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ABSTRACT BACKGROUND: Patient safety culture is part of the organizational profile of healthcare institutions and is associated with better quality of care. OBJECTIVE: To assess patient safety culture in a university hospital. DESIGN AND SETTING: Hospital-based cross-sectional study conducted in a public university hospital in São Paulo, Brazil, between September and December 2015. METHODS: We randomly selected 68 sectors of the hospital, to include up to 5 employees from each sector, regardless of length of experience. We used the validated Brazilian version of the Hospital Survey on Patient Safety Culture (HSOPS) via an electronic interface. We calculated the percentage of positive responses for each dimension of the HSOPS and explored the differences in age, experience, occupation and educational level of respondents using the chi-square test. RESULTS: Out of 324 invited respondents, 314 (97%) accepted the invitation and were surveyed. The sample presented predominance of women (72%), nursing staff (45%) and employees with less than six years’ experience at the hospital (60%). Nine out of the 12 dimensions showed percentages of positive responses below 50%. The worst results related to “nonpunitive response to errors” (16%). A better safety culture was observed among more experienced staff, nurses and employees with a lower educational level. In the previous year, no events were reported by 65% of the participants. CONCLUSIONS: The patient safety culture presented weaknesses and most of professionals had not reported any event in the previous year. A policy for improvement and cyclical assessment is needed to ensure safe care.

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ABSTRACT BACKGROUND: Coronary heart disease (CHD) remains a major cause of mortality worldwide and in Brazil. Use of standard medications after CHD has been proven to avoid new events and reduce early mortality. OBJECTIVES: This study aimed to analyze secondary prevention of CHD and its association with the baseline characteristics of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). DESIGN AND SETTING: Cross-sectional analysis on ELSA-Brasil data. METHODS: Secondary prevention of CHD recommended in standard guidelines (antiplatelet plus beta-blocker plus lipid-lowering drug, with or without angiotensin-converting enzyme inhibitors, ACEI, or angiotensin receptor blockers, ARB) was evaluated in relation to sociodemographic data and the time since the coronary event. The chi-square test, one-way analysis of variance (ANOVA) and Mann-Whitney test were performed, as necessary. RESULTS: Among 15,094 participants, 2.7% reported a previous diagnosis of CHD. Use of recommended drugs for secondary prevention was reported by almost 35% of the participants. Medication use for secondary prevention was generally more frequent among high-income participants than among low-income participants. Use of ARB and ACEI was different between participants who had private health insurance and those who only used the public healthcare system. Men were more likely to use medication than women. The frequency with which participants used the recommended drugs was similar in all time periods after CHD, but use of only one drug increased progressively across time periods. CONCLUSION: The use of medication for secondary prevention of CHD was lower than what is recommended in standardized guidelines, especially among women and lower-income participants.

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ABSTRACT BACKGROUND: There are still few studies on predictors of smoking cessation in Brazilian samples. Experimentation with tobacco during adolescence (ETA) may be one of the important predictors. OBJECTIVE: This study aimed, within the context of a treatment-seeking group of subjects, to test the hypothesis that ETA negatively affects the outcome of smoking cessation during adulthood. DESIGN AND SETTING: Retrospective (historic) cohort study conducted at a psychosocial care center in São Paulo, Brazil, between 2007 and 2010. METHODS: Data on sociodemographics, smoking and medical profiles were obtained through self-report questionnaires that were completed at the baseline and at any follow-up appointment. Logistic regression models were constructed to describe factors associated with the outcome of smoking cessation, measured according to the self-reported four-week success rate among 367 outpatient smokers. RESULTS: ETA was found to be associated with not quitting smoking through the treatment (odds ratio = 0.57; 95% confidence interval = 0.33-0.96; P < 0.05), even after adjustment for dependence level, sociodemographics, nicotine patch use and number of years of smoking. CONCLUSIONS: Early exposure to nicotine may lead to higher risk of continuing smoking after treatment, in adulthood.

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ABSTRACT BACKGROUND: The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations. OBJECTIVE: The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America. DESIGN AND SETTING: Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center. METHODS: Patients with benign thyroid disease (Graves’ disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records. RESULTS: 1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia. CONCLUSION: Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.

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ABSTRACT BACKGROUND: Atrial fibrillation (AF) is the most common form of supraventricular arrhythmia following ST-elevation myocardial infarction (STEMI). The CHA2DS2-VASc and CHADS2 scores are used to estimate thromboembolic risk in cases of AF. Their usefulness in predicting the development of AF in patients presenting STEMI is unknown. OBJECTIVE: To evaluate the predictive value of the CHADS2 and CHA2DS2-VASc scores in patients with AF following STEMI. DESIGN AND SETTING: This prospective cohort study on 696 patients with STEMI was conducted at a tertiary-level cardiology clinic in a public university hospital. METHODS: Models including clinical and laboratory parameters were constructed to test the predictive value of CHADS2 and CHA2DS2-VASc scores. Patients were divided into two groups: with and without AF. Predictors of AF were determined using multivariate regression analysis. RESULTS: In the patients with AF, CHADS2 and CHA2DS2-VASc scores were significantly higher than in those without AF (for both P < 0.001). Factors associated with AF in multivariate analyses included CHA2DS2-VASc score (odds ratio, OR: 1.48; 95% confidence interval, CI: 1.25-1.75; P < 0.001), peak creatine kinase-myocardial binding (OR: 1.002; 95% CI: 1.00-1.003; P = 0.0024), duration of the coronary intensive care unit stay (OR: 1.69; 95% CI: 1.24-12.30; P = 0.001) and no use of renin-angiotensin system blockers (OR: 2.16; 95% CI: 1.14-4.10; P = 0.0017). Receiver operating characteristic curve analyses showed that CHA2DS2-VASc scores were significant predictors for new-onset AF (C-statistic: 0.698; 95% CI: 0.631-0.765; P < 0.001). CONCLUSION: CHADS2 and CHA2DS2-VASc scores predicted new AF in patients presenting STEMI.

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ABSTRACT BACKGROUND: There is evidence that genetic predisposition and epigenetic alteration (e.g. DNA methylation) play major roles in lung cancer. In our genetic epidemiological studies, rs1970764 in oncogene PPP1R13L was most consistently associated with lung cancer risk. Here, we explored the role of PPP1R13L methylation in lung cancer development. DESIGN AND SETTING: Analytical cross-sectional study (45 lung cancer cases and 45 controls), conducted in China. METHODS: We investigated the DNA methylation status of 2,160 cytosine-phosphate-guanine (CpG) sites in the PPP1R13L promoter region using the EpiTYPER assay of the Sequenom MassARRAY platform. RESULTS: In the whole study group, the methylation levels of CpG-6, CpG-9, CpG-20 and CpG-21 were significantly lower and those of CpG-16 were significantly higher in cases than in controls. Among smokers, the methylation levels at five CpG sites (CpG-6, CpG-11, CpG-15, CpG-20 and CpG-21) were statistically significantly lower among cases. Among men, the methylation levels at four CpG sites (CpG-11, CpG-15, CpG-20 and CpG-21) were significantly lower among cases. Regarding smokers, the methylation levels at CpG-7.8 and CpG-21 among cases and at CpG-22 among controls were significantly lower, compared with nonsmokers. The frequency of positivity for methylation was not significantly different between lung cancer cases and controls (68.22% for cases and 71.87% for controls; P = 0.119). CONCLUSION: Our study on a Chinese population suggests that lung cancer patients have aberrant methylation status (hypomethylation tended to be more frequent) in peripheral blood leukocytes at several CpG sites in the PPP1R13L promoter region and that exposure to smoking may influence methylation status.

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ABSTRACT BACKGROUND: The Bournemouth questionnaire is a multidimensional instrument for evaluating health domains among patients with low back pain. OBJECTIVE: The objective of this study was to translate and cross-culturally adapt the Bournemouth questionnaire for individuals with low back pain, to Brazilian Portuguese. DESIGN AND SETTINGS: This was a cross-sectional study conducted at the Federal University of São Carlos. METHODS: The Brazilian version of the Bournemouth questionnaire was developed following the processes of translation, back-translation, committee review and pre-testing. The translation phase involved two independent bilingual translators whose mother language was Brazilian Portuguese. The back-translation phase involved two independent translators whose mother language was English. In order to verify comprehension of the questionnaire, 44 individuals (43.1% men) with low back pain, and with mean age of 45.4 ± 13.8 years, participated in the pre-testing phase. RESULTS: During the translation phase, some terms and expressions were changed to obtain cultural equivalence to the original Bournemouth questionnaire. In the pre-testing phase, each item of the questionnaire showed a comprehension level of over 90%. CONCLUSION: The Bournemouth questionnaire was translated and culturally adapted to the Portuguese language, to be used among individuals with low back pain.

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ABSTRACT BACKGROUND: The most recent editions of diagnostic manuals have proposed important modifications in posttraumatic stress disorder (PTSD) criteria. The International Trauma Questionnaire (ITQ) is the gold-standard measurement for assessing PTSD and complex PTSD in accordance with the model of the 11th International Classification of Diseases (ICD-11). OBJECTIVE: The aim of this study was to adapt the ITQ for the Brazilian context. DESIGN AND SETTING: The translation and cross-cultural adaptation of the ITQ for use in Brazilian Portuguese was performed in trauma research facilities in Porto Alegre, Rio de Janeiro and Belo Horizonte, Brazil. METHODS: The adaptation followed five steps: (1) translation; (2) committee synthesis; (3) experts’ evaluation through the content validity index (CVI) and assessment of interrater agreement though kappa statistics; (4) comprehension test with clinical and community samples (n = 35); and (5) final back-translation and authors’ evaluation. RESULTS: Two independent translations were conducted. While working on a synthesis of these translations, the committee proposed changes in six items to adapt idiomatic expressions or to achieve a more accurate technical fit. Both the expert judges’ evaluation (CVI > 0.7; k > 0.55) and the pretest in the target population (mean comprehension > 3) indicated that the adapted items were adequate and comprehensible. The final back-translation was approved by the authors of the original instrument. CONCLUSION: ITQ in its Brazilian Portuguese version achieved satisfactory content validity, thus providing a tool for Brazilian research based on PTSD models of the ICD-11.

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ABSTRACT BACKGROUND: Gestational trophoblastic diseases (GTDs) are treatable rare tumors with wide distribution. The estimated incidence of GTDs varies dramatically between different regions globally. In early pregnancy, there may be high human chorionic gonadotropin (HCG) concentrations, normal or slightly increased free T4 (fT4) and subnormal thyroid-stimulating hormone (TSH), causing hyperthyroidism ranging from subclinical to severe. Beta-HCG causes thyrotoxicosis through thyroid stimulation in patients with trophoblastic tumors. OBJECTIVE: To assess thyroid function among patients diagnosed with complete or partial hydatidiform mole, within the GTD spectrum. DESIGN AND SETTING: Cross-sectional study based on patients’ medical records at Van University Hospital, Van, Turkey. METHODS: 50 patients monitored due to diagnoses of hydatidiform mole were included and were examined regarding thyroid function. Thyroid gland size and volume were measured using thyroid ultrasonography. Beta-HCG, TSH, fT4, free T3 (fT3), total T4 (TT4), total T3 (TT3), anti-thyroid peroxidase (anti-TPO), anti-thyroglobulin (anti-TG) and thyroglobulin levels were measured. RESULTS: Among these patients, 15 (30%) were diagnosed with complete hydatidiform mole and 35 (70%) with partial hydatidiform mole, according to pathology results. Those with complete hydatidiform mole were older (P = 0.003), with higher number of pregnancies (P = 0.032), lower TSH level (P = 0.011) and higher fT4 and TT4 levels (P = 0.04; P = 0.028), compared with partial hydatidiform mole patients. CONCLUSION: In hydatidiform mole patients, thyroid disease severity increases with age, parity, beta-HCG level and mole size. However, prospective multicenter studies on this topic are needed, with larger numbers of patients and closer monitoring.

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ABSTRACT BACKGROUND: Ultrasonography is currently used in investigating many vascular diseases, especially for guiding vascular access. OBJECTIVE: The objective here was to summarize the evidence from Cochrane systematic reviews (SRs) on the effects of ultrasound-guided vascular access as an intervention approach. DESIGN AND SETTING: Review of SRs, conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo. METHODS: A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the effects of ultrasound guidance as a therapeutic approach towards performing any vascular access. The key characteristics and results of all the reviews included were summarized and discussed. RESULTS: Three SRs on venous access at all ages and one review on arterial access in pediatric participants were included. There was low to moderate certainty of evidence that ultrasound increased the success rate from the first puncture and the overall success rate of the procedure; and reduced the total rate of perioperative and postoperative adverse events, number of punctures, time needed to achieve success and rate of failure to place catheters. CONCLUSION: Evidence of low to moderate quality showed that ultrasound-guided vascular access seems to reduce the total rate of perioperative and postoperative complications/adverse effects, number of punctures, time needed to achieve success and rate of failure to perform venous catheterization in adults and arterial punctures in children. There is a lack of information regarding ultrasound-guided arterial puncture in adults. Further studies are still imperative for reaching solid conclusions, especially regarding arterial ultrasound-guided access.

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ABSTRACT CONTEXT: Rapunzel syndrome is a rare form of gastric trichobezoar that develops through outstretching of the bezoar from the stomach to the intestine. CASE REPORT: A 12-year-old girl who had been diagnosed with celiac disease six years earlier was brought to the department of pediatric gastroenterology because of abdominal distension. A palpable mass was detected. A trichobezoar that stretched to the small intestine was removed surgically. The patient was diagnosed as having anxiety and depressive disorder, and treatment started. Following the treatment, her previous trichophagia completely disappeared. CONCLUSION: Presence of trichobezoar should be kept in mind, especially when young girls who have psychiatric problems suffer from gastrointestinal symptoms.

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ABSTRACT CONTEXT: Adverse reactions associated with prick tests are rare but may be present as serious systemic reactions. CASE REPORT: A 38-year-old female nursing technician complained of three episodes of anaphylaxis in one year, all in the workplace. To investigate latex allergy, the patient underwent the prick test with latex, and immediately developed a rash, itchy skin, hoarseness, dyspnea and dry cough. Her condition improved promptly after appropriate measures were established for controlling her anaphylaxis. CONCLUSION: The skin test must be performed under medical supervision, since complications that can lead to life-threatening reactions, if support measures are not readily implemented, have been attributed to this test.

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ABSTRACT CONTEXT: Dermoid cysts are well-defined cysts containing sebaceous glands and dermal structures. In the literature, dermoid cysts and associated closure defects have been described in the same locations. CASE REPORT: In this case, a dermoid cyst was found at the base of the mouth with a coexisting closure defect in the occipital calvarium. Additional abnormalities were also observed, including posterior myeloschisis, right cerebellar dysgenesis, vermian hypogenesis and posterior fusion of the second and third vertebrae. The finding of a dermoid cyst located at the base of the mouth is discussed here, with additional imaging findings. CONCLUSION: Dermoid cysts in the head and neck region may be accompanied by posterior fossa abnormalities.