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PURPOSE: To evaluate the governmental costs of patients undergoing phacoemulsification and extracapsular cataract extraction at a public hospital in a developing country. METHODS: A prospective study was conduced with 205 patients. The subjects were randomized for cataract surgery using either phacoemulsification or extracapsular cataract extraction techniques. RESULTS: Of the 205 patients, 101 patients were submitted to phacoemulsificationand 104 patients were submitted to extracapsular cataract extraction. Brazilian Health Care System expenditures for the surgery and the postoperative period were US$ 95.49 more in the phacoemulsification group than in the extracapsular cataract extractiongroup. If we take into account Social Security expenditures, then we estimate that the average difference for the total direct cost for the government for the surgery and the postoperative period for both procedures was US$ 50.91 or approximately half of the initial difference in cost for the phacoemulsification surgery. The total cost of cataract surgery for the government (excluding social security) was estimated at US$ 258.79 for extracapsular cataract extraction and US$ 309.70 for phacoemulsification per patient. Focusing only on working patients, the total cost was US$ 342.21 for phacoemulsification and US$ 587.71 for extracapsular cataract extraction, a difference of US$ 245.50. This difference can be considered monetarily and socially justifiable when the benefits of the surgical technique are evaluated. CONCLUSION: Under the conditions of this study, we observed that phacoemulsification was an efficient procedure with regard to the impact on public health care system, when all costs are assessed comprehensively, mainly for subjects with regular jobs.

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INTRODUCTION: Actinic cheilitis (AC) is considered to be a pre-malignant lesion or an incipient and superficial form of lip squamous cell carcinoma. It is commonly found in individuals whose occupational activities are related to chronic sun exposure and the definitive diagnosis is performed with biopsy. Althoug Exfoliative cytology has been used as a screening procedure to evaluate cancer of the oral cavity no studies have proposed the use of exfoliative cytologic analysis to evaluate and diagnose AC. OBJECTIVE: The purpose of this study was to evaluate lower lip lesions on fishermen related to chronic solar exposure using clinical, cytologic and histopathologic analyses. PATIENTS AND METHODS: Smears taken from the vermilion of the lower lips of 125 fishermen and 30 control individuals were subjected to cytologic analysis. RESULTS: The harvested cells were sufficient for cytologic analysis in 83.2% of the samples. Sixteen fishermen exhibited prominent lower lip lesions that justified biopsy and histological studies. In total, 4 specimens were malignant (3.2%), and 12 displayed epithelial dysplasia, demonstrating that the prevalence of epithelial dysplasia and malignant lesions was high among the fishermen population. These conditions were strongly associated with infiltration and blurring of the vermilion margin of the lower lip. CONCLUSION: The cytologic analysis was not useful for detecting epithelial dysplasia or malignant alterations.

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BACKGROUND: A synchronism exists between the respiratory and cardiac cycles. However, the influence of the inspiratory muscle weakness in chronic obstructive pulmonary disease (COPD) on cardiac autonomic control is unknown. The purpose of the present investigation was to evaluate the influence of respiratory muscle strength on autonomic control in these patients. METHODS: Ten chronic obstructive pulmonary disease patients (69±9 years; FEV1/FVC 59±12% and FEV1 41±11% predicted) and nine age-matched healthy volunteers (64±5 years) participated in this study. Heart-rate variability (HRV) was obtained at rest and during respiratory sinusal arrhythmia maneuver (RSA-M) by electrocardiograph. RESULTS: Chronic obstructive pulmonary disease patients demonstrated impaired cardiac autonomic modulation at rest and during RSA-M when compared with healthy subjects (p<0.05). Moreover, significant and positive correlations between maximal inspiratory pressure (MIP) and the inspiratory-expiratory difference (ΔIE) (r = 0.60, p<0.01) were found. CONCLUSION: Patients with chronic obstructive pulmonary disease presented impaired sympathetic-vagal balance at rest. In addition, cardiac autonomic control of heart rate was associated with inspiratory muscle weakness in chronic obstructive pulmonary disease. Based on this evidence, future research applications of respiratory muscle training may bring to light a potentially valuable target for rehabilitation.

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BACKGROUND: Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE: To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS: Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS: Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6-3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20-160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6-30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20-150 min). CONCLUSION: The endoscopic submucosal dissection technique was feasible in our service with a high success rate.

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OBJECTIVES: To investigate whether oxidized low-density lipoprotein is a suitable predictor of peripheral arterial disease severity. The role of oxidized low-density lipoprotein in the pathogenesis of atherosclerosis has already been investigated. Its relevance as a predictor of the appearance and worsening of coronary arterial disease is also well known. However, the same is not true regarding peripheral arterial disease. METHOD: Eighty-five consecutive patients with an ankle-brachial pressure index (ABPI) < 0.9 and the presence of either intermittent claudication or critical lower leg ischemia were included. The plasma level of IgG autoantibodies against oxidized low-density lipoprotein was evaluated through an enzyme-linked immunosorbent assay. The results were categorized into quartiles according to the ankle-brachial pressure index (a marker of peripheral arterial disease severity), and significant differences were investigated with the Kruskal-Wallis test. RESULTS: There was no significant difference between the quartiles for this population (p = 0.33). No correlation was found between the ankle-brachial pressure index and oxidized low-density lipoprotein levels in subjects with clinically evident peripheral arterial disease with a wide range of clinical manifestations. CONCLUSIONS: Oxidized low-density lipoprotein is not a good predictor of peripheral arterial disease severity.

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OBJECTIVES: To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants. INTRODUCTION: The prevalence and management of cholelithiasis in renal transplant patients is not well established. METHODS: A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied. Patients were evaluated for the presence of cholelithiasis and related symptoms, previous cholecystectomies and other abdominal surgeries, time on dialysis, and general data (gender, age, number of pregnancies, and body mass index). RESULTS: Cholelithiasis was found in 41 out of 342 patients (12%). Twelve of these patients, all symptomatic, had previously undergone cholecystectomies. Five out of 29 patients who had not undergone surgery were symptomatic. Overall, 17 patients (41.5%) were symptomatic. Their mean age was 54 (range 32-74) years old; 61% were female, and their mean body mass index was 25.4. Nineteen (76%) out of 25 women had previously been pregnant, with an average of 3.6 pregnancies per woman. CONCLUSIONS: The frequency of cholelithiasis was similar to that reported in the literature for the general population. However, the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications.

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OBJECTIVE: To evaluate the effects of sildenafil on the autonomic nervous system in patients with severe obstructive sleep apnea. METHODS: Thirteen male patients with severe obstructive sleep apnea (mean age 43±10 years with a mean body mass index of 26.7±1.9 kg/m²) received a single 50-mg dose of sildenafil or a placebo at bedtime. All-night polysomnography and heart rate variability were recorded. Frequency domain analysis of heart rate variability was performed for the central five-minute sample of the longest uninterrupted interval of slow wave and rapid eye movement sleep, as well as for one-minute samples during apnea and during slow wave and rapid eye movement sleep after resumption of respiration. RESULTS: Compared to the placebo, sildenafil was associated with an increase in the normalized high-frequency (HFnu) components and a decrease in the low/high-frequency components of the heart rate variability ratio (LF/HF) in slow wave sleep (p<0.01 for both). Differences in heart rate variability parameters between one-minute post-apnea and apnea samples (Δ= difference between resumption of respiration and apnea) were assessed. A trend toward a decreasing magnitude of ΔLF activity was observed during rapid eye movement sleep with sildenafil in comparison to placebo (p=0.046). Additionally, Δ LF/HF in SWS and rapid eye movement sleep was correlated with mean desaturation (sR= -0.72 and -0.51, respectively, p= 0.01 for both), and Δ HFnu in rapid eye movement sleep was correlated with mean desaturation (sR= 0.66, p= 0.02) and the desaturation index (sR= 0.58, p = 0.047). CONCLUSIONS: The decrease in arousal response to apnea/hypopnea events along with the increase in HFnu components and decrease in LH/HF components of the heart rate variability ratio during slow wave sleep suggest that, in addition to worsening sleep apnea, sildenafil has potentially immediate cardiac effects in patients with severe obstructive sleep apnea.

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OBJECTIVE: For patients with Poland's syndrome, a transverse skin fold in the anterior axillary pillar, infra-clavicular depression and an anomalous breast contour are the most uncomfortable disfigurements. This study aims to demonstrate that superior aesthetic results can be achieved by using a laparoscopically harvested omentum flap to treat this condition. METHODS: From a prospectively maintained clinical database of patients undergoing a laparoscopic omentum flap procedure for breast reconstruction, all of the patients with Poland's syndrome were identified and their outcomes were studied. RESULTS: Thirteen consecutive patients with Poland's syndrome were treated and evaluated regarding breast contour, reconstruction of the anterior axillary pillar and filling of the infra-clavicular depression. Implants were employed beneath the flap in 76% of cases to improve symmetry. In 23% of cases, a contra-lateral mastopexy was performed, and in 15% of cases, a breast implant was used. The consistency of the flap is similar to natural breast tissue and only a small incision in the breast fold is needed. The majority of patients (85%) were female, with a mean age of 26 (18-53). The flap is extremely malleable, adapts to irregular surfaces, and has a long vascular pedicle. Additionally, its removal does not leave a scar at the donor site as the removal of muscular flaps does. For example, the removal of the latissimus dorsi flap causes a deformity in the dorsal contour. The mean operative time was 201 minutes (80-350) and the mean hospital stay was 2.3 days (1-5). CONCLUSIONS: The outcomes of these patients revealed that the omentum flap technique provided superior amelioration of the deformities caused by Poland's syndrome when compared with other reconstructive options.

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OBJECTIVE: Non-pituitary tumors have been reported in a subset of patients harboring germline mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene. However, no detailed investigations of non-pituitary tumors of AIP-mutated patients have been reported so far. PATIENTS: We examined a MEN1- and p53-negative mother-daughter pair with acromegaly due to somatotropinoma. Subsequently, the mother developed a large virilizing adrenocortical carcinoma and a grade II B-cell non-Hodgkin's lymphoma. DESIGN: Mutational analysis was performed by automated sequencing. Loss-of-heterozygosity (LOH) analysis was carried out by sequencing and microsatellite analysis. AIP expression was assessed through quantitative PCR (qPCR) and immunohistochemistry. RESULTS: The functional inactivating mutation c.241C>T (R81X), which blocks the AIP protein from interacting with phosphodiesterase 4A (PDE4A), was identified in the heterozygous state in the leukocyte DNA of both patients. Analyzing the tumoral DNA revealed that the AIP wild-type allele was lost in the daughter's somatotropinoma and the mother's adrenocortical carcinoma. Both tumors displayed low AIP protein expression levels. Low AIP gene expression was confirmed by qPCR in the adrenocortical carcinoma. No evidence of LOH was observed in the DNA sample from the mother's B-cell lymphoma, and this tumor displayed normal AIP immunostaining. CONCLUSIONS: Our study presents the first molecular analysis of non-pituitary tumors in AIP-mutated patients. The finding of AIP inactivation in the adrenocortical tumor suggests that further investigation of the potential role of this recently identified tumor suppressor gene in non-pituitary tumors, mainly in those tumors in which the cAMP and the 11q13 locus are implicated, is likely to be worthwhile.

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INTRODUCTION: Informatics and automation are important tools for the reduction of work, errors and costs in a hospital pharmacy. OBJECTIVES: To describe the structuring and function of an informatized system for the dispensing of medications and to assess its effect on nursing and pharmacy services during the period from 1997 to 2003. MATERIALS AND METHODS: In this descriptive and retrospective study, we performed an analysis of documents addressing the structuring and implementation of the informatized medication dispensing system. In addition, we analyzed the perceptions of nurses, pharmacists and pharmacy assistants who participated in the structuring phase of the system when interviewed about the effect of informatization on administrative aspects (e.g., requisition of medications, presentation of the dispensed medication and system operationalization). RESULTS: The major advantages provided by the new system were 1) the elimination of manual transcripts for prescribed medications, 2) increased speed, 3) better identification of the doses prescribed by physicians, 4) medication labels containing all necessary identification and 5) practicality and safety of optical bar code-based verification of the requested and dispensed medications. CONCLUSIONS: The great majority of the interviewees considered the informatized medication supply system to be of good quality. Analysis of the data provided information that could contribute to the expansion and refinement of the system, provide support for studies regarding the utilization of medications and offer new perspectives for work and productivity.

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OBJECTIVE: The importance of type V collagen and its relationships with other types of collagen and with vascular and epithelial apoptosis were studied in a model of chemical carcinogenesis in the mouse lung. METHODS: Two groups of male Balb/c mice were studied: a) animals that received two intraperitoneal doses of 3 g/kg urethane carcinogen (urethane group = 24); and b) animals submitted to a sham procedure, comparable to the test group (control group = 7). Both groups were sacrificed after 120 days. In situ detection of apoptosis, immunohistochemistry, immunofluorescence and histomorphometry were used to evaluate the fraction occupied by the tumor, vascular and epithelial apoptosis, and type V, III and I collagen fibers in the lung parenchyma from both groups. RESULTS: The lung parenchyma from the urethane group showed low fractions of vascular and epithelial apoptosis as well as reduced type V collagen fibers when compared to the control group. A significant direct association was found between type V and III collagen fibers and epithelial apoptosis, type V collagen fibers and vascular apoptosis, and type V and type I collagen fibers. CONCLUSION: The results show that a direct link between low amounts of type V collagen and decreased cell apoptosis may favor cancer cell growth in the mouse lung after chemical carcinogenesis, suggesting that strategies aimed at preventing decreased type V collagen synthesis or local responses to reduced apoptosis may have a greater impact in lung cancer control.

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PURPOSE: The purpose of this study was to evaluate the relative importance of the different static stabilizers of the posterolateral corner of the knee in cadavers. METHODS: Tests were performed with the application of a varus and external rotation force to the knee in extension at 30 and 60 degrees of flexion using 10 cadaver knees. The forces were applied initially to an intact knee and then repeated after a selective sectioning of the ligaments into the following: section of the lateral collateral ligament; section of the lateral collateral ligament and the popliteofibular complex; and section of the lateral collateral ligament, the popliteofibular complex and the posterolateral capsule. The parameters studied were the angular deformity and stiffness when the knees were submitted to a 15 Newton-meter varus torque and a 6 Newton-meter external tibial torque. Statistical analysis was performed using the ANOVA (Analysis of Variance) and Tukey's tests. RESULTS AND CONCLUSION: Our findings showed that the lateral collateral ligament was important in varus stability at 0, 30 and 60 degrees. The popliteofibular complex was the most important structure for external rotation stability at all angles of flexion and was also important for varus stability at 30 and 60 degrees. The posterolateral capsule was important for varus stability at 0 and 30 degrees and for external rotation stability in extension. Level of evidence: Level IV (cadaver study).

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Research in the field of cardiopulmonary disease in Brazil has been very active in recent decades. The combination of PUBMED, SCieLO, open access and online searching has provided a significant increase in the visibility of Brazilian journals. This newly acquired international visibility has in turn resulted in the appearance of more original research reports in the Brazilian scientific press. This review is intended to highlight part of this work for the benefit of the readers of "Clinics." We searched through PUBMED for noteworthy articles published in Brazilian medical journals included in the Journal of Citation Reports of the Institute of Scientific Information to better expose them to our readership. The following journals were examined: "Arquivos Brasileiros de Cardiologia," "Arquivos Brasileiros de Endocrinologia e Metabologia," "Brazilian Journal of Medical and Biological Reviews," "Jornal Brasileiro de Pneumologia," "Jornal de Pediatria," "Revista Brasileira de Cirurgia Cardiovascular," "Revista da Associação Médica Brasileira," Revista da Escola de Enfermagem U.S.P." and "São Paulo Medical Journal." These journals publish original investigations in the field of cardiopulmonary disease. The search produced 71 references, which are briefly examined.