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Clinics, Volume: 66, Issue: 1, Published: 2011
  • The stability of fish populations: how changes in the environment may affect people with epilepsy Editorials

    Cysneiros, Roberta M; Arida, Ricardo M; Terra, Vera C; Nejm, Mariana B; Scorza, Fulvio A
  • Reflexões críticas sobre os três erres, ou os periódicos brasileiros excluídos

    Rocha e Silva, Mauricio
  • Prevalence of potential drug interactions in patients in an intensive care unit of a university hospital in Brazil Clinical Sciences

    Reis, Adriano Max Moreira; Cassiani, Silvia Helena De Bortoli

    Abstract in English:

    OBJECTIVES: To investigate the prevalence of potential drug interactions at the intensive care unit of a university hospital in Brazil and to analyze their clinical significance. METHODS: This cross-sectional retrospective study included 299 patients who had been hospitalized in the intensive care unit of the hospital. The drugs administered during the first 24 hours of hospitalization, in the 50th length-ofstay percentile and at the time of discharge were analyzed to identify potential drug-drug and drug-enteral nutrition interactions using DRUG-REAXH software. The drugs were classified according to the anatomical therapeutic chemical classification. RESULTS: The median number of medications per patient was smaller at the time of discharge than in the 50th length-of-stay percentile and in the first 24 hours of hospitalization. There was a 70% prevalence of potential drug interactions at the intensive care unit at the studied time points of hospitalization. Most of the drug interactions were either severe or moderate, and the scientific evidence for the interactions was, in general, either good or excellent. Pharmacodynamic interactions presented a subtle predominance in relation to pharmacokinetic interactions. The occurrence of potential drug interactions was associated with the number of medications administered and the length of stay. Medications that induced cytochrome P450, drugs that prolong the QT interval and cardiovascular drugs were pharmacotherapy factors associated with potential drug interactions. CONCLUSION: The study showed that potential drug interactions were prevalent in the intensive care unit due to the complexity of the pharmacotherapies administered. The interactions were associated with the number of drugs, the length of stay and the characteristics of the administered medications.
  • Evolution of critically ill patients with gastroschisis from three tertiary centers Clinical Sciences

    Tannuri, Ana Cristina A; Sbragia, Lourenço; Tannuri, Uenis; Silva, Luanna M; Leal, Antonio José G; Schmidt, Augusto Frederico S; Oliveira-Filho, Antonio G; Bustorff-Silva, Joaquim Murray; Vicente, Yvone A. M. V. A; Tazima, Maria de Fátima G. S; Pileggi, Flávio O; Camperoni, Alexandra L

    Abstract in English:

    OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4¡6.7 mEq/L, and the mean serum albumin level was 2.35¡0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.
  • Entrapped victims in motor vehicle collisions: characteristics and prehospital care in the city of São Paulo, Brazil Clinical Sciences

    Dias, Adriano Rogério Navarro; Abib, Simone de Campos Vieira; Poli-de-Figueiredo, Luiz Francisco; Perfeito, João Aléssio Juliano

    Abstract in English:

    OBJECTIVE: To examine the severity of trauma in entrapped victims and to identify risk factors for mortality and morbidity. INTRODUCTION: Triage and rapid assessment of trauma severity is essential to provide the needed resources during prehospital and hospital phases and for outcome prediction. It is expected that entrapped victims will have greater severity of trauma and mortality than non-entrapped subjects. METHODS: A transverse, case-control, retrospective study of 1203 victims of motor vehicle collisions treated during 1 year by the prehospital service in São Paulo, Brazil was carried out. All patients were drivers, comprising 401 entrapped victims (33.3%) and 802 non-entrapped consecutive controls (66.7%). Sex, age, mortality rates, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), corporal segments, timing of the prehospital care and resource use were compared between the groups. The results were analysed by χ2, Zres, analysis of variance and Bonferroni tests. RESULTS: Entrapped victims were predominantly men (84.8%), aged 32±13.1 years, with immediate mortality of 10.2% and overall mortality of 11.7%. They had a probability of death at the scene 8.2 times greater than that of non-entrapped victims. The main cause of death was hemorrhage for entrapped victims (45.2%) and trauma for non-entrapped victims. Of the entrapped victims who survived, 18.7% had a severe GCS (OR = 10.62), 12% a severe RTS (OR = 9.78) and 23.7% were in shock (OR = 3.38). Entrapped victims were more commonly transported to advanced life support units and to tertiary hospitals. CONCLUSION: Entrapped victims had greater trauma severity, more blood loss and a greater mortality than respective, non-entrapped controls.
  • Clinically low-risk prostate cancer: evaluation with transrectal doppler ultrasound and functional magnetic resonance imaging Clinical Sciences

    Novis, Maria Inês; Baroni, Ronaldo Hueb; Cerri, Luciana Mendes de Oliveira; Mattedi, Romulo Loss; Buchpiguel, Carlos Alberto

    Abstract in English:

    OBJECTIVES: To evaluate transrectal ultrasound, amplitude Doppler ultrasound, conventional T2-weighted magnetic resonance imaging, spectroscopy and dynamic contrast-enhanced magnetic resonance imaging in localizing and locally staging low-risk prostate cancer. INTRODUCTION: Prostate cancer has been diagnosed at earlier stages and the most accepted classification for low-risk prostate cancer is based on clinical stage T1c or T2a, Gleason score <6, and prostate-specific antigen (PSA) <10 ng/ml. METHODS: From 2005 to 2006, magnetic resonance imaging was performed in 42 patients, and transrectal ultrasound in 26 of these patients. Seven patients were excluded from the study. Mean patient age was 64.94 years and mean serum PSA was 6.05 ng/ml. The examinations were analyzed for tumor identification and location in prostate sextants, detection of extracapsular extension, and seminal vesicle invasion, using surgical pathology findings as the gold standard. RESULTS: Sixteen patients (45.7%) had pathologically proven organ-confined disease, 11 (31.4%) had positive surgical margin, 8 (28.9%) had extracapsular extension, and 3 (8.6%) presented with extracapsular extension and seminal vesicle invasion. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy values for localizing low-risk prostate cancer were 53.1%, 48.3%, 63.4%, 37.8% and 51.3% for transrectal ultrasound; 70.4%, 36.2%, 65.1%, 42.0% and 57.7% for amplitude Doppler ultrasound; 71.5%, 58.9%, 76.6%, 52.4% and 67.1% for magnetic resonance imaging; 70.4%, 58.7%, 78.4%, 48.2% and 66.7% for magnetic resonance spectroscopy; 67.2%, 65.7%, 79.3%, 50.6% and 66.7% for dynamic contrast-enhanced magnetic resonance imaging, respectively. Sensitivity, specificity, PPV, NPV and accuracy values for detecting extracapsular extension were 33.3%, 92%, 14.3%, 97.2% and 89.7% for transrectal ultrasound and 50.0%, 77.6%, 13.7%, 95.6% and 75.7% for magnetic resonance imaging, respectively. For detecting seminal vesicle invasion, these values were 66.7%, 85.7%, 22.2%, 97.7% and 84.6% for transrectal ultrasound and 40.0%, 83.1%, 15.4%, 94.7% and 80.0% for magnetic resonance imaging. CONCLUSION: Although preliminary, our results suggest that imaging modalities have limited usefulness in localizing and locally staging clinically low-risk prostate cancer.
  • Identification of platelet refractoriness in oncohematologic patients Clinical Sciences

    Ferreira, Aline Aparecida; Zulli, Roberto; Soares, Sheila; Castro, Vagner de; Moraes-Souza, Helio

    Abstract in English:

    OBJECTIVES: To identify the occurrence and the causes of platelet refractoriness in oncohematologic patients. INTRODUCTION: Platelet refractoriness (unsatisfactory post-transfusion platelet increment) is a severe problem that impairs the treatment of oncohematologic patients and is not routinely investigated in most Brazilian services. METHODS: Forty-four episodes of platelet concentrate transfusion were evaluated in 16 patients according to the following parameters: corrected count increment, clinical conditions and detection of anti-platelet antibodies by the platelet immunofluorescence test (PIFT) and panel reactive antibodies against human leukocyte antigen class I (PRA-HLA). RESULTS: Of the 16 patients evaluated (median age: 53 years), nine (56%) were women, seven of them with a history of pregnancy. An unsatisfactory increment was observed in 43% of the transfusion events, being more frequent in transfusions of random platelet concentrates (54%). Platelet refractoriness was confirmed in three patients (19%), who presented immunologic and non-immunologic causes. Alloantibodies were identified in eight patients (50%) by the PIFT and in three (19%) by the PRA-HLA. Among alloimmunized patients, nine (64%) had a history of transfusion, and three as a result of pregnancy (43%). Of the former, two were refractory (29%). No significant differences were observed, probably as a result of the small sample size. CONCLUSION: The high rate of unsatisfactory platelet increment, refractoriness and alloimmunization observed support the need to set up protocols for the investigation of this complication in all chronically transfused patients, a fundamental requirement for the guarantee of adequate management.
  • Results of the surgical treatment of non-advanced megaesophagus using Heller-Pinotti's surgery: Laparotomy vs. Laparoscopy Clinical Sciences

    Lopes, Luiz Roberto; Braga, Nathália da Silva; Oliveira, Gustavo Carvalho de; Coelho Neto, João de Souza; Camargo, Marcelo Amade; Andreollo, Nelson Adami

    Abstract in English:

    INTRODUCTION: Dysphagia is the important symptom in achalasia, and surgery is the most common treatment. The Heller-Pinotti technique is the method preferred by Brazilian surgeons. For many years, this technique was performed by laparotomy, and now the laparoscopic method has been introduced. The objective was to evaluate the immediate and long-term results of patients submitted to surgery by either laparotomy or laparoscopy. MATERIALS AND METHODS: A total of 67 patients submitted to surgery between 1994 and 2001 with at least 5 years of follow-up were evaluated retrospectively and divided into two groups: laparotomy (41 patients) and laparoscopy (26 patients). Chagas was the etiology in 76.12% of cases. Dysphagia was evaluated according to the classification defined by Saeed et al. RESULTS: There were no cases of conversion to open surgery. The mean duration of hospitalization was 3.32 days for laparotomy and 2.54 days for laparoscopy (p<0.05). An improvement in dysphagia occurred with both groups reporting good or excellent results (laparotomy: 73.17% and laparoscopy: 73.08%). Mean duration of follow-up was 8 years. CONCLUSIONS: There was no difference between the two groups with respect to relief from dysphagia, thereby confirming the safety and effectiveness of the Heller-Pinotti technique, which can be performed by laparotomy or laparoscopy, depending on the surgeon's experience.
  • Effect of physiological overload on pregnancy in women with mitral regurgitation Clinical Sciences

    Borges, Vera T. M; Matsubara, Beatriz B; Magalhães, Claudia G; Peraçoli, Jose C; Rudge, Marilza V. C

    Abstract in English:

    OBJECTIVES: to evaluate the structural and functional heart abnormalities in women with mitral regurgitation during pregnancy. INTRODUCTION: Women with mitral regurgitation progress well during pregnancy. However, the effects on the heart of the association between pregnancy and mitral regurgitation are not well established. METHODS: This is a case-control, longitudinal prospective study. Echocardiograms were performed in 18 women with mitral regurgitation at the 12th and 36th week of pregnancy and on the 45th day of the puerperium. Twelve age-matched healthy and pregnant women were included as controls and underwent the same evaluation as the study group. RESULTS: Compared with controls, women with mitral regurgitation presented increased left cardiac chambers in all evaluations. Increasing left atrium during pregnancy occurred only in the mitral regurgitation group. At the end of the puerperium, women with mitral regurgitation showed persistent enlargement of the left atrium compared with the beginning of pregnancy (5.0 ± 1.1 cm vs 4.6 ± 0.9 cm; p<0.05). Reduced left ventricular relative wall thickness (0.13 ± 0.02 vs 0.16 ± 0.02; p<0.05) and an increased peak of afterload (278 ± 55 g/cm² vs 207 ± 28 g/cm²;p<0.05) was still observed on the 45th day after delivery in the mitral regurgitation group compared with controls. CONCLUSIONS: Pregnancy causes unfavorable structural alterations in women with mitral regurgitation that are associated with an aggravation of the hemodynamic overload.
  • Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study Clinical Sciences

    França Bisneto, Edgard Novaes; Freitas, Maura Cristina; Paula, Emygdio José Leomil de; Mattar Jr, Rames; Zumiotti, Arnaldo Valdir

    Abstract in English:

    OBJECTIVE: To compare the functional results of carpectomy and four-corner fusion surgical procedures for treating osteoarthrosis following carpal trauma. METHODS: In this prospective randomized study, 20 patients underwent proximal row carpectomy or four-corner fusion to treat wrist arthritis and their functional results were compared. The midcarpal joint was free of lesions in all patients. RESULTS: Both proximal row carpectomy and four-corner fusion reduced the pain. All patients had a decreased range of motion after surgery. The differences between groups were not statistically significant. CONCLUSIONS: Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non-union advanced collapse (SLAC/SNAC) wrist without degenerative changes in the midcarpal joint.
  • Impact of MELD allocation policy on survival outcomes after liver transplantation: a single-center study in northeast Brazil Clinical Sciences

    Batista, Thales Paulo; Sabat, Bernardo David; Melo, Paulo Sérgio V.; Miranda, Luiz Eduardo C.; Fonseca-Neto, Olival Cirilo L.; Amorim, Américo Gusmão; Lacerda, Cláudio Moura

    Abstract in English:

    OBJECTIVE: To analyze the impact of model for end-stage liver disease (MELD) allocation policy on survival outcomes after liver transplantation (LT). INTRODUCTION: Considering that an ideal system of grafts allocation should also ensure improved survival after transplantation, changes in allocation policies need to be evaluated in different contexts as an evolutionary process. METHODS: A retrospective cohort study was carried out among patients who underwent LT at the University of Pernambuco. Two groups of patients transplanted before and after the MELD allocation policy implementation were identified and compared using early postoperative mortality and post-LT survival as end-points. RESULTS: Overall, early postoperative mortality did not significantly differ between cohorts (16.43% vs. 8.14%; p = 0.112). Although at 6 and 36-months the difference between pre-vs. post-MELD survival was only marginally significant (p = 0.066 and p = 0.063; respectively), better short, medium and long-term post-LT survival were observed in the post-MELD period. Subgroups analysis showed special benefits to patients categorized as nonhepatocellular carcinoma (non-HCC) and moderate risk, as determined by MELD score (15-20). DISCUSSION: This study ensured a more robust estimate of how the MELD policy affected post-LT survival outcomes in Brazil and was the first to show significantly better survival after this new policy was implemented. Additionally, we explored some potential reasons for our divergent survival outcomes. CONCLUSION: Better survival outcomes were observed in this study after implementation of the MELD criterion, particularly amongst patients categorized as non-HCC and moderate risk by MELD scoring. Governmental involvement in organ transplantation was possibly the main reason for improved survival.
  • A real-life study of the effectiveness of different pharmacological approaches to the treatment of smoking cessation: re-discussing the predictors of success Clinical Sciences

    Prado, Gustavo Faibischew; Lombardi, Elisa Maria Siqueira; Bussacos, Marco Antônio; Arrabal-Fernandes, Frederico Leon; Terra-Filho, Mário; Santos, Ubiratan de Paula

    Abstract in English:

    OBJECTIVE: To evaluate the effectiveness of nicotine replacement therapy (NRT), bupropion, nortriptyline and combination therapy and describe factors associated with treatment success. INTRODUCTION: Clinical trials clearly demonstrate the efficacy of pharmacotherapy in smoking cessation. However, it is only after its use in real-life settings that clinical effectiveness and limitations of a treatment are fully known. METHODS: Patients attended a four-session cognitive-behavioral program and received medicines free of charge. Abstinence from smoking was assessed at each visit. RESULTS: A total of 868 smokers (68.8% women) were included. Their mean age was 49.6 years; the amount smoked was 25 cigarettes/day and the Fagerströ m Score was 6.6. Abstinence rates after 6 months and 1 year were 36.5% and 33.6%. In univariate analysis, male gender, age (>50), higher number of cigarettes smoked, cardiovascular comorbidities, longer interval from the last cigarette and combined treatment of nortriptyline plus NRT were predictive of abstinence, while neuropsychiatric comorbidities and the answer ''yes'' to the question ''Do you smoke more often during the first hours after waking'' were correlated with failure. In a multivariate model, predictors of abstinence were neuropsychiatric comorbidities, the answer ''yes'' to the question ''Do you smoke more often during the first hours after waking'' and combined treatment of nortriptyline plus NRT. Male gender and a longer period from the last cigarette were correlated with lower abstinence rate. CONCLUSION: Satisfactory success rates were obtained in a teaching hospital. Factors such as age, daily cigarette consumption, number of pack-years and dependency score were not reliable markers of abstinence. The combination nortriptyline+NRT was independently associated with higher abstinence rates.
  • Fallopian tube origin of supposed ovarian high-grade serous carcinomas Clinical Sciences

    Diniz, Patricia Martini; Carvalho, Jesus Paula; Baracat, Edmund Chada; Carvalho, Filomena M

    Abstract in English:

    INTRODUCTION: Serous carcinomas are the most frequent histologic type of ovarian and peritoneal cancers, and can also be detected in the endometrium and fallopian tubes. Serous carcinomas are usually high-grade neoplasms when diagnosed, yet the identification of an associated precursor lesion remains challenging. Pathological examination of specimens obtained from prophylactic bilateral salpingo-oophorectomies that were performed for patients harboring BRCA1/2 mutations suggests that high-grade serous carcinomas may arise in the fallopian tubes rather than in the ovaries. OBJECTIVE: To investigate the presence and extent of fallopian tube involvement in cases of serous pelvic carcinomas. METHODS: Thirty-four cases of serous pelvic carcinoma with clinical presentations suggesting an ovarian origin were analyzed retrospectively. Histologic samples of fallopian tube tissues were available for these cases and were analyzed. Probable primary site, type of tubal involvement, tissues involved in the neoplasia and vascular involvement were evaluated. RESULTS: Fallopian tube involvement was observed in 24/34 (70.6%) cases. In 4 (11.8%) of these cases, an intraepithelial neoplasia was present, and therefore these cases were hypothesized to be primary from fallopian tubes. For an additional 7/34 (20.6%) cases, a fallopian tube origin was considered a possible primary. CONCLUSIONS: Fallopian tubes can be the primary site for a subset of pelvic high-grade serous carcinomas.
  • IL-2, IL-5, TNF-α and IFN-γ mRNA expression in epidermal keratinocytes of systemic lupus erythematosus skin lesions Clinical Sciences

    Carneiro, José Ronaldo M; Fuzii, Hellen T; Kayser, Cristiane; Alberto, Fernando L; Soares, Fernando A; Sato, Emília I; Andrade, Luís Eduardo C

    Abstract in English:

    OBJECTIVE: To analyze cytokine gene expression in keratinocytes from patients with systemic lupus erythematosus (SLE). INTRODUCTION: Keratinocytes represent 95% of epidermal cells and can secrete several cytokines. METHODS: Keratinocytes were obtained by laser microdissection from 21 patients with SLE (10 discoid and 11 acute lesions) at involved and uninvolved sites. All patients were receiving a low/moderate prednisone dose and 18 were receiving chloroquine diphosphate. IL-2, IL-5, TNF-α and IFN-γ gene expression was evaluated by real-time PCR and expressed as the ratio (R) to a pool of skin samples from 12 healthy volunteers. RESULTS: Heterogeneity in cytokine gene expression was found among patients with SLE. Eighteen of 38 valid SLE samples (47%) presented overexpression (R>1) of at least one cytokine. Lesional skin samples tended to show higher cytokine expression than samples from uninvolved skin (p = 0.06). IL-5 and IFN-γ were the most commonly overexpressed cytokines. Samples with cytokine overexpression corresponded to more extensive and severe lesions. Prednisone dose did not differ between samples without cytokine overexpression (15.71±3.45 mg/day) and those with overexpressed cytokines (12.68±5.41 mg/day) (p = 0.216). Samples from all patients not receiving diphosphate chloroquine had at least one overexpressed cytokine. CONCLUSIONS: The heterogeneous keratinocyte cytokine gene expression reflects the complex immunological and inflammatory background in SLE. Patients with severe/extensive skin lesions showed a higher frequency of cytokine gene overexpression. Increased IFN-γ and IL-5 expression suggests that Th1 and Th2 cells are involved in SLE skin inflammation. The possibility that prednisone and antimalarial drugs may have contributed to low cytokine gene expression in some samples cannot be ruled out.
  • Prevalence and related factors for anorgasmia among reproductive aged women in Hesarak, Iran Clinical Sciences

    Najafabady, Mitra Tadayon; Salmani, Zahra; Abedi, Parvin

    Abstract in English:

    INTRODUCTION: Orgasmic dysfunction in women is characterized by persistent or recurrent delay in or absence of orgasm following a normal sexual excitement phase. Research has shown that almost two thirds of women have concerns about their sexual relationship. Sexual dysfunction has many problems for couples; some researchers found that up to 67% of divorces related to sexual disorders. OBJECTIVE: The aim of this cross-sectional study was to assess the prevalence and related factors of anorgasmia among reproductive age Iranian women. METHODS: This study was conducted in 2006-7 in Hesarak, Karaj, Iran. A total of 1200 women were randomly recruited to the study. Sexual satisfaction questions were prepared according to the Enrich Sexual Satisfaction Questionnaire. Orgasms were assessed according to the relevant questions in the Female Sexual Function Index (FSFI) questionnaire. The data were analyzed using SPSS version 11; Chi-square, Mann-Whitney and independent t-test were used for statistical purposes. RESULTS: This study showed that the prevalence of anorgasmia among Iranian women in Hesarak, Karaj, was 26.3%. There was a significant difference between the anorgasmic and normal orgasm groups regarding the women's age, age at marriage, duration of marriage and education during puberty (p<0.05). Some psychological factors, e.g. anxiety, fatigue, pain, feeling of guilt, anti-masculine feelings and embarrassment in sexual relationships were higher in the anorgasmic group (p<0.001). DISCUSSION: The results of this study showed that the prevalence of anorgasmia in Hesarak is high and most of the anorgasmic women were highly unsatisfied with their sexual relationship compared to the normal orgasm group. CONCLUSION: The prevalence of anorgasmia among Iranian women in Hesarak, Karaj, is high and some socio-demographic and psychological factors have a strong relationship with anorgasmia.
  • Sensitivity and specificity of auditory steady-state response testing Clinical Sciences

    Rabelo, Camila Maia; Schochat, Eliane

    Abstract in English:

    INTRODUCTION: The ASSR test is an electrophysiological test that evaluates, among other aspects, neural synchrony, based on the frequency or amplitude modulation of tones. OBJECTIVE: The aim of this study was to determine the sensitivity and specificity of auditory steady-state response testing in detecting lesions and dysfunctions of the central auditory nervous system. METHODS: Seventy volunteers were divided into three groups: those with normal hearing; those with mesial temporal sclerosis; and those with central auditory processing disorder. All subjects underwent auditory steady-state response testing of both ears at 500 Hz and 2000 Hz (frequency modulation, 46 Hz). The difference between auditory steady-state response-estimated thresholds and behavioral thresholds (audiometric evaluation) was calculated. RESULTS: Estimated thresholds were significantly higher in the mesial temporal sclerosis group than in the normal and central auditory processing disorder groups. In addition, the difference between auditory steady-state response-estimated and behavioral thresholds was greatest in the mesial temporal sclerosis group when compared to the normal group than in the central auditory processing disorder group compared to the normal group. DISCUSSION: Research focusing on central auditory nervous system (CANS) lesions has shown that individuals with CANS lesions present a greater difference between ASSR-estimated thresholds and actual behavioral thresholds; ASSR-estimated thresholds being significantly worse than behavioral thresholds in subjects with CANS insults. This is most likely because the disorder prevents the transmission of the sound stimulus from being in phase with the received stimulus, resulting in asynchronous transmitter release. Another possible cause of the greater difference between the ASSR-estimated thresholds and the behavioral thresholds is impaired temporal resolution. CONCLUSIONS: The overall sensitivity of auditory steady-state response testing was lower than its overall specificity. Although the overall specificity was high, it was lower in the central auditory processing disorder group than in the mesial temporal sclerosis group. Overall sensitivity was also lower in the central auditory processing disorder group than in the mesial temporal sclerosis group.
  • Outcome of children hospitalized with community-acquired pneumonia treated with aqueous penicillin G Clinical Sciences

    Simbalista, Raquel; Araújo, Marcelo; Nascimento-Carvalho, Cristiana M

    Abstract in English:

    OBJECTIVE: To describe the evolution and outcome of children hospitalized with community-acquired pneumonia receiving penicillin. METHODS: A search was carried out for all hospitalized community-acquired pneumonia cases in a 37-month period. Inclusion criteria comprised age >2 months, intravenous penicillin G use at 200,000 IU/kg/day for >48 h and chest x-ray results. Confounders leading to exclusion included underlying debilitating or chronic pulmonary illnesses, nosocomial pneumonia or transference to another hospital. Pneumonia was confirmed if a pulmonary infiltrate or pleural effusion was described by an independent radiologist blind to the clinical information. Data on admission and evolution were entered on a standardized form. RESULTS: Of 154 studied cases, 123 (80%) and 40 (26%) had pulmonary infiltrate or pleural effusion, respectively. Penicilli was substituted by other antibiotics in 28 (18%) patients, in whom the sole significant decrease was in the frequency of tachypnea from the first to the second day of treatment (86% vs. 50%, p = 0.008). Among patients treated exclusively with penicillin G, fever (46% vs. 26%, p = 0.002), tachypnea (74% vs. 59%, p = 0.003), chest indrawing (29% vs. 13%, p<0.001) and nasal flaring (10% vs. 1.6%, p = 0.001) frequencies significantly decreased from admission to the first day of treatment. Patients treated with other antimicrobial agents stayed longer in the hospital than those treated solely with penicillin G (16±6 vs. 8±4 days, p<0.001, mean difference (95% confidence interval) 8 (6-10)). None of the studied patients died. CONCLUSION: Penicillin G successfully treated 82% (126/154) of the study group and improvement was marked on the first day of treatment.
  • Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients Clinical Sciences

    Nascimento, Bartolomeu; Lin, Yulia; Callum, Jeannie; Reis, Marciano; Pinto, Ruxandra; Rizoli, Sandro

    Abstract in English:

    OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.
  • Echocardiographic evaluation during weaning from mechanical ventilation Clinical Sciences

    Schifelbain, Luciele Medianeira; Vieira, Silvia Regina Rios; Brauner, Janete Salles; Pacheco, Deise Mota; Naujorks, Alexandre Antonio

    Abstract in English:

    INTRODUCTION: Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation. OBJECTIVES: To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T-tube; and comparing patient subgroups: success vs. failure in weaning. METHODS: Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T-tube. Pressure support ventilation vs. T-tube and weaning success vs. failure were compared using ANOVA and Student's t-test. The level of significance was p<0.05. RESULTS: Twenty-four adult patients were evaluated. Seven patients failed at the first weaning attempt. No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T-tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had higher levels of oxygenation. CONCLUSION: No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables during pressure support ventilation and T-tube. However cardiac structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully weaned patients
  • Relationship between depression and apolipoproteins A and B: a case-control study Clinical Sciences

    Sadeghi, Masoumeh; Roohafza, Hamidreza; Afshar, Hamid; Rajabi, Fereshteh; Ramzani, Mohamadarash; Shemirani, Hasan; Sarafzadeghan, Nizal

    Abstract in English:

    OBJECTIVE: To investigate the relation between major depressive disorder and metabolic risk factors of coronary heart disease. INTRODUCTION: Little evidence is available indicating a relationship between major depressive disorder and metabolic risk factors of coronary heart disease such as lipoprotein and apolipoprotein. METHODS: This case-control study included 153 patients with major depressive disorder who fulfilled the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), and 147 healthy individuals. All participants completed a demographic questionnaire and Hamilton rating scale for depression. Anthropometric characteristics were recorded. Blood samples were taken and total cholesterol, high-and low-density lipoproteins and apolipoproteins A and B were measured. To analyze the data, t-test, χ2 test, Pearson correlation test and linear regression were applied. RESULTS: Depression was a negative predictor of apolipoprotein A (β = -0.328, p<0.01) and positive predictor of apolipoprotein B (β = 0.290, p<0.05). Apolipoprotein A was inversely predicted by total cholesterol (β = -0.269, p<0.05) and positively predicted by high-density lipoprotein (β = 0.401, p<0.01). Also, low-density lipoprotein was a predictor of apolipoprotein B (β = 0.340, p<0.01). The severity of depression was correlated with the increment in serum apolipoprotein B levels and the decrement in serum apolipoprotein A level. CONCLUSION: In view of the relationship between apolipoproteins A and B and depression, it would seem that screening of these metabolic risk factors besides psychological interventions is necessary in depressed patients
  • Prediction of large esophageal varices in cirrhotic patients using classification and regression tree analysis Clinical Sciences

    Hong, Wan-dong; Dong, Le-mei; Jiang, Zen-cai; Zhu, Qi-huai; Jin, Shu-Qing

    Abstract in English:

    OBJECTIVES: Recent guidelines recommend that all cirrhotic patients should undergo endoscopic screening for esophageal varices. That identifying cirrhotic patients with esophageal varices by noninvasive predictors would allow for the restriction of the performance of endoscopy to patients with a high risk of having varices. This study aimed to develop a decision model based on classification and regression tree analysis for the prediction of large esophageal varices in cirrhotic patients. METHODS: 309 cirrhotic patients (training sample, 187 patients; test sample 122 patients) were included. Within the training sample, the classification and regression tree analysis was used to identify predictors and prediction model of large esophageal varices. The prediction model was then further evaluated in the test sample and different Child-Pugh classes. RESULTS: The prevalence of large esophageal varices in cirrhotic patients was 50.8%. A tree model that was consisted of spleen width, portal vein diameter and prothrombin time was developed by classification and regression tree analysis achieved a diagnostic accuracy of 84% for prediction of large esophageal varices. When reconstructed into two groups, the rate of varices was 83.2% for high-risk group and 15.2% for low-risk group. Accuracy of the tree model was maintained in the test sample and different Child-Pugh classes. CONCLUSIONS: A decision tree model that consists of spleen width, portal vein diameter and prothrombin time may be useful for prediction of large esophageal varices in cirrhotic patients
  • Neurophysiological aspects and their relationship to clinical and functional impairment in patients with chronic obstructive pulmonary disease Clinical Sciences

    Rocco, Carolina Chiusoli de Miranda; Sampaio, Luciana Maria Malosá; Stirbulov, Roberto; Corrêa, João Carlos Ferrari

    Abstract in English:

    OBJECTIVE: The purpose was to assess functional (balance L-L and A-P displacement, sit-to-stand test (SST) and Tinetti scale - balance and gait) and neurophysiological aspects (patellar and Achilles reflex and strength) relating these responses to the BODE Index. INTRODUCTION: The neurophysiological alterations found in patients with chronic obstructive pulmonary disease (COPD) are associated with the severity of the disease. There is also involvement of peripheral muscle which, in combination with neurophysiological impairment, may further compromise the functional activity of these patients. METHODS: A cross-sectional study design was used. Twenty-two patients with moderate to very severe COPD (>60 years) and 16 age-matched healthy volunteers served as the control group (CG). The subjects performed spirometry and several measures of static and dynamic balance, monosynaptic reflexes, peripheral muscle strength, SST and the 6-minute walk test. RESULTS: The individuals with COPD had a reduced reflex response, 36.77±3.23 (p<0.05) and 43.54±6.60 (p<0.05), achieved a lower number repetitions on the SST 19.27±3.88 (p<0.05), exhibited lesser peripheral muscle strength on the femoral quadriceps muscle, 24.98±6.88 (p<0.05) and exhibited deficits in functional balance and gait on the Tinetti scale, 26.86±1.69 (p<0.05), compared with the CG. The BODE Index demonstrated correlations with balance assessment (determined by the Tinetti scale), r = 0.59 (p<0.05) and the sit-to-stand test, r = 0.78 (p<0.05). CONCLUSIONS: The individuals with COPD had functional and neurophysiological alterations in comparison with the control group. The BODE Index was correlated with the Tinetti scale and the SST. Both are functional tests, easy to administer, low cost and feasible, especially the SST. These results suggest a worse prognosis; however, more studies are needed to identify the causes of these changes and the repercussions that could result in their activities of daily living
  • Histomorphometric and sympathetic innervation of the human internal thoracic artery Basic Researches

    Reddy, Sreenivasulu; Kumar, Pramod; Prasad, Keerthana

    Abstract in English:

    INTRODUCTION: Internal thoracic artery (ITA) is an established arterial graft for the coronary artery by-pass surgery. Special micro-anatomical features of the ITA wall may protect it from age related pathological changes. One of the complications seen after coronary artery bypass grafting is vasospasm. Sympathetic nerves may be involved in vasospasm. OBJECTIVE: To ascertain the sympathetic innervation of the internal thoracic artery and to assess the effect of aging on this artery by histomorphometry. METHOD: Fifty-four human internal thoracic artery samples were collected from 27 cadavers (19 male and 8 female) with ages of 19 to 83 years. Samples were divided into three age groups: G1, 19-40 years; G2, 41-60 years; G3, >61 years. Sections (thickness 5 mm) of each sample were taken and stained with hematoxylin-eosin and Verhoeff-Van Gieson stains. Five of fifty-four samples were processed for tyrosine hydroxylase immunostaining. RESULTS: The thickness of the tunica intima was found to be constant in all age groups, whereas the thickness of the tunica media decreased in proportion to age. Verhoeff-Van Gieson staining showed numerous elastic laminae in the tunica media. Significant differences (p<0.0001) in the number of elastic laminae were found between G1 with G2 cadavers, between G2 and G3 cadavers and between G3 and G1 cadavers. Tyrosine hydroxylase immunostaining demonstrated sympathetic fibers, located mainly in the tunica adventitia and the adventitia-media border. The sympathetic nerve fiber area and sympathetic index were found to be 0.0016 mm² and 0.012, respectively. DISCUSSION: Histology of the ITA showed features of the elastic artery. This may be associated with lower incidence of Atherosclerosis or intimal hyperplasia in ITA samples even in elderly cases. Low sympathetic index (0.012) of ITA may be associated with fewer incidences of sympathetic nervous systems problems (vasospasm) of the ITA. CONCLUSION: Sympathetic nerve fibers are present in the adventitia of the internal thoracic artery. This is an elastic artery, although anatomically it is considered to be medium-sized. The sympathetic index may be used for analysis of sympathetic nerve fiber-related problems of the internal thoracic artery
  • Protective effect of sildenafil citrate on contralateral testis injury after unilateral testicular torsion/detorsion Basic Researches

    Yíldíz, Hamit; Durmus, Ali Said; Şimşek, Halil; Yaman, Mine

    Abstract in English:

    OBJECTIVES: This study was designed to investigate prevention of contralateral testicular injury with sildenafil citrate after unilateral testicular torsion/detorsion. METHODS: Thirty-seven adult male rats were divided into four groups: sham operated (group 1, n = 7), torsion/detorsion + saline (group 2, n = 10), torsion/detorsion + 0.7 mg of sildenafil citrate (group 3, n = 10) and torsion/detorsion + 1.4 mg of sildenafil citrate (group 4, n = 10). Unilateral testicular torsion was created by rotating the right testis 720º in a clockwise direction for 2 h in other groups, except for group 1, which was served as sham group. After torsion (2 h) and detorsion (2 h) periods, rats were killed. RESULTS: The level of reduced glutathion (GSH) (p<0.05) and the activities of catalase (p<0.01) and glutathione peroxidase (p<0.05) in the contralateral testis from group 2 were significantly lower and nitric oxide (NO) (p<0.05) level in the contralateral testis were significantly higher than those of group 1. Administration of low-dose sildenafil citrate (group 3) prevented the increases in malondialdehyde and NO levels and decreases in glutathione peroxidase activities and GSH values induced by testicular torsion. However, administration of high-dose sildenafil citrate (group 4) had no effect on these testicular parameters (p>0.05). Histopathological changes were detected in groups 2, 3 and 4. CONCLUSION: These results suggest that biochemically and histologically torsion/detorsion injury occurs in the contralateral testis following 2-h torsion and 2-h detorsion and that administration of low-dose sildenafil citrate before detorsion prevents ischemia/reperfusion cellular damage in testicular tissue.
  • Gynura procumbens Merr. decreases blood pressure in rats by vasodilatation via inhibition of calcium channels Basic Researches

    Hoe, See-Ziau; Lee, Chen-Neng; Mok, Shiueh-Lian; Kamaruddin, Mohd Yusoff; Lam, Sau-Kuen

    Abstract in English:

    INTRODUCTION: Gynura procumbens has been shown to decrease blood pressure via inhibition of the angiotensinconverting enzyme. However, other mechanisms that may contribute to the hypotensive effect have not been studied. OBJECTIVES: To investigate the cardiovascular effects of a butanolic fraction of Gynura procumbens in rats. METHODS: Anaesthetized rats were given intravenous bolus injections of butanolic fraction at doses of 2.5-20 mg/kg in vivo. The effect of butanolic fraction on vascular reactivity was recorded in isolated rat aortic rings in vitro. RESULTS: Intravenous administrations of butanolic fraction elicited significant (p<0.001) and dose-dependent decreases in the mean arterial pressure. However, a significant (p<0.05) decrease in the heart rate was observed only at the higher doses (10 and 20 mg/kg). In isolated preparations of rat aortic rings, phenylephrine (1×10-6 M)- or potassium chloride (8×10-2 M)-precontracted endothelium-intact and -denuded tissue; butanolic fraction (1×10-6-1×10-1 g/ml) induced similar concentration-dependent relaxation of the vessels. In the presence of 2.5×10-3 and 5.0×10-3 g/ml butanolic fraction, the contractions induced by phenylephrine (1×10-9-3×10-5 M) and potassium chloride (1×10-2-8×10-2 M) were significantly antagonized. The calcium-induced vasocontractions (1×10-4-1×10-2 M) were antagonized by butanolic fraction concentration-dependently in calcium-free and high potassium (6×10-2 M) medium, as well as in calcium- and potassium-free medium containing 1×10-6 M phenylephrine. However, the contractions induced by noradrenaline (1×10-6 M) and caffeine (4.5×10-2 M) were not affected by butanolic fraction. CONCLUSION: Butanolic fraction contains putative hypotensive compounds that appear to inhibit calcium influx via receptor-operated and/or voltage-dependent calcium channels to cause vasodilation and a consequent fall in blood pressure.
  • Cardioprotection conferred by exercise training is blunted by blockade of the opioid system Basic Researches

    Galvão, Tatiana F. G; Matos, Katt C; Brum, Patrícia C; Negrão, Carlos E; Luz, Protásio Lemos da; Chagas, Antônio Carlos P

    Abstract in English:

    OBJECTIVES: To investigate the effect of opioid receptor blockade on the myocardial protection conferred by chronic exercise and to compare exercise training with different strategies of myocardial protection (opioid infusion and brief periods of ischemia-reperfusion) preceding irreversible left anterior descending coronary ligation. INTRODUCTION: The acute cardioprotective effects of exercise training are at least partly mediated through opioid receptor-dependent mechanisms in ischemia-reperfusion models. METHODS: Male Wistar rats (n = 76) were randomly assigned to 7 groups: (1) control; (2) exercise training; (3) morphine; (4) intermittent ischemia-reperfusion (three alternating periods of left anterior descending coronary occlusion and reperfusion); (5) exercise training+morphine; (6) naloxone (a non-selective opioid receptor blocker) plus morphine; (7) naloxone before each exercise-training session. Myocardial infarction was established in all groups by left anterior descending coronary ligation. Exercise training was performed on a treadmill for 60 minutes, 5 times/week, for 12 weeks, at 60% peak oxygen (peak VO2). Infarct size was histologically evaluated. RESULTS: Exercise training significantly increased exercise capacity and ΔVO2 (VO2 peak - VO2 rest) (p<0.01 vs. sedentary groups). Compared with control, all treatment groups except morphine plus naloxone and exercise training plus naloxone showed a smaller infarcted area (p<0.05). No additional decrease in infarct size occurred in the exercise training plus morphine group. No difference in myocardial capillary density (p = 0.88) was observed in any group. CONCLUSIONS: Exercise training, morphine, exercise training plus morphine and ischemia-reperfusion groups had a smaller infarcted area than the control group. The effect of chronic exercise training in decreasing infarct size seems to occur, at least in part, through the opioid receptor stimulus and not by increasing myocardial perfusion
  • Limits to clinical trials in surgical areas Review

    Demange, Marco Kawamura; Fregni, Felipe

    Abstract in English:

    Randomized clinical trials are considered to be the gold standard of evidence-based medicine nowadays. However, it is important that we point out some limitations of randomized clinical trials relating to surgical interventions. There are limitations that affect the external and internal validity of many surgical study designs. Some limitations can be bypassed, but can make it more difficult for the study to be carried out. Other limitations cannot be bypassed. When it is intended to extrapolate the result of a randomized clinical trial, the premise is that the performed or to be performed intervention will be similar wherever applied and/or for every doctor using it. However, no matter how standardized the technique may be, the results are not similar for all surgeons, which implies a significant limitation to surgical randomized clinical trials concerning external validity. When considering the various limitations presented for performing surgical trials capable of generating scientific evidence within the patterns currently proposed in the evidence level classifications of medical publications, it is necessary to rethink whether those scientific evidence levels are similarly applicable to surgical works and to nonsurgical trials. We currently live in a time of supposed ''inferiority'' of surgical scientific works under the optics of the current quality criteria for a ''suitable'' clinical trial
  • IDH1 mutations in a Brazilian series of Glioblastoma Rapid Communication

    Uno, Miyuki; Oba-Shinjo, Sueli Mieko; Silva, Roseli da; Miura, Flavio; Clara, Carlos Afonso; Almeida, José Reynaldo Walther de; Malheiros, Suzana M. F; Bianco, André Macedo; Brandt, Reynaldo; Ribas, Guilherme Carvalhal; Feres, Halim; Dzik, Carlos; Rosemberg, Sérgio; Stavale, João Norberto; Teixeira, Manoel Jacobsen; Marie, Suely K. N
  • New HNF-1α nonsense mutation causes maturity-onset diabetes of the young type 3 Rapid Communication

    Nogaroto, Viviane; Svidnicki, Paulo Vinicius; Bonatto, Naieli; Milléo, Fábio Quirillo; Almeida, Mara Cristina de; Vicari, Marcelo Ricardo; Artoni, Roberto Ferreira
  • An unusual case of a tortuous abdominal aorta with a common celiacomesenteric trunk: demonstrated by angiography Case Reports

    Kara, Engin; Celebi, Baris; Yildiz, Altan; Ozturk, Nail; Uzmansel, Deniz
  • Celiac crisis with ataxia in a child Case Reports

    Oba, Jane; Escobar, Ana Maria; Schvartsman, Benita G. S; Gherpelli, José Luiz
  • Totally laparoscopic ureteroneocystostomy with intracorporeal tailoring for primary obstructive megaureter Case Reports

    Mitre, Anuar Ibrahim; Lestingi, Jean Felipe Prodocimo; Arap, Marco Antonio; Lucon, Antonio Marmo; Srougi, Miguel
  • Re: comparison between two shock wave regimens using frequencies of 60 and 90 impulses per minute for urinary stones Letter To The Editor

    Ho, Christopher C. K
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