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1.  Factors associated to unrelieved pain in a Morrocan Emergency Department 
Background
In the light of the impact that pain has on patients, emergency department (ED) physicians need to be well versed in its management, particularly in its acute presentation. The goal of the present study was to evaluate the prevalence of unrelieved acute pain during ED stay in a Moroccan ED, and to identify risk factors of unrelieved pain.
Methods
Prospective survey of patients admitted to the emergency department of Ibn Sina teaching university hospital in Rabat (Morocco). All patients with acute pain over a period of 10 days, 24 hours each day were included. From each patient, demographic and clinical data, pain characteristics, information concerning pain management, outcomes, and length of stay were collected. Pain intensity was evaluated both on arrival and before discharge using Numerical Rating Scale (NRS). Comparison between patient with relieved and unrelieved pain, and factors associated with unrelieved pain were analyzed using stepwise forward logistic regression.
Results
Among 305 patients who complained of acute pain, we found high levels of intense to severe pain at ED arrival (91.1%). Pain intensity decreased at discharge (46.9%). Unrelieved pain was assessed in 24.3% of cases.
Patients with unrelieved pain were frequently accompanied (82.4% vs 67.1%, p = 0.012), and more admitted daily than night (8 am-20 pm: 78.4% vs 64.9%; 21 pm-7 am: 21.6% vs 35.1%, p = 0.031), and complained chiefly of pain less requently (56.8% vs 78.8%, p<0.001). They had progressive pain (73% vs 44.2%, p<0.001), and had a longer duration of pain before ED arrival (72-168 h: 36.5% vs 16.9%; >168 h: 25.5% vs 17.7%, p<0.001).
In multivariate analysis, predictor factors of unrelieved pain were: accompanied patients (OR = 2.72, 95% CI = 1.28- 5.76, p = 0.009), pain as chief complaint (OR = 2.32, 95% CI = 1,25-4.31, p = 0.007), cephalic site of pain (OR = 6.28, 95% CI = 2.26-17.46, p<0.001), duration of pain before admission more than 72 hours (72-168 h (OR = 7.85, 95% CI = 3.13-25.30, p = 0.001), and >168 h (OR = 4.55, 95% CI = 1.77-14.90, p = 0.02).
Conclusion
This study reported high levels of intense to severe pain at ED arrival. However, one quarter patients felt on discharge from the ED that their pain had not been relieved. The relief of pain in ED depend both sociodemographic, clinical, and pain characteristics factors.
doi:10.1186/1755-7682-7-48
PMCID: PMC4233084  PMID: 25400695
Emergency department; Pain; Pain relief; Unrelieved pain
2.  Uterine tumor resembling ovarian sex cord tumor (UTROSCT), case report with literature review 
Introduction
Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are uterine neoplasms of unknown histiogenesis which show near complete differentiation towards ovarian sex cord elements and are postulated to arise from pluripotential uterine mesenchymal cells or endometrial stromal cells with secondary sex cord differentiation.
Case presentation
A 48 year old post-menopausal women presented with abnormal uterine bleeding for which she underwent total abdominal hysterectomy with bilateral salpingo-ophorectomy. Gross examination revealed a gelatinous grayish white tumor confined to the myometrium, 7 cm in maximum dimention. Microscopic examination revealed monomorphic round to oval tumor cells in anastomosing cords and trabeculae with myxoid background. Immunohistochemically, tumor cells showed diffuse positivity for vimentin, CD99 and S100, while focal positivity was seen with pancytokeratin immunostain. The case was diagnosed as UTROSCT. No evidence of metastasis was found on systemic clinical and radiologic workup.
Conclusion
UTROSCT are rare uterine tumors which can be diagnosed with certainty on morphologic and immunohistochemical grounds. It is important to recognize these tumors as they behave differently from endometrial stromal tumors with sex cord like elements (ESTSCLE).
doi:10.1186/1755-7682-7-47
PMCID: PMC4230524  PMID: 25395990
Uterine tumors resembling ovarian sex cord tumors (UTROSCT); Endometrial stromal tumor with sex cord like elements (ESTSCLE); CD99
3.  Glucose and lipid assessment in patients with acute stroke 
Background
Stroke is a major health issue in Nigeria and it is also a common cause of emergency admissions. Stroke often results in increased morbidity, mortality and reduced quality of life in people thus affected. The risk factors for stroke include metabolic abnormalities such as dyslipidaemia and diabetes mellitus (DM). The stress of an acute stroke may present with hyperglycaemia and in persons without a prior history of DM, may be a pointer to stress hyperglycaemia or undiagnosed DM.
Methodology
This was a cross sectional study carried out over a period of one year in a teaching hospital in Lagos, Nigeria. Patients with acute stroke admitted to the hospital within three days of the episode of stroke and who met other inclusion criteria for the Study were consecutively recruited. Clinically relevant data was documented and biochemical assessments were carried out within three days of hospitalization. Tests for lipid profile, glycosylated haemoglobin(HbA1c), and blood glucose at presentation were carried out. The presence of past history of DM, undiagnosed DM, stress hyperglycaemia and abnormal lipid profile were noted. Students t test and Chi square were the statistical tests employed.
Results
A total of 137 persons with stroke were recruited of which 107 (76%) met the defining criteria for ischaemic stroke. The mean age and age range of the Study subjects were 62.2 (11.7) and 26–89 years respectively. The Study subjects were classified according to their glycaemic status into the following categories viz; stress hyperglycaemia, euglycaemia, DM and previously undiagnosed DM. Stress hyperglycaemia occurred commonly in the fifth decade of life and its incidence was comparable between those with cerebral and haemorrhagic stroke. The commonly occurring lipid abnormalities were elevated LDL-C and low HDL.
Conclusions
The detection of abnormal metabolic milieu is a window of opportunity for aggressive management in persons with stroke as this will improve outcome. Routine screening for hyperglycaemia in persons with stroke using glycosylated haemoglobin tests and blood glucose may uncover previously undiagnosed DM.
doi:10.1186/1755-7682-7-45
PMCID: PMC4221686  PMID: 25379056
4.  Evaluation of a web based tool to improve health behaviours in healthcare staff 
Background
A web-based tool was developed and piloted by being made available to healthcare staff in Wales from September 2012 to March 2013. This evaluation included two primary outcome measures: general health and mental well-being, and six secondary outcome measures: sickness absence, alcohol use, healthy eating, smoking, physical activity and maintaining a healthy BMI. The aim was to assess the feasibility of a web-based tool to improve health behaviours in healthcare staff.
Methods
Healthcare staff joined via a website, chose two of five challenges, and recorded their health behaviours using an online tool on a regular basis. Evaluation was undertaken by comparing baseline and follow up questionnaires.
Results
1708 individuals explored the programme’s website, of whom 1320 selected two lifestyle challenges to address. Of these 346 individuals (26.2%; 346/1320) completed the end of project evaluation questions for the main outcome and provided the basis of the evaluation. Comparing pre:post data among respondents who engaged with the programme as a whole, self-reported general health status improved in 35.3% (n = 122, p = 0.001); mental health status improved in 33% (n = 110, p = 0.02); alcohol consumption score (AUDIT-C classification) fell in 27.2% (n = 71, p = 0.001); reported fruit and vegetable consumption (7 day recall) increased (p = 0.001); average time spent on vigorous exercise increased from 40.6 minutes a week to 67.6 minutes a week (p = 0.001); and 41 individuals noted a positive change to their BMI classification category (p = 0.001).
Conclusions
Combining interactive web-based tools as part of a multi-media programme is feasible, increases health behaviours and generates interest among a proportion of the healthcare workforce. Further work is required to improve maintenance of engagement over time.
doi:10.1186/1755-7682-7-44
PMCID: PMC4197304  PMID: 25320639
5.  Association of type IV spinal muscular atrophy (SMA) with myoclonic epilepsy within a single family 
Background
Spinal muscular atrophies (SMAs) are a group of disorders characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem. It is transmitted by autosomal recessive inheritance and most of these conditions are linked to SMN gene. Even if the clinical picture is mainly dominated by the diffuse muscular atrophy, some patients can also show atypical clinical features such as myoclonic epilepsy (“SMA plus”), which may be related to other genes. In particular, the association of SMA and progressive myoclonic epilepsy (PME) has been previously described.
Case presentation
We present a case of two brothers with late onset SMA associated with a unique form of non progressive myoclonic epilepsy without cognitive impairment or ataxia. They had identical clinical and electrophysiological features.
Conclusions
The association of SMA with myoclonic epilepsy may constitute a separate and genetically independent syndrome with unique clinical and electrophysiological findings. Collection of similar cases with genetic studies is needed to define the phenotype clearly and to identify new genes and molecular pathogenetic mechanisms involved in this condition.
doi:10.1186/1755-7682-7-42
PMCID: PMC4182784  PMID: 25278999
Spinal muscular atrophy; Myoclonic epilepsy
6.  Time intervals and associated factors of emergency treatment: first insight into Pakistani system 
The objective of this study is to determine the time interval from decision to seek medical help and arrival of the patients to the emergency department (ED). The duration of stay in ED was also calculated. This study also assesses factors responsible delayed presentation to hospital. This prospective study was conducted during day timings (9 am to 3 pm) from May 2012 to August 2012 in ED at Civil Hospital, Karachi. Patients older than 18 years and meeting the inclusion criteria were considered to be eligible for the study. Statistical analysis was done using SPSS version 17. The study sample consisted of 4,226 patients with a response rate of 96.5%. The median decision time was 146 minutes (IQR = 74–339), median transit time was 84 minutes (IQR = 42–188), median physician time was 58 minutes (IQR = 47–103), median diagnostic time was 148 minutes (IQR = 135–192), median transfer time was 155 minutes (IQR = 118–274) and the median ED LOS was 327 minutes (IQR = 209–488). Patient beliefs regarding spontaneous resolution of the symptoms was the most common reason (44.8%) cited for increased time spent in taking decision to seek medical help. Mode of transportation other than ambulance and traffic gridlock were the most common reasons found to be significantly associated with increased transit time (p < 0.05). The time intervals calculated from our study were found to be higher than studies reported from countries. This calls for urgent intervention for formulation of triage systems to improve patient treatment and satisfaction.
doi:10.1186/1755-7682-7-41
PMCID: PMC4258270  PMID: 25484915
Emergency; Medicine; Civil Hospital; Karachi; Pakistan; Prehospital; Hospital; Delay; Decision time; Transit time; Physician time; Diagnostic time; Transfer time; Chest pain; Abdominal; Respiratory; Neurologic; Urogenital; Musculoskeletal; Trauma; Poisoning; Firearm
7.  Cardiac autonomic responses induced by a single bout of exercise with flexible pole 
Background
Flexible poles are tools used to provide rapid eccentric and concentric muscle contractions. It lacks in the literature studies that analyze acute cardiovascular responses in different exercises performed with this instrument. It was investigated the acute effects of exercise with flexible poles on heart period in healthy women.
Methods
The study was performed on 32 women between 18 and 25 years old. It was evaluated the heart rate variability (HRV) in the time (SDNN, RMSSD and pNN50) and frequency domain (HF, LF and LF/HF ratio). The subjects remained at rest for 10 minutes. After the rest period, the volunteers performed the exercises with the flexible poles. Immediately after the exercise protocol, the volunteers remained seated at rest for 60 minutes and HRV were analyzed.
Results
It was observed no significance changes in the time domain (SDNN: p = 0.14; RMSSD: p = 0.8 and pNN50: p = 0.86) and frequency domain indices (LF (nu): 0.4; LF (ms2): p = 0.34; HF (nu): p = 0.4; HF (ms2): p = 0.8 and LF/HF ratio: p = 0.3) between before and after single bout of exercise with flexible pole.
Conclusion
A single bout of exercise with flexible pole did not significantly change cardiac autonomic regulation in healthy women.
doi:10.1186/1755-7682-7-40
PMCID: PMC4180838  PMID: 25278998
Cardiovascular system; Autonomic nervous system; Exercise therapy
8.  Paroxysmal nocturnal hemoglobinuria presenting as cerebral venous sinus thrombosis: a case report 
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a rare type of acquired hemolytic anemia that is frequently associated with thrombophilia. It may rarely present with cerebral venous sinus thrombosis, which manifests clinically with signs of raised intracranial pressure and requires lifelong anticoagulation therapy. One such rare presentation was seen in a 28 years old male who had history of recurrent episodes of passing red colored urine and this time presented with severe headache. He was diagnosed to have cerebral venous sinus thrombosis and on further workup was found to be suffering from PNH.
doi:10.1186/1755-7682-7-39
PMCID: PMC4138960  PMID: 25143784
9.  Double-lumen catheter in the right jugular vein induces two sub-endothelial abscesses in an unusual place, the transition between the superior vena cava and the right atrium: a case report 
Endocarditis is a type of infection that is common in internal medicine wards and in haemodialysis clinics. The location that is most affected are the heart valves. Herein, we report a case of an uncommon abscess, a sub-endothelial abscess between the transition of the superior vena cava and the right atrium. There were several emboli to the lung and foot, and the agent was related to Staphylococcus aureus and a double-lumen catheter. Usually, this type of abscess is located in valves, either the tricuspid valve if related to catheters or injection drug use or the mitral valve if related to other causes. An exhaustive review was made, but we found no information about the location of this abscess and the rarity of the event motivating the report of infection.
doi:10.1186/1755-7682-7-37
PMCID: PMC4125593  PMID: 25110520
Endocarditis; Central venous catheters; Renal dialysis; Hospitalisation
10.  Diagnostic utility of p53 and CK20 immunohistochemical expression grading urothelial malignancies 
Introduction
Current grading system in application by WHO/ISUP divides urothelial malignancies in low and high grade by morphologic criteria while strict segregation may become cumbersome in limited tissue specimens. As grading these carcinomas are of utmost prognostic significance after depth of invasion, therefore we evaluated the role of immunohistochemical expression of p53 and cytokeratin 20 as an adjuctive tool in grading urothelial carcinoma.
Methods
The study was conducted in Aga khan university hospital, Histopathology section from December 2010 till June 2011 for duration of six months. It involved 95 cases of urothelial carcinomas diagnosed on trans-uretheral resection specimens of bladder growth. Immunohistochemical expression of p53 and cytokeratin 20 was performed according to standard protocols and correlated with grade and depth of invasion.
Results
There were 48 cases (50.5%) of low grade and 47 cases (49.5%) of high grade urothelial carcinoma included in the study. Male to female ratio was 4.3:1. Majority of patients (80%) were seen in 45 to 90 years age group. Diffuse positive expression of cytokerain 20 was noted in 33 cases (68.8%) of high grade and 19 (40.4%) low grade tumors. Strong positive expression of p53 was seen in 35 cases (72.9%) of high grade while only 17 cases (36.2%) of low grade tumors showed strong p53 expression.
Conclusion
Significant difference in expression of Cytokeratin 20 and p53 was found between low and high grade urothelial carcinoma. Therefore we suggest combined use of these markers may be helpful in assigning grade to urothelial carcinoma especially when histologic features are borderline.
doi:10.1186/1755-7682-7-36
PMCID: PMC4119421  PMID: 25089155
Papillary urothelial carcinoma; p53; Cytokeratin 20
11.  Individual and social vulnerabilities upon acquiring tuberculosis: a literature systematic review 
Tuberculosis is a contagious infectious disease mainly caused by the bacteria Mycobacterium tuberculosis that still meets the priority criteria - high magnitude, transcendence and vulnerability - due to the threat it poses to public health. When taking into consideration the vulnerability conditions that favor the onset of the disease, this article aimed to investigate the implications originated from individual and social vulnerability conditions in which tuberculosis patients are inserted. Databases like MEDLINE, LILACS and SciELO were searched in Portuguese, Spanish and English using the descriptors tuberculosis and vulnerability, and 183 articles were found. After the selection criterion was applied, there were 22 publications left to be discussed. Some of the aspects that characterize the vulnerability to tuberculosis are: low-income and low-education families, age, poor living conditions, chemical dependency, pre-existing conditions/aggravations like diabetes mellitus and malnutrition, indigenous communities, variables related to health professionals, intense border crossings and migration, difficulty in accessing information and health services and lack of knowledge on tuberculosis. Much as such aspects are present and favor the onset of the disease, several reports show high incidence rates of tuberculosis in low vulnerability places, suggesting that some factors related to the disease are still unclear. In conclusion, health promotion is important in order to disfavor such conditions or factors of vulnerability to tuberculosis, making them a primary target in the public health planning process and disease control.
doi:10.1186/1755-7682-7-35
PMCID: PMC4110238  PMID: 25067955
Tuberculosis; Vulnerability; Social vulnerability; Vulnerability analysis; Vulnerability study; Health vulnerability; Transmissible diseases prevention
12.  Energy and nutrient intakes among Sri Lankan adults 
Introduction
The epidemic of nutrition related non-communicable diseases such as type 2 diabetes mellitus and obesity has reached to epidemic portion in the Sri Lanka. However, to date, detailed data on food consumption in the Sri Lankan population is limited. The aim of this study is to identify energy and major nutrient intake among Sri Lankan adults.
Methods
A nationally-representative sample of adults was selected using a multi-stage random cluster sampling technique.
Results
Data from 463 participants (166 Males, 297 Females) were analyzed. Total energy intake was significantly higher in males (1913 ± 567 kcal/d) than females (1514 ± 458 kcal/d). However, there was no significant gender differences in the percentage of energy from carbohydrate (Male: 72.8 ± 6.4%, Female: 73.9 ± 6.7%), fat (Male: 19.9 ± 6.1%, Female: 18.5 ± 5.7%) and proteins (Male: 10.6 ± 2.1%, Female: 10.9 ± 5.6%).
Conclusion
The present study provides the first national estimates of energy and nutrient intake of the Sri Lankan adult population.
doi:10.1186/1755-7682-7-34
PMCID: PMC4110527  PMID: 25067954
Dietary survey; Nutrition survey; Energy intake; Sri Lanka; Adults
13.  Morphologic spectrum of glial tumors: an increased trend towards oligodendroglial tumors in Pakistan 
Background
Glial tumors are most common brain tumors in our population. While the exact etiology and pathogenesis is unknown, the evaluation of current trends in the frequency and morphology of glial tumors is imperative to constitute better diagnostic and treatment protocols. Data pertaining to frequency and spectrum of glial tumors is scarcely available in our population. The aim of this study was to determine the morphologic spectrum of glial tumors prevalent in our population.
Method
126 cases of glial tumors were retrospectively analyzed over a period of 5 years. Patients from all age groups and both genders were included in this study. Glial tumors were classified and graded according to WHO classification.
Results
Glial tumors were more common in males with a sex ratio of 2:1 and mean age of 38.26 years. Astrocytomas were most common glial tumors (51.6%) followed by oligodendrogliomas (23%). Glioblastoma was the most frequent astrocytic tumor and was incomparably frequent in older age group.
Conclusion
In our study, Oligodendrogliomas and mixed oligoastrocytomas represent major pattern of disease in comparison with available regional data. Knowledge of these changing trends and patterns of glial tumor morphology and frequency can help in improvements and applications of newly emerging diagnostic and treatment modalities.
doi:10.1186/1755-7682-7-33
PMCID: PMC4088292  PMID: 25009580
Glial tumors; Astrocytoma; Oligodendroglioma; Glioblastoma; Mixed oligoastrocytoma
14.  Predictive factors of left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis: a retrospective study of 159 patients 
Background
Mitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients.
Methodology
This is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast.
Result
Left atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient (OR: 18.753, 1.21, CI [1,838-191,332], [1,064-1,376], p: 0.013, 0.004, respectively) were found to be independently associated to the presence of spontaneous echo contrast.
Conclusion
Patients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up.
doi:10.1186/1755-7682-7-32
PMCID: PMC4081018  PMID: 24995039
Mitral stenosis; Left atrial spontaneous contrast; Transesophageal echocardiography; Anticoagulation
15.  Unexpected triggers for pheochromocytoma-induced recurrent heart failure 
Pheochromocytoma crisis typically presents as paroxysmal episodes of headache, tachycardia, diaphoresis or hypertension. We describe an uncommon case of recurrent non-hypertensive heart failure with systolic dysfunction in a young female due to pheochromocytoma compression. It presented as acute pulmonary oedema while straining during pregnancy and later on as cardiogenic shock after a recreational body massage. Such crisis occurring during pregnancy is rare. Moreover, of the few reported cases of pheochromocytoma-induced cardiogenic shock, recreational body massage has not yet been reported as a trigger for this condition.
doi:10.1186/1755-7682-7-30
PMCID: PMC4077553  PMID: 24987459
Body massage; Cardiogenic shock; Heart failure; Pheochromocytoma; Pregnancy
16.  Changes in full blood count parameters in leptospirosis: a prospective study 
Background
Leptospirosis presents diagnostic challenges to clinicians, in settings where other acute febrile illness are prevalent. The patterns of serial changes in haematological parameters in leptospirosis has not been evaluated previously.
Methods
Clinical and laboratory data were collected prospectively from patients with leptospirosis in two hospitals in Sri Lanka. Leptospirosis was diagnosed based on WHO clinical criteria with confirmation using Microscopic Agglutination Test titre > 400 or 4 fold rise between acute and convalescent samples. Full blood count parameters were analysed up to the 14th day of illness.
Results
Data from 201 patients with leptospirosis were available. Leukocyte counts and absolute neutrophil counts showed a decline over the first 5 days of illness, then rose until the end of the second week. On day 3 of fever, the majority (75%) had normal leukocyte counts, and by day 5, leukocytosis was seen only in 38.1%; leucopenia was an uncommon finding. Lymphopenia was seen in over half on day 5, declining to just under a quarter of patients by day 10. Platelets declined over the first 6 days and then gradually rose. Thrombocytopenia was seen in nearly three-fourths of patients by day 5. Haemoglobin and haematocrit levels declined over the course of illness. Total white cell and neutrophil counts were higher, and haemoglobin and haematorcrit were significantly lower, in patients with severe disease.
Conclusions
Neither leukocytosis nor lymphopenia were prominent features, while thrombocytopenia was seen during the 3rd to 5th day of illness, with dropping haemoglobin levels. Neutrophilia and low haemoglobin levels appear to predict severe disease. These findings may be of use to clinicians in differentiating leptospirosis from other acute infections like dengue, and could help in predicting severe leptospirosis.
doi:10.1186/1755-7682-7-31
PMCID: PMC4094533  PMID: 25018781
Leptospirosis; Platelets; Neutrophils; Lymphocytes
17.  Orquestic regulation of neurotransmitters on reward-seeking behavior 
The ventral tegmental area is strongly associated with the reward system. Dopamine is released in areas such as the nucleus accumbens and prefrontal cortex as a result of rewarding experiences such as food, sex, and neutral stimuli that become associated with them. Electrical stimulation of the ventral tegmental area or its output pathways can itself serve as a potent reward. Different drugs that increase dopamine levels are intrinsically rewarding. Although the dopaminergic system represent the cornerstone of the reward system, other neurotransmitters such as endogenous opioids, glutamate, γ-Aminobutyric acid, acetylcholine, serotonin, adenosine, endocannabinoids, orexins, galanin and histamine all affect this mesolimbic dopaminergic system. Consequently, genetic variations of neurotransmission are thought influence reward processing that in turn may affect distinctive social behavior and susceptibility to addiction. Here, we discuss current evidence on the orquestic regulation of different neurotranmitters on reward-seeking behavior and its potential effect on drug addiction.
doi:10.1186/1755-7682-7-29
PMCID: PMC4108978  PMID: 25061480
Dopamine; Orexin; Serotonin; Galanin; Histamine; Endocannabinoids; Reward-seeking behavior; Drug addiction
18.  Ventricular trigeminy in a patient with serologically confirmed dengue haemorrhagic fever 
Background
Cardiac arrhythmias occur during the acute stage of Dengue Haemorrhagic Fever. Dengue myocarditis is the most likely cause of the arrhythmias.
Case presentation
We report a 55-year-old patient with Dengue Haemorrhagic Fever presenting with transient ventricular trigeminy which has not been reported before.
Conclusion
Among many other known cardiac arrhythmia seen in DHF, ventricular trigeminy is also a possibility. Clinicians should be aware of this cardiac rhythm abnormality that can occur in dengue patients.
doi:10.1186/1755-7682-7-28
PMCID: PMC4046007  PMID: 24904689
Dengue fever; Ventricular trigeminy; Dengue myocarditis
19.  Auditory stimulation with music influences the geometric indices of heart rate variability in men 
Background
Chronic classical music was reported to increase parasympathetic activitywhen evaluating heart rate variability (HRV). It is poor in the literature investigation of the acute effects of baroque and heavy metal styles of musical auditory stimulation on HRV. In this study we evaluated the acute effects of relaxant baroque and excitatory heavy metal music on the geometric indices of HRV in healthy men.
Method
The study was performed in 12 healthy men between 18 and 30 years old. We excluded persons with previous experience with music instrument and those who had affinity with the song styles. We analyzed the following indices: RRtri, TINN and Poincaré plot (SD1, SD2 and SD1/SD2 ratio). HRV was recorded at rest for ten minutes. Subsequently they were exposed to relaxant baroque or excitatory heavy metal music for five minutes through an earphone. After the first music exposure they remained at rest for more five minutes and them they were exposed again to Baroque or Heavy Metal music (65–80 dB). The sequence of songs was randomized for each individual.
Results
The RRTri and SD2 indices were reduced during the heavy metal musical auditory stimulation (p < 0.05). No changes were observed regarding TINN, SD1 and SD1/SD2 ratio (p > 0.05).The qualitative Poincaré plot analysis indicated that during relaxant classical baroque music there was observed a higher beat-to-beat dispersion of RR intervals compared with no music exposure and during excitatory heavy metal musical auditory stimulation, showing higher HRV.
Conclusion
We suggest that excitatory heavy metal music acutely decreases global HRV.
doi:10.1186/1755-7682-7-27
PMCID: PMC4039650  PMID: 24883104
Autonomic nervous system; Auditory stimulation; Cardiovascular system; Music
20.  Novel occupational therapy interventions may improve quality of life in older adults with dementia 
Background
Dementia is a major health problem in advancing age with no definitive treatment. Occupational therapy interventions are recognized strategies in treatment of dementia. Quality of life (QOL) assessment has been reliably used as an objective index of an individual’s well being pertaining to interventions in dementia. A randomized controlled trial was conducted to study the effects of a novel occupational therapy program in improving QOL of subjects having mild to moderate dementia.
Methodology
273 subjects older than 60 years were screened. 196 were excluded having cognitive impairment with no dementia (CIND). Remaining 77 subjects after satisfying DSM IV criteria for diagnosis of dementia were included in the study and were randomly assigned to experimental and control groups. Experimental group received a novel occupational therapy regimen along with medical treatment, while control group received only medical treatment for 5 weeks. Outcome measures included standard occupational therapy assessment and WHOQOL-BREF. Subjects were assessed at baseline and post intervention.
Result
The mean age of participants was 69.39 years with male preponderance (80.5% male, 19.5% female). The quality of life (QOL) scores of physical and psychological domain in experimental groups significantly increased from 37.30 ± 5.42 and 45.13 ± 3.52 to 45.43 ± 7.32 and 51.50 ± 6.46 respectively. The QOL scores in social and environmental domains did not change significantly. The QOL scores in control groups declined in all domains with statistical significance found in social and environmental domain. (29.67 ± 4.58 and 38.49 ± 1.77 to 28.45 ± 5.26 and 38.18 ± 2.15 respectively).
Conclusion
This novel occupational therapy program improved the short term physical performance and psychological well being domain of quality of life in older adults with dementia. An improved physical performance is achieved by physical exercise of novel program and it creates sense of independency, increased motivation, positive outlook and reduced behavioral and psychological symptoms. The long term effects of the intervention can be ascertained in a study with longer period of intervention and follow-up.
Trial registration
[CTRI/2014/01/004290]
doi:10.1186/1755-7682-7-26
PMCID: PMC4076057  PMID: 24982692
Dementia; Occupational therapy; Quality of life; WHOQOL-BREFF
21.  Fractal correlation property of heart rate variability in response to the postural change maneuver in healthy women 
Background
We evaluated the effects of the PCM on the fractal analysis of the HRV in healthy women
Method
We evaluated healthy women between 18 and 30 years old. HRV was analyzed in the time (SDNN, RMSSD, NN50 and pNN50) and frequency (LF, HF and LF/HF ratio) domains as well as short and long-term fractal exponents (alpha-1 and alpha-2) of the detrended fluctuation analysis (DFA). HRV was recorded at rest for ten minutes at seated rest and then the women quickly stood up from a seated position in up to three seconds and remained standing for 15 minutes. HRV was recorded at the following time: rest, 0–5 min, 5–10 min and 10–15 min during standing.
Results
We observed decrease (p < 0.05) in the time-domain indices of HRV between seated and 10–15 minutes after the volunteer stood up. The LF (ms2) and HF (ms2) indices were also reduced (p < 0.05) at 10–15 minutes after the volunteer stood up compared to seated while the LF (nu) was increased at 5–10 min and 10–15 min (p < 0.05). The short-term alpha-1 exponent was increased (p < 0.05) at all moments investigated compared to seated. Increase in the properties of short-term fractal correlations of heart rate dynamics accompanied by a decrease in the parasympathetic modulation and global HRV was observed in response to the postural change maneuver.
Conclusion
We suggest that fractal analysis of HRV is more sensitive than frequency and time-domain analysis of HRV during the postural change maneuver.
doi:10.1186/1755-7682-7-25
PMCID: PMC4030044  PMID: 24910714
Autonomic nervous system; Cardiovascular system; Nonlinear dynamics; Physiology
22.  Effect of systemic inflammation on level of ferritin seminal in chronic renal male patient undergoing hemodialysis 
Background
Most hemodialysis patients present with chronic systemic inflammation characterized by the elevation of serum C-reactive protein (CRP) levels and/or the production of proinflammatory interleukins by the immune system in response to the hemodialysis process. Plasma ferritin(PF) is one of the parameters used to correct anemia. An PF level of >500 ng/mL is not recommended for correction of anemia because of the uncertainty of whether these levels are elevated because of anemia or a mere reaction to inflammation. we aimed to study the effects of inflammation on seminal ferritin (SF) levels and hypothesized that SF is not affected because of the testicular immune privilege.
Methods
A prospective prevalence study was conducted at the Department of Hemodialysis of the University Hospital of Brasília (HuB) between June 2010 and July 2011. The sample included 60 chronic renal patients undergoing hemodialysis and 20 control subjects from the health promotion general outpatient clinic. All participants were males aged 18–60 years. Inflammation was assessed through serum CRP levels, and the testicular condition was determined by measuring sex hormone levels. In the patient group, inflammation was considered to be present when CRP was >5 mg/L (n = 27) and absent when CRP was ≤5 mg/L (n = 33). Control group (n = 20) CRP was ≤1 mg/L. Blood and semen were collected via arm venoclysis and after voluntary masturbation, respectively. CRP was measured by turbidimetry; PF, SF, and sex hormone levels by immunochemoluminescence. Statistical significance was set at p < 0.05.
Results
There was no significant difference in mean SF levels among patients with inflammation (295.34 ± 145.39 ng/mL), those without inflammation (324.42 ± 145.51 mg/mL), and controls (335.70 ± 075.90 ng/mL; p = 0.49). There was no correlation between mean SF and PF levels in the patients with and without inflammation). All participants were eugonadal with mean serum FSH, LH, and testosterone levels of 3.76 ± 2.17 mUI/mL, 7.00 ± 3.53 mUI/mL, and 454.18 ± 173.08 ng/dL, respectively.
Conclusion
Systemic inflammation did not significantly alter SF levels in eugonadal hemodialysis patients.
doi:10.1186/1755-7682-7-23
PMCID: PMC4022435  PMID: 24834129
Chronic renal disease; Ferritin; Semen; Sex hormones; Testis
23.  Evolution of female urinary continence after physical therapy and associated factors 
Background
Urinary incontinence (UI) is defined as any involuntary loss of urine that can influence the quality of life, personal hygiene and social interaction. The types of UI that most affect women are stress urinary incontinence, urge incontinence and mixed urinary incontinence. There are several risk factors that result in specific treatments. We aimed to investigate the evolution of female urinary continence after physical therapy intervention and its associated factors.
Method
A retrospective cross-sectional study was conducted with 71 participants who were discharged from physiotherapy sector from August 2006 to April 2012 and met the inclusion criteria.
Results
Among the studied variables, the number of sessions and completion of home pelvic floor exercises showed a significant association. The urinary continence appeared in 43.7% of the cases, and factors, performance of home exercises, and number of sessions showed a significant association.
Conclusion
The number of sessions and completion of home pelvic floor exercises showed a significant relationship with each other.
doi:10.1186/1755-7682-7-24
PMCID: PMC4024111  PMID: 24839462
Urinary incontinence; Patient outcome assessment; Urogynecology; Women’s health
24.  Prevalence of burnout syndrome in clinical nurses at a hospital of excellence 
Background
Burnout syndrome can be defined as long-term work stress resulting from the interaction between constant emotional pressure associated with intense interpersonal involvement for long periods of time and personal characteristics. We investigated the prevalence/propensity of Burnout syndrome in clinical nurses, and the factors related to Burnout syndrome-associated such as socio-demographic characteristics, work load, social and family life, leisure activities, extra work activities, physical activities, and work-related health problems.
Method
We conducted a cross-sectional, quantitative, prospective epidemiological study with 188 surgical clinic nurses. We used the Maslach Burnout Inventory (MBI), which is a socio-demographic questionnaire and the most widely used instrument to assess Burnout syndrome (three basic dimensions: emotional exhaustion, despersonalization and professional underachievement). The socio-demographic profile questionnaire wascomposed of questions regarding identification, training, time at work, work characteristics and personal circumstances.
Results
The prevalence of Burnout syndrome was higher (10.1%) and 55, 4% of subjects had a propensity to develop this syndrome. The analysis of the socio-demographic profile of the nurse sample studied showed that most nurses were childless married women, over 35 years of age, working the day shift for 36 hours weekly on average, with 2-6 years of post-graduation experience, and without extra employments. Factors such as marital status, work load, emotion and work related stress aggravated the onset of the syndrome.
Conclusion
The prevalence and propensity of Burnout syndrome were high. Some factors identified can be useful for the adoption of preventive actions in order to decrease the prevalence of the clinical nurses Burnout syndrome.
doi:10.1186/1755-7682-7-22
PMCID: PMC4031323  PMID: 24860618
Burnout; Professional; Syndrome; Nursing
25.  Association between central auditory processing mechanism and cardiac autonomic regulation 
Background
This study was conducted to describe the association between central auditory processing mechanism and the cardiac autonomic regulation.
Methods
It was researched papers on the topic addressed in this study considering the following data bases: Medline, Pubmed, Lilacs, Scopus and Cochrane. The key words were: “auditory stimulation, heart rate, autonomic nervous system and P300”.
Results
The findings in the literature demonstrated that auditory stimulation influences the autonomic nervous system and has been used in conjunction with other methods. It is considered a promising step in the investigation of therapeutic procedures for rehabilitation and quality of life of several pathologies.
Conclusion
The association between auditory stimulation and the level of the cardiac autonomic nervous system has received significant contributions in relation to musical stimuli.
doi:10.1186/1755-7682-7-21
PMCID: PMC4022404  PMID: 24834128
Auditory stimulation; Autonomic nervous system; Heart rate; P300

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