Differences between remaining ability and loss of capacity in maximum aerobic impairment.

In the evaluation of exercise intolerance of patients with respiratory diseases the American Medical Association (AMA) and the American Thoracic Society (ATS) have proposed similar classification for rating aerobic impairment using maximum oxygen uptake (VO2max) normalized for total body weight (ml min-1 kg-1). However, subjects with the same VO2max weight-corrected values may have considerably different losses of aerobic performance (VO2max expressed as % predicted). We have proposed a new, specific method for rating loss of aerobic capacity (VO2max, % predicted) and we have compared the two classifications in a prospective study involving 75 silicotic claimants. Logistic regression analysis showed that the disagreement between rating systems (higher dysfunction by the AMA/ATS classification) was associated with age > 50 years (P < 0.005) and overweight (P = 0.04). Interestingly, clinical (dyspnea score) and spirometric (FEV1) normality were only associated with the VO2max, % predicted, normal values (P < 0.01); therefore, in older and obese subjects the AMA/ATS classification tended to overestimate the aerobic dysfunction. We conclude that in the evaluation of aerobic impairment in patients with respiratory diseases, the loss of aerobic capacity (VO2max, % predicted) should be used instead of the traditional method (remaining aerobic ability, VO2max, in ml min-1 kg-1).

A retrospective study of kidney transplant recipients from living unrelated donors.

Due to the shortage of cadaveric organs, kidneys from living unrelated donors (LUD) are increasingly being used for transplantation. The long-term outcome for LUD recipients is not completely known. This study was undertaken to evaluate the long-term graft survival in LUD recipients and compare it with that of cadaver donor allograft recipients. Three hundred and sixty-four LUD and 3881 cadaveric kidney recipients were evaluated using data obtained through the Brazilian Renal Transplant Registry. Transplants performed between January 1, 1987, and June 30, 1996, were eligible for analysis. Graft and patient survival were estimated by the Kaplan-Meier method. Sixty percent of the LUD were from spouses. The median duration of follow-up was 23.8 mo (0 to 117.2 mo). Patient survival rates were not significantly different for LUD and cadaveric kidney recipients (69% [95% confidence interval (CI), 61.9 to 76.1%] versus 73.2% [71 to 75.4%] at 5 yr; 69% [61.9 to 76.1%] versus 60.6% [55.1 to 66.1%] at 9.6 yr). Graft survival rates for recipients of LUD allografts were similar to those for cadaveric kidneys at 5 yr (50.1% [43.2 to 57%] versus 50.4% [48.1 to 52.8%]) and higher, although not significantly, at 9.6 yr (45.7% [37.7 to 53.7%] versus 32.7% [26.4 to 39%], respectively, P = 0.14). In a multivariate analysis using the Cox proportional hazards regression model, after adjusting for recipient age, race, history of previous transplantation, and year of transplantation, the risk of graft failure was 16% (95% CI, -3% to 31%) lower for LUD than cadaveric recipients. We conclude that LUD are an excellent alternative to cadaveric kidney donors. The long-term patient and graft survival rates for recipients of LUD allografts are at least as good as those for recipients of cadaveric kidneys.

Differences between remaining ability and loss of capacity in maximum aerobic impairment

In the evaluation of exercise intolerance of patients with respiratory diseases the American Medical Association (AMA) and the American Thoracic Society (ATS) have proposed similar classifications for rating aerobic impairment using maximum oxygen uptake (VO2max) normalized for total body weight (ml min(-1) kg(-1)).However, subjects with the same VO2max weight-corrected values may have considerably different losses of aerobic performance (VO2max expressed as percent predicted). We have proposed a new, specific method for rating loss of aerobic capacity (VO2max, percent predicted) and we have compared the two classifications in a prospective study involving 75 silicotic claimants. Logistic regression analysis showed that the disagreement between rating systems (higher dysfunction by the AMA/ATS classification) was associated with age>50 years (P<0.005) and overweight (P=0.04). Interestingly, clinical (dyspnea score) and spirometric (FEV(1)) normality were only associated with VO2max, percent predicted, normal values (P<0.01); therefore, in older and obese subjects the AMA/ATS classification tended to overestimate the aerobic dysfunction. We conclude that in the evaluation of aerobic impairment in patients with respiratory diseases, the loss of aerobic capacity (VO2max, percent predicted) should be used instead of the traditional method (remaining aerobic ability, VO2max, in ml min(-1) Kg(-1)).

The software challenge for the next decade: the global objects scenario.

This paper discusses the advantages of developing software as pattern-based components. The design and implementation of a pattern-based suite of software components specially constructed for the electronic patient record is presented. The methodology and the lessons learned in the development of these components are discussed. Finally, some comments about the globalization and the need for more integration among component developers in a worldwide basis is discussed.

Model of computerized academic medical clinic.

In the traditional medical graduation course, the student receives a great amount of information while training at the Outpatient Care; the student assumes the physician's role, collecting all the information regarding the patient's clinical history and learns to get along with patients as well. During the attendance process, several factors interfere in the academic teaching, such as limitations of room numbers, amount of patients, difficulties in obtaining medical records, paper illegibility, among other problems. Due to those difficulties, the Model of Computerized Academic Health Clinic, implies in a new learning paradigm in the medical practice, rethinking the traditional process of learning-attendance, where the old model, in which attendance is restricted to a place, is extended in an open atmosphere of shared knowledge, rich of computer resources. The pilot project was implanted in the Pediatrics General Health Clinic of UNIFESP/EPM. It allows that the fifth-year medical students, residents, trainees and tutors use computerized clinics, connected with the academic net of UNIFESP and to the Internet. All the computing and information resources settled at the Outpatient Care improved the organization of its services, increased the medical students' curiosity, improved their participation in learning through interactive programs and clinical attendance.

Latin American Registry of dialysis and renal transplantation: 1993 annual dialysis data report.

BACKGROUND: The Latin American Registry of Dialysis and Transplantation was created in October 1991 and comprises the National Societies of Nephrology from 21 countries with a total population of 468.56 million inhabitants. METHODS: This report includes data from 21,181 patients from Argentina, Brazil, Chile, El Salvador, Panama, Paraguay, Peru, Puerto Rico, Uruguay, and Venezuela who were receiving chronic dialysis treatment during 1993. Data was collected by individual patient questionnaires except from Chile and Brazil where the data was obtained from a local centre questionnaire. RESULTS: The prevalence rate averaged 131.1 per million population. The mean age of the 8972 incident patients was 50.5 years, with 58.2% males. The more frequent causes of renal failure were glomerulopathies (22.6%), vascular nephropathy (20.9%) and diabetes (16.9%). Haemodialysis was the most used treatment (88.3%). Gross mortality was 21.1% and the more frequent causes of death were cardiac complications and infections. The analysis of mortality risk factors using a logistic regression model showed that diabetics patients older than 65 years had the highest probability of death (43.0%) and patients with glomerulonephritis, younger than 65 years had the lowest (8.0%). The adjusted mortality rate was 241 deaths/1000 patient-years at risk when the USRDS 1987-1989 white mortality rate by age groups and primary diseases was used as standard. CONCLUSION: In spite of the economic difficulties, very important efforts have been made to treat ESRD patients and gross mortality statistics in some countries are similar to those reported by other regional registries.

A microcomputer-based transplantation registry.

We describe a microcomputer-based program developed for the Brazilian Kidney Transplant Registry. The system can construct life tables and survival curves online, without the need to export the database. From 1987 through 1993, 6069 kidney transplants were reported; 3485 (57.4%) were from living donors and 2584 from cadavers. The proportion of cadaveric transplants increased from 28.5% in 1987 to 58.1% in 1993. Overall kidney transplantation activity was 8.1 patients per million population per year. Sixty-four percent of the patients were male, and 71% were white. The mean age was 33.4 years. The primary renal diseases most frequently reported were glomerulonephritis (43.6%) and hypertensive renal disease (13.6%). Only 3.6% of the recipients were diabetic. Patient and graft survival rates have improved in recent years. We expect that cadaveric organ procurement programs will continue to develop in our country, increasing the number of organ transplantations and creating a more equal distribution of cadaveric organs.

Comparative study of intensive care unit (ICU) performance.

It is possible to evaluate ICU performance using severity-of-illness systems, but are these systems objective enough to draw comparison between different units? A software was developed to allow data collection and calculation of the score APACHE II [1] and administrative hospital indicators. To provide homogeneity, all data were collected following the same protocol and verified by one author.

Educational program on ophthalmology.

To minimize the learning problems, related to the present teaching method, we developed the Educational Program on Ophthalmology, that offers an interactive and self-controlled way of learning, through the multimedia and hypertext (hypermedia) resources to the students. The software has 200 images (pictures and photos), 40 minutes of digitized voice (.WAV), 50 minutes of video animation (.AVI) and more than 200 links. The first evaluation demonstrated a great interest from the medical graduated students, who feel motivated with the utilization of the software.

Decision support system for individualized nursing procedures: SAPIEN-Tx.

The present work proposes a Decision Support System for nursing procedures: SAPIEN-Tx. The discussion includes the acquisition, modeling , and implementation of nursing expertise professionals in Renal Transplant. It was developed to obtain better quality healthcare services, as well as an effective contribution to the nursing professional in the global assistance of their clientele. We used the KADS methodology to develop the system knowledge base. This methodology permitted us to perform the knowledge modeling with quality and organization. In opposition to the old method, errors were detected before the implementation, avoiding possible modification on the whole project structure.

Aspectos epidemiológicos do tratamento dialítico na Grande Säo Paulo / Epidemiologic aspects of the dialysis treatment in Great Säo Paulo

OBJETIVO: Apresentar dados epidemiológicos sobre o tratamento de pacientes com insuficiência renal terminal na Grande Säo Paulo. MATERIAL E MÉTODOS: Pacientes em diálise na Grande Säo Paulo distribuídos em 15 Escritórios Regionais de Saúde (ERSAs), durante o ano de 1991. Dados coletados pela Secretaria de Saúde do Estado. RESULTADOS: Houve aumento de 18,6 por cento no número de pacientes vivos em diálise de 1/janeiro a 31/dezembro (n=2.425 a 2.875). Os pacientes estavam distribuídos em 40 centros de diálise, dos quais 25 estavam localizados apenas nos ERSAs 1,2 e 3. Dependendo do ERSA, uma percentagem variável de 37 por cento a 88 por cento dos pacientes näo residiam na regiäo de tratamento. Ao final do ano, 79 por cento dos pacientes estavam em hemodiálise, 15 por cento em diálise ambulatorial peritoneal contínua e 6 por cento em diálise peritoneal intermitente. Os diagnósticos mais freqüentemente reportados de doença de base foram: indeterminado, glomerulonefrite, hipertensäo e diabetes (36 por cento, 27 por cento, 17 por cento e 8 por cento, respectivamente). Iniciaram tratamento dialítico durante o ano, 1.483 casos novos, correspondendo à incidência de 83 pacientes por milhäo da populaçäo (PMP). A prevalência de pacientes em tratamento dialítico no meio do ano foi de 148 pmp. A taxa de fatalidade anual global foi de 17,2 pacientes em cada 100 pacientes em diálise (variaç o nos ERSAs: 12,0-32,5). A sobrevida atuarial dos pacientes que iniciaram tratamento em 1991 foi de 80,2 por cento ao final do primeiro ano. Receberam transplante renal 246 pacientes, correspondendo à taxa de 14 transplantes por milhäo da populaçäo. CONCLUSOES: Em geral, a assistência prestada através de tratamento dialítico na Grande Säo Paulo é satisfatória. Há desigualdades em relaçäo à assistência nos diferentes ERSAs e que devem refletir na distribuiçäo de hospitais de atendimento terciário na regiäo.

[Epidemiologic aspects of the dialysis treatment in Grande São Paulo. Comissão Regional de Nefrologia da Secretaria da Saúde de São Paulo and Centro de Informática da Escola Paulista de Medicina]. / Aspectos epidemiológicos do tratamento dialítico na Grande São Paulo. Comissão Regional de Nefrologia da Secretaria da Saúde de São Paulo e Centro de Informática da Escola Paulista de Medicina.

OBJECTIVE: Epidemiological data about the treatment of patients with end-stage renal disease in the Great Sao Paulo, Brazil, are presented. MATERIAL AND METHODS: Patients on dialysis in the city of Sao Paulo and surroundings, distributed in 15 Regional Offices of Health (ERSAs), during 1991, were studied. Data were collected by the Secretary of Health of the State of Sao Paulo. RESULTS: There was an increase of 18.6% in the number of alive patients on dialysis from January 1 to December 31 (n = 2,425 to 2,875). Patients were treated in 40 dialysis centers, of which 24 were located in the ERSAs 1, 2 and 3. Depending on the ERSA, a percentage of patients varying from 37% to 88% did not live in the same region where they received treatment. At the end of the year, 79% of the patients were on hemodialysis, 15% on continuous ambulatory peritoneal dialysis and 6% on intermittent peritoneal dialysis. The diagnoses more frequently reported of primary disease were non-determined, glomerulonephritis, hypertension and diabetes (36%, 27%, 17% and 8%, respectively). New cases (1,483) initiated dialysis during the year, corresponding to an incidence rate of 83 patients per million population (pmp). The prevalence of patients on dialysis was 148 pmp. The annual fatality rate was 17.2% (range in the ERSAs: 12.0-3.5). The actuarial one year survival for the patients who started treatment in 1991 was 80.2%. 246 patients received transplantation, corresponding to 14 patients pmp. CONCLUSIONS: Dialysis treatment provided in the Great Sao Paulo is satisfactory.(ABSTRACT TRUNCATED AT 250 WORDS)

Kidney transplantation from living unrelated donors.

OBJECTIVE: To compare patient and graft survival of recipients of kidneys from living, unrelated donors (LUDs); cadaveric donors; and living, related donors (LRDs) matched for zero (mismatched), one, or two (identical) haplotypes. DESIGN: Cohort study. SETTING: Sixty-three renal transplantation centers affiliated with the Brazilian Transplantation Registry (accounting for more than 95% of the transplantation activity in Brazil). PATIENTS: Patients having renal transplantation between January 1987 and March 1991. Of 2892 patients, 165 (6%) received transplants from LUDs; 964 (33%), from cadaveric donors; 183 (6%), from zero haplotype, HLA-matched LRDs; 1259 (44%), from one haplotype-matched LRDs; and 321 (11%), from two haplotype-matched LRDs. MEASUREMENTS: Patient and graft survival. Patients were followed for an average of 15.8 months. RESULTS: After adjustment for age, race, diagnosis of primary disease, history of previous transplantation, cyclosporine use, and number of transplants from LUDs per center, patient survival did not differ statistically for recipients of kidneys from LUDs and recipients of cadaveric kidneys (risk ratio [RR], 1.16; 95% Cl, 0.68 to 1.98). Little difference was seen between the adjusted death rate for recipients of zero haplotype-matched LRDs and recipients of cadaveric kidneys (RR, 1.13; Cl, 0.69 to 1.87). Similarly, in a multivariate analysis, recipients of kidneys taken from LUDs and zero haplotype-matched LRDs had a risk for graft failure that did not differ statistically from that of cadaveric kidney recipients (RR, 0.74; Cl, 0.45 to 1.22 and RR, 0.82; Cl, 0.53 to 1.25, respectively). CONCLUSIONS: Graft survival for recipients of kidneys from LUDs is similar to that from zero haplotype-matched LRDs and is at least as good as that achieved with cadaveric transplants.

Survival analysis of 1563 renal transplants in Brazil: report of the Brazilian Registry of Renal Transplantation.

Little is known about renal transplantation activity in developing countries. The objective of this study was to evaluate patient and graft survival among the different types of renal transplant recipients in Brazil. The study population consisted of 1563 patients receiving renal grafts for the first time between 1 October 1987 and 31 December 1989 in 49 transplant centres in Brazil. Data were prospectively collected through individual patient questionnaires. Of the 1563 transplantations performed, 1051 (67%) were from living donors, 467 (30%) from cadaver donors, and 45 (3%) unspecified. A total of 963 (62%) transplants came from living related donors (10% HLA-identical, 45% HLA-haploidentical and 6% HLA-distinct). Among the transplant recipients, only 7% were more than 55 years old, 5% were younger than 15 and 4% had diabetes mellitus. Blacks accounted for 24% of patients receiving transplants. An immunosuppressive regimen, including cyclosporin was used in 75% of cadaver kidney recipients, in 42% of living donor kidney recipients; and in 43% and 75% of HLA-haploidentical and HLA-distinct living related donor recipients, respectively. At 2 years, patient survival for living donor and cadaver donor transplant recipients was 89% and 80% respectively, and graft survival was 76% and 61% respectively. Patient survival for recipients of HLA-identical, haploidentical, and distinct living related donor kidneys was respectively 94%, 90%, and 81% at 2 years, and graft survival was 90%, 75%, and 65% respectively. Graft survival for recipients of HLA-distinct living related donor and non-related donor kidneys compared to cadaver donor kidneys was not significantly different at 2 years (63% vs 61%, P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Nutritional assessment of chronic renal patients in hemodialysis programs. A multicenter study]. / Avaliação nutricional em pacientes renais crônicos em programa de hemodiálise. Estudo multicêntrico.

The food intake and the nutritional status of 100 chronic renal failure patients on maintenance hemodialysis in 10 facilities in the city of São Paulo were studied. The average food intake obtained through 3 days of dietary diaries showed a caloric intake of 26.6 +/- 10kcal/kg/day (mean +/- SD), 24% below the minimum daily caloric intake recommendation and a protein intake of 1.03 +/- 1.4g/kg/day which averaged the minimum recommended for chronic renal patients on hemodialysis. The average intakes of calcium (418.6 +/- 294.9mg), phosphate (813.5 +/- 335.2mg) and iron (10.5 +/- 4.9mg) were also low. Mean serum albumin was 3.9 +/- 0.7g/dl and only 3.1% of the patients had albumin levels below 3.0g/dl. There was no difference between the real and ideal body weight. On the other hand 69% of women and 25% of men had the triceps skin fold (TSF) in the 5th percentile while 24% of women and 79% of men exhibited values of the muscle arm circumference (MAC) in the same percentile. Moreover there were inverse and significant correlations between the time on dialysis and TSF for women (r = -0.19) and the time on dialysis and MAC for men (r = -0.16). This study shows that our patients on hemodialysis have a poor food intake, with marked reduction of fat and muscle stores. The undernourished state observed tended to be more pronounced with the duration of the dialysis treatment and could influence negatively on the morbidity and mortality of these patients.

Hypertension and economic activities in São Paulo, Brazil.

A study of the prevalence of hypertension was undertaken among workers in 10 subsectors of the economy in São Paulo, a major urban-industrial area of Brazil. Included in the study were 5500 subjects 15-65 years of age, employed in 57 randomly selected firms. Hypertension rates (DBP greater than or equal to 90 mm Hg) were higher among males up to 44 years of age. There was a decreasing gradient from mild to moderate and severe forms in all groups. Severity tended to increase with age in all groups. Black males showed higher rates than whites (29.2% vs 16.7%, p less than 0.05), the excess being partially accounted for by moderate and severe forms (40% vs 20%). Subjects who overworked showed a trend toward higher hypertension rates. Higher rates in four subsectors (metallurgy, finance, transport, and journalism), aside from the distribution of known risk factors and job selection, may reflect a variety of work-related stressors.

Kidney transplantation in leprosy

despite the high frequency of renal involvement associated with Hansen's disease and the persistent occurrence of leprosy, especially in the underveloped countries, reference to kidney transplantation in these patients is rare. Secondary amyloidosis and a nephritic process possibly mediated by immune complexes are present in one-half of the leprosy pateints studied either by autopsy or by kidney biopsy.