Spinal Cord Stimulation in Refractory Postherpetic Neuralgia in Portugal: A Case Report.

Postherpetic neuralgia is one of the most severe complications after herpes zoster infection. Patients who experience persistent pain despite conservative treatment may benefit from interventional therapies, such as spinal cord stimulation. We present the case of a patient with severe refractory postherpetic neuralgia in the right T8 to L1 distribution who responded effectively to spinal cord stimulation. After its implantation, the patient had improvements in pain intensity, pain-related interference, quality of life, and satisfaction, with a simultaneous reduction of previous medications. This case report highlights the role of spinal cord stimulation in refractory neuropathic pain secondary to herpes zoster.

Thalamic volumetric abnormalities in type 1 diabetes mellitus and 'peripheral' neuropathy.

We hypothesized that thalamic volumes of patients with type 1 diabetes mellitus (DM) and nonpainful diabetic peripheral neuropathy (DPN) would be reduced relative to thalamic volumes of patients with type 1 DM and painful DPN. We calculated the standardized thalamic volumetric difference between these groups in a pilot sample to obtain a statistical power of 80% at a 5% significance level. Hence, we measured thalamic volumes from 15 patients with nonpainful DPN (10 women, mean age = 49 years, standard deviation [SD] = 11.5) and from 13 patients with painful DPN (8 women, mean age = 43 years, SD = 12.5) by using a manual segmentation approach. A volumetric difference of approximately 15% was found between the nonpainful (mean = 5072 mm3, SD = 528.1) and painful (mean = 5976 mm3, SD = 643.1) DPN groups (P < 0.001). Curiously, a volumetric difference between the left (mean = 5198 mm3, SD = 495.0) and the right (mean = 4946 mm3, SD = 590.6) thalamus was also found in patients with nonpainful DPN (P < 0.01), but not in patients with painful DPN (P = 0.97). Patients with nonpainful DPN have lower thalamic volumes than those with painful DPN, especially in the right thalamus.

Association between Serum Vitamin D and Diabetic Retinopathy in Portuguese Patients with Type 1 Diabetes.

INTRODUCTION: Recently, vitamin D has gained importance as a diabetes risk modifier. Our aim was to assess the association between serum vitamin D levels and the prevalence of diabetic retinopathy in patients with type 1 diabetes. MATERIAL AND METHODS: Retrospective review of a population of patients with type 1 diabetes followed in a Portuguese tertiary center. Patients were included if they had an ophthalmological evaluation and a serum 25-hydroxyvitamin D level determination within the same year. Logistic regression analysis was used to adjust for possible confounders. RESULTS: We included 182 patients (47% male), and 57% (n = 103) had signs of diabetic retinopathy. We found a significant association between lower circulating levels of 25-hydroxyvitamin D levels and a greater prevalence of diabetic retinopathy after adjusting for confounders (duration of diabetes, estimated glomerular filtration rate, age, sex, metabolic control, season, dyslipidemia and hypertension) (OR = 0.94; 95% CI 0.90 - 0.99, p = 0.023). Longer duration of diabetes and worse metabolic control also remained associated with diabetic retinopathy in the multivariate analysis (OR = 1.20; 95% CI 1.13 - 1.27, p < 0.001 and OR = 4.13; 95% CI 1.34 - 12.7, p = 0.013, respectively). CONCLUSION: Lower levels of vitamin D were associated with an increased prevalence of diabetic retinopathy in patients with type 1 diabetes, after adjusting for possible confounders. Future controlled studies may elucidate the molecular routes for this association as well as the role of supplementation in the prevention of diabetes microvascular complications.

Introdução: A vitamina D tem vindo a ganhar importância como um modificador do risco de diabetes. O objetivo deste estudo foi avaliar a associação entre os níveis séricos de vitamina D e a prevalência de retinopatia diabética em pacientes com diabetes tipo 1. Material e Métodos: Estudo retrospetivo de uma população de doentes com diabetes tipo 1, seguidos num centro hospitalar terciário português. Os pacientes foram incluídos se tivessem uma avaliação oftalmológica e um doseamento dos níveis de 25-hidroxivitamina D no mesmo ano. Os ajustes para eventuais variáveis confundidoras foi realizado recorrendo a uma análise de regressão logística. Resultados: Foram incluídos 182 doentes (47% sexo masculino), dos quais 57% (n = 103) demonstravam sinais de retinopatia diabética. Foi encontrada uma associação significativa entre níveis inferiores de 25-hidroxivitamina D circulante sérica e uma maior prevalência de retinopatia diabética, depois do ajuste para os confundidores incluídos (duração da diabetes, taxa de filtração glomerular estimada, idade, sexo, controlo metabólico, estação do ano, dislipidemia e hipertensão) (OR = 0,94; 95% IC 0,90 - 0,99, p = 0,023). Uma maior duração da diabetes, assim como um pior controlo metabólico, mantiveram também uma associação significativa com uma maior prevalência de retinopatia diabética na análise multivariada (OR = 1,20; 95% IC 1,13 - 1,27, p < 0,001; OR = 4,13; 95% IC 1,34 - 12,7, p = 0,013, respetivamente). Conclusão: Níveis inferiores de vitamina D séricos demonstraram-se associados a uma prevalência superior de retinopatia diabética em pacientes com diabetes tipo 1, após o ajuste para eventuais variáveis confundidoras. Futuramente, estudos experimentais poderão estabelecer as vias moleculares implicadas nesta associação, assim como um papel concreto da suplementação na prevenção das complicações microvasculares da diabetes.

Changing trends in the prevalence of diabetic retinopathy in type 1 diabetes mellitus from 1990 to 2018: A retrospective study in a Portuguese population.

PURPOSE: To estimate the prevalence of diabetic retinopathy /(DR) in a Portuguese population with type 1 diabetes (T1DM). METHODS: Retrospective review of all patients with T1DM, whose reference center was Centro Hospitalar de São João, a tertiary center in Portugal, who were diagnosed between 1990 and 2018. DR was classified based on fundus examination in medical records as (0) no evidence of retinopathy, (1) mild non-proliferative retinopathy (NPDR); (2) moderate to severe non-proliferative retinopathy (NPDR) and (3) proliferative retinopathy (PDR). Patients were classified according to the eye with a worse retinopathy stage. Follow-up was considered as time between the diagnosis of diabetes and the last funduscopic evaluation. RESULTS: 233 patients met the inclusion and exclusion criteria. The prevalence of any DR at less than 5, 10, 15, 20 and more than 20-years of DM was 1.8%, 10.4%, 34.8%, 54.1% and 71.2% respectively. The overall prevalence of DR was 43.3% (n = 101). At the last observation, 43 patients (18.5%) had mild NPDR, 34 patients (14.6%) had moderate to severe NPDR and 24 patients (10.3%) had PDR. The longer the disease duration, the higher the number of patients with DR. CONCLUSION: The prevalence of DR in our cohort was 34.8% after 15 years of systemic disease and 54.1% after 20 years, which is lower than what has been reported in the literature. Further multicentric prospective studies, are needed to clarify changes in the epidemiology of DR in type 1 diabetics.

Risk factors for prevalent diabetic retinopathy and proliferative diabetic retinopathy in type 1 diabetes.

PURPOSE: Age at diagnosis of type 1 diabetes (DM1) has been implied as an important factor associated with the development of the microvascular complications. Our aim was to identify factors associated with prevalent diabetic retinopathy (DR) and proliferative diabetic retinopathy (PDR) in DM1 people with early and late-onset. METHODS: We reviewed medical records from all DM1 people from the reference area of a tertiary center (about 340,000 persons). Univariate and multivariate logistic regression were used to assess the relationship between potential risk factors (sociodemographic, diabetes-related, co-morbidities, and laboratory parameters) and prevalent DR/PDR. We performed an analysis comparing patients diagnosed before (early-onset) and after (late-onset) 18 years of age. RESULTS: We included 140 patients in early-onset DM1 group and 169 in late-onset DM1 group. Longer duration of diabetes and HbA1c remained associated with prevalent DR in both groups after adjusting for potential risk factors. Nephropathy was associated with prevalent DR in the late-onset group but not in the early-onset group. Peripheral neuropathy remained associated with prevalent PDR when modeled together in the multivariate model. High BMI demonstrated a significative association with PDR in early but not in the late-onset DM1 group. CONCLUSIONS: Although previous reports suggest that age at DM1 diagnosis may have a role in DR prevalence, the risk factors for DR in early and late-onset DM1 were similar for both groups. Duration of disease and lifelong metabolic control were the major predictors for DR in both groups. Nephropathy was associated with DR in patients with late-onset disease. Neuropathy was associated with PDR occurrence in both groups. BMI was associated with PDR early-onset DM1 group.

Prevalence and Determinants of Painful and Painless Neuropathy in Type 1 Diabetes Mellitus.

Aims: To evaluate (1) the prevalence of diabetic distal symmetrical sensory-motor polyneuropathy (DSPN) and painful DSPN among patients with type 1 diabetes mellitus (DM1) aged over 18 years and (2) the determinant factors of neuropathy and pain in those patients. Materials and Methods: An epidemiological, cross-sectional, observational study was performed; 330,386 people were included, and a total of 444 people were diagnosed with DM1. After exclusion of possible confounders, 360 patients were assessed for painless and painful DSPNs using neurological examination and questionnaires for neuropathy and pain. Odds ratio (OR) and confidence intervals (95% CI) were estimated using multinomial logistic regression models. The analysis was based on a framework with four conceptual levels that consider feasible pathways between several risk factors: (1) socio-demographic factors and diabetes duration, (2) patient habits, (3) co-morbidities, and (4) metabolic factors and disease complications. Results: The prevalence of DSPN and painful DSPN were 42.8 and 18.9%, respectively. Diabetes duration was positively associated with painful (OR = 1.107, 95% CI: 1.107-1.139) and painless DSPN (OR = 1.069, 95% CI: 1.043-1.096). Education level was negatively associated with painful DSPN (OR = 0.889, 95% CI: 0.826-0.957). Sex (female) was positively associated only with painless DSPN (OR = 1.769, 95% CI: 1.007-3.107). Being a current or former smoker was positively associated only with painless DSPN (OR = 1.940, 95% CI: 1.069-3.518). Hypertension was positively associated with painful DSPN (OR = 2.474, 95% CI: 1.110-5.512) and painless DSPN (OR = 2.565, 95% CI: 1.252-5.256). Glycated hemoglobin (HbA1c) was positively associated only with painless DSPN (OR = 1.193, 95% CI: 1.018-1.399). Conclusions: Diabetes duration and hypertension have a direct impact on the development of painful and painless DSPN. However, female sex and HbA1c have a direct effect only on the development of painless DSPN, and education level has an indirect effect on the development of painful DSPN. Therefore, it can be concluded that different etiological factors have different contributions to the development of neuropathy and pain.

Determinants of non-nociceptive pain in Rheumatoid Arthritis.

INTRODUCTION: Features suggestive of neuropathic pain (NP) have been described in RA in addition to nociceptive pain. We aimed to determine the clinical predictors of NP in RA patients and study its association with radiographic structural damage. METHODS: Cross-sectional study was performed with RA patients followed at our Rheumatology department. Patients with diagnosed neuropathy of other origin, non-RA related risk factors for NP (e.g. diabetes mellitus) or fibromyalgia according to expert opinion were excluded. Demographic and clinical data were collected and disease activity/functional measures were evaluated. Two questionnaires were applied to assess NP: the Leeds Assessment of Neuropathic Symptoms (LANSS) and the painDETECT questionnaire (PDQ). Radiographs performed in up to 12 months before/after the evaluation were classified according to the modified van der Heijde Sharp´s method. Univariate and multivariate logistic regression were performed to identify the predictors of NP. RESULTS: 112 patients were included. 86 (77%) were women, with a mean (SD) age of 55.1 (10.8) years and median disease duration of 13 [2-41] years. 45 (40%) patients had NP by the LANSS (≥12) and 28% had a possible/likely NP in the PDQ (≥13). Female sex was predictive of NP by both tests and disease duration was inversely associated with LANSS NP. After adjusting for those two variables, pain VAS and TJC were positive predictors of NP by both tests. The same was not true for SJC, ESR or CRP levels. DAS28-CRP was significantly associated with PDQ NP, losing its statistical significance after adjustment for TJC and pain VAS. The HAQ score increased the odds of NP for both tests, independently of DAS 28-CRP. Positivity for ACPA and previous/current hydroxychloroquine treatment had lower odds of NP. 90 patients performed radiographic evaluation. Joint narrowing score was a significant negative predictor of LANSS NP. After adjusting for global radiographic score, current methotrexate treatment had lower odds of LANSS NP and previous/current leflunomide was a positive predictor of NP by both tests. CONCLUSION: NP was associated with disease activity/functional scores but not with objective inflammatory measures. Greater structural damage, increased disease duration and ACPA positivity did not seem to increase the odds of NP. Possible association of NP and underlying csDMARD treatment was uncovered.

Topical action of Buriti oil (Mauritia flexuosa L.) in myositis induced in rats.

PURPOSE: To analyze the topical effects of Buriti oil (Mauritia flexuosa L.) in induced myositis in rats. METHODS: Thirty six male rats divided into three groups: Control group (C), induced myositis group (MI) and induced myositis group reated with Mauritia flexuosa L. (MT). After inducing myositis with 1% acetic acid, was topically applied 0.5 ml of Mauritia flexuosa L.extract on the posterior region of the right gastrocnemius muscle in animals belonging to group MT, for 7 and 14 days. RESULTS: The neutrophil number there was statistically significant difference, after 7 and 14 days, between groups C and MI (p <0.001) (p<0.01). The group MT there was a significant difference in relation to MI group in both experimental times with (p<0.001). The number of fibroblasts in the 14 days showed that when comparing the groups M and MT the differences were also significant (p<0.001). As for the DLL, in 7 days, there was a significant difference between group C and MI group (p <0.001). When considering the MT group, there was a significant difference in relation to the MI group (p <0.001). CONCLUSION: The extract of Mauritia flexuosa L. leaves lessened acute and chronic inflammation, increased fibroblast proliferation and reduced macroscopically edema.

Topical action of Buriti oil (Mauritia flexuosa L) in myositis induced in rats

Abstract Purpose: To analyze the topical effects of Buriti oil (Mauritia flexuosa L.) in induced myositis in rats. Methods: Thirty six male rats divided into three groups: Control group (C), induced myositis group (MI) and induced myositis group reated with Mauritia flexuosa L. (MT). After inducing myositis with 1% acetic acid, was topically applied 0.5 ml of Mauritia flexuosa L.extract on the posterior region of the right gastrocnemius muscle in animals belonging to group MT, for 7 and 14 days. Results: The neutrophil number there was statistically significant difference, after 7 and 14 days, between groups C and MI (p <0.001) (p<0.01). The group MT there was a significant difference in relation to MI group in both experimental times with (p<0.001). The number of fibroblasts in the 14 days showed that when comparing the groups M and MT the differences were also significant (p<0.001). As for the DLL, in 7 days, there was a significant difference between group C and MI group (p <0.001). When considering the MT group, there was a significant difference in relation to the MI group (p <0.001). Conclusion: The extract of Mauritia flexuosa L. leaves lessened acute and chronic inflammation, increased fibroblast proliferation and reduced macroscopically edema.

Validation and Reliability of the Portuguese Version of the Michigan Neuropathy Screening Instrument.

BACKGROUND: Diabetic peripheral neuropathy is very common in the diabetic population. Early screening for foot pathology is of the utmost importance. The Michigan Neuropathy Screening Instrument (MNSI) is an easy, brief, and noninvasive screening tool. The aim of this study was to validate the semantics and characteristics of both sections of the Portuguese translation of the MNSI for Portuguese diabetic patients. METHODS: A cross-sectional study was performed on 87 type 1 and 2 diabetic patients at our outpatient endocrinology department. The final sample was composed of 76 patients. Nerve conduction studies were requested, but only a subsample of 42 patients agreed to participate in them. RESULTS: The scale was internally consistent (Cronbach's alpha > 0.70 in section A, or a clinical history questionnaire and a physical examination [section B]), and the scores of both sections were positively correlated (r = 0.70; P < 0.001). With regard to stability, MNSI scores between test/retest showed high stability (intraclass correlation coefficient = 0.91). The receiver-operating characteristic (ROC) demonstrated its validity, with ROC curve values for section A, section B, and sections A + B of 0.913, 0.798, and 0.906 respectively. Considering a cut off of ≥ 3 in section A and of ≥ 2 in section B, we obtained a sensitivity of 100% and 86%; a specificity of 64% and 61%; a positive predictive value of 80% and 73%; and a negative predictive value of 100% and 79%, respectively. CONCLUSIONS: The Portuguese MNSI is a reliable and valid tool for screening diabetic neuropathy.

Cross-Cultural Psychometric Assessment of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale in the Portuguese Population.

BACKGROUND: Chronic pain is a well-known phenomenon. The differential diagnosis between neuropathic and nociceptive pain syndromes is a challenge. Consequently, assessment instruments that can distinguish between these conditions in a standardized way are of the utmost importance. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) is a screening tool developed to identify chronic neuropathic pain. The aim of this study was the Portuguese language translation, linguistic adaptation of the LANSS pain scale, its semantic validation, internal consistency, temporal stability, as well its validity and discriminative power. METHODS: LANSS Portuguese version scale was applied to 165 consecutive patients attending the pain clinic: 103 fulfilled the clinical criteria for the diagnosis of pain of neuropathic origin and the remaining 62 fulfilled the criteria for nociceptive pain. RESULTS: The scale proved to be an internally consistent (Cronbach's alpha = 0.78) and reliable instrument with good test-retest stability (r = 0.7; P < 0.001). However, its validity and specificity with a cutoff point of ≥ 12, for differentiating patients with neuropathic pain from those with non-neuropathic pain, had 89% sensitivity, 74% specificity, positive predictive value of 85%, and negative predictive value of 81%. CONCLUSIONS: The Portuguese LANSS version pain scale properties lead us to the conclusion that such a cross-cultural version is a reliable and valid instrument for the differentiation of this type of pain. Its usage is recommended.

Opinião dos alunos quanto ao ensino dos diagnósticos de enfermagem segundo a taxonomia da NANDA / Students opinion as to the teaching of the nursing diagnosis according to NANDA

Acreditando na importância do dignóstico de enfermagem, o seu ensino foi introduzido há 4 anos nas disciplinas de Assistência de Enfermagem à Saúde da Mulher e Enfermagem Perinatal, no 6º período do curso de graduação em enfermagem da UNICAMP. Com o intuito de avaliar essa experiência, propusémo-nos a levantar a opinião dos alunos e obter subsídios para aprimorar o ensino. Foram ministradas 4 horas de ensino teórico e indicada bibliografia básica. A aplicação prática supervisionada foi desenvolvida durante 21 horas numa unidade neonatal e 45 horas em centros de saúde. Ao término das disciplinas, 16 alunos responderam a um questionário com questões fechadas e abertas. O grupo de alunos respondentes foi unânime em considerar válido o estudo dos diagnósticos de enfermagem. A maioria considerou mais adequado introduzir o ensino 3º semestre, quando se iniciam os procedimentos básicos de enfermagem. Quanto à dificuldade de aprendizado do uso dos diagnósticos, 68,7 por cento dos alunos relataram um nível de dificuldade superior a 25 por cento e inferior a 75 por cento. O grupo de alunos como um todo achou que o estudo do diagnóstico de enfermagem trouxe modificações no seu conceito de assistência de enfermagem.

Programa educativo em medidas de precauçäo universais: uma metodologia de abordagem / Updating measures on universal precautions: a new approach methodology

No Centro de Atençäo Integral à Saúde da Mulher (CAISM) desenvolveu-se um programa de reciclagem sobre as Medidas de Precauçäo Universais (MPU) e divulgou-se, através de uma cartilha, essas medidas e os procedimentos em caso de acidente de trabalho. Primeiramente, o funcionário era sensibilizado para a questäo do estresse e sua influência sobre a qualidade de vida e, após, era realizada a reciclagem promovendo-se a reflexäo sobre as consequências da näo adoçäo das MPU. Foram respondidos e analisados 286 pré-testes e 242 pós-testes com um índice de acertos significativamente maior nestes últimos (p<0,01), principalmente quanto ao uso adequado de luvas.

Contribuiçäo ao estudo de conhecimentos sobre doenças sexualmente transmissíveis (DST) entre adolescentes

Expöe-se pesquisa realizada entre adolescentes de ambos os sexos, da faixa etária de 10 a 20 anos, que frequentavam, em 1983, os Centros de Vivência do Jardim Munhoz, Jardim Piratininga e Vila Yolanda, ligados à Secretaria da Promoçäo Social da Prefeitura do Município de Osasco - SP. Os objetivos foram: verificar os conhecimentos dos jovens sobre alguns aspectos das Doenças Sexualmente Transmissíveis (DST), relacionar esses conhecimentos com idade, sexo, escolaridade e Centro de Vivência que frequentavam; verificar como essa populaçäo avaliava seus conhecimentos sobre o assunto; quem, na opiniäo desses jovens, estaria em condiçöes de orientá-los e qual a pessoas que escolheriam para fazer essas orientaçöes. Pretendeu-se com este trabalho subsidiar os profissionais dos campos da saúde e da educaçäo, conscientes da necessidade de se levar aos jovens informaçöes seguras sobre as DST e suas conseqüências. Os resultados mostraram que os adolescentes estudados têm conhecimento sobre DST relacionados apenas com a idade e Centros de Vivência que frequentavam. O grupo etário de 15 a 20 anos demonstrou maior conhecimento sobre o assunto do que o grupo etário de 10 a 14 anos. O Centro do Jardim Munhoz demonstrou menor conhecimento do que os Centros de Piratininga e Vila Yolanda, apenas nos nomes das doenças. A maior proporçäo da populaçäo alvo considerou razoáveis seus conhecimentos sobre o tema. O grupo etário mais velho soube avaliá-los melhor do que o grupo etário mais novo. Na opiniäo da maioria dos adolescentes estudados, o médico é a pessoa indicada e escolhida para orientá-los sobre essas enfermidades.