Congenital anomalies in pregnancies with overt and pregestational type 2 diabetes: a gray portrayal from a cohort in Brazil.

OBJECTIVE: To describe the frequency and types of congenital anomalies and associated risk factors in Brazilian women with type 2 diabetes. METHODS: In this retrospective cohort study between 2005 and 2021, we included all pregnant participants with type 2 diabetes from the two major public hospitals in southern Brazil. We collected data from the electronic hospital records. Congenital anomalies were classified by the 10th revised International Classification of Diseases, Q chapter, enhanced by the EUROCAT registry classification, and categorized by type and gravity. We used multiple Poisson regression with robust estimates to estimate risks. RESULTS: Among 648 participants, we excluded 19, and 62 were lost to follow-up; therefore, we included 567 participants. Overt diabetes arose in 191 participants (33.7%, 95% CI 30.0% - 38.0%). Less than 20% of the participants supplemented folate. Congenital anomalies occurred in 78 neonates (13.8%, CI 11.0 - 16.9%), 73 babies (93.6%) presented major anomalies, and 20 (10.5%) cases occurred in participants with overt diabetes. Cardiac anomalies were the most frequent (43 isolated and 12 combined). Pre-eclampsia was associated with an increased risk in the analyses including all women (adjusted RR 1.87 (95% CI 1.23-2.85), p = 0.003), but not in analyses including only women with an HbA1c measured up to the 14th gestational age. HbA1c, either measured at any time in pregnancy (adjusted RR 1.21 (95% CI 1.10-1.33), p < 0.001) or up to the first 14 weeks (adjusted RR 1.22, 95% CI 1.10-1.35, p < 0.001) was the only sustained risk factor. Risk factors such as maternal age, obesity, diabetes diagnosis, or use of antidiabetic medications were not associated with congenital anomalies. CONCLUSION: We found a high frequency of congenital anomalies associated with poor maternal glycemic control and revealed an almost universal lack of preconception care. An urgent call to action is mandatory for the reversal of this gray scenario.

Effects of chlorthalidone plus amiloride compared with amlodipine on short-term blood pressure variability in individuals with hypertension and obstructive sleep apnea: a randomized controlled trial.

OBJECTIVE: To compare the effects of chlortalidone plus amiloride and amlodipine on blood pressure (BP) variability in patients with hypertension and obstructive sleep apnea syndrome (OSA). METHODS: A randomized, controlled, double-blind trial enrolled men and women aged 40 years or older with a diagnosis of OSA (apnea-hypopnea index 10-40 apneas/h of sleep) confirmed by overnight laboratory polysomnography and systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg. Participants were randomized to receive chlortalidone 25 mg plus amiloride 5 mg daily or amlodipine 10 mg daily for 8 weeks. BP variability was calculated from 24-hour ambulatory BP monitoring at baseline and follow-up using the following indices: SD, coefficient of variation, average real variability (ARV), time-rate index, and variability independent of the mean (VIM). RESULTS: The study included 65 patients, with 33 assigned to the chlortalidone plus amiloride group and 32 to the amlodipine group. Participants in both groups had similar baseline characteristics. Short-term BP variability decreased within groups for SD and ARV indexes for 24-hour systolic BP and daytime systolic BP, but statistically significant time*group interactions were found for sleep systolic SD and VIM, with greater reduction in patients treated with amlodipine. CONCLUSION: In brief, our study has shown that the use of chlorthalidone in combination with amiloride and amlodipine produces comparable effects on short-term BP variability in patients with hypertension and OSA. Therefore, our findings suggest that BP variability may not be a significant factor when choosing between these medications for the treatment of hypertension and OSA.

A Brazilian cohort of pregnant women with overt diabetes: analyses of risk factors using a machine learning technique.

Objective: Pregnancy complicated by type 2 diabetes is rising, while data on type 2 diabetes first diagnosed in pregnancy (overt diabetes) are scarce. We aimed to describe the frequency and characteristics of pregnant women with overt diabetes, compare them to those with known pregestational diabetes, and evaluate the potential predictors for the diagnosis of overt diabetes. Subjects and methods: A retrospective cohort study including all pregnant women with type 2 diabetes evaluated in two public hospitals in Porto Alegre, Brazil, from May 20, 2005, to June 30, 2021. Classic and obstetric factors associated with type 2 diabetes risk were compared between the two groups, using machine learning techniques and multivariable analysis with Poisson regression. Results: Overt diabetes occurred in 33% (95% confidence interval: 29%-37%) of 646 women. Characteristics of women with known or unknown type 2 diabetes were similar; excessive weight was the most common risk factor, affecting ~90% of women. Age >30 years and positive family history of diabetes were inversely related to a diagnosis of overt diabetes, while previous delivery of a macrosomic baby behaved as a risk factor in younger multiparous women; previous gestational diabetes and chronic hypertension were not relevant risk factors. Conclusion: Characteristics of women with overt diabetes are similar to those of women with pregestational diabetes. Classic risk factors for diabetes not included in current questionnaires can help identify women at risk of type 2 diabetes before they become pregnant.

A Brazilian cohort of pregnant women with overt diabetes: analyses of risk factors using a machine learning technique

ABSTRACT Objective: Pregnancy complicated by type 2 diabetes is rising, while data on type 2 diabetes first diagnosed in pregnancy (overt diabetes) are scarce. We aimed to describe the frequency and characteristics of pregnant women with overt diabetes, compare them to those with known pregestational diabetes, and evaluate the potential predictors for the diagnosis of overt diabetes. Subjects and methods: A retrospective cohort study including all pregnant women with type 2 diabetes evaluated in two public hospitals in Porto Alegre, Brazil, from May 20, 2005, to June 30, 2021. Classic and obstetric factors associated with type 2 diabetes risk were compared between the two groups, using machine learning techniques and multivariable analysis with Poisson regression. Results: Overt diabetes occurred in 33% (95% confidence interval: 29%-37%) of 646 women. Characteristics of women with known or unknown type 2 diabetes were similar; excessive weight was the most common risk factor, affecting ~90% of women. Age >30 years and positive family history of diabetes were inversely related to a diagnosis of overt diabetes, while previous delivery of a macrosomic baby behaved as a risk factor in younger multiparous women; previous gestational diabetes and chronic hypertension were not relevant risk factors. Conclusion: Characteristics of women with overt diabetes are similar to those of women with pregestational diabetes. Classic risk factors for diabetes not included in current questionnaires can help identify women at risk of type 2 diabetes before they become pregnant.

Exploring the Gantt chart as a tool to highlight double report in case series published during the first wave of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, some studies describing different aspects of the infection included very similar participants, rising suspicion about double reporting. We aimed to evaluate the Gantt chart as a tool to highlight possible double reporting. The chart is routinely used in business applications to depict tasks of a project, by plotting horizontal bars against time, showing their time span and overlaps. METHODS: All case reports and case series of pregnant women with COVID-19, published by July 15, 2020, were included. Initial and final dates of participants' enrollment, country, city, hospital, and number of pregnancies were plotted in the Gantt chart. Bars stand for enrollment dates of each study, according to hospital and city, thus allowing comparisons. RESULTS: We included 116 articles in the present analysis. The Gantt chart highlighted papers in which some participants were likely the same, thus allowing easier identification of double reporting of cases. Combining all information and pregnancy characteristics and outcomes helped to recognize duplications when the authors did not acknowledged the previous publication. CONCLUSIONS: Unintended double reporting may occur, especially in exceptional times. The Gantt chart may help researchers to visually identify potential duplications, thus avoiding biased estimates in systematic reviews or meta-analysis.

A snapshot of the prevalence of endocrine disorders in pregnancies complicated by coronavirus disease 2019: A narrative review with meta-analysis.

BACKGROUND: Some maternal characteristics indicate worse prognosis in pregnant women with coronavirus disease 2019 (COVID-19). OBJECTIVE: To describe the prevalence of endocrine disorders in pregnancies involving COVID-19, and its impact on maternal outcomes. SEARCH STRATEGY: Search terms were "pregnancy" and "COVID-19". SELECTION: PubMed, Embase, medRxiv, and Cochrane worksheet from February to July 2020 were searched. DATA COLLECTION AND ANALYSIS: Articles describing endocrine disorders in pregnancies with and without COVID-19 involvement were considered. We performed meta-analyses of prevalence using random-effect models and estimated relative risk and 95% confidence intervals (CI) of maternal outcomes relative to presence of endocrine disorders. MAIN RESULTS: Articles included (n = 141) were divided into three data sets: individual (119 articles, 356 women), case series (17 articles, 1064 women), and national registries (7 articles, 10 178 women). Prevalence of obesity ranged from 16% to 46% and hyperglycemia in pregnancy (HIP) ranged from 8% to 12%. In data set 1, HIP and obesity were risk factors for severe disease in crude and age-adjusted models, although not for intensive care unit admission. In data from two national registries, risk of dying was 5.62 (95% CI 0.30-105.95) in women with diabetes and 2.26 (95% CI 1.03-4.96) in those with obesity. CONCLUSION: Obesity and HIP were prevalent in pregnant women with severe COVID-19.

Intra- and interobserver reproducibility of pancreatic perfusion by computed tomography.

The aim of this study was to measure intra- and interobserver agreement among radiologists in the assessment of pancreatic perfusion by computed tomography (CT). Thirty-nine perfusion CT scans were analyzed. The following parameters were measured by three readers: blood flow (BF), blood volume (BV), mean transit time (MTT) and time to peak (TTP). Statistical analysis was performed using the Bland-Altman method, linear mixed model analysis, and intraclass correlation coefficient (ICC). There was no significant intraobserver variability for the readers regarding BF, BV or TTP. There were session effects for BF in the pancreatic body and MTT in the pancreatic tail and whole pancreas. There were reader effects for BV in the pancreatic head, pancreatic body and whole pancreas. There were no effects for the interaction between session and reader for any perfusion parameter. ICCs showed substantial agreement for the interobserver measurements and moderate to substantial agreement for the intraobserver measurements, with the exception of MTT. In conclusion, satisfactory reproducibility of measurements was observed for TTP in all pancreatic regions, for BF in the head and BV in the tail, and these parameters seem to ensure a reasonable estimation of pancreatic perfusion.

Temporal changes in characteristics and outcomes among pregnant women with pre-gestational diabetes.

OBJECTIVE: To evaluate pregnancy outcomes among women with pre-gestational diabetes. METHODS: Retrospective analysis of pregnant women with type 1 or type 2 diabetes attending a university hospital in Brazil. Maternal characteristics and pregnancy outcomes were compared among deliveries between May 1, 2005, and December 31, 2010, and between January 1, 2011, and December 31, 2015. Risks were calculated by Poisson regression. RESULTS: In total 220 women were included. Type 1 diabetes was more frequent in 2005-2010 than in 2011-2015, and type 2 diabetes was more frequent in 2011-2015 (P=0.005). History of macrosomia (P=0.011), hypertensive disorders of pregnancy (P=0.015), and pre-gestational excess weight (body mass index >25 kg/m2 ; P=0.003) was more frequent in 2011-2015. For women with type 1 diabetes, pre-gestational weight (P=0.007) and glycated hemoglobin (P=0.026) were higher in 2011-2015. For women with type 2 diabetes, previous hypertensive disorders of pregnancy (P=0.032) were more prevalent and family history of diabetes (P<0.001) less prevalent in 2011-2015. Adverse pregnancy outcomes were similar for type 1 and type 2, and across both periods. CONCLUSION: Type 2 diabetes became more common over the two time periods and women with type 1 diabetes had higher pre-gestational weight. Perinatal outcomes were similar.

Influence of maternal weight gain on birth weight: a gestational diabetes cohort.

Objective Our objective was to evaluate gestational weight gain (GWG) patterns and their relation to birth weight. Subjects and methods We prospectively enrolled 474 women with gestational diabetes mellitus (GDM) at a university hospital (Porto Alegre, Brazil, November 2009-May 2015). GWG was categorized according to the 2009 Institute of Medicine guidelines; birth weight was classified as large (LGA) or small (SGA) for gestational age. Adjusted relative risks (aRRs) and 95% confidence intervals (95% CIs) were determined. Results Adequate GWG occurred in 121 women [25.5%, 95% CI: 22, 30%]; excessive, in 180 [38.0%, 95% CI: 34, 43%]; and insufficient, in 173 [36.5%, 95% CI: 32, 41%]. In women with normal body mass index (BMI), the prevalence of SGA was higher in those with insufficient compared to adequate GWG (30% vs. 0%, p < 0.001). In women with BMI ≥ 25 kg/m2, excessive GWG increased the prevalence of LGA [aRR 2.58, 95% CI: 1.06, 6.29] and protected from SGA [aRR 0.25, 95% CI: 0.10, 0.64]. Insufficient vs. adequate GWG did not influence the prevalence of SGA [aRR 0.61, 95% CI: 0.31, 1.22]; insufficient vs. excessive GWG protected from LGA [aRR 0.46, 95% CI: 0.23, 0.91]. Conclusions One quarter of this cohort achieved adequate GWG, indicating that specific ranges have to be tailored for GDM. To prevent inadequate birth weight, excessive GWG in women with higher BMI and less than recommended GWG in normal BMI women should be avoided; less than recommended GWG may be suitable for overweight and obese women.

Influence of maternal weight gain on birth weight: a gestational diabetes cohort

ABSTRACT Objective Our objective was to evaluate gestational weight gain (GWG) patterns and their relation to birth weight. Subjects and methods We prospectively enrolled 474 women with gestational diabetes mellitus (GDM) at a university hospital (Porto Alegre, Brazil, November 2009-May 2015). GWG was categorized according to the 2009 Institute of Medicine guidelines; birth weight was classified as large (LGA) or small (SGA) for gestational age. Adjusted relative risks (aRRs) and 95% confidence intervals (95% CIs) were determined. Results Adequate GWG occurred in 121 women [25.5%, 95% CI: 22, 30%]; excessive, in 180 [38.0%, 95% CI: 34, 43%]; and insufficient, in 173 [36.5%, 95% CI: 32, 41%]. In women with normal body mass index (BMI), the prevalence of SGA was higher in those with insufficient compared to adequate GWG (30% vs. 0%, p < 0.001). In women with BMI ≥ 25 kg/m2, excessive GWG increased the prevalence of LGA [aRR 2.58, 95% CI: 1.06, 6.29] and protected from SGA [aRR 0.25, 95% CI: 0.10, 0.64]. Insufficient vs. adequate GWG did not influence the prevalence of SGA [aRR 0.61, 95% CI: 0.31, 1.22]; insufficient vs. excessive GWG protected from LGA [aRR 0.46, 95% CI: 0.23, 0.91]. Conclusions One quarter of this cohort achieved adequate GWG, indicating that specific ranges have to be tailored for GDM. To prevent inadequate birth weight, excessive GWG in women with higher BMI and less than recommended GWG in normal BMI women should be avoided; less than recommended GWG may be suitable for overweight and obese women.

Height Prediction From Ulna Length of Critically Ill Patients.

BACKGROUND: Ulna length (UL) has been used in mathematical formulas to predict the body height of healthy and sick individuals. However, the evaluation of its use with patients admitted to intensive care units (ICU) is scarce. The objective of this study was to develop a mathematical equation to estimate critically ill patients' height using the UL measure and to evaluate its agreement with measured standing height. METHODS: This cross-sectional study was performed at the ICU of a tertiary hospital in Brazil. A total of 100 patients aged ≥18 years who had their body height measured before ICU admission were enrolled. The equation was developed through multiple linear regression, and its agreement was assessed through paired Student's t test and Bland-Altman plot. RESULTS: The following formula was obtained: height in cm = 153.492 - (7.97 × sex [sex: male = 1, female = 2]) + (0.974 × UL [in cm]). The difference between means of measured height (MH) and height estimated from UL was not significant (166.26 ± 8.75 cm and 166.30 ± 5.29 cm, respectively, P = .96), and a significant correlation (r = 0.624, P < .001) was detected. In the Bland-Altman analysis, UL was in agreement with MH; however, there was a significant bias (P < .001) suggesting that it may be disproportional and dependent on the average's height value. CONCLUSION: The mathematical equation for height estimation using UL developed in this study matched the MH of critically ill patients. However, we suggest more studies for its validation.

Noninvasive Methods of Predicting Large Esophageal Varices in Children With Intrahepatic Portal Hypertension.

OBJECTIVE: Esophageal variceal bleeding is a severe complication of portal hypertension. The standard diagnostic screening test and therapeutic procedure for esophageal varices (EV) is endoscopy, which is invasive in pediatric patients. This study aimed to evaluate the role of noninvasive parameters as predictors of large varices in children with intrahepatic portal hypertension. METHODS: Participants included in this cross-sectional study underwent a screening endoscopy. Variceal size, red marks, and portal gastropathy were assessed and rated. Patients were classified into two groups: Group 1 (G1) with small or no varices and Group 2 (G2) with large varices. The population consisted of 98 children with no history of gastrointestinal (GI) bleeding, with a mean age of 8.9 ±â€Š4.7 years. The main outcome evaluated was the presence of large varices. RESULTS: The first endoscopy session revealed the presence of large varices in 32 children. The best noninvasive predictors for large varices were platelets (Area under the ROC Curve [AUROC] 0.67; 95% CI 0.57-0.78), the Clinical Prediction Rule (CPR; AUROC 0.65; 95% CI 0.54-0.76), and risk score (AUROC 0.66; 95% CI 0.56-0.76). The logistic regression model showed that children with a CPR value under 114 were 8.59 times more likely to have large varices. Risk scores higher than -1.2 also increased the likelihood of large varices (OR 6.09; P = 0.014), as did a platelet count/spleen size z score lower than 25 (OR 3.99; P = 0.043). The combination of these three tests showed a high negative predictive value. CONCLUSIONS: The CPR, the risk score, and the platelet count/spleen size z score could be helpful in identifying cirrhotic children who may be eligible for endoscopy.

A method for the assessment of facial hedonic reactions in newborns / Método para a avaliação de reações faciais hedônicas em recém-nascidos

Abstract Objective: This study describes a quantitative and qualitative methodology to assess hedonic responses to sweet stimulus in healthy newborns. Methods: A descriptive, cross-sectional, observational study, with healthy newborns (up to 24 h of life), between 37 and 42 gestational weeks, vaginally born and breastfed previously to all tests. The evaluation of the newborns reactions was performed by hedonic facial expression analysis, characterized by facial expressions with rhythmic serial tongue protrusion after neutral or sweet solution intake. Initially, 1 mL of water solution was provided to the newborn, followed by a 1-minute recording. Afterwards, the same amount of 25% sucrose solution was provided, performing a second recording. The concordance between researchers was analyzed by the Bland-Altman statistical method. Results: A total of 100 newborns (n = 49 males, n = 51 females; mean lifetime = 15 h 12 min ± 6 h 29 min) were recorded for neutral and sucrose solution intake, totaling 197 videos (n = 3 missing in the water treatment). These videos were double-blind analyzed and the test revealed a 90% concordance between the two trained researchers, in relation to both solutions. The intraclass correlation coefficient was 0.99 for both solutions, with a significant increase in frequency of hedonic expressions evoked by sucrose solution intake. Conclusions: These results confirm that the proposed method has an efficient power to detect significant differences between neutral and sucrose stimuli. In conclusion, this evaluation method of hedonic facial reactions in newborns reflects the response to a specific taste.

Resumo Objetivo: Descrever quantitativamente e qualitativamente uma metodologia para avaliar as respostas faciais hedônicas, em recém-nascidos saudáveis, ao estímulo doce. Métodos: Trata-se de um estudo descritivo, transversal e observacional, com recém-nascidos saudáveis (com até 24 horas de vida), entre 37-42 semanas gestacionais, nascidos por parto vaginal e alimentados previamente aos testes. A avaliação das reações hedônicas dos recémnascidos foi considerada pelas expressões faciais com séries rítmicas de protrusões de língua após a ingestão de solução neutra ou doce. Inicialmente, 1 mL de solução neutra (água) foi fornecida para o recém-nascido, seguido de uma filmagem de 1 minuto. Sequencialmente, a mesma quantidade de solução de sacarose 25% foi fornecida, realizando-se uma segunda gravação. A concordância entre os pesquisadores foi analisada pelo método estatístico de Bland-Altman. Resultados: Um total de 100 recém-nascidos (n = 49 do sexo masculino, n = 51 do sexo feminino, tempo de vida média = 15 h 12 min ± 6 h 29 min) foram registrados para a ingestão de solução neutra e de sacarose, totalizando 197 vídeos (n = 3 perdas para o tratamento água). Estes vídeos foram analisados em duplo-cego e o teste revelou uma concordância de 90%, para ambas as soluções, entre os pesquisadores treinados. O coeficiente de correlação intraclasse foi de 0,99 para as duas substâncias, com um aumento significativo nas frequências das expressões faciais hedônicas evocadas pela ingestão de sacarose. Conclusões: Estes resultados confirmam que o método proposto possui poder estatístico eficiente para detectar diferenças entre estímulos neutros e sacarose. Em conclusão, este método de avaliação de reações faciais hedônicas em recém-nascidos reflete a resposta para um gosto específico.

A method for the assessment of facial hedonic reactions in newborns.

OBJECTIVE: This study describes a quantitative and qualitative methodology to assess hedonic responses to sweet stimulus in healthy newborns. METHODS: A descriptive, cross-sectional, observational study, with healthy newborns (up to 24h of life), between 37 and 42 gestational weeks, vaginally born and breastfed previously to all tests. The evaluation of the newborns reactions was performed by hedonic facial expression analysis, characterized by facial expressions with rhythmic serial tongue protrusion after neutral or sweet solution intake. Initially, 1mL of water solution was provided to the newborn, followed by a 1-minute recording. Afterwards, the same amount of 25% sucrose solution was provided, performing a second recording. The concordance between researchers was analyzed by the Bland-Altman statistical method. RESULTS: A total of 100 newborns (n=49 males, n=51 females; mean lifetime=15h 12min±6h 29min) were recorded for neutral and sucrose solution intake, totaling 197 videos (n=3 missing in the water treatment). These videos were double-blind analyzed and the test revealed a 90% concordance between the two trained researchers, in relation to both solutions. The intraclass correlation coefficient was 0.99 for both solutions, with a significant increase in frequency of hedonic expressions evoked by sucrose solution intake. CONCLUSIONS: These results confirm that the proposed method has an efficient power to detect significant differences between neutral and sucrose stimuli. In conclusion, this evaluation method of hedonic facial reactions in newborns reflects the response to a specific taste.

Efficacy of a referral center for patient-centered care in multiple myeloma: a cohort study.

BACKGROUND: Within the Brazilian Unified Health System (SUS), Referral Centers (RCs) are care facilities that provide specialized services. The objective of this study was to evaluate the efficacy of care provided to patients with multiple myeloma (MM) at a specialized RC (Hospital de Clínicas de Porto Alegre Referral Center for Multiple Myeloma, CRMM-HCPA) and to compare quality of life between patients with MM treated at CRMM-HCPA and those treated at non-RC facilities. METHODS: A 6-month cohort study was conducted in patients with MM receiving thalidomide from the Rio Grande do Sul State Health Department and treated at CRMM-HCPA and patients receiving treatment at other, non-RC care facilities. Thirty-two patients were included in the study, 19 from CRMM-HCPA and 13 from other institutions. To analyze the efficacy of care provided at CRMM-HCPA, the main outcome measure was the time from diagnosis to referral for autologous hematopoietic stem cell transplantation (HSCT). This outcome measure was assessed using questionnaires specifically designed for this study. Quality of life was also assessed, using the SF-36 questionnaire. RESULTS: Time from MM diagnosis to referral for autologous HSCT in each group was measured only in patients aged ≤ 65 years (n = 25); of these, 15 were recruited from CRMM-HCPA and 10 from other institutions. In this analysis, there was a significant difference (p = 0.036) in time elapsed between diagnosis and referral for autologous HSCT, which was significantly shorter for patients treated at CRMM-HCPA (median, 9 months; IQR, 8.5-14.5) than for those treated elsewhere (median, 24 months; IQR, 16-24). On quality of life analysis, there was a significant difference in the Social Functioning domain of the SF-36 questionnaire, which relates to performance of social activities (p = 0.02). CONCLUSIONS: The Referral Center model provided seems to be a more efficient treatment strategy as compared with other health care facilities, as it enabled a reduction in time to transplantation. Patients treated at CRMM-HCPA demonstrated greater ease in performing social activities, with less interference from physical or emotional problems.

Return to work after renal transplantation: a study of the Brazilian Public Social Security System.

BACKGROUND: Return to work is an objective parameter used worldwide to evaluate the success of organ transplantation and is especially feasible after renal transplantation. This study sought to describe the frequency of return to work after renal transplantation and related characteristics. METHODS: Retrospective cohort of 511 isolated kidney transplant recipients was recruited from a Brazilian referral center from January 2005 to December 2009; all were matched to the public social security database to determine inclusion and benefit awards, as well as the rate of resumption of contributions to the public social security system, a surrogate marker of work rehabilitation. Characteristics associated with work return were analyzed. RESULTS: No social security records were found for 28 subjects. The remaining 483 subjects had a mean age of 45±13 years; 62% were male; 401 (83%) received some public social security benefit; 298 were paying dues and could, therefore, receive temporary or permanent disability benefits. Of these, 78 subjects made social security payments after transplantation, resulting in a work return rate of 26% (95% confidence interval, 21-32). Younger age, living donor graft, and chronic glomerulonephritis were significantly associated with return to work. CONCLUSION: In Brazil, most renal transplant recipients are on social security benefits, but only a small proportion return to work after surgery. Clinical characteristics may help define work resumption trends.

Prognostic implications of the difference between left ventricular ejection fractions after stress and at rest in addition to the quantification of myocardial perfusion abnormalities obtained with gated SPECT.

BACKGROUND: The prognostic significance of the difference between poststress and at rest left ventricular ejection fraction (ΔLVEF) in patients sent for diagnostic myocardial perfusion study (MPS) is not well characterized. The purpose of this study was to prospectively evaluate the ability of ΔLVEF in further risk stratifying these patients in addition to the severity/extent of myocardial perfusion abnormalities expressed as the total perfusion deficit at stress (sTPD), according to the type of stress used. METHODS AND RESULTS: Two-day 99mTc-MIBI MPS after stress and rest were obtained for 507 patients subdivided according to the type of stress used, sTPD values, and ΔLVEF. Subsequent cardiac events were determined through a standardized questionnaire applied 1, 2, and 6 years after MPS. Independent of the type of stress used, the 6-year event rate with progressive perfusion and functional abnormalities combined was significant for total events, all-cause death, cardiac death, and revascularization but not for myocardial infarct. When ΔLVEF decreased by more than -10%, only those individuals with sTPD of 5% or less had increased 6-year total event rates [5.9% vs 15% for those submitted to treadmill test (P < 0.001) and 8.3% vs 19% when submitted to pharmacological stress (P = 0.001)]. An sTPD greater than 5% was the only variable predictive of total events when multivariate analysis was applied (P < 0.001 for treadmill exercise and P = 0.033 for dipyridamole). CONCLUSIONS: Estimation of ΔLVEF in addition to sTPD seems to improve risk stratification for future events when ΔLVEF decreases by more than -10% for those individuals with normal or near-normal myocardial perfusion (sTPD ≤ 5%). An sTPD greater than 5% was a better prognostic indicator of future events when compared with ΔLVEF for individuals with greater perfusion abnormality at stress.

Predictors of relapse in the second follow-up year post cognitive-behavior therapy for panic disorder / Preditores de recaída no segundo ano após terapia cognitivo-comportamental para pacientes com transtorno de pânico

OBJECTIVE: To investigate predictors of relapse two years after a brief cognitive-behavior group therapy in patients with panic disorder who had failed to respond to pharmacologic treatment. METHOD: A total of 56 patients with panic disorder were followed who had met remission criteria at 1 year evaluation after 12 sessions of cognitive-behavior group therapy. Demographic and clinical features and life stressors were investigated as predictors of relapse. RESULTS: At the 2 year assessment, 39 (70 percent) patients maintained remission status and use of medication was reduced significantly, such that 36 (64 percent) patients were not undergoing any psychiatric treatment. Among all independent variables investigated, only "conflict" as a stressful life event, RR = 3.20 (CI95 percent 1.60; 7.20 - p = 0.001), and the severity or residual anxiety symptoms, RR = 3.60 for each scale point (CI95 percent 1.02; 1.08 - p < 0.001), emerged as nonredundant predictors. CONCLUSION: In spite of the high treatment gains across two years of follow-up, clinicians should pay attention to stress management and to the role of residual symptoms during this period. Results were discussed in the context of treatment cost-efficacy and potential strategies to prolong treatment gains from cognitive-behavior group therapy.

OBJETIVO: Investigar os preditores de recaída após dois anos de terapia cognitivo-comportamental em grupo breve para pacientes com transtorno do pânico que não responderam ao tratamento farmacológico. MÉTODO: Um total de 56 pacientes com transtorno do pânico que preencheram os critérios de remissão em um ano de avaliação após as 12 sessões da terapia cognitivo-comportamental em grupo foram acompanhados. As características demográficas, clínicas e os estressores de vida foram investigados como preditores de recaída. RESULTADOS: No segundo ano de avaliação, 39 (70 por cento) pacientes mantiveram-se em remissão e o uso de medicação reduziu significativamente, de tal forma que 36 (64 por cento) pacientes não estavam em tratamento psiquiátrico. Entre todas as variáveis independentes investigadas, somente o "conflito" como evento estressor de vida, RR = 3,20 (CI95 por cento 1,60; 7,20 - p = 0,001) e a gravidade ou os sintomas residuais de ansiedade, RR = 3,60 para cada ponto a mais da escala (CI95 por cento 1,02; 1,08 - p < 0,001), foram preditores de recaída. CONCLUSÃO: A despeito dos ganhos do tratamento através dos dois anos, os terapeutas devem manter-se atentos em relação ao manejo do estresse e no papel dos sintomas residuais de ansiedade durante este período. Os resultados são discutidos no contexto de custo-eficácia do tratamento e nas potenciais estratégias para prolongar os ganhos da terapia cognitivo-comportamental em grupo.

Predictors of relapse in the second follow-up year post cognitive-behavior therapy for panic disorder.

OBJECTIVE: To investigate predictors of relapse two years after a brief cognitive-behavior group therapy in patients with panic disorder who had failed to respond to pharmacologic treatment. METHOD: A total of 56 patients with panic disorder were followed who had met remission criteria at 1 year evaluation after 12 sessions of cognitive-behavior group therapy. Demographic and clinical features and life stressors were investigated as predictors of relapse. RESULTS: At the 2 year assessment, 39 (70%) patients maintained remission status and use of medication was reduced significantly, such that 36 (64%) patients were not undergoing any psychiatric treatment. Among all independent variables investigated, only "conflict" as a stressful life event, RR = 3.20 (CI95% 1.60; 7.20 - p = 0.001), and the severity or residual anxiety symptoms, RR = 3.60 for each scale point (CI95% 1.02; 1.08 - p < 0.001), emerged as nonredundant predictors. CONCLUSION: In spite of the high treatment gains across two years of follow-up, clinicians should pay attention to stress management and to the role of residual symptoms during this period. Results were discussed in the context of treatment cost-efficacy and potential strategies to prolong treatment gains from cognitive-behavior group therapy.