The impact of atrial fibrillation and long-term oral anticoagulant use on all-cause and cardiovascular mortality: A 12-year evaluation of the prospective Brazilian Study of Stroke Mortality and Morbidity.

BACKGROUND: Atrial fibrillation is a predictor of poor prognosis after stroke. AIMS: To evaluate atrial fibrillation and all-cause and cardiovascular mortality in a stroke cohort with low socioeconomic status, taking into consideration oral anticoagulant use during 12-year follow-up. METHODS: All-cause mortality was analyzed by Kaplan-Meier survival curve and Cox regression models to estimate hazard ratios and 95% confidence intervals (95% CI). For specific mortality causes, cumulative incidence functions were computed. A logit link function was used to calculate odds ratios (OR) with 95% CIs. Full models were adjusted by age, sex, oral anticoagulant use (as a time-dependent variable) and cardiovascular risk factors. RESULTS: Of 1121 ischemic stroke participants, 17.8% had atrial fibrillation. Overall, 654 deaths (58.3%) were observed. Survival rate was lower (median days, interquartile range-IQR) among those with atrial fibrillation (531, IQR: 46-2039) vs. non-atrial fibrillation (1808, IQR: 334-3301), p-log rank < 0.0001). Over 12-year follow-up, previous atrial fibrillation was associated with increased mortality: all-cause (multivariable hazard ratios, 1.82; 95% CI: 1.43-2.31) and cardiovascular mortality (multivariable OR, 2.07; 95% CI: 1.36-3.14), but not stroke mortality. In the same multivariable models, oral anticoagulant use was inversely associated with all-cause mortality (oral anticoagulant time-dependent effect: multivariable hazard ratios, 0.47; 95% CI: 0.30-0.50, p = 0.002) and stroke mortality (oral anticoagulant time-dependent effect ≥ 6 months: multivariable OR, 0.09; 95% CI: 0.01-0.65, p-value = 0.02), but not cardiovascular mortality. CONCLUSIONS: Among individuals with low socioeconomic status, atrial fibrillation was an independent predictor of poor survival, increasing all-cause and cardiovascular mortality risk. Long-term oral anticoagulant use was associated with a markedly reduced risk of all-cause and stroke mortality.

IgG4-related Disease: a diagnostic challenge.

Immunoglobulin IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition with a characteristic histopathological appearance that can affect almost any organ. The clinical features result from a focal or diffuse appearance of a tumor-like swelling of the affected organs, identified by physical and/or imaging examination. Herein, we report the case of a 38-year-old male complaining of a worsening chronic right lumbar pain associated with legs and scrotum edema. He also had itchy and erythematous cutaneous lesions on the abdominal wall over the last 8 months, and complained of a diffuse and mild to moderate abdominal discomfort. On examination, the liver was firmly enlarged and tender. His legs had 2+ symmetrical pitting edema extending from his feet to just above the knees. An abdominal computed tomography scan showed a large mass (10 x 8 x 4cm) involving the abdominal infrarenal aorta and the iliac arteries, and compressing the inferior vena cava, with dilated iliac veins, raising the possibility of lymphoproliferative disease. During the initial investigation, the laboratory workup revealed anemia, without other marked changes. A laparoscopic-guided biopsy of the peri-aortic mass was undertaken. The histological report associated with IgG4 immunoglobulin measurement rendered the diagnosis of IgG4-RD. The patient had a favorable outcome after the use of glucocorticoids with the abdominal mass remission.

"Shadow" OSCE examiner. A cross-sectional study comparing the "shadow" examiner with the original OSCE examiner format.

OBJECTIVES: Feedback is a powerful learning tool, but a lack of appropriate feedback is a very common complaint from learners to teachers. To improve opportunities for feedback on objective structured clinical examinations (OSCEs), a modified examiner role, termed the "shadow" examiner, was tested. This study aims to present and analyze comparisons between the "shadow" examiner and the original OSCE examiner format. METHODS: In 2011, experiments were carried out with modifications to the examiner's role to define the "shadow" examiner format. From February 2012 to May 2014, research was conducted with 415 6th-year medical students. Of these students, 316 were randomly assigned to assessments by both "shadow" and "fixed" examiners. Pearson correlation analysis with linear regression, Student's t-tests and Bland-Altman plots were the statistical methods used to compare the assessment modes. To strengthen the analysis, checklist items were classified by domain. RESULTS: High correlations between the "shadow" and "fixed" examiners' global scores were observed. The results of the analysis of specific domains demonstrated higher correlations for cognitive scores and lower correlations for affective scores. No statistically significant differences between the mean examiner global scores were found. The Bland-Altman analysis showed that the "shadow" examiners' affective scores were significantly higher than those of the "fixed" examiners, but the magnitude of this difference was small. CONCLUSION: The modified examiner role did not lead to any important bias in the students' scores compared with the original OSCE examiner format. This new strategy may provide important insights for formative assessments of clinical performance.

Sobrediagnóstico: prejudicando pacientes em nome da saúde / Sobrediagnóstico: daño a las personas en nombre da la salud / Overdiagnosis: harming people in the name of health

À medida que os avanços médico-tecnológicos continuam a se tornar mais facilmente disponíveis, o diagnóstico de pseudo-doenças atingiu o cerne dos sistemas de saúde e tornou-se uma das atividades mais prejudiciais da medicina moderna, tanto individual quanto coletivamente, pois ameaça a sustentabilidade dos sistemas de saúde. Aqui descrevemos um caso hipotético, mas baseado em casos reais, de uma jovem de 36 anos diagnosticada com um carcinoma papilífero de tireoide após ter sido submetida a um check-up excessivo e desnecessário solicitado por um ginecologista em uma consulta de rotina. (AU)

As medical technological advances continue to become more readily available, diagnosis of pseudo-disease has hit the heart of medicine and has become one of the most harmful activities in modern medicine, both individually and collectively speaking as it threatens the sustainability of health systems. Here we describe a hypothetical case (but based on many similar real ones) of a young adult woman in her middle 30's that has been diagnosed with a papillary thyroid cancer after she had been submitted to an excessive and unnecessary check-up elicited by a gynaecologist in a routine medical consultation. (AU)

Susceptibility to antibiotics in urinary tract infections in a secondary care setting from 2005-2006 and 2010-2011, in São Paulo, Brazil: data from 11,943 urine cultures.

INTRODUCTION: Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases. OBJECTIVES: The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance. PATIENTS AND METHODS: We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2. RESULTS: Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011. CONCLUSION: E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

"Shadow" OSCE examiner. A cross-sectional study comparing the "shadow" examiner with the original OSCE examiner format

OBJECTIVES: Feedback is a powerful learning tool, but a lack of appropriate feedback is a very common complaint from learners to teachers. To improve opportunities for feedback on objective structured clinical examinations (OSCEs), a modified examiner role, termed the "shadow" examiner, was tested. This study aims to present and analyze comparisons between the "shadow" examiner and the original OSCE examiner format. METHODS: In 2011, experiments were carried out with modifications to the examiner's role to define the "shadow" examiner format. From February 2012 to May 2014, research was conducted with 415 6th-year medical students. Of these students, 316 were randomly assigned to assessments by both "shadow" and "fixed" examiners. Pearson correlation analysis with linear regression, Student's t-tests and Bland-Altman plots were the statistical methods used to compare the assessment modes. To strengthen the analysis, checklist items were classified by domain. RESULTS: High correlations between the "shadow" and "fixed" examiners' global scores were observed. The results of the analysis of specific domains demonstrated higher correlations for cognitive scores and lower correlations for affective scores. No statistically significant differences between the mean examiner global scores were found. The Bland-Altman analysis showed that the "shadow" examiners' affective scores were significantly higher than those of the "fixed" examiners, but the magnitude of this difference was small. CONCLUSION: The modified examiner role did not lead to any important bias in the students' scores compared with the original OSCE examiner format. This new strategy may provide important insights for formative assessments of clinical performance.

Calcium score to evaluate chest pain in the emergency room.

Some authors have suggested that a zero calcium score (CAC) can be used to rule out the diagnosis of acute coronary syndrome. Objective this study is to evaluate the diagnostic accuracy of a zero CAC when compared to the coronary computed tomography angiography (CCTA) at the emergency department. 135 symptomatic patients with no previous coronary heart disease (CHD) who presented to the emergency department were submitted to CAC and CCTA to rule out CHD. All patients had normal electrocardiogram and cardiac biomarkers and were TIMI risk score 0 to 2. The CCTA was considered positive if any obstructive lesion (> 50%) was identified. The mean age was 51.7 ± 13.6 years with 50.6% of men. Seventy-three (54.1%) patients had a calcium score of zero. Of them, 3 (4.1%) had an obstruction > 50 % and underwent invasive coronary angiography. Calcium score showed a sensitivity of 92.9%, specificity of 75.3%, positive and negative predictive values of, respectively, 62.9% and 95.9%. Positive and negative likelihood ratios were respectively of 3.7 and 0.09 to detect lesions greater than 50% in the CCTA. A negative likelihood ratio of 0.09 is very good to rule out most cases of significant coronary obstruction in epidemiologic studies. However, it is important to understand that in a clinical scenario, all evidence including history, clinical examination, data from eletrocardiogram and myocardial biomarkers have to be interpreted together. In our study, three cases with a zero CAC score had coronary obstruction higher than 50% at the CCTA.

C-reactive protein as an inflammatory marker of acute infections outside intensive care settings: case report and evidence-based literature review.

We present the clinical case of a 76-year-old woman with delirium caused by multiple factors, including pneumonia. Although this type of case is quite common in clinical practice, it provides us with an opportunity to discuss laboratory testing in this context, with a special focus on the role of C-reactive protein (CRP). We present data regarding the requests for determination of serum CRP levels at the University of São Paulo University Hospital over the past few years. We also present a review of the medical literature on the topic, as well as clinical epidemiology concepts related to the impact that CRP testing has on the medical decision-making process.

Susceptibility oo antibiotics in urinary tract nfections in a secondary care ssetting from 2005-2006 and 2010-2011, in são paulo, Brazil: data from 11,943 urine cultures / Suscetibilidade a antibióticos em infecções de trato urinário em um hospital secundário, 2005-2006 e 2010-2011, em São Paulo, Brasil: dados de 11.943 uroculturas

Introduction: Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases. Objectives: The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance. Patients and methods: We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2. Results: Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011. Conclusion: E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

Introdução: A infecção do trato urinário (ITU) tem alta incidência e recorrência, e o tratamento é empírico na maioria dos casos. Objetivos: O objetivo deste estudo foi analisar as culturas de urina realizadas em um hospital secundário, durante dois períodos: 2005-2006 e 2010-2011, para estimar a resistência microbiana. Pacientes e métodos: Foram analisadas 11.943 culturas aeróbicas de urina de acordo com um conjunto de dados demográficos básicos e susceptibilidade aos antibióticos, obedecendo às normas do Clinical and Laboratory Standards Institute (CLSI) para Vitek 1 e 2. Resultados: A maioria dos participantes era adulta e jovem atendida no Serviço de Emergência. E. coli foi a mais freqüente (70,2%) entre as 75 espécies isoladas. Resistência de todos os isolados foi ≥ 20% para sulfametoxazol/trimetoprim (SMX/TMP), norfloxacina, nitrofurantoína, cefazolina e ácido nalidíxico, apesar de E. coli ter sido mais suscetível (resistência ≥ 20% apenas para SMX/TMP e ácido nalidíxico) entre todos os isolados, levando em conta a porcentagem de resistência e o número de antibióticos testados. Resistência às fluoroquinolonas foi de 12%. Fatores de risco para E. coli: sexo feminino e idade < 65 anos. Homens e pacientes com mais de 65 anos apresentaram isolados mais resistentes. Beta-lactamases de espectro estendido (ESBL) foram identificadas em 173 de 5.722 isolados Gram-negativos (3,0%), 2010-2011. Conclusões: E. coli foi o isolado mais sensível a antibióticos. Houve uma evolução significativa da resistência antimicrobiana entre os dois períodos. Foi preocupante o aumento da resistência às fluoroquinolonas.

Hemorrhagic syndrome and acute renal failure in a pregnant woman after contact with Lonomia caterpillars: a case report

Um caso de uma gestante de 37 semanas que desenvolveu uma sindrome hemorragica e insuficiência renal aguda apos contato com lagartas do genero Lonomia e relatado. O acidente desencadeou trabalho de parto prematuro e a paciente deu a luz a um recém nascido vivo. Alguns aspectos fisiopatologicos do sangramento genital e da insuficiência renal aguda säo discutidos

Doenças tireoidianas subclínicas e fatores de risco cardiovascular em mulheres com mais de 40 anos em seu local de trabalho / Subclinical thyroid dysfunction and risk factors for cardiovascular disease in women at the workplace

Introdução: As disfunções tireoidianas subclínicas são comuns na prática clínica, particularmente entre mulheres de meia idade. Existem algumas evidências de que as disfunções tireoidianas subclínicas podem afetar o risco cardiovascular de forma negativa, além de afetar a qualidade de vida e produzir sintomas somáticos e psicológicos. Entretanto ainda existe muita controvérsia sobre se o tratamento destas disfunções afeta positivamente algum desfecho clínico e se estaria indicado realizar um rastreamento populacional destas disfunções. Objetivo: Este estudo teve como objetivo determinar a freqüência das disfunções tireoidianas subclínicas e sua associação com fatores de risco cardiovasculares tradicionais e com alguns fatores psico-sociais em mulheres com 40 anos ou mais em seu local de trabalho. Métodos: Estudo transversal de rastreamento com funcionárias da Universidade de São Paulo com 40 anos ou mais. Todas as participantes foram entrevistadas e responderam a quatro questionários específicos validados [um questionário sobre características sócio-demográficas, o questionário de angina de Rose, o Short Form Health Survey - 36 (SF-36) e o Self-Report Questionnaire (SRQ-20)], foram submetidas a mensuração de medidas antropométricas e da pressão arterial e tiveram uma amostra de sangue colhida para avaliação de função tireoidiana (TSH e T4-livre) e anticorpos antitireoperoxidase (anti-TPO), glicemia de jejum e colesterol total, LDL-colesterol e HDL-colesterol. Em uma subamostra do estudo também foi dosada a proteína C ultra-sensível (hsCPR). As mulheres foram analisadas de acordo com seu estado funcional tireoidiano. Resultados: Das 736 funcionárias com 40 anos ou mais convidadas a participar, 314 (42,7%) aceitaram o convite...

Rational: Subclinical thyroid dysfunction is very common in clinical practice, particularly among middle-aged women. There is some evidence that subclinical thyroid dysfunction may affect cardiovascular risk in a negative fashion, and also affect quality of life and produce somatic and psychological symptoms. There remains much controversy as whether there should be a population based screening for these dysfunctions and whether treatment of these dysfunctions have any positive impact on clinical outcomes. Objective: The aim of this study was to determine the approximate frequency of subclinical thyroid dysfunction and its association with traditional cardiovascular risk factors as well as some psychosocial factors in women 40 years of age or older at the worksite. Methods: Cross-sectional screening study with women 40 years of age or older, working at the University of São Paulo. All the women answered four specific questionnaires [a questionnaire on socio-demographic characteristics, the Rose Angina Questionnaire, the Short Form Health Survey -36 (SF-36) and the Self- Report Questionnaire (SRQ-20)], had antropometric variables and blood pressure measured, and blood analyzed for total-cholesterol, LDL-cholesterol, HDL-cholesterol, tryglicerides, fasting glucose, thyroid-stimulating hormone (TSH), free-thyroxine (free-T4) and anti-thyreoperoxidase antibodies (anti-TPO). In a sub-sample of these women high-sensitive C reactive protein (hsCRP) was measured. Women were analyzed according to their thyroid function status. Results: Of the 736 women invited to participate, 314 (42.7%) accepted the invitation. The frequencies of subclinical hypothyroidism and subclinical hyperthyroidism were, respectively, 7.3% and 5.1%. Positive antibodies against thyreoperoxidase were present in 51 women (16.2%). TSH levels < 10 mIU/l were present in 78.3% of women with subclinical hypothyroidism...

Dietas e hipertensäo arterial: Intersalt e estudo DASH / Diet and hypertension: Intersalt and DASH diet study

A importância da dieta e de outros fatores de estilo de vida no controle da hipertensäo arterial sistêmica vem sendo enfatizada nas últimas décadas. Apresentamos dois grandes estudos que contribuíram muito para o entendimento do efeito da dieta sobre a pressäo arterial. O estudo Intersalt foi um estudo transversal que correlacionou a ingestäo média de sal, estimada pela excreçäo urinária de sal em 24 horas de diversas populações, associando-a com a prevalência de hipertensäo arterial sistêmica e com os níveis pressóricos médios. O DASH foi um estudo randomizado, controlado e multicêntrico, que comparou o efeito de três padrões dietéticos sobre a pressäo arterial, mostrando que uma dieta rica em frutas, verduras e laticínios desnatados, escassa em gorduras saturadas e colesterol, pode reduzir a pressäo arterial tanto quanto a monoterapia com anti-hipertensivos em hipertensos no estágio 1. Posteriormente, um segundo estudo com a dieta DASH associada à ingestäo de quantidades reduzidas de sal mostrou um importante efeito sinérgico na diminuiçäo dos níveis pressóricos

Epidemiologia da hipertensão arterial no Brasil e no mundo / Epidemiology of arterial hypertension in Brazil and in the world

A hipertensão arterial sistêmica deve ser considerada um problema de saúde pública. É um importante fator de risco cardiovascular e sua prevalência gira em tomo de 20 por cento. Grande parte dos hipertensos desconhece sua condição e, dos que conhecem, apenas cerca de 30 por cento apresentam um controle adequado. No Brasil, apesar de não haver estudo de prevalência com representatividade nacional e com padronização adequada os estudos localizados mostram sempre valores elevados.