Arthur de Sá Ferreira

Chinese medicine pattern differentiation and its implications for clinical practice

Chinese medicine practitioners apply the differentiation reasoning for decision-making. The wide scope of Chinese medicine intervention provides coverage of methods and techniques with applications to primary, secondary and tertiary levels of prevention. The rapid evolution of mathematical and computational techniques allowed the implementation of several models for pattern differentiation that were tested for several physiologic systems. Concurrently, it is argued that pattern differentiation might improve the efficacy of either traditional or conventional medical interventions. This article reviewed the influence of pattern differentiation into clinical practice organized by medical field: general pattern differentiation; genitourinary (recurrent cystitis); cardiovascular (coronary heart disease; arterial hypertension; angina pectoris); neurology (stroke); surgery; metabolic (diabetes mellitus); hepatic (cirrhosis); gastrointestinal (chronic superficial gastritis); orthopedic (low back pain; rheumatoid arthritis; cervical spondylosis; elbow arthritis); oncology (gastric mucosal dysplasia; lung cancer); gynecologic and obstetric manifestations (nausea and vomiting). The reviewed studies presented achievements that have contributed to the integration of Chinese medicine and evidence-based medicine in the treatment of many mild and severe diseases. Target diseases considered as major public health problems were also investigated and the results are promising regarding the possibility to treat guided by pattern differentiation.

Misdiagnosis and undiagnosis due to pattern similarity in Chinese medicine: a stochastic simulation study using pattern differentiation algorithm

Whether pattern similarity causes misdiagnosis and undiagnosis in Chinese medicine is unknown. This study aims to test the effect of pattern similarity and examination methods on diagnostic outcomes of pattern differentiation algorithm (PDA). A dataset with 73 Zangfu single patterns was used with manifestations according to the Four Examinations, namely inspection (Ip), auscultation and olfaction (AO), inquiry (Iq) and palpation (P). PDA was applied to 100 true positive and 100 true negative manifestation profiles per pattern in simulation. Four runs of simulations were used according to the Four Examinations: Ip, Ip+AO, Ip+AO+Iq and Ip+AO+Iq+P. Three pattern differentiation outcomes were separated, namely correct diagnosis, misdiagnosis and undiagnosis. Outcomes frequencies, dual pattern similarity and pattern-dataset similarity were calculated. Dual pattern similarity was associated with Four Examinations (gamma = -0.646, P < 0.01). Combination of Four Examinations was associated (gamma = -0.618, P < 0.01) with decreasing frequencies of pattern differentiation errors, being less influenced by pattern-dataset similarity (Ip: gamma = 0.684; Ip+AO: gamma = 0.660; Ip+AO+Iq: gamma = 0.398; Ip+AO+Iq+P: gamma = 0.286, P < 0.01 for all combinations). Applied in an incremental manner, Four Examinations progressively reduce the association between pattern similarity and pattern differentiation outcome and are recommended to avoid misdiagnosis and undiagnosis due to similarity.

Adiposity and postural balance control: correlations between bioelectrical impedance and stabilometric signals in elderly Brazilian women

OBJECTIVE: The purpose of this study was to investigate the correlation between body adiposity and postural control in elderly women. INTRODUCTION: Aging and obesity account for a significant portion of healthcare spending. Life expectancy is increasing worldwide, and Rio de Janeiro has the largest proportion of elderly residents of all Brazilian states. METHODS: A total of 45 women underwent bioelectrical impedance analysis, waist circumference measurements, weight and height measurements, and stabilometric tests in eight different stance conditions (opened and closed bases with both eyes opened and closed and right and left tandem and unilateral stances with eyes opened). During unilateral stances, the number of hand or foot contacts was counted. RESULTS: Weight, body mass index, waist circumference, fat percentage, and fat mass showed statistically significant (p<0.05) and positive correlations with the number of contacts made during unilateral stances. The subjects with greater fat mass showed significantly higher anterior-posterior standard deviation and range when their eyes were closed. The sway area was also greater for this group in opened base when their eyes were closed. DISCUSSION: The results relating body adiposity and postural control can be explained by the difficulty of maintaining a greater quantity of body fat mass within the limits of the individual support base, especially while assuming a unilateral stance. CONCLUSION: The subjects with a greater fat mass exhibited poor balance control, indicating that body adiposity level was associated with postural control in the elderly women examined in the present study.

Zangfu zheng (patterns) are associated with clinical manifestations of zang shang (target-organ damage) in arterial hypertension

BackgroundHypertension is a clinical condition that manifests target-organ damage (TOD) with symptoms. This study investigates the association between Zangfu patterns and symptomatic manifestations of TOD.MethodsDatasets with manifestations of Zangfu patterns (Liver-fire blazing upwards; Kidney-yin deficiency and Liver-yang rising; obstruction of phlegm and dampness of Heart/Liver/Gallbladder; qi and blood deficiency leading to Liver-yang rising; Kidney-yin/yang deficiency) and TODs (cerebrovascular, heart and kidney) were compiled from literature. The Pattern Differentiation Algorithm was used to test and to determine diagnostic accuracy with these datasets. A questionnaire was developed from datasets and applied to 43 subjects newly diagnosed with hypertension. Pattern differentiation was performed and the results were statistically analyzed for association between descriptions of patterns and TOD.ResultsThe observed diagnostic accuracy, sensitivity and specificity were 98.0%, 96.2% and 99.8% respectively. Similarity between patterns and TOD datasets was mostly negligible. Twelve manifestations demonstrated high prevalence, namely red tongue (81.4%), headache (72.1%), irritability (67.4%), palpitation (60.5%), blurred vision, insomnia and mental fatigue (58.1%), frequent nocturnal urination, numbness in feet and hands, shortness of breath (55.8%), and heavy limbs sensation, wiry pulse (51.2%). No significant association was found between blood pressure variables (systolic, diastolic, mean, pulse pressure) and manifestations.ConclusionZangfu patterns are associated with clinical manifestations of TOD. Manifestations associated patterns indicate morbid conditions to be secondary to hypertension rather than simple blood pressure.

Diagnostic accuracy of pattern differentiation algorithm based on Chinese medicine theory: a stochastic simulation study

BackgroundClinical practice of Chinese medicine requires little information for differentiation of Zang-fu patterns. This study is to test the impact of information amount on the diagnostic accuracy of pattern differentiation algorithm (PDA) using stochastic simulation of cases.MethodsA dataset with 69 Zang-fu single patterns was used with manifestations according to the Four Examinations, namely inspection (Ip), auscultation and olfaction (AO), inquiry (Iq) and palpation (P). A variable quantity of available information (N%) was randomly sampled to generate 100 true positive and 100 true negative manifestation profiles per pattern to which PDA was applied. Four runs of simulations were used according to the Four Examinations: Ip, Ip+AO, Ip+AO+Iq and Ip+AO+Iq+P. The algorithm performed pattern differentiation by ranking a list of diagnostic hypotheses by the amount of explained information F%. Accuracy, sensitivity, specificity and negative and positive predictive values were calculated.ResultsUse the Four Examinations resulted in the best accuracy with the smallest cutoff value (N% = 28.5%), followed by Ip+AO+Iq (33.5%), Ip+AO (51.5%) and Ip (52.0%). All tested combinations provided concave-shaped curves for accuracy, indicating an optimal value subject to N%-cutoff. Use of N%-cutoff as a secondary criterion resulted in 94.7% (94.3; 95.1) accuracy, 89.8% (89.1; 90.6) sensitivity, and 99.5% (99.3; 99.7) specificity with the Four Examinations.ConclusionPattern differentiation based on both explained and optimum available information (F% and N%-cutoff) is more accurate than using explained and available information without cutoff (F% and N%). Both F% and N%-cutoffshould be used as PDAs objective criteria to perform Zang-fu single pattern differentiation.

Herbal Medicines for Cardiovascular Diseases

The global burden of disease has driven a broad shift from communicable, maternal, neonatal, and nutritional causes to noncommunicable diseases. Cardiovascular diseases (CVDs) remain the most prevalent cause of human morbidity and mortality all over the world [1]. According to the survey by Global Burden of Disease Study, 29.6% of all deaths worldwide were caused by CVDs in 2010 [2]. It is estimated that the number of people that die from CVDs, mainly from heart disease and stroke, will increase to more than 24 million by 2030 [3]. Despite progress in molecular medicine and biology and translational scientific efforts on improvement of diagnostic and therapeutic strategies over the past 20 years, CVDs continue to be a major global health problem. The use of herbal medicines, one of the main therapeutic approaches of complementary and alternative medicine (CAM), can be tracked back thousands of years ago in the East [4]. Currently, there is a recent resurgence of the use of herbal medicines in popularity among patients in the West and they were consumed by more than 15 million people in the US [5]. With increasing enhancement of peoples awareness of self-care and concerning on the inevitable adverse effects of conventional medicine, herbal medicines are favored by people with CVDs all over the world for their unique advantages in preventing and curing diseases, rehabilitation, and health care [6]. There is growing evidence showing that many herbal medicines and their active ingredients contribute to the standard therapy for CVDs, for example, aspirin, digitalis, and reserpine [7]. Despite enormous interests in the medicinal uses by consumers, there is still a great deal of confusion and misunderstanding about their identification, effectiveness, pharmacology, toxicology, and herb-drug interaction to science world [8]. Therefore, the role of herbal medicines in CVDs still needs more scientific and clinical data proving their efficacy and safety. The special issue aims to summarize the current progress of promising herbal medicines and their extractions for various CVDs. Altogether, we gathered 31 papers for publication, out of which 14 papers were accepted. The original research articles and reviews in this issue cover a wide range of topics, including coronary heart disease, hypertension, heart failure, dyslipidemia, and arrhythmia. Five papers addressed the clinical application and the mechanism of herbal medicines in the treatment of coronary heart disease. “A multicentre randomized clinical trial on efficacy and safety of huxin formula in patients undergoing percutaneous coronary intervention” provided evidence on huxin formula, an experienced Chinese medicine formula, for the treatment of patients undergoing percutaneous coronary intervention. “Traditional formula, modern application: Chinese medicine formula sini tang improves early ventricular remodeling and cardiac function after myocardial infarction in rats” evaluated the improvement of early ventricular remodeling and cardiac function in myocardial infarction in rats by sini tang, which is a traditional Chinese classical herbal formula first described by Zhongjing Zhang (150–219 A.D.). “The comparative study on expression of SIRT1 signal transduction by xuefuzhuyu capsule” tested the protective effect of xuefuzhuyu formula, another classical herbal formula in traditional Chinese medicine (TCM), on ischemic myocardial cells induced by ischemia through SIRT1-mediated signal transduction pathway. “Protective effects of shen-yuan-dan, a traditional Chinese medicine, against myocardial ischemia/reperfusion injury in vivo and in vitro” investigated the effectiveness and mechanisms of shen-yuan-dans pharmacological postconditioning on myocardial ischemia/reperfusion injury by targeting the phosphatidylinositol 3-kinase/Akt (PI3K/Akt) pathway. “Ligusticum wallichii extract inhibited the expression of IL-1β after AMI in rats” addressed the effects of Ligusticum wallichii (chuanxiong) extract on IL-1βexpression in myocardium and central nervous system after acute myocardial infarction. Hypertension is an important public-health challenge worldwide and a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease. Prevention, detection, treatment, and control of this condition should receive high priority. How about the role of TCM for managing hypertension? One review article “Traditional Chinese medicine syndromes for essential hypertension: a literature analysis of 13,272 patients” analyzed the diagnosis rules and common TCM syndromes of hypertension and recommended the corresponding Chinese herbal medicines and formulas. “Chinese herbal medicine bushen qinggan formula for blood pressure variability and endothelial injury in hypertensive patients: a randomized controlled pilot clinical trial” examined the therapeutic effects of bushen qinggan formula as adjunctive therapy for antihypertensive drugs on mean blood pressure, blood pressure variability, and endothelial function for hypertension. One paper “Yiqi huoxue recipe improves heart function through inhibiting apoptosis related to endoplasmic reticulum stress in myocardial infarction model of rats” explored the mechanism of cardioprotective effects of yiqi huoxue formula in rats with myocardial infarction-induced heart failure by inhibiting endoplasmic reticulum stress response pathway. Two papers discussed the cardiovascular protective effects of Hawthorn (Crataegus oxyacantha). “Effect of Crataegus usage in cardiovascular disease prevention: an evidence-based approach” reviewed the cardiovascular pharmacological properties of Crataegus in vivo and in vitro. “Evaluation of a Crataegus-based multiherb formula for dyslipidemia: a randomized, double-blind, placebo-controlled clinical trial” examined the effects of a multiherb formula containing Crataegus pinnatifida on plasma lipid and glucose levels in Chinese patients with dyslipidemia. Finally, “Yiqihuoxuejiedu formula inhibits vascular remodeling by reducing proliferation and secretion of adventitial fibroblast after balloon injury” analyzed effects and mechanisms of the yiqihuoxuejiedu formula on inhibiting vascular remodeling, especially adventitial remodeling. “Ganoderma lucidum polysaccharides reduce lipopolysaccharide-induced interleukin-1β expression in cultured smooth muscle cells and in thoracic aortas in mice” examined the effects of an extract of Ganoderma lucidum (Reishi) polysaccharides on interleukin-1β expression by human aortic smooth muscle cells (HASMCs) and the underlying mechanism. A review article “Aspirin resistance and promoting blood circulation and removing blood stasis: current situation and prospectives” provided insight into the relationship between aspirin resistance and blood stasis syndrome and explored the therapeutic role of Chinese herbal medicines with promoting blood circulation and removing blood stasis for this condition. Recently, a great progress has been made focusing on the effectiveness and safety of herbal medicines in patients with CVDs. Some RCTs and systematic reviews provided strong evidence for clinical usage. The special issue presented the updated knowledge of partial herbal medicines for CVDs, which unraveled a complex posttranscriptional gene-regulating machinery and paved the evidence-based way. Xingjiang Xiong Francesca Borrelli Arthur de Sa Ferreira Tabinda Ashfaq Bo Feng

Determination of radial artery compliance can increase the diagnostic power of pulse wave velocity measurement

Pulse wave velocity (PWV) is an indicator associated with the arterial stiffness. Although this technique has been used in the diagnosis of systemic arterial hypertension (SAH), it cannot supply alone enough information about the pathogenesis of this disturbance. This paper aims to determine the compliance of brachial-radial arterial segment by applying a three-element windkessel model, and by using the same pressure waveforms acquired to calculate the PWV. The proposed method to determine the arterial compliance was evaluated with a physical simulation of the arterial system, where parameters were known, resulting in an estimation error of 0.73 x 10(-7) cm5 dyne(-1). In a clinical study the estimated compliance was statistically different (p < 0.01) in a controlled group ((3.12 +/- 3.53) x 10(-7) cm5 dyne(-1)) and in an SAH group ((1.04 +/- 0.74) x 10(-7) cm5 dyne(-1)). It was observed that the PWV value calculated using the maximum of the first derivative of the pressure waveform upstroke as characteristic points was the best correlated (r = -0.71) with the determined compliance. Because SAH normally results, among other causes. from a decreased arterial compliance the results suggest that the determined compliance could be used concomitantly with PWV to supply more diagnostic information about the pathogenesis of SAH.

Three-section transmission-line arterial model for noninvasive assessment of vascular remodeling in primary hypertension

Abstract High central arterial blood pressure can be sustained by the capacity of living arteries to respond to hemodynamic stimuli by changing their structural and/or functional characteristics. These adaptations are considered to occur in a time-dependency, in which different patterns of vascular geometry are identified at all stages. This paper proposes a three-section transmission-line model of the brachial-radial arterial segment and a rational procedure to analyze its transfer function that can be used to interpret the longitudinal remodeling process of medium-sized arteries. The three sections of the model correspond to different arterial segments of the forearm. The model processed pressure signals collected noninvasively from normotensive and hypertensive volunteers at brachial and radial arteries. Aiming to explain possible hypertrophic inward remodeling, geometrical model parameters obtained from normotensive individuals were modified in order to generate high-pressure pulses observed in the hypertensive subjects. The resulting transfer functions for the hypertrophy adaptation exhibit properties related to the pathophysiology of the remodeling process, mainly the reduced amplification of the higher harmonics of the pulse waveform. The results suggest the model can be used to assess noninvasively the hypertension-induced adaptations related to geometrical characteristics of the medium-size arteries.

Benign Paroxysmal Positional Vertigo: comparison of two recent international guidelines

UNLABELLED Benign Paroxysmal Positional Vertigo (BPPV) is characterized by vertigo, lasting for a few seconds and usually managed by head positioning maneuvers. To educate clinicians concerning the state-of-the art knowledge about its management, the international societies developed guidelines. AIM the aim of this paper is to discuss, in a practical fashion, the current options available to manage BPPV. METHOD STUDY DESIGN non-systematic review. This study reviews two recent guidelines regarding the evaluation and treatment of BPPV. The first one was published by the American Academy of Otolaryngology Head and Neck surgery (AAO-HNS) and the other by the American Academy of Neurology (AAN). The similarities were presented in different tables. RESULTS Those guidelines presented differences regarding methods. Only the AAO-HNS guidelines recommend the Dix-Hallpike test for the diagnosis of BPPV. Only canalith repositioning maneuver, Semont maneuver and vestibular rehabilitation had showed some benefit and were recommended as good treatment options. CONCLUSIONS Both guidelines fulfilled all the aspects required for clinicians to diagnosed and manage BPPV; only the AAO-HNSs guidelines were more comprehensive and of better quality.

Correlation between posture, balance control, and peripheral muscle function in adults with cystic fibrosis.

Abstract Background: In addition to pulmonary involvement, adults with cystic fibrosis (CF) are at higher risk of developing skeletal muscle dysfunction, nutritional depletion, and bone and joint disease. Objective: This study aimed to assess the correlation between posture, balance, and peripheral muscle function in adults with CF. Methods: A cross-sectional study of 14 clinically stable patients who were subjected to postural assessment (photogrammetry), stabilometry, and peripheral muscle function. Results: Comparing the right and left sides of the body, there were significant differences for the following variables: horizontal and vertical head alignments; heel angle; and vertical alignment of the trunk (p < 0.001 for all). Variables that represent the head-trunk position and the position of the lower limbs showed correlations with stabilometric parameters. The strongest correlation was observed between the vertical alignment of the body and the medial-lateral range (ρ = −0.73; p = 0.002). We also noted a significant correlation between the quadriceps muscle strength and the medial lateral range (ρ = −0.69; p = 0.003). Conclusions: In adults with CF, it is possible that the imbalance occurs by both distortion of the head–trunk relationship and lower extremity abnormalities as noted by the reduced quadriceps muscle strength.