RESUMO
OBJECTIVE: Forced normalization (FN) is an intriguing phenomenon characterized by the emergence of psychiatric disturbances following the establishment of seizure control or reduction in the epileptic activity in a patient with previous uncontrolled epilepsy. We aim to describe the clinical characteristics of the condition. METHODS: We conducted a systematic review on MEDLINE, EMBASE, Cochrane, and Scielo from January 1953 to January 2018. Clinical, electrographic, and imaging data were gathered. We considered all outcomes in children and adults. We performed no meta-analyses due to the limited available data. RESULTS: Of 2606 abstracts identified, 36 fulfilled the FN diagnostic criteria; 193 FN episodes were evaluated and 77 of them were analyzed extensively. Sixty percent of cases were female. Mean age ± standard deviation (SD) was 28.3 ± 14.2 years. The majority of patients had focal (80%) symptomatic (44%) epilepsy. Most patients reported a high ictal frequency (58%) and were on polytherapy (51%). Patients presented psychosis (86.4%), mood disorders (25.8%), and dissociation (4.5%) as the main manifestations. In the psychosis group, persecutory (52.6%) and reference (47.3%) delusions were frequent. FN was provoked by an antiepileptic drug (AED) (48.5%) mainly levetiracetam, epilepsy surgery (31.8%), or vagus nerve stimulation (13.6%). Treatment was homogeneous including anticonvulsant withdrawal (47%) or taper (25%); antipsychotics were initiated in the majority of cases (73%). Psychiatric symptoms were partially controlled in 35%, with complete resolution of symptoms in the remaining 65% of cases. The majority of patients (87%) with AED trigger and withdrawal presented complete resolution of symptoms in comparison to 28.5% of patients triggered by surgery. SIGNIFICANCE: Forced normalization is an entity whose pathophysiology remains uncertain. Antipsychotic drug use does not predict complete resolution of psychiatric symptoms in comparison with AED withdrawal. Although there is a positive response to treatment in patients with FN triggered by drugs, the prognosis is obscure in patients with surgery triggered FN.
Assuntos
Epilepsia/tratamento farmacológico , Transtornos Psicóticos/etiologia , Anticonvulsivantes/uso terapêutico , Epilepsia/complicações , Humanos , Transtornos Psicóticos/fisiopatologia , Indução de RemissãoRESUMO
People with epilepsy (PWE) are less physically active compared with the general population. Explanations include prejudice, overprotection, unawareness, stigma, fear of seizure induction and lack of knowledge of health professionals. At present, there is no consensus on the role of exercise in epilepsy. This paper reviews the current evidence surrounding the risks and benefits associated with physical activity (PA) in this group of patients. In the last decade, several publications indicate significant benefits in physiological and psychological health parameters, including mood and cognition, physical conditioning, social interaction, quality of life, as well as potential prevention of seizure presentation. Moreover, experimental studies suggest that PA provides mechanisms of neuronal protection, related to biochemical and structural changes including release of ß-endorphins and steroids, which may exert an inhibitory effect on the occurrence of abnormal electrical activity. Epileptic discharges can decrease or disappear during exercise, which may translate into reduced seizure recurrence. In some patients, exercise may precipitate seizures. Available evidence suggests that PA should be encouraged in PWE in order to promote wellbeing and quality of life. There is a need for prospective randomized controlled studies that provide stronger clinical evidence before definitive recommendations can be made.
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Epilepsia/psicologia , Exercício Físico/psicologia , Qualidade de Vida/psicologia , Esportes , Consenso , Humanos , Convulsões/complicaçõesRESUMO
Epilepsy has afflicted humanity during most of the extent of documented history. The Aztecs believed that illnesses were punishments that were sent from a furious goddess. In particular, epilepsy was considered in Aztec culture as a "sacred disease", and convulsions were traditionally associated with a deified woman who had died at childbirth. As the goddess Shiva and Apasmâra in ancient India and Saint Valentine in Germany, Tlazolteotl was considered able to bring about and send away epilepsy. We performed a comprehensive review to identify Tlazolteotl depictions and its historical context related with epilepsy. Tlazolteotl is one of the most endearing and complex goddesses of the Mesoamericans. She was the deity of the black fertile and fecund earth that gains its energy from death and in turn feeds life. Associated with purification, expiation, and regeneration, she embodied fertility and turned all garbage, physical and metaphysical, into rich life. This article reviews the most relevant artistic works related with Tlazolteotl. We also present a modern depiction of the Aztec goddess of epilepsy from the Mexican artist Eduardo Urbano Merino, displaying the supernatural view of epilepsy in America.
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Epilepsia/história , Religião e Medicina , Convulsões , Feminino , História Antiga , História Medieval , Humanos , GravidezRESUMO
The impact of health and disease has led many artists to depict these themes for thousands of years. Specifically, epilepsy has been the subject of many famous works, likely because of the dramatic and misunderstood nature of the clinical presentation. It often evokes religious and even mythical processes. Epilepsy surgical treatment has revolutionized the care of selected patients and is a relatively recent advance. Epilepsy surgery has been depicted in very few artistic works. The first portrait showing a potential surgical treatment for patients with epilepsy was painted in the 12th century. During the Renaissance, Bosch famously provided artistic commentary on traditional beliefs in "The stone of madness". Several of these works demonstrate a surgeon extracting a stone from a patient's head, at one time believed to be the source of all "folly", including epileptic seizures, psychosis, intellectual disability, depression, and a variety of other illnesses. There are some contemporary art pieces including themes around epilepsy surgery, all of them depicting ancient Inca Empire procedures such as trepanning. This article reviews the most relevant artistic works related with epilepsy surgery and also its historical context at the time the work was produced. We also present a painting from the Mexican artist Eduardo Urbano Merino that represents the patient's journey through refractory epilepsy, investigations, and ultimately recovery. Through this work, the artist intends to communicate hope and reassurance to patients going through this difficult process.
Assuntos
Arte , Epilepsia/cirurgia , Neurocirurgia/história , Arte/história , Epilepsia/história , História do Século XV , História do Século XVI , História do Século XVII , História do Século XVIII , História do Século XIX , História do Século XX , História do Século XXI , História Medieval , Humanos , Neurocirurgia/métodosRESUMO
Currently, there is intense clinical research into various aspects of the medical risks relating to epilepsy, including total and cause-specific mortality, accidents and injuries in patients with epilepsy and mortality related with seizures. Submersion injuries, motor vehicle accidents, burns, and head injuries are among the most feared epilepsy-related injuries. Published risk factors for injuries include the number of antiepileptic drugs, history of generalized seizures, and seizure frequency. In general, studies focusing on populations with more severe forms of epilepsy tend to report substantially higher risks of injuries than those involving less selected populations. On the other hand, studies based in non selected populations of people with epilepsy have not shown an increase frequency of injuries in people with epilepsy compared with the general population. Some studies have shown that patients with epilepsy are more frequently admitted to the hospital following an injury. Possible explanations include are more cautious attitude of clinicians toward injuries occurring in the setting of seizures; hospitalization required because of seizures and not to the injuries themselves; and hospitalization driven by other issues, such as comorbidities, which are highly prevalent in patients with epilepsy. This article reviews information about specific type of injuries such as fractures, burns, concussions, dislocations, etc. Finally this article review in a comprehensive way information of mortality in patients with epilepsy. Aspects of mortality discussed in this review are: epidemiology, causes of mortality, sudden death in epilepsy and prevention measures.
Assuntos
Acidentes/estatística & dados numéricos , Epilepsia/epidemiologia , Ferimentos e Lesões/epidemiologia , Prevenção de Acidentes , Adulto , Queimaduras/epidemiologia , Queimaduras/prevenção & controle , Causas de Morte , Comorbidade , Morte Súbita/epidemiologia , Morte Súbita/prevenção & controle , Epilepsia/mortalidade , Epilepsia Generalizada , Evolução Fatal , Fraturas Ósseas/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Luxações Articulares/epidemiologia , Masculino , Prevalência , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Ferimentos e Lesões/prevenção & controleRESUMO
OBJECTIVE OF THE STUDY: The skin blood flow (SBF) has been known to oscillate in frequency and amplitude. The nature and type of these oscillations have remained obscure. We studied the oscillations of the SBF in frequency and amplitude with non invasive techniques during normal breathing at rest and compared it to the oscillations during rhythmic paced breathing at 6 cycles per minute. SUBJECTS AND METHODS: Thirty healthy subjects were studied under normothermic conditions. The following variables were recorded: 1) EKG signal; 2) SBF signal given by an infrared photoplethysmograph; 3) respiratory movements (RM). A correlation of the frequency of the respiration, the SBF and the EKG was made. The variability of the amplitudes of the SBF, RR intervals and pulse intervals was analyzed in the time domain and with spectral analysis using Fourier analysis. RESULTS: We found no clear respiratory modulation of the amplitude of the SBF during natural breathing at rest. With default breathing there was a low frequency oscillations (LF 0.04 to 0.15 Hz) modulation of the amplitude of the SBF that was non respiratory in nature. During rhythmic breathing at 0.1 Hz there was a strong modulation at LF of the SBF with a typical waxing and waning appearance, decreasing in amplitude during the tachycardia period and increasing in amplitude during the bradycardia period. CONCLUSIONS: Under normothermic conditions there is a consistent variability of the frequency and amplitude of the SBF with normal and rhythmic breathing. While breathing at rest the modulation of SBF amplitude was clearly seen at LF and non respiratory related. With rhythmic breathing there is a strong modulation of amplitude and frequency at the respiratory frequency.
Assuntos
Fibras Adrenérgicas/fisiologia , Fluxo Sanguíneo Regional , Respiração , Fenômenos Fisiológicos da Pele , Pele/irrigação sanguínea , Pele/inervação , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
OBJECTIVE OF THE STUDY: The skin blood flow (SBF) has been known to oscillate in frequency and amplitude. The nature and type of these oscillations have remained obscure. We studied the oscillations of the SBF in frequency and amplitude with non invasive techniques during normal breathing at rest and compared it to the oscillations during rhythmic paced breathing at 6 cycles per minute. SUBJECTS AND METHODS: Thirty healthy subjects were studied under normothermic conditions. The following variables were recorded: 1) EKG signal; 2) SBF signal given by an infrared photoplethysmograph; 3) respiratory movements (RM). A correlation of the frequency of the respiration, the SBF and the EKG was made. The variability of the amplitudes of the SBF, RR intervals and pulse intervals was analyzed in the time domain and with spectral analysis using Fourier analysis. RESULTS: We found no clear respiratory modulation of the amplitude of the SBF during natural breathing at rest. With default breathing there was a low frequency oscillations (LF 0.04 to 0.15 Hz) modulation of the amplitude of the SBF that was non respiratory in nature. During rhythmic breathing at 0.1 Hz there was a strong modulation at LF of the SBF with a typical waxing and waning appearance, decreasing in amplitude during the tachycardia period and increasing in amplitude during the bradycardia period. CONCLUSIONS: Under normothermic conditions there is a consistent variability of the frequency and amplitude of the SBF with normal and rhythmic breathing. While breathing at rest the modulation of SBF amplitude was clearly seen at LF and non respiratory related. With rhythmic breathing there is a strong modulation of amplitude and frequency at the respiratory frequency.
Assuntos
Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Fibras Adrenérgicas/fisiologia , Fluxo Sanguíneo Regional , Respiração , Fenômenos Fisiológicos da Pele , Pele , Pele/inervaçãoRESUMO
UNLABELLED: The Raynaud's syndrome is an episodic skin ischemia manifested by pallor, cyanosis and erythema of the fingers in response to cold or emotional stress. The exact pathophysiology is unknown but it has been hypothetised that may be due to an autonomic alteration in the sympathetic innervation of skin blood vessels. OBJECTIVE: To study the changes of heart rate and skin blood flow (SBF) in healthy subjects and in patients with secondary Raynaud's syndrome during different respiratory maneuvers: 1. spontaneous respiration; 2. rhythmic respirations (RR), 3. sudden inspirations (SI), and 4. Valsalva maneuver (VM). METHODS: We studied 22 healthy subjects and 22 patients with secondary Raynaud's syndrome. The variables measured were: 1) RR intervals; 2) amplitudes of SBF; 3) percentage of decrease of SBF; 4) latency of the maximum decrease of SBF. RESULTS: In all patients with secondary Raynaud's syndrome the SBF was decreased basally during spontaneous rations and during all respiratory maneuvers (p < 0.001). The mean latency of recovery of the SBF was prolonged during sudden deep inspiration. The patients with Raynaud also had significant basal tachycardia at rest (p < 0.003). CONCLUSIONS: The basal skin blood flow during spontaneous respirations and in asymptomatic periods is decreased in patients with Raynaud's syndrome; this may be related to endothelial arterioral damage. The SBF was also significantly decreased dynamically during sudden inspirations (SI), rhythmic breathing (RR) and Valsalva maneuver (VM). This dynamic change suggests sympathetic hyperactivity.
Assuntos
Doença de Raynaud/fisiopatologia , Pele/irrigação sanguínea , Adulto , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Masculino , Respiração , Fatores de Tempo , Manobra de Valsalva , VasoconstriçãoRESUMO
El síndrome de Raynaud se caracteriza por isquemia cutánea digital episódica, manifestada por palidez, cianosis y rubor de los dedos de manos y pies expuestos al frío o cuando el paciente está sujeto a un estrés emocional. No se conoce el mecanismo fisiopatológico exacto; la hipótesis más invocada es una alteración autonómica en la inervación simpática de los vasos sanguíneos de la piel. Objetivo: Estudiar los cambios de la frecuencia cardíaca y el flujo sanguíneo de la piel (FSP) en sujetos sanos y en pacientes con síndrome de Raynaud durante las siguientes condiciones: 1. respiración espontánea (RE), 2. respiración rítmica (RR), 3. inspiración profunda repentina (IPR), 4. maniobra de Valsalva (MV). Método: Se estudiaron 22 sujetos sanos y 22 pacientes con síndrome de Raynaud secundario. Las variables medidas fueron: 1. intervalo R-R; 2. amplitud de FSP; 3. porcentaje de disminución de FSP; 4. latencia de la máxima disminución del FSP. Resultados: Los pacientes con síndrome de Raynaud presentaron mayor taquicardia basal. La amplitud del FSP se encontró disminuido durante la respiración espontánea y durante las maniobras respiratorias (P < 0.001). La vasoconstricción estuvo prolongada ya que la latencia promedio de recuperación del FSP estuvo prolongada en IPR y MV en comparación de los sujetos controles. Conclusión: La amplitud del FSP basal está disminuida en los pacientes con síndrome de Raynaud, durante períodos asintomáticos; esto sugiere daño endotelial. También se encontró disminuido con las diversas maniobras respiratorias (RR, IPR y MV). Este cambio dinámico sugiere hiperactividad simpática hacia los vasos sanguíneos de la piel.
The Raynaud's syndrome is an episodic skin ischemia manifested by pallor, cyanosis and erythema of the fingers in response to cold or emotional stress. The exact pathophysiology is unknown but it has been hypothetised that may be due to an autonomic alteration in the sympathetic innervation of skin blood vessels. Objective: To study the changes of heart rate and skin bloodflow (SBF) in healthy subjects and in patients with secondary Raynaud's syndrome during different respiratory maneuvers: 1. spontaneous respiration; 2. rhythmic respirations (RR), 3. sudden inspirations (SI), and 4. Valsalva maneuver (VM). Methods: We studied 22 healthy subjects and 22 patients with secondary Raynaud's syndrome. The variables measured were: 1) RR intervals; 2) amplitudes of SBF; 3) percentage of decrease of SBF; 4) latency of the maximum decrease of SBF. Results: In all patients with secondary Raynaud's syndrome the SBF was decreased basally during spontaneous respirations and during all respiratory maneuvers (p < 0.001). The mean latency of recovery of the SBF was prolonged during sudden deep inspiration. The patients with Raynaud also had significant basal tachycardia at rest (p < 0.003). Conclusions: The basal skin blood flow during spontaneous respirations and in asymptomatic periods is decreased in patients with Raynaud's syndrome; this may be related to endothelial arterioral damage. The SBF was also significantly decreased dynamically during sudde3n inspirations (SI), rhythmic breathing (RR) and Valsalva maneuver (VM). This dynamic change suggests sympathetic hyperactivity.
Assuntos
Adulto , Feminino , Humanos , Masculino , Doença de Raynaud/fisiopatologia , Pele/irrigação sanguínea , Velocidade do Fluxo Sanguíneo , Respiração , Fatores de Tempo , Manobra de Valsalva , VasoconstriçãoRESUMO
BACKGROUND: Advances in neonatal care over the past decades have meant that an increasing number of very premature infants survive today than in years past. One of the main factors contributing to the survival of these infants is development in ventilatory support. However, this has lead to lung injury and an increase in the incidence of bronchopulmonary dysplasia (BDP). METHODS: A case-control study was conducted at the National Institute of Perinatology Neonatal Intensive Care Unit in Mexico City, Mexico to evaluate the risk factors associated with the development of BPD in premature infants requiring ventilatory support within the first days of life for respiratory failure. Twenty two cases and 22 control premature infants admitted to the Neonatal Unit requiring assisted ventilation and that survived for more than 28 days were included. The neonatal and maternal risk factors that were considered for analysis were the following; mode of delivery, antenatal steroids, gestational age, birth weight, Apgar scores, sepsis, patent ductus arteriosus, and ventilation parameters. RESULTS: Factors associated with the development of BPD were late sepsis (OR 7.29, 95% CI 1.61-35.8, p=0.002), and two or more episodes of sepsis (OR 7.60, 95% CI 1.46-44.6, p=0.004). Other risk factors were low birth weight and younger gestational age at birth. CONCLUSIONS: Similar to what has been reported by other investigators in developed countries, our study showed that neonatal sepsis, low birth weight, and gestational age were associated with BPD in our patients.
Assuntos
Displasia Broncopulmonar/etiologia , Adulto , Displasia Broncopulmonar/fisiopatologia , Estudos de Casos e Controles , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso , México , Oxigenoterapia , Estudos Retrospectivos , Fatores de Risco , SepseRESUMO
INTRODUCTION: Obesity is a chronic condition, in which different systems of the body are affected. There are some previous studies in which the prevalence of psychiatric disorders in extreme obese patients has been reported, but there are some methodological problems. As far as we know this is the first report of the prevalence of psychiatric disorders in obese patients that need to have a surgical treatment for this disorder in Mexico. The main goal of this study was to determine the prevalence and risk factors of psychiatric disorders in extreme obese patients candidates to bariatric surgery. MATERIAL AND METHODS: The Structured Clinical Interview for DSM-IV (SCID) axis I disorders, were performed in 70 obese patients that will undergo for bariatric surgery. Also the medical files were reviewed in order to obtain the main medical conditions related to obesity. RESULTS: There were 25 men and 35 women in this study (average age +/- s.d = 39.0 +/- 10.4). The Body Mass Index (BMI) was 53.8 +/- 11.9. Sixty percent of the patients had some psychiatric disorder in the axis I of DSM-IV. The most frequent psychiatric problem that was observed was anxiety disorders. The main medical problems observed were: arterial hypertension (59%), diabetes mellitus type 2 (29%) and obstructive sleep apnea syndrome (29%). The BMI and diabetes mellitus were associated with a lower risk for presenting a psychiatric disorder (for a BMI of 65.5 +/- 10.3 kg/m2: OR 0.26, CI 0.05-1.15, p = 0.04; for diabetes mellitus: OR 0.20, CI 0.03-1.05, p = 0.02). CONCLUSIONS: More than half of the patients had at least one psychiatric disorder in axis 1 of DSM-IV, related mostly to anxiety and mood disorders. Our findings point out the importance of psychiatric and psychological intervention in this group of patients, in which a follow up and adherence of medical, nutritional and psychological problems could be the difference, between a good or bad prognosis. Follow-up studies with obese patients after bariatric surgery, will be important to support our findings.
Assuntos
Transtornos Mentais/complicações , Transtornos Mentais/epidemiologia , Obesidade Mórbida/complicações , Adulto , Feminino , Humanos , Masculino , Obesidade Mórbida/cirurgia , Prevalência , Índice de Gravidade de DoençaAssuntos
Miastenia Gravis/cirurgia , Timectomia/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miastenia Gravis/complicações , Prognóstico , Fatores Sexuais , Timoma/complicações , Timoma/cirurgia , Neoplasias do Timo/complicações , Neoplasias do Timo/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: To identify the frequency and factors associated with therapy noncompliance in type-2 diabetes mellitus patients. MATERIAL AND METHODS: A cross-sectional study was carried out in 79 patients with type-2 diabetes mellitus seen in major hospitals of Mexico City. Patients were visited at home, from March 1998 to August 1999, to measure compliance with prescribed therapy. Complying patients were defined as those taking at least 80% of their pills or 80% of their corresponding insulin dose. The degree of compliance with therapy components (diet, amount of exercise, and keeping appointments) was measured. RESULTS: The average age of study subjects was 59 years (SD 11 years); 73% (n = 58) were female subjects. The overall frequency of noncompliance was 39%. Noncompliance rates were: 62% for dietary recommendations, 85% for exercise, 17% for intake of oral hypoglycemic medication, 13% for insulin application, and 3% for appointment keeping. Hypertension plus obesity was the only factor significantly associated with noncompliance (OR 4.58, CI 95% 1.0, 22.4, p = 0.02). CONCLUSIONS: The frequency of therapy noncompliance was very high, especially for diet and exercise.
Assuntos
Diabetes Mellitus Tipo 2/psicologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Adulto , Idoso , Comorbidade , Depressão/epidemiologia , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/terapia , Terapia por Exercício , Feminino , Humanos , Hipertensão/epidemiologia , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Fatores SocioeconômicosAssuntos
Doenças Genéticas Inatas/genética , Genética Médica , Doenças do Sistema Nervoso/genética , Neurologia , Doença de Alzheimer/genética , Doença de Alzheimer/metabolismo , Mapeamento Cromossômico , Doenças Genéticas Inatas/terapia , Predisposição Genética para Doença , Terapia Genética , Humanos , Isquemia/genética , Doenças Mitocondriais/genética , Doenças do Sistema Nervoso/terapia , Doenças Neuromusculares/classificação , Doenças Neuromusculares/genética , Doença de Parkinson/genéticaRESUMO
OBJECTIVE: To identify the frequency and factors associated with therapy noncompliance in type-2 diabetes mellitus patients. MATERIAL AND METHODS: A cross-sectional study was carried out in 79 patients with type-2 diabetes mellitus seen in major hospitals of Mexico City. Patients were visited at home, from March 1998 to August 1999, to measure compliance with prescribed therapy. Complying patients were defined as those taking at least 80 percent of their pills or 80 percent of their corresponding insulin dose. The degree of compliance with therapy components (diet, amount of exercise, and keeping appointments) was measured. RESULTS: The average age of study subjects was 59 years (SD 11 years); 73 percent (n=58) were female subjects. The overall frequency of noncompliance was 39 percent. Noncompliance rates were: 62 percent for dietary recommendations, 85 percent for exercise, 17 percent for intake of oral hypoglycemic medication, 13 percent for insulin application, and 3 percent for appointment keeping. Hypertension plus obesity was the only factor significantly associated with noncompliance (OR 4.58, CI 95 percent 1.0, 22.4, p=0.02). CONCLUSIONS: The frequency of therapy noncompliance was very high, especially for diet and exercise
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , /psicologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Comorbidade , Depressão/epidemiologia , /dietoterapia , /tratamento farmacológico , /terapia , Terapia por Exercício , Hipertensão/epidemiologia , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Fatores SocioeconômicosRESUMO
INTRODUCTION: Approximately 10% of patients with myasthenia gravis also have thymomas. The objective of this study was to describe the evolution after the thymectomy in 10 cases of myasthenia gravis associated with thymomas. METHODS: The study was based in a cohort of 132 patients with the diagnosis of myasthenia gravis, that underwent thymectomy between 1987 and 1997, and had at least three years of follow-up. We found 10 cases (7%) of thymomas. We analyzed the following variables: sex, age, associated diseases, disease evolution, Osserman, dose of edrophonium before surgery, steroid use before surgery, types of thymectomy, Osserman after surgery, pathology findings, and evolution. We used descriptive statistics according to the measurement level of the variables. RESULTS: Four (40%) were women and 6 (60%) were men. The antibodies against the acetylcholine receptor were tested in only 5 (50%) patients, and in all of them they were positive. 4 (40%) patients had complications after the thymectomy, being 2 (20%) of them myasthenic crisis, one (10%) pneumonia and another (10%) hemorrhage in the surgical wound. Six (60%) cases had malignant thymomas and 4 (40%) were benign. In the follow-up, 4 (40%) patients had a good clinical response of myasthenia gravis and 6 (60%) had no changes. CONCLUSION: The response to thymectomy was not as good as the response of the vast majority of patients with myasthenia gravis without thymomas. We found a high frequency of malignant thymomas in our patients.
Assuntos
Timectomia , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Thymectomy is considered the most effective treatment for achieving sustained improvement as well as remission in patients with myasthenia gravis (MG), and most neurologists favor the use of this procedure. The main focus of many current studies is to determine response-predicting factors. METHODS: Clinical records of 152 patients with an established diagnosis of MG who underwent thymectomy at our institution were reviewed. The purpose was to evaluate outcome of surgical management for MG and prognostic factors that influence that outcome. RESULTS: The majority of patients were women (119 of 152); mean age was 32.10 +/- 14.42 years, while time elapsed from diagnosis to surgery was 20.67 +/- 19.7 months. Transsternal thymectomy was performed on 113 patients and transcervical on 39. Forty percent of patients achieved remission and 28% showed improvement; with this, a good response to thymectomy was seen in 68% of patients (n = 103). The most important variables associated with remission were <60 years of age, <2 years of preoperative symptoms, and use of pyridostigmine at low doses. Factors related with poor response were >60 years of age, preoperative Osserman stage other than II, use of high doses of pyridostigmine, use of corticosteroids, and presence of thymic atrophy or thymoma in histopathologic analyses. There was no mortality, although 20 patients (13%) presented complications. CONCLUSIONS: Mexican patients with MG undergoing thymectomies show improvement and remission rates similar to those reported by other studies. Age, length of symptoms, thymic pathology, and medications appear to be predictors of response to thymectomy for MG.
Assuntos
Miastenia Gravis/mortalidade , Miastenia Gravis/cirurgia , Timo/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Indução de Remissão , Fatores Sexuais , Timectomia , Timo/patologia , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: In the diagnosis of autonomic disturbances, the variability of skin blood flow (SBF) and the sympathetic skin response (SSR) in response to several respiratory maneuvers are not routinely studied. OBJECTIVE: We sought to standardize the method of SBF variability and SSR in healthy subjects during four respiratory maneuvers: 1) spontaneous breathing (SB); 2) rhythmic breathing at a rate of 6 per minute (RB); 3) sudden deep inspiration (SDI); 4) Valsalva maneuver (VM). SUBJECTS, MATERIAL AND METHOD: We studied 30 healthy subjects with a mean age of 32 years, 60% were men and 40% women. We used a photopletysmograph in the finger pad to measure SBF and surface electrodes on the palms of the hand to register the SSR. We also recorded the ECG and the respiratory movements. The variables were: 1) amplitude of SBF; 2) latency and duration of SSR; 3) percentage of decrease of the SBF during the maneuvers compared with the basal flow. RESULTS: During spontaneous breathing there was no respiratory modulation of the SBF and during RB the SBF was modulated with respiration. With SDI there was a 60% decrease of the SBF. VM induced a larger SBF decrease of 72 per cent. A significant statistical difference was revealed when we compared the decrease of SBF basal breathing with SDI and VM (P < 0.001). The difference was also significant between the SDI and VM (P < 0.001). The SBF decrease recovered more slowly after the SDI (beat 7) than after the VM (veat 6). The SBF decrease was more pronounced in magnitude during the VM. The latency of the SSR appears spontaneously and at random in 57% of subjects during normal breathing but it appeared consistently during RB, SDI, and VM. The latency of SSR was longer during SB (1.7 +/- 0.7 s), RB (1.6 +/- 0.7 s) than SDI (0.7 +/- 0.5 s) and VM (0.8 +/- 0.9 s) (P > 0.050). Duration of the SSR was significantly longer in the SDI (around 7.8 +/- 2.4 s) and during the VM (8 +/- 2.5 s) as compared to normal breathing (6.3 +/- 1.0 s) and RB (6.4 +/- 1.5 s) (P < 0.009). CONCLUSIONS: SB and RB induce periodic modulation of sympathetic activity to skin blood vessels and sweat glands. SDI and VM produced a much greater activation of sympathetic skin activity than SB and RB. The increased SSR duration and the profound SBF decrease with SDI and VM as compared to SB or RB are consistent with this hypothesis. The latency of the SSR is much shorter with SDI and VM than with SB or RB. The most likely explanation is that the SSR, under these circumstances, results from a central command. The recovery to normal SBF is faster after the VM as compared to SDI. This suggests that the withdrawal of sympathetic responses is faster after the VM. The explanation for this is unknown but suggests that it might be baroreceptor mediated.