Claudia Arab

Heart rate variability measure in breast cancer patients and survivors: A systematic review

PURPOSE In the current study, we aimed to review literature findings showing the clinical importance of cardiac autonomic modulation assessed by heart rate variability analysis in breast cancer (BC) patients and survivors. METHODS We conducted a systematic review according to The PRISMA Statement in Medline, Scopus and Web of Science (_-2015) databases. The search was limited to articles in English language, published in peer-reviewed journals, and with adult age samples only (e.g., women, patients, or survivors, diagnosed with BC in any stage). We included observational studies and randomized trials. Detailed heart rate variability analysis (instruments, data collection protocol, and analysis methods) was required. Search terms included autonomic nervous system, heart rate variability, sympathetic and parasympathetic nervous system, autonomic dysfunction, vagal nervous and breast neoplasms, breast cancer and breast tumor. RESULTS Twelve studies were included in this review. The clinical importance of cardiac autonomic modulation assessed by heart rate variability analysis in BC patients and survivors is demonstrated by association with effects of BC surgery, and treatments, and the adverse effects of surgery and treatments on survivors (e.g., cardiotoxicity, fatigue, and stress). LIMITATIONS The strength of evidence of included studies is low: small samples size and heterogeneity, presence of confounders, and observational studies design. CONCLUSIONS The heart rate variability analysis could be used as a complementary non-invasive tool for the early diagnosis and better prognosis of autonomic dysfunction, and survival in BC patients. There are many potential clinical applications of heart rate variability analysis in BC patients, and the employment of such approaches could lead to lower impairment of autonomic function in this individuals.

Mental health problems among medical students in Brazil: a systematic review and meta-analysis

Objective: To provide a comprehensive picture of mental health problems (MHPs) in Brazilian medical students by documenting their prevalence and association with co-factors. Methods: We systematically searched the MEDLINE/PubMed, SciELO, LILACS, and PsycINFO databases for cross-sectional studies on the prevalence of MHPs among medical students in Brazil published before September 29, 2016. We pooled prevalences using a random-effects meta-analysis, and summarized factors associated with MHP. Results: We included 59 studies in the analysis. For meta-analyses, we identified the summary prevalence of different MHPs, including depression (25 studies, prevalence 30.6%), common mental disorders (13 studies, prevalence 31.5%), burnout (three studies, prevalence 13.1%), problematic alcohol use (three studies, prevalence 32.9%), stress (six studies, prevalence 49.9%), low sleep quality (four studies, prevalence 51.5%), excessive daytime sleepiness (four studies, prevalence 46.1%), and anxiety (six studies, prevalence 32.9%). Signs of lack of motivation, emotional support, and academic overload correlated with MHPs. Conclusion: Several MHPs are highly prevalent among future physicians in Brazil. Evidence-based interventions and psychosocial support are needed to promote mental health among Brazilian medical students.

Application and outcomes of therapy combining transcranial direct current stimulation and virtual reality: a systematic review.

Abstract Purpose: To evaluate the methods and major outcomes of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) therapy in randomized controlled trials. Method: A systematic review was performed following PRISMA guidelines using PubMed, PubMed Central, Web of Science and CAPES periodic databases, with no time restriction. The studies were screened for the following inclusion criteria: human subjects, combination of VR and tDCS methods, and randomized controlled study design. All potentially relevant articles were independently reviewed by two researchers, who reached a consensus on which articles met the inclusion criteria. The PEDro scale was used to evaluate the studies. Results: Eleven studies were included, all of which utilized a variety of tDCS and VR application methods. The main outcomes were found to be beneficial in intervention groups of different populations, including improvements in body sway, gait, stroke recovery, pain management and vegetative reactions. Conclusions: The use of tDCS combined with VR showed positive results in both healthy and impaired patients. Future studies with larger sample sizes and homogeneous participants are required to confirm the benefits of tDCS and VR. Implications for Rehabilitation tDCS with VR intervention can be an alternative to traditional rehabilitation programs. tDCS with VR is a promising type of intervention with a variety of positive effects. Application of tDCS with VR is appropriated to both healthy and impaired patients. There is no consensus of tDCS with VR application.

Reply to the letter “Cardiac autonomic evaluation in breast cancer patients: role of cytokines and heart rate recovery”

We received a letter about our recently published article. Okutucu et al. have suggested certain evaluations for future investigations. The suggestions were about assessments of cardiac autonomic modulation, cytokines and heart rate recovery (HRR) in breast cancer patients. We agree with the authors and are thankful for the suggestions. Our responses to these suggestions are given in the following. We agree with the authors and consider that investigating the relationship between breast cancer staging, cardiac autonomic modulation and inflammation is promising. In our article, we also discussed our result (i.e., lower vagal modulation in advanced breast cancer patients compared to early-stages) and we proposed that this could be due to the neuroimmunomodulatory role of the vagus nerve in cancer [1]. Cancer tumors progress under the influence of inflammation [2]. Animal model studies have shown interesting relationships between vagal modulation, inflammation and tumor progression. Recently, Partecke et al. [3] showed that vagotomy was associated with increased tumor growth and worse survival in cancer models mediated through tumorassociated macrophages and tumor necrosis factor alpha. A tumor-directed immune response, involving cytolytic CD8 + T cells, Th1 cells and NK cells, seems to protect against tumor development and progression, while a Th2 polarized response promotes the tumor development and progression [4]. In cancer patients, De Couck et al. [5] found that the relationship between HRV (the vagal nerve index) and survival of patients with pancreatic cancer was statistically mediated by an inflammatory marker (C-reactive protein). Now, Gidron et al. [6] tested a new composite biomarker, the neuroimmunomodulation (NIM) index, that reflects the autonomic and inflammatory systems together, in relation to cancer prognosis. Similarly, patients with non-small cell lung cancer and a relatively high NIM index had a nearly double survival time compared to those with low NIM [6]. Independently of tumor stage, biomarkers of inflammation have been shown to be important prognostic markers for long-term survival in breast cancer patients [7]. Together, these results all propose an inter-relationship between vagal nerve activity, inflammation and cancer progression. Unfortunately, in our study, we could not evaluate inflammatory parameters to examine their relationship with autonomic (vagal) modulation and cancer stage. Nevertheless, we agree that studies about this topic are promising and should be performed. The second suggestion of Okutucu et al. was the assessment of heart rate recovery (HRR)—the rate of decline in the heart rate (HR), mostly after cessation of an exercise test. As very well-cited by Okutucu et al., HRR is a useful instrument to assess autonomic nervous system and is related to cardiovascular health. Therefore, studies about recovery time are very important. HRR can be modeled by an exponential curve [8]. This curve is composed by both a fast and a slow phase. The first and fast phase shows a rapid decline and is dictated by the cardiac parasympathetic (vagal) reactivation. The second and slow phase is characterized by a gradual decline in HR promoted by both vagal reactivation and sympathetic withdrawal [8]. Studies suggest 30 s after exercise cessation as a specific index for vagally mediated HRR [8], and RMSSD was shown to effectively reflect the autonomic effects in recovery [9]. According to Goldberger et al. [10], parasympathetic reactivation can be interpreted * Claudia Arab ac.arabclaudia@gmail.com

Correction to: Reply to the letter “Cardiac autonomic evaluation in breast cancer patients: role of cytokines and heart rate recovery”

Unfortunately, errors occurred in the original article.

Breast disease in men in metropolitan São Paulo - Brazil

Although rare, breast cancer in males represents 1% of all cancer in men, and has shown increasing incidence in 25 years. To analyze age, gender, type of procedure performed and diagnosis of all cases of breast diseases in a public hospital in Sao Paulo, Brazil, with special focus on men. Cross‐sectional study of breast surgery in 2010‐2014 at Hospital Municipal Universitario de Sao Bernardo do Campo, Brazil. In the period 999 breast surgery were carried out. Patients with benign diseases were about 30 years old and patients with malignant diseases were over 50. Most surgical procedures performed on men were on the benign condition of gynaecomastia (n=21). The prevalence of breast cancer in the male population attending the public health system in Sao Bernardo was 0.27 (per 100,000). There was a single record of malignant disease in men, a 65 years old man, with histological diagnosis of ductal carcinoma. Surgical pathology of the breast in men is a rare event, and accounts for about 2.4% of mammary surgery in the municipality of São Bernardo do Campo. Awareness is necessary for health professionals and the media, regarding breast pathologies in the male population, to reduce the prejudice in the search for an early diagnosis of a condition so strongly linked to the female for the majority of people.

Augmentative and alternative communication in children with Down’s syndrome: a systematic review

BackgroundThe use of technology to assist in the communication, socialization, language, and motor skills of children with Down’s syndrome (DS) is required. The aim of this study was to analyse research findings regarding the different instruments of ‘augmentative and alternative communication’ used in children with Down’s syndrome.MethodsThis is a systematic review of published articles available on PubMed, Web of Science, PsycInfo, and BVS using the following descriptors: assistive technology AND syndrome, assistive technology AND down syndrome, down syndrome AND augmentative and alternative communication. Studies published in English were selected if they met the following inclusion criteria: (1) study of children with a diagnosis of DS, and (2) assistive technology and/or augmentative and alternative communication analysis in this population.ResultsA total of 1087 articles were identified. Thirteen articles met the inclusion criteria. The instruments most used by the studies were speech-generating devices (SGDs) and the Picture Exchange Communication System (PECS).ConclusionTwelve instruments that provided significant aid to the process of communication and socialization of children with DS were identified. These instruments increase the interaction between individuals among this population and their peers, contributing to their quality of life and self-esteem.