Clinics, Volume: 64, Issue: 9, Published: 2009
  • In the September 2009 issue of Clinics Editorial

    Rocha-e-Silva, Mauricio
  • Reasons for resubmission of research projects to the research ethics committee of a University Hospital in São Paulo, Brazil Clinical Sciences

    Bueno, Mariana; Brevidelli, Maria Meimei; Cocarelli, Thaís; Santos, Gianni Mara Silva dos; Ferraz, Maria Auxiliadora; Mion Jr., Décio

    Abstract in English:

    INTRODUCTION: It is important to know the reasons for resubmitting research projects to the Research Ethics Committee in order to help researchers to prepare their research projects, informed consent forms and needed research documentation. OBJECTIVES: To verify the reasons for resubmitting projects that were previously rejected by the Ethics Committee. METHOD: This is a cross-sectional study that evaluated research projects involving human beings. Research projects were submitted in 2007 to the Research Ethics Committee of the Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. RESULTS: One thousand two hundred and fifty six research projects were submitted to the ethics committee and the average time for evaluating the research projects and related documents until a final decision was reached was 49.95 days. From the total, 399 projects were reviewed in 2 or more meetings until a final decision was reached. Of these, 392 research projects were included in the study; 35 projects were subsequently excluded for involving animals. Among the research projects included, 42.5% concerned research with new drugs, vaccines and diagnostic tests, 48.5% consisted of undergraduate students' research projects, 68.9% of the research had no sponsorship, and 97.5% were eventually approved. The main reasons for returning the projects to the researchers were the use of inadequate language and/or difficulty of understanding the informed consent form (32.2%), lack of information about the protocol at the informed consent form (25.8%), as well as doubts regarding methodological and statistical issues of the protocol (77.1%). Other reasons for returning the research projects involved lack of, inaccuracy on or incomplete documentation, need of clarification or approval for participation of external entities on the research, lack of information on financial support. CONCLUSION: Among the research projects that were returned to the researchers for additional clarification, the main reasons were inadequacies or doubts about the terms used in the informed consent form as well as lack of information regarding the research at the informed consent form and methodological and statistical issues regarding the protocol.
  • Analysis of HFE and non-HFE gene mutations in Brazilian patients with hemochromatosis Clinical Sciences

    Bittencourt, Paulo Lisboa; Marin, Maria Lúcia Carnevale; Couto, Cláudia Alves; Cançado, Eduardo Luiz Rachid; Carrilho, Flair José; Goldberg, Anna Carla

    Abstract in English:

    BACKGROUND: Approximately one-half of Brazilian patients with hereditary hemochromatosis (HH) are neither homozygous for the C282Y mutation nor compound heterozygous for the H63D and C282Y mutations that are associated with HH in Caucasians. Other mutations have been described in the HFE gene as well as in genes involved in iron metabolism, such as transferrin receptor 2 (TfR2) and ferroportin 1 (SCL40A1). AIMS: To evaluate the role of HFE, TfR2 and SCL40A1 mutations in Brazilian subjects with HH. PATIENTS AND METHODS: Nineteen male subjects (median age 42 [range: 20-72] years) with HH were evaluated using the Haemochromatosis StripAssay A®. This assay is capable of detecting twelve HFE mutations, which are V53M, V59M, H63D, H63H, S65C, Q127H, P160delC, E168Q, E168X, W169X, C282Y and Q283, four TfR2 mutations, which are E60X, M172K, Y250X, AVAQ594-597del, and two SCL40A1 mutations, which are N144H and V162del. RESULTS: In our cohort, nine (47%) patients were homozygous for the C282Y mutation, two (11%) were heterozygous for the H63D mutation, and one each (5%) was either heterozygous for C282Y or compound heterozygous for C282Y and H63D. No other mutations in the HFE, TfR2 or SCL40A1 genes were observed in the studied patients. CONCLUSIONS: One-third of Brazilian subjects with the classical phenotype of HH do not carry HFE or other mutations that are currently associated with the disease in Caucasians. This observation suggests a role for other yet unknown mutations in the aforementioned genes or in other genes involved in iron homeostasis in the pathogenesis of HH in Brazil.
  • Oral maxillofacial fractures seen at a ugandan tertiary hospital: a six-month prospective study Clinical Sciences

    Kamulegeya, Adriane; Lakor, Francis; Kabenge, Kate

    Abstract in English:

    AIM: To investigate the epidemiological characteristics of maxillofacial fractures and associated fractures in patients seen in the Oral Surgery Unit of Mulago Hospital, Kampala, Uganda. METHODOLOGY: A six-month prospective study was conducted. Data collected included socio-demographic factors, type and etiology of injury, additional fractures, and post-surgery complications. RESULTS: One hundred thirty-two (132) cases ranging from 5-70 yrs of age were reported, with a male: female ratio of 7.7:1. The 21-30 yr age group was the largest, comprising 51.51% of cases (n=68). Road traffic accidents contributed to 56.06% (n=74) of fractures. In total, 66% of the sample (n=87) suffered isolated mandibular fractures. Symphyseal and maxillary fractures were the most common mandibular and mid-facial fractures, respectively. Among associated fractures, the femur was most affected. A total of 39 (29.54%) of patients had post-operative complications, of which infection accounted for 48.71% (n= 19), and malocclusion accounted for 17.94% (n=7). CONCLUSIONS: Anticipated changes in maxillofacial trauma trends necessitate regular epidemiologic studies of facial fractures to allow for development and implementation of timely novel preventive measures.
  • Prognostic influence of clinical and pathological factors in medullary thyroid carcinoma: a study of 53 cases Clinical Sciences

    Brandão, Lenine G.; Cavalheiro, Beatriz G.; Junqueira, Consuelo R.

    Abstract in English:

    OBJECTIVES AND INTRODUCTION: Medullary thyroid carcinoma, a neoplasia of intermediate prognosis and differentiation, does not always respond predictably to known treatments. This study aimed to correlate the clinical progression of surgically treated patients with clinical and pathological data. METHODS: A total of 53 patients were followed for 75 months (mean average) in tertiary-care hospital. The clinical status of patients at the end of the study period was characterized to determine correlations with a range of disease aspects. A value of p < 0.05 was considered statistically significant. RESULTS: Twenty-two patients (41.5%) were alive and disease-free at the end of the follow-up period; twenty-three patients (43.4%) had persistent disease; and eight patients (15.1%) had recurrent disease. Four patients (7.6%) died from medullary thyroid carcinoma with clinical and/or imaging evidence of neoplasia. The following aspects demonstrated statistically significant correlations with the final medical condition: positive initial cervical examination (p = 0.002); neoplastic extensions to the thyroid capsule (p = 0.004) and adjacent tissues (p = 0.034); cervical lymph node metastases (p < 0.001); diameter of neoplasia (p = 0.018); TNM (tumor, node and metastasis) Stage (p = 0.001) and evidence of distant and/or cervical diseases in the absence of a cure (p = 0.011). Through logistic regression, the presence of cervical lymph node metastases was considered an independent variable (p < 0.001). CONCLUSIONS: Clinical and pathological aspects of patients with surgically treated medullary thyroid carcinomas are predictors of disease progression. Specifically, even treated cervical lymph node metastases are significantly correlated with disease progression.
  • Crack cocaine use and its relationship with violence and HIV Clinical Sciences

    Carvalho, Heraclito Barbosa de; Seibel, Sergio Dario

    Abstract in English:

    OBJECTIVES: To evaluate crack cocaine use practices, risk behaviors associated with HIV infection among drug users, and their involvement with violence. INTRODUCTION: HIV infections are frequent among drug users due to risky sexual behavior. It is generally accepted that crack cocaine use is related to increased levels of violence. Several reports point to an increase in violence from those involved in drug trafficking. Although HIV infections and risky sexual behavior among drug users have been quite well studied, there are few studies that evaluate violence as it relates to drugs, particularly crack. METHODS: A total of 350 drug users attending drug abuse treatment clinics in São Paulo, Brazil were interviewed about their risky behaviors. Each patient had a serological HIV test done. RESULTS: HIV prevalence was 6.6% (4.0 to 10.2). Violence was reported by 97% (94.7 to 99.1) of the subjects (including cases without personal involvement). Acts of violence such as verbal arguments, physical fights, threats, death threats, theft, and drug trafficking were significantly higher among crack users. A decrease in frequency of sexual intercourse was observed among users of injected drugs, though prostitution was observed as a means of obtaining drugs. A high number of crack cocaine users had a history of previous imprisonment, many for drug-related infractions. DISCUSSION: The data presented are in accordance with other reports in the literature, and they show a correlation between drug use, imprisonment, violence, and drug trafficking. CONCLUSION: A high HIV prevalence and associated risky sexual behaviors were observed among crack cocaine users. The society and the authorities that deal with violence related to crack users and drug trafficking should be aware of these problems.
  • Quality of life among HIV-infected patients in Brazil after initiation of treatment Clinical Sciences

    Campos, Lorenza Nogueira; César, Cibele Comini; Guimarães, Mark Drew Crosland

    Abstract in English:

    INTRODUCTION: Despite improvement in clinical treatment for HIV-infected patients, the impact of antiretroviral therapy on the overall quality of life has become a major concern. OBJECTIVE: To identify factors associated with increased levels of self-reported quality of life among HIV-infected patients after four months of antiretroviral therapy. METHODS: Patients were recruited at two public health referral centers for AIDS, Belo Horizonte, Brazil, for a prospective adherence study. Patients were interviewed before initiating treatment (baseline) and after one and four months. Quality of life was assessed using a psychometric instrument, and factors associated with good/very good quality of life four months after the initiation of antiretroviral therapy were assessed using a cross-sectional approach. Logistic regression was used for analysis. RESULTS: Overall quality of life was classified as 'very good/good' by 66.4% of the participants four months after initiating treatment, while 33.6% classified it as 'neither poor nor good/poor/very poor'. Logistic regression indicated that >8 years of education, none/mild symptoms of anxiety and depression, no antiretroviral switch, lower number of adverse reactions and better quality of life at baseline were independently associated with good/very good quality of life over four months of treatment. CONCLUSIONS: Our results highlight the importance of modifiable factors such as psychiatric symptoms and treatment-related variables that may contribute to a better quality of life among patients initiating treatment. Considering that poor quality of life is related to non-adherence to antiretroviral therapy, careful clinical monitoring of these factors may contribute to ensuring the long-term effectiveness of antiretroviral regimens.
  • Quality of life in the late follow-up of ulcerative colitis patients submitted to restorative proctocolectomy with sphincter preservation over ten years ago Clinical Sciences

    Meyer, Alberto Luiz Monteiro; Teixeira, Magaly Gêmeo; Almeida, Maristela Gomes de; Kiss, Desidério Roberto; Nahas, Sergio Carlos; Cecconello, Ivan

    Abstract in English:

    OBJECTIVE: To evaluate, by means of the Inflammatory Bowel Disease Questionnaire (IBDQ), the quality of life of ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago. METHODS: The study consisted of 36 patients interviewed using the Inflammatory Bowel Disease Questionnaire. The score scale, resulting from the addition of each answer, ranged from 32 to 224, where the highest score indicates the best quality of life. The chi square test was used to verify the existence of meaningful differences between the results of the questionnaire and age, and gender proportion. For each section, as well as for all of them combined, the Kruskal-Wallis test was used to verify if there were differences in the Inflammatory Bowel Disease Questionnaire scores among the groups in relation to the proportions. RESULTS: After applying the Inflammatory Bowel Disease Questionnaire, it was determined that quality of life was considered excellent for 9 (25%), good for 11 (30.6%), regular for 13 (36.1%), and bad for 3 (8.3%) patients. In our study, we determined that 85% of the patients were pleased with and thankful for the surgery that they underwent. CONCLUSION: We can conclude that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods.
  • Comparative evaluation of oculometric variables in graves' ophthalmopathy Clinical Sciences

    Miot, Hélio Amante; Fernandes, Leonardo Parr dos Santos; Jorge, Edson Nassib; Pivotto, Daniel Rosito; Nogueira, Célia Regina; Mazeto, Gláucia Maria Ferreira da Silva

    Abstract in English:

    OBJECTIVES: To estimate oculometric parameters of Graves' ophthalmopathy in comparison to healthy eyes using digital photography and digital image analysis. INTRODUCTION: Graves' ophthalmopathy is the main cause of eye proptosis. Because these protrusions cause clinically perceived distortions in orbital architecture, digital photographs can be used to detect and quantify these changes. METHODS: We carried out a cross-sectional study comprising 12 healthy volunteers and 15 Graves' ophthalmopathy patients with the purpose of evaluating the use of simple, non-invasive digital photography to estimate oculometric parameters of Graves' ophthalmopathy and compare them with the parameters of unaffected eyes. Facial photographs of cases and controls were taken in a standardized manner. Oculometric parameters were compared between the groups and then correlated to proptometer measures. RESULTS: All estimated oculometric variables showed significant differences between the groups, in particular with regard to mediopupilar aperture, lateral height, distance from the iris edge to the lateral boundary of the palpebral fissure, and distance from the higher point of the iris to the lateral limit of the palpebral fissure. The product of medial aperture and horizontal palpebral fissure also revealed greater discrepancy between the groups. Proptometer measures showed significant linear correlation between the distance from the iris edge to the lateral boundary of the palpebral fissure and between the distance from the higher point of the iris to the lateral limit of palpebral fissure (p<0.05). CONCLUSIONS: Comparative analysis of oculometric parameters in Graves' ophthalmopathy suggests that eye proptosis is related to an asymmetric increase in lateral oculometric measures. Standardized digital photographs can be used in clinical practice to objectively estimate oculometric parameters of Graves' ophthalmopathy patients.
  • Does the evaluation of coagulation factors contribute to etiological diagnosis of pleural effusions? Clinical Sciences

    Vaz, Marcelo Alexandre Costa; Vargas, Francisco Suso; Marinho, Felipe Costa de Andrade; D'Amico, Élbio Antonio; Rocha, Tânia Rubia Flores; Teixeira, Lisete Ribeiro

    Abstract in English:

    OBJECTIVE: The aim of this study was to identify the participation of the coagulation system in the differential diagnosis of pleural effusions. INTRODUCTION: Imbalance between immunologic and metabolic factors triggers a sequence of events resulting in pleural reactions and accumulation of fluid. The coagulation system, which is fundamental for the maintenance of homeostasis, contributes to the inflammatory process responsible for pleural effusions, and participates in cellular proliferation and migration as well as in the synthesis of inflammatory mediators. METHODS: We evaluated the laboratory profile of coagulation and fibrinolysis in 54 pleural fluids (15 transudates and 39 exudates). RESULTS: The coagulation system acts according to the pathophysiologic mechanisms involved in the development of pleural effusions. In inflammatory effusions (exudates), there is activation of coagulation with increased levels of fragment 1+2 and thrombin-antithrombin complex in addition to reduction of fibrinogen levels due to fibrinolysis and fibrin tissue incorporation. As a consequence, there is activation of the fibrinolytic system with increased levels of fibrin degradation products, including the D-dimer. These changes are not sufficient for differentiation of different subgroups of exudates. In transudates, these events were observed to a lesser degree. CONCLUSION: The coagulation system plays an important role in the development of pleural diseases. Coagulation tests show differences between transudates and exudates but not among exudate subgroups. Understanding the physiopathological mechanisms of pleural disorders may help to define new diagnostic and therapeutic approaches.
  • Variability in the origin of the obturator artery Basic Research

    Pai, Mangala M.; Krishnamurthy, Ashwin; Prabhu, Latha V; Pai, Manohar V.; Kumar, Senthil A.; Hadimani, Gavishiddappa A.

    Abstract in English:

    INTRODUCTION: General surgeons dealing with laparoscopic herniorrhaphy should be aware of the aberrant obturator artery that crosses the superior pubic ramus and is susceptible to injuries during dissection of the Bogros space and mesh stapling onto Cooper's ligament. The obturator artery is usually described as a branch of the anterior division of the internal iliac artery, although variations have been reported. MATERIALS AND METHODS: The present study was conducted on 98 pelvic halves of embalmed cadavers, and the origin and course of the obturator artery were traced and noted. RESULTS: In 79% of the specimens, the obturator artery was a branch of the internal iliac artery. It branched off at different levels either from the anterior division or posterior division, individually or with other named branches. In 19% of the cases, the obturator artery branched off from the external iliac artery as a separate branch or with the inferior epigastric artery. However, in the remaining 2% of the specimens, both the internal and the external iliac arteries branched to form an anastomotic structure within the pelvic cavity. CONCLUSION: The data obtained in this study show that it is more common to find an abnormal obturator artery than was reported previously, and this observation has implications for pelvic surgeons and is of academic interest to anatomists. Surgeons dealing with direct, indirect, femoral, or obturator hernias need to be aware of these variations and their close proximity to the femoral ring.
  • The scientific production of full professors of the faculdade de medicina da universidade de São Paulo: a view of the period of 2001-2006 Basic Research

    Cardoso, Suely Campos; Gattás, Gilka Jorge Figaro

    Abstract in English:

    INTRODUCTION: The scientific production of institutions of higher education, as well as the dissemination and use of this published work by peer institutions, can be assessed by means of quantitative and qualitative measurements. This type of analysis can also serve as the basis of further academic actions. Variables such as the type of evaluation, the number of faculty members and the decision to include or exclude researchers who are not professors are difficult to measure when comparing different schools and institutions. OBJECTIVES: The purpose of this study was to assess the scientific production of tenured faculty from the Universidade de São Paulo, Faculdade de Medicina performed from 2001 to 2006. METHODS: Medline/PubMed database was considered and the Impact factors (IFs - Journal Citation Report, 2006) and the number of generated citations (Web of Science/ISI Thomson) were also evaluated. RESULTS: The analysis of the scientific production of 66 full professors (level MS-6) revealed 1,960 scientific articles published in 630 scientific journals, of which 31.3% were Brazilian and 68.7% were from international sources. Among these, 47% of the articles were published in 62.9% of the journals with IFs above 10, although 16.4% of the journals did not have assigned IF values. We verified that 45% of the published articles received 9,335 citations (average of 11 + 17), with the majority of these (8,968 citations) appearing in international scientific journals. CONCLUSIONS: Our results indicate that it is possible to analyze the scientific production of a learning institution by the number of papers published by full professors, taking into account not only their academic position and influence, but also the fact that publication is an opportunity to stimulate joint projects with other members of the same institution.
  • Mesenteric microcirculatory dysfunctions and translocation of indigenous bacteria in a rat model of strangulated small bowel obstruction Basic Research

    Zanoni, Fernando Luiz; Benabou, Simon; Greco, Karin Vicente; Moreno, Ana Carolina Ramos; Cruz, José Walber Miranda Costa; Filgueira, Fernando Paranaiba; Martinez, Marina Baquerizo; Figueiredo, Luiz Francisco Poli de; Silva, Maurício Rocha e; Sannomiya, Paulina

    Abstract in English:

    PRUPOSE: Bacterial translocation has been shown to occur in critically ill patients after extensive trauma, shock, sepsis, or thermal injury. The present study investigates mesenteric microcirculatory dysfunctions, the bacterial translocation phenomenon, and hemodynamic/metabolic disturbances in a rat model of intestinal obstruction and ischemia. METHODS: Anesthetized (pentobarbital 50 mg/kg, i.p.) male Wistar rats (250-350 g) were submitted to intestinal obstruction or laparotomy without intestinal obstruction (Sham) and were evaluated 24 hours later. Bacterial translocation was assessed by bacterial culture of the mesenteric lymph nodes (MLN), liver, spleen, and blood. Leukocyte-endothelial interactions in the mesenteric microcirculation were assessed by intravital microscopy, and P-selectin and intercellular adhesion molecule (ICAM)-1 expressions were quantified by immunohistochemistry. Hematocrit, blood gases, lactate, glucose, white blood cells, serum urea, creatinine, bilirubin, and hepatic enzymes were measured. RESULTS: About 86% of intestinal obstruction rats presented positive cultures for E. coli in samples of the mesenteric lymph nodes, liver, and spleen, and 57% had positive hemocultures. In comparison to the Sham rats, intestinal obstruction induced neutrophilia and increased the number of rolling (~2-fold), adherent (~5-fold), and migrated leukocytes (~11-fold); this increase was accompanied by an increased expression of P-selectin (~2-fold) and intercellular adhesion molecule-1 (~2-fold) in the mesenteric microcirculation. Intestinal obstruction rats exhibited decreased PaCO2, alkalosis, hyperlactatemia, and hyperglycemia, and increased blood potassium, hepatic enzyme activity, serum urea, creatinine, and bilirubin. A high mortality rate was observed after intestinal obstruction (83% at 72 h vs. 0% in Sham rats). CONCLUSION: Intestinal obstruction and ischemia in rats is a relevant model for the in vivo study of mesenteric microcirculatory dysfunction and the occurrence of bacterial translocation. This model parallels the events implicated in multiple organ dysfunction (MOD) and death.
  • Memantine prevents cardiomyocytes nuclear size reduction in the left ventricle of rats exposed to cold stress Basic Research

    Meneghini, Adriano; Ferreira, Celso; Abreu, Luiz Carlos de; Valenti, Vitor E.; Ferreira, Marcelo; F. Filho, Celso; Murad, Neif

    Abstract in English:

    OBJECTIVES: Memantine is an N-methyl-d-aspartate (NMDA) glutamate receptor antagonist used to treat Alzheimer's disease. Previous studies have suggested that receptor blockers act as neuroprotective agents; however, no study has specifically investigated the impact that these drugs have on the heart. We sought to evaluate the effects of memantine on nuclear size reduction in cardiac cells exposed to cold stress. METHOD: We used male EPM-Wistar rats (n=40) divided into 4 groups: 1) Matched control (CON); 2) Memantine-treated rats (MEM); 3) Rats undergoing induced hypothermia (IH) and 4) Rats undergoing induced hypothermia that were also treated with memantine (IHM). Animals in the MEM and IHM groups were treated by oral gavage administration of 20 mg/kg/day memantine over an eight-day period. Animals in the IH and IHM groups were submitted to 4 hours of hypothermia in a controlled environment with a temperature of - 8ºC on the last day of the study. RESULTS: The MEM group had the largest cardiomyocyte nuclear size (151 ± 3.5 μm³ vs. CON: 142 ± 2.3 μm³; p<0.05), while the IH group had the smallest mean value of nuclear size. The nuclear size of the IHM group was preserved (125 ± 2.9 μm³) compared to the IH group (108 ± 1.7 μm³; p<0.05). CONCLUSION: Memantine prevented the nuclear size reduction of cardiomyocytes in rats exposed to cold stress.
  • Acute chest syndrome in pregnant women with hemoglobin SC disease Letter to the Editors

    Nomura, Roseli Mieko Yamamoto; Igai, Ana Maria Kondo; Tosta, Karine; Fonseca, Guilherme Henrique Hencklain; Gualandro, Sandra Fatima Menosi; Zugaib, Marcelo
  • Classic abdominoplasty: a new approach to the correction of the abdominal wall deformity in patients with bladder exstrophy - a case report Letter to the Editors

    Moura, Tatiana; Lima Junior, Jonas Eraldo de; Sakae, Eduardo; Aki, Fabio; Giron, Amilcar Martins; Ferreira, Marcus Castro
  • Unusual combination of reversible splenial lesion and meningitis-retention syndrome in aseptic meningomyelitis Letter to the Editors

    Tascilar, Nida; Aydemir, Hande; Emre, Ufuk; Unal, Aysun; Atasoy, H. Tugrul; Ekem, Sureyya
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