Scielo RSS <![CDATA[Sao Paulo Medical Journal]]> http://www.scielo.br/rss.php?pid=1516-318020180001&lang=es vol. 136 num. 1 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[Keeping a watchful eye on the food giants and cleansing the temple of nutritional medicine and epidemiology]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100001&lng=es&nrm=iso&tlng=es <![CDATA[Accidents involving motorcycles and potential years of life lost. An ecological and exploratory study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100004&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT AND OBJECTIVE: Traffic accidents have gained prominence as one of the modern epidemics that plague the world. The objective of this study was to identify the spatial distribution of potential years of life lost (PYLL) due to accidents involving motorcycles in the state of São Paulo, Brazil. DESIGN AND SETTING: Ecological and exploratory study conducted in São Paulo. METHODS: Data on deaths among individuals aged 20-39 years due to motorcycle accidents (V20-V29 in the International Classification of Diseases, 10th revision) in the state of São Paulo in the years 2007-2011 were obtained from DATASUS. These data were stratified into a database for the 63 microregions of this state, according to where the motorcyclist lived. PYLL rates per 100,000 inhabitants were calculated. Spatial autocorrelations were estimated using the Global Moran index (IM). Thematic, Moran and Kernel maps were constructed using PYLL rates for the age groups of 20-29 and 30-39 years. The Terraview 4.2.2 software was used for the analysis. RESULTS: The PYLL rates were 486.9 for the ages of 20-29 years and 199.5 for 30-39 years. Seventeen microregions with high PYLL rates for the age group of 20-29 years were identified. There was higher density of these rates on the Kernel map of the southeastern region (covering the metropolitan region of São Paulo). There were no spatial autocorrelations between rates. CONCLUSIONS: The data presented in this study identified microregions with high accident rates involving motorcycles and microregions that deserve special attention from regional managers and traffic experts. <![CDATA[Cross-sectional study on the association between frailty and violence against community-dwelling elderly people in Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100010&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: The physical, emotional and cognitive limitations that may be present in the aging process, coupled with family unpreparedness, may lead to greater dependence among the elderly. This favors development of frailty syndrome and greater levels of violence against the elderly. The objective here was to analyze the association between violence against the elderly and frailty; and the geographic distribution of violence against the elderly according to the presence of frailty syndrome. DESIGN AND SETTING: Cross-sectional study on 705 community-dwelling elderly people in Uberaba (MG), Brazil. METHODS: The Fried frailty phenotype and conflict tactics scale were used. Data were analyzed using descriptive statistics, the chi-square test and a logistic regression model. The intensity of the events and the relationship between clusters of violence and frailty status were assessed by means of kernel estimation. RESULTS: The adjusted analysis indicated that pre-frailty and frailty were associated with physical and verbal aggression (odds ratio, OR = 1.51; 95% confidence interval, CI: 1.04-2.19; OR = 2.12; 95% CI: 1.29-3.47), frailty was associated with physical aggression (OR = 2.48; 95% CI: 1.25-4.94) and pre-frailty and frailty were associated with verbal aggression (OR = 1.48; 95% CI: 1.03-2.15; OR = 2.15; 95% CI: 1.31-3.52), respectively. Regardless of frailty status and its relationship with violence, clusters of occurrences were larger in similar regions in the southeastern part of the municipality; but superimposition of overlays relating to aggression showed that for frail individuals the clusters were smaller than for non-frail and pre-frail individuals. CONCLUSIONS: The condition of frailty was associated with greater chances of violence against the elderly. <![CDATA[Prevalence of electrocardiographic abnormalities in primary care patients according to sex and age group. A retrospective observational study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100020&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Knowledge of the prevalence of electrocardiographic abnormalities in a population is useful for interpreting the findings. The aim here was to assess the prevalence of electrocardiographic abnormalities and self-reported comorbidities and cardiovascular risk factors according to sex and age group among Brazilian primary care patients. DESIGN AND SETTING: Observational retrospective study on consecutive primary care patients in 658 cities in the state of Minas Gerais, Brazil, whose digital electrocardiograms (ECGs) were sent for analysis to the team of the Telehealth Network of Minas Gerais (TNMG). METHODS: All ECGs analyzed by the TNMG team in 2011 were included. Clinical data were self-reported and electrocardiographic abnormalities were stratified according to sex and age group. RESULTS: A total of 264,324 patients underwent ECG examinations. Comorbidities and cardiovascular risk factors were more frequent among women, except for smoking. Atrial fibrillation and flutter, premature beats, intraventricular blocks, complete right bundle branch block and left ventricular hypertrophy were more frequent among men, and nonspecific ventricular repolarization abnormalities and complete left bundle branch block among women. CONCLUSION: Electrocardiographic abnormalities were relatively common findings, even in the younger age groups. The prevalence of electrocardiographic abnormalities increased with age and was higher among men in all age groups, although women had higher frequency of self-reported comorbidities. <![CDATA[C-reactive protein/albumin ratio is associated with lung function among children/adolescents with cystic fibrosis: a three-year longitudinal study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100029&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Chronic lung infections, inflammation and depletion of nutritional status are considered to be prognostic indicators of morbidity in patients with cystic fibrosis. The aim of this study was to investigate the association between inflammatory markers and lung function, nutritional status and morbidity among children/adolescents with cystic fibrosis. DESIGN AND SETTINGS: Prospective three-year longitudinal study conducted in an outpatient clinic in southern Brazil. METHODS: Children/adolescents aged 1-15 years with cystic fibrosis were enrolled. Nutritional status was determined from weight-to-length and body mass index-to-age z-scores and was classified as acceptable, at risk or nutritional failure. Tumor necrosis factor-α, interleukin-1β, myeloperoxidase, C-reactive protein and C-reactive protein/albumin ratio were analyzed. Lung function was evaluated based on the forced expiratory volume in the first second and morbidity according to the number of hospitalizations for pulmonary exacerbation and infections by Pseudomonas aeruginosa. Lung function, nutritional status and morbidity were the outcomes. Odds ratios and 95% confidence intervals were to evaluate the effect of baseline inflammatory markers on the clinical outcomes after three years of follow-up and p-values &lt; 0.05 were considered significant. RESULTS: We evaluated 38 children/adolescents with cystic fibrosis: 55% female; median age (with interquartile range), 3.75 years (2.71-7.00). Children/adolescents with high C-reactive protein/albumin ratio at baseline had odds of 18 (P = 0.018) of presenting forced expiratory volume in the first second ≤ 70% after three years. The other inflammatory markers were not associated with the outcomes. CONCLUSION: C-reactive protein/albumin ratio was associated with forced expiratory volume in the first second ≤ 70% after three years. <![CDATA[Epidemiological situation of acquired immunodeficiency syndrome (AIDS)-related mortality in a municipality in northeastern Brazil. A retrospective cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100037&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT AND OBJECTIVE: The number of acquired immunodeficiency syndrome (AIDS)-related deaths covers different segments of the population differently, making monitoring of this mortality essential. The aim of this study was to describe the epidemiological situation of AIDS-related mortality in a municipality in the northeastern region of Brazil. DESIGN AND SETTING: Retrospective cross-sectional study based on data from death certificates in the mortality information system of the Health Information Center, Municipal Health Foundation, Brazil. METHODS: Between 2003 and 2013, we investigated death certificates on which AIDS-related mortality was reported. Sociodemographic data, year, place, type of establishment where death occurred and underlying and associated causes that led to AIDS-related death were described. The Mann-Kendall test was used to verify the growth trend of the standardized mortality rate over the period studied. RESULTS: Among the 1,066 AIDS-related deaths, 69.7% were among men; 47.2% of the individuals were 28-41 years of age, 32.7% had had 4-7 years of schooling, 66.9% were pardos (mixed race), 55.7% were unmarried and 15.3% were housekeepers. Hospitals were the site of 97% of the deaths, and 91% occurred at public hospitals. Respiratory failure was the main cause of death. The prevalence of infectious and parasitic diseases was 99.0%. AIDS-related mortality increased by 160% over the period studied, from 5.5/100,000 inhabitants in 2003 to 14.3/100,000 in 2013. CONCLUSION: In the Brazilian municipality studied here, AIDS-related mortality was most prevalent among men and young adults of lower socioeconomic level. Over the period studied, the mortality rate increased. <![CDATA[Sensory-motor training versus resistance training among patients with knee osteoarthritis: randomized single-blind controlled trial]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100044&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Osteoarthritis of the knee is defined as a progressive disease of the synovial joints and is characterized by failure of joint damage repair. The objective here was to compare the effectiveness of sensory-motor training versus resistance training among patients with knee osteoarthritis. DESIGN AND SETTING: Randomized, single-blinded controlled trial conducted at the outpatient service of the University of Santo Amaro. METHODS: A total of 64 patients were randomly assigned to sensory-motor training or resistance training. The evaluations were performed at baseline and 16 weeks after the intervention and included pain evaluation on a visual analogue scale, isometric quadriceps femoris force measurement using a dynamometer, Timed Up and Go test, Tinetti balance scale, Western Ontario and McMaster Universities osteoarthritis index, and the SF-36 quality-of-life questionnaire. Data analysis was performed using analysis of variance with repeated measurements and Cohen’s effect size. RESULTS: Sensory-motor training may be a plausible alternative and showed a small effect on pain and a medium effect on maximal voluntary isometric contraction. Resistance training showed a small effect on balance and a medium effect on mobility. CONCLUSION: Resistance training and sensory motor training for the lower limbs among patients with knee osteoarthritis seemed to present similar effects on pain and function. However, because there was a considerable risk of type 2 error, further randomized clinical trials are still needed to provide a sound conclusion. <![CDATA[Educational inequality in Rio de Janeiro and its impact on multimorbidity: evidence from the Pró-Saúde study. A cross-sectional analysis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100051&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Information about multimorbidity is scarce in developing countries. This study aimed to estimate the association of educational attainment with occurrences of multimorbidity in a population of public employees on university campuses in Rio de Janeiro. DESIGN AND SETTING: We conducted cross-sectional analyses on baseline data (1999-2001) from 3,253 participants in the Pró-Saúde study, conducted in Brazil. METHODS: The prevalence of multimorbidity, defined as a self-reported history of medical diagnoses of two or more chronic conditions, was estimated according to sex, age, smoking, obesity and educational level. The association between education and multimorbidity was estimated using odds ratios (OR) and the relative and slope indices of inequality, in order to quantify the degree of educational inequality among individuals with multimorbidity in this population. RESULTS: Greater age, female sex, smoking and obesity had direct associations with multimorbidity; and tobacco exposure and obesity also showed direct relationships with poorer educational level. There was a monotonic inverse linear trend between educational level and the presence of multimorbidity among women, with twice the odds (OR 2.47; 95% confidence interval, CI: 1.42-4.40) between extremities of schooling categories. There was excess multimorbidity of 22% at the lowest extremity of schooling, thus showing that women with worse educational status were more affected by the outcome. No trend and no excess multimorbidity was seen among men. CONCLUSIONS: Educational inequality is an important determinant for development of multimorbidity. Men and women experience its effect differently. Researchers need to consider that sex may be an effect modifier in multimorbidity studies. <![CDATA[Proportion of doctors who stayed in the state of Tocantins after finishing medical residency: preliminary results from a cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100059&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT AND OBJECTIVE: Few studies have assessed the impact of medical residencies on the public healthcare system. The aim here was to assess the number of specialists who remained in the state of Tocantins after finishing the medical residency program during the first two years of the first programs (2013 and 2014). DESIGN AND SETTING: Cross-sectional and exploratory study conducted at the Federal University of Tocantins in Brazil. METHODS: All graduates of medical residency programs in Tocantins, of the years 2013 and 2014, were interviewed by telephone and e-mail between May and July 2014. RESULTS: Information was obtained from 37 graduates from medical residency. Seventeen (50.0%) were working in the state public healthcare system and only six (17.6%) in a municipal service in June 2014. Considering only the 24 doctors who had never worked in the state of Tocantins before their residency, it was observed that two who graduated in 2013 (20.0%) and five who graduated in 2014 (35.7%), i.e. seven out of the total number (29.2%), had established their homes in Tocantins. CONCLUSIONS: The number of graduates from medical residency who stayed in the state of Tocantins in 2013 and 2014 was small. However, this was related to the absence of other programs for continuation of the specialization. The state healthcare system was primarily responsible for employment of these doctors within public services. On the other hand, hiring by municipal services was extremely low. <![CDATA[Carotid intima-media thickness in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): a narrative review]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100064&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Carotid intima-media thickness (CIMT), as measured by ultrasound, has been used in large studies as a non-invasive marker for subclinical atherosclerosis. The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a cohort of 15,105 civil servants in six Brazilian cities that included CIMT evaluation in its baseline assessment. The aim of the present narrative review was to provide an overview of ELSA-Brasil CIMT articles published up to July 31, 2017. DESIGN AND SETTING: Narrative review of ELSA-Brasil CIMT studies using baseline assessment data. METHODS: We searched PubMed for the terms “ELSA-Brasil” and “intima-media”. This search yielded 21 published articles using CIMT data from the ELSA-Brasil baseline assessment, which were included in this review. We also present information about intima-media thickness assessment from ongoing onsite reevaluations of the study participants. RESULTS: Most published studies focused on the association with traditional and novel cardiovascular risk factors. Studies also presented information about the ELSA-Brasil CIMT protocol at baseline and CIMT value distribution in this large sample. CONCLUSIONS: Analyses on the ELSA-Brasil data led to important insights on CIMT interpretation and physiology. Besides the highlighted contributions which have already been made in this field, new data gathered during the ongoing third onsite assessment will enable investigation of substantially new research questions. <![CDATA[What do Cochrane systematic reviews say about non-surgical interventions for urinary incontinence in women?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100073&lng=es&nrm=iso&tlng=es ABSTRACT BACKGROUND: Urinary incontinence is a highly prevalent condition that impacts self-esteem and overall quality of life. Many non-surgical treatment options are available, ranging from pharmacological approaches to pelvic exercises. We aimed to summarize the available evidence regarding these non-surgical interventions. DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP). METHODS: A sensitive search was conducted to identify all Cochrane systematic reviews that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included 20 Cochrane systematic reviews: 4 assessing methods of vesical training, 3 evaluating pharmacological interventions, 4 studying pelvic floor muscle training approaches and 9 aimed at other alternatives (such as urethral injections, weighted vaginal cone use, acupuncture, biostimulation and radiofrequency therapy). The reviews found that the evidence regarding the benefits of these diverse interventions ranged in quality from low to high. CONCLUSIONS: This review included 20 Cochrane systematic reviews that provided evidence (of diverse quality) for non-pharmacological interventions for patients with urinary incontinence. Moderate to high quality of evidence was found favoring the use of pelvic floor muscle training among women with urinary incontinence. To establish solid conclusions for all the other comparisons, further studies of good methodological quality are needed. <![CDATA[Bariatric surgery in individuals with severe cognitive impairment: report of two cases]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100084&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT: Bariatric surgery has become the gold-standard treatment for refractory morbid obesity. Obesity is frequently associated with certain syndromes that include coexisting cognitive deficits. However, the outcomes from bariatric surgery in this group of individuals remain incompletely determined. CASE REPORT: A 25-year-old male with Prader-Willi syndrome, whose intelligence quotient (IQ) was 54, was admitted with a body mass index (BMI) of 55 kg/m2, associated with glucose intolerance. He underwent the Scopinaro procedure for biliopancreatic diversion, with uneventful postoperative evolution, and presented a 55% loss of excess weight one year after the surgery, with resolution of glucose intolerance, and without any manifestation of protein-calorie malnutrition. A 28-year-old male with Down syndrome, whose IQ was 68, was admitted with BMI of 41.5 kg/m2, associated with hypertension. He underwent Roux-en-Y gastric bypass, with uneventful postoperative evolution. He presented a 90% loss of excess weight one year after the surgery, with resolution of the hypertension. CONCLUSION: Bariatric surgery among individuals with intellectual impairment is a controversial topic. There is a tendency among these individuals to present significant weight loss and comorbidity control, but less than what is observed in the general obese population. The severity of the intellectual impairment may be taken into consideration in the decision-making process regarding the most appropriate surgical technique. Bariatric surgery is feasible and safe among these individuals, but further research is necessary to deepen these observations.<hr/>RESUMO CONTEXTO: A cirurgia bariátrica tornou-se o tratamento padrão ouro para a obesidade mórbida refratária. A obesidade está frequentemente associada a certas síndromes nas quais também coexistem déficits cognitivos, entretanto, os resultados da cirurgia bariátrica nesse grupo de indivíduos ainda não foram completamente determinados. RELATO DE CASO: Um homem de 25 anos com síndrome de Prader-Willi, cujo quociente de inteligência (QI) era estimado em 54, foi admitido com índice de massa corporal (IMC) de 55 kg/m2, associado com intolerância à glicose. Foi submetido a uma derivação biliopancreática à Scopinaro, com evolução pós-operatória sem complicações significativas. Apresentou perda de 55% do excesso de peso um ano após a cirurgia, com resolução da intolerância à glicose, sem manifestação de desnutrição proteico-calórica. Outro paciente, homem de 28 anos com syndrome de Down, cujo QI era de 68, foi admitido com IMC de 41,5 kg/m2, associado a hipertensão arterial. Foi submetido ao bypass gástrico em Y de Roux, com evolução pós-operatória sem complicações. Apresentou perda de 90% do excesso de peso após um ano e resolução da hipertensão. CONCLUSÃO: A cirurgia bariátrica em indivíduos com déficits intelectuais é um tópico controverso. Existe uma tendência entre esses indivíduos de apresentar perda de peso e controle de comorbidades significativos, porém menores que os observados na população obesa geral. A gravidade do déficit intelectual pode ser considerada no processo de decisão sobre a técnica cirúrgica mais adequada. A cirurgia bariátrica é factível e segura nesse grupo de indivíduos. Porém, mais estudos são necessários para aprofundar estas observações. <![CDATA[Report of a rare case and review of adult intestinal duplication at the opposite side of mesenteric margin]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100089&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT: To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification. CASE REPORT: We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. CONCLUSION: Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed. <![CDATA[Wealth inequality and weak primary care in the city of São Paulo: ingredients for a dysfunctional and ineffective healthcare system]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100094&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT: To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification. CASE REPORT: We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. CONCLUSION: Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed. <![CDATA[Unethical research trend: shadow libraries]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100096&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT: To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification. CASE REPORT: We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. CONCLUSION: Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed. <![CDATA[ERRATUM]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802018000100098&lng=es&nrm=iso&tlng=es ABSTRACT CONTEXT: To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification. CASE REPORT: We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. CONCLUSION: Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed.