• In the october 2009 issue of Clinics Editorial

    Rocha-e-Silva, Mauricio
  • Serum alanine aminotransferase levels, hematocrit rate and body weight correlations before and after hemodialysis session Clinical Sciences

    Lopes, Edmundo Pessoa; Sette, Luis Henrique B. C.; Sette, Jorge Bezerra C.; Luna, Carlos F.; Andrade, Amaro M.; Moraes, Maviael; Sette, Paulo C. A.; Menezes, Roberto; Cavalcanti, Rui L.; Conceição, Sergio C.

    Abstract in English:

    PURPOSE: To evaluate alanine aminotransferase levels before and after a hemodialysis session and to correlate these values with the hematocrit rate and weight loss during hemodialysis. PATIENTS AND METHODS: The serum alanine aminotransferase levels, hematocrit rate and body weight were measured and correlated before and after a single hemodialysis session for 146 patients with chronic renal failure. An receiver operating characteristic (ROC) curve for the serum alanine aminotransferase levels collected before and after hemodialysis was plotted to identify hepatitis C virus-infected patients. RESULTS: The mean weight loss of the 146 patients during hemodialysis was 5.3% (p < 0.001). The mean alanine aminotransferase levels before and after hemodialysis were 18.8 and 23.9 IU/, respectively, denoting a significant 28.1% increase. An equally significant increase of 16.4% in the hematocrit rate also occurred after hemodialysis. The weight loss was inversely correlated with the rise in both the alanine aminotransferase level (r = 0.3; p < 0.001) and hematocrit rate (r = 0.5; p < 0.001). A direct correlation was found between the rise in alanine aminotransferase levels and the hematocrit during the hemodialysis session (r = 0.4; p < 0.001). Based on the ROC curve, the upper limit of the normal alanine aminotransferase level should be reduced by 40% relative to the upper limit of normal if the blood samples are collected before the hemodialysis session or by 60% if blood samples are collected after the session. CONCLUSION: In the present study, significant elevations in the serum alanine aminotransferase levels and hematocrit rates occurred in parallel to a reduction in body weight after the hemodialysis session. These findings suggest that one of the factors for low alanine aminotransferase levels prior to hemodialysis could be hemodilution in patients with chronic renal failure.
  • Childhood eye diseases in southwestern Nigeria: a tertiary hospital study Clinical Sciences

    Onakpoya, Oluwatoyin Helen; Adeoye, Adenike Odunmorayo

    Abstract in English:

    BACKGROUND: Eye diseases are important cause of medical consultation in children, with the spectrum varying in different localities. This study aimed to determine the spectrum of childhood eye diseases in a tertiary hospital serving rural and semi-rural communities. METHODS: We conducted a retrospective review of all patients less than 15 years old who presented to the eye clinic of Wesley Guild Hospital Ilesa, Nigeria between January 2001 and December 2006. Data on age at presentation, age at onset of disease, sex and diagnosis were collected and analyzed using SPSS. A p value less than 0.05 was considered statistically significant. RESULTS: We evaluated the reports of 286 children, with a male:female ratio of 1:1.1. Children aged 11-15 years made up the largest group (p=0.013). Ocular trauma (21.7%), allergic conjunctivitis (17.8%), infections of the eye and its adnexa (15.4%) and refractive errors (14.3%) were the most common conditions. Ocular injury was more common in males (p=0.002) and children aged 6-10 years, and 87.1% of these cases were a closed globe injury. Infections were seen more commonly among females and children aged 0-5 years, with keratitis representing 40.9% of these cases. Congenital eye disease represented 13.3% of childhood eye diseases. CONCLUSION: The prevalent childhood eye diseases recorded here can lead to absenteeism from school and are potentially blinding. Health education aimed at the prevention of ocular trauma and prompt presentation for the management of other eye diseases should be encouraged.
  • A contralateral eye study comparing apodized diffrative and full diffrative lenses: wavefront analysis and distance and near uncorrected visual acuity Clinical Sciences

    Santhiago, Marcony Rodrigues de; Netto, Marcelo Vieira; Barreto Jr, Jackson; Gomes, Beatriz de Abreu Fiuza; Schaefer, Arthur; Kara-Junior, Newton

    Abstract in English:

    PURPOSE: To evaluate intraindividual visual acuity, wavefront errors and modulation transfer functions in patients implanted with two diffractive multifocal intraocular lenses. METHODS: This prospective study examined 40 eyes of 20 cataract patients who underwent phacoemulsification and implantation of a spherical multifocal ReSTOR intraocular lens in one eye and an aspheric Tecnis ZM900 multifocal intraocular lens in the other eye. The main outcome measures, over a 3-month follow-up period, were the uncorrected photopic distance and near visual acuity and the defocus curve. The visual acuity was converted to logMAR for statistical analysis and is presented in decimal scale. The wavefront error and modulation transfer function were also evaluated in both groups. RESULTS: At the 3-month postoperative visit, the mean photopic distance uncorrected visual acuity (UCVA) was 0.74 ± 0.20 in the ReSTOR group and 0.76 ± 0.22 in the Tecnis group (p=0.286). The mean near UCVA was 0.96 ± 0.10 in the ReSTOR group and 0.93 ± 0.14 in the Tecnis group (p=0.963). The binocular defocus curve showed measurements between the peaks better than 0.2 logMAR. The total aberration, higher-order aberration and coma aberration were not significantly different between the groups. The spherical aberration was significantly lower in the Tecnis group than in the ReSTOR group. (p=0.004). Both groups performed similarly for the modulation transfer function. CONCLUSION: The ReSTOR SN60D3 and Tecnis ZM 900 intraocular lenses provided similar photopic visual acuity at distance and near. The diffractive intraocular lenses studied provided a low value of coma and spherical aberrations, with the Tecnis intraocular lens having a statistically lower spherical aberration compared to the ReSTOR intraocular lens. In the 5 mm pupil diameter analyses, both intraocular lens groups showed similar modulation transfer functions.
  • Treatment of cutaneous tumors with topical 5% imiquimod cream Clinical Sciences

    Alessi, Sabrina Sisto; Sanches, Jose Antonio; Oliveira, Walmar Roncalli de; Messina, Maria Cristina; Pimentel, Eugenio Raul de Almeida; Festa Neto, Cyro

    Abstract in English:

    INTRODUCTION: There are various approaches to the treatment of cutaneous tumors; one of them is treatment with imiquimod, a synthetic toll-like receptor agonist with a low molecular weight that offers a topical, noninvasive, and non-surgical therapeutic option. The main objective of our study was to provide data on 89 patients who used a 5% imiquimod cream for the treatment of cutaneous tumors at the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas from 2003 to 2008. MATERIALS AND METHODS: Here, we present our experience in the treatment of 123 cutaneous tumors of various types, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), Bowen's disease, erythroplasia of Queyrat, Paget's disease, and trichoepithelioma, with 5% imiquimod cream from 2003 to 2008 in the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas. Patients were divided into two separate groups according to their diagnosis and comorbidities; these comorbidities included epidermodysplasia verruciformis, xeroderma pigmentosum, albinism, basal cell nevus syndrome, Brooke-Spiegler syndrome, HIV, chronic lymphocytic leukemia, B-cell lymphoma, and kidney transplantation. Treatment duration, response to imiquimod, follow-up, recurrence, and local and systemic reactions associated with use of the drug were analyzed. Epidemiological data were obtained and cure rates were calculated. RESULTS: The ratio of women to men was 1.28:1, and the mean age was 63.1 years. Tumors were located mainly on the face, back, trunk, and legs. For patients with comorbidities, the overall cure rate was 38%. These specific patients demonstrated cure rates of 83.5% for superficial BCC and 50% for Bowen's disease. Aggressive BCC and superficial and nodular BCC did not present a good response to treatment. Trichoepitheliomas and nodular BCC showed a partial response, and erythroplasia of Queyrat showed a complete response. For patients without comorbidities, the overall cure rate was 73%. For these patients, the cure rates were 85.7% for superficial and nodular BCC, 88% for superficial BCC, 57% for Bowen's disease, 50% for nodular BCC, and 50% for aggressive BCC. One SCC lesion demonstrated a complete response, and tumors caused by Paget's disease and erythroplasia of Queyrat presented a partial response. None of the tumors considered as clinically cured recurred. Thirty-seven lesions demonstrated no response to imiquimod. Having a cutaneous comorbidity, high-risk tumors such as mixed aggressive BCC (sclerodermiform or micronodular), nodular BCC, or Bowen's disease, and presenting no local reaction to imiquimod were considered as risk factors for a worse prognosis. We demonstrate that patients with no response to imiquimod, even when they demonstrated no local reaction, can undergo another cycle of six weeks of imiquimod treatment and show a complete response. The healing pattern led to good cosmetic outcomes, and the side effects were tolerable. CONCLUSIONS: Our experience confirms imiquimod as an effective treatment option for several types of cutaneous tumors, especially in patients without the cutaneous comorbidities cited above and with low-risk tumors. Imiquimod has a relatively low cost compared to other therapeutic options and can be delivered via ambulatory care to patients with surgery contraindications, and its side effects are tolerable.
  • Combining cognitive screening tests for the evaluation of mild cognitive impairment in the elderly Clinical Sciences

    Ladeira, Rodolfo B.; Diniz, Breno S.; Nunes, Paula V.; Forlenza, Orestes V.

    Abstract in English:

    OBJECTIVE: To determine the accuracy of the Mini-Mental State Examination combined with the Verbal Fluency Test and Clock Drawing Test for the identification of patients with mild cognitive impairment and Alzheimer's disease (AD). METHOD: These tests were used to evaluate cognitive function in 247 older adults. Subjects were divided into three groups according to their cognitive state: mild cognitive impairment (n=83), AD (n=81), cognitively unimpaired controls (n=83), based on clinical and neuropsychological data. The diagnostic accuracy of each test for discriminating between these diagnostic groups (mild cognitive impairment or AD vs. controls) was examined with the aid of Receiver Operating Characteristic (ROC) curves. Additionally, we evaluated the benefit of the combination of tests on diagnostic accuracy. RESULTS: Although they were accurate enough for the identification of Alzheimer's disease, neither test alone proved adequate for the correct separation of patients with mild cognitive impairment from healthy subjects. Combining these tests did not improve diagnostic accuracy, as compared to the Mini-Mental State Examination alone, in the identification of patients with mild cognitive impairment or Alzheimer's disease. CONCLUSIONS: The present data do not warrant the combined use of the Mini-Mental State Examination, the Verbal Fluency Test and the Clock Drawing Test as a sufficient diagnostic schedule in screening for mild cognitive impairment. The present data do not support the notion that the combination of test scores is better that the use of Mini-Mental State Examination scores alone in the screening for Alzheimer's disease.
  • Development and evaluation of a head-controlled human-computer interface with mouse-like functions for physically disabled users Clinical Sciences

    Pereira, César Augusto Martins; Bolliger Neto, Raul; Reynaldo, Ana Carolina; Luzo, Maria Cândida de Miranda; Oliveira, Reginaldo Perilo

    Abstract in English:

    OBJECTIVES: The objectives of this study were to develop a pointing device controlled by head movement that had the same functions as a conventional mouse and to evaluate the performance of the proposed device when operated by quadriplegic users. METHODS: Ten individuals with cervical spinal cord injury participated in functional evaluations of the developed pointing device. The device consisted of a video camera, computer software, and a target attached to the front part of a cap, which was placed on the user's head. The software captured images of the target coming from the video camera and processed them with the aim of determining the displacement from the center of the target and correlating this with the movement of the computer cursor. Evaluation of the interaction between each user and the proposed device was carried out using 24 multidirectional tests with two degrees of difficulty. RESULTS: According to the parameters of mean throughput and movement time, no statistically significant differences were observed between the repetitions of the tests for either of the studied levels of difficulty. CONCLUSIONS: The developed pointing device adequately emulates the movement functions of the computer cursor. It is easy to use and can be learned quickly when operated by quadriplegic individuals.
  • Relationship of BODE Index to functional tests in chronic obstructive pulmonary disease Clinical Sciences

    Regueiro, Eloisa Maria Gatti; Pires Di Lorenzo, Valéria Amorim; Basso, Renata Pedrolongo; Pessoa, Bruna Varanda; Jamami, Mauricio; Costa, Dirceu

    Abstract in English:

    OBJECTIVE: To determine if there is a correlation between the BODE Index and variables assessed during the Activities of Daily Living assessment, performance on lower limber tests, and peripheral muscle impairment of the upper limb in patients with chronic obstructive pulmonary disease. MATERIALS AND METHODS: Ten men (aged 58 to 80 years old) with moderate to very severe obstruction were evaluated and classified by the BODE Index. They were evaluated by pulmonary ventilation (V•E), oxygen consumption (V•O2), and carbonic gas production (V•CO2) on the ADL assessment; Distance Walking (DW) in the Six Minute Walking Test (6MWT) and the Six Minute Walking Test on Treadmill (6MWTT); number of repetitions in the Sit-to-Stand Test; and the Hand Grip Strength Test. Correlations were evaluated between the classification and the tests performed (Pearson and Spearman test, p<0.05). RESULTS: The mean of the total score for the BODE Index was 2.80 (±1.03), with three patients scoring in the first quartile (Q1) and seven scoring in the second quartile (Q2). This Index showed a negative correlation with the 6MWTT (r=-0.86), the Sit-to-Stand Test (r=-0.66), and the Hand Grip Strength Test (r=-0.83). CONCLUSIONS: Our results show that there is no correlation between the BODE Index and the ventilatory and metabolic responses in the Activities of Daily Living assessment. On the other hand, a correlation was observed between the BODE Index and the variables assessed in the 6MWTT, Sit-to-Stand Test, and Hand Grip Strength Test in moderate to very severe Chronic Obstructive Pulmonary Disease patients. This suggests that these tests can be employed as predictors of physical exercise capacity, perhaps as complementary tests to the BODE Index.
  • Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique Clinical Sciences

    Turker, Gurkan; Kaya, Fatma Nur; Gurbet, Alp; Aksu, Hale; Erdogan, Cuneyt; Atlas, Ahmet

    Abstract in English:

    OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications.
  • Petroleum ether extract of Cissus quadrangularis (Linn.) enhances bone marrow mesenchymal stem cell proliferation and facilitates osteoblastogenesis Clinical Sciences

    Potu, Bhagath Kumar; Bhat, Kumar MR; Rao, Muddanna S; Nampurath, Gopalan Kutty; Chamallamudi, Mallikarjuna Rao; Nayak, Soubhagya Ranjan; Muttigi, Manjunatha S

    Abstract in English:

    OBJECTIVE: To evaluate the effects of the petroleum ether extract of Cissus quadrangularis on the proliferation rate of bone marrow mesenchymal stem cells, the differentiation of marrow mesenchymal stem cells into osteoblasts (osteoblastogenesis) and extracellular matrix calcification. This study also aimed to determine the additive effect of osteogenic media and Cissus quadrangularis on proliferation, differentiation and calcification. METHODS: MSCs were cultured in media with or without Cissus quadrangularis for 4 weeks and were then stained for alkaline phosphatase. Extracellular matrix calcification was confirmed by Von Kossa staining. marrow mesenchymal stem cells cultures in control media and osteogenic media supplemented with Cissus quadrangularis extract (100, 200, 300 µg/mL) were also subjected to a cell proliferation assay (MTT). RESULTS: Treatment with 100, 200 or 300 µg/mL petroleum ether extract of Cissus quadrangularis enhanced the differentiation of marrow mesenchymal stem cells into ALP-positive osteoblasts and increased extracellular matrix calcification. Treatment with 300 µg/mL petroleum ether extract of Cissus quadrangularis also enhanced the proliferation rate of the marrow mesenchymal stem cells. Cells grown in osteogenic media containing Cissus quadrangularis exhibited higher proliferation, differentiation and calcification rates than did control cells. CONCLUSION: The results suggest that Cissus quadrangularis stimulates osteoblastogenesis and can be used as preventive/alternative natural medicine for bone diseases such as osteoporosis.
  • Mortality in anesthesia: a systematic review Review

    Braz, Leandro Gobbo; Braz, Danilo Gobbo; Cruz, Deyvid Santos da; Fernandes, Luciano Augusto; Módolo, Norma Sueli Pinheiro; Braz, José Reinaldo Cerqueira

    Abstract in English:

    This systematic review of the Brazilian and worldwide literature aims to evaluate the incidence and causes of perioperative and anesthesia-related mortality. Studies were identified by searching the Medline and Scielo databases, followed by a manual search for relevant articles. Our review includes studies published between 1954 and 2007. Each publication was reviewed to identify author(s), study period, data source, perioperative mortality rates, and anesthesia-related mortality rates. Thirty-three trials were assessed. Brazilian and worldwide studies demonstrated a similar decline in anesthesia-related mortality rates, which amounted to fewer than 1 death per 10,000 anesthetics in the past two decades. Perioperative mortality rates also decreased during this period, with fewer than 20 deaths per 10,000 anesthetics in developed countries. Brazilian studies showed higher perioperative mortality rates, from 19 to 51 deaths per 10,000 anesthetics. The majority of perioperative deaths occurred in neonates, children under one year, elderly patients, males, patients of ASA III physical status or poorer, emergency surgeries, during general anesthesia, and cardiac surgery followed by thoracic, vascular, gastroenterologic, pediatric and orthopedic surgeries. The main causes of anesthesia-related mortality were problems with airway management and cardiocirculatory events related to anesthesia and drug administration. Our systematic review of the literature shows that perioperative mortality rates are higher in Brazil than in developed countries, while anesthesia-related mortality rates are similar in Brazil and in developed countries. Most cases of anesthesia-related mortality are associated with cardiocirculatory and airway events. These data may be useful in developing strategies to prevent anesthesia-related deaths.
  • Recent trends in Brazilian medical research: an overview Review

    Rocha-e-Silva, Mauricio

    Abstract in English:

    This article reviews 69 original research articles published in 6 Brazilian Medical Journals recently incorporated into the Institute for Scientific Information Journal of Citation Reports, with a view of making them comprehensively available to the readership of CLINICS within a subject category division. We expect this review to increase the visibility of a wide specter of original Brazilian research which may otherwise remain relatively unseen by the interested readership
  • Guidelines on management of human infection with the novel virus influenza A (H1N1): a report from the Hospital das Clínicas of the University of São Paulo Review

    Hajjar, Ludhmila Abrahao; Schout, Denise; Galas, Filomena Regina Barbosa Gomes; Uip, David Everson; Levin, Anna Sara Shafferman; Caiaffa Filho, Helio Hehl; Sakane, Pedro Takanori; Suslik, Carlos Alberto; Teixeira, Jose Manoel de Camargo; Bonfa, Eloisa; Barone, Antonio Alci; Martins, Milton de Arruda; Boulos, Marcos; Auler Jr., Jose Otavio Costa

    Abstract in English:

    The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas "bundles" for the control of the pandemic novel influenza A (H1N1).
  • Epidemiology of human infection with the novel virus influenza A (H1H1) in the Hospital das Clínicas, São Paulo, Brazil - june-september 2009 Review

    Schout, Denise; Hajjar, Ludhmila Abrahao; Galas, Filomena Regina Barbosa Gomes; Uip, David Everson; Levin, Anna Sara Shafferman; Caiaffa Filho, Helio Hehl; Sakane, Pedro Takanori; Suslik, Carlos Alberto; Teixeira, Jose Manoel de Camargo; Bonfa, Eloisa; Barone, Antonio Alci; Martins, Milton de Arruda; Boulos, Marcos; Auler Jr., Jose Otavio Costa

    Abstract in English:

    The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3% of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC) is a reference center for H1N1 cases in São Paulo. During the winter of 2009, 472 patients in this hospital were diagnosed with H1N1 infection; of these, 210 were admitted, and 16 died. To control this pandemic and to provide adequate care for these patients, the Hospital das Clínicas implemented "bundles" including prevention strategies, an epidemiologic surveillance service, availability of fast diagnosis, antiviral treatment and training of staff. The purpose of this manuscript is to describe the epidemiologic features of novel human influenza A (H1N1) infection in the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the winter period of the 2009 pandemic.
  • Fatal bronchovascular fistula after a single lung transplantation: a case report Letter to the Editor

    Samano, Marcos Naoyuki; Saka, Juliana Akemi; Caramori, Marlova Luzzi; Pêgo-Fernandes, Paulo Manuel; Jatene, Fabio Biscegli
  • Occipito-vertebral dissociation in connection with extensive cervical spine malsegmentation in a boy with möbius syndrome Letter to the Editor

    Al Kaissi, Ali; Klaushofer, Klaus; Grill, Franz
  • Oral intraneural perineurioma: report of two cases Letter to the Editor

    Rocha, Lília Alves; Lopes, Sílvia Maria Paparotto; Silva, Alan Roger dos Santos; Lopes, Márcio Ajudarte; Vargas, Pablo Agustin
Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
E-mail: clinics@hc.fm.usp.br