Extracorporeal shockwave therapy (ESWT) has analgesic and anti-inflammatory effects. With the evolu- tion and comprehension of its biological and physical mechanisms, the application of ESWT on other pathologies has also been studied, especially in musculoskeletal diseases. Recently, studies on animal models have shown its angiogenic capacity and a higher rate of local re-epithelization. These small stud- ies led to few trials using low-energy, radial ESWT to treat problematic chronic skin ulcers. Skin ulcers have diverse etiologies, ranging from pressure ulcers, burns, venous or arterial ulcers, and even diabetic ulcers. Their treatment is usually a challenge, due to the long-term treatment and high costs.
The study examined the effects of high-voltage pulsed current (HVPC) electrical stimulation on chronic leg ulcers. 27 subjects with 42 chronic leg ulcers were randomly assigned to receive either HVPC or sham treatment 3 times per week for 4 weeks. Wound size and appearance were assessed initially and after treatment. HVPC reduced wound size by an average of 44.3% compared to 16.0% for sham treatment, indicating HVPC can accelerate healing of chronic leg ulcers.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
The study evaluated the efficacy of paraffin bath therapy for hand osteoarthritis. 56 patients were randomly assigned to either a treatment group receiving paraffin baths or a control group. Outcome measures including pain, hand function, range of motion and strength were assessed at baseline, 3 weeks and 12 weeks. At 12 weeks, the treatment group showed significantly greater improvements in pain, range of motion and strength compared to the control group. Paraffin bath therapy appeared effective in reducing pain and maintaining strength for hand osteoarthritis over 12 weeks.
This randomized controlled trial investigated the effectiveness of pulsatile dry cupping therapy compared to no intervention for knee osteoarthritis. 40 patients were randomly assigned to receive either 8 cupping sessions over 4 weeks or no treatment. Outcome measures including pain, stiffness, physical function, and quality of life were assessed at 4 and 12 weeks. At 4 weeks, cupping resulted in significantly greater improvements in pain, physical function, and quality of life scores compared to the control group. Many benefits were still present at 12 weeks, though some scores were no longer significantly different. The study provides preliminary evidence that cupping may be an effective treatment for relieving symptoms of knee osteoarthritis.
To Follow Dermatological Treatment Regimens – Patients' and Providers' Vi...ricklock78
Adherence to long-term therapy for chronic illness is on average 50%. However, regarding adherence to derma- tological treatment the existing literature is limited. The aim of the study was to acquire an understanding of issues associated with adherence to dermatological therapy. Focus group interviews were used in two types of fora: patients with chronic dermatological diseases and health care providers, including doctors, nurses and pharmacists working in dermatological care. Results reveal the providers' view of a suboptimal rate of adherence.
This document summarizes three studies that evaluated the effectiveness of repositioning schedules for preventing pressure ulcers in hospitalized patients. A systematic review by Gillespie et al. found insufficient evidence from three randomized controlled trials to determine whether particular repositioning positions or frequencies reduced pressure ulcer development. A study by Bergquist-Beringer et al. found that patients who were routinely repositioned every 24 hours had a 14% lower risk of pressure ulcers. A systematic review by Moore et al. did not identify any randomized controlled trials comparing different repositioning techniques or frequencies.
This study compared cognitive rigidity and differentiation in patients with depression alone and patients with comorbid depression and fibromyalgia. Thirty-one patients with both depression and fibromyalgia were matched with 31 patients who had depression alone based on age, sex, and number of depressive episodes. Patients completed measures of depressive symptoms and cognitive structure using repertory grid technique. Results showed that depressed patients with fibromyalgia had higher levels of depressive symptoms, greater cognitive rigidity, and lower cognitive differentiation compared to depressed patients without fibromyalgia. This suggests more extreme and polarized thinking patterns in patients with comorbid depression and chronic pain. The findings could help inform future treatment approaches for this patient group.
Hyperbaric oxygen therapy (HBOT) facilitated healing of chronic foot ulcers in patients with diabetes according to a randomized controlled trial. In the trial, 94 patients with diabetic foot ulcers of at least 3 months duration were assigned to receive either HBOT or a placebo treatment of hyperbaric air over 40 sessions. At 1-year follow-up, complete healing of the index ulcer occurred in 52% of patients receiving HBOT compared to 29% of patients receiving the placebo air, a statistically significant difference. Fewer major amputations also occurred in the HBOT group compared to the placebo group. The study provides evidence that HBOT can help facilitate healing of chronic diabetic foot ulcers when used as an adjunct to standard
The study examined the effects of high-voltage pulsed current (HVPC) electrical stimulation on chronic leg ulcers. 27 subjects with 42 chronic leg ulcers were randomly assigned to receive either HVPC or sham treatment 3 times per week for 4 weeks. Wound size and appearance were assessed initially and after treatment. HVPC reduced wound size by an average of 44.3% compared to 16.0% for sham treatment, indicating HVPC can accelerate healing of chronic leg ulcers.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
The study evaluated the efficacy of paraffin bath therapy for hand osteoarthritis. 56 patients were randomly assigned to either a treatment group receiving paraffin baths or a control group. Outcome measures including pain, hand function, range of motion and strength were assessed at baseline, 3 weeks and 12 weeks. At 12 weeks, the treatment group showed significantly greater improvements in pain, range of motion and strength compared to the control group. Paraffin bath therapy appeared effective in reducing pain and maintaining strength for hand osteoarthritis over 12 weeks.
This randomized controlled trial investigated the effectiveness of pulsatile dry cupping therapy compared to no intervention for knee osteoarthritis. 40 patients were randomly assigned to receive either 8 cupping sessions over 4 weeks or no treatment. Outcome measures including pain, stiffness, physical function, and quality of life were assessed at 4 and 12 weeks. At 4 weeks, cupping resulted in significantly greater improvements in pain, physical function, and quality of life scores compared to the control group. Many benefits were still present at 12 weeks, though some scores were no longer significantly different. The study provides preliminary evidence that cupping may be an effective treatment for relieving symptoms of knee osteoarthritis.
To Follow Dermatological Treatment Regimens – Patients' and Providers' Vi...ricklock78
Adherence to long-term therapy for chronic illness is on average 50%. However, regarding adherence to derma- tological treatment the existing literature is limited. The aim of the study was to acquire an understanding of issues associated with adherence to dermatological therapy. Focus group interviews were used in two types of fora: patients with chronic dermatological diseases and health care providers, including doctors, nurses and pharmacists working in dermatological care. Results reveal the providers' view of a suboptimal rate of adherence.
This document summarizes three studies that evaluated the effectiveness of repositioning schedules for preventing pressure ulcers in hospitalized patients. A systematic review by Gillespie et al. found insufficient evidence from three randomized controlled trials to determine whether particular repositioning positions or frequencies reduced pressure ulcer development. A study by Bergquist-Beringer et al. found that patients who were routinely repositioned every 24 hours had a 14% lower risk of pressure ulcers. A systematic review by Moore et al. did not identify any randomized controlled trials comparing different repositioning techniques or frequencies.
This study compared cognitive rigidity and differentiation in patients with depression alone and patients with comorbid depression and fibromyalgia. Thirty-one patients with both depression and fibromyalgia were matched with 31 patients who had depression alone based on age, sex, and number of depressive episodes. Patients completed measures of depressive symptoms and cognitive structure using repertory grid technique. Results showed that depressed patients with fibromyalgia had higher levels of depressive symptoms, greater cognitive rigidity, and lower cognitive differentiation compared to depressed patients without fibromyalgia. This suggests more extreme and polarized thinking patterns in patients with comorbid depression and chronic pain. The findings could help inform future treatment approaches for this patient group.
Hyperbaric oxygen therapy (HBOT) facilitated healing of chronic foot ulcers in patients with diabetes according to a randomized controlled trial. In the trial, 94 patients with diabetic foot ulcers of at least 3 months duration were assigned to receive either HBOT or a placebo treatment of hyperbaric air over 40 sessions. At 1-year follow-up, complete healing of the index ulcer occurred in 52% of patients receiving HBOT compared to 29% of patients receiving the placebo air, a statistically significant difference. Fewer major amputations also occurred in the HBOT group compared to the placebo group. The study provides evidence that HBOT can help facilitate healing of chronic diabetic foot ulcers when used as an adjunct to standard
1) The study investigated the differences in cerebral activity and clinical efficacy between acupuncture and sham acupuncture treatment for functional dyspepsia (FD).
2) 72 FD patients were randomly assigned to receive either real acupuncture or sham acupuncture for 4 weeks. 10 patients from each group also underwent PET scans before and after treatment.
3) Results showed acupuncture was more effective at reducing dyspeptic symptoms compared to sham acupuncture based on clinical scores. Acupuncture also produced greater deactivation of brain regions like the brainstem, anterior cingulate cortex, insula, thalamus, and hypothalamus compared to sham acupuncture. Deactivation of these regions correlated with improvement in clinical scores for
Damage control surgery is a strategy used for critically ill patients with abdominal emergencies to control bleeding or contamination through an abbreviated initial surgery, allow physiological recovery, and perform definitive repair later. It has been applied to non-trauma emergencies like hemorrhage and sepsis. While evidence is limited to retrospective case series, damage control surgery appears to be a logical approach for severely ill general surgery patients based on its success in trauma. It facilitates life-saving intervention and stabilization before complete repair.
This document discusses the application of damage control surgery principles from trauma surgery to non-traumatic abdominal emergencies. Damage control surgery involves abbreviated laparotomy to control hemorrhage or contamination, followed by physiological resuscitation and delayed definitive repair. While evidence is limited to retrospective case series, damage control surgery is increasingly used for conditions like uncontrolled bleeding, sepsis, and mesenteric ischemia. It facilitates life-saving intervention for critically ill patients and allows physiological restoration before definitive repair. The benefits depend on careful patient selection and application of a staged surgical approach when patients present with physiological derangement from hemorrhagic or septic shock.
- A study was conducted at Green Pastures Hospital in Nepal to assess woundcare practices for pressure ulcers in leprosy patients and evaluate knowledge of wound prevention and treatment.
- A review of patient records from 2009-2014 showed reductions in ulcer healing time, readmissions for ulcers, and severe ulcers requiring surgery, suggesting improved care. However, current woundcare practices did not fully follow protocols.
- Focus groups and interviews with patients and staff found generally good knowledge of leprosy, ulcer causes, and prevention measures, but identified opportunities to strengthen woundcare and self-care management.
Consensus Guidelines For The Management Of Chronic Pelvic PainEliana Cordero
The document provides clinical practice guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC) for the management of chronic pelvic pain (CPP). It includes:
1) An overview of CPP, including its burden and complex multifactorial causes.
2) Recommendations across various areas of CPP management, including general assessment, myofascial pain, medications, imaging, and multidisciplinary care.
3) Evidence and guidelines related to specific sources of CPP, such as endometriosis, adnexal torsion, hysterectomy, and interstitial cystitis.
4) Emphasis on the need for improved education of healthcare professionals and research
This study compared remission rates in 5,848 rheumatoid arthritis patients from 24 countries using different definitions of remission. The overall remission rate varied substantially depending on the definition used, from 8.6% using the ACR definition to 19.6% using DAS28. Remission rates also varied considerably between countries. Regardless of the definition, factors associated with higher remission rates included male sex, higher education, shorter disease duration, fewer comorbidities, and regular exercise. The results indicate that reported remission rates need to be interpreted based on the specific definition of remission that was applied.
This study evaluated the effectiveness of a regenerating matrix therapy (RGTA/CACIPLIQ20) for treating chronic wounds. 16 patients with 22 chronic wounds received twice weekly applications of CACIPLIQ20 for up to 4 weeks. Wound size and pain were measured before, during, and after treatment. The results showed that CACIPLIQ20 significantly reduced wound size by 15-18% and pain levels by 60-70% within 4 weeks. Patient and clinician satisfaction with the treatment also remained high. The therapy may help facilitate wound healing and alleviate wound-related pain.
This randomized controlled trial found that subcutaneous methylnaltrexone effectively treated opioid-induced constipation in terminally ill patients. 48% of patients receiving methylnaltrexone had a bowel movement within 4 hours, compared to 15% of placebo patients. Pain scores and adverse events were similar between groups. While an effective treatment, methylnaltrexone's subcutaneous route and cost may limit its use in some settings like home hospice care. The study demonstrates the value of rigorous research methods to inform palliative care practice.
Gabapentin reduced acute pain after mastectomy and decreased the incidence of chronic pain in two studies. A single dose of gabapentin was ineffective for reducing thoracotomy pain when an epidural was also used. Regional anesthesia and intravenous lidocaine reduced chronic pain incidence after mastectomy or thoracotomy in several studies. Ketamine and intercostal cryoanalgesia did not reduce chronic pain. Total intravenous anesthesia may reduce post-thoracotomy pain in one study.
This document summarizes a meta-analysis of individual patient data from three large randomized controlled trials (ProCESS, ARISE, and ProMISe) that evaluated the effectiveness of early goal-directed therapy (EGDT) compared to usual care for treating septic shock. The meta-analysis included a total of 3,723 patients from 138 hospitals in 7 countries. The primary outcome was all-cause mortality at 90 days, with secondary outcomes including in-hospital mortality, length of stay, and costs. The meta-analysis found no significant difference in 90-day mortality between EGDT and usual care. EGDT was associated with longer intensive care unit and cardiovascular support, but higher costs. Subgroup analyses found no
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
Ginger compress therapy was studied to understand its effects on people with osteoarthritis. 10 participants received daily ginger compresses for a week. The compresses created:
1) A meditative state of relaxation and stillness of thoughts, allowing positive reconsideration of life's challenges.
2) A feeling of constant, penetrating warmth that spread throughout the body and increased relaxation.
3) A positive change in outlook, with past memories viewed with fresh insight and acceptance, renewing interest in the world.
This document describes a study examining the relationship between bisphosphonate (BP) treatment for osteoporosis and risks of general infection and osteonecrosis of the jaw (ONJ) using marginal structural models. The study used claims data from over 400,000 postmenopausal women to develop causal relationships while addressing time-dependent confounding and biases. Results from weighted Cox models suggested BP treatment was associated with a lower risk of general infection compared to no osteoporosis treatment or other osteoporosis medications. Results for ONJ risk were inconclusive due to low event rates.
The document provides updated guidelines from the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. It summarizes the evidence from systematic reviews on various topics related to opioid use. The guidelines consist of 16 evidence-based recommendations developed using the GRADE system. Some of the key recommendations include: (1) For patients with mild to moderate pain, starting with a step II opioid or low-dose step III opioid is recommended; (2) Morphine, oxycodone, and hydromorphone are recommended as first-choice step III opioids as they showed no important differences in efficacy or tolerability; (3) Immediate-release oral morphine administered every 4 hours
This research article examines the ethical dilemmas faced by palliative care physicians through surveys and interviews with 30 palliative care specialists in Mexico.
The study identified 113 common dilemmas, most frequently regarding sedation, home administration of opioids, and institutional regulations. It was observed that truth-telling and bidirectional trust between patients and providers are core to palliative medicine ethics. The most prominent virtues among participants were justice and professional humility. Physicians in palliative care see themselves most importantly as educators and advisers who provide medical assistance.
The research aims to better understand the values that guide decision-making in palliative care in order to improve care for patients at the end of life. It finds rediscovering virtues in clinical practice can
This study analyzed 2,430 cases of acute bronchiolitis in infants treated in the emergency departments of Spanish hospitals between October 2007 and March 2008. The majority of cases were mild, though many received multiple diagnostic tests and treatments. Treatments used in the acute phase included inhaled beta-2 agonists, antipyretics, oral steroids, and nebulized adrenaline, while in the maintenance phase included inhaled beta-2 agonists, oral steroids, oral beta-2 agonists, and antibiotics. The appropriateness of treatments was analyzed using consensus guidelines, finding 64% of acute phase and 55.9% of maintenance phase treatments were inappropriate. Significant variability was seen between hospitals.
This document summarizes 5 studies that compared maggot debridement therapy (MDT) to conventional debridement therapy (CDT) for wound healing. Most studies found MDT to be as effective as or better than CDT at removing dead tissue from wounds. Specifically, 2 studies found MDT removed only dead tissue, allowing faster healing, while 1 study found no difference in healing rates between MDT and CDT. The studies examined wounds in patients with diabetes and chronic wounds. Overall, the studies suggest MDT is a viable alternative to CDT, especially for wounds that require fast debridement.
Development of Best Practice Guidelines for Cutaneous T-Cell Lymphoma (CTCL) ...DUNCAN RASUGU
The use of the traditional method of whirlpools in controlling ulcerations in MF remains a great challenge. According to research, removal of the gross contaminants and toxic debris from the wounds together with the dilution of the surface bacteria is a threat that has been observed among many patients that undergo the traditional treatment. The purpose of this work is to develop the guidelines for an alternative treatment of wounds using Vashe Solution Therapy.
Gauri thy ca salivary whc research 3.30.12declen007
Two patterns of salivary pain were identified in patients who received 131I therapy for differentiated thyroid cancer between 7 days to 3 months after treatment: continuous pain and intermittent pain. Continuous pain lasted months or years for some patients, while intermittent pain episodes lasted minutes to weeks. Intermittent pain was more commonly triggered by eating than continuous pain. Further study is needed to better characterize these two patterns of salivary pain and their underlying causes to help clinicians manage patients' pain.
Hyperbaric oxygen therapy for wound managementPratikJugnake1
This study examined the effect of hyperbaric oxygen therapy (HBOT) combined with standard wound care for treating grade 3 diabetic foot ulcers according to the University of Texas wound classification system. The study found that of 206 patients with grade 3 ulcers who received HBOT plus standard care, 72% achieved complete or near-complete wound healing, while 13% required amputations. Patients who completed more sessions of HBOT, especially over 30 sessions, had better outcomes with fewer amputations. The study concludes that HBOT can help heal grade 3 diabetic foot ulcers when added to standard wound care.
This document summarizes two cases of radiation therapy accidents and their consequences. Case 1 involved a miscalculation of treatment time in Costa Rica in 1996 that led to an overexposure and the deaths of 17 patients. Case 2 occurred in Panama in 2000 when a treatment planning system incorrectly calculated treatment times after a change in data entry, overexposing 28 patients and killing 5. Accidental underexposure can lead to tumor mismanagement while overexposure causes early complications like necrosis and late complications in slowly-dividing tissues. Establishing quality assurance programs, training, and safety protocols can help prevent such accidents.
1) The study investigated the differences in cerebral activity and clinical efficacy between acupuncture and sham acupuncture treatment for functional dyspepsia (FD).
2) 72 FD patients were randomly assigned to receive either real acupuncture or sham acupuncture for 4 weeks. 10 patients from each group also underwent PET scans before and after treatment.
3) Results showed acupuncture was more effective at reducing dyspeptic symptoms compared to sham acupuncture based on clinical scores. Acupuncture also produced greater deactivation of brain regions like the brainstem, anterior cingulate cortex, insula, thalamus, and hypothalamus compared to sham acupuncture. Deactivation of these regions correlated with improvement in clinical scores for
Damage control surgery is a strategy used for critically ill patients with abdominal emergencies to control bleeding or contamination through an abbreviated initial surgery, allow physiological recovery, and perform definitive repair later. It has been applied to non-trauma emergencies like hemorrhage and sepsis. While evidence is limited to retrospective case series, damage control surgery appears to be a logical approach for severely ill general surgery patients based on its success in trauma. It facilitates life-saving intervention and stabilization before complete repair.
This document discusses the application of damage control surgery principles from trauma surgery to non-traumatic abdominal emergencies. Damage control surgery involves abbreviated laparotomy to control hemorrhage or contamination, followed by physiological resuscitation and delayed definitive repair. While evidence is limited to retrospective case series, damage control surgery is increasingly used for conditions like uncontrolled bleeding, sepsis, and mesenteric ischemia. It facilitates life-saving intervention for critically ill patients and allows physiological restoration before definitive repair. The benefits depend on careful patient selection and application of a staged surgical approach when patients present with physiological derangement from hemorrhagic or septic shock.
- A study was conducted at Green Pastures Hospital in Nepal to assess woundcare practices for pressure ulcers in leprosy patients and evaluate knowledge of wound prevention and treatment.
- A review of patient records from 2009-2014 showed reductions in ulcer healing time, readmissions for ulcers, and severe ulcers requiring surgery, suggesting improved care. However, current woundcare practices did not fully follow protocols.
- Focus groups and interviews with patients and staff found generally good knowledge of leprosy, ulcer causes, and prevention measures, but identified opportunities to strengthen woundcare and self-care management.
Consensus Guidelines For The Management Of Chronic Pelvic PainEliana Cordero
The document provides clinical practice guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC) for the management of chronic pelvic pain (CPP). It includes:
1) An overview of CPP, including its burden and complex multifactorial causes.
2) Recommendations across various areas of CPP management, including general assessment, myofascial pain, medications, imaging, and multidisciplinary care.
3) Evidence and guidelines related to specific sources of CPP, such as endometriosis, adnexal torsion, hysterectomy, and interstitial cystitis.
4) Emphasis on the need for improved education of healthcare professionals and research
This study compared remission rates in 5,848 rheumatoid arthritis patients from 24 countries using different definitions of remission. The overall remission rate varied substantially depending on the definition used, from 8.6% using the ACR definition to 19.6% using DAS28. Remission rates also varied considerably between countries. Regardless of the definition, factors associated with higher remission rates included male sex, higher education, shorter disease duration, fewer comorbidities, and regular exercise. The results indicate that reported remission rates need to be interpreted based on the specific definition of remission that was applied.
This study evaluated the effectiveness of a regenerating matrix therapy (RGTA/CACIPLIQ20) for treating chronic wounds. 16 patients with 22 chronic wounds received twice weekly applications of CACIPLIQ20 for up to 4 weeks. Wound size and pain were measured before, during, and after treatment. The results showed that CACIPLIQ20 significantly reduced wound size by 15-18% and pain levels by 60-70% within 4 weeks. Patient and clinician satisfaction with the treatment also remained high. The therapy may help facilitate wound healing and alleviate wound-related pain.
This randomized controlled trial found that subcutaneous methylnaltrexone effectively treated opioid-induced constipation in terminally ill patients. 48% of patients receiving methylnaltrexone had a bowel movement within 4 hours, compared to 15% of placebo patients. Pain scores and adverse events were similar between groups. While an effective treatment, methylnaltrexone's subcutaneous route and cost may limit its use in some settings like home hospice care. The study demonstrates the value of rigorous research methods to inform palliative care practice.
Gabapentin reduced acute pain after mastectomy and decreased the incidence of chronic pain in two studies. A single dose of gabapentin was ineffective for reducing thoracotomy pain when an epidural was also used. Regional anesthesia and intravenous lidocaine reduced chronic pain incidence after mastectomy or thoracotomy in several studies. Ketamine and intercostal cryoanalgesia did not reduce chronic pain. Total intravenous anesthesia may reduce post-thoracotomy pain in one study.
This document summarizes a meta-analysis of individual patient data from three large randomized controlled trials (ProCESS, ARISE, and ProMISe) that evaluated the effectiveness of early goal-directed therapy (EGDT) compared to usual care for treating septic shock. The meta-analysis included a total of 3,723 patients from 138 hospitals in 7 countries. The primary outcome was all-cause mortality at 90 days, with secondary outcomes including in-hospital mortality, length of stay, and costs. The meta-analysis found no significant difference in 90-day mortality between EGDT and usual care. EGDT was associated with longer intensive care unit and cardiovascular support, but higher costs. Subgroup analyses found no
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
Ginger compress therapy was studied to understand its effects on people with osteoarthritis. 10 participants received daily ginger compresses for a week. The compresses created:
1) A meditative state of relaxation and stillness of thoughts, allowing positive reconsideration of life's challenges.
2) A feeling of constant, penetrating warmth that spread throughout the body and increased relaxation.
3) A positive change in outlook, with past memories viewed with fresh insight and acceptance, renewing interest in the world.
This document describes a study examining the relationship between bisphosphonate (BP) treatment for osteoporosis and risks of general infection and osteonecrosis of the jaw (ONJ) using marginal structural models. The study used claims data from over 400,000 postmenopausal women to develop causal relationships while addressing time-dependent confounding and biases. Results from weighted Cox models suggested BP treatment was associated with a lower risk of general infection compared to no osteoporosis treatment or other osteoporosis medications. Results for ONJ risk were inconclusive due to low event rates.
The document provides updated guidelines from the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. It summarizes the evidence from systematic reviews on various topics related to opioid use. The guidelines consist of 16 evidence-based recommendations developed using the GRADE system. Some of the key recommendations include: (1) For patients with mild to moderate pain, starting with a step II opioid or low-dose step III opioid is recommended; (2) Morphine, oxycodone, and hydromorphone are recommended as first-choice step III opioids as they showed no important differences in efficacy or tolerability; (3) Immediate-release oral morphine administered every 4 hours
This research article examines the ethical dilemmas faced by palliative care physicians through surveys and interviews with 30 palliative care specialists in Mexico.
The study identified 113 common dilemmas, most frequently regarding sedation, home administration of opioids, and institutional regulations. It was observed that truth-telling and bidirectional trust between patients and providers are core to palliative medicine ethics. The most prominent virtues among participants were justice and professional humility. Physicians in palliative care see themselves most importantly as educators and advisers who provide medical assistance.
The research aims to better understand the values that guide decision-making in palliative care in order to improve care for patients at the end of life. It finds rediscovering virtues in clinical practice can
This study analyzed 2,430 cases of acute bronchiolitis in infants treated in the emergency departments of Spanish hospitals between October 2007 and March 2008. The majority of cases were mild, though many received multiple diagnostic tests and treatments. Treatments used in the acute phase included inhaled beta-2 agonists, antipyretics, oral steroids, and nebulized adrenaline, while in the maintenance phase included inhaled beta-2 agonists, oral steroids, oral beta-2 agonists, and antibiotics. The appropriateness of treatments was analyzed using consensus guidelines, finding 64% of acute phase and 55.9% of maintenance phase treatments were inappropriate. Significant variability was seen between hospitals.
This document summarizes 5 studies that compared maggot debridement therapy (MDT) to conventional debridement therapy (CDT) for wound healing. Most studies found MDT to be as effective as or better than CDT at removing dead tissue from wounds. Specifically, 2 studies found MDT removed only dead tissue, allowing faster healing, while 1 study found no difference in healing rates between MDT and CDT. The studies examined wounds in patients with diabetes and chronic wounds. Overall, the studies suggest MDT is a viable alternative to CDT, especially for wounds that require fast debridement.
Development of Best Practice Guidelines for Cutaneous T-Cell Lymphoma (CTCL) ...DUNCAN RASUGU
The use of the traditional method of whirlpools in controlling ulcerations in MF remains a great challenge. According to research, removal of the gross contaminants and toxic debris from the wounds together with the dilution of the surface bacteria is a threat that has been observed among many patients that undergo the traditional treatment. The purpose of this work is to develop the guidelines for an alternative treatment of wounds using Vashe Solution Therapy.
Gauri thy ca salivary whc research 3.30.12declen007
Two patterns of salivary pain were identified in patients who received 131I therapy for differentiated thyroid cancer between 7 days to 3 months after treatment: continuous pain and intermittent pain. Continuous pain lasted months or years for some patients, while intermittent pain episodes lasted minutes to weeks. Intermittent pain was more commonly triggered by eating than continuous pain. Further study is needed to better characterize these two patterns of salivary pain and their underlying causes to help clinicians manage patients' pain.
Hyperbaric oxygen therapy for wound managementPratikJugnake1
This study examined the effect of hyperbaric oxygen therapy (HBOT) combined with standard wound care for treating grade 3 diabetic foot ulcers according to the University of Texas wound classification system. The study found that of 206 patients with grade 3 ulcers who received HBOT plus standard care, 72% achieved complete or near-complete wound healing, while 13% required amputations. Patients who completed more sessions of HBOT, especially over 30 sessions, had better outcomes with fewer amputations. The study concludes that HBOT can help heal grade 3 diabetic foot ulcers when added to standard wound care.
This document summarizes two cases of radiation therapy accidents and their consequences. Case 1 involved a miscalculation of treatment time in Costa Rica in 1996 that led to an overexposure and the deaths of 17 patients. Case 2 occurred in Panama in 2000 when a treatment planning system incorrectly calculated treatment times after a change in data entry, overexposing 28 patients and killing 5. Accidental underexposure can lead to tumor mismanagement while overexposure causes early complications like necrosis and late complications in slowly-dividing tissues. Establishing quality assurance programs, training, and safety protocols can help prevent such accidents.
Pilot Study of Massage in Veterans with Knee OsteoarthritisMichael Juberg
This pilot study assessed the feasibility and preliminary efficacy of Swedish massage therapy for 25 veterans with knee osteoarthritis. The study found high retention and adherence rates, suggesting massage was feasible and acceptable for veterans. Veterans receiving 8 weekly one-hour massage sessions experienced statistically significant improvements in self-reported knee pain, stiffness, function, and quality of life, as well as trends toward improved range of motion. The results support further study of massage as a treatment approach for knee osteoarthritis in veterans.
Hyperbaric oxygen treatment for University of Texas grade.pptxPratik Jugnake
This study retrospectively analyzed 206 patients with grade 3 diabetic foot ulcers who received hyperbaric oxygen therapy (HBOT) in addition to standard wound care. The results found that the majority (67%) achieved complete or near-complete wound healing. Patients who did not complete the full course of HBOT sessions were more likely to require amputation. Patients without local ischemia had better overall results. While HBOT requires more research, this study adds to evidence it may improve healing outcomes for severe diabetic foot ulcers when added to standard care.
Radiotherapy for painful bone metastasesbigsky_2009
This document discusses radiotherapy treatment options for painful bone metastases. It summarizes that pain from bone metastases is commonly treated successfully with local external beam irradiation. There is controversy around whether single dose treatments requiring one visit or fractionated courses requiring multiple visits are more effective. While many radiotherapists still use fractionated regimens, the evidence shows that single fractions are as effective in relieving pain from bone metastases. For widespread bone metastases, hemibody irradiation should be considered to avoid repeated local treatments, though it is more toxic.
Effectiveness of Low-Level Lasers in the Management of Recurrent Aphthous Sto...DrHeena tiwari
This study assessed the effectiveness of low-level lasers in treating recurrent aphthous stomatitis. 30 subjects with minor, major, or herpetiform aphthae were treated with lasers and their pain was evaluated using VAS scores. For all groups, pain was significantly less after 24 hours and further reduced at 72 hours compared to pre-treatment levels. At 1 week, pain scores were minimal or zero. The results demonstrated that low-level lasers provide effective pain relief and accelerated healing for recurrent aphthous stomatitis lesions.
This study compared the success rates of traditional intraoral versus a new extraoral technique for reducing temporomandibular joint dislocations. 58 dislocation reduction attempts were randomly allocated to the two methods. The traditional intraoral method was successful in 86.2% of cases, while the new external method was only successful in 55.2% of cases, a statistically significant difference. While the external method has benefits of avoiding hand bites, the study found it had a lower success rate than the traditional intraoral approach and often required additional techniques for reduction. More research is needed to better evaluate the potential advantages and disadvantages of the new external reduction method.
This study compared outcomes of patients with MDR/XDR Acinetobactor baumannii pneumonia treated with tigecycline or colistin. 70 patients received either tigecycline (n=30) or colistin (n=40). There were no significant differences in clinical outcomes between the two groups except nephrotoxicity, which only occurred in the colistin group. While the study indicates comparable efficacy, limitations include its small size, retrospective design, and exclusions. Further large randomized studies are still needed to properly evaluate tigecycline and optimal treatment combinations for MDR infections.
Adverse effects of delayed antimicrobial treatment and surgical source contro...Manuel Pivaral
This study analyzed data from a cluster-randomized trial to assess the impact of timing of antimicrobial therapy and surgical source control on outcomes in patients with sepsis. It found that delays in antimicrobial treatment were associated with increased mortality and risk of progression to septic shock. Each hour of delay was associated with a 0.42% increase in mortality. Delays over 6 hours significantly increased mortality. Delay in surgical source control was also associated with decreased success of source control and increased mortality, though these effects were not significant after adjusting for confounders. The results suggest management of sepsis requires timely antimicrobial therapy and source control to optimize outcomes.
Aloe Vera vs. SSD in the Treatment of Burns-Clinical StudyJohn Fisher
This study compared the efficacy of Aloe Vera gel to 1% silver sulfadiazine cream for treating partial thickness burns. 50 patients with burns covering less than 25% of their total body surface area were randomly assigned to have their wounds dressed with either Aloe Vera gel or silver sulfadiazine cream. Patients treated with Aloe Vera gel showed significantly faster wound healing, with epithelialization beginning by the 5th day and complete healing within 40 days on average, compared to longer healing times for those treated with silver sulfadiazine. Aloe Vera gel also provided faster pain relief. The authors concluded that Aloe Vera gel demonstrated advantages over silver sulfadiazine for burn wound dressing by promoting earlier wound healing and pain relief
1) The document discusses various biophysical agents (BPAs) that can be used to treat and prevent pressure injuries, including electrical stimulation, phototherapy, ultrasound, negative pressure wound therapy, and hyperbaric oxygen.
2) Most studies show that BPAs like electrical stimulation can significantly improve wound healing and reduce wound size compared to standard wound care.
3) Common BPAs used for pressure injuries include electrical stimulation, which has strong evidence and recommendations for use, as well as phototherapy, ultrasound, negative pressure wound therapy, and hyperbaric oxygen. These modalities aid wound healing in various ways such as increasing blood flow and promoting granulation tissue formation.
The preoperative administration of low doses of ketamine and clonidine before induction anesthesia appeared to provide benefits in morbidly obese patients undergoing open bariatric surgery. Patients receiving ketamine and clonidine required less sevoflurane, lower doses of fentanyl, and had a shorter time to tracheal extubation compared to controls. They also consumed less tramadol postoperatively and reported less pain in the first 6 hours based on visual analog scale scores. The combination of ketamine and clonidine allowed for reduced doses of anesthetic drugs while improving postoperative recovery outcomes.
Cutimed® Epiona is a new 3D MatrixTM technology that was shown to fast-track healing in a clinical study of 31 patients with chronic wounds. After 3 weeks, the mean reduction in wound area was almost 40% and 14 wounds were reduced by 50% or more. Complete wound healing occurred in 3 wounds within 3 weeks. The study demonstrated Cutimed® Epiona's ability to enhance tissue generation and promote healing in stalled wounds through its unique porous structure and scaffold that mimics the extracellular matrix.
The main findings of upper endoscopy in 133 patients with laryngopharyngeal reflux were:
1. Gastritis was found in 77% of patients, esophagitis in 59%, and hypofunction of the cardia in 40%.
2. Hiatal hernia was identified in 32% of patients.
3. Barrett's esophagus and neoplasms were found in 9% and 2.2% of patients respectively.
4. Only 12% of patients had a normal endoscopy.
5. Helicobacter pylori was positive in 30% of patients.
The dry needling of myofascial pain syndrome trigger points provided pain relief compared to sham needling.
Application of Pstim in Clinical Practice MaxiMedRx
The P-Stim and ANSiStim™ miniaturized device is designed to administer auricular point stimulation treatment over several days. The ear provides numerous points for stimulation within a small area. Stimulation is performed by electrical pulses emitted through strategically positioned needles. The ANSiscope device monitors the pain condition of the patient before, during and after the treatment.
The P-Stim and ANSiStim™ point stimulation therapy is mainly used to treat pain. Use of the device is recommended for pre-operative, intra-operative and post-operative pain therapy as well as for the treatment of chronic pain. DyAnsys is researching the possibilities of using this concept for the treatment of depression, addiction and allergy.
P-Stim and ANSiStim™ therapy allows continuous point stimulation over a period of several days while offering the patient a high degree of comfort and mobility. Use of the P-Stim and ANSiStim™ therapy provides advantages over drug therapy by minimizing possible side-effects caused by pain medications (i.e. opioid). In most cases, the patient continues to lead a normal life without side effects or any loss of quality of life.
This survey aimed to assess clinicians' use of stereotactic radiotherapy and targeted therapies for metastatic renal cell carcinoma and determine support for future clinical trials. The primary objective was to evaluate the proportion of clinicians using radiotherapy for metastatic renal cell carcinoma. Secondary objectives included evaluating the proportion using targeted therapies and radiotherapy simultaneously, stopping targeted therapies for radiotherapy, and supporting further research. The online survey was distributed to members of urology and oncology groups in Australia and New Zealand to collect data on current practices. Results and conclusions will be presented at an upcoming conference.
ABSTRACT- The treatment of carbuncle is early administration of antibiotics and surgery. The commonest surgical approach is Saucerization and Incision & Drainage (I&D). Two cases are presented here, one underwent Saucerization and then primary split thickness skin grafting. Another un-derwent I&D for her carbuncle. They were followed up for 8 weeks to assess their outcome. Saucerization produced the shortest length of hospital stay while I&D resulted in shortest wound healing. As a new modality of treatment now-a-days two new modalities gaining popularity for better cosmetic purpose: primary split thickness skin grafting & transposition of local skin/musculocutaneous flap.
Keywords: carbuncle, surgery, good glycemic control
This study evaluated the effectiveness of progressive muscle relaxation (PMR) exercises in reducing pain and fatigue among 100 hospitalized cancer patients receiving radiotherapy. The patients were randomly assigned to an intervention group that received four PMR sessions over 4 weeks or a control group that received standard treatment. Pain was measured using a numerical pain rating scale and fatigue was measured using a cancer fatigue scale before and after the intervention. The results showed a significant reduction in reported pain and fatigue scores in the PMR group compared to the control group, indicating that PMR exercises can effectively reduce pain and fatigue in hospitalized cancer patients receiving radiotherapy when used as an adjuvant therapy.
The document summarizes an evidence based project presentation on negative pressure wound therapy (NPWT) for diabetic foot ulcers (DFU). It includes objectives of the presentation, background information on evidence based nursing practice and DFUs. It also outlines the research question comparing NPWT to standard moist wound therapy for healing diabetic foot ulcers over 60 days. A literature review was conducted and findings from 5 systematic reviews showing NPWT increases healing rates for DFUs are summarized. National guidelines also support the use of NPWT for DFUs.
Nejm journal watch practice changing articles 2014Jaime dehais
This document provides a compilation of summaries of the latest practice-changing articles from NEJM Journal Watch. It includes summaries of articles on topics such as delayed or no antibiotic prescriptions for respiratory infections, physical therapy being beneficial for knee osteoarthritis, low-dose steroids being better than high-dose for COPD exacerbations, a diagnostic algorithm for upper-extremity deep vein thrombosis, evidence that meniscal tears may not require surgery, improvements in mental health with smoking cessation, doubts cast on flu drugs by meta-analyses, the 2014 recommended childhood immunization schedule, sentinel lymph node biopsies for thin melanomas, age-specific d-dimer cutoffs for pulmonary embolism, evidence that FOD
Similar to Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review (20)
Manual Clínico de Acupuntura Médica para Tratamento da Síndrome Pós-COVID-19 tem como proposta didática minorar os danos e as sequelas que se seguem após a resolução dessa crítica doença. Não se dirige à fase aguda. O livro aprofunda os conhecimentos.
Além de aprofundar os conhecimentos da Fisiopatologia da doença, sobretudo questiona como a Acupuntura Médica pode contribuir para a recuperação. Converge para a síntese de conhecimentos: a racionalidade médica ocidental com a visão milenar da Medicina Tradicional Chinesa.
Aplica a Acupuntura em suas diversas técnicas em microssistemas.
Manual Clínico de Acupuntura Médica para Tratamento da Síndrome Pós-COVID-19 apresenta 4 Editores, 7 Editores Associados, 76 Colaboradores, 54 capítulos, em um total de 464 páginas.
Seu público-alvo é formado por médicos acupunturistas e das demais Especialidades.
MENSAGEM
do PRESIDENTE
Chegamos a 15ª edição do Congresso Brasileiro de Dor – CBDOR.
Diante do difícil momento que vivemos, nos apegamos à certeza dos dias melhores que acreditamos estarem por vir. Estamos nos encontrando dentro desse “novo normal” e bastante empenhados em organizar um encontro memorável e, sem dúvida alguma ofereceremos um conteúdo científico de altíssima qualidade.
Convidaremos profissionais de renome para fomentar busca por inovações, novas abordagens terapêuticas e diagnósticos da dor. Essa diretoria, juntamente com sua comissão cientifica, nossos comitês e a equipe SBED não medirá esforços para garantir o sucesso do nosso congresso, que tem como maior interesse a sua satisfação e atualização.
Será uma oportunidade única para troca de experiências e retorno ao convívio com nossos colegas.
Esperamos por você.
Paulo Renato Barreiros da Fonseca
Presidente SBED – Gestão 2020 / 2021
1) O documento discute a prática da acupuntura sob a ótica da medicina ocidental e os riscos da sua prática por não médicos.
2) Também aborda a importância de se complementar o conhecimento milenar da acupuntura com os avanços da ciência ocidental para o desenvolvimento da especialidade.
3) Por fim, relata o lançamento de uma nova revista científica pelo Conselho Regional de Medicina de São Paulo voltada para residentes e estudantes de medicina.
O documento discute a acupuntura como uma modalidade terapêutica da Medicina Tradicional Chinesa que utiliza agulhas para tratar diversas doenças e sintomas. A acupuntura é reconhecida mundialmente como um tratamento eficaz para dor e está sendo cada vez mais utilizada no Brasil em hospitais públicos. No entanto, existem alguns cuidados a serem tomados ao escolher um profissional e durante as sessões de acupuntura.
O documento descreve o programa oficial do 14o Congresso Brasileiro de Dor, que ocorrerá entre os dias 19 a 22 de junho de 2019 no Centro de Convenções Frei Caneca em São Paulo. O programa inclui palestras sobre radiofrequência, bruxismo, termografia, terapias por ondas de choque e ultrassom nos bloqueios.
O documento descreve o programa do XXIII Congresso Brasileiro de Acupuntura, que ocorrerá em Fortaleza entre 20 e 23 de novembro de 2019. O tema principal será dor e contará com palestrantes nacionais e internacionais renomados para discutir diversos assuntos relacionados à fisiopatologia, diagnóstico e tratamento da dor por meio da acupuntura.
Curso de Especialização em Acupuntura Médica e Medicina Chinesa do CEIMEC - Turma 2019
Início: Março de 2019
Curso reconhecido pelo Colégio Médico Brasileiro de Acupuntura (CMBA). Válido para Prova de Título de Especialista em Acupuntura (TEAC)
Belo Horizonte, Minas Gerais - 27, 28 e 29 de Julho de 2018
Organização: Colégio Médico Brasileiro de Acupuntura (CMBA)
Presidente: Dr. Hildebrando Sábato
Participação palestrantes:
Dr. Hong Jin Pai
Dr. Marcus Yu Bin Pai
O documento discute o tratamento da lombalgia crônica através da acupuntura. Resume estudos que mostram que a acupuntura é mais eficaz na redução da dor do que nenhum tratamento ou acupuntura simulada. Um estudo específico comparou acupuntura profunda com acupuntura superficial em pontos fixos e encontrou melhora significativa na qualidade de vida apenas para o grupo que recebeu acupuntura profunda.
O documento dá as boas-vindas aos participantes do VIII Congresso Interdisciplinar de Dor da Universidade de São Paulo (CINDOR) e fornece informações sobre o evento, incluindo comissões organizadoras, palestrantes convidados, programação, trabalhos científicos e parceiros.
Este documento fornece informações sobre o Dr. Marcus Yu Bin Pai, médico especialista em acupuntura e fisiatria. Apresenta detalhes sobre a formação acadêmica e experiência profissional do Dr. Pai, além de descrever brevemente a acupuntura, suas indicações e mecanismos de ação.
A Terapia de Ondas de Choque é um método de tratamento não invasivo, que utiliza ondas mecânicas de alta pressão, para o tratamento de diversas condições musculoesqueléticas, sendo bastante utilizado na fisiatria, medicina esportiva, e ortopedia.
Seus principais benefícios são o rápido alívio da dor e restauração da mobilidade.
Além disso, não é necessário o uso de anestésicos, fazendo com que seja uma terapia ideal para acelerar a recuperação e a cura de diversas patologias que causam dor aguda ou crônica.
Por Dr. Marcus Yu Bin Pai
Evidências científicas da Acupuntura no tratamento de dores crônicas. A Acupuntura é um método terapêutico que consiste na inserção de agulhas em pontos específicos para a estimulação e liberação de neurotransmissores, para o controle de dor, e outras patologias. Aprenda mais sobre a Acupuntura e o que ela pode fazer por você.
O Dr. Hong Jin Pai é médico pioneiro na área de Acupuntura no Brasil, formado pela Faculdade de Medicina da USP, atuando no atendimento ambulatorial assistencial e didático no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), participando e coordenando de estudos científicos no HC-FMUSP, e também como especialista em Acupuntura em sua clínica particular há mais de 25 anos.
O Dr. Hong é também autor e colaborador de diversos livros tanto para o público médico e público leigo nas áreas de Acupuntura e Dor, tendo colaborado e escrito dezenas de livros.
Já organizou e participou de dezenas de congressos internacionais de Acupuntura e Dor tanto no Brasil como no exterior. Atuou politicamente na luta para o reconhecimento da Acupuntura como especialidade médica pelo Conselho Federal de Medicina, e é médico professor em cursos de especialização em Acupuntura no HC-FMUSP e no Centro Integrado de Medicina Tradicional Chinesa (CEIMEC), colaborando na formação de milhares de médicos acupunturistas.
O Dr. Hong é formado em 1979 pela Faculdade de Medicina da Universidade de São Paulo (FMUSP), fez Residência Médica em Patologia Clínica. Logo após o término da especialização, foi o primeiro médico brasileiro a fazer pós-graduação em Acupuntura e Medicina Tradicional Chinesa nos Hospitais mais conceituados da China, onde aprendeu com os melhores mestres. Retornando ao Brasil em 1988, iniciou o tratamento por Acupuntura na Liga de Cefaléia e na Liga de Dor da FMUSP.
1. O documento apresenta um estudo sobre os efeitos da acupuntura em pacientes com asma leve e moderada.
2. 183 pacientes participaram do estudo randomizado e controlado, porém apenas 74 concluíram o tratamento.
3. Os resultados indicaram que a acupuntura pode melhorar sintomas, função pulmonar e qualidade de vida em alguns pacientes com asma.
Este estudo epidemiológico avaliou a prevalência, causas e fatores associados à dor crônica no município de São Paulo. A prevalência de dor crônica encontrada foi de 28,7%, sendo maior em mulheres, na faixa etária de 50-59 anos e em indivíduos obesos. Problemas na coluna e dor de cabeça/enxaqueca foram as comorbidades mais comuns entre os entrevistados com dor crônica.
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TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
1. 35
REVIEWARTICLE Benefits of extracorporeal shockwave in the
treatment of skin ulcers: a literature review
Marcus Yu Bin Pai1
, Juliana Takiguti Toma1
, Danielle Bianchini Rampim2
, Marta Imamura3
,
Linamara Rizzo Battistella4
1
Resident Physician, HC FMUSP Physical Medicine
and Rehabilitation Institute.
2
Assistant Physician, HC FMUSP Physical Medicine
and Rehabilitation Institute.
3
Physiatrist, HC FMUSP Physical Medicine and
Rehabilitation Institute.
4
Full Professor in the Department of Legal
Medicine, Medical Ethics, Social and Occupational
Medicine, University of São Paulo School of
Medicine.
Mailing address:
Instituto de Medicina Física e Reabilitação
Marcus Yu Bin Pai
Rua Domingo de Soto, 100
CEP 05716-150
São Paulo - SP
E-mail: marcus.pai@hc.fm.usp.br
Received on March 01, 2016.
Accepted on March 16, 2016.
DOI: 10.5935/0104-7795.20160008
ABSTRACT
Extracorporeal shockwave therapy (ESWT) has analgesic and anti-inflammatory effects. With the evolu-
tion and comprehension of its biological and physical mechanisms, the application of ESWT on other
pathologies has also been studied, especially in musculoskeletal diseases. Recently, studies on animal
models have shown its angiogenic capacity and a higher rate of local re-epithelization. These small stud-
ies led to few trials using low-energy, radial ESWT to treat problematic chronic skin ulcers. Skin ulcers
have diverse etiologies, ranging from pressure ulcers, burns, venous or arterial ulcers, and even diabetic
ulcers. Their treatment is usually a challenge, due to the long-term treatment and high costs. Objective:
To review the literature and evaluate the efficacy of ESWT in caring for skin ulcers of various etiologies:
diabetic ulcers, pressure ulcers, burns, post-traumatic ulcers, venous and arterial ulcers. Method: A lit-
erature review was made, with only human trials included. Results: 9 articles were selected that fulfilled
the eligibility criteria. The studies included evaluations of 788 patients. The manuscripts demonstrated a
largevariabilityregardingtheinterventionsmade.Therewasheterogeneityregardinginterventiontime,
number of pulses, frequency of sessions, and also the number of sessions, energy density used, and the
typeofshockwaveusedintherapies.Someoftheincludedtrialsfoundahigherrateofcompletewound
healing and faster epithelization in patients with chronic lesions, unresponsive to the traditional mea-
sures. However, there were few studies in the literature with proper methodological quality. Conclusion:
ESWT is a promising alternative for the treatment of patients unresponsive to conventional measures.
The results are promising, although the evidence regarding wound healing and acceleration of wound
healing is still limited. The studies selected did not report any significant side effects.
Keywords: High-Energy Shock Waves, Treatment Outcome, Therapeutics
2. 36
Acta Fisiatr. 2016;23(1):35-41 Pai MYB, Toma JT, Rampim DB, Imamura M, Battistella LR
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
INTRODUCTION
Extracorporeal shock wave therapy
(ESWT) was originally used for lithotripsy of
kidney stones.1
In recent years, however, with
the evolution and understanding of its physi-
cal and biological mechanisms, its application
was studied in various other diseases, mainly
in bone, muscle, and tendon affections such
as pseudoarthrosis, plantar fasciitis, and later-
al epicondylitis.1,2,3
In ESWT, mechanical acoustic waves
are transmitted through liquid and gaseous
means, with their biological effect coming
from the mechanical action of these ultrasonic
vibrations on the tissues.1
This technique has an analgesic and anti-in-
flammatory action,2,3
it induces neovascular-
ization,4
and its mechanical stimulation results
in the proliferation of various cells such as the
osteoblasts.5
Other studies have demonstrated
its angiogenic capacity and improvement of mi-
crocirculation in animal models,6,7,8
resulting in
an accelerated angiogenesis and higher rate of
local re-epithelization. According to Takahashi,
it also presents an antibacterial effect against
Staphylococcus aureus.9
These studies led to the beginning of us-
ing radial low energy ESWT in the treatment
and management of various problematic skin
lesions. Cutaneous ulcers have different eti-
ologies, ranging from pressure ulcers, burns,
arterial and venous ulcers, and even diabetic
ulcers.10,11
These injuries are still an important
cause of morbidity and mortality, presenting
an impact on the quality of life of patients due
to complications such as pain, infections, and
amputations, as well as on their relatives, re-
sulting not only in a health problem, but also
in a social and economic one.11,12
Their treatment is challenging due to its
prolonged duration (resulting in difficulties
regarding the clinical follow-up) and also high
costs.11,12
The conservative treatment gener-
ally consists of a multidisciplinary team, in-
volving mainly a medical and a nursing team
to perform the cleaning, hydration, debride-
ment, and dressing of the lesions.11,12
OBJECTIVE
To evaluate the efficacy of ESWT in the
healing of ulcers of various etiologies: diabet-
ic, pressure, burns, post-traumatic, venous
and arterial vascular, through a literature re-
view.
Secondary objectives
• To compare ESWT with other estab-
lished therapies.
• To evaluate the different prescrip-
tions of ESWT in relation to the quan-
tity of pulses, frequency, number of
sessions, and energy density used.
METHODS
Search methods
A literature review was conducted using
the following scientific databases: Medline/
Pubmed, SciELO, LILACS, Cochrane, and PEDro.
The following keywords were used in English:
shock waves AND skin ulcers, shock waves
AND diabetic foot, shock waves AND leg ul-
cer, shock waves AND foot ulcer, shock waves
AND ulcer, shock waves AND wound healing,
and their respective terms in Portuguese. Two
authors made the selection and evaluation of
articles independently. With the selected arti-
cles, the authors gathered to discuss the inclu-
sion and exclusion of articles in the review. In
case there was disagreement between the re-
viewers, a third reviewer would be requested
to analyze the differences. However, this was
not necessary.
Types of studies
Only clinical studies on humans were in-
cluded in this review. Articles in Portuguese
and English were included. The search was
limited to articles published between 2000
and 2014. Articles repeated in the databases
were excluded as well as studies of experi-
mentation on animals and case reports.
The methodological quality and the risk
of bias of the studies were evaluated by two
authors using the Jadad and the Van Tulder
scales. Due to the small number of clinical
studies on humans, low methodological quali-
ty and few randomized and controlled studies,
these were also included in this review.
Types of participants in the studies
Adults (over 18 years of age), with acute or
chronic ulcers of various causes, such as ulcers
on diabetic feet, vascular ulcers, venous and
arterial ulcers, pressure ulcers, ulcers caused
by burns, and post-traumatic ulcers.
Types of interventions
This review included studies with patients
receiving only shock wave therapies, and also
comparative studies with patients in other
groups receiving other treatments, such as
the standard cleaning treatment for injuries
and dressings, and also therapy in the hyper-
baric chamber.
Types of outcome measurements
Studies included presented at least one of
these primary outcomes:
• Size of lesion
• Closure of the lesion
• Healing time
• Pain
RESULTS
Description of the studies
Through electronic search, 24 articles
were found with 9 articles meeting the inclu-
sion criteria (Chart 1 and Chart 2). Duplicate
articles were manually removed. The studies
included comprised 788 patients.
Included were 3 articles from Austria (590
patients), 2 from Italy (70 patients), 1 from
Taiwan (77 patients), 1 from Germany (28 pa-
tients), 1 from Spain (15 patients) and 1 from
England (8 patients). All the articles were pub-
lished in the English language.
Description of individual studies
Moretti et al.13
assessed 30 patients with
ulcers on diabetic feet. The patients were
randomly divided into 2 groups, with the first
group (B) receiving standard treatment with
debridement and wound dressing, and the
second group (A) receiving ESWT. The ESWT
group received 3 applications of shock waves,
every 72 hours, with duration of 1 to 2 min-
utes. They used 100 pulses per cm2
of lesion
with density in the flow of 0.03 mJ/mm,2
with
radial focus. The size of ulcers was evaluated
through photos and calculation of the areas
through computer software. The results were
tabulated in terms of days needed for the clos-
ing of the ulcers. The proportion of patients (in
%) that presented closing of the lesions and
the rate of re-epithelization between the two
groups were also compared. Group A showed
closing of 53.33% of lesions by the end of the
study, compared to 33.33% from group B. As
for ulcers healed during the 20 weeks, the
mean time was 60.8 ± 4.7 days in group A and
82.2 ± 4.7 days in group B (p < 0.001). There
was also a statistically significant difference
in the rate of re-epithelization between the 2
groups, with 2.97 ± 0.34 mm2
/die in group A
and 1.30 ± 0.26 in group B (p < 0.001). Thus,
3. Acta Fisiatr. 2016;23(1):35-41 Pai MYB, Toma JT, Rampim DB, Imamura M, Battistella LR
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
37
Chart 1. Selected studies, ESWT= extracorporeal shock wave therapy
Authors/
Year
Study Subjects Evaluation criteria Intervention Results
Moretti
et al.13
2009
30 patients with ulcers in
diabetic feet
- Area of lesion
- Closing rate of the
lesion
- Closing time
1- Active group (A):
standard treatment
+ ESWT
2- Control group (C):
standard treatment
After 20 weeks of treatment,
complete closure of ulcer in
53.33% of the patients in Group
A, and 33.33% in group C.
Average time for closing the
lesion was 60.8 days in Group A
and 82.2 in group C (p < 0.001).
Improvement in the rate of
re-epithelization of 2.97 mm2
/die
in group A and 1.30 mm2
/die in
group C (p < 0.001)
Larking
et al.14
2010
8 patients with pressure
ulcers (total of 9 ulcers).
- Area of lesion 1- Active group (A):
Radial ESWT
2- Sham group
(S): Placebo ESWT,
without emission of
waves.
Crossover after
2-week washout
Patients initially in Group A: dif-
ference in lesion size of -0.83, 8
weeks after the ESWT (p < 0.05).
Patients initially in group S: diffe-
rence in lesion size of -1,15, after
8 weeks of ESWT (p < 0.05).
Schaden
et al.15
2007
208 patients with
chronic and acute skin
ulcers
- Closing rate
of lesion (100%
epithelization)
1 single group with
ESWT
156 (75%) patients with comple-
te closure.
32 patients lost.
81% of patients with lesions <
10 cm2 had healed lesions, vs.
61.8% of the lesions > 10 cm2
(p
= 0.005)
Wang
et al.16
2010
77 patients with ulcers
on diabetic feet
- Assessment of the
area of lesion
- Evaluation of blood
perfusion
- Histopathological
studies
1- Active group (A):
ESWT(n = 39)
2- Control group (C):
hyperbaric oxygen
therapy (n = 38)
57% (A) vs. 25% (C) completely
closed ulcers (p = 0.003)
>50% improvement in 32% (A) vs.
15% (C) (p = 0.071).
Without changes in 11% (A) vs.
60% (C) (p < 0.001)
Wolff
et al.17
2011
282 patients with
chronic skin ulcers
- Mortality after
30 days of ESWT
(hemorrhagic shock,
PTE, ICVD)
- Closing rate of
lesions.
Single group,
one arm, open
prospective study
Complete closing of lesion in 191
patients ( 74.03%). 24 patients
lost.
Arnó
et al.18
2009
15 patients with burns in
the trauma center
- Area of lesion
- Healing Rate
Single group, one
arm
1 patient lost. 12 with complete
closure of the lesion, after 15
days on average.
Saggini
et al.19
2008
40 patients with
ulcers of various
etiologies, with lesions
more than 3 months,
with no response to
conservative treatment.
- Evaluation of re-
epithelization rate
- Pain assessment
(NBS scale)
- Evaluation of
exudate, granulation
tissue, and fibrin /
necrotic tissue.
1- Group A (ESWT) 30
patients (32 ulcers)
2- Grupo Controle
- Control Group
- 10 patients with
standard treatment
Non-randomized
Complete closure in 16 (50%)
in group A. in all lesions, there
was a decrease in the exudate,
increase of granulation tissue,
reduction in lesion size after
4-6 sessions (p < 0.01), and
reduction of pain (p < 0.001).
Comparison with control group
showed improvement in the
process of healing (p < 0.01)
Ottoman
et al.20
2010
28 patients with skin
graft
- Evaluation of
the time for re-
epithelization
1- Group A (ESWT)
2- Control group -
standard treatment
Improvement of the time for
re-epithelization, with 13.9 ± 2.0
days for the ESWT group and
16.7 ± 2.0 days for the control
group (p = 0.0001)
Dumfarth
et al.21
2008
100 patients with vein
graft for myocardial
revascularization
- ASEPSIS score 1- Group A (ESWT)
2- Control group -
standard treatment
ASEPSIS reduced in the ESWT
group indicating better healing
(4.4 ± 5.3) and (11.6 ± 8.3, p =
0.0001).
Lower infection rate in the ESWT
group (4% vs. 22%, p = 0.015)
both the improvement rate and the healing
time were better in the ESWT group, with a
statistically significant difference.
Larking et al.14
evaluated 8 hospitalized
patients, with 9 pressure ulcers. The patients
were randomly allocated into two groups, the
first (A) with ESWT treatment, and the sec-
ond, (B) with an ESWT placebo. The ESWT was
performed with 200 impulses, a frequency of
5 per second, and 100 pulses per cm2
with en-
ergy of 0.1 J/mm2
. The patients included were
initially observed for a period of 3 weeks, be-
ing then submitted to treatment with ESWT
or a placebo, with 4 weekly sessions. After a
2-week washout period, there was an inter-
section of the groups. The lesion area was
examined after the therapy sessions for 12
weeks. In the group that received the ESWT
treatment, there was a statistically significant
improvement 6 weeks after the beginning of
treatment (difference in lesion size of -0.83,
p < 0.05, 8 weeks after the ESWT). However,
in the group that received the placebo treat-
ment, there was a statistically significant im-
provement 14 weeks after the beginning of
the study (or 8 weeks after the beginning of
the ESWT), with a difference in lesion size of
-1,15, p < 0.05 after 8 weeks of ESWT.
Schaden et al.15
assessed 208 patients
with cutaneous lesions of various etiologies,
including trauma, arterial or venous insuffi-
ciency, pressure ulcers, and also burns. The
patients were combined into a single group
treated with ESWT. Radial and superficial ESWT
were applied, with a median of 2.8 sessions of
ESWT, with an average duration of 3 minutes.
Of the 208 patients included in the article, 176
completed the treatment, with 156 of these
(88.6%) presenting complete closing of their
lesions. Complete closure of the lesion was
associated with its size, where 81% of patients
with lesions < 10 cm2
had complete closure
compared to 61.8% of those with lesions >
10 cm2
(p = 0.005). The duration of the lesion
also influenced the healing, with 83% closure
for lesions with < 1 month compared to 57.1%
for lesions with > 1 month (p < 0.001). Younger
patients presented more healing improvement
than did the elderly (p < 0.001). Complete clo-
sure showed no statistically significant differ-
ence for patients with diabetes (12/14, 85.7%)
or without it (144/194, 74.2%).
Wang et al.16
evaluated 72 patients with
ulcers on diabetic feet. These were random-
ly divided into 2 groups: group A received
ESWT, and group B received hyperbaric oxy-
gen therapy (HOT). The ESWT group received
treatment with at least 500 impulses at 4 Hz
with power of 0.23 mJ/cm2
, every 2 weeks for
6 weeks. Group B received hyperbaric oxygen
therapy daily, with a total of 20 sessions. There
was complete closure in 57% and 25%, respec-
tively (p = 0.003), improvement of ≥ 50% in
32 compared to 15% (p = 0.071), no changes
in 11% and 60% (p < 0.001), and no patient
showed worsening of their lesions in either
the ESWT or HOT groups. In the histological
analysis, greater concentration, proliferation,
and cellular activity was found in patients
after ESWT than after HOT. There was also a
significant increase in intravenous nitric oxide,
VEGF, and expression of PCNA after ESWT. A
significant improvement of local blood perfu-
sion was also present after ESWT (p < 0.04),
and not after HOT (p = 0.140).
4. 38
Acta Fisiatr. 2016;23(1):35-41 Pai MYB, Toma JT, Rampim DB, Imamura M, Battistella LR
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
Wolff et al.17
evaluated 282 patients from
September 2003 to February 2007. The pa-
tients included presented cutaneous ulcers
of various etiologies (excluding 2nd or 3rd
degree burns) with duration of more than 30
days. Thirty days after the last ESWT session,
the primary outcome was death while second-
ary outcomes were the closure rate of lesions,
and the number of ESWT sessions needed,
the rate of lesions that did not heal and the
number of sessions until the abandonment
of treatment. The first 2 ESWT sessions were
weekly, with the interval increased to 2 weeks
after the second session. An average of 167
pulses/cm2
were used, with a frequency of 5
Hz and energy of 0.1 mJ/mm2
. The Wound Bed
Score (WBS) was applied before each appli-
cation; this is a scale that offers a predictive
factor as to the success of the healing, incor-
porating the following parameters in its score:
edges, presence of pressure ulcers, greater
depth of lesion, amount of exudate, edema,
perilesional dermatitis, perilesional fibrosis,
and local hyperemia. Twenty-four (8.51%) of
the patients were lost in the follow-up. No pa-
tient died within 30 days of the last ESWT ses-
sion. 191 patients (74.03%) had their injuries
healed, with an average of 2 sessions needed.
Lesions aged 4 to 12 weeks showed a success
rate of 82.23%. Lesions aged 4 to 12 months
presented complete healing in 63.64%, while
in lesions with duration greater than 1 year
the rate was 28.57%.
Arnó et al.18
conducted a prospective pilot
study on 15 patients with burns on less than
5% of the body surface, and applied 2 ESWT
sessions to them, on the 3rd and 5th days
after the lesions occurred. The shock waves
were applied with 100 impulses/cm2
and en-
ergy of 0.15 mJ/mm2
. Before each session,
laser Doppler was used to evaluate the depth
of the lesion and perfusion alterations. After
that, the patients were evaluated weekly for
one month, and then monthly. If there was
no re-epithelization of the lesion in up to 2.5
weeks after ESWT, surgical debridement was
performed on the lesion. One patient was lost,
and 12 other patients presented complete clo-
sure of their lesions. Thus, 2 patients who did
not report improvement underwent surgical
debridement and skin graft.
Saggini et al.19
evaluated 40 patients
with chronic ulcers of the lower limbs, of
various etiologies, such as diabetic ulcers,
vascular, and post traumatic, who had no
response to conservative treatment. The
mean age of the lesions was 5.3 months
and the mean age of the patients of 60.4
years. Thirty patients received ESWT (32
ulcers), and 10 received conservative mea-
sures and served as a control group. In the
ESWT group, the average area of ulcers was
initially 5.29 cm2
, with dimensions ranging
from 1.2 x 2 to 5.4 x 2.8 cm. Between the
4th and 6th ESWT session, there was com-
plete closure of the lesions in 16 of the
patients in the ESWT group (50%) with p <
0.01. All the lesions showed a decrease of
exudate, and an increase in the percentage
of granulation tissue in relation the necrotic
tissue/fibrin (p < 0.01). There was also a re-
duction in pain after the ESWT (p < 0.001).
Ottoman et al.20
evaluated the rate of
re-epithelization in the skin grafts of 28 pa-
tients. The patients were divided into 2
groups, the first (A) with a radial ESWT session
and standard treatment, and the second (B)
with only standard treatment. The average
time of treatment was 13 minutes, using 100
impulses/cm2
, with energy to 0.1 mJ/mm2
.
The average time for full closure for patients
in group A was 13.9 ± 2.0 days, and 16.7 ± 2.0
days for group B, with p = 0.0001.
Dumfarth et al.21
conducted a study with
prophylactic ESWT in cutaneous lesions of
patients who would undergo coronary revas-
cularization surgery. It evaluated 100 patients,
with 50 in an ESWT group and 50 in a control
group. The ESWT was applied at the site of the
vein harvesting for the bypass, with 25 impuls-
es/cm2
, at 5 Hz and energy of 0.1 mJ/mm2
. The
post-operative lesions were evaluated by the
ASEPSIS scale that evaluates additional treat-
ments, erythema, purulent exudate, isolation
of bacteria, presence of serous secretion, sep-
aration of deep tissue, and duration of hospi-
talization. Lower ASEPSIS scores were found
in the ESWT group (4.4 ± 5.3) in comparison
with the control group (11.6 ± 8.3, p = 0.0001).
There was also a smaller rate of lesions that
became infected in the ESWT group (4%, p =
0.015) in comparison with the control group
(22%).
ESWT v. conservative therapy
Moretti et al.13
and Ottoman et al.20
com-
pared ESWT with conservative therapy with
local debridement and dressings, and found a
statistically significant decrease in the average
time of closure for the lesions. Moretti et al.13
also found a statistically significant difference
in the rate of closure of the lesions of the pa-
tients submitted to ESWT. Dumfarth et al.21
found a lower ASEPSIS score in patients of the
ESWT group when compared with the conser-
vative group, and also a lower rate of subse-
quent infections.
ESWT v. other treatments
Wang16
compared ESWT with hyperbaric
oxygen therapy in patients with ulcers on di-
abetic feet. The ESWT group presented higher
rates of complete closure (57% vs. 25%, p =
0.003), improvement of ≥ 50% (32% vs. 15%,
p = 0.071) and lower rates of lesions without
change (11% vs. 60%, p < 0.001). Wang16
also
performed a histological analysis between
the groups. In the ESWT group, there was sig-
nificant increase of intravenous nitric oxide,
VEGF, expression of PCNA, and also of local
blood perfusion after ESWT (p < 0.04).
Chart 2. ESWT parameters used.
Author Patients Número pulsos/
Frequência
Sessions Energy Density Type
Moretti et al.13
2009
15 ESWT, 15
control
100 per cm2
/? 3 (every 72 hours) 0.03 mJ/mm2
Radial
Larking et al.14
2010
9 ulcers ESWT 300 per cm2
/5 Hz 4 (1 per week) 0.1 J/mm2
?
Schaden et al.15
2007
208 ESWT 100 to 1000 per
cm2
/5 Hz
2.8 on average
(1 every 7/14
days)
0.1 J/mm2
Radial
Wang et al.16
2010
39 TOC, 38 HBO > 500/4 Hz 6 (2 per week) 0.23 mJ/cm2
Focal
Wolff et al.17
2011 282 ESWT 100 to 300 per
cm2
/ 5 Hz
1 to 10 sessions
(weekly)
0.10 mJ/mm2
Radial
Arno et al.18
2009 15 ESWT 500/? 2 (3 and 5 days
post burns)
0.15 mJ/mm2
Radial
Saggini et al.19
2008
30 ESWT, 10
control
100 per cm2
/4 Hz 4 to 10 (1 every 2
weeks)
0.037 mJ/mm2
Focal
Ottoman et al.20
2010
13 ESWT, 15
control
100 per cm2
/? 1 0.1 mJ/mm2
Radial
Dumfarth et al.21
2008
50 ESWT, 50
control
25 per cm2
/5 Hz 1 0.1 mJ/mm2
Radial
ESWT = extracorporeal shock wave therapy HOT = hyperbaric oxygen therapy
5. Acta Fisiatr. 2016;23(1):35-41 Pai MYB, Toma JT, Rampim DB, Imamura M, Battistella LR
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
39
Side effects
The ESWT side effects reported in the lit-
erature include local bleeding, petechiae, he-
matomas, seroma, and worsening of pain, and
also potentially more serious effects such as
syncope and headaches.22
The selected articles have not reported
significant adverse effects such as cardiac,
neurological, dermatological, or allergic ef-
fects. The adverse effects found were local er-
ythema and mild local pain with VAS < 318
not
requiring interruption of the therapy.
Possible Bias
Some of the studies were performed with
authors and/or co-authors with possible con-
flicts of interest, such as being partners of
manufacturers of ESWT devices.15,17,20,21
DISCUSSION
The use of extracorporeal shock waves
in renal lithotripsy, aiming to dissolve kidney
stones, started in the 80s. After that, in the 90s,
shock wave therapy was being used in Europe,
mainly in Germany and Austria, initially for
orthopedic pathologies such as Achilles ten-
dinitis and plantar fasciitis, after experimental
studies indicated a potential effect of neovas-
cularization, periosteal stimulus and also an
analgesic and anti-inflammatory action.1,2,3
Its
exact mechanism of action is unknown.
In ESWT, the acoustic mechanical waves
used can be of low or high energy, depending on
the pathology to be treated, causing microbub-
bles in the tissues affected. The mechanical im-
pact of these waves generates this eruption, re-
sulting in a series of local physiological changes.
The tissue repair of a lesion involves regen-
eration and fibrous healing. These processes
involve a complexity of vascular, cellular, and
biochemical factors. Initially, there is a local in-
flammatory reaction, with the action of inflam-
matory cells such as neutrophils, lymphocytes,
macrophages, and also vascular endothelial cells.
The inflammatory cells are induced by various
chemical mediators in the target tissue, such
as histamine, prostaglandin (PGE2), nitric oxide
(NO), and interleukins IL1 and IL6, stimulating
the inflammatory response with reabsorption of
cell debris and blood extravasation by phagocytic
cells.23
After the resolution of inflammation with
the removal of the exudate, there is the forma-
tion of granulation tissue due to endothelial and
fibroblast proliferation. There is an increase in
the quantity of collagen, replacement of collagen
type I with type III, differentiation of fibroblasts
into myofibroblasts, and the formation of new
vessels.24
Basic research and animal models indicate
a potential action on the stimulation of endo-
thelial NO,24
increased expression of vascular
endothelial growth factor (VGEF), increased
modulation of oxygen radicals, decreased in-
filtration of leukocytes, reduced apoptosis of
tissues, the recruitment of fibroblasts,24
and
an increase in insulin-like growth factor type
1 (IGF-I),23
therefore resulting in a suppression
of local inflammation and an increase in neo-
vascularization with increased local peripheral
tissue perfusion, with direct and/or indirect
effects to the endothelial stimulation, with an
increased rate of epithelization and local con-
nective tissue.25
According to Schaden et al.15
The ESWT in
both acute and chronic lesions is well toler-
ated, with no need to use anesthetics for its
application. In one study, patients reported an
increase of local pain during the application
of therapy, although this increase was mild
and tolerated.18
In the literature, the adverse
effects most commonly found are pain, local
hyperemia, and the appearance of petechiae
and small hematomas. Other more unusual
adverse effects include migraines and vasova-
gal syncopes.22
There are few studies in the literature eval-
uating its biological effects on the healing of
skin ulcers, with the oldest article being from
2007. Only 9 studies were found, with only
one study being prospective, double-blind,
and randomized.14
Most of the studies had
low methodological quality, with no control
group, lacking in blinding, in data standardiza-
tion, and in sample loss, with failures in the
randomization, and poorly defined inclusion
and exclusion criteria-all of which hampered
the decision-making based on the literature
and the comparison between research find-
ings (Chart 3 and Chart 4).
As the research on the effects of shock
waves on the healing of skin ulcers has begun
recently, the present study also included those
studies with low methodological quality, such
as the case series by Arnó et al.18
and Schaden
et al.15
for the description and discussion of
their results. Only Wang et al. performed sam-
pling calculation. Some of the studies included
did not describe their losses.19,21
The random-
ization details of the study by Moretti et al.13
were not described. In view of that, the pres-
ent analysis saw no homogeneity regarding
the number of participants.
Only one study was double blind. The
ESWT equipment offers the possibility of us-
ing a placebo applicator, with the same phys-
ical characteristics as the original applicator,
however without the emission of waves.
Only Larking et al.14
used a comparison be-
tween a real ESWT and a sham ESWT. The
other studies included compared ESWT with
hyperbaric oxygen therapy,16
with a standard
treatment,13,19,20,21
or were case series with
ESWT.15,17,18
The studies showed a variety of different
intervention standards. There was hetero-
geneity in the intervention time, number of
pulses, and in the frequency of sessions, as
well as in the number of sessions, the energy
density applied, and also in the type of shock
waves used in the therapies. The parameters
employed varied from 25 up to 1000 pulses
per cm2
. The frequency used, when described,
was 4 to 5 Hz. The number of sessions also
varied from a single session to 10 weekly ses-
sions, and the energy used varied from 0.03
mJ/mm2
to 0.1 J/mm2
. There was also no con-
sensus as to the interval necessary between
sessions, with some studies performing the
therapy every 2 days, but most varying be-
tween one and two weeks (Chart 2).
The intensity and dose of therapies var-
ied even for patients of the same study. In the
studies by Want et al.16
and Schaden et al.15
the number of sessions and energy was de-
pendent on the size of the ulcer. Other stud-
ies by Saggini et al.19
and Wolff et al.17
showed
that the number of sessions varied from 4 to
10 and from 1 to 10, respectively. Thus, it is
not possible to accurately assess the establish-
ment of a standard treatment dose.
No direct comparison between the use
of focal or radial waves was found in the lit-
erature. Most of the studies used radial shock
waves, with only two studies using focal
waves, whereas the article by Larking et al.14
did not describe the type of stimulus used.
As to the results, Moretti et al.13
found
a higher rate in the healing of the lesions in
patients undergoing ESWT in relation to the
conservative treatment (53.33% vs. 33.33%),
and also a statistically significant decrease in
healing time (60.8 ± 4.7 and 82.2 ± 4.7 days).
Larking et al.14
conducted a study with placebo
ESWT, and also found a statistically significant
reduction in lesion size after the initiation of
treatment. Arnó et al.18
conducted a study
with a single group with no control, and found
a complete closure of lesions in 80% of the
patients. Saggini19
also found a significant clo-
sure rate, and also a reduced exudate, an in-
creased percentage of granulation tissue, and
also reduced pain after ESWT sessions.
Cutaneousulcersarelesionswithaprolonged
and challenging treatment, and may involve high
costs. The conservative standard treatment con-
sists of cleaning, debridement, and dressings. In
6. 40
Acta Fisiatr. 2016;23(1):35-41 Pai MYB, Toma JT, Rampim DB, Imamura M, Battistella LR
Benefits of extracorporeal shockwave in the treatment of skin ulcers: a literature review
Chart 3. Jaddad Assessment Scale
Randomized Appropriate randomization Double blind Appropriate double blind Description of losses
Moretti et al.13
Yes No No No Yes
Larking et al.14
Yes Yes Yes Yes Yes
Schaden et al.15
No No No No Yes
Wang et al.16
Yes Yes No No Yes
Wolff et al.17
No No No No Yes
Arnó et al.18
No No No No Yes
Saggini et al.19
No No No No No
Ottoman et al.20
Yes No No No Yes
Dumfarth et al.21
Yes No No No No
Chart 4. Van Tulder Assessment Scale
Appropriate
randomiza-
tion
Allocation
conceal-
ment
Groups
with similar
prognostic
indicators
Blinding
all patient
outcomes
Blinding
Researchers
Blinding
Outcome
Evaluator
Co-inter-
ventions
avoided or
similar
Acceptable
conformity
all groups
Loss rate
described
and
acceptable
Similar time
of outcome
The analysis
includes
intention of
treatment
Moretti
et al.13
No No Yes No No No Yes Yes Yes Yes No
Larking
et al.14
Yes Yes No Yes Yes Yes Yes Yes Yes Yes No
Schaden
et al.15
No No No No No No Yes Yes Yes Yes Yes
Wang
et al.16
Yes No Yes No No No No Yes Yes Yes No
Wolff
et at.17
No No No No No No Yes Yes Yes Yes No
Arnó
et al.18
No No Yes No No No Yes Yes Yes No No
Saggini
et al.19
No No Yes No No ? Yes Yes No No No
Ottoman
et al.20
No Yes Yes No No ? Yes Yes Yes Yes No
Dumfarth
et al.21
No No No No No No Yes Yes No Yes No
general, the patients also present other compli-
cations and systemic diseases, such as diabetes
mellitus, vascular diseases such as venous insuf-
ficiency, making the treatment and healing of the
lesions more difficult. These lesions, when chron-
ic, present a high incidence of local and systemic
infections, resulting in an increase in the morbid-
ity and mortality of these patients, and also in a
significant worsening of their quality of life.11,12
CONCLUSION
Clinical perspectives
ESWT appears to be a promising alternative
for patients who do not respond well to conser-
vative therapies, and possibly also as a primary
treatment, showing promising results but with
limited evidence regarding the decrease of heal-
ing time and acceleration in the closure of the le-
sions. The studies selected have reported no sig-
nificant side effects, indicating it is a safe therapy.
Research Prospects
There are few studies in the literature
with appropriate methodological quality.
ESWT is a new therapy, with few studies in
the orthopedic area and even fewer in re-
lation to cutaneous lesions. Several basic
studies and animal models have demon-
strated some of its biological effects. There
is a need for more rigorous prospective and
randomized studies to analyze its effects
and biological mechanisms, and also for
the standardization of the number of puls-
es, frequency, power, and the number and
interval of sessions to be performed for an
effective treatment.
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