Scielo RSS <![CDATA[Sao Paulo Medical Journal]]> http://www.scielo.br/rss.php?pid=1516-318020140004&lang=en vol. 132 num. 4 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[Clinical research training]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400197&lng=en&nrm=iso&tlng=en <![CDATA[Spatial distribution of deaths due to Alzheimer's disease in the state of São Paulo, Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400199&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Alzheimer's disease is a common cause of dementia and identifying possible spatial patterns of mortality due to this disease may enable preventive actions. The objective of this study was to identify spatial distribution patterns of mortality due to Alzheimer's disease in the state of São Paulo. DESIGN AND SETTING: Ecological and exploratory study conducted in all municipalities in the state of São Paulo. METHODS: Data on Alzheimer's disease mortality in the state of São Paulo between 2004 and 2009 were obtained from DATASUS (the Department of Informatics in the Brazilian Ministry of Health). Death rates per 100,000 inhabitants were then calculated and spatial analysis was performed by constructing a death rate map, global Moran index and local Moran index, which were used to obtain the Moran map. The kernel technique was also applied. The Terra View 4.0.0 software was used. RESULTS: 13,030 deaths due to Alzheimer were reported in the state of São Paulo (rate of 5.33 deaths/100,000 inhabitants). São José do Rio Preto, Ribeirão Preto, Bauru and Araçatuba had higher rates. The Moran index was I = 0.085 (P &lt; 0.002). The Moran map identified 42 municipalities that merit intervention and the kernel estimator identified a high density of deaths in the northwestern region of the state. CONCLUSION: Higher densities of deaths due to Alzheimer were concentrated more to the north and northwest of the state of São Paulo. It was possible to identify municipalities that have priority for interventions to reduce the death rates due to this disease. <hr/> CONTEXTO E OBJETIVO: A doença de Alzheimer é uma frequente causa de demência e a identificação de possíveis padrões espaciais da mortalidade por essa doença pode permitir ações preventivas. O objetivo do trabalho foi identificar padrões espaciais da distribuição da mortalidade por doença de Alzheimer no estado de São Paulo. DESENHO E LOCAL DE ESTUDO: Estudo ecológico e exploratório realizado em todos os municípios do estado de São Paulo. MÉTODOS: Foram obtidos, do DATASUS (Departamento de Informática do SUS, Sistema Único de Saúde), dados sobre mortalidade por doença de Alzheimer, no estado de São Paulo entre 2004 e 2009. Foi calculada a taxa de óbitos por 100.000 habitantes e realizou-se a análise espacial, por meio da construção do mapa da taxa de óbitos, do índice global de Moran e do índice local de Moran, utilizado para a obtenção do Moran Map. Aplicou-se também a técnica de kernel. Foi utilizado o programa TerraView 4.0.0. RESULTADOS: Foram notificados 13.030 óbitos por Alzheimer no estado de São Paulo (taxa de 5,33 óbitos/100.000 habitantes). São José do Rio Preto, Ribeirão Preto, Bauru e Araçatuba apresentaram altas taxas. O índice de Moran encontrado foi I = 0.085 (P &lt; 0,002). O Moran Map identificou 42 municípios que merecem intervenção e o estimador de kernel identificou alta densidade de óbitos na região noroeste do estado. CONCLUSÕES: Maiores densidades de óbitos por Alzheimer se concentraram mais ao norte e noroeste do estado de São Paulo. Foi possível identificar municípios que têm prioridade de intervenção para diminuição das taxas de óbitos por esta doença. <![CDATA[Clinical and laboratorial features of spontaneous bacterial peritonitis in southern Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400205&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Spontaneous bacterial peritonitis (SBP) is a severe complication that occurs in 8-27% of hospitalized patients with liver cirrhosis and ascites, with high mortality rates. This study aimed to identify the clinical characteristics associated with SBP. DESIGN AND SETTING: Cross-sectional study, conducted in a public university. METHODS: The study consecutively included individuals with liver cirrhosis and ascites between September 2009 and March 2012. Forty-five patients were included: mean age 53.2 ± 12.3 years, 82.2% male, 73.8% Caucasian, mean Model of End-stage Liver Disease (MELD) score of 19.5 ± 7.2, and 33.3% with SBP. The subjects were divided into two groups: SBP and controls. RESULTS: Comparison between individuals with SBP and controls showed that those with SBP had lower mean prothrombin activity time (36.1 ± 16.0% versus 47.1 ± 17.2%; P = 0.044) and lower median serum-ascites albumin gradient (SAAG) (1.2 versus 1.7, P = 0.045). There was a tendency towards higher mean MELD in the SBP group, not significant (22.2 ± 7.6 versus 17.9 ± 6.7; P = 0.067). There was a strong positive correlation between the neutrophil count in ascitic fluid and serum leukocyte count (r = 0.501; P = 0.001) and a negative correlation between the neutrophil count in ascitic fluid with prothrombin activity time (r = -0.385; P = 0.011). CONCLUSION: A few characteristics are associated with the presence of SBP, especially liver dysfunction, SAAG and peripheral leukocytosis. <hr/> CONTEXTO E OBJETIVO: Peritonite bacteriana espontânea (PBE) é uma complicação grave que ocorre em 8-27% dos pacientes hospitalizados com cirrose hepática e ascite, e apresenta altas taxas de mortalidade. O objetivo deste estudo é identificar as características clínicas associadas à PBE. TIPO DE ESTUDO E LOCAL: Estudo transversal, conduzido em uma universidade pública. MÉTODOS: O estudo incluiu, consecutivamente, indivíduos com cirrose hepática e ascite entre setembro 2009 e março 2012. Foram incluídos 45 indivíduos com média de idade de 53,2 ± 12,3 anos, sendo 82,2% homens, 73,8% brancos, com MELD (Modelo para Doença Hepática Terminal) de 19,5 ± 7,2, e 33,3% com PBE. Os indivíduos foram divididos em dois grupos: PBE e controles. RESULTADOS: Quando se compararam os indivíduos com PBE aos controles, observou-se menor média de tempo de atividade da protrombina (TAP; 36,1 ± 16,0% versus 47,1 ± 17,2%; P = 0,044) e menor mediana de gradiente albumina soro-ascite (GASA; 1,2 versus 1,7; P = 0,045). Houve tendência do grupo com PBE de apresentar maior média de MELD, sem significância estatística (22,2 ± 7,6 versus 17,9 ± 6,7; P = 0,067). Foi observada forte correlação positiva entre neutrófilos do líquido ascítico e contagem sérica de leucócitos (r = 0,501; P = 0,001) e correlação negativa de neutrófilos do líquido ascítico com TAP (r = -0,385; P = 0,011). CONCLUSÃO: Poucas características estão associadas à presença de PBE, em especial a disfunção hepática, o GASA e a leucocitose periférica. <![CDATA[Continuing education on child development for primary healthcare professionals: a prospective before-and-after study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400211&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Children's developmental disorders are often identified late by healthcare professionals working in primary care. The aim of this study was to assess the impact of a continuing education program on child development, on the knowledge and practices of these professionals. DESIGN AND SETTING: Prospective single-cohort study (before-and-after study), conducted in the city of Belém, Pará , Brazil. METHODS: Two hundred and twenty-one professionals working in primary healthcare (82.2%) participated in a continuing education program on child development and were assessed before and after implementation of the program through tests on their knowledge of child development, consisting of 19 questions for physicians and 14 for nurses, and questionnaires on their professional practices. RESULTS: One to three years after the program, the mean number of correct answers in the tests had increased from 11.5 to 14.3 among physicians in the Healthy Family Program (Programa Família Saudável, PFS); 13.0 to 14.3 among physicians in Municipal Health Units (Unidades Municipais de Saúde, UMS); 8.3 to 10.0 among PFS nurses; and 7.8 to 9.4 among UMS nurses. In interviews with mothers attended by these professionals before the program, only 21.7% reported that they were asked about their children's development, 24.7% reported that the professional asked about or observed their children's development and 11.1% received advice on how to stimulate them. After the program, these percentages increased to 34.5%, 54.2% and 30.3%, respectively. CONCLUSIONS: Professionals who participated in the program showed improved performance regarding child development knowledge and practices. <hr/> CONTEXTO E OBJETIVO: Alterações do desenvolvimento em crianças frequentemente têm sido tardiamente identificadas por profissionais de saúde que atuam na atenção básica. O objetivo deste estudo foi avaliar o impacto de um programa de educação permanente sobre desenvolvimento infantil nos conhecimentos e práticas desses profissionais. TIPO DE ESTUDO E LOCAL: Estudo de coorte única prospectivo (antes-e-depois), realizado no município de Belém, Pará, Brasil. MÉTODOS: 221 (82,2%) profissionais da rede básica de saúde que participaram do programa de educação permanente sobre desenvolvimento infantil foram avaliados antes e após a implantação do programa, através de testes sobre seus conhecimentos em desenvolvimento infantil com 19 questões para médicos e 14 para enfermeiros, e questionários sobre sua prática profissional. RESULTADOS: Um a três anos após o programa, a média de perguntas certas dos testes aumentou de 11,5 para 14,3 entre os médicos do Programa da Família Saudável (PFS); 13,0 para 14,3 entre os médicos de Unidades Municipais de Saúde (UMS); 8,3 para 10,0 entre os enfermeiros de PFS e 7,8 para 9,4 entre os enfermeiros de UMS. Nas entrevistas com mães atendidas por esses profissionais, verificou-se que, antes do programa, apenas 21,7% informaram que foram indagadas sobre o desenvolvimento dos seus filhos, 24,7% relataram que o profissional perguntou ou observou o desenvolvimento da sua criança e 11,1% receberam orientação sobre como estimulá-las; após o programa, esses percentuais aumentaram para 34,5%, 54,2% e 30,3%, respectivamente. CONCLUSÃO: Profissionais que participaram do programa apresentaram melhor desempenho quanto aos conhecimentos e práticas sobre desenvolvimento infantil. <![CDATA[Incidence of postoperative dyspepsia is not associated with prophylactic use of drugs]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400219&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Preoperative fasting guidelines do not recommend H2 receptor antagonists or proton pump inhibitors. This study investigated prophylactic use of gastric protection and the incidence of dyspeptic symptoms in the immediate postoperative period. DESIGN AND SETTING: Non-randomized observational investigation in a post-anesthesia care unit. METHODS: American Society of Anesthesiologists risk classification ASAP1 and ASAP2 patients over 18 years of age were evaluated to identify dyspeptic symptoms during post-anesthesia care for up to 48 hours, after receiving or not receiving prophylactic gastric protection during anesthesia. History of dyspeptic symptoms and previous use of such medications were exclusion criteria. The odds ratio for incidence of dyspeptic symptoms with use of these medications was obtained. RESULTS: This investigation studied 188 patients: 71% women; 50.5% ASAP1 patients. Most patients received general anesthesia (68%). Gastric protection was widely used (n = 164; 87.2%), comprising omeprazole (n = 126; 76.8%) or ranitidine (n = 38; 23.2%). Only a few patients did not receive any prophylaxis (n = 24; 12.8%). During the observation, 24 patients (12.8%) reported some dyspeptic symptoms but without any relationship with prophylaxis (relative risk, RR = 0.56; 95% confidence interval, CI: 0.23-1.35; P = 0.17; number needed to treat, NNT = 11). Omeprazole, compared with ranitidine, did not reduce the chance of having symptoms (RR = 0.65; 95% CI: 0.27-1.60; P = 0.26; NNT = 19). CONCLUSION: This study suggests that prophylactic use of proton pump inhibitors or H2 receptor antagonists was routine for asymptomatic patients and was not associated with postoperative protection against dyspeptic symptoms. <hr/> CONTEXTO E OBJETIVO: Diretrizes para jejum pré-operatório não recomendam antagonistas dos receptores H2 ou inibidores da bomba de prótons. Este estudo investigou o uso profilático de proteção gástrica e a incidência de sintomas dispépticos no período pós-operatório imediato. TIPO DE ESTUDO E LOCAL: Estudo observacional não aleatorizado em unidade de recuperação pós-anestésica. MÉTODOS: Pacientes ASAP1 e ASAP2, classificação de risco da American Society of Anesthesiologists, com mais de 18 anos de idade, foram avaliados para identificar sintomas dispépticos durante a recuperação pós-anestésica em até 48 horas, tendo ou não recebido proteção gástrica profilática durante a anestesia. História de sintomas dispépticos e uso prévio de tais medicamentos foram critérios de exclusão. A razão de chances para incidência de sintomas dispépticos com uso desses medicamentos foi obtida. RESULTADOS: Foram estudados 188 pacientes, 71% mulheres, 50,5% dos pacientes ASAP1. A maioria dos pacientes recebeu anestesia geral (68%). Proteção gástrica foi amplamente usada (n = 164; 87,2%), consistindo de omeprazol (n = 126; 76,8%) ou ranitidina (n = 38; 23,2%). Poucos pacientes não receberam qualquer profilaxia (n = 24; 12,8%). Durante a observação, 24 pacientes (12,8%) relataram alguns sintomas dispépticos, porém sem relação com profilaxia (risco relativo, RR = 0,56; intervalo de confiança, IC 95% 0,23-1,35, P = 0,17; número necessário para tratar, NNT = 11). Omeprazol, comparado à ranitidina, não reduziu a chance de ter sintomas (RR = 0,65; IC 95% 0,27-1,60; P = 0,26; NNT = 19). CONCLUSÃO: Este estudo sugere que o uso profilático de inibidores da bomba de prótons ou antagonistas do receptor H2 foi rotina em pacientes assintomáticos e não esteve associado com proteção pós-operatório para dispepsia. <![CDATA[Cluster analysis to identify elderly people's profiles: a healthcare strategy based on frailty characteristics]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400224&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVES: The new social panorama resulting from aging of the Brazilian population is leading to significant transformations within healthcare. Through the cluster analysis strategy, it was sought to describe the specific care demands of the elderly population, using frailty components. DESIGN AND SETTING: Cross-sectional study based on reviewing medical records, conducted in the geriatric outpatient clinic, Hospital de Clínicas, Universidade Estadual de Campinas (Unicamp). METHODS: Ninety-eight elderly users of this clinic were evaluated using cluster analysis and instruments for assessing their overall geriatric status and frailty characteristics. RESULTS: The variables that most strongly influenced the formation of clusters were age, functional capacities, cognitive capacity, presence of comorbidities and number of medications used. Three main groups of elderly people could be identified: one with good cognitive and functional performance but with high prevalence of comorbidities (mean age 77.9 years, cognitive impairment in 28.6% and mean of 7.4 comorbidities); a second with more advanced age, greater cognitive impairment and greater dependence (mean age 88.5 years old, cognitive impairment in 84.6% and mean of 7.1 comorbidities); and a third younger group with poor cognitive performance and greater number of comorbidities but functionally independent (mean age 78.5 years old, cognitive impairment in 89.6% and mean of 7.4 comorbidities). CONCLUSION: These data characterize the profile of this population and can be used as the basis for developing efficient strategies aimed at diminishing functional dependence, poor self-rated health and impaired quality of life. <hr/> CONTEXTO E OBJETIVOS: O panorama social do envelhecimento da população brasileira promete transformações significativas na atenção à saúde. Por meio da estratégia de análise por conglomerados (cluster), procurou-se descrever demandas de cuidados na população de idosos, utilizando componentes da fragilidade. TIPO DE ESTUDO E LOCAL: Estudo transversal baseado em revisão de registros médicos, realizado no Ambulatório de Geriatria do Hospital de Clínicas da Universidade Estadual de Campinas (Unicamp). MÉTODOS: Foram analisados 98 idosos usuários deste ambulatório por meio da análise de conglomerados, utilizando instrumentos para a avaliação do status geriátrico global e das características de fragilidade. RESULTADOS: As variáveis que mais fortemente influenciaram a formação dos conglomerados foram idade, capacidades funcional e cognitiva, presença de comorbidades e número de medicamentos utilizados, sendo o modelo com quatro agrupamentos estatisticamente mais robusto. Podem-se identificar três grupos principais de idosos, o primeiro de bom desempenho cognitivo e funcional, porém com elevada prevalência de comorbidades (idade média 77.9 anos, 28.6% com déficit cognitivo, média de 7.4 comorbidades); outro caracterizado por idade mais avançada, maior comprometimento cognitivo e maior dependência (idade média 88.5 anos, 84.6% com déficit cognitivo, média de 7.1 comorbidades); e ainda outro de menor idade, pior desempenho cognitivo e maior número de comorbidades, porém funcionalmente independentes (idade média 78.5 anos, 89.6% com déficit cognitivo, média de 4.9 comorbidades). CONCLUSÃO: Esses dados caracterizam o perfil dessa população e servem como substrato para o desenvolvimento de estratégias cujos objetivos sejam diminuir a dependência funcional, autopercepção ruim de saúde e comprometimento da qualidade de vida. <![CDATA[Perineal trauma after vaginal delivery in healthy pregnant women]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400231&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Despite all the medical care provided during delivery labor, perineal injury is still prevalent and may lead to diverse pelvic floor disorders. The aim here was to investigate the prevalence of obstetric and anal sphincter injuries (OASIS) in healthy pregnant women after vaginal delivery. DESIGN AND SETTING: Cross-sectional study involving 3,034 patients with singletons in a secondary hospital for low-risk cases. METHODS: A standardized questionnaire was prepared and applied to medical files that had been completely filled out (classification of the Royal College of Obstetricians and Gynecologists, RCOG) in order to identify OASIS and analyze risk factors associated with mild and severe perineal lacerations. RESULTS: The women's mean age was 25 years; more than half (54.4%) were primiparae. Almost 38% of the participants had perineal lacerations; these were severe in 0.9% of the cases. Previous vaginal delivery (odds ratio, OR: 1.64 [1.33-2.04]) and forceps delivery (OR: 2.04 [1.39-2.97]) were risk factors associated with mild perineal injuries (1st and 2nd OASIS classifications). Only remaining standing for prolonged periods during professional activity (OR: 2.85 [1.34-6.09]) was associated with severe perineal injuries. CONCLUSION: The prevalence of severe perineal injuries was concordant with data in the literature. The variable of standing position was considered to be a risk factor for severe perineal injury and should be further investigated. <hr/> CONTEXTO E OBJETIVOS: Apesar do cuidado médico executado durante o trabalho de parto, os traumas perineais ainda são prevalentes e podem levar a várias desordens do assoalho pélvico. O objetivo foi investigar a prevalência de injúrias obstétricas e do esfíncter anal em mulheres saudáveis após parto vaginal. DESENHO E LOCAL DE ESTUDO: Estudo transversal envolvendo 3.034 pacientes com recém-natos únicos de um hospital secundário de baixo risco. MÉTODOS: Um questionário padronizado foi preparado e aplicado aos prontuários completamente preenchidos (classificação do Royal College of Obstetricians and Gynecologists) para identificar as lesões obstétricas e do esfíncter anal e analisar fatores de risco associados com lacerações perineais leves e graves. RESULTADOS: A média de idade das mulheres era 25 anos; mais da metade (54,4%) era primípara. Quase 38% das participantes tiveram lacerações perineais; estas foram graves em 0,9% dos casos. A presença de parto vaginal prévio (odds ratio, OR, 1,64 [1,33-2,04]) e o parto fórceps (OR 2,04 [1,39-2,97]) foram fatores de risco associados às lesões perineais leves (primeira e segunda classificações de lesão esfíncter e anal). Somente a posição em pé prolongada durante a atividade profissional (OR 2,85 [1,34-6,09]) estava associada com lesões perineais graves. CONCLUSÃO: A prevalência de trauma perineal grave concordou com dados da literatura. A variável posição em pé foi considerada fator de risco para trauma perineal grave e necessita ser investigada. <![CDATA[Systemic lupus erythematosus activity and beta two microglobulin levels]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400239&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: Systemic lupus erythematosus (SLE) is an autoimmune disease with a cyclical clinical course. Evaluation of the clinical activity of this disease is important for choosing the correct treatment. The objective of this study was to analyze the value of beta-2 microglobulin (β2M) serum levels in determining SLE clinical activity. DESIGN AND SETTING: Cross-sectional analytical study conducted at the rheumatology outpatient clinic of a private university hospital. METHODS: 129 SLE patients were studied regarding disease activity using SLEDAI (SLE Disease Activity Index) and cumulative damage using SLICC ACR (SLE International Collaborating Clinics/American College of Rheumatology Damage Index for SLE). At the same time, the β2M serum level, ESR (erythrocyte sedimentation rate), anti-dsDNA (anti-double-stranded DNA) and C3 and C4 complement fractions were determined. RESULTS: β2M levels correlated positively with SLEDAI (P = 0.02) and ESR (P = 0.0009) and negatively with C3 (P = 0.007). Patients who were positive for anti-dsDNA had higher β2M serum levels (P = 0.009). CONCLUSION: β2M levels are elevated in SLE patients with active disease. <hr/> CONTEXTO E OBJETIVO: O lúpus eritematoso sistêmico (LES) é uma doença autoimune com curso clínico flutuante. Determinar a atividade clínica da doença é importante na escolha do tratamento correto. O objetivo deste estudo foi o de analisar se os níveis séricos de beta-2 microglobulina (β2M) têm valor na determinação da atividade clínica do LES. TIPO DE ESTUDO E LOCAL: Estudo transversal, analítico, realizado no ambulatório de reumatologia de um hospital universitário particular. MÉTODOS: 129 pacientes com LES foram estudados para atividade da doença pelo SLEDAI (SLE Disease Activity Index) e para dano cumulativo pelo SLICC (SLE International Collaborating Clinics/American College of Rheumatology Damage Index for SLE). Simultaneamente foram determinados os valores séricos de β2M, das frações C3 e C4 do complemento, VHS (velocidade de hemossedimentação) e anti dsDNA (DNA de dupla fita). RESULTADO: Encontrou-se correlação positiva entre níveis de β2M com o SLEDAI (P = 0,02), com VHS (P = 0,0009) e correlação negativa com níveis de C3 (P = 0,007). Pacientes com presença de anti dsDNA tinham níveis mais altos de β2M (P = 0,009). CONCLUSÃO: Níveis de β2M estão elevados em pacientes de LES com doença ativa. <![CDATA[Rational use of blood calcium determinations]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400243&lng=en&nrm=iso&tlng=en CONTEXT AND OBJECTIVE: This study was motivated by the recent excessive increase in requests for blood calcium determinations and laboratory tests in general, in the Hospital das Clínicas complex of Faculdade de Medicina, Universidade de São Paulo (HCFMUSP). Its aim was to suggest rules for the determination of total and ionized calcium in our intensive care units, emergency department, wards and outpatient services, thus contributing towards improving the quality of medical care and achieving more appropriate use of human and financial resources. DESIGN AND SETTING: Critical analysis on clinical and laboratory data and the pertinent scientific literature, conducted by the study group for rational clinical laboratory use, which is part of the Central Laboratory Division, HCFMUSP. METHODS: The study group reviewed scientific publications, statistics and clinical and laboratory data concerning requests for total and ionized calcium determinations in the settings of intensive care units, emergency department, wards and outpatient services. RESULTS: From this critical analysis, clinical decision flow diagrams aimed at providing guidance for ordering these tests were constructed. CONCLUSIONS: Use of the proposed flow diagrams may help to limit the numbers of inappropriate requests for ionized and total calcium determinations, with consequent reductions in the number of tests, risks to patients and unnecessary costs. <hr/> CONTEXTO E OBJETIVO: Este trabalho foi motivado pelo recente aumento excessivo de solicitações de dosagem de cálcio no sangue, assim como de exames laboratoriais em geral, no complexo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). Seu objetivo foi sugerir regras para a determinação de cálcio total e iônico nas nossas unidades de terapia intensiva, pronto-socorro, enfermarias e ambulatórios e contribuir para a melhoria da qualidade da assistência médica, com utilização mais adequada dos recursos humanos e financeiros. TIPO DO ESTUDO E LOCAL: Análise crítica de dados clínicos, laboratoriais e da literatura médica pertinente, realizada pelo grupo de estudos para o uso racional do laboratório clínico, vinculado à Divisão de Laboratório Central do HCFMUSP. MÉTODOS: O grupo de estudos reviu publicações científicas, estatísticas e dados clínico-laboratoriais relativos às solicitações de cálcio total e iônico nos ambientes das unidades de terapia intensiva, prontos-socorros, enfermarias e ambulatórios. RESULTADOS: A partir dessa análise crítica, foram construídos fluxogramas de decisão clínica que visam orientar a requisição desses testes. CONCLUSÕES: A utilização dos fluxogramas propostos pode ajudar a limitar a solicitação inadequada das dosagens de cálcio total e iônico, com consequente redução do número de exames, de riscos para os pacientes e de custos desnecessários. <![CDATA[Rare cavernous hemangioma of adrenal gland: case report]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400249&lng=en&nrm=iso&tlng=en CONTEXT: Cavernous hemangiomas of the adrenal gland are rare benign neoplastic tumors. The clinical presentation of adrenal hemangiomas is usually vague, and they are often discovered incidentally through imaging examination s performed for other reasons. CASE REPORT: We report the case of a non-functional adrenal hemangioma found incidentally in a 37-year-old man with a one-year history of headache and hypertension. A right adrenal mass was detected by means of magnetic resonance imaging. Physical examination and all laboratory values were unremarkable. The patient underwent laparoscopic right adrenal gland resection. Histopathological evaluation confirmed adrenal cavernous hemangioma. CONCLUSIONS: Most occurrences of cavernous hemangiomas of the adrenal gland are non-functional and often discovered incidentally. Although rare, these unusual benign adrenal masses should form part of the differential diagnosis of adrenal neoplasms. The proper treatment for adrenal cavernous hemangioma is surgical removal. <hr/> CONTEXTO: Hemangiomas cavernosos da glândula adrenal são tumores neoplásicos raros, benignos. A apresentação clínica dos hemangiomas adrenais é geralmente vaga e muitas vezes eles são descobertos acidentalmente por exame imagiológico realizado por outras razões. RELATO DE CASO: Nós relatamos um caso de hemangioma adrenal não funcional encontrado por acaso em um homem de 37 anos de idade com histórico de um ano de dor de cabeça e hipertensão. Foi detectada massa adrenal direita por meio de ressonância magnética. Exame físico e todos os valores de laboratoriais estavam normais. O paciente foi submetido a cirurgia laparoscópica para ressecção da glândula adrenal direita. Avaliação histopatológica confirmou hemangioma adrenal cavernoso. CONCLUSÃO: A maioria dos hemangiomas cavernosos de glândula adrenal são não funcionais e muitas vezes descobertos por acaso. Embora raras, essas massas adrenais benignas devem ser parte de um diagnóstico diferencial de neoplasias suprarrenais. O tratamento adequado para o hemangioma adrenal cavernoso é a remoção cirúrgica. <![CDATA[Cytogenetic profile of patients with Down syndrome in southern Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400253&lng=en&nrm=iso&tlng=en CONTEXT: Cavernous hemangiomas of the adrenal gland are rare benign neoplastic tumors. The clinical presentation of adrenal hemangiomas is usually vague, and they are often discovered incidentally through imaging examination s performed for other reasons. CASE REPORT: We report the case of a non-functional adrenal hemangioma found incidentally in a 37-year-old man with a one-year history of headache and hypertension. A right adrenal mass was detected by means of magnetic resonance imaging. Physical examination and all laboratory values were unremarkable. The patient underwent laparoscopic right adrenal gland resection. Histopathological evaluation confirmed adrenal cavernous hemangioma. CONCLUSIONS: Most occurrences of cavernous hemangiomas of the adrenal gland are non-functional and often discovered incidentally. Although rare, these unusual benign adrenal masses should form part of the differential diagnosis of adrenal neoplasms. The proper treatment for adrenal cavernous hemangioma is surgical removal. <hr/> CONTEXTO: Hemangiomas cavernosos da glândula adrenal são tumores neoplásicos raros, benignos. A apresentação clínica dos hemangiomas adrenais é geralmente vaga e muitas vezes eles são descobertos acidentalmente por exame imagiológico realizado por outras razões. RELATO DE CASO: Nós relatamos um caso de hemangioma adrenal não funcional encontrado por acaso em um homem de 37 anos de idade com histórico de um ano de dor de cabeça e hipertensão. Foi detectada massa adrenal direita por meio de ressonância magnética. Exame físico e todos os valores de laboratoriais estavam normais. O paciente foi submetido a cirurgia laparoscópica para ressecção da glândula adrenal direita. Avaliação histopatológica confirmou hemangioma adrenal cavernoso. CONCLUSÃO: A maioria dos hemangiomas cavernosos de glândula adrenal são não funcionais e muitas vezes descobertos por acaso. Embora raras, essas massas adrenais benignas devem ser parte de um diagnóstico diferencial de neoplasias suprarrenais. O tratamento adequado para o hemangioma adrenal cavernoso é a remoção cirúrgica. <![CDATA[Vaccines for preventing herpes zoster in older adults]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400255&lng=en&nrm=iso&tlng=en BACKGROUND: Herpes zoster or, as it is commonly called, 'shingles' is a neurocutaneous disease characterised by the reactivation of varicella zoster virus (VZV), the virus that causes chickenpox, which is latent in the dorsal spinal ganglia when immunity to VZV declines. It is an extremely painful condition which can often last for many weeks or months, impairing the patient's quality of life. The natural aging process is associated with a reduction of cellular immunity which predisposes to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production, therefore avoiding viral reactivation. A herpes zoster vaccine with an active virus has been approved for clinical use among older adults by the Food and Drug Administration and has been tested in large populations. OBJECTIVE: To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults. METHODS Search methods: We searched the following sources for relevant studies: CENTRAL 2012, Issue 7, MEDLINE (1948 to July week 1, 2012), EMBASE (2010 to July 2012), LILACS (1982 to July 2012) and CINAHL (1981 to July 2012). We also reviewed reference lists of identified trials and reviews for additional studies. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine with placebo or no vaccine, to prevent herpes zoster in older adults (mean age &gt; 60 years). Data collection and analysis: Two review authors independently collected and analysed data using a data extraction form. They also carried out an assessment of risk of bias. MAIN RESULTS: We identified eight RCTs with a total of 52,269 participants. Three studies were classified at low risk of bias. The main outcomes on effectiveness and safety were extracted from one clinical trial with a low risk of bias. Four studies compared zoster vaccine versus placebo; one study compared high-potency zoster vaccine versus low-potency zoster vaccine; one study compared refrigerated zoster vaccine versus frozen zoster vaccine; one study compared live zoster vaccine versus inactivated zoster vaccine and one study compared zoster vaccine versus pneumococcal polysaccharide vaccine (pneumo 23). Confirmed cases of herpes zoster were less frequent in patients who received the vaccine than in those who received a placebo: risk ratio (RR) 0.49 (95% confidence interval (CI) 0.43 to 0.56), with a risk difference (RD) of 2%, and number needed to treat to benefit (NNTB) of 50. Analyses according to age groups indicated a greater benefit in participants aged 60 to 69 years, RR 0.36 (95% CI 0.30 to 0.45) and in participants aged 70 years and over, RR 0.63 (95% CI 0.53 to 0.75). Vaccine-related systemic adverse effects were more frequent in the vaccinated group (RR 1.29, 95% CI 1.05 to 1.57, number needed to treat to harm (NNTH) = 100). The pooled data risk ratio for adverse effects for participants with one or more inoculation site adverse effect was RR 4.51 (95% CI 2.35 to 8.68), and the NNTH was 2.8 (95% CI 2.3 to 3.4). Side effects were more frequent in younger (60 to 69 years) than in older (70 years and over) participants. AUTHORS' CONCLUSIONS: Herpes zoster vaccine is effective in preventing herpes zoster disease. Although vaccine benefits are larger in the younger age group (60 to 69 years), this is also the age group with more adverse events. In general, zoster vaccine is well tolerated; it produces few systemic adverse events and injection site adverse effects of mild to moderate intensity. <![CDATA[Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802014000400256&lng=en&nrm=iso&tlng=en BACKGROUND: Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. OBJECTIVE: To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo-controlled trials and regulatory comments. METHODS Search methods: We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non-manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. Selection criteria: Randomised, placebo-controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. Data collection and analysis: We extracted clinical study reports and assessed risk of bias using purpose-built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention-to-treat (ITT) population. All trials were sponsored by the manufacturers. MAIN RESULTS: We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non-identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation. For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P &lt; 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P &lt; 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza-infected and non-influenza-infected subgroups (P = 0.53). Hospitalisations. Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI -0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal. In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI -0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia. Oseltamivir significantly reduced self reported, investigator-mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator-mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media. Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment. Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four-fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I2 statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on-treatment period. There was a dose-response effect on psychiatric events in the two oseltamivir "pivotal" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four-fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I2 = 0%). Prophylaxis. In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non-influenza, influenza-like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on- and off-treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI -2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB &gt; 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). AUTHORS' CONCLUSIONS: Oseltamivir and zanamivir have small, non-specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus-specific mechanism of action proposed by the producers does not fit the clinical evidence.