Márcio Moysés de Oliveira

Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury

OBJECT In recent years, the role of decompressive craniectomy for the treatment of traumatic brain injury (TBI) in patients with refractory intracranial hypertension has been the subject of several studies. The purpose of this review was to evaluate the contribution of decompressive craniectomy in reducing intracranial pressure (ICP) and increasing cerebral perfusion pressure (CPP) in these patients. METHODS Comprehensive literature searches were performed for articles related to the effects of decompressive craniectomy on ICP and CPP in patients with TBI. Inclusion criteria were as follows: 1) published manuscripts, 2) original articles of any study design except case reports, 3) patients with refractory elevated ICP due to traumatic brain swelling, 4) decompressive craniectomy as a type of intervention, and 5) availability of pre- and postoperative ICP and/or CPP data. Primary outcomes were ICP decrease and/or CPP increase for assessing the efficacy of decompressive craniectomy. The secondary outcome was the persistence of reduced ICP 24 and 48 hours after the operation. RESULTS Postoperative ICP values were significantly lower than preoperative values immediately after decompressive craniectomy (weighted mean difference [WMD] -17.59 mm Hg, 95% CI -23.45 to -11.73, p < 0.00001), 24 hours after (WMD -14.27 mm Hg, 95% CI -24.13 to -4.41, p < 0.00001), and 48 hours after (WMD -12.69 mm Hg, 95% CI -22.99 to -2.39, p < 0.0001). Postoperative CPP was significantly higher than preoperative values (WMD 7.37 mm Hg, 95% CI 2.32 to 12.42, p < 0.0001). CONCLUSIONS Decompressive craniectomy can effectively decrease ICP and increase CPP in patients with TBI and refractory elevated ICP. Further studies are necessary to define the group of patients that can benefit most from this procedure.

Levodopa for idiopathic restless legs syndrome: evidence-based review

Restless legs syndrome (RLS) is a sensory motor disorder characterized by a distressing urge to move the legs and sometimes also other parts of the body usually accompanied by a marked sense of discomfort or pain in the leg or other affected body part. The prevalence of RLS is estimated at 2.7 to 5% of adults and it is more common in women. The treatment of RLS with levodopa has been reported thus a systematic synthesis of evidence is necessary to evaluate the effectiveness and safety of levodopa for RLS. Systematic review of randomized or quasi‐randomized, double blind trials on levodopa. Relief of restless legs symptoms marked on a validated scale, subjective sleep quality, sleep quality measured by night polysomnography and actigraphy, quality of life measured by subjective measures, adverse events associated with the treatments. Nine eligible clinical trials were included. The subjective analyses of these studies showed contradictory results, although the objective analyses showed that treatment group had a statistically significant improvement of periodic leg movement (PLM) index, favoring the treatment group. The most commonly adverse event seen was gastrointestinal symptoms. The short‐term treatment with levodopa was demonstrated effective and safety for PLM, but there was only few trials assessing long‐term treatment and the augmentation phenomenon in RLS. Further long‐term randomized controlled trials using standard follow‐up measurements as the International RLS Study Group Rating Scale are necessary.

ANTICONVULSANTS TO TREAT IDIOPATHIC RESTLESS LEGS SYNDROME : Systematic review

BACKGROUND Restless legs syndrome (RLS) is a sensory motor disorder characterized by a distressing urge to move the legs and sometimes also other parts of the body usually accompanied by a marked sense of discomfort or pain in the leg or other affected body part. Many treatments have been used to minimize the discomfort of the disease, among them the anticonvulsant therapy. AIM This review aims to evaluate the efficacy and safety of anticonvulsant treatment for idiopathic RLS. METHOD Systematic review of randomized or quasi-randomized, double blind trials on anticonvulsant treatment for RLS. OUTCOMES relief of RLS symptoms, subjective and objective sleep quality, quality of life, and adverse events associated with the treatments. RESULTS A total of 231 patients were randomized in three cross over studies and one parallel study. Three studies with carbamazepine, one with sodium valproate, and one with gabapentin, and they were very heterogeneous so we could not perform a meta-analysis. CONCLUSIONS There is no scientific evidence on RLS treatment with anticonvulsants for clinical practice.

The pharmacological treatment for uremic restless legs syndrome: Evidence-based review†

Restless legs syndrome (RLS) is a common and often misdiagnosed entity among the general population and it may be more common among dialysis patients, with an estimated prevalence of 6.6 to 21.5%. The treatment for uremic RLS has been controversial and therefore a systematic synthesis of the evidence is needed in order to evaluate the effectiveness and safety of treatments for uremic RLS. This was a systematic review of randomized or quasi‐randomized double‐blind trials on treatments for uremic RLS. The outcomes considered were relief of RLS symptoms marked on a validated scale, subjective sleep quality, sleep quality measured using night polysomnography and actigraphy, quality of life measured subjectively, and adverse events associated with these treatments. Six eligible clinical trials were included. The results from subjective analyses in these studies were divergent, although objective analyses in one trial showed that there was a statistically significant improvement in periodic leg movement while asleep in the treatment group. No combined analysis (meta‐analysis) was performed. The most common adverse event seen was gastrointestinal symptoms. Only a few therapeutic trials on patients with uremia with RLS have been published, and there is insufficient scientific evidence to favor any specific therapeutic regimen for uremic‐associated RLS. Therapy using levodopa, dopaminergic agonists, anticonvulsants, and clonidine tend to be effective, but further studies are needed.

Methods for increasing upper airway muscle tonus in treating obstructive sleep apnea: systematic review

ObjectiveTreatment of obstructive sleep apnea (OSA) using methods for increasing upper airway muscle tonus has been controversial and poorly reported. Thus, a review of the evidence is needed to evaluate the effectiveness of these methods.DesignThe design used was a systematic review of randomized controlled trials.Data sourcesData sources are from the Cochrane Library, Medline, Embase and Scielo, registries of ongoing trials, theses indexed at Biblioteca Regional de Medicina/Pan-American Health Organization of the World Health Organization and the reference lists of all the trials retrieved.Review methodsThis was a review of randomized or quasi-randomized double-blind trials on OSA. Two reviewers independently applied eligibility criteria. One reviewer assessed study quality and extracted data, and these processes were checked by a second reviewer. The primary outcome was a decrease in the apnea/hypopnea index (AHI) of below five episodes per hour. Other outcomes were subjective sleep quality, sleep quality measured by night polysomnography, quality of life measured subjectively and adverse events associated with the treatments.Data synthesisThree eligible trials were included. Two studies showed improvements through the objective and subjective analyses, and one study showed improvement of snoring, but not of AHI while the subjective analyses showed no improvement. The adverse events were reported and they were not significant.ConclusionsThere is no accepted scientific evidence that methods aiming to increase muscle tonus of the stomatognathic system are effective in reducing AHI to below five events per hour. Well-designed randomized controlled trials are needed to assess the efficacy of such methods.

Methods to increase muscle tonus of upper airway to treat snoring: systematic review

BACKGROUND Snoring is the noise caused by vibration during the in-breath; and which structure actually vibrates depends on many factors. OBJECTIVE The treatment of snoring with methods to increase muscle tonus of upper airway has been controversial, and poorly reported, thus a review of evidence is necessary to evaluate the effectiveness of these methods. METHOD A review of randomized or quasi-randomized, double blind trials on snoring treatment that have employed any method to increase muscle tonus of upper airway like phonotherapy or physical therapy among others. OUTCOMES decrease or completely stop of snoring, sleep quality, quality of life, and adverse events. RESULTS Three eligible trials were potentially analyzed, but none of them could provide good scientific evidence favoring the intervention. The objective analyses of one study showed improvement of snoring, although the objective sub-analyses and subjective analyses showed controversial results. The adverse events were not reported. CONCLUSION There is no enough evidence to support the recommendation of methods to increase muscle tonus of upper airways in treatment of snoring. Well designed randomized clinical trials are needed to asses the efficacy of such methods, and a standard and worldwide accepted method for snoring assessment would be useful for future researches.

Oropharyngeal examination as a predictor of obstructive sleep apnea: pilot study of gag reflex and palatal reflex

UNLABELLED Obstructive sleep apnea (OSA) has high prevalence and may cause serious comorbidities. The aim of this trial was to show if simple noninvasive methods such as gag reflex and palatal reflex are prospective multivariate assessments of predictor variables for OSA. METHOD We evaluate gag reflex and palatal reflex, of fifty-five adult patients, and their subsequent overnight polysomnography. RESULTS Forty-one participants presented obstructive sleep apnea. The most relevant findings in our study were: [1] absence of gag reflex on patients with severe obstructive apnea (p=0.001); [2] absence of palatal reflex on moderate obstructive apnea patients (p=0.02). CONCLUSION Gag reflex and palatal reflex, a simple noninvasive test regularly performed in a systematic neurological examination can disclose the impact of the local neurogenic injury associated to snoring and/or obstructive sleep apnea syndrome.

Síndrome das Pernas Inquietas: Revisão e Atualização

SUMMARY Restless Legs Syndrome (RLS) is a sensory-motor disorder that causes great discomfort, and is still of little knowledge for a large amount of patients and physicians. Because of this lack of knowledge, a large number of patients receive a wrong diagnoses and an inadequate treatment. Recently, the genetic components of RLS have been more studied and comprehended, what can improve the understanding of the physiopathology of this disease. The main goal of this paper is to present a review and update of the knowledge concerning RLS. The most used diagnostic methods nowadays, as long as a variety of treatment options are presented in a detailed way, always looking for the best scientific evidence for each situation.

15. Levodopa for idiopathic restless legs syndrome: Systematic review

Background: Restless Legs Syndrome (RLS) is a sensory motor disorder characterized by a distressing urge to move the legs and sometimes also other parts of the body usually accompanied by a marked sense of discomfort or pain in the leg or other affected body part. The prevalence of RLS is estimated at 2.7–5% of adults and it is more common in women. The treatment of RLS with levodopa has been reported thus a systematic synthesis of evidence is necessary to evaluate the effectiveness and safety of levodopa for RLS. Method: It was a systematic review of randomized or quasi-randomized, double blind trials on levodopa. Relief of restless legs symptoms marked on a validated scale, subjective sleep quality, sleep quality measured by night polysomnography and actigraphy, quality of life measured by subjective measures, adverse events associated with the treatments. Results: Nine eligible clinical trials were included. The subjective analyses of these studies showed controversial results, although the objective analyses showed that treatment group had a statistically significant improvement of periodic leg movement (PLM) index, favoring the treatment group. The most commonly adverse event seen was gastrointestinal symptoms. Conclusions: The short-term treatment with levodopa was demonstrated effective and safety for PLM, but there was only few trials assessing long-term treatment and the augmentation phenomenon in RLS. Further long-term randomized controlled trials using standard follow-up measurements as the International RLS Study Group Rating Scale are necessary.

13. Speech disorders in obstructive sleep apnea syndrome: Systematic review

Background: Obstructive sleep apnea (OSA) is a common disorder, and estimates of prevalence may affect 5–7% in general population. The treatment of OSA is based on Continuous Positive Airway Pressure (CPAP) appliance and Mandibular Advancement Oral Appliances. Phonoaudiologic approach for treatment of patients with Obstructive Sleep Apnoea has been controversial, and the aim of this review was to evaluate the effectiveness of these phonoaudiologic interventions. Method: It was a review of randomized or quasi-randomized, double blind trials on OSA. Outcomes: decrease of apnea/hypopnea index (AHI), daytime somnolence, and snoring measured by a validated scale. Results: Two eligible trials were potentially analyzed, but none of them could provide good scientific evidence favoring the intervention. The objective analysis of these studies showed improvement of OSA, and an improvement of snoring by subjective analysis. However the poor methodological quality and the heterogeneity of the results limited us to pool the results. Conclusions: There is no accepted scientific evidence on phonoaudiologic approach for treatment of OSA. Well designed RCTs are needed to assess the efficacy of these interventions. Supported by FAPESP 02/02145-1, 99/08189-6 (L.B.C. Carvalho and G.F. Prado).