsequently underwent a standardized questionnaire (MINI) to obtain their respective psychiatric diagnoses. After exclusion criteria, 113 of these patients were subjected to a specific questionnaire for diagnosis of IBS according to diagnostic criteria of Rome III. Results: Of the 113 patients, 70 (61.9%) were female and 43 (38.1%) male, 70 (61.9%) were 31 years of age or older. The married or in a stable union patients made up a total of 61 patients (54%), the same number found for patients who attended higher education (54%). Among the patients, 92 (81.4%) lived in the capital and 82(72.6%) reported having non-white complexion. The prevalence IBS according to the diagnostic criteria of Rome III was 40.7%, and the subtype diarrhea was the most common (20.4%), followed by the mixed subtype (12.4%) and finally the constipation subtype (8%). The prevalence in patients diagnosed with depression was 29.6%, with generalized anxiety disorder in 60%, and in those with panic disorder, 58.3%. Conclusion: The results of this Brazilian populational study are in agreement with previous studies performed in various regions of the world, that using similar parameters of evaluation show a higher prevalence of IBS in psychiatric patients than in the general population. The prevalence of IBS according to the Rome III criteria was 40.7% in this population with psychiatric diseases.
Correlação entre alcoolemia, álcool no ar expirado e exame clínico em um estudo clínico monitorado de ingestão de álcool
(Faculdade Ciências Médicas de Minas Gerais, 2017-12-06) Freitas, Rodrigo Gomes de; Wainstein, Alberto Julius Alves; Wainstein, Ana Paula Drummond Lage
Background: Policies that establish maximum blood alcohol concentrations (BACs) or breath alcohol concentration (BrACs) for drivers while driving can reduce traffic accidents by approximately 20%. In Brazil, the National Transit Council (CONTRAN) considers positive BAC and/or BrAC tests or signs of psychomotor capacity alterations as evaluated by a police authority to be an administrative infraction or even a crime. The observed clinical symptoms of alcohol intoxication based on a subject's appearance may not necessarily reflect the quantified BAC and/or BrAC. Methods: Brazilian health volunteers (n=15) drank ethanol (40% v/v) and, at scheduled times, the subjects underwent blood draws for BAC analysis, were tested for BrAC analysis, and underwent psychomotor alteration assessments performed by M (medical authority) and NM (non-medical authority). This study compared the clinical symptoms identified by M and a NM with BAC and BrAC measurements. Results: Concentration time profiles of the BACs and BrACs of the volunteer subjects were generated. The BAC values reached a peak at 60min and subsequently decreased with time. The average BrAC values decreased with time after ingestion. During the evaluations, M was able to identify a lack of static equilibrium until 240 min and a lack of dynamic equilibrium until 120 min. A lack of upper limb motor coordination was observed until 90 min, and a lack of coordination in the lower limbs was observed only during the first hour. Regarding the tests performed by NM, the signs related to the subjects' appearances were observed more frequently until 60 min. The other analyzed symptoms were not identified. Naturally, the signs reported by both M and NM disappeared with time. Conclusion: The evaluations of psychomotor changes performed by Brazilian M were superior to those performed by NM. However, independent of the examiner, at the alcohol concentrations reached in this study, the psychomotor alteration evaluations were ineffective compared with the BAC and BrAC results.
Efeito agudo da hidroterapia sobre a pressão arterial e o augmentation index em grávidas hipertensas crônicas
(Faculdade Ciências Médicas de Minas Gerais, 2017-12-19) Linhares, Giovana Macêdo; Malachias, Marcus Vinícius Bolívar
Acute effect of hydrotherapy on blood pressure and augmentation index in chronic hypertensive pregnant women Introduction and objectives: Chronic hypertension and elevation of augmentation index in pregnancy are associated with the risk of complications such as superimposed preeclampsia and low fetal growth. The impact of hydrotherapy had not yet be enassessed in this context.Objectives: To evaluate the acute effect of a session of aquatic physiotherapy (hydrotherapy), a modality of non-pharmacological treatment, on blood pressure and augmentation index in chronic hypertensive pregnant women.Methods: A cross-sectional controlled study evaluated the effect of a hydrotherapy session on the blood pressure and arterial stiffness of pregnant women. We used Mobil-O-Graph-NG equipment for arterial variables, before and after a hydrotherapy session, involving stretching, warming, strengthening and relaxation.Results: We evaluated 36 pregnant women, 12 hypertensives, 24 controls, 30.4 ± 4.8 years old, 29.2 ± 3,3 weeks of gestation. In both groups, we observed reduction in augmentation index adjusted for 75 bpm (hypertensives: 28.8 ± 7.3%, before, 22.4 ± 6.9%, after, p = 0.024 and controls: 29.1 ± 7 , P= 0.001), and heart rate reduction (hypertensives: 93.4 ± 11.8 bpm, before, 82.4 ± 10.0 bpm, after, p <0.001 and controls: 91.4 ± 13.4 bpm, before, 81.5 ± 12.6 bpm, then; p <0.001). Hydrotherapy promoted a borderline significant redution in systolic blood pressure in hypertensive patients (139.6 ± 12.1 mmHg, before, 130.1 ± 12.6 mmHg, later, p= 0.050). Conclusions: We demonstrated for the first time that a hydrotherapy session acutely reduces the arterial stiffness expressed by the augmentation index, as well as attenuation in the heart rate of hypertensive pregnant women, regardless of the reduction of the blood pressure. The intervention proved to be safe and could represent a potential accessory non-pharmacological strategy for the prevention of maternal-fetal complications associated with chronic hypertension during pregnancy.
Estudo transversal para avaliar o impacto da mutação R302Q na sub-unidade γ2 da proteína quinase ativada por AMP em vias metabólicas
(Faculdade Ciências Médicas de Minas Gerais, 2018-02-26) Souza, André Chuster de; Sternick, Eduardo Back
Introduction: The R302Q mutation in the γ2 subunit of the PRKAG2 gene is associated with alterations in the metabolism of AMPK (AMP-activated protein kinase), enzyme responsible for the control of cellular energy homeostasis. The result of the PRKAG2 mutation is the loss of AMPK γ2 subunit function, characterizing a metabolic defect responsible for a glycogen metabolism disease. The phenotype resulting from this mutation includes ventricular hypertrophy, sinus bradycardia, conduction system abnormalities, atrial arrhythmias, ventricular pre-excitation syndrome, progressive heart failure and sudden cardiac death. Extra cardiac manifestations may occur in rare patients, mostly due to skeletal muscle glycogen storage. The objective of the present study is to examine the effect of the R302Q mutation of the PRKAG2 gene on metabolic pathways focusing on diabetes mellitus type 2, obesity and metabolic syndrome. Methods: This is an observational study with 26 heterozygous adults for the R302Q γ2 mutation and 44 individuals with a negative genotype for the given mutation. Clinical, anthropometric, biochemical were collected and previously validated questionnaires were applied. Results: Individuals with a positive genotype for the R302Q γ2 mutation had higher values of body mass index, waist-hip ratio and cutaneous skin-folds when compared to the control group. Carriers of the R302Q mutation had higher levels of gamma glutamyltransferase, bilirubin, fasting glucose and glycosylated hemoglobin. The HOMA model demonstrated lower levels of HOMA%B with similar levels of HOMA%S, consistent with a reduction in the activity of beta-pancreatic cells, with preserved insulin sensitivity. Conclusion: The R302Q γ2 mutation is associated with increased adiposity and reduced beta pancreatic cell activity, playing a key role in the genesis of the metabolic syndrome in this population.
Criopreservação de oócitos para fertilidade futura: comparação da resposta ovariana entre pacientes oncológicas e não oncológicas
(Faculdade Ciências Médicas de Minas Gerais, 2018-03-27) Moraes, Camila Cruz de; Marinho, Ricardo Mello
Background: the cryopreservation of human embryos in in vitro fertilization (IVF) cycles is a well-established, reliable and routinely performed technique in assisted reproduction laboratories. Oocyte cryopreservation gained importance because it became an option to preserve the fertility of women with cancer or other diseases whose treatment could compromise their ovarian reserve. Currently, the group that seeks the oocytes cryopreservation most is women who have a desire to be mothers, but who do not see the possibility of becoming pregnant at the moment, either for lack of partner or professional, economic or personal issues. The difference between these two groups is: patients who freeze their oocytes by postponing motherhood are healthy, while cancer patients are carriers of a potentially fatal, consumptive illness. It is questioned whether the cancer patients would have a smaller ovarian reserve, presenting a lower response during ovulation induction. Objective: evaluate if the occurrence of a diagnosis of cancer interferes, in some way, in ovarian function, prior to the treatment of the disease. Material and methods: retrospective study, through analysis of medical records and the electronic database of the laboratory with information about ovarian stimulation cycles for oocytes cryopreservation. Results: The mean age was 35.13 ± 3.72 years, and 51.6% of the pacients were between 36 and 40 years old. The majority of patients were single, 57.6% in both groups. 82.1% of the patients presented normal weight to the body mass index (BMI) in both groups. Most women had no pregnancies (85.5%), no births (95.1%), and no abortions (89.6%) prior to cryopreservation. Most patients, 85.9%, performed only one puncture. In most cycles, the Antagonist protocol was used for the non-oncologic and oncological groups (74.4% and 86.4%, respectively). The mean number of gonadotrophin (FSH and hMG) units used was 2,288.1 ± 1,159.4 for non-cancer patients and 2,355.9 ± 1,182 for cancer patients. For 28.3% of the women there were 13 days of induction until the day of the ovarian puncture. The mean number of oocytes obtained for non-cancer patients was 11.4 ± 8 and for cancer patients this number was 13.8 ± 9. The mean number of frozen mature oocytes was 9.7 ± 7 for the non oncological group and 11.2 ± 7.2 for the oncological group. The majority (63.1%) of the patients, frozen up to 10 oocytes per cycle. The most incident cancer was the breast cancer. There was no significant difference in ovarian response according to the type of cancer. Conclusion: The response to ovarian stimulation of oncological and non-oncological patients is similar, since the number of oocytes obtained and frozen from the two groups studied was similar
Acidose metabólica e o estado nutricional nos pacientes em hemodiálise
(Faculdade Ciências Médicas de Minas Gerais, 2018-04-06) Machado, Renata Silva; Passos, Maria do Carmo Friche; Almeida, Alessandra Maciel
Background: The prevalence of malnutrition in hemodialysis patients is high, being a marker of poor prognosis in chronic kidney disease. Metabolic acidosis is frequent in a dialysis patient, and has been associated with mortality. Objectives: To evaluate metabolic acidosis and nutritional status of hemodialysis patients. Methods: Cross sectional study in patients on hemodialysis in a single center. Information was collected in medical records and evaluation of the presence of metabolic acidosis and nutritional status as measured by anthropometric and biochemical indicators. Results: The sample consisted of 63 patients, male (54%) and 45 to 64 years old (58.7%). The mean dialysis time was 5.49 ± 4.39 years. The mean value of body mass index was 24.95 ± 6.81 kg / m2 and albumin was 3.93 ± 0.31 g / dL. The prevalence of metabolic acidosis was 77.8%. There was a negative linear correlation between bicarbonate and creatinine (p = 0.006) without correlation with anthropometric and albumin indicators. Patients malnourished according to Body Mass Index gained more interdialytic weight (p = 0.006). They were classified as malnourished by body mass index (55.55%), arm circumference index (14.29%) and 49.20% of patients by albumin (<4.0 g / dL). Creatinine levels were higher in patients aged 45 to 64 years (p = 0.032) and in males. No differences were observed by time in hemodialysis in relation to age, interdialytic weight gain, laboratory and anthropometric measures. Conclusion: The prevalence of metabolic acidosis was high, and there was no correlation with nutritional status. Bicarbonate <22mEq / L correlated with higher creatinine values unrelated to nutritional status. Nutritional assessment by body mass index was in agreement with the Brazilian literature, and albumin indicated elevated malnutrition. The dialysis time did not affect the nutritional evaluation parameters.
Glomerulopatias: evolução clínica, recorrência e sobrevida do enxerto em pacientes submetidos ao transplante renal
(Faculdade Ciências Médicas de Minas Gerais, 2019-04-24) Figueiredo Júnior, Humberto Eustáquio; Nascimento, Evaldo; Oliveira, Raquel Aparecida Salustriano Fabreti de
Background: Glomerulopathies (GP) are a group of diseases that can lead to renal failure and need for dialysis, being the third cause of end stage renal disease (ESRD) in Brazil. Recurrent GP after kidney transplantation is a complication of kidney transplantation that could negatively affect kidney function and graft survival. Objectives: This study aimed to evaluate the outcome, graft survival and GP recurrence and its predictors in kidney-transplanted patients. Methods: The patients were divided into two groups: G1 (with GP; n=95) and G2 (with other causes of ESRD (n=373). Graft survival analyses were performed using the Kaplan-Meier for living donor (LD) and deceased donor (DD), for subtype of GP and for recurrence. Multivariate Cox regression analysis were used to investigate the predictors for graft loss and for GP recurrence. Pre-transplant diagnosis of GP in G1 was made based on clinical manifestation and/or biopsy. Post-transplant GP was classified in true recurrence or transplant GP (Tx-GP). Results: The proportion of rejection episodes and the mean serum creatinine levels in the first month after transplantation and in the following months were similar between G1 and G2 for LD and DD. Disease recurrence was observed in nine patients who received kidney from a LD, of which four lost their grafts. In patients who received kidney from a DD, recurrence was also observed in nine patients, of which three lost their grafts. No statistically significant differences in graft survival between G1 and G2 in relation to LD and DD were noted (P=0.299 and 0.434, respectively). However, differences in graft survival were found when GP subtypes and GP recurrence were analysed. The predictors of graft loss were delayed graft function (hazard ratio (HR)=2.226, P=0.002), rejection episodes (HR=1.904, P=0.017), and recurrence or Tx-GP (HR=3.243, P=0.006). The predictors of disease recurrence or Tx-GP were age (HR=0.945, P=0.028) and cold ischaemia time (HR=1.117, P=0.003). Conclusions: Kidney transplantation remains a reasonable treatment for GP with ESRD, although the possibility of disease recurrence. Loss of renal function due to IgA nephropaty was observed in the long term. For patients with focal segmental glomerulosclerosis, the decision on transplantation should be thoroughly discussed between the doctor and the patient because of the high rates of recurrence and allograft failure.
Avaliação da qualidade de vida e analgesia de pacientes com tumores sólidos e em uso de opióides
(Faculdade Ciências Médicas de Minas Gerais, 2019-05-17) Pos, Alexandre Mio; Wainstein, Alberto Julius Alves; Wainstein, Ana Paula Drummond Lage
Introduction: Use of opioid analgesics remains being the main therapy for pain control in cancer patients. However, ample evidence persists showing that treatment is still inadequate. Data on this dilemma and its impact on patients' lives are still scarce in our population. Objective: To evaluate the impact of opioid use on analgesia and qual ity of life of patients with solid tumors. Material and Methods: This cross-sectional, analytical study was carried out between January and December 2017 in a Tertiary Referral Unit for Cancer Treatment. The pain, depression and quality of life were eval uated through validated instruments that included the Pain Management Index (PMI), European Organization for Research and Treatment of Cancer-Core 30 (EORTEC QLQ.C30), Beck Depression Inventory (BDI), Karnofsky Performance Status (KPS), Douleur Neuropathique 4 (DN4), Brief Pain Inventory-Short Form (BPI-SF). Results: 100 patients with advanced solid tumors and making use of opioids were studied. 82% of them reported daily pain being 58% with intense pain. 57% were making use of morphine with a mean dose of 49 Morphine Milligram Equivalent (MME) and PMI was negative in 34% of sample. Neuropathic pain (NP) was found in 72% and BDI was greater than 12 in 90% of patients. The pain was related to all BPI variables, mood, general activity, work and pleasure of living. Conclusion: Despite the substantial neg ative impact of pain on QOL, no international consistency was found among the clinical factors studied with QOL itself. This gap can be interpreted due to persistence of high levels of subtreatment, depression and neuropathic pain, associated with the use of low doses of opiates and adjuvant drugs in the sample
Estudo caso-controle para avaliar influência autonômica na bradicardia dos pacientes com a mutação R302Q no gene PRKAG2
(Faculdade Ciências Médicas de Minas Gerais, 2019-06-28) Santos, Pedro Paulo Nascimento dos; Sternick, Eduardo Back
Background: It has been shown that bradycardia in the mutant murine model with ɣ2- AMPK mutation is caused by sinus node remodeling. We aim to assess the autonomic nervous system (ANS) phenotype in a cohort of carriers of R302Q PRKAG2 gene mutation and to assess its role in the sinus bradycardia occurring in PRKAG2 cardiomyopathy. Methods: This case-control cross-sectional study included twenty-seven individuals from five families, carriers of ɣ2 subunit PRKAG2 mutation and 27 relatives without the mutation, matched by sex and age as a control group, who underwent ANS evaluation by means of heart rate (HR) variability assessment using time and frequency domain parameters during 10 minutes supine resting and 24-hour Holter, resting and post phenylephrine baroreflex sensitivity, Valvalsa and respiratory maneuvers, Handgrip, head-up tilt table testing, basal and post orthostatism serum epinephrine, norepinephrine, and dopamine, serum NTproBNP, and pharmacologic dual autonomic blockade with atropine and propranolol (we classified in 3 types of response, 1 being normal, 2 with mildly abnormal intrinsic HR, 3 with severely abnormal intrinsic HR plus no response to atropine). Results: Control and PRKAG2 Groups had 55.6% females and similar age (36.3+14 vs 36.8+14.6 years, p=0.8). Holter HRV parameters were significantly higher in PRKAG2 group, particularly SDNN, SDRR and RMSSD and Total Power, as well as higher incidence of frequent atrial ectopy (7.4% vs 48.1%, p= 0.016). Systolic BP during Valsalva phase1 was higher among PRKAG2 subjects (124.80±13.72 vs 133.59±15.28, p=0.031). Results from baroreflex sensitivity, Valsalva and respiratory maneuvers, Handgrip, head-up tilt table testing did not differ among study Groups. Total peripheral resistance (TPRI) group was higher in PRKAG2 subjects at rest (3.406.77+1309.59 dyn.sec.cm-5 ; p< 0.0001) as well as after phenylephrine bolus (5717.19 + 2231.52 vs 3569.30 + 1292.32 dyn.sec.cm-5 ; p< .0001). PRKAG2 subjects had a slower HR at rest (52.2+8.2 vs 64.4+14.5 beats/ min; p= 0.0006), after atropine (92.8+19 vs 116.7+18.2 beats/ min; p< 0.0001), and intrinsic HR (67.6+21.4 vs 95.7+13.5 beats/ min; p<0.0001). After 1 year of follow-up 3 type-2 patients (20%) (PRKAG2 Group) had a major cardiac event (1 sudden death and 2 pacemakers). Conclusions: The autonomic nervous system plays no role in the bradycardia associated with PRKAG2 cardiomyopathy. There is evidence in favor of a heightened sympathetic drive in PRKAG2 subjects, which could have an impact in the risk of sudden death. Type 2 response to pharmacologic ANS blockade predicted major arrhythmic events in one year.
Avaliação da cirurgia citorredutora associada à quimioterapia intraperitoneal em centros oncológicos de Belo Horizonte
(Faculdade Ciências Médicas de Minas Gerais, 2019-07-05) Marcos, Priscilla Rossi Baleeiro; Wainstein, Ana Paula Drummond Lage; Wainstein, Alberto Julius Alves
Introduction: Intraperitoneal chemotherapy (IPC) is a highly complex process of drug delivering with curative intent to carefully selected patients with advanced peritoneal carcinomatosis (PC). Objective: This study aimed to evaluate the use of IPC, in a real-life setting, and assess the patient’s profile and outcomes. Method: A retrospective descriptive study was performed through the analysis of medical charts of patients hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy. Eligible patients presented ECOG performance status scores of 0 or 1 and peritoneal metastasis. Results: Twenty-six patients, with 72% of females, and the mean age of 55.19±11.21 were included. Ovarian cancer (50%), pseudomyxoma peritonei (34.6%), and colorectal cancer (15.3%) were the most common primary tumors. The individuals in the HIPEC group presented better ECOG score compared to the EPIC group (76.2% vs. 20%). In 92.3% of the cases, IPC was indicated as rescue therapy for relapsed tumors; in 57.6% of the cases, it was delivered after a second recurrence. Patients with pseudomyxoma peritonei (7.6%) received HIPEC as primary therapy after cytoreductive surgery. Only subjects with ovarian cancer receiver EPIC (19.2% of the included patients), all after a second recurrenThere was no difference in time to progression, considering HIPEC or EPIC treatments. Conclusion: Although complex, peritonectomy combined with IPC can be performed in referral centers with acceptable levels of morbidity and mortality
Avaliação longitudinal do eletrocardiograma do atleta jovem
(Faculdade Ciências Médicas de Minas Gerais, 2019-12-18) Aleixo, Haroldo Christo; Sternick, Eduardo Back
Background: Competitive sports practice is associated with an increase in the risk of sudden cardiac death in athletes with a silent preexistent non diagnosed cardiovascular condition. Aiming to tackle this real threat, a number of preparticipation cardiovascular protocols have been implemented with varying results. One of the suggested strategies uses the resting electrocardiogram as a screening tool. However, the definition of abnormal findings in the young athlete is still debated, and there is lack of consensus in the literature. Objectives: report electrocardiographic patterns of Brazilian soccer players; evaluate current accepted normal electrocardiographic patterns in the young athlete and to assess its longitudinal variability overtime, from adolescence to early adulthood; Methods: Between 2009 and 2019, 487 male athletes (14,1± 2,0 years-old) participated and their 1503 electrocardiograms were analyzed according to the International Recommendations Criteria (2017). The athletes that competed for a minimum of two consecutive seasons were included in the study. All athletes were evaluated at admission and also before the onset of every new season of competition. Medical evaluation consisted of an individual medical assessment and resting electrocardiogram. In the present study we reviewed all electrocardiograms and clinical charts of these athletes. Results: T-wave inversion was found in 65 (13,3%) athletes, 14,7% (5/34) pretos, 14,4% (44/306) pardos, and 10,9% (16/147) brancos. TWI proportion in electrocardiograms was significantly higher in pretos (p=0,003). Age was inversely correlated to TWI in V1-V3 (p=0,01) and directly correlated when occurring in inferior leads (p<0,001). Twenty two athletes (4,5%) had and abnormal electrocardiogram, and 10 of them (2,1%) had two or more borderline findings. From the evolutionary point of view, the non-deep T-wave inversions (<2,0mm) in inferior leads completely disappeared in 7 of 7 athletes, while it was also observed in 3 of 10 athletes with T-wave inversion in the lateral leads. On the second study, after an interval of 4 years between medical evaluations, unprecedented marked inferolateral repolarization alterations were observed in a former asymptomatic athlete, with no history of heart disease. Conclusions: Both studies reveal the dynamic electrocardiographic patterns likely to occur during adolescence thru early adulthood and suggest that electrocardiogram must be periodically repeated in athletes during this phase.
Análise eletromiográfica e propriedades clinimétricas do teste muscular manual da cinesiologia aplicada
(Faculdade Ciências Médicas de Minas Gerais, 2020-03-13) Oliveira, Décio Gomes de; Kirkwood, Renata Noce
Background: The Applied Kinesiology’s manual muscle test (AK-MMT) is a clinical assessment tool that can be used to identify motor control changes in neurologically healthy subjects. The AK-MMT classifies muscles as ‘facilitated’ or ‘inhibited’ and the hypothesis that explains this difference is that inhibited muscles present a latency delay. Objective: Investigate the hypothesis of the latency delay in inhibited muscles and test the clinimetric properties of the AK-MMT. Methods: A cross-sectional and methodological study was conducted in 38 participants with a mean age of 41.1 years (SD 14.8). Electromyography integrated with an electrical goniometer and a hand-held dynamometer were used to measure latency, angular displacement and muscle force of the gluteus medius muscles, respectively. Inter- and intra rater reliability of two examiners with different levels of experience were obtained using Intraclass Correlation Coefficient (ICC). Muscle force, latency and joint angular displacement were compared between groups (facilitated vs. inhibited) using Mann-Whitney U test. Latency and angular displacement were also compared within groups by paring the participants that presented facilitated gluteus medius in one side and inhibited in the opposite one using the Wilcoxon paired test. For the concurrent validity of the AK-MMT in classifying an inhibited muscle as weak was conducted the receiver operating characteristic curve (ROC curve), by using as the test variable the strength test obtained with the dynamometer. Results: Intra- and inter-examiner reliability was excellent, with ICC’s > 0.9. When the whole sample was considered there was no significant difference in latency, but the Wilcoxon paired test showed a significantly difference delay in latency time of the inhibited muscles (mean 0.10 s vs. 0.18 s, p=0.007) compared to the facilitated gluteus medius. Force and peak force of the inhibited gluteus medius were significantly decreased compared to the facilitated ones. Joint angular displacement was significantly greater in the inhibited group. ROC curve showed an area under the curve of 0.743, demonstrating that the classification of the most experienced examiner discriminated the force between groups (p=0.001), which means that the test has concurrent validity. Conclusion: The results have demonstrated that AK-MMT has good clinimetric properties and support the hypothesis that the AK-MMT is sensitive to differences in strength and latency. This means that physical therapists have now a tool to identify neuromuscular dysfunctions that is reliable, valid and easy to be applied in clinical environment. In addition to providing information about the strength and quality of muscle contraction, the use of TMM AK can facilitate the development of therapeutic strategies aimed at correcting motor control dysfunctions, commonly overlooked in the treatment of acute pain and degenerative musculoskeletal disorders.
Impacto do estado nutricional pré-transplante nos desfechos clínicos, sobrevida do enxerto e risco de morte em pacientes transplantados renais
(Faculdade Ciências Médicas de Minas Gerais, 2020-04-09) Santos, Marina Ribeiro de Oliveira; Nascimento, Evaldo; Oliveira, Raquel Aparecida Salustriano Fabreti de
Introduction: Chronic kidney disease is currently considered a health problem worldwide and protein-energy malnutrition in these patients is frequent and an important predictor of morbidity and mortality. Kidney transplantation can improve patient's quality of life and survival, but complications after the procedure are still significant and may be associated with the recipient's nutritional status. Little consideration is given to nutrition in the preparation phase and in kidney transplant surgery and, therefore, the prevalence of malnourished patients before and after transplantation and the influence of the nutritional status on results after the procedure are still underestimated. Objectives: To assess the impact of the nutritional status in recipients before kidney transplantation on renal function, clinical outcomes, graft survival and risk of death. Material and Methods: In this retrospective cohort study including 451 transplanted patients between 2008 and 2018, at University Hospital of The Faculty of Medical Sciences, an easy to use nutritional screening tool was developed for patients in preparation for kidney transplantation, based on anthropometric, laboratory and clinical data. For this, a risk score was elaborated with these data. The sum of all components of the score varies from 0 to 12 points. The patients were stratified into three groups, according to the final score: G1 (0 to 2 points) = low risk; G2 (2-4 points) = moderate risk and G3 (> 5 points) = high risk of malnutrition. Results: Stratifying the 451 patients based on the pre-transplant risk score, G1 was composed of 90, G2 of 292 and G3 of 69 patients. G1 patients maintained the lowest creatinine levels at the time of hospital discharge after transplantation, when compared to the other two groups (p = 0.012). Transplant recipients from G3 had a higher proportion of graft losses, with the mean graft survival time in months being 100.56 + 46.49 in G1, 94.64 + 54.34 in G2 and 77.76 +49.01 in G3 (p = 0.044). The Kaplan-Meier survival curve showed better survival for patients in G1, when compared to the other groups (p = 0.046). G3 patients had almost three times greater risk of graft loss (Hazard Ratio [HR] 2.94; 95% CI; 1.084-7.996). Sensitized patients and patients with delayed graft function had almost twice the risk (HR 1,904, 95% CI 1,168-3,105; HR 1,921, 95% CI 1,238-2,980) and patients with cellular rejection or humoral rejection had a 2.18 times greater risk (HR 2,180, 95% CI 1,251-3,798) of graft loss. Conclusion: Kidney transplant patients with a higher risk of malnutrition according to the pre transplant score were associated with worse outcomes and graft survival. The nutritional screening tool is easy to be used in clinical practice to evaluate the patient in preparation for kidney transplant.
Simulação de alta fidelidade comparada à de baixa fidelidade no suporte avançado de vida cardiovascular
(Faculdade Ciências Médicas de Minas Gerais, 2020-05-08) Alcântara, Rafael Barbosa; Scalabrini Neto, Augusto; Almeida, Alessandra Maciel
Introduction: Teaching skills and knowledge using simulation is a useful and important tool for training students in the healthcare students. This teaching model is a constant challenge for institutions and professionals. In a productive and safe environment, there is the possibility of training and assessing students regarding their knowledge, skills and behavioral aspects. In order to achieve that, it uses reliable tools such as checklists to follow a standardized teaching and assessment script. The American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) training program relies on simulation for teaching the trainees. Conflicting results are observed in the literature regarding the real benefit of using high fidelity simulation in ACLS courses or in ACLS scenarios. In view of the various forms of teaching using simulation, it becomes necessary to identify the most effective method for training the ACLS. Objectives: (1) To develop a checklist that represents the scenario elaborated by the researchers for the care of cardiorespiratory arrest (PCR) using a Likert scale, (2) To compare the effectiveness of high and low fidelity simulation methods in the training of ACLS using the checklist created. Materials and methods: A checklist was developed using items from a previous one and adding more items created by experts. Final adjustments were made based on the training video, before the approval of the final version. Once the checklist was ready to use, an experimental study was conducted with 55 medical students from the Medical Sciences Faculty of Minas Gerais (FCM-MG) of the 3rd and 4th years. All students completed all phases of the study. Thirty seven were female (67.3%) and the average age was 21.7 ± 1.46 years. The training followed the following steps: (1) Theoretical and practical training of students randomly distributed in groups: experimental (n = 30), which carried out training in high-fidelity simulation and control group (n = 25), of low fidelity. (2) Subsequently, the teams were subjected to a practical assessment of the team's performance using the checklist. Results: Thirty (81.1%) out of 37 checklist items assessed by the experts were scored the highest grade by all of them in a scale from 1 to 4, other six items (16.2%d) were scored 3 by at least one evaluator, and only one (2.7%) was scored 1. Highest grade was scored for 91.9% of the items, exceeding the 85% goal. All students completed the study. Thirty-seven were female and the average age was 21.7 ± 1.46 years. The high fidelity group was compose mainly by females (90.9%) and received more training in emergency and acute care (60.6%, p = 0.002). Practical performance scores were similar for both groups (p = 0.14). Conclusion: The designed checklist based on the 2015 guidelines of the AHA proved to be reliable, with high agreement between the experts. By assessing different types of simulation, this study suggested that there was no advantage in the use of high-fidelity teaching methods.
Função sexual e alterações metabólicas e hormonais em mulheres usuárias de anticoncepcionais hormonais e não hormonais de longa permanência
(Faculdade Ciências Médicas de Minas Gerais, 2020-07-15) Moreira, Igor Fernando de Aquino; Almeida, Alessandra Maciel; Rezende, Bruno Almeida
Background: Female sexual dysfunction is a common condition that negatively impacts the emotional health and quality of life of the affected individuals. Long-acting reversible contraceptives (LARCs) are becoming increasingly popular due to their effectiveness and convenience. LARCs can be hormonal (etonogestrel releasing implant—ENG and Levonorgestrel intrauterine system—LNG) or non-hormonal (copper intrauterine device— CuIUD and copper silver intrauterine device—SIUD). There are very few studies that assess the influence on LARCS on sexual function are lacking.This study aimed to assess changes in sexual function as well as metabolic and hormonal parameters in women after implantation with LARCs. Methods: In this prospective cohort study, we assessed 80 women who visited the Military Police Hospital in Brazil for LARCs placement. The study participants were divided into 4 groups according to the type of LARC received: ENG n=17; LNG n=21, CuIUD n=18 and SIUD n=23. The four groups were evaluated twice (prior to LARC placement and approximately 3 months later) for sexual function, using the Female Sexual Function Index (FSFI) and Female Sexual Quotient (QS-F) questionnaires. Metabolic and hormonal parameters were also assessed using blood tests. p<0.05 was considered to indicate statistical significance. Results: We observed an improvement in sexual function with CuIUD placement according to QS-F (p<0.017) and SIUD (FSFI: p=0.06 and QS-F: p<0.001). However, ENG worsened sexual function according to FSFI and QS-F (p<0.001 and p=0.003), across all domains. A decrease in sex hormone-binding globulin (SHBG) was observed for all groups (LNG: p=0.019; ENG: p=0.024; CuIUD: p=0.010; SIUD: p=0.022) and an increase in total testosterone levels (p=0.007 and p = 0.003) and prolactin (p=0.049 and p=0.001) with CuIUD and SIUD placement. Hemoglobin levels increased with LIS (p<0.001) and ENG (p=0.025) and decreased with CuIUD placement (p<0.001). Conclusion: The use of non-hormonal LARCS improved sexual function, especially in the desire domain. Etonogestrel implants, had a negative influence on sexual function, probably by blocking ovarian function, and thus reducing the production of androgens and estrogens. SIUD placement was superior as it improved sexual function, interfered less with hormonal levels, and did not decrease hemoglobin levels.
Influência do uso da pressão positiva nas vias aéreas sobre os índices de rigidez arterial de pacientes com apneia obstrutiva do sono grave
(Faculdade Ciências Médicas de Minas Gerais, 2020-07-16) Pereira, Patrícia de Souza Pinto; Machado, Maria da Gloria Rodrigues; Silva, José Felippe Pinho da
Introduction: Obstructive sleep apnea (OSA) and arterial stiffness are associated with an increased risk of cardiovascular morbidity and mortality and worsening patients' quality of life. Studies of the association between reduced arterial stiffness and cardiovascular risk with adherence to treatment with positive airway pressure (PAP) by individuals with OSA are not well established. Objetive: To evaluate the impact of PAP therapy on arterial stiffness, quality of life and sleep in patients diagnosed with severe OSA. Method: 43 patients with OSA participated in this study, being 21 users of PAP (OSA-PAP) and 22 non-users (OSA C). Arterial stiffness was assessed by the brachial oscillometry device and quality of life by the specific Quebec Sleep Questionnaire (QSQ). Results: In this case-control study, pulse wave velocity (PWV) was similar in both groups (9.22 ± 1.52 versus 8.44 ± 1.28, p = 0.090), and augmentation index (AIx @ 75) was significantly higher in the OSA-PAP group (28.95 ± 8.53 versus 21.44 ± 9.46, p = 0.035). In the OSA-PAP group, the multiple regression model identified that the variable, total time of use of PAP explained 45.0% of the AIx @ 75 variability [F (1.17) = 13.898; p <0.001; R²: 0.450. The OSA-PAP group had better cardiac function, evidenced by the greater stroke volume (64.41 ± 12.67 versus 72.83 ± 10.5 ml, p = 0.048) and lower heart rate (75 ± 13 versus 65 ± 12 bpm, p = 0.014). The sub-items of the QSQ questionnaire were similar in both groups. Conclusion: The analysis of the positive effects of PAP should not be limited to the impact of this therapy only on quality of life and peripheral blood pressure. The data reveal that AIx @ 75 can be valuable for assessing the stiffness of a patient with severe OSA whose sample is homogeneous and that PAP improves hemodynamic function independently of arterial stiffness. In addition, the total time of use of PAP is negatively related to AIx @ 75.
Delineamento epidemiológico do câncer do colo do útero no Brasil e da cobertura de estratégias de prevenção, com auxílio de modelo geoespacial, para fundamentar ações para seu controle
(Faculdade Ciências Médicas de Minas Gerais, 2020-07-31) Pescuite, Luana Tamara; Rodrigues, Angélica Nogueira
Introduction: According to the latest data from the World Health Organization (WHO), cervical cancer (CC) was classified as the fourth female tumor in incidence and mortality in the world. In Brazil, the National Cancer Institute (INCA) predict around 16,710 new cases for the 2020-2022 triennium, with an estimated risk of 16.35 cases per 100 thousand women, and registered 6,526 deaths in 2018, corresponding to the third tumor in incidence (except non-melanoma tumors) and the fourth in mortality. The Ministry of Health (MS), in partnership with INCA, developed the Brazilian Guidelines for Cervical Cancer Screening, which determine the cervical cytology collection in patients aged 25 to 64 years. The MnS has incorporated a tetravalent vaccine against subtypes 6, 11, 16 and 18 of HPV for girls aged 9 to 14 years old and boys aged 11 to 14 years old. Objectives: CC's epidemiological profile at national level and by federative units, relating incidence and mortality together with the coverage of screening and immunization programs, determining priority areas for intervention through improvements in public health policies. Material and Methods: Ecological study evaluating data on incidence, mortality, vaccination coverage against HPV in girls aged 9 to 14 years and proportion of Pap screening in women aged 25 to 64 years, provided by the MS and INCA. Using the geospatial model, the variables were classified by states and maps were elaborated from the overlap of these variables for visualization and comparison of deficient areas, conceiving a geographical representation of the priority areas for directing interventions by health managers. Results: Seven of the 27 (25.9%) Brazilian states have an incidence of more than 20 cases per 100,000. There is a greater burden of the disease in the North, where all states, except Roraima, have an incidence of more than 18.85 cases per 100,000 women per year, and where all states, without exception, have a mortality rate greater than 6.93 cases per 100,000 women per year. Our analysis also shows an overlap of higher incidence and higher mortality from CC concentrated in the northern region of the country (states of Acre, Amapá, Amazonas, Pará, Roraima, Tocantins) and in a state in the northeast region (Maranhão). Brazil's geographic mapping highlighted a national disparity in HPV vaccination and Pap coverage, both with low median rates. Conclusion: Despite the promise of the recent implantation of HPV vaccination, its full impact will take decades to occur, and these data argue that continuous efforts are needed to improve access to screening and treatment for CC and reduce the lives lost by this preventable disease. The results also suggest that vaccination rates against HPV are below the target, at the risk of repeating Pap test trajectory: an efficient but underutilized tool for CC control.
Câncer em pacientes transplantados renais: evolução clínica e sobrevida do enxerto e do receptor
(Faculdade Ciências Médicas de Minas Gerais, 2020-10-19) Pinto Filho, Valter Alves; Nascimento, Evaldo; Oliveira, Raquel Aparecida Salustriano Fabreti de
Introduction. The end-stage renal disease (ESRD) has become an important public health problem in the world and kidney transplantation is considered the best treatment for ESRD in comparison with dialysis. In order to avoid graft rejection, the transplanted patient underwent continuous treatment with immunosuppressive drugs, whose side effects are associated with the development of different types of cancer (CA) with an important risk factor for mortality. The risk for malignant diseases can increase by two to 20 times in transplant patients. Despite this, cancer screening in the transplant population is inadequate and lacks specific guidelines. Objective. The aim of this study was to analyze the occurrence of cancer in kidney transplant patients, risk factors, clinical evolution and graft and patient survival. Material and methods. This case-control study included 100 patients who received a kidney transplant in the period of 2008 to 2018 at the Transplant Unit of the University Hospital Medical Sciences. Of these, 25 patients who developed CA were assigned to the case group and 75 patients without CA after transplantation were assigned to the control group. All patients were interviewed to survey risk factors such as smoking habit, family history among others before transplant and also screened for malignancies by laboratory and imaging exams. The immunosuppressive therapy was performed with induction immunotherapy in sensitized patients; maintenance triple immunosuppressive therapy using calcineurin inhibitor, methylprednisolone, and sodium mycophenolate. After transplantation, clinical suspicion associated with a positive history of malignancies motivated the initial screening for CA. If CA diagnosis was confirmed, the patient was underwent appropriate treatment. The logistic regression models to obtain the odds ratios and Kaplan-Meier method for survival curves were used in the analyzes. Results. An association of the risk factors as causes of ESRD, time in dialysis, smoking habit, family history of CA, rejection episodes, induction immunotherapy, and maintenance triple immunosuppression with CA development was not observed. Non-melanoma skin cancer was the most common, accounting for 60% of the cases, which was followed by stomach and prostate CA and lymphoproliferative diseases (4% each). The most frequent age range with CA diagnosis was 50–59 years and the highest number of diagnoses was noted from the fifth to seventh year after transplant (43.83%). Graft and patient survival was similar between the groups. Fifty per cent of the patients that died in the case group was due to CA. Conclusion. Association between CA development and the risk factors family history and smoking habit was not observed, and no differences in allograft and patient survival were found between the groups. However, CA can occur early after transplantation, significantly affecting the patient's quality of life. Due to the continuous use of immunosuppression in transplant patients and the high risk of CA, we suggest screening for oncological diseases.