Hermes de Freitas Barbosa

Increased capsaicin receptor TRPV1 in the peritoneum of women with chronic pelvic pain.

ObjectiveTo investigate the expression of capsaicin receptor [transient receptor potential vanilloid type-1 (TRPV1)] in the peritoneum of women with chronic pelvic pain (CPP). MethodsA case-control study was conducted on 25 women with CPP and 10 controls. Samples of the rectouterine excavation (2 cm2) were obtained by laparoscopy, fixed in 4% formaldehyde, and underwent immunohistochemistry analysis using rabbit anti-TRPV1 (1:400) polyclonal antibodies and anti-protein gene product 9.5 (PGP 9.5) (1:2000) as a neuronal marker. Ten sequential images of high magnification fields (×40) were captured from each slide and the area identified with the antibody was calculated with Kontron V2.0 software. ResultsImmunoreactivity to TRPV1 was sparsely detected in the nervous tissue and epithelium of endometriotic lesions. The percent area of immunoreactivity for TRPV1 [expressed as median (range)] was greater in specimens from women with CPP, 1.02% (0.54 to 2.93), than from women without the disease, 0.14% (0.07 to 1.12) (P<0.0001). This greater expression was not secondary to an increase in neuronal fibers because there was also a significant difference in the percent area TRPV1:PGP 9.5 ratio between women with CPP, 1.18 (0.26 to 4.63), and controls, 0.15 (0.06 to 0.95) (P=0.0003). DiscussionTRPV1 may play an important role in the maintenance and perpetuation of symptoms in women with CPP. In view of the immunoreactivity detected for TRPV1, the endometriotic lesion may have the ability to interfere with nociception or with the inflammatory peritoneal environment in women with CPP. Further studies are needed to elucidate the participation of TRPV1 in CPP and its association with endometriosis.

Uterine leiomyoma: understanding the impact of symptoms on womens' lives.

BackgroundMost women report negative experience about the symptoms of uterine leiomyoma (UL) in their lives, such as abnormal uterine bleeding and pelvic pain. Many studies have been conducted about efficacy of UL treatment, but little research has been performed about womens health related quality of life (HRQL).MethodsThis is a semi-structured, descriptive, observational, qualitative study that was performed during eight months. Focus group (FG) interviews were performed with women attending at a tertiary hospital in Brazil, who were consecutively included in the study. Seventy women with symptomatic UL were recruited to this study. FG duration was one hour with mediators with 5-6 women at each group. Collected data from discussions was processed according to thematic analysis and stored at a qualitative software.ResultsWomen were negatively influenced by the presence of symptomatic UL. The major themes that were noticed during analysis were: beliefs and attitudes towards UL; limitation to social and professional activities; sensation of fear/unfairness/discouragement towards the symptoms and adverse effects during treatment with GnRH analogs.ConclusionsSymptomatic UL has a negative impact on womens HRQL. Health providers should consider such impact when counseling women on their treatment options, since it may have an important influence in these patients’ decision-making process. While current pharmacological treatments may improve disease specific outcomes, such as bleeding intensity and tumor volume, they fail on actually improving quality of life.

Chronic pelvic pain: multifactorial influences

RATIONALE Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with diagnosis and treatment being more difficult. From a clinical viewpoint, CPP is defined as non-cyclic, non-menstrual pain lasting at least 6 months and sufficiently severe to interfere with habitual activities and requiring clinical or surgical treatment. Thus, CPP is a syndrome resulting from a complex interaction of the nervous, musculoskeletal and endocrine systems and also influenced by psychological and sociocultural factors. CPP is influenced by emotional aspects with an impact on quality of life, and involving high costs for health services. Its aetiology is not always clear and a cure or significant improvement of symptoms is not always obtained with the treatments employed, with constant frustration of the professionals involved. It can be seen that its treatment is often unsatisfactory, simply providing temporary relief of symptoms. METHODS In the present study, we reviewed the bibliography regarding pelvic pain, with emphasis on emotional aspects and on the importance of a multidimensional approach to the care for these patients. RESULTS AND CONCLUSIONS New investigations are needed to clarify these relations and interventions in a more effective manner. Interdisciplinary care can minimize the impact of the disease, helping the patients to cope with symptoms and improving their quality of life.

Fatores de risco para infecções de sítio cirúrgico em pacientes operadas por câncer de mama

PURPOSE: to identify the risk factors associated with the occurrence of surgical site infection (SSI) in surgeries for the treatment of breast cancer. METHODS: the study was conducted on 140 women submitted to treatment of invasive breast cancer during the period from January 2001 to December 2002. SSI was defined as infection occurring up to 30 days after surgery and was related to the operation, according to the standard criteria adopted by the Centers for Disease Control and Prevention (CDC), USA. SSI were considered to be superficial when they involved only the skin and subcutaneous tissue and deep when they involved deep tissues at the site of incision, such as fascia and muscles. The risk factors related to patient were age, hormonal status, staging, body mass index (BMI) and hemoglobin, and the factors related to surgery were type of operation, time of hospitalization, duration of surgery, and formation of seroma and hematoma. Data concerning numerical nonparametric variables were analyzed by the Mann-Whitney test and quantitative variables were analyzed by the Fisher exact test. RESULTS: of the 140 patients studied, 29 (20.7%) presented SSI, which were superficial in 19 (13.6%) and deep in 10 (71%); 111 patients did not present SSI and represented the control group. The risk factors associated with the patient and the disease were locally advanced stage (odds ratio = 27; 95% CI: 1.1-6.5) and obesity, represented by a mean BMI of 32.2 kg/m2 in the patients with SSI and a mean BMI of 27.2 kg/m2 in the control group (p<0.0001). The factors related to treatment of the disease were the use of neoadjuvant chemotherapy (odds ratio = 2.7 (95% CI: 1.1-6.5), the duration of surgery, whose median value was 165 minutes for the patients who developed the infection and 137 minutes for the control group (p=0.02), and the number of days of use of the postoperative drain, whose median value was 6 days for the patients with SSI and 5 days for the control group (p=0.048). CONCLUSION: on the basis of the identification of risk factors such as advanced stage, neoadjuvant chemotherapy and obesity, preoperative care for these patients should be emphasized. The use of an accurate surgical technique may reduce the impact of other factors such as surgical time and time of use of the drain.

Endometriosis of the soleus and gastrocnemius muscles

OBJECTIVE To document a rare case of endometriosis in the soleus and gastrocnemius muscles. DESIGN Case report. SETTING Tertiary care center. PATIENT(S) A 30-year-old fertile woman presented with moderate dysmenorrhea associated with calf pain and bulging that had been gradually worsening over the last years, particularly during menses. A mass in the soleus and gastrocnemius muscles was identified in ultrasonography and magnetic resonance imaging. INTERVENTION(S) Endometriosis was diagnosed by incisional biopsy on the basis of histopathology, and wide excisional biopsy was performed. MAIN OUTCOME MEASURE(S) Unusual clinical presentation of endometriosis. RESULT(S) The patient was disease free for 2 months. Recurrence of the lesion was then diagnosed, and a new surgical approach was planned. CONCLUSION(S) Endometriosis in muscles is a rare event, and existing theories are not totally sufficient in explaining it.

Endometriose umbilical sem cirurgia pélvica prévia

PURPOSE: to present a series of cases of umbilical endometriosis in patients in reproductive age, with no previous pelvic surgery. METHODS: four patients aged between 33 and 43 years were included in the study. They all presented umbilical bleeding associated or not with pelvic pain, and medical history varied from two months to four years. Abdominal wall ultrasound was performed for diagnosis support before surgical excision of the umbilical lesions, and histological examination was also performed. RESULTS: the ultrasonographic evaluation of the four patients showed hypoechogenic umbilical lesion suggestive of endometriosis. All patients were submitted to surgical excision and histological examination of the lesions. CA-125 serum levels were measured in three of the patients, but they were within normal ranges (from 6.8 to 10.1 U/mL). In addition to umbilical surgery, laparoscopy was performed in all patients, but only one presented concomitant pelvic endometriosis. In a one-year follow-up, patients maintained asymptomatic and there was no recurrence of the lesions. CONCLUSIONS: umbilical endometriosis is a rare entity, but it may be remembered as a possibility in cases of umbilical nodulations or bleeding, even if there is no previous history of pelvic surgery with endometrial manipulation. Its treatment is always surgical and, in general, it is enough to promote complete elimination of the lesion and of the symptoms.

Dental and medical advertising: comparative analysis of the rules of professional conduct

In health care professional activities, advertising is an issue that raises serious discussions and is the cause of some ethical suits in professional entities, since every advertising should follow the provisions of the Code of Professional Responsibility. Therefore, this research study aimed at analyzing, comparing and discussing articles related to advertising and marketing, considering the current regulations from dental and medical entities. In Dentistry, this subject is ruled by the Code of Professional Conduct, Chapter XVI, ‘From advertising and marketing’. In Medicine, information is found in two regulations and in several chapters of the Code of Medical Ethics and in Resolution No. 1.974/2011 of the Federal Council of Medicine, which establishes the guiding criteria for medical advertising. The three regulations present articles that refers to participation in mass media, required information in advertisements, use of sensationalism and self-promotion, and publishing of unproven specialties and titles, highlighting the importance of these topics. The medical regulation also includes participation in publishing ads of manufacturing companies and an exclusive committee to deal with advertising and marketing issues, topics that are not considered in the dental regulation. Indexing terms: Forensic Medicine. Health care marketing services. Legal Dentistry.

Alta por solicitud contra indicación médica sin riesgo inminente de muerte

La respuesta a la solicitud de alta de parte del paciente, contraria a la indicacion medica, sin riesgo inminente de muerte, apunta a garantizar su autonomia. No obstante, no se trata de un tema poco polemico. El objetivo de este estudio fue caracterizar la conducta del medico ante el pedido de alta. Se realizo un estudio de caso, de caracter cualitativo, a partir de entrevistas individuales semi-estructuradas con medicos asistentes del hospital publico universitario. Se realizaron ocho entrevistas, las cuales fueron grabadas y transcritas, y los datos se trabajaron a partir del analisis de contenido. Se concluyo que los entrevistados consideran importante aclarar al paciente los riesgos de su decision, la cual debera ser respetada en caso de que se sostenga; reconocen tambien la importancia de la documentacion de alta y la imposibilidad de emitir recetas cuando no existe una alternativa cientificamente reconocida. Se evidencia, ademas, la preocupacion del medico en relacion a las consecuencias legales de atender la peticion del paciente.Abstract The response to the request by a patient for a medical discharge order against medical advice without immi-nent risk of death is no more than respecting his or her autonomy. Yet this is not a peaceful issue. The objective of this study was to describe the conduct of doctors facing demands for medical discharge. A qualitative type case study was conducted based on semi-structured individual interviews with doctors of the Emergency Unit of HC-FMRP-USP. Eight interviews were recorded, transcribed, and the data was analyzed by content analysis. We found that doctors stress the importance of informing the patient about the risks of their decision, which should be respected if he or she maintains his position; and also highlighted the importance of documenta-tion and the impossibility of issuing prescriptions when there is no scientifically recognized alternative. The concern of the doctor regarding the legal implications of accepting the patient’s request was also noted. Keywords:

Request for a medical discharge order against medical advice without imminent risk of death

La respuesta a la solicitud de alta de parte del paciente, contraria a la indicacion medica, sin riesgo inminente de muerte, apunta a garantizar su autonomia. No obstante, no se trata de un tema poco polemico. El objetivo de este estudio fue caracterizar la conducta del medico ante el pedido de alta. Se realizo un estudio de caso, de caracter cualitativo, a partir de entrevistas individuales semi-estructuradas con medicos asistentes del hospital publico universitario. Se realizaron ocho entrevistas, las cuales fueron grabadas y transcritas, y los datos se trabajaron a partir del analisis de contenido. Se concluyo que los entrevistados consideran importante aclarar al paciente los riesgos de su decision, la cual debera ser respetada en caso de que se sostenga; reconocen tambien la importancia de la documentacion de alta y la imposibilidad de emitir recetas cuando no existe una alternativa cientificamente reconocida. Se evidencia, ademas, la preocupacion del medico en relacion a las consecuencias legales de atender la peticion del paciente.Abstract The response to the request by a patient for a medical discharge order against medical advice without immi-nent risk of death is no more than respecting his or her autonomy. Yet this is not a peaceful issue. The objective of this study was to describe the conduct of doctors facing demands for medical discharge. A qualitative type case study was conducted based on semi-structured individual interviews with doctors of the Emergency Unit of HC-FMRP-USP. Eight interviews were recorded, transcribed, and the data was analyzed by content analysis. We found that doctors stress the importance of informing the patient about the risks of their decision, which should be respected if he or she maintains his position; and also highlighted the importance of documenta-tion and the impossibility of issuing prescriptions when there is no scientifically recognized alternative. The concern of the doctor regarding the legal implications of accepting the patient’s request was also noted. Keywords:

Alta a pedido contra indicação médica sem iminente risco de morte

La respuesta a la solicitud de alta de parte del paciente, contraria a la indicacion medica, sin riesgo inminente de muerte, apunta a garantizar su autonomia. No obstante, no se trata de un tema poco polemico. El objetivo de este estudio fue caracterizar la conducta del medico ante el pedido de alta. Se realizo un estudio de caso, de caracter cualitativo, a partir de entrevistas individuales semi-estructuradas con medicos asistentes del hospital publico universitario. Se realizaron ocho entrevistas, las cuales fueron grabadas y transcritas, y los datos se trabajaron a partir del analisis de contenido. Se concluyo que los entrevistados consideran importante aclarar al paciente los riesgos de su decision, la cual debera ser respetada en caso de que se sostenga; reconocen tambien la importancia de la documentacion de alta y la imposibilidad de emitir recetas cuando no existe una alternativa cientificamente reconocida. Se evidencia, ademas, la preocupacion del medico en relacion a las consecuencias legales de atender la peticion del paciente.Abstract The response to the request by a patient for a medical discharge order against medical advice without immi-nent risk of death is no more than respecting his or her autonomy. Yet this is not a peaceful issue. The objective of this study was to describe the conduct of doctors facing demands for medical discharge. A qualitative type case study was conducted based on semi-structured individual interviews with doctors of the Emergency Unit of HC-FMRP-USP. Eight interviews were recorded, transcribed, and the data was analyzed by content analysis. We found that doctors stress the importance of informing the patient about the risks of their decision, which should be respected if he or she maintains his position; and also highlighted the importance of documenta-tion and the impossibility of issuing prescriptions when there is no scientifically recognized alternative. The concern of the doctor regarding the legal implications of accepting the patient’s request was also noted. Keywords: