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Moreno D.H.,University of Sao Paulo | Cacione D.G.,UNIFESP Escola Paulista de Medicina | Baptista-Silva J.C.C.,Federal University of Sao Paulo
Cochrane Database of Systematic Reviews | Year: 2016

Background: An abdominal aortic aneurysm (AAA) is the pathological enlargement of the aorta and can develop in both men and women. Progressive aneurysm enlargement can lead to rupture. The rupture of an AAA is frequently fatal and accounts for the death from haemorrhagic shock of at least 45 people per 100,000 population. The outcome of people with ruptured AAA varies among countries and healthcare systems, with mortality ranging from 53% to 90%. Definitive treatment for ruptured AAA includes open surgery or endovascular repair. The management of haemorrhagic shock is crucial for the person's outcome and aims to restore organ perfusion and systolic blood pressure above 100 mm Hg through immediate and aggressive fluid replacement. This rapid fluid replacement is known as the normotensive resuscitation strategy. However, evidence suggests that infusing large volumes of cold fluid causes dilutional and hypothermic coagulopathy. The association of these factors may exacerbate bleeding, resulting in a 'lethal triad' of hypothermia, acidaemia, and coagulopathy. An alternative to the normotensive resuscitation strategy is the controlled (permissive) hypotension resuscitation strategy, with a target systolic blood pressure of 50 to 100 mm Hg. The principle of controlled or hypotensive resuscitation has been used in some management protocols for endovascular repair of ruptured AAA. It may be beneficial in preventing blood loss by avoiding the clot disruption caused by the rapid increase in systolic blood pressure; avoiding dilution of clotting factors, platelets and fibrinogen; and by avoiding the temperature decrease that inhibits enzyme activity involved in platelet and clotting factor function. Objectives: To compare the effects of controlled (permissive) hypotension resuscitation and normotensive resuscitation strategies for people with ruptured AAA. Search methods: The Cochrane Vascular Information Specialist searched the Specialised Register (April 2016) and the Cochrane Register of Studies (CENTRAL (2016, Issue 3)). Clinical trials databases were searched (April 2016) for details of ongoing or unpublished studies. Selection criteria: We sought all published and unpublished randomised controlled trial (RCTs) that compared controlled hypotension and normotensive resuscitation strategies for the management of shock in patients with ruptured abdominal aortic aneurysms. Data collection and analysis: Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Main results: We identified no RCTs that met the inclusion criteria. Authors' conclusions: We found no RCTs that compared controlled hypotension and normotensive resuscitation strategies in the management of haemorrhagic shock in patients with ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and renal failure. High quality studies that evaluate the best strategy for managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required. © 2016 The Cochrane Collaboration. Source


de Sousa R.T.,University of Sao Paulo | Zanetti M.V.,University of Sao Paulo | Busatto G.F.,University of Sao Paulo | Mouro M.G.,UNIFESP Escola Paulista de Medicina | And 5 more authors.
Journal of Psychiatric Research | Year: 2014

Background: Altered nitric oxide (NO) signaling has been associated with the pathophysiology of Bipolar Disorder (BD), directly affecting neurotransmitter release and synaptic plasticity cascades. Lithium has shown to regulate NO levels in preclinical models. However, no study has addressed peripheral NO levels in unmedicated BD. Also, lithium's effects on NO levels have not been studied in humans. Methods: Plasma NO was evaluated in subjects with BD I and II during a depressive episode (n=26). Subjects had a score of ≥18 in the 21-item Hamilton Depression Rating Scale and were followed-up during a 6-week trial with lithium. Plasma NO levels were also compared to matched healthy controls (n=28). NO was determined by chemiluminescence method. Results: Lithium treatment significantly increased plasma NO levels after 6 weeks of treatment in comparison to baseline levels in bipolar depression (p=0.016). Baseline NO levels during depressive episodes showed no difference when matching up to healthy controls (p=0.66). Conclusion: The present findings suggest that lithium upregulates NO signaling in unmedicated BD with short illness duration. Further studies with larger samples are needed to confirm the effects of lithium on NO pathway and its association with synaptic plasticity and therapeutics of BD. © 2014 . Source


Catena F.,UNIFESP Escola Paulista de Medicina | Doty J.F.,University of Tennessee at Chattanooga | Jastifer J.,St. Alphonsus Coughlin Foot and Ankle Clinic | Coughlin M.J.,St. Alphonsus Coughlin Foot and Ankle Clinic | Stevens F.,Tri City Orthopaedics
Foot and Ankle International | Year: 2014

Background: Operative correction of a hammertoe deformity is often accomplished by excision of the articular surface of the proximal interphalangeal joint (PIP) and fixation across the joint. This study aimed to prospectively evaluate clinical and radiographic outcomes of hammertoe operative correction utilizing an internal implant and assess its ability to maintain postoperative alignment. Methods: Twenty-nine patients (53 toes) with a painful rigid hammertoe deformity were prospectively enrolled and operatively treated with resection arthroplasty of the PIP joint and fixation with an implant. Five patients were lost to follow-up, and 24 patients (42 toes) returned at an average of 12 months for final clinical and radiographic evaluation. All patients were evaluated pre- and postoperatively by AOFAS and Visual Analog Pain Scale (VAS) scores. On physical exam, the location and magnitude of the deformity, callosities, and digit circumference were recorded. Radiological parameters evaluated were digital alignment, successful union, implant position, and bone reaction. Results: All patients reported satisfaction at final follow-up, with an average improvement of AOFAS score from 52 (range, 24-87 points) to 71 (range, 42-95 points) points. The mean VAS pain score improved from 5 points (range, 2 to 10) preoperatively to 1 point (range, 0 to 5) postoperatively. Of patients, 87% reported an ability to return to their preoperative activities without limitations. Regarding digital alignment, there were no recurrent deformities or transverse plane deformities; 1 toe presented with a minor digital rotational deformity at final follow-up. Postoperative radiographs indicated 100% of proximal interphalangeal (PIP) joints with good alignment, and 81% demonstrated bony union. Conclusion: Our results suggest that utilization of an internal implant for hammertoe correction was safe and provided acceptable alignment, pain reduction, and improved function at final follow-up. © The Author(s) 2014. Source


Jastifer J.R.,Saint Alphonsus Coughlin Foot and Ankle Clinic | Catena F.,UNIFESP Escola Paulista de Medicina | Doty J.F.,UT Erlanger Foot and Ankle Institute | Stevens F.,TCO | Coughlin M.J.,Saint Alphonsus Coughlin Foot and Ankle Clinic
Foot and Ankle International | Year: 2014

Background: Plantar fasciitis affects nearly 1 million people annually in the United States. Traditional nonoperative management is successful in about 90% of patients, usually within 10 months. Chronic plantar fasciitis develops in about 10% of patients and is a difficult clinical problem to treat. A newly emerging technology, low-level laser therapy (LLLT), has demonstrated promising results for the treatment of acute and chronic pain. Methods: Thirty patients were administered LLLT and completed 12 months of follow-up. Patients were treated twice a week for 3 weeks for a total of 6 treatments and were evaluated at baseline, 2 weeks post procedure, and 6 and 12 months post procedure. Patients completed the Visual Analog Scale (VAS) and Foot Function Index (FFI) at study followup periods. Results: Patients demonstrated a mean improvement in heel pain VAS from 67.8 out of 100 at baseline to 6.9 out of 100 at the 12-month follow-up period. Total FFI score improved from a mean of 106.2 at baseline to 32.3 at 12 months post procedure. Conclusion: Although further studies are warranted, this study shows that LLLT is a promising treatment of chronic plantar fasciitis. © The Author(s) 2014. Source


Nery C.,UNIFESP Escola Paulista de Medicina | Coughlin M.J.,St. Alphonsus Foot and Ankle Clinic | Baumfeld D.,Felicio Rocho Hospital | Mann T.S.,UNIFESP Escola Paulista de Medicina | And 2 more authors.
Foot and Ankle International | Year: 2013

Background: Instability of the lesser metatarsophalangeal (MTP) joints has been widely reported and plantar plate insufficiency is a key part of this pathologic process. The diagnosis is made clinically but can be aided by imaging studies, particularly magnetic resonance imaging (MRI); however, the sensitivity and accuracy of this method compared to direct visualization of these lesions has not yet been established, nor has interobserver accuracy of MRI been assessed for evaluation of plantar plate pathology. In this study, our goals were to identify the accuracy of the MRI in describing plantar plate tears when compared to direct arthroscopic visualization using an anatomic grading system and to test the influence of an anatomic grading system in the accuracy of the MRI readings. Methods: We evaluated the clinical exam, MRI scans, and arthroscopic findings of 35 patients with lesser MTP instability. Results: Using an anatomic grading system, a distinct improvement in the radiological evaluation and interpretation occurred. Knowledge of the pattern of plantar plate tears by a radiologist enabled them to locate and describe the type of tears of the plantar plate on the MRI. The amount of training and the experience of the radiologist were also important factors in our study. The senior radiologists had much better levels of accuracy (Group A, 77.0%; Group B, 88.5%) than less experienced radiologists. Conclusion: Prior knowledge of the pathophysiology and morphological types of lesions of the plantar plates was helpful for accurate identification and description of the tears by the radiologist. Level of Evidence: Level II, prospective comparative study. © The Author(s) 2013. Source

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