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OBJECTIVE: The objective of this study was to determine predictors of in-hospital mortality among older patients admitted to a geriatric care unit. INTRODUCTION: The growing number of older individuals among hospitalized patients demands a thorough investigation of the factors that contribute to their mortality. METHODS: This was a prospective observational study implemented from February 2004 to October 2007 in a tertiary university hospital. A consecutive sample of 922 patients was evaluated for possible inclusion in this study. Patients hospitalized for palliative care, those who declined to participate, and those with incomplete data were excluded, resulting in a group of 856 patients aged 60 to 104 years. Bivariate and multivariate analyses were performed to determine associations between in-patient mortality and gender, age, length of stay, number of prescribed medications and diagnoses at admission, history of heart failure, neoplastic disease, immobility syndrome, delirium, infectious disease, and laboratory tests at admission (serum albumin and creatinine). RESULTS: The overall mortality rate was 16.4%. The following factors were associated with higher in-hospital mortality: delirium (OR=4.13, CI=2.65-6.44, P<.001), neoplastic disease (OR=3.38, CI=2.11-5.42, P<.001), serum albumin levels at admission <3.3mg/ dL (OR=3.23, CI=2.03-5.13, P<.001), serum creatinine levels at admission >1.3mg/dL (OR=2.39, CI=1.53-3.72, P<.001), history of heart failure (OR=1.97, CI=1.20-3.22, P=.007), immobility (OR=1.84, CI=1.16-2.92, P =.009), and advanced age (OR=1.03, CI=1.01-1.06, P=.019). CONCLUSIONS: This study strengthens the perception of delirium as a mortality predictor among older inpatients. Cancer, immobility, low albumin levels, elevated creatinine levels, history of heart failure and advanced age were also related to higher mortality rates in this population.

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INTRODUCTION: The goal of antihypertensive treatment is to reduce blood pressure without interfering in health-related quality of life (HRQL) OBJECTIVE: This study aimed to assess the influence of hypertension control upon HRQL in hypertensive patients with and without complications. MATERIALS AND METHODS: Seventy-seven hypertensive outpatients (71% women, 58% white, 60% with elementary school level education, average age 54 ± 8 years) were observed during a 12-month special care program (phase 1: clinical visits every two months, donation of all antihypertensive medications, meetings with a multidisciplinary team, and active telephone calls) and three years of standard care (phase 2: clinical visits every four months, medication provided by the drugstore of the hospital with a two-hour wait and a possible lack of medication, no meetings with a multidisciplinary team or active telephone calls). The patient HRQL was assessed using Bulpitt and Fletcher's Specific Questionnaire, as well as the SF-36 scores. Hypertensive patients were divided into "with complications" (n=37, diastolic blood pressure great than 110 mm Hg for patients with or without treatment, with clinically evident target-organ or other associated illness) and "without complications" (n=40). The variables studied were quality of life, blood pressure control, hypertension gravity, and demographic characteristics. RESULTS: In hypertensive patients with and without complications, both the systolic and diastolic blood pressure were significantly higher (p<0.05) in phase 2 of observation (143±18/ 84±11 and 144±21/93±11 mm Hg for patients with and without complications , respectively) relative to phase 1 (128±17/ 75±13 and 128±15/ 83±11mmHg). The proportion of patients with controlled blood pressure (defined as a blood pressure less than 140/90 mm Hg) decreased from 70% to 49% in the "with complications" group and from 78% to 50% in the "without complications" group during phase 2 of observation. The patients with complications showed a decrease in bodily pain, vitality, and mental health component summary scores in both phases. In phase 2, the patients without complications had significantly better HRQL scores compared to complicated patients using both the Bulpitt and Fletcher's Questionnaire and the SF-36 assessment of physical capacity, bodily pain, and vitality domain summary scores. With regards to hypertension control, there was a significant decrease from phase 1 to phase 2 in the vitality component summary scores and an increase in the emotional aspect component summary scores assessed by the SF-36, whereas Bulpitt and Fletcher's Questionnaire showed no differences in these scores. CONCLUSION: Special care programs with multidisciplinary activities, individualized and personalized assistance, easy access to pharmacological treatment, frequent meetings, and active telephone calls for hypertensive patients significantly increase blood pressure control but do not interfere with the HRQL.

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OBJECTIVE: To investigate the recognition of depressive symptoms of major depressive disorder (MDD) by general practitioners. INTRODUCTION: MDD is underdiagnosed in medical settings, possibly because of difficulties in the recognition of specific depressive symptoms. METHODS: A cross-sectional study of 316 outpatients at their first visit to a teaching general hospital. We evaluated the performance of 19 general practitioners using Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect depressive symptoms and compared them to 11 psychiatrists using Structured Clinical Interview Axis I Disorders, Patient Version (SCID I/P). We measured likelihood ratios, sensitivity, specificity, and false positive and false negative frequencies. RESULTS: The lowest positive likelihood ratios were for psychomotor agitation/retardation (1.6) and fatigue (1.7), mostly because of a high rate of false positive results. The highest positive likelihood ratio was found for thoughts of suicide (8.5). The lowest sensitivity, 61.8%, was found for impaired concentration. The sensitivity for worthlessness or guilt in patients with medical illness was 67.2% (95% CI, 57.4-76.9%), which is significantly lower than that found in patients without medical illness, 91.3% (95% CI, 83.2-99.4%). DISCUSSION: Less adequately identified depressive symptoms were both psychological and somatic in nature. The presence of a medical illness may decrease the sensitivity of recognizing specific depressive symptoms. CONCLUSIONS: Programs for training physicians in the use of diagnostic tools should consider their performance in recognizing specific depressive symptoms. Such procedures could allow for the development of specific training to aid in the detection of the most misrecognized depressive symptoms.

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INTRODUCTION: A cataract is defined as an opacity of any portion of the lens, regardless of visual acuity. In some advanced cases of cataracts, in which good fundus visualization is not possible, an ultrasound examination provides better assessment of the posterior segment of the globe. OBJECTIVES: This study aims to evaluate the ultrasonographic records of patients with advanced cataracts who were examined during cataract campaigns. METHODS: The ultrasonographic findings obtained from 215 patients examined in cataract campaigns conducted by the Hospital das Clínicas Department of Ophthalmology of the Faculdade de Medicina da Universidade de São Paulo between the years of 2005 and 2007 were evaluated, and the utility of this exam in changing the treatment procedures was studied. RESULTS: A total of 289 eyes from 215 patients were examined. Of the eyes examined, 77.5% presented with findings in the vitreous cavity and the posterior pole. A posterior vitreous detachment with no other complications was observed in 47.4% of the eyes. The remaining 30.1% presented with eye diseases that could result in a reduced visual function after surgery. The most frequent eye diseases observed were diffuse vitreous opacity (12.1% of the eyes) and detachment of the retina (9.3% of the eyes). DISCUSSION: In many cases, the ultrasonographic evaluation of the posterior segment revealed significant anomalies that changed the original treatment plan or contra-indicated surgery. At the very least, the evaluation was useful for patient counseling. CONCLUSION: The ultrasonographic examination revealed and differentiated between eyes with cataracts and eyes with ocular abnormalities other than cataracts as the cause of poor vision, thereby indicating the importance of its use during ocular evaluation.

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INTRODUCTION: Ovarian cancer is generally diagnosed at advanced stages of the disease; therefore, poor prognoses are typical. The development of tumor markers is thus of utmost importance. Prostasin is a protease that in normal tissues is highly expressed only in the prostate gland and seminal fluid. A previous study showed that prostasin is highly overexpressed in ovarian cancer cell lines. This study sought to evaluate the expression of prostasin in ovarian cancer. METHODS: Fresh tumor samples of ovarian epithelial cancer (n: 12) were analyzed for expression of prostasin mRNA (messenger ribonucleic acid) by conventional and real time quantitative PCR (polymerase chain reaction). As a standard control, a normal prostate sample was analyzed. RESULTS: Using conventional PCR, prostasin was detected in all but one sample. Using quantitative PCR, prostasin was over-expressed in all but one of the samples as compared to the control (prostate). CONCLUSIONS: These findings indicate that prostasin is overexpressed in many epithelial ovarian cancers. Further studies of prostasin as a potential biomarker for this disease are warranted.

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INTRODUCTION AND OBJECTIVES: Recurrent aphthous stomatitis (RAS) is the most common type of ulcerative disease of the oral mucosa. Despite its worldwide occurrence and the extensive amount of research that has been devoted to the subject, the etiology of RAS remains unclear. Nevertheless, several hereditary, nutritional, infectious and psychological factors have been associated with RAS. The aim of this case-control study was to assess the influence of psychological stress on the manifestation of RAS. METHOD: Fifty patients were enrolled in the trial. Twenty-five RAS patients constituted the study group and another 25 non-RAS patients who were similarly matched for sex, age and socioeconomic status constituted the control group. Each patient was evaluated in terms of the four domains of stress (emotional, physical, social and cognitive) using an internationally validated questionnaire, which was comprised of 59 items and measured the frequency and intensity of stress symptoms. The RAS group was interviewed during an active RAS episode. Completed questionnaires were submitted to proper analytical software and interpreted by an expert psychologist. RESULTS: There was a higher level of psychological stress among RAS group patients when compared to the control group (P < 0.05). CONCLUSION: Psychological stress may play a role in the manifestation of RAS; it may serve as a trigger or a modifying factor rather than being a cause of the disease.

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INTRODUCTION: The within-breath analysis of respiratory mechanics by the monofrequency Forced Oscillation Technique (mFOT) is of great interest in both physiopathology studies and the diagnosis of respiratory diseases. However, there are limited data on the use of this technique in the analysis of asthma. This study evaluates within-breath mechanics of asthmatic individuals and the contribution of the mFOT in the asthma diagnosis. METHODS: Twenty-two healthy and twenty-two asthmatic subjects, including patients with mild (n=8), moderate (n=8), and severe (n=6) obstruction, were studied. Forced Oscillation Technique data were interpreted using the mean respiratory impedance (Zt), the impedance during inspiration (Zi), expiration (Ze), at the beginning of inspiration (Zii), and at expiration (Zie). The peakto-peak impedance (Zpp) was also calculated by the subtraction of Zii from Zie. Receiver operating characteristic curves were used to determine the sensitivity (Se) and specificity (Sp) of m Forced Oscillation Technique parameters in identifying asthma. RESULTS: Respiratory impedance values were significantly higher in asthmatics: Zt (p<0.001), Zi (p<0.001), Ze (p<0.001), Zii (p<0.001), Zie (p<0.001), and Zpp (p<0.003). The best parameters for detecting asthma were Zi, Zii, and Zie (Se=90.9%, Sp=90.9%), followed by Zt and Ze. These results are in close agreement with recently published theories and pathophysiological fundamentals. CONCLUSIONS: mFOT permits a non-invasive and detailed analysis in different phases of the respiratory cycle, providing parameters that are adequate for the diagnosis of asthma with high accuracy. These results confirm the high clinical and scientific potential of this methodology in the evaluation of asthmatic patients.

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OBJECTIVE: To compare common carotid intima-media thickness (IMT) between the two major Brazilian ethnic groups (those of African descent and those of European descent) among individuals with one or more risk factors for atherosclerotic disease. METHOD: Two hundred and six patients with one or more risk factors for atherosclerotic disease were evaluated in a cross-sectional study in which their clinical, ethnic and Demographic characteristics were collected. All patients underwent duplex ultrasound examination of their carotid vessels to obtain IMT measurements. RESULTS: One hundred and fifty-three patients (74.3%) had a carotid IMT greater than 1.0 mm at one or more point of measurement in at least one common carotid artery. There was a significant correlation between older age and mean carotid wall thickness (R=0.479 / P<0.01). Multivariate analysis identified male sex, arterial hypertension and older age as variables associated with increased IMT (P<0.05 for all variables). When IMT was compared between the two ethnic groups in this study, no significant differences were noted. Euro-descendants and Afro-descendants had similar IMT values, even when the groups were stratified by degree of IMT (normal vs. increased) and presence of stroke and/or transient ischemic attack (yes vs. no). CONCLUSIONS: The risk factors associated with increased common carotid artery IMT in Brazilian individuals are similar to those in previously described populations. No differences were observed between the two main Brazilian ethnic groups. Longitudinal studies are required for a better evaluation of the incidence, etiologic factors and evolution of carotid intimomedial thickening in this population.

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PURPOSE: To evaluate the performance of automated perimetry of elderly subjects naïve to AP after listening to a Mozart sonata. INTRODUCTION: Automated perimetry (AP) is a psychophysical test used to assess visual fields in patients with neurological disorders and glaucoma. In a previous study, Fiorelli et al. showed that young subjects who listened to a Mozart sonata prior to undergoing AP performed better in terms of reliability than those who did not listen to the sonata. METHODS: Fifty-two AP-naïve, normal subjects underwent Automated perimetry (SITA 24-2). The study group (25 subjects) underwent AP after listening to Mozart's Sonata for Two Pianos in D Major, and the control group (27 subjects) underwent Automated perimetry without prior exposure to the music. RESULTS: The study group had significantly lower false negative rates and a lower visual field reliability score than the controls (P=0.04 and P=0.04, respectively). The test time was shorter for the study group (P=0.03). DISCUSSION: This study shows that elderly subjects, when exposed to the Mozart sonata immediately before AP testing, have lower false negative rates and lower visual field reliability scores when compared with an age- and gender-matched control group. Our results differ from those of Fiorelli et al. who found lower false positive rates and less fixation loss in addition to lower false negative rates. CONCLUSION: Listening to a Mozart sonata seems to improve automated perimetry reliability in elderly subjects.

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The purpose of this study was to compare esophageal infusion with 0.1 N hydrochloridric acid (HCl) to esophageal infusion with saline in patients presenting with typical gastroesophageal reflux symptoms and erosive esophagitis. METHODS: Upper gastrointestinal endoscopy was performed on 44 prospective subjects, 29 of whom were included in the study. Eighteen patients presented with normal esophagi (Control Group "C"), nine of whom were infused with HCl and nine with saline. Eleven patients presented with erosive esophagitis (Lesion Group "L"), five of whom were infused with HCl and six with saline. Biopsies of the esophageal mucosa were collected before and after infusions. RESULTS: No statistically significant difference was found between the two types of infusions in terms of the dilation of the intercellular space of the esophageal epithelium, regardless of the status of the patient. CONCLUSIONS: Response to HCl infusion cannot be used as a marker for gastroesophageal reflux disease.

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BACKGROUND: Non-invasive detection of atherosclerosis is critical for its prevention. OBJECTIVE: To correlate non-invasively detectable indicators of coronary atherosclerosis, or Coronary Artery Disease (i.e., classical risk factors, hs-CRP test results, carotid intima-media thickness, endothelial function, ankle-brachial index and calcium score by computed tomography) with the extent of coronary disease assessed by the Friesinger index from conventional coronary angiography. METHODS: We conducted a prospective study of 100 consecutive patients, mean age 55.1 ± 10.7 years, 55% men and 45% women. Patients with acute coronary syndrome, renal dialytic insufficiency, collagen disease and cancer were not included. All patients were subjected to clinical evaluation and laboratory tests. Endothelial function of the brachial artery and carotid artery were evaluated by high-resolution ultrasound; ankle-brachial index and computed tomography for coronary determination of calcium score were also performed, and non-HDL cholesterol and TG/HDL-c ratio were calculated. All patients were subjected to coronary angiography at the request of the assistant physician. We considered patients without an obstructive lesion (< 29% stenosis) demonstrated by coronary angiography to be normal. RESULTS: Univariate analysis showed that calcium score, HDL-c, TG/HDL ratio and IMT were significantly correlated with the Friesinger index. However, multivariate analysis indicated that only calcium score and low HDL-c levels correlated significantly with the extension of CAD. On the other hand, hs-CRP, LDL-c, flow-mediated dilation, and Framingham score did not correlate with the Friesinger index. ROC analysis showed that calcium score, HDL-c and TG-HDL ratio accurately predicted extensive CAD in a statistically significant manner. CONCLUSION: It is possible to approximately determine the presence and extent of CAD by non-invasive methods, especially by calcium score, HDL-c and TG/HDL-c ratio assays.

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INTRODUCTION: Bariatric surgery has become increasingly more recommended for the treatment of morbidly obese individuals for whom it is possible to identify co-morbidities other than alterations in pulmonary function. The objective of this study was to evaluate the effects of conventional chest physiotherapy (CCP) and of conventional physiotherapy associated with transcutaneous electrical diaphragmatic stimulation (CCP+TEDS) on pulmonary function and respiratory muscle strength in patients who have undergone Roux-en-Y gastric bypass. METHODS: In total, 44 female patients with an average age of 37 ± 7.3 years and an average body mass index (BMI) of 47.4 ± 6.5 K/m² were selected as candidates for Roux-en-Y gastric bypass laparoscopy. They were evaluated for pulmonary volume and flow using spirometry and maximum respiratory pressure through manovacuometry during the preoperative period and on the fifteenth and thirtieth postoperative days. RESULTS: No differences were detected between CCP and CCP+TEDS, and both factors contributed to the maintenance of pulmonary flow and volume as well as inhalation muscle strength. Exhalation muscle strength was not maintained in the CCP group at fifteen or thirty days postoperative, but it was maintained in patients treated with conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation. DISCUSSION: These results suggest that both conventional chest physiotherapy and conventional chest physiotherapy + transcutaneous electric diaphragmatic stimulation prevent the reduction of pulmonary function during the Roux-en-Y gastric bypass postoperative period, and that transcutaneous electric diaphragmatic stimulation also contributes to expiratory muscle strength.

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OBJECTIVE: To evaluate the roles of oxidative stress and lipid peroxidation in the ventricular remodeling that is induced by tobacco smoke exposure after myocardial infarction. METHODS: After induced myocardial infarction, rats were allocated into two groups: C (control, n=25) and ETS (exposed to tobacco smoke, n=24). After 6 months, survivors were submitted to echocardiogram and biochemical analyses. RESULTS: Rats in the ETS group showed higher diastolic (C = 1.52 ± 0.4 mm², ETS = 1.95 ± 0.4 mm²; p=0.032) and systolic (C = 1.03 ± 0.3, ETS = 1.36 ± 0.4 mm²/g; p=0.049) ventricular areas, adjusted for body weight. The fractional area change was smaller in the ETS group (C = 30.3 ± 10.1 %, ETS = 19.2 ± 11.1 %; p=0.024) and E/A ratios were higher in ETS animals (C = 2.3 ± 2.2, ETS = 5.1 ± 2.5; p=0.037). ETS was also associated with a higher water percentage in the lung (C = 4.8 (4.3-4.8), ETS = 5.5 (5.3-5.6); p=0.013) as well as higher cardiac levels of reduced glutathione (C = 20.7 ± 7.6 nmol/mg of protein, ETS = 40.7 ± 12.7 nmol/mg of protein; p=0.037) and oxidized glutathione (C = 0.3 ± 0.1 nmol/g of protein, ETS = 0.9 ± 0.3 nmol/g of protein; p=0.008). No differences were observed in lipid hydroperoxide levels (C = 0.4 ± 0.2 nmol/mg of tissue, ETS = 0.1 ± 0.1 nmol/mg of tissue; p=0.08). CONCLUSION: In animals exposed to tobacco smoke, oxidative stress is associated with the intensification of ventricular remodeling after myocardial infarction.

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Hypercalcitoninemia has frequently been reported as a marker for medullary thyroid carcinoma. Currently, calcitonin measurements are mostly useful in the evaluation of tumor size and progression, and as an index of biochemical improvement of medullary thyroid carcinomas. Although measurement of calcitonin is a highly sensitive method for the detection of medullary thyroid carcinoma, it presents a low specificity for this tumor. Several physiologic and pathologic conditions other than medullary thyroid carcinoma have been associated with increased levels of calcitonin. Several cases of thyroid nodules associated with increased values of calcitonin are not medullary thyroid carcinomas, but rather are related to other conditions, such as hypercalcemias, hypergastrinemias, neuroendocrine tumors, renal insufficiency, papillary and follicular thyroid carcinomas, and goiter. Furthermore, prolonged treatment with omeprazole (> 2-4 months), beta-blockers, glucocorticoids and potential secretagogues, have been associated with hypercalcitoninemia. An association between calcitonin levels and chronic auto-immune thyroiditis remains controversial. Patients with calcitonin levels >100 pg/mL have a high risk for medullary thyroid carcinoma (~90%-100%), whereas patients with values from 10 to 100 pg/mL (normal values: <8.5 pg/mL for men, < 5.0 pg/mL for women; immunochemiluminometric assay) have a <25% risk for medullary thyroid carcinoma. In multiple endocrine neoplasia type 2 (MEN2), RET mutation analysis is the gold-standard for the recommendation of total preventive thyroidectomy to relatives at risk of harboring a germline RET mutation (50%). False-positive calcitonin results within MEN2 families have led to incorrect indications of preventive total thyroidectomy to RET mutation negative relatives. In this review, we focus on the differential diagnosis of hypercalcitoninemia, underlining its importance for the avoidance of misdiagnosis of medullary thyroid carcinoma and consequent incorrect recommendation for thyroid surgery.