Scielo RSS <![CDATA[Sao Paulo Medical Journal]]> http://www.scielo.br/rss.php?pid=1516-318020160005&lang=en vol. 134 num. 5 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[From screening-driven medicine to symptom-driven medicine]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500369&lng=en&nrm=iso&tlng=en <![CDATA[Bipedal locomotion, spinal pain and psychiatric disorders. Is this our future?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500371&lng=en&nrm=iso&tlng=en <![CDATA[Towards a unified and standardized definition of the frailty phenotype]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500373&lng=en&nrm=iso&tlng=en <![CDATA[Prevalence of chronic spinal pain and identification of associated factors in a sample of the population of São Paulo, Brazil: cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500375&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Chronic spinal pain, especially low-back pain and neck pain, is a leading cause of years of life with disability. The aim of the present study was to estimate the prevalence of chronic spinal pain among individuals aged 15 years or older and to identify the factors associated with it. DESIGN AND SETTING: Cross-sectional epidemiological study on a sample of the population of the city of São Paulo. METHOD: Participants were selected using random probabilistic sampling and data were collected via face-to-face interviews. The Hospital Anxiety and Depression Scale (HADS), EuroQol-5D, Alcohol Use Disorders Identification Test (AUDIT), Fagerström test for nicotine dependence and Brazilian economic classification criteria were used. RESULTS: A total of 826 participants were interviewed. The estimated prevalence of chronic spinal pain was 22% (95% confidence interval, CI: 19.3-25.0%). The factors independently associated with chronic spinal pain were: female sex, age 30 years or older, schooling level of four years or less, symptoms compatible with anxiety and high physical exertion during the main occupation. Quality of life and self-rated health scores were significantly worse among individuals with chronic spinal pain. CONCLUSION: The prevalence of chronic spinal pain in this segment of the population of São Paulo was 22.0%. The factors independently associated with chronic pain were: female sex, age 30 years or older, low education, symptoms compatible with anxiety and physical exertion during the main occupation.<hr/>RESUMO CONTEXTO E OBJETIVO: A dor de coluna crônica, especialmente dor lombar e cervical, é uma causa importante de anos de vida com incapacidade. O objetivo deste estudo foi estimar a prevalência de algias vertebrais crônicas em indivíduos com 15 ou mais anos de idade e identificar fatores associados. TIPO DE ESTUDO E LOCAL: Estudo epidemiológico de corte transversal em uma amostra da população da cidade de São Paulo. MÉTODO: A seleção de participantes foi feita por amostragem probabilística aleatória e a colheita de dados, por entrevistas presenciais. Foram utilizadas a escala hospitalar de ansiedade e depressão (HADS), o EuroQol-5D, o teste de identificação de desordens devido ao uso de álcool (AUDIT), o teste de Fagerström para dependência de nicotina e o critério de classificação econômica Brasil. RESULTADOS: Um total de 826 participantes foi entrevistado. A prevalência de algias vertebrais crônicas foi estimada em 22% (intervalo de confiança, IC 95%: 19,3-25,0). Os fatores independentemente associados com algias vertebrais crônicas foram: sexo feminino, 30 ou mais anos de idade, quatro anos ou menos de escolaridade, sintomas compatíveis com ansiedade e esforço intenso físico durante a ocupação principal. Participantes com algias vertebrais crônicas apresentaram escores de qualidade de vida e autoavaliação de saúde significativamente piores. CONCLUSÃO: A prevalência de algias vertebrais crônicas em um segmento da população de São Paulo foi de 22%. Os fatores independentemente associados à dor crônica foram: sexo feminino, idade igual ou superior a 30 anos, baixa escolaridade, sintomas compatíveis com ansiedade e esforço físico durante a ocupação principal. <![CDATA[Frailty syndrome in an independent urban population in Brazil (FIBRA study): a cross-sectional populational study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500385&lng=en&nrm=iso&tlng=en ABSTRACT: CONTEXT AND OBJECTIVE: Frailty is a multifactorial syndrome. The aim of this study was to determine the prevalence and characteristics of frailty syndrome in an elderly urban population. DESIGN AND SETTING: Cross-sectional study carried out at the homes of a randomized sample representing the independent elderly individuals of Ribeirão Preto, Brazil. METHODS: Sociodemographic characteristics, clinical data and criteria of the frailty phenotype were obtained at the subjects' homes; 385 individuals were evaluated. Frailty was defined based on detection of weight loss, exhaustion, weakness, slowness and low physical activity level. Individuals with three or more of these characteristics were classified as frail and those with one or two as pre-frail. Specific cutoff points for weakness, slowness and low physical activity level were calculated. RESULTS: The participants' mean age was 73.9 ± 6.5 years, and 64.7% were women. 12.5% had lost weight over the last year; 20.5% showed exhaustion, 17.1% slowness, 24.4% low physical activity level and 20.5% weakness. 9.1% were considered frail and 49.6% pre-frail. Frail subjects were older, attended more medical visits, had a higher chance of hospitalization within the last 12 months and had more cerebrovascular events, diabetes, neoplasms, osteoporosis and urinary and fecal incontinence. CONCLUSION: In this independent elderly population, there were numerous frail and pre-frail individuals. Frailty syndrome was associated with high morbidity. Cutoff points for weakness, slowness and low physical activity level should be adjusted for the population under study. It is essential to identify frail and pre-frail older individuals for appropriate interventions.<hr/>RESUMO: CONTEXTO E OBJETIVO: Fragilidade é uma síndrome multifatorial. O objetivo deste estudo foi determinar a prevalência e características da síndrome da fragilidade em uma população urbana de idosos. TIPO DE ESTUDO E LOCAL: Estudo transversal realizado nas casas em amostra randomizada para representar os idosos independentes de Ribeirão Preto, Brasil. MÉTODO: Características sociodemográficas, dados clínicos e critérios do fenótipo da fragilidade foram obtidos nas casas. Foram avaliados 385 idosos. A definição da fragilidade foi baseada na detecção de perda de peso, exaustão, fraqueza, lentidão e baixo nível de atividade física. Idosos com três ou mais destas características foram classificados com frágeis; com uma ou duas características como pré-frágeis. Foram calculados pontos de corte específicos para fraqueza, lentidão e baixo nível de atividade física. RESULTADOS: A média de idade dos participantes foi de 73,9 ± 6,5 anos, com 64,7% de mulheres. 12,5 % perderam peso no último ano, 20,5% tiveram exaustão, 17,1% lentidão, 24,5% baixo nível de atividade física e 20,5% fraqueza. Foram considerados frágeis 9,1% e pré-frágeis 49,6%. Os frágeis eram mais velhos, foram em mais consultas médicas, tiveram maior chance de internação nos últimos 12 meses e tiveram mais eventos cerebrovasculares, diabetes, neoplasias, osteoporose, incontinência fecal e urinária. CONCLUSÃO: Em uma população idosa independente, existem vários indivíduos frágeis e pré-frágeis. A síndrome da fragilidade foi associada com alta morbidade. Pontos de corte para fraqueza, lentidão e baixo nível de atividade física devem ser ajustados para a população em estudo. É essencial identificar idosos frágeis e pré-frágeis para intervenções apropriadas. <![CDATA[Cardiovascular risk factors associated with frailty syndrome among hospitalized elderly people: a cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500393&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Identification of frailty syndrome and its relationship with cardiovascular risk factors among hospitalized elderly people is important, since this may contribute towards broadening of knowledge regarding this association within tertiary-level services. This study aimed to evaluate the cardiovascular risk factors associated with frailty syndrome among hospitalized elderly people. DESIGN AND SETTING: Observational cross-sectional study in a public teaching hospital. METHODS: The participants were elderly patients admitted to clinical and surgical wards. The cardiovascular risk factors assessed were: body mass index (BMI), waist circumference, systemic arterial hypertension (SAH), blood glucose, total cholesterol, high-density lipoproteins (HDL), low-density lipoproteins (LDL) and triglycerides. To identify frailty syndrome, the method proposed by Fried was used. The data were analyzed through descriptive statistics, chi-square test (P &lt; 0.10) and multinomial logistic regression (P &lt; 0.05). RESULTS: A total of 205 individuals were evaluated. It was found that 26.3% (n = 54) of the elderly people were frail, 51.7% (n = 106) were pre-frail and 22% (n = 45) were non-frail. The preliminary bivariate analysis (P &lt; 0.10) for the regression model showed that frailty was associated with BMI (P = 0.016), LDL cholesterol (P = 0.028) and triglycerides (P = 0.093). However, in the final multivariate model, only overweight remained associated with the pre-frail condition (odds ratio, OR = 0.44; 95% confidence interval, CI = 0.20-0.98; P = 0.045). CONCLUSION: States of frailty were highly present in the hospital environment. The pre-frail condition was inversely associated with overweight.<hr/>RESUMO CONTEXTO E OBJETIVO: A identificação da síndrome de fragilidade em idosos hospitalizados em interface com fatores de risco cardiovascular é relevante, pois pode contribuir para a ampliação do conhecimento sobre essa relação no nível de serviço terciário. Este estudo objetivou avaliar os fatores de risco cardiovascular associados à síndrome de fragilidade em idosos hospitalizados. TIPO DE ESTUDO E LOCAL: Estudo observacional transversal em hospital público de ensino. MÉTODOS: Participaram idosos internados nas clínicas médica e cirúrgica. Os fatores de risco cardiovascular avaliados foram: índice de massa corporal (IMC), circunferência abdominal, hipertensão arterial sistêmica (HAS), glicemia, colesterol total, lipoproteínas de alta densidade (HDL), lipoproteínas de baixa densidade (LDL) e triglicérides. Para identificar a síndrome de fragilidade, utilizou-se o método proposto por Fried. Os dados foram analisados por estatística descritiva, teste qui-quadrado (P &lt; 0,10) e regressão logística multinomial (P &lt; 0,05). RESULTADOS: Foram incluídos 205 indivíduos. Constatou-se que 26,3% (n = 54) dos idosos eram frágeis, 51,7% (n = 106) pré-frágeis e 22% (n = 45) não frágeis. A análise bivariada preliminar (P &lt; 0,10) para o modelo de regressão indicou associações da fragilidade com as variáveis IMC (P = 0,016), colesterol LDL (P = 0,028) e triglicérides (P = 0,093). Entretanto, no modelo multivariado final, apenas a variável excesso de peso permaneceu associada à condição de pré-fragilidade (odds ratio, OR = 0,44; intervalo de confiança, IC 95% = 0,20-0,98; P = 0,045). CONCLUSÃO: Os estados de fragilidade apresentaram-se elevados em ambiente hospitalar. A condição de pré-fragilidade foi inversamente associada ao excesso de peso. <![CDATA[Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500400&lng=en&nrm=iso&tlng=en ABSTRACT: CONTEXT AND OBJECTIVE: Personal resilience is associated with several mental health outcomes. The Connor-Davidson resilience scale (CD-RISC) is a widely used self-report measurement of resilience. This study aimed to investigate the reliability and validity of a Brazilian Portuguese version of the CD-RISC. DESIGN AND SETTING: Cross-sectional validation study carried out in the outpatient clinics of a public university hospital. METHODS: The cross-cultural adaptation followed established guidelines and involved interviews with 65 adults in psychiatric and non-psychiatric outpatient clinics at a teaching hospital. Validation was assessed through concurrent application of the Lipp Brazilian Stress Symptom Inventory (ISSL), Self-Report Questionnaire (SRQ), Sheehan Disability Scales (SDS) and Chronic Pain Grade (CPG) to 575 patients at the same setting. Temporal stability was verified through a second application to 123 participants. RESULTS: Factor analysis identified four factors, named tenacity, adaptability-tolerance, reliance on support from outside and intuition. The alpha coefficient of 0.93 and intraclass correlation coefficient of 0.84 indicated good internal consistency and temporal stability. Significant correlations between this version of the CD-RISC and the ISSL, SRQ, SDS and CPG were noted. The patients at the outpatient clinic for borderline personality had resilience scores that were significantly lower than those of the patients at the general anxiety or post-traumatic stress outpatient clinics. CONCLUSION: This Brazilian Portuguese version of the Connor-Davidson resilience scale exhibited adequate reliability and validity among a sample of Brazilian adult patients.<hr/>RESUMO: CONTEXTO E OBJETIVO: A resiliência pessoal está associada a diversos desfechos em saúde mental. A escala de resiliência de Connor-Davidson (CD-RISC) vem sendo amplamente empregada como uma medida autorrelatada de resiliência. Este estudo teve por objetivo verificar a confiabilidade e a validade de uma versão da CD-RISC para o português no contexto cultural brasileiro. DESENHO E LOCAL: Estudo transversal de validação conduzido nos ambulatórios de hospital público universitário. MÉTODOS: De acordo com diretrizes bem conhecidas, a adaptação cultural foi feita com 65 adultos entrevistados em ambulatórios psiquiátricos e não psiquiátricos de um hospital de ensino. A validação se deu pela aplicação concorrente do Inventário de Stress para Adultos de Lipp (ISSL), Questionário de Autorrelato de Sintomas (SRQ), Escalas de Incapacidade de Sheehan (SDS) e Escala Graduada de Dor Crônica (CPG) a 575 pacientes do mesmo hospital. A estabilidade temporal foi verificada numa segunda aplicação a 123 participantes. RESULTADOS: A análise fatorial identificou quatro fatores, nomeados como tenacidade, adaptabilidade-tolerância, amparo e intuição. Um coeficiente alfa de 0,93 e um coeficiente de correlação intraclasse de 0,84 indicaram adequadas consistência interna e estabilidade temporal. Correlações significativas entre esta versão da CD-RISC e o ISSL, SRQ, SDS e CPG foram identificadas. Os pacientes do ambulatório para personalidade borderline tiveram escores de resiliência significativamente mais baixos que os pacientes dos ambulatórios geral de ansiedade ou de estresse pós-traumático. CONCLUSÃO: A presente versão em português da escala de resiliência de Connor-Davidson apresentou confiabilidade e validade adequadas numa amostra de pacientes brasileiros adultos. <![CDATA[Translation to Brazilian Portuguese, cultural adaptation and reproducibility of the questionnaire "Ankylosing Spondylitis: What do you know?"]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500407&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Ankylosing spondylitis (AS) generates inflammation and pain in entheses, peripheral joints and the spine. Education regarding AS can improve patients' disability. Thus, it is important to assess patients' knowledge. There is no instrument in the literature for assessing knowledge of AS in Portuguese. The aim here was to translate to the Brazilian Portuguese language, culturally adapt and test the reliability of the questionnaire "Ankylosing Spondylitis: What do you know?" and to correlate the findings with other factors. DESIGN AND SETTING: Original article regarding validation of questionnaire, produced at the Federal University of Sao Paulo (Unifesp). METHODS: For translation and cultural adaptation, Guilleman methodology was used. After the first phase, the reliability was tested on 30 patients. Correlations between these scores and other factors were examined. RESULTS: In the interobserver assessment, the Pearson correlation coefficient and Cronbach's alpha were 0.831 and 0.895, respectively. In the intraobserver evaluation, the intraclass correlation coefficient and Cronbach's alpha were 0.79 and 0.883, respectively. At this stage, the score for area of knowledge A showed correlations with ethnicity and education; the score for area D, with age; the total score and scores for areas A and B with "social aspects" of SF-36; and the score for area D with "pain", "vitality" and "emotional aspects" of SF-36. CONCLUSION: The Brazilian version of the questionnaire "Ankylosing Spondylitis: What do you know?" was created. It is reproducible and correlates with education level, ethnicity and the SF-36 domains "social aspects" and "emotional aspects".<hr/>RESUMO CONTEXTO E OBJETIVO: A espondilite anquilosante (EA) gera inflamação e dor em enteses, articulações periféricas e coluna vertebral. A educação na EA pode melhorar a incapacidade dos pacientes. Assim, é importante avaliar o conhecimento do paciente. Não há na literatura instrumento que avalie o conhecimento da EA na língua portuguesa. O objetivo foi traduzir para a língua portuguesa brasileira, realizar a adaptação cultural e testar a confiabilidade do questionário Ankylosing Spondylitis: What do you know? e relacionar os resultados com outros fatores. TIPO DE ESTUDO E LOCAL: Artigo original de validação de questionário realizado na Universidade Federal de São Paulo (Unifesp). MÉTODOS: Para tradução e adaptação cultural, foi utilizada a metodologia de Guilleman. Depois da primeira fase, a confiabilidade foi testada em 30 pacientes. Correlações entre esses escores e outros fatores foram avaliadas. RESULTADOS: Na avaliação interobservador, o coeficiente de correlação de Pearson e o alpha de Cronbach foram de 0,831 e 0,895, respectivamente. Na avaliação intra-observador, o coeficiente de correlação intraclasse e o alpha de Cronbach foram de 0,79 e 0,883, respectivamente. Nesta etapa, foram encontradas correlações entre etnia e escolaridade e a área de conhecimento A, e entre idade e a área D; entre o escore total e escores das áreas A e B e "aspectos sociais" do SF-36 e entre a área D e "dor", "vitalidade" e "aspectos emocionais" do SF-36. CONCLUSÃO: Foi criada a versão brasileira do questionário "Ankylosing Spondylitis: What do you know?", que é reprodutível e se correlaciona com escolaridade, etnia e os domínios "aspectos sociais" e "aspectos emocionais" do SF-36. <![CDATA[Prevalence of knee arthroplasty in the state of São Paulo between 2003 and 2010]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500417&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: The volume of knee arthroplasty procedures has increased over the last decade. The aim of this study was to estimate the frequency of these procedures performed within the public healthcare system of the state of São Paulo between 2003 and 2010. DESIGN AND SETTING: Cross-sectional study conducted in the state of São Paulo by researchers at Hospital do Servidor Público do Estado de São Paulo. METHODS: A sample of 10,952 patients (7,891 females and 3,061 males) who underwent primary total knee arthroplasty (TKA) and revision of total knee arthroplasty (RTKA) in the state of São Paulo between 2003 and 2010 was evaluated. The patients were cataloged using the public healthcare service's TABNET software. All of the patients presented primary osteoarthritis of the knee. The variables of gender, number of primary TKA procedures and number of RTKA procedures were evaluated. RESULTS: A total of 10,952 TKA procedures were performed (annual average of 1369), of which 9,271 (85%) were TKA and 1,681 (15%), RTKA. Of the TKA procedures, 72% were carried out on females (P &lt; 0.0001), while 70% of the RTKA procedures were on females (P &lt; 0.0001). The average ratio of TKA to RTKA was 5.5:1 (P &lt; 0.0001); the ratios in 2003 and 2010 were 9.0:1 and 4.4:1 (P &lt; 0.0001), respectively. CONCLUSION: The number and frequency of TKA and RTKA procedures increased in the state of São Paulo between 2003 and 2010. This increase was relatively greater in RTKA than in TKA and was predominantly in female patients.<hr/>RESUMO CONTEXTO E OBJETIVO: O volume das artroplastias de joelho tem crescido na última década. O objetivo deste estudo foi estimar a frequência desses procedimentos realizados no Sistema Público de Saúde (SUS) do Estado de São Paulo no período de 2003 a 2010. TIPO DE ESTUDO E LOCAL: Estudo transversal conduzido por pesquisadores do Hospital do Servidor Público Estadual. MÉTODOS: Foi avaliada uma amostra de 10.952 pacientes (7.891 mulheres e 3.061 homens) submetidos a artroplastia primária total de joelho (ATJ) e a revisão de artroplastia total de joelho (RATJ) no estado de São Paulo entre 2003 e 2010. Os pacientes foram catalogados por meio do programa TABNET do SUS. Todos os pacientes eram portadores de osteoartrite primária do joelho. As variáveis analisadas foram: gênero, número de ATJs e número de RATJs. RESULTADOS: No total, 10.592 ATJs foram realizadas (média anual de 1.369 procedimentos), com 9.271 (85%) ATJs e 1.691 (15%) RATJ. Das ATJ, 72% ocorreram em mulheres (P &lt; 0.0001), enquanto 70% das RATJs foram em mulheres (P &lt; 0.0001). A relação média de ATJ para RATJ foi de 5.5:1 (P &lt; 0.0001), com proporção em 2003 e 2010 de 9.0:1 e 4.4:1 (P &lt; 0.0001), respectivamente. CONCLUSÃO: O número e a prevalência das ATJs e RATJs aumentaram no estado de São Paulo no período de 2003 a 2010. Essa elevação foi relativamente maior nas RATJs quando comparadas com as ATJs e ocorreu predominantemente nos pacientes do sexo feminino. <![CDATA[Stages of hyperglycemia and common mental disorders in adults - The Brazilian Study of Adult Health (ELSA-Brasil)]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500423&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Diabetes mellitus and depressive disorders frequently coexist. However, this relationship has been little evaluated across stages of hyperglycemia and for a broad range of common mental disorders (CMDs). The objective here was to investigate the association between CMDs and stages of glycemia. DESIGN AND SETTING: Cross-sectional study conducted among civil servants aged 35-74 years participating in the ELSA-Brasil cohort. METHODS: CMDs were classified using the Clinical Interview Schedule - Revised (CIS-R). Glycemia was classified in stages as normal, intermediate hyperglycemia, newly classified diabetes or previously known diabetes, based on oral glucose tolerance testing, glycated hemoglobin (HbA1c), self-reported diabetes and medication use. Blood glucose control was assessed according to HbA1c. RESULTS: CMDs were most prevalent in individuals with previously known diabetes. After adjustments, associations weakened considerably and remained significant only for those with a CIS-R score ≥ 12 (prevalence ratio, PR: 1.15; 95% confidence interval, CI: 1.03-1.29). Intermediate hyperglycemia did not show any association with CMDs. For individuals with previously known diabetes and newly classified diabetes, for every 1% increase in HbA1c, the prevalence of depressive disorders became, respectively, 12% and 23% greater (PR: 1.12; 95% CI: 1.00-1.26; and PR: 1.23; 95% CI: 1.04-1.44). CONCLUSION: Individuals with previously known diabetes had higher CIS-R scores. Among all individuals with diabetes, worse blood glucose control was correlated with depressive disorder. No relationship between intermediate hyperglycemia and CMDs was observed, thus suggesting that causal processes relating to CMDs, if present, must act more proximally to diabetes onset.<hr/>RESUMO CONTEXTO E OBJETIVO: Diabetes mellitus e transtornos depressivos frequentemente coexistem. No entanto, essa relação tem sido pouco avaliada nos estágios hiperglicêmicos e em uma amplitude maior de transtornos mentais comuns (TMCs). O objetivo foi investigar a associação entre TMCs e estágios de glicemia. TIPO DE ESTUDO E LOCAL: Estudo transversal realizado com funcionários públicos com idade entre 35-74 anos participantes da coorte ELSA-Brasil. MÉTODOS: TMCs foram classificados usando o instrumento Clinical Interview Schedule - Revised (CIS-R). Para a classificação dos estágios de glicemia, foi utilizado o teste de tolerância a glicose, hemoglobina glicada (HbA1c), relato pessoal de diabetes e uso de medicamentos. A glicemia foi categorizada como: normal, hiperglicemia intermediária, classificação nova de diabetes, e diabetes prévio. Controle glicêmico foi avaliado pela HbA1c. RESULTADOS: TMCs foram mais prevalentes nos pacientes com diabetes prévio. Após ajustes, as associações foram consideravelmente enfraquecidas, permanecendo significativas somente para aqueles com escore do CIS-R ≥ 12 (razão de prevalência, RP: 1,15; intervalo de confiança de 95%, IC: 1,03-1,29). Hiperglicemia intermediária não teve associação com CMDs. Para aqueles com diabetes prévio e classificação nova de diabetes, para cada aumento de 1% na HbA1c, a prevalência de transtorno depressivo foi, respectivamente, 12% e 23% maior (RP: 1,12; IC: 1,00-1,26 e RP: 1,23; IC: 1,04-1,44). CONCLUSÃO: Aqueles com diabetes prévio tiveram escore do CIS-R mais elevado. Entre todos com diabetes, o controle glicêmico pior foi relacionado ao transtorno depressivo. Não foi observada relação entre hiperglicemia intermediária e TMCs, sugerindo que a relação causal relacionada aos TMCs, se presente, deve agir de forma mais próxima ao início de diabetes. <![CDATA[The effect of sleep apnea severity on cardiac autonomic activity during night time in obstructive sleep apnea patients]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500430&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Impaired autonomic cardiac function is an important consequence of obstructive sleep apnea (OSA). This impairment is mainly due to intermittent hypoxia episodes following apneas. However, the impact of apnea severity on autonomic cardiac function remains unclear. The aim of this study was to evaluate the relationship between the severity of sleep apnea and heart rate turbulence (HRT) and heart rate variability (HRV) in OSA. DESIGN AND SETTING: Observational cross-sectional study conducted in the Departments of Cardiology and Pulmonary Diseases, Afyon Kocatepe University, Turkey. METHODS: 106 patients with OSA and 27 healthy volunteers were enrolled. Based on apnea hypopnea index (AHI) values, obstructive sleep apnea severity was classified as follows: mild OSA (AHI ≥ 5 and &lt; 15), moderate OSA (AHI ≥ 15 and ≤ 30) and severe OSA (AHI &gt; 30). HRV and HRT parameters were assessed via 24-hour digital Holter electrocardiogram recordings for all subjects. RESULTS: HRV and HRT results were significantly lower among OSA patients than among control subjects (P &lt; 0.05). However, there were no significant differences in HRT and HRV between the three patient subgroups. Correlations did emerge between AHI and the NN-interval parameter RMSSD and between oxygen desaturation and turbulence slope (respectively: r = -0.22, P = 0.037; and r = -0.28, P = 0.025). CONCLUSION: HRT and HRV results deteriorate in OSA. Correlations between apnea severity and these parameters seem to be present.<hr/>RESUMO CONTEXTO E OBJETIVO: Função autonômica cardíaca prejudicada é consequência importante da apneia obstrutiva do sono (AOS). Este prejuízo deve-se principalmente a episódios de hipóxia intermitente após apneias. No entanto, o impacto da gravidade da apneia na função cardíaca autonômica permanece obscuro. O objetivo deste estudo foi avaliar a relação entre gravidade da apneia do sono com turbulência da frequência cardíaca (TFC) e variabilidade da frequência cardíaca (VFC) em pacientes com AOS. DESENHO E LOCAL: Estudo observacional transversal conduzido nos Departamentos de Cardiologia e Doenças Pulmonares, Afyon Kocatepe University, Turkey. MÉTODOS: 106 pacientes com AOS e 27 voluntários saudáveis foram recrutados. Com base nos valores do índice de apneia-hypopneia (IAH), a gravidade da apneia obstrutiva do sono foi classificada assim: AOS leve (IAH ≥ 5 e &lt; 15), AOS moderada (IAH ≥ 15 e ≤ 30) e AOS grave (IAH &gt; 30). Parâmetros da VFC e TFC foram avaliados por meio de gravações de eletrocardiograma digital Holter de 24 horas para todos os sujeitos. RESULTADOS: Os resultados da VFC e TFC foram significativamente menores nos pacientes com OSA, em comparação com indivíduos controle (P &lt; 0,05). No entanto, não houve diferenças significativas em VFC e TFC, entre os três subgrupos de pacientes. Correlações surgiram entre IAH e o parâmetro do intervalo-NN, RMSSD, e entre dessaturação de oxigênio e declive da turbulência (respectivamente; r = -0,22, P = 0,037; e r = -0,28, P = 0,025). CONCLUSÃO: Os resultados da VFC e TFC deterioram em AOS. Parece haver relação entre a gravidade da apneia e tais parâmetros. <![CDATA[Trends in mortality from ill-defined causes among the elderly in Brazil, 1979-2013: ecological study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500437&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Mortality measurements are traditionally used as health indicators and are useful in describing a population's health situation through reporting injuries that lead to death. The aim here was to analyze the temporal trend of proportional mortality from ill-defined causes (IDCs) among the elderly in Brazil from 1979 to 2013. DESIGN AND SETTING: Ecological study using data from the Mortality Information System of the Brazilian Ministry of Health. METHODS: The proportional mortality from IDCs among the elderly was calculated for each year of the study series (1979 to 2013) in Brazil, and the data were disaggregated according to sex and to the five geographical regions and states. To analyze time trends, simple linear regression coefficients were calculated. RESULTS: During the study period, there were 2,646,194 deaths from IDCs among the elderly, with a decreasing trend (ß -0.545; confidence interval, CI: -0.616 to -0.475; P &lt; 0.000) for both males and females. This reduction was also observed in the macroregions and states, except for Amapá. The states in the northeastern region reported an average reduction of 80%. CONCLUSIONS: Mortality from IDCs among the elderly has decreased continuously since 1985, but at different rates among the different regions and states. Actions aimed at improving data records on death certificates need to be strengthened in order to continue the trend observed.<hr/>RESUMO CONTEXTO E OBJETIVO: Medidas de mortalidade são tradicionalmente usadas como indicadores de saúde e são úteis na descrição da situação de saúde de uma população relatando lesões que levam à morte. O objetivo foi analisar a tendência temporal da mortalidade proporcional por causas mal definidas (CMD) em idosos no Brasil entre 1979 e 2013. DESENHO E LOCAL: Estudo ecológico utilizando dados do Sistema de Informação de Mortalidade do Ministério da Saúde no Brasil. MÉTODOS: A mortalidade proporcional por CMD em idosos foi calculada para cada ano da série estudada (1979 a 2013) no Brasil, e os dados foram desagregados por sexo e de acordo com as cinco regiões geográficas e estados. Foi empregado o coeficiente de regressão linear simples para analisar a tendência temporal. RESULTADOS: Durante o período de estudo, houve 2.646.194 mortes por CMD em idosos, com uma tendência decrescente (ß -0,545; intervalo de confiança, IC: -0,616 a -0,475; P &lt; 0,000) em homens e mulheres. Essa redução também foi observada nas macrorregiões e estados, com exceção do Amapá. Os estados da região Nordeste registraram uma redução média de 80%. CONCLUSÕES: A mortalidade por causas mal definidas em idosos tem diminuído continuamente desde 1985 em ritmos distintos entre as regiões e estados. As ações destinadas a melhorar os registros de dados em certificados de óbito devem ser fortalecidas para dar continuidade na tendência observada. <![CDATA[Transcranial direct current stimulation for treatment-resistant obsessive-compulsive disorder: report on two cases and proposal for a randomized, sham-controlled trial]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500446&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT AND OBJECTIVE: Neuromodulation techniques for treating obsessive-compulsive disorder (OCD) have expanded through greater understanding of the brain circuits involved in this disorder. Transcranial direct current stimulation (tDCS), a non-invasive technique, has been studied as an alternative for treatment-resistant OCD. We describe the design of a clinical trial using tDCS for OCD and report on the outcomes from two patients with primary OCD who were resistant to cognitive-behavioral therapy and to selective serotonin reuptake inhibitors, and who received tDCS in an open manner during the training phase for the study procedures. DESIGN AND SETTING: Methodological description of a clinical trial using tDCS for treatment-resistant OCD at a university hospital; and a report on two cases. METHODS: The proposed study is randomized, sham-controlled and double-blind. Forty-four patients will be randomized to either active or sham intervention. The active intervention consists of applying an electric current of 2 mA, with the cathode positioned in the region corresponding to the supplementary motor cortex (bilaterally) and the anode positioned in the deltoid. The primary outcome will be the reduction in baseline YBOCS (Yale-Brown Obsessive Compulsive Scale) score at the end of week 4. The secondary outcomes will be depression and anxiety symptoms. Genetic markers, cortical excitability and neurocognitive performance will be investigated. RESULTS: The first patient showed significant improvement, whereas the second remained symptomatic after four weeks and after six months. tDCS was well tolerated. CONCLUSION: tDCS for treatment-resistant OCD merits randomized controlled trials that test its effectiveness.<hr/>RESUMO CONTEXTO E OBJETIVO: Técnicas de neuromodulação para o tratamento do transtorno obsessivo compulsivo (TOC) vêm se expandindo com o melhor entendimento dos circuitos cerebrais envolvidos no transtorno. A estimulação transcraniana por corrente contínua (ETCC), uma técnica não invasiva, vem sendo estudada como alternativa para o TOC resistente aos tratamentos convencionais. Descrevemos o desenho de um ensaio clínico utilizando a ETCC para o TOC e relatamos os desfechos de dois pacientes com TOC primário resistentes à terapia cognitivo-comportamental e aos inibidores seletivos de recaptura da serotonina, que receberam ETCC de modo aberto durante a fase de treino dos procedimentos do estudo. TIPO DE ESTUDO E LOCAL: Descrição metodológica de um ensaio clínico utilizando ETCC para o TOC resistente num hospital universitário e relato de dois casos. MÉTODOS: O estudo proposto é randomizado, controlado por sham e duplo-cego. 44 pacientes serão randomizados para intervenção ativa ou simulada (sham ). A intervenção ativa consiste em aplicar uma corrente elétrica de 2 mA, com cátodo posicionado na região correspondente à área cortical motora suplementar (bilateralmente) e ânodo posicionado no deltoide. Desfecho primário: redução do escore inicial da escala YBOCS (Yale-Brown Obsessive Compulsive Scale) ao final da quarta semana. Desfechos secundários: sintomas depressivos e ansiosos. Marcadores genéticos, excitabilidade cortical e performance em testes neurocognitivos serão investigados. RESULTADOS: O primeiro paciente apresentou melhora significativa, enquanto o segundo permaneceu sintomático ao término das quatro semanas e após seis meses. A ETCC foi bem tolerada. CONCLUSÃO: A ETCC para o tratamento do TOC resistente merece ensaios clínicos randomizados que testem sua efetividade. <![CDATA[Severe lower urinary tract symptoms due to anteriorly located midline prostatic cyst arising from the bladder neck in a young male: case report]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500451&lng=en&nrm=iso&tlng=en ABSTRACT CONTEXT: Prostatic cysts are uncommon. These cysts are usually asymptomatic and are diagnosed incidentally during ultrasonographic examination. On rare occasions, they may cause drastic symptoms. CASE REPORT: We report on a case of severely symptomatic anteriorly located prostatic cyst arising from the bladder neck in a 30-year-old man presenting with lower urinary tract symptoms, without clinical evidence of benign prostatic hyperplasia. Transrectal ultrasonography (TRUS), computed tomography (CT) and cystourethroscopy demonstrated a projecting prostatic cyst that occupied the bladder neck at the precise twelve o'clock position. It was acting as a ball-valve, such that it obstructed the bladder outlet. Transurethral unroofing of the cyst was performed and the patient's obstructive symptoms were successfully resolved. Histopathological examination indicated a retention cyst. CONCLUSIONS: It should be borne in mind that midline prostate cysts can be a reason for bladder outlet obstruction in a young male. Such patients may have tremendous improvement in symptoms through transurethral unroofing of the cyst wall.<hr/>RESUMO CONTEXTO: Cistos prostáticos são incomuns. Esses cistos são geralmente assintomáticos e são diagnosticados incidentalmente durante o exame ultrassonográfico. Raramente podem causar sintomas importantes. RELATO DE CASO: Relatamos um caso sintomático de grave cisto prostático de localização anterior, originário do colo da bexiga de um homem de 30 anos de idade, que apresentou sintomas do trato urinário inferior, sem evidência clínica de hiperplasia prostática benigna. Ultrassonografia transretal (TRUS), tomografia computadorizada (CT) e cistouretroscopia demonstraram um cisto prostático saliente que ocupou o colo da bexiga na posição exata de 12 horas. O cisto estava agindo como uma válvula de esfera, obstruindo a saída da bexiga. Retirada da cobertura do cisto foi realizada por via transuretral e os sintomas obstrutivos do paciente foram resolvidos com sucesso. O exame histopatológico indicou um cisto de retenção. CONCLUSÕES: Deve ser lembrado que a linha média do cisto de próstata pode ser motivo de obstrução da saída da bexiga em um jovem do sexo masculino. Esses pacientes podem ter notável melhoria nos sintomas com retirada da cobertura por via transuretral da parede do cisto. <![CDATA[A rare association of intussusception and celiac disease in a child]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500457&lng=en&nrm=iso&tlng=en ABSTRACT: CONTEXT: Intussusception is a common cause of acute intestinal obstruction in the pediatric population and it is normally idiopathic. Rare cases of chronic intussusception require investigation with greater attention. CASE REPORT: We present a clinical case of a three-year-old boy with aqueous diarrhea, abdominal distension, vomiting and weight loss over a two-month period. During the investigation, abdominal ultrasound showed imaging of intussusception. The intraoperative findings showed the intussusception had resolved spontaneously. In further investigation, it was found that the diarrhea was malabsorptive and, after the patient underwent upper gastrointestinal endoscopy, a diagnosis of celiac disease was made. After a gluten-free diet was introduced, the patient showed complete remission of symptoms and regained weight, and normal growth was reestablished. CONCLUSION: If the clinical presentation of intussusception is unusual, etiological investigation should be undertaken. In this case report, celiac disease was the underlying cause.<hr/>RESUMO: CONTEXTO: Intussuscepção é uma causa frequente de obstrução intestinal aguda em pacientes pediátricos, e geralmente é idiopática. Raros casos de intussuscepção crônica devem ser investigados com maior atenção. RELATO DE CASO: Apresentaremos um caso clínico de um menino de três anos com diarreia aquosa, distensão abdominal, vômito e perda de peso por dois meses, cuja investigação por ultrassonografia abdominal revelou imagem de intussuscepção. Os achados intraoperatórios mostraram que a intussuscepção havia se resolvido espontaneamente. Em investigação subsequente, foi identificado que a diarreia era malabsortiva e, após a realização de endoscopia digestiva alta, foi feito diagnóstico de doença celíaca. Foi iniciada dieta com restrição de glúten e o paciente teve remissão completa dos sintomas, recuperou peso e o crescimento foi restabelecido. CONCLUSÃO: Caso a apresentação clínica de intussuscepção não seja a habitual, deve-se prosseguir a investigação etiológica. No caso clínico apresentado, doença celíaca foi a causa subjacente. <![CDATA[Gamma-glutamyl transferase and pulmonary embolism]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500461&lng=en&nrm=iso&tlng=en ABSTRACT: CONTEXT: Intussusception is a common cause of acute intestinal obstruction in the pediatric population and it is normally idiopathic. Rare cases of chronic intussusception require investigation with greater attention. CASE REPORT: We present a clinical case of a three-year-old boy with aqueous diarrhea, abdominal distension, vomiting and weight loss over a two-month period. During the investigation, abdominal ultrasound showed imaging of intussusception. The intraoperative findings showed the intussusception had resolved spontaneously. In further investigation, it was found that the diarrhea was malabsorptive and, after the patient underwent upper gastrointestinal endoscopy, a diagnosis of celiac disease was made. After a gluten-free diet was introduced, the patient showed complete remission of symptoms and regained weight, and normal growth was reestablished. CONCLUSION: If the clinical presentation of intussusception is unusual, etiological investigation should be undertaken. In this case report, celiac disease was the underlying cause.<hr/>RESUMO: CONTEXTO: Intussuscepção é uma causa frequente de obstrução intestinal aguda em pacientes pediátricos, e geralmente é idiopática. Raros casos de intussuscepção crônica devem ser investigados com maior atenção. RELATO DE CASO: Apresentaremos um caso clínico de um menino de três anos com diarreia aquosa, distensão abdominal, vômito e perda de peso por dois meses, cuja investigação por ultrassonografia abdominal revelou imagem de intussuscepção. Os achados intraoperatórios mostraram que a intussuscepção havia se resolvido espontaneamente. Em investigação subsequente, foi identificado que a diarreia era malabsortiva e, após a realização de endoscopia digestiva alta, foi feito diagnóstico de doença celíaca. Foi iniciada dieta com restrição de glúten e o paciente teve remissão completa dos sintomas, recuperou peso e o crescimento foi restabelecido. CONCLUSÃO: Caso a apresentação clínica de intussuscepção não seja a habitual, deve-se prosseguir a investigação etiológica. No caso clínico apresentado, doença celíaca foi a causa subjacente. <![CDATA[Screening for chronic kidney disease and inequity]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500463&lng=en&nrm=iso&tlng=en ABSTRACT: CONTEXT: Intussusception is a common cause of acute intestinal obstruction in the pediatric population and it is normally idiopathic. Rare cases of chronic intussusception require investigation with greater attention. CASE REPORT: We present a clinical case of a three-year-old boy with aqueous diarrhea, abdominal distension, vomiting and weight loss over a two-month period. During the investigation, abdominal ultrasound showed imaging of intussusception. The intraoperative findings showed the intussusception had resolved spontaneously. In further investigation, it was found that the diarrhea was malabsorptive and, after the patient underwent upper gastrointestinal endoscopy, a diagnosis of celiac disease was made. After a gluten-free diet was introduced, the patient showed complete remission of symptoms and regained weight, and normal growth was reestablished. CONCLUSION: If the clinical presentation of intussusception is unusual, etiological investigation should be undertaken. In this case report, celiac disease was the underlying cause.<hr/>RESUMO: CONTEXTO: Intussuscepção é uma causa frequente de obstrução intestinal aguda em pacientes pediátricos, e geralmente é idiopática. Raros casos de intussuscepção crônica devem ser investigados com maior atenção. RELATO DE CASO: Apresentaremos um caso clínico de um menino de três anos com diarreia aquosa, distensão abdominal, vômito e perda de peso por dois meses, cuja investigação por ultrassonografia abdominal revelou imagem de intussuscepção. Os achados intraoperatórios mostraram que a intussuscepção havia se resolvido espontaneamente. Em investigação subsequente, foi identificado que a diarreia era malabsortiva e, após a realização de endoscopia digestiva alta, foi feito diagnóstico de doença celíaca. Foi iniciada dieta com restrição de glúten e o paciente teve remissão completa dos sintomas, recuperou peso e o crescimento foi restabelecido. CONCLUSÃO: Caso a apresentação clínica de intussuscepção não seja a habitual, deve-se prosseguir a investigação etiológica. No caso clínico apresentado, doença celíaca foi a causa subjacente. <![CDATA[Chemotherapy for advanced non-small cell lung cancer in the elderly population]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500465&lng=en&nrm=iso&tlng=en ABSTRACT BACKGROUND: Approximately 50% of patients with newly diagnosed non-small cell lung cancer (NSCLC) are over 70 years of age at diagnosis. Despite this fact, these patients are underrepresented in randomized controlled trials (RCTs). As a consequence, the most appropriate regimens for these patients are controversial, and the role of single-agent or combination therapy is unclear. In this setting, a critical systematic review of RCTs in this group of patients is warranted. OBJECTIVES: To assess the effectiveness and safety of different cytotoxic chemotherapy regimens for previously untreated elderly patients with advanced (stage IIIB and IV) NSCLC. To also assess the impact of cytotoxic chemotherapy on quality of life. METHODS: Search methods: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (1966 to 31 October 2014), EMBASE (1974 to 31 October 2014), and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to 31 October 2014). In addition, we handsearched the proceedings of major conferences, reference lists from relevant resources, and the ClinicalTrial.gov database. Selection criteria: We included only RCTs that compared non-platinum single-agent therapy versus non-platinum combination therapy, or non-platinum therapy versus platinum combination therapy in patients over 70 years of age with advanced NSCLC. We allowed inclusion of RCTs specifically designed for the elderly population and those designed for elderly subgroup analyses. Data collection and analysis: Two review authors independently assessed search results, and a third review author resolved disagreements. We analyzed the following endpoints: overall survival (OS), one-year survival rate (1yOS), progression-free survival (PFS), objective response rate (ORR), major adverse events, and quality of life (QoL). MAIN RESULTS: We included 51 trials in the review: non-platinum single-agent therapy versus non-platinum combination therapy (seven trials) and non-platinum combination therapy versus platinum combination therapy (44 trials). Non-platinum single-agent versus non-platinum combination therapy Low-quality evidence suggests that these treatments have similar effects on overall survival (hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.72 to 1.17; participants = 1062; five RCTs), 1yOS (risk ratio (RR) 0.88, 95% CI 0.73 to 1.07; participants = 992; four RCTs), and PFS (HR 0.94, 95% CI 0.83 to 1.07; participants = 942; four RCTs). Non-platinum combination therapy may better improve ORR compared with non-platinum single-agent therapy (RR 1.79, 95% CI 1.41 to 2.26; participants = 1014; five RCTs; low-quality evidence). Differences in effects on major adverse events between treatment groups were as follows: anemia: RR 1.10, 95% 0.53 to 2.31; participants = 983; four RCTs; very low-quality evidence; neutropenia: RR 1.26, 95% CI 0.96 to 1.65; participants = 983; four RCTs; low-quality evidence; and thrombocytopenia: RR 1.45, 95% CI 0.73 to 2.89; participants = 914; three RCTs; very low-quality evidence. Only two RCTs assessed quality of life; however, we were unable to perform a meta-analysis because of the paucity of available data. Non-platinum therapy versus platinum combination therapy Platinum combination therapy probably improves OS (HR 0.76, 95% CI 0.69 to 0.85; participants = 1705; 13 RCTs; moderate-quality evidence), 1yOS (RR 0.89, 95% CI 0.82 to 0.96; participants = 813; 13 RCTs; moderate-quality evidence), and ORR (RR 1.57, 95% CI 1.32 to 1.85; participants = 1432; 11 RCTs; moderate-quality evidence) compared with non-platinum therapies. Platinum combination therapy may also improve PFS, although our confidence in this finding is limited because the quality of evidence was low (HR 0.76, 95% CI 0.61 to 0.93; participants = 1273; nine RCTs). Effects on major adverse events between treatment groups were as follows: anemia: RR 2.53, 95% CI 1.70 to 3.76; participants = 1437; 11 RCTs; low-quality evidence; thrombocytopenia: RR 3.59, 95% CI 2.22 to 5.82; participants = 1260; nine RCTs; low-quality evidence; fatigue: RR 1.56, 95% CI 1.02 to 2.38; participants = 1150; seven RCTs; emesis: RR 3.64, 95% CI 1.82 to 7.29; participants = 1193; eight RCTs; and peripheral neuropathy: RR 7.02, 95% CI 2.42 to 20.41; participants = 776; five RCTs; low-quality evidence. Only five RCTs assessed QoL; however, we were unable to perform a meta-analysis because of the paucity of available data. AUTHORS' CONCLUSIONS: In people over the age of 70 with advanced NSCLC who do not have significant co-morbidities, increased survival with platinum combination therapy needs to be balanced against higher risk of major adverse events when compared with non-platinum therapy. For people who are not suitable candidates for platinum treatment, we have found low-quality evidence suggesting that non-platinum combination and single-agent therapy regimens have similar effects on survival. We are uncertain as to the comparability of their adverse event profiles. Additional evidence on quality of life gathered from additional studies is needed to help inform decision making <![CDATA[Anabolic steroids for rehabilitation after hip fracture in older people]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000500467&lng=en&nrm=iso&tlng=en ABSTRACT BACKGROUND: Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture. OBJECTIVES: To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people. METHODS: Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013. Selection criteria: Randomized controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture. Data collection and analysis: Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality. MAIN RESULTS: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low. These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention. Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilization or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events. Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.