Uso da fotobiomodulação laser no tratamento de úlceras venosas: uma revisão sistemática / Laser photobiomodulation in the treatment of venous ulcers: a systematic review

O objetivo do presente trabalho foi relatar a eficácia da fotobiomodulação laser na abordagem de úlceras venosas de membros inferiores e como se dá o papel da enfermagem nesse contexto. Tratou-se de uma revisão sistemática que utilizou as bases de dados eletrônicas PubMed, BVS, SCIELO e Lilacs, além da busca no repositório de teses e dissertações pelo cruzamento dos descritores livres e provenientes do DeCS através dos operadores booleanos AND e OR: "laserterapia", "fotobiomodulação laser" e "úlceras venosas". Os critérios de inclusão estabelecidos foram estudos prospectivos, teses e dissertações escritas nos idiomas inglês, português e espanhol, e publicações entre o período de 2010-2020. A revisão foi conduzida conforme metodologia PRISMA, utilizou-se os critérios de Jadad para avaliação da qualidade dos manuscritos. Dos 104 artigos encontrados, apenas 8 contemplavam os critérios de inclusão, tendo uma população total de 942 pacientes. Notou-se que a maioria dos estudos mostrou a eficácia do uso da laserterapia, principalmente quando associado ao uso da terapêutica comum, como a terapia compressiva, agentes tópicos e farmacoterapia. A fotobiomodulação laser demonstrou ser eficaz, porém ainda são necessários mais estudos com o objetivo de uniformizar os parâmetros de aplicação dessa modalidade terapêutica.

The objective of this work was to investigate the effectiveness of laser photo-biomodulation in lower limb venous ulcers and the role of nursing in this context. This is a systematic review, using the PubMed, BVS, SCIELO and Lilacs electronic databases in addition to searching the repository of thesis and dissertations by crossing the free descriptors coming from the DeCS through the Boolean operators AND and OR: "laser therapy", "laser photo-biomodulation" and "venous ulcers". The inclusion criteria were prospective studies, theses and dissertations written in English, Portuguese, or Spanish, and publications in the 2010-2020 period. From the 104 articles found, only 8 met the inclusion criteria, with a total population of 942 patients. It could be observed that most studies showed the effectiveness of using laser therapy, especially when associated with the use of common therapy, such as the compressive therapy, topical agents, and pharmacotherapy. The laser photo-biomodulation was also shown as being effective, but further studies are needed to standardize the application parameters for this therapeutic modality.

Diferenciação odonto/osteogênica de células-tronco mesenquimais fotomoduladas em hidrogel com incorporação de proteína morfogenética óssea 4 / Odonto/osteogenic differentiation of photomodulated mesenchymal stem cells in BMP4-loaded hydrogel

Este estudo avaliou a influência da fototerapia a laser (FTL) na proliferação e diferenciação de células-tronco da polpa dentária humana (DPSCs; do inglês, Dental Pulp Stem Cells ) encapsuladas em carreador injetável e termoresponsivo (PL; Pluronic® F-127, Sigma-Aldrich, MO, EUA) com incorporação de proteína morfogenética óssea 4 recombinante humana (rhBMP4) (sistema PL/rhBMP4). O biomaterial foi caracterizado de acordo com seus perfis de embebição e dissolução, liberação de rhBMP4 e sua estrutura morfológica. DPSCs foram isoladas, caracterizadas e encapsuladas em PL para confirmar sua viabilidade e seu potencial de diferenciação (adipo e osteogênico) em comparação com células-tronco mesenquimais de medula óssea (BMMSCs; do inglês, Bone Marrow Mesenchymal Stem Cells). Quando encapsuladas no sistema PL/rhBMP4, DPSCs foram irradiadas com duas densidades de energia diferentes utilizando laser de diodo de fosfeto de índio-gálio-alumínio (InGaAlP), modos contínuo, pontual e em contato [660 nm, 0,028 cm2, 20 mW, 0,71 W/cm2, 3 J/cm2 (4 s) ou 5 J/cm2 (7 s)]. Os ensaios de PKH26 (do inglês, Red Fluorescent Cell Linker), CFU-F (do inglês, Coloning Forming Units - Fibroblastic), e MTT (do inglês, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide)) foram utilizados para avaliar adesão/proliferação, diferenças na capacidade formadora de colônias e viabilidade das DPSCs (neste último caso sob estresse nutricional), respectivamente. Finalmente, a diferenciação odonto/osteogênica foi analisada por qRT-PCR e confirmada por ensaio de vermelho de alizarina. O biomaterial embebeu e dissolveu rapidamente; densa rede tubular e reticular com poros interconectados foi observada.

DPSCs e BMMSCs apresentaram alta viabilidade celular quando encapsuladas em PL. Ambas as linhagens celulares tiveram êxito em se diferenciar em tecidos adiposo e ósseo. De acordo com o PKH26, DPSCs puderam aderir e proliferar no sistema PL/rhBMP4. DPSCs irradiadas encapsuladas tanto em PL como em PL/rhBMP4 formaram mais CFU-F que os controles não irradiados. Sob estresse nutricional, DPSCs semeadas no PL e irradiadas com 5 J/cm2 exibiram maior taxa de viabilidade celular em relação aos grupos não irradiados e irradiados com 3 J/cm2. Na presença de rhBMP4, os grupos irradiados tanto com 3 J/cm2 quanto com 5 J/cm2 apresentaram deposição mineral precoce quando comparados aos grupos não irradiados. Ainda, após 21 dias de diferenciação odonto/osteogênica, DPSCs irradiadas produziram maior quantidade de nódulos mineralizados. A irradiação com 5 J/cm2 levou ao aumento significativo da expressão de genes envolvidos na diferenciação odonto/osteogênica, como colágeno tipo I (COL1A1), osteocalcina (OCN), proteína da matriz dentinária 1 (DMP1), sialofosfoproteina dentinária (DSPP) e proteína heat shock 27 kDa (HSPB1). A associação entre rhBMP4 e FTL promove proliferação e diferenciação odonto/osteogênica de DPSCs acelerando e aumentando notavelmente a formação de tecido mineralizado, em especial quando a densidade de energia de 5 J/cm2 é aplicada.

This study evaluated the influence of laser phototherapy (LPT) on dental pulp stem cells (DPSCs) proliferation and differentiation upon encapsulation in an injectable and thermo-responsive cell carrier (PL; Pluronic® F-127, Sigma-Aldrich, MO, USA) loaded with human recombinant bone morphogenetic protein 4 (rhBMP4)(PL/rhBMP4 system). The biomaterial was characterized according to its swelling and dissolution profiles, release of rhBMP4 and morphological structure. DPSCs were isolated, characterized and encapsulated in PL to confirm their viability and multilineage differentiation potential (adipo and osteogenic) in comparison to bone marrow mesenchymal stem cells (BMMSCs). When encapsulated in the PL/rhBMP4 system, DPSCs were irradiated with two different energy densities using a continuous-wave indium-gallium-aluminum-phosphide (InGaAlP) diode laser [660 nm, 0.028 cm2, 20 mW, 0.71 W/cm2, 3 J/cm2 (4 s) or 5 J/cm2 (7 s)] in punctual and contact modes. The PKH26 (Red Fluorescent Cell Linker), the CFU-F (Coloning Forming Units - Fibroblastic), and the MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide] assays were used to assess differences in cell adhesion/proliferation, colony forming units formation ability, and cell viability of DPSCs (in this case under nutritional stress), respectively. Then, alizarin red and qRT-PCR analyzes were used to evaluate odonto/osteogenic differentiation. The biomaterial swelled and dissolved rapidly; dense tubular and reticular network morphology with well-interconnected pores was observed. DPSCs and BMMSCs presented high cell viability when encapsulated in PL. Both cell lineages successfully differentiated into bone or adipose tissues. According to PKH26,

DPSCs were able to adhere and proliferate in the PL/rhBMP4 system. Irradiated DPSCs encapsulated in either PL or PL/rhBMP4 system formed more CFU-F than non-irradiated controls. Under nutritional stress, DPSCs encapsulated in the hydrogels with no rhBMP4 and irradiated at 5 J/cm2 exhibited higher cell viability than the other groups. In the presence of rhBMP4, the groups irradiated both at 3 and 5 J/cm2 energy densities displayed earlier mineral deposition than the non-irradiated groups. Moreover, after 21 days of odonto/osteogenic differentiation, irradiated DPSCs produced greater nodule formation than the control groups. At the energy density of 5 J/cm2, there were significant upregulation of genes involved in odonto/osteoblast differentiation, such as type I collagen (COL1A1), osteocalcin (OCN), dentin matrix protein 1 (DMP1), dentin sialophosphoprotein (DSPP) and heat shock protein 27 kDa (HSPB1). The association between rhBMP4 and LPT promotes cell proliferation and odonto/osteogenic differentiation of DPSCs accelerating and increasing the formation of mineralized tissue, in particular when the energy density of 5 J/cm2 is applied.

Diferenciação odonto/osteogênica de células-tronco mesenquimais fotomoduladas em hidrogel com incorporação de proteína morfogenética óssea 4 / Odonto/osteogenic differentiation of photomodulated mesenchymal stem cells in BMP4-loaded hydrogel

Este estudo avaliou a influência da fototerapia a laser (FTL) na proliferação e diferenciação de células-tronco da polpa dentária humana (DPSCs; do inglês, Dental Pulp Stem Cells ) encapsuladas em carreador injetável e termoresponsivo (PL; Pluronic® F-127, Sigma-Aldrich, MO, EUA) com incorporação de proteína morfogenética óssea 4 recombinante humana (rhBMP4) (sistema PL/rhBMP4). O biomaterial foi caracterizado de acordo com seus perfis de embebição e dissolução, liberação de rhBMP4 e sua estrutura morfológica. DPSCs foram isoladas, caracterizadas e encapsuladas em PL para confirmar sua viabilidade e seu potencial de diferenciação (adipo e osteogênico) em comparação com células-tronco mesenquimais de medula óssea (BMMSCs; do inglês, Bone Marrow Mesenchymal Stem Cells). Quando encapsuladas no sistema PL/rhBMP4, DPSCs foram irradiadas com duas densidades de energia diferentes utilizando laser de diodo de fosfeto de índio-gálio-alumínio (InGaAlP), modos contínuo, pontual e em contato [660 nm, 0,028 cm2, 20 mW, 0,71 W/cm2, 3 J/cm2 (4 s) ou 5 J/cm2 (7 s)]. Os ensaios de PKH26 (do inglês, Red Fluorescent Cell Linker), CFU-F (do inglês, Coloning Forming Units - Fibroblastic), e MTT (do inglês, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide)) foram utilizados para avaliar adesão/proliferação, diferenças na capacidade formadora de colônias e viabilidade das DPSCs (neste último caso sob estresse nutricional), respectivamente. Finalmente, a diferenciação odonto/osteogênica foi analisada por qRT-PCR e confirmada por ensaio de vermelho de alizarina. O biomaterial embebeu e dissolveu rapidamente; densa rede tubular e reticular com poros interconectados foi observada. DPSCs e BMMSCs apresentaram alta viabilidade celular quando encapsuladas em PL. Ambas as linhagens celulares tiveram êxito em se diferenciar em tecidos adiposo e ósseo. De acordo com o PKH26, DPSCs puderam aderir e proliferar no sistema PL/rhBMP4. DPSCs irradiadas encapsuladas tanto em PL como em PL/rhBMP4 formaram mais CFU-F que os controles não irradiados. Sob estresse nutricional, DPSCs semeadas no PL e irradiadas com 5 J/cm2 exibiram maior taxa de viabilidade celular em relação aos grupos não irradiados e irradiados com 3 J/cm2. Na presença de rhBMP4, os grupos irradiados tanto com 3 J/cm2 quanto com 5 J/cm2 apresentaram deposição mineral precoce quando comparados aos grupos não irradiados. Ainda, após 21 dias de diferenciação odonto/osteogênica, DPSCs irradiadas produziram maior quantidade de nódulos mineralizados. A irradiação com 5 J/cm2 levou ao aumento significativo da expressão de genes envolvidos na diferenciação odonto/osteogênica, como colágeno tipo I (COL1A1), osteocalcina (OCN), proteína da matriz dentinária 1 (DMP1), sialofosfoproteina dentinária (DSPP) e proteína heat shock 27 kDa (HSPB1). A associação entre rhBMP4 e FTL promove proliferação e diferenciação odonto/osteogênica de DPSCs acelerando e aumentando notavelmente a formação de tecido mineralizado, em especial quando a densidade de energia de 5 J/cm2 é aplicada.

This study evaluated the influence of laser phototherapy (LPT) on dental pulp stem cells (DPSCs) proliferation and differentiation upon encapsulation in an injectable and thermo-responsive cell carrier (PL; Pluronic® F-127, Sigma-Aldrich, MO, USA) loaded with human recombinant bone morphogenetic protein 4 (rhBMP4)(PL/rhBMP4 system). The biomaterial was characterized according to its swelling and dissolution profiles, release of rhBMP4 and morphological structure. DPSCs were isolated, characterized and encapsulated in PL to confirm their viability and multilineage differentiation potential (adipo and osteogenic) in comparison to bone marrow mesenchymal stem cells (BMMSCs). When encapsulated in the PL/rhBMP4 system, DPSCs were irradiated with two different energy densities using a continuous-wave indium-gallium-aluminum-phosphide (InGaAlP) diode laser [660 nm, 0.028 cm2, 20 mW, 0.71 W/cm2, 3 J/cm2 (4 s) or 5 J/cm2 (7 s)] in punctual and contact modes. The PKH26 (Red Fluorescent Cell Linker), the CFU-F (Coloning Forming Units - Fibroblastic), and the MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide] assays were used to assess differences in cell adhesion/proliferation, colony forming units formation ability, and cell viability of DPSCs (in this case under nutritional stress), respectively. Then, alizarin red and qRT-PCR analyzes were used to evaluate odonto/osteogenic differentiation. The biomaterial swelled and dissolved rapidly; dense tubular and reticular network morphology with well-interconnected pores was observed. DPSCs and BMMSCs presented high cell viability when encapsulated in PL. Both cell lineages successfully differentiated into bone or adipose tissues. According to PKH26, DPSCs were able to adhere and proliferate in the PL/rhBMP4 system. Irradiated DPSCs encapsulated in either PL or PL/rhBMP4 system formed more CFU-F than non-irradiated controls. Under nutritional stress, DPSCs encapsulated in the hydrogels with no rhBMP4 and irradiated at 5 J/cm2 exhibited higher cell viability than the other groups. In the presence of rhBMP4, the groups irradiated both at 3 and 5 J/cm2 energy densities displayed earlier mineral deposition than the non-irradiated groups. Moreover, after 21 days of odonto/osteogenic differentiation, irradiated DPSCs produced greater nodule formation than the control groups. At the energy density of 5 J/cm2, there were significant upregulation of genes involved in odonto/osteoblast differentiation, such as type I collagen (COL1A1), osteocalcin (OCN), dentin matrix protein 1 (DMP1), dentin sialophosphoprotein (DSPP) and heat shock protein 27 kDa (HSPB1). The association between rhBMP4 and LPT promotes cell proliferation and odonto/osteogenic differentiation of DPSCs accelerating and increasing the formation of mineralized tissue, in particular when the energy density of 5 J/cm2 is applied.

Comparación de la eficacia de la fototerapia convencional con tubos de luz azul vs. LEDs / Comparison of the efficacy of conventional phototherapy with blue light tubes vs LEDs

Introducción: La hiperbilirrubinemia (HB) es la principal causa de ingreso en unidades neonatales de bajo riesgo. Nuevos dispositivos de fototerapia (FT) permiten el uso de irradiación a dosis alta. Objetivo: Comparar la eficacia de la FT aplicada con equipos de tubos de luz azul (30 µW/cm2/nm) y FT con tecnología LED’s a dos niveles de irradiancia (30 y 40 µW/ cm2/nm) en términos de duración del tratamiento. Material y métodos: Estudio prospectivo, controlado y randomizado. Los recién nacidos de término o cercanos al término que necesitaban tratamiento con luminoterapia fueron aleatorizados a tres grupos: 1) luz azul a 30 µW/cm2/nm (LC), 2) LED a 30 µW/cm2/nm (L30), y 3) LED a 40 µW/cm2/nm (L40). Resultados: Se incluyeron 165 pacientes, 54 en LC, 56 en L30 y 55 en el grupo L40. El peso al nacer, edad gestacional, horas a la aleatorización y los valores BST al ingreso a FT (18,9 ± 2 mg/dl en BL, 18,9 ± 2,2 en L30 y 19 ± 1,6 en L40) fueron similares. El tiempo total (horas) de FT fue: 54,4 ± 6,9 en LC, 53,4 ± 10,7 en L30 y 41,7 ± 6 en L40 (p <0,001). Los niveles de BST en la interrupción de FT (10,1 ± 1,7 mg/dl, 9,9 ± 1 y 8,9 ± 1,8, p = 0,002) y 24 horas después (9,6 ± 1,3 mg/dl, 9,8 ± 1,4 y 9 ± 1,8, p = 0,04) fueron menor en el grupo L40. Conclusiones: El tratamiento con LEDs a 40 µW/cm2/nm reduce en 12 horas la duración del tratamiento en comparación con LEDs o luz azul a 30 µW/cm2/nm.

Introduction: Hyperbilirubinemia (HB) is the main cause of admission to low risk neonatal units. New phototherapy devices (PT) allow the use of high dose of irradiance. Objective: To compare the efficacy of PT in terms of hours of treatment between blue light tubes and LEDs equipments with two levels of irradiance. Material and methods: Prospective controlled trial. Term or near-term infants with need of PT treatment according to AAP recommendations were randomized into three groups: blue lights PT with 30 µW/cm2/nm (BL) or LEDs PT with 30 µW/cm2/nm (L30) or 40 µW/cm2/nm (L40) at skin level. Results: 165 patients were included, 54 in the BL group, 56 in L30 and 55 in L40 group. Birth weight, gestational age, postnatal hours at randomization and total serum bilirubin (TSB) level at entry (18.9 ± 2 mg/dl in BL, 18.9 ± 2.2 in L30 and 19 ± 1.6 in L40) were similar between groups. Total time of PT were 54.4 ± 6.9 hours in BL, 53.4 ± 10.7 in L30 and 41.7 ± 6 in L40 (p <0.001). TSB levels at PT discontinuation (10.1 ± 1.7 mg/dl, 9.9 ± 1 and 8.9 ± 1.8, p = 0.002) and 24 hours later (9.6 ± 1.3 mg/dl, 9.8 ± 1.4 and 9 ± 1.8, p = 0.04) were lower in L40 group.Conclusions: PT treatment with LEDs at µW/cm2/nm reduced the duration of treatment in 12 hours compared with BL or LEDs at 30 µW/cm2/nm.

Eficácia da fototerapia associada à sulfadiazina de prata no tratamento de úlceras venosas crônicas / Efficacy of the phototherapy associated with silver sulphadiazine in the treatment of chronic venous ulcers

Introdução: Várias são as propostas terapêuticas para úlceras de perna venosas crônicas (UVCs), como curativos, ultrassom, aparelhos fotobioestimuladores (laser/LED) e outros. Objetivo: Analisar a eficácia da fototerapia (LED 660/890 nm) com curativo diário de sulfadiazina de prata 1 por cento creme (SDZ) para úlceras venosas crônicas. Métodos: Estudo randomizado, duplo-cego, com aparelho fototerápico com 2 sondas: 1 (LED 660 nm/5mW) e 2 (1 LED 660 nm e 32 LED 890 nm/500 mW). Selecionaram-se 20 pacientes (n = 32 úlceras) do Ambulatório de Úlceras CSE–FMRP–USP, constituindo-se grupos: G1-sonda 1+SDZ; G2-sonda 2+SDZ e G3-SDZ, seguidos por 90 dias. Aplicaram-se sobre as úlceras, as sondas pontualmente (3,0 J/cm2, 30 seg/5cm2, 2x/semana) e posterior curativo SDZ. Quinzenalmente, foram fotografadas e avaliadas pelo software Image Jâ, mensurando-se as áreas [total, de esfacelo (E); e de tecido de granulação (G)], calculando-se índices de cicatrização das úlceras [ICU = (Ai-Af)/Ai)] e relação E/G. Resultados: G2 apresentou redução significante no 30º e 90º dia (p 0,4, G2 alcançou este índice em 75 por cento das úlceras no 30º e 90º dias, enquanto 33 por cento do G1, somente no 60º. Conclusão: A fototerapia (LED’s) associada à SDZ acelerou processo de cicatrização das UVCs (G1/G2), comparada ao creme isoladamente (G3), pelos ICUs e pela relação E/G.

Introduction: Many therapeutic forms were used to treat chronic venous ulcers such as dressing, ultrasound, photobiostimulator (laser/LED) and other. Objective: To analyze effectiveness of photo­therapy (LED 660/890 nm) with 1 percent silver sulfadiazine cream (SDZ) in chronic venous ulcers. Method: Randomized and double-blind study using the phototherapy device with 2 probes: 1 (LED 660 nm/5mW) and 2 (1 LED 660 nm and 32 LED 890 nm, 500 mW). Twenty patients were selected (n = 32 ulcers) from Ulcer Outpatient Clinic of the School Health Center –FMRP–USP, divided into groups: G1-probe1+SDZ, G2-probe2+SDZ and G3-SDZ, during 90 days. The probes were applied on ulcers, punctually (3 J/cm2, 30 sec/5cm2, twice/week) and posterior daily SDZ’s dressing. Fortnightly, the ulcers were photographed and evaluated by Image J® software, measuring the areas [total, sphacellus (S) and granulation tissue(G)], calculating wound healing rate [WHR = (iA-fA)/iA)] and S/G relation. Results: G2 presented significant reduction in the 30th and 90th days (p 0.4, G2 achieved this rate in 75 percent of the ulcers in the 30th and 90th days, while 33 percent of the G1 only in the 60th days. Conclusion: The phototherapy (LED) associated with SDZ accelerated wound healing of the venous ulcers (G1/G2) compared the cream (G3) by WHRs and S/G relation.

Irradiance of phototherapy equipment in maternity wards in Maceió / La irradiación de los aparatos de fototerapia en las maternidades de Maceió / Irradiância dos aparelhos de fototerapia nas maternidades de Maceió

The effectiveness of neonatal hyperbilirubinaemia treatment depends directly on the amount of energy emitted by light (irradiance). This cross-sectional study aimed to determine the irradiance of phototherapy equipment in maternity wards in Maceió, AL, Brazil. All equipment in use in the neonatal units in Maceió was included in the study, totaling 36 devices, except those in maintenance. The measurement of irradiance was carried out with a radiometer. We observed that 72.20 percent of the equipment presented efficient irradiance and 27.76 percent were inefficient. The conclusion is that the majority of phototherapy devices are emitting the minimum required irradiance for neonatal jaundice treatment.

La eficacia del tratamiento de la hiperbilirrubinemia neonatal depende directamente de la cantidad de energía emitida por la luz (irradiación). Este es un estudio transversal que objetivó determinar la irradiación de los aparatos de fototerapia en las maternidades de Maceió. Es un muestreo por censo, ya que incluyó todos los aparatos en uso en las unidades neonatales de Maceió, en el total de treinta y seis aparatos (36), excluyéndose aquellos que estaban en manutención. La medición de la irradiación fue realizada con un radiómetro. Se observó que 72,20 por ciento de los aparatos presentaron irradiación eficaz y 27,76 por ciento de los aparatos fueron ineficaces. Se concluye que la mayoría de los aparatos de fototerapia está emitiendo la irradiación mínima terapéutica para el tratamiento de la ictericia neonatal.

A eficácia do tratamento da hiperbilirrubinemia neonatal está na dependência direta da quantidade de energia emitida pela luz (irradiância). Este é um estudo transversal que objetivou determinar a irradiância dos aparelhos de fototerapia nas maternidades de Maceió. A amostragem foi censitária, pois incluiu todos os aparelhos em uso nas unidades neonatais de Maceió, no total de trinta e seis aparelhos (36), excluindo-se aqueles que estavam em manutenção. A medição da irradiância foi realizada com um radiômetro. Observou-se que 72,20 por cento dos aparelhos apresentaram eficácia quanto à sua irradiância e 27,76 por cento dos aparelhos foram ineficazes. Concluiu-se que a maioria dos aparelhos de fototerapia está emitindo a irradiância mínima terapêutica para o tratamento da icterícia neonatal.

Efectividad del Puva oral versus Uvb de banda estrecha en la Psoriasis: metanálisis / Effectiveness of oral PUVA versus narrow band UVB in: metanalysis

La psoriasis es una enfermedad inflamatoria crónica que afecta tanto a hombres como a mujeres, y puede presentarse a cualquier edad, con una prevalencia de 1 - 3% de la población mundial. Existen múltiples modalidades terapéuticas, divididas en medicamentos tópicos y sistémicos dentro de los cuales se encuentra la fototerapia. Objetivo: establecer la efectividad de los psoralenos orales más la luz ultravioleta A versus la luz ultravioleta B de banda estrecha, en el tratamiento de la psoriasis moderada a severa. Para ello se realizó un metanálisis con base en la revisión sistemática de la literatura que incluyera ensayos clínicos aleatorizados que compararan la efectividad del tratamiento con PUVA versus el tratamiento con NB-UVB. Todos los estudios fueron evaluados por tres investigadores, tanto en la calidad metodológica como en los criterios de inclusión y exclusión, y sólo se incluyeron aquellos ensayos clínicos con calificación mayor o igual a 1++ según la escala de Jadad. Resultados: La búsqueda arrojó 110 artículos, los cuales en su mayoría fueron descartados debido a que no cumplían los criterios de inclusión propuestos, quedando solo tres estudios en el análisis final: Yones et al, Markham et al y Gordon et al, y en los cuales se encontraron diferencias estadísticamente significativas a los tres y seis meses de seguimiento a favor de PUVA, pero con poco peso estadístico. Conclusiones: La terapia con PUVA mas psoraleno oral tiene tendencia a mostrar mayor efectividad que la terapia NB-UVB, pero el reducido número de estudios impide establecer una conclusión de forma definitiva.

Psoriasis is a chronic inflammatory condition with a worldwide prevalence of 1-3% that affects both men and women and may presents at any age. Multiple therapeutic modalities exist: topical and systemic medications within which phototherapy is found. Objective: to establish the efectiveness of oral psoralens plus ultraviolet A light versus narrow band ultraviolet B light in the treatment of moderate to severe psoriasis. Methods: A meta-analysis based on the systematic review of literature was performed. All clinical studies included were randomized clinical trials that compared the effectiveness of PUVA vs NB-UVB treatment. All studies were evaluated by three researchers, both according to the methodological quality and to the inclusion and exclusion criteria. Only those clinical trials with a score equal to or greater than 1++ according to the Jadad scale were included. Results: The search found 110 articles, of which the majority were discarded due that they did not meet the inclusion criteria proposed, leaving only three trials for the final analysis: Yones et al, Markham et al y Gordon et al. These trials compared the effectiveness of oral psoralen PUVA versus NB-UVB. Statistically significant differences were found at three and six months follow up in favor of PUVA treatment, but having a low evidence weight. Conclusions: PUVA with oral psoralen tends to show a higher efectiveness than NBUVB therapy, but the reduced number of studies does not allow for a definitive conclution.

Effect of sling application on efficacy of phototherapy in healthy term neonates with nonhemolytic jaundice: a randomized conrolled trial.

OBJECTIVE: To evaluate the efficacy of white reflecting material (slings) hung from the sides of compact fluorescent lamp (CFL) phototherapy equipment in reducing the duration of phototherapy in healthy term neonates with non-hemolytic jaundice. DESIGN: Randomized controlled trial. SETTING: Postnatal ward of a tertiary level neonatal unit. PARTICIPANTS AND INTERVENTION: Healthy term neonates with non-hemolytic jaundice between 24 hours and 10 days of age were randomly assigned to receive single surface phototherapy with (n=42) or without slings (n=42). OUTCOME MEASURE: Duration of phototherapy in hours (h) and the requirement of exchange transfusion. RESULTS: Birthweight (2790+/-352 vs. 2923+/-330 g), gestation (38+/-1.3 vs. 37+/-1.0 wk) and initial serum total bilirubin (STB) (16.6+/-2.4 vs. 16.1+/-2.2 mg/dL) were comparable between the two groups. There was no significant difference in the duration of phototherapy (mean+/-SD) between the Sling (23.3+/-12.9 h) and No sling (24.9+/-15.4 h) groups (P=0.6). The irradiance of photo-therapy equipment (microwatt/cm2, mean+/-SD) was higher in Sling group compared to No sling group (195.8+/-24.2 versus 179.7+/-27.7, P=0.01). There was a trend towards a higher rate of fall of serum total bilirubin (mg/dL, mean +/-SD) in the Sling group (0.23+/-0.49) compared to No sling group (0.03+/-0.47) (P=0.06). CONCLUSION: Though hanging of white reflective sling on sides of CFL phototherapy equipment resulted in marginal increase in irradiance, it did not decrease the duration of phototherapy.

Effectiveness of double-surface intensive phototherapy versus single-surface intensive phototherapy for neonatal hyperbilirubinemia.

OBJECTIVE: To compare the efficacy and adverse effects of double-surface intensive phototherapy (DsIPT) and single-surface intensive phototherapy (SsIPT) in term newborn infants with hyperbilirubinemia. DESIGN: Prospective randomized controlled trial. MATERIAL AND METHOD: Healthy full-term infants with nonhemolytic hyperbilirubinemia (total serum bilirubin between 13.0 to 19.9 mg/dl) were allocated randomly to two modes of phototherapy. Group 1 infants received single-surface intensive phototherapy. Group 2 infants received double-surface intensive phototherapy Serum bilirubin, body weight, body temperature and number of defecation were measured at 24 and 48 hours after phototherapy. RESULTS: Sixty infants were studied, 30 in each group. Baseline characteristics were similar in both groups. The initial mean serum bilirubin had no statistically significant difference between SsIPT and the DsIPT groups. After 24 and 48 hours of phototherapy, mean serum bilirubin in the group receiving SsIPT declined 3.5 +/- 1.7 and 6.5 +/- 2.3 mg/dl, while in the DsIPT group, the mean serum bilirubin declined 5.4 +/- 2.0 and 8.4 +/- 2.1 mg/dl respectively. The mean body temperature after 24 hours of phototherapy in the DsIPT group was higher than SsIPT group significantly. The number of defecation in the SsIPT group increased significantly after 24 and 48 hours of phototherapy, but the body weight change in both groups was not statistically significant. CONCLUSION: DsIPT was significantly more effective in reducing serum bilirubin than SsIPT in the term jaundiced infants after 24 and 48 hours of treatment. The adverse effect of DsIPT found in the present study was the increased of body temperature after 24 hours of phototherapy.

Standard guidelines of care: laser and IPL hair reduction.

Laser-assisted hair removal, Laser hair removal, Laser and light-assisted hair removal, Laser and light-assisted, long-term hair reduction, IPL photodepilation, LHE photodepilation; all these are acceptable synonyms. Laser (Ruby, Nd Yag, Alexandrite, Diode), intense pulse light, light and heat energy system are the different light-/Laser-based systems used for hair removal; each have its advantages and disadvantages. The word "LONG-TERM HAIR REDUCTION" should be used rather than permanent hair removal. Patient counseling is essential about the need for multiple sessions. PHYSICIANS' QUALIFICATIONS: Laser hair removal may be practiced by any dermatologist, who has received adequate background training during postgraduation or later at a centre that provides education and training in Lasers or in focused workshops providing such training. The dermatologist should have adequate knowledge of the machines, the parameters and aftercare. The physician may allow the actual procedure to be performed under his/her direct supervision by a trained nurse assistant/junior doctor. However, the final responsibility for the procedure would lie with the physician. FACILITY: The procedure may be performed in the physician's minor procedure room. Investigations to rule out any underlying cause for hair growth are important; concurrent drug therapy may be needed. Laser parameters vary with area, type of hair, and the machine used. Full knowledge about the machine and cooling system is important. Future maintenance treatments may be needed.

Effect of voltage stabilizer on the light intensity output of curing units

The success rate of light composite restorative treatments is in close relation to the light intensity of the light curing units. The purpose of this study was to evaluate the rate of light intensity of visible light curing units, before and after voltage stabilizer application. This study was performed on 82 light curing units in all clinics and dental offices of Yazd city. For evaluating light exit intensity, Hilux radiometer was used. At first, the light intensity was measured, and then by use of 220 V electrical voltage stabilizer the light exit intensity was recorded. Results were analyzed using Pearson and Spearman tests. Mean range of light intensity before and after voltage stabilizer was 241.3 and 272.6 mW/cm2 respectively. There were statistically significant differences between before and after use of voltage stabilizer [p < 0.05]. Considering the light intensity, 64.7% of the light curing units were suitable for optimum curing and 8.6% were in group that required increase light exposure time. 21.9% did not completely cure the composites, and 4.8% were in group with higher light intensity 2 [over 500 mW/Cm2]. Light intensity output of the curing units in dental clinics of Yazd city were less than expected, but by using voltage stabilizer, the light intensity was significantly increased

Avaliação da eficácia clínica de uma nova modalidade de fototerapia utilizando diodos emissores de luz / Efficacy of new microprocessed phototherapy system with five high intensity light emitting diodes (Super LED)

OBJETIVO: Avaliar a eficácia terapêutica de um sistema de fototerapia microprocessada que utiliza diodos emissores de luz (Super LED) de alta intensidade no tratamento da hiperbilirrubinemia em recém-nascidos prematuros. MÉTODOS: Ensaio clínico, randomizado e controlado, utilizando a fototerapia Super LED no grupo experimental e duas fototerapias halógenas no grupo controle. A randomização foi realizada em blocos e estratificada por peso de nascimento. A duração da fototerapia e a queda nos níveis séricos de bilirrubina total nas primeiras 24 horas de tratamento foram os principais desfechos analisados. RESULTADOS: Foram estudados 88 recém-nascidos, 44 no grupo da fototerapia Super LED e 44 no grupo da fototerapia halógena. As características demográficas da população foram semelhantes nos dois grupos. O nível sérico médio inicial de bilirrubina no grupo do Super LED (10,1±2,4 mg por cento) foi semelhante ao do grupo que recebeu fototerapia halógena (10,9±2,0 mg por cento). A queda percentual na concentração sérica de bilirrubina total nas primeiras 24 horas de tratamento foi significativamente maior (27,9 versus 10,7 por cento, p < 0,01), e a duração do tratamento foi significativamente menor (36,8 versus 63,8 h, p < 0,01) no grupo do Super LED do que no grupo que recebeu fototerapia halógena. Após 24 horas de tratamento, um número significativamente maior de recém-nascidos recebendo fototerapia Super LED atingiu níveis de bilirrubina que permitiram a suspensão da fototerapia (23 versus 10, p < 0,01). CONCLUSÕES: Os resultados demonstram que a eficácia da fototerapia Super LED é significativamente maior do que a da fototerapia halógena no tratamento da hiperbilirrubinemia de recém-nascidos prematuros.

OBJECTIVES: To evaluate the efficacy of a microprocessed phototherapy (PT) system with five high intensity light emitting diodes (Super LED) for the treatment of neonatal hyperbilirubinemia of premature infants. METHODS: Randomized clinical trial using Super LED phototherapy in the study group and twin halogen spotlight phototherapy in the control group. A stratified blocked randomization, based on birth weight, was performed. The duration of phototherapy and the rate of decrease of total serum bilirubin (TSB) concentration in the first 24 hours of treatment were the main outcome measures. RESULTS: We studied 88 infants, 44 in the Super LED group and 44 in the halogen spotlight PT group. The demographic characteristics of the patients in both groups were similar. Infants in the Super LED group had a similar mean initial serum bilirubin level (10.1±2.4 mg percent) to those receiving halogen spotlight treatment (10.9±2.0 mg percent). After 24 hours of treatment, the decrease in total serum bilirubin levels was significantly greater in the Super LED group (27.9 vs. 10.7 percent, p< 0.01) and duration of phototherapy was significantly shorter in this group (36.8 h vs. 63.8 h, p < 0.01). After 24 hours of treatment, a significantly greater number of patients receiving Super LED phototherapy had reached serum bilirubin concentrations low enough to allow withdrawal of treatment (23 vs. 10, p < 0.01). CONCLUSIONS: Our results demonstrate that the efficacy of Super LED phototherapy for treating hyperbilirubinemia in premature infants was significantly better than halogen phototherapy.

Ultraviolet protective properties of branded and unbranded sunglasses available in the Indian market in UV phototherapy chambers.

BACKGROUND: Patients receiving phototherapy for various dermatoses are at increased risk of eye damage due to ultraviolet (UV) rays. They are prescribed UV protective sunglasses by dermatologists but their exact protecting effects are not known. AIM: To study the ultraviolet protective properties of branded and unbranded UV protective sunglasses available in the Indian market, in UV phototherapy chambers. METHODS: Sixteen different branded and unbranded UV protective sunglasses were collected from two opticians in Mumbai. Baseline irradiance of the UV chamber was calculated by exposing the photosensitive probe of UV photometer in the chamber. Then, the photosensitive probe of the UV photometer was covered with the UV protective glass to be studied and irradiance was noted. Such readings were taken for each of the UV protective sunglasses. The percentage reduction in the UV rays' penetration of different UV protective sunglasses was calculated. RESULTS: Thirteen sunglasses provided > 80% reduction in UVA rays penetration, of which four were branded (out of the four branded studied) and nine were unbranded (out of the 12 unbranded studied). More than 70% reduction in UVB penetration was provided by 12 sunglasses, which included 10 unbranded and two branded sunglasses. CONCLUSION: All branded sunglasses provided good protection against UVA penetration, but UVB protection provided by both branded and unbranded sunglasses was not satisfactory. A few unbranded sunglasses had poor efficacy for UVA and UVB spectra; one branded glass had poor efficacy for protection against the UVB spectrum. The efficacy of sunglasses used for phototherapy should be assessed before use.

Randomized controlled trial of compact fluorescent lamp versus standard phototherapy for the treatment of neonatal hyperbilirubinemia.

BACKGROUND: Special blue tube lights of standard length are used in most neonatal units to deliver phototherapy. Of late, special blue compact fluorescent lamp phototherapy equipments have been introduced in India, which are claimed to be better than standard tube lights. AIM: To compare special blue compact fluorescent lamp (CFL) phototherapy with special blue standard-length tube lights (STL). METHODS: This randomized, controlled trial was conducted in a level III NICU. Neonates, otherwise healthy, of gestation greater than 34 weeks with hyperbilirubinemia requiring phototherapy, were included. Rh iso-immunized babies, those who underwent prior exchange transfusion and whose parents declined to consent were excluded. By stratified block randomization, babies were allocated to receive phototherapy by CFL or STL. CFL and STL were both special blue lights with irradiance maintained above 15 microWatts/nm/cm2. Total serum bilirubin (TSB) was measured 12 hourly till phototherapy was stopped or an exchange transfusion was done. Temperature and clinical and laboratory parameters of dehydration were recorded 12 hourly till 72 hrs. Nursing staff answered an objectivized proforma about the disadvantageous effects on nurses. RESULTS: Fifty babies were enrolled in each group. Baseline characteristics, causes of jaundice, hemolysis, baseline TSB and irradiance were similar in both groups. Mean duration of phototherapy (P = 0.98) was similar in both groups. Kaplan-Meier analysis of phototherapy duration showed no difference in the survival curves of the 2 groups (P = 0.6). Axillary temperature was similar in both groups and no baby was dehydrated. Nursing staff reported no significant differences between CFL and STL visavis glare hurting the eyes, giddiness and headache. CONCLUSIONS: CFL phototherapy has no superiority over STL phototherapy in terms of efficacy and adverse effects on the neonate and effects on nursing staff.

Thai healthy newborns have a higher risk.

Kernicterus is a preventable but devastating neurologic disorder with life long complications. It is caused by severe and inadequately treated hyperbilirubinemia during the newborn period. In the present paper potential causes and risk factors for the occurrence of kernicterus related to the Thai health system that are responsible for the care of newborn infants before and after discharge are discussed. Potential risk reduction strategies for the Thai health system are purposed Some efforts to improve the quality of Thai newborn care particularly newborns with jaundice that have been made are mentioned. An adherence to the American Academy of Pediatrics clinical guideline for management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation for those strategies that are feasible to follow will help reduce the prevalence of severe hyperbilirubinemia and bilirubin encephalopathy.

Progress in phototherapy

The purpose of this article is to present a recent advance in phototherapy employed on newborn babies with jaudice. The efficacy of this treatment depends on the intensity of emitted light; it is believed that a dose between 6-12 nm is necessary. The usefulness of phototherapy in healthy, full-term infants is currently being questioned. Therefore, the adequate use of this therapy should be emphasized until a consensus is reached on its advantages and disadvantages.

Bilirrubinometria transcutânea: importante método na triagem do recém-nascido com hiperbilirrubinemia / Transcuneous bilirubinometry: important method in evaluation of newborn with hyperbilirubinemia

Um total de 210 medidas foram efetuadas com o bilirrubinômetro transcutâneo (BTc) na regiäo frontal de 210 recém-nascidos sadios, brancos, a termo, e que näo foram submetidos à fototerapia ou exsanguinotransfusäo. As BTc apresentaram boa correlaçäo com a bilirrúbina sérica (BS) (r = 0894; p < 0,001). A sensibilidade do teste foi de 92% e a especificidade de 90%, identificando todas as crianças com BS > 13mg/dl, com determinaçöes falso-negativas de 0,95% e falso-positivas de 8,58%. O valor preditivo negativo de 98% prediz corretamente a ausência de hiperbilirrubinemia em todos os casos. A BTc pode ser recomendada para identificar icterícia neonatal significante em RNs