Maria Salete Costa Gurgel

Qualidade de vida em mulheres após tratamento da incontinência urinária de esforço com fisioterapia

PURPOSE: to compare womens quality of life (QoL) before and after physical therapy treatment for stress urinary incontinence (SUI). METHODS: an uncontrolled clinical trial of 26 women, who had mainly complaints of SUI. Post-menopausal women with overactive bladder, cystocele >grade II and previous surgical/conservative treatments were excluded from the study. The physiotherapy treatment relied on 12 individual pelvic floor exercises assisted by electromyographyc-biofeedback sessions. A total of 200 contractions were carried out, divided in phasic (quick) and tonic (slow). The tool used to evaluate QoL was the Kings Health Questionnaire (KHQ), before and after the treatment. RESULTS: there was a decrease in the urinary symptoms, particularly in urinary frequency, nocturia, urgency and urinary incontinence. Regarding the QoL, there was a significant improvement in the following domain scores: general health perception (49.0±24.0 versus 26.9±15.7; p=0.0015), incontinence impact (78.2±28.2 versus 32.1±30.5; p=0.001), activity limitation (75.0±28.2 versus 13.5±22.6; p<0.001), physical limitation (72.4±29.4 versus 15.4±24.5; p<0.001), social limitations (38.3±28.6 versus 6.4±14.5; p<0.001), emotions (59.0±33.8 versus 14.1±24.7; p=0.0001, sleep/energy (34.0±23.8 versus 6.4±16.4; p=0.001) and severity measures (66.9±19.6 versus 22.3±24.2; p<0.001), except for personal relationships (60.5±33.9 versus 41.7±16.7; p=0.0679). CONCLUSIONS: there was an improvement in several aspects of womens QoL treated by physiotherapy, when evaluated with a specific tool, the KHQ.

Knowledge, attitude and practice of mammography among women users of public health services

OBJECTIVE To evaluate knowledge, attitude and practice related to mammography among women users of local health services, identifying barriers to its performance. METHODS A total of 663 women were interviewed at 13 local health centers in a city of Southeastern Brazil, in 2001. Interviewees were randomly selected at each center and they were representative from different socioeconomic conditions. The number of interviewees at each center was proportional to monthly mean appointments. For data analysis, answers were described as knowledge, attitude, practice and their respective adequacies and then they were correlated with control variables through the chi-square test. RESULTS Only 7.4% of the interviewees had adequate knowledge on mammography, while 97.1% of women had an adequate attitude. The same was seen for the practice of mammography that was adequate in 35.7% of the cases. The main barrier to mammography was lack of referral by physicians working at the health center (81.8%). There was an association between adequacy of attitude and five years or more of education and being married. There was also an association between adequacy of mammography practice and being employed and family income up to four minimum wages. CONCLUSIONS Women users of local health services had no adequate knowledge and practice related to mammography despite having an adequate attitude about this exam.

Polymorphisms in the 5′- and 3′-untranslated region of the VEGF gene and sporadic breast cancer risk and clinicopathologic characteristics

AbstractThe wild and the variant alleles of the C936T and G634C vascular endothelial grow factor (VEGF) polymorphisms seem to be linked to higher angiogenic phenotype than the remaining alleles and may act on breast cancer (BC) origin. We investigated the influence of the VEGF C936T and G634C polymorphisms on the occurrence and clinicopathologic characteristics of sporadic breast cancer (SBC) in 235 patients and 235 controls. Peripheral blood samples of all individuals were analysed by the polymerase chain reaction for identification of genotypes and by enzyme-linked immunosorbent assay (ELISA) for quantification of serum VEGF levels. The variant 634CC genotype isolated (16.2% versus 10.7%, P  = 0.01) and in combination with the wild 936CC genotype (10.6% versus 5.5%, P  = 0.01) were more common in patients than in controls. The carriers of the respective genotypes were under a 2.20-fold and a 3.08-fold increased risks for the disease. Additionally, the frequency of the wild 936CC genotype was higher in patients with tumours of histological grade III compared to those with tumours of I+II histological grades (84.0% versus 64.7%, P  = 0.004) and in patients with positive oestrogen receptor tumours compared to those with tumours lacking oestrogen receptor expression (84.7% versus 73.9%, P  = 0.02). Similar serum values of VEGF were seen in patients and controls with the distinct genotypes of the VEGF. The data suggest that the VEGF wild 936CC and the variant 634CC genotypes constitute inherited determinants of SBC and SBC aggressiveness in Brazil, but are not significant predictors of circulating VEGF levels.

Adherence to the opportunistic mammography screening in public and private health systems

PURPOSE to assess compliance with the recommendations for opportunistic breast cancer screening by mammography. METHODS 460 women from the town of Taubaté, São Paulo, Brazil, were followed-up prospectively after the index mammography, 327 of them attended by the public health system and 133 by the private system. We evaluated the prevalence of mammography repetition, the adherence rates and predictive factors associated with the current recommendations of mammographic screening. The association of the outcomes with the independent variables was studied by obtaining the risk rates (RR) and the respective 95% confidence intervals (95%CI). The adjusted prevalence rates were calculated by the COX regression model. RESULTS although more than 90% of the studied women repeated the mammography at least once, the rate of correct compliance with the recommendations of mammographic screening, with repetition of the procedure every 24 months, was low (about 30% of the study sample). The preditive factors associated with compliance with mammographic screening were related to the unequal access to public or private healthcare services (RR=1.77; 95%CI=1.26-2.48) and to previous screening (RR=3.07; 95%CI=1.86-5.08). CONCLUSION we concluded that compliance with the recommendations of opportunistic mammographic screening for breast cancer was low in both studied population segments.

Qualidade de vida e sexualidade de mulheres tratadas de câncer de mama

OBJETIVO: avaliar a qualidade de vida e aspectos da sexualidade de mulheres com câncer de mama segundo o tipo de cirurgia e caracteristicas sociodemograficas. METODOS: realizou-se um estudo de corte transversal com 110 mulheres tratadas ha pelo menos um ano por câncer de mama no Centro de Atencao Integral a Saude da Mulher da UNICAMP. A qualidade de vida foi avaliada por meio do questionario WHOQOL-bref e as questoes sobre sexualidade, por um questionario especifico, no qual se utilizou o coeficiente alpha de Cronbach para verificar validade e concordância das respostas (alpha=0,72) e a tecnica de analise fatorial com criterio de autovalor e rotacao maxima de variância, resultando em dois componentes assim denominados: intrinseco ou intimidade (como a mulher se ve sexualmente) e extrinseco ou atratividade (como a mulher acredita que os outros a veem sexualmente). As variaveis sociodemograficas foram avaliadas nos dominios do questionario da OMS e nos componentes de sexualidade por meio do teste de Kruskal-Wallis seguido pelo teste de Mann-Whitney e pela correlacao de Spearman. RESULTADOS: idade, escolaridade, tipo de cirurgia e tempo desde a cirurgia nao influenciaram a qualidade de vida nos dominios fisico, meio ambiente, psicologico e relacoes sociais. Mulheres com relacionamento marital estavel tiveram escores maiores nos dominios psiquico (p=0,04) e relacoes sociais (p=0,02). Maior nivel socioeconomico influenciou a qualidade de vida nos dominios fisico (p=0,01) e meio ambiente (p=0,002). Em relacao a sexualidade, houve influencia da idade no componente extrinseco (p=0,0158). Mulheres com relacionamento marital estavel tiveram escores maiores de qualidade de vida em ambos os componentes de sexualidade. Maior escolaridade influenciou positivamente no fator intrinseco. Mulheres submetidas a quadrantectomia ou a mastectomia com reconstrucao imediata apresentaram melhores escores em relacao a atratividade quando comparadas as mastectomizadas sem reconstrucao. CONCLUSOES: melhor nivel socioeconomico e de escolaridade, relacao marital estavel e cirurgia com conservacao mamaria estao associados a melhores taxas de qualidade de vida, inclusive a sexual.

Immediate breast reconstruction with transverse latissimus dorsi flap does not affect the short-term recovery of shoulder range of motion after mastectomy.

Immediate breast reconstruction, depending on the surgical strategy, can result in anatomic modifications that may affect the shoulder apparatus. This study compares the recovery of shoulder range of motion (ROM), after mastectomy, in women with and without immediate breast reconstruction with latssimus dorsi flap (LDF). This was a prospective study with 87 women who underwent mastectomy (41 with LDF). Shoulder ROM was assessed with goniometry, with a universal full-circle manual goniometer, prior to surgery, and on a weekly basis during the first 4 weeks postoperatively. Reconstruction with LDF was not associated with a decrease in shoulder ROM (P = 0.84). By the end of the 4-week assessment program, women in both groups still had an average reduction of 30 degrees in their shoulder ROM compared with baseline. Factors significantly associated with a reduction in shoulder ROM during the recovery period were complete dissection of the axilla, current smoking behavior, and presence of painful axillary cords. It is likely that breast reconstruction with LDF has little or no effect on shoulder ROM in the immediate postoperative period. It is also possible that LDF effects (if any) are overridden by the major reduction (over 30% in the immediate postoperative period, subsiding partially during the first weeks postoperatively) in shoulder ROM caused by mastectomy.

Exercícios livres versus direcionados nas complicações pós-operatórias de câncer de mama

OBJETIVO: Avaliar a associacao entre o tipo dos exercicios fisioterapicos com a incidencia de complicacoes pos-operatorias em mulheres submetidas a mastectomia radical ou quadrantectomia com linfadenectomia axilar. METODOS: Ensaio clinico randomizado com 60 mulheres. O grupo direcionado fez exercicios seguindo um protocolo preestabelecido de 19 exercicios (n=30) e o grupo livre fez exercicios sem sequencia e numero de repeticoes preestabelecidos (n=30). Realizou-se uma avaliacao inicial da paciente na fase pre-operatoria e reavaliacoes nos 14o, 28o e 42o dias pos-operatorio, analisando-se como volume total de secrecao drenada, tempo total de permanencia do dreno, incidencia de seroma e de deiscencia da ferida cirurgica e circunferencia do membro superior ipsolateral. RESULTADOS: O grupo direcionado permaneceu, em media, 12,17 ± 2,96 dias com o dreno, enquanto o grupo livre 11,96 ± 2,32 dias, nao havendo diferenca significativa entre os grupos. A quantidade de secrecao drenada durante a permanencia do dreno tambem se mostrou semelhante entre os grupos, sendo em media de 1308,71 ± 562,6 ml no grupo direcionado e 1391,62 ± 644,65ml no grupo de exercicios livres. As incidencias de seroma e de deiscencia da ferida cirurgica nao se mostraram influenciadas pelo tipo de exercicio em nenhum dos momentos avaliados. No grupo direcionado, 7,4% e 3,4% das mulheres apresentaram seroma nos 28o e 42o dias, respectivamente, enquanto 3,6% e 3,6% do grupo livre, respectivamente, nos mesmos momentos de avaliacao. A incidencia de deiscencia da ferida cirurgica tambem foi semelhante nos dois grupos, sendo que no grupo direcionado foi de 20% no 14o dia, 31% no 28o dia e 10,3% no 42o dia de pos-operatorio. No grupo livre a incidencia foi de 23,3% no 14o dia, 33,3% no 28o dia e 22,2% no 42o dia de pos-operatorio. A circunferencia do membro superior no grupo direcionado nao apresentou diferenca significativa em nenhum dos momentos avaliados. CONCLUSAO: As complicacoes nao se apresentaram influenciadas pela forma de aplicacao dos exercicios.

Avaliação das compensações linfáticas no pós-operatório de câncer de mama com dissecção axilar através da linfocintilografia Evaluation of lymphatic compensation by lymphoscintigraphy in the postoperative period of breast cancer surgery with axillary dissection

The lymphatic system is a component of the human body that is closely related to the venous system. However, scientific knowledge of this system is limited. The etiology and risk factors for the development of postoperative lymphedema in patients with breast cancer seem to be multifactorial and have not been fully understood yet. The objective of this review of the literature was to describe lymphoscintigraphic pattern and to evaluate upper limb lymphatic compensation following breast cancer surgery with axillary dissection.

Características mamográficas do câncer de mama associadas aos polimorfismos GSTM1 e GSTT1

INTRODUCTION: Enzymes of the Glutathione S-transferase system (GST) modulate the effects of exposure to several cytotoxic and genotoxic agents. The GSTM1 and GSTT1 genes are polymorphic in humans and their deletions have been associated to increased risk of many cancers, including breast cancer. OBJECTIVE: To evaluate the occurrence of homozygous deletions of the GSTM1 and GSTT1 genes in women with sporadic breast cancer and in women without cancer and to compare breast cancer mammographic features between patients with and without these deletions. METHODS: The study evaluated 100 patients with sporadic breast cancer treated from September 2004 to June 2005 and 169 women without cancer, determining the frequency of the above-mentioned deletions by PCR and calculating the odds ratios and their 95% confidence intervals. Medical files and mammograms of 100 patients with breast cancer were evaluated and correlated with mammographic features such as density, mammographic findings and the BI-RADS classification. These findings were correlated with the genetic deletions by the PR (Prevalence-Ratio) with their respective 95% confidence intervals. RESULTS: The GSTM1 gene was deleted in 40% of the cancers and in 44.4% of controls (OR = 1.20; CI 95% 0.70 - 2.04; p=0.5659) while the GSTT1 gene was deleted in 20% and 19.5%, respectively (OR = 0.73; CI 95% 0.37-1.44; p=0.4124). High mammographic density had been associated with GSTM1 deletion (PR 2.43; CI 1.11 to 4.08). GST deletions were not associated with predominant mammographic findings and the BI-RADS classification. CONCLUSION: GSTM1 homozygous deletion was associated with high mammographic density.

Axillary Web Syndrome: Practical Implications

To the Editor: In 2001, Dr. Moskovitz (1) described a series of 44 cases showing a not so rare complication that lacked literature references regarding the surgical approach to the axilla: axillary web syndrome (AWS). The concept described was the presence of a network of visible fibrous cords underneath the axillar skin, hardened and painful upon performance of shoulder abduction. The network is always present in the axilla and extends along the medial face of the ipsilateral arm, frequently below the cubital cavity and occasionally until the base of the thumb. Typically there are two or three palpable cords of tissue under the skin which are hardened, painful, and are not erythematic. There is no increase in temperature nor systemic symptoms. A 55-year-old woman, came in the Ferreira de Rezende S/S Physical Therapy Clinic 7 days after the breast surgery with an 18-month diagnosis of systemic erythematic lupus employing cloroquin 400 mg. Her mammography showed a 4 cm long focus of grouped and pleomorphic microcalcifications in the superlateral quadrant of the left breast and images of multiple bilateral nodules. A mammary ultrasound was done that showed multiple, simple bilateral cysts in correspondence with the nodules on mammography, and magnification of the microcalcifications on the left confirmed the initial suspicious diagnosis. The patient underwent a biopsy of the microcalcifications whose pathologic anatomy revealed atypical ductal hyperplasia and a focus of “in situ” ductal carcinoma of 2 mm. Then a mastectomy was performed with axillar dissection. Pathologic examination revealed the absence of residual neoplasia and 22 axillary lymph nodes were negative for metastasis. After 14 postoperative days a pain began in the arm ipsilateral to the surgery that worsened with flexion (160 degrees) and abduction (145 degrees) of the shoulder. Three cords were observed in the examination, which were hardened, fibrous, nonerythematic, and painful, beginning in the axilla and running down the medial face of the arm, reaching the cubital cavity. The algesia and range of movement of flexion (110 degrees) and abduction (80 degrees) of the shoulder worsened significantly around the 22nd day; more evident fibrous cords were noted in the examination and extended to the base of the thumb. Beginning with the 31st postoperative day, the pain progressively improved, with slight restriction of range of movement (130 degrees in flexion and 110 degrees in abduction) of the shoulder and regression of the fibrous cords. On the 83rd postoperative day the patient no longer complained of pain. In the physical examination the fibrous cords had completely disappeared and there was no functional impairment of the arm ipsilateral to the surgery. The main hypothesis relating to AWS physiopathology is lymph vein rupture during the axillar procedure, unrelated to the number of lymph nodes compromised or with the stage of the illness, but solely to the surgery itself. The pathologic anatomy analysis of fibrous cords showed the presence of lymphatic veins and superficially dilated veins with thrombi in their interior (1). A lymph vein alteration occurs, with stagnation and hypercoagulation, as a consequence of the superficial venous stagnation, lymphatic rupture, and tissue alteration caused by axillar intervention (2). It is important to differentiate simple articular restriction or postoperative muscular shortening as well as the fear of pain from movement. The patient initially shows good postoperative evolution, then begins to complain of intense pain accompanied by limitation in range of movement, mainly in abduction. This limitation is 90 degrees or less in 74% of the cases, with spontaneous resolution (1).