Prognosis related to staging systems for chronic lymphocytic leukemia.

CONTEXT: Chronic lymphocytic leukemia (CLL) is a clonal lymphoproliferative disorder, characterized by B lymphocytic proliferation. CLL is the most frequent adult leukemia in Western countries, accounting for 25 to 30% of all white leukemic patients. OBJECTIVE: To evaluate clinical and staging characteristics in prognosis of chronic lymphocytic leukemia. DESIGN: Evaluation of clinical-staging data. SETTING: Universidade Federal de São Paulo - Escola Paulista de Medicina / Universidade de Alfenas. SAMPLE: 73 patients diagnosed from 1977 to 1994. MAIN MEASUREMENTS: Sex, ethnic origin, age, lymphadenopathy, splenomegaly, hepatomegaly, three or more areas of lymphoid enlargement, hemoglobin (g/dl), lymphocytes/mm3, Platelets/mm3 RESULTS: Mean survival of patients was 76 months, median age was 65 years, ranging from 33 to 87. Forty-four patients (60.3%) were male and 29 (39.7%) female. CONCLUSION: The Binet system determined a better prognosis than Rai.

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.

Graduaçäo médica e especializaçäo: uma incompatibilidade aparente / Medical graduation and specialization: an apparent incompatibility

Objetivo. Este artigo apresenta resultados parciais da pesquisa, desencadeada a partir de 1989, de avaliaçäo continuada do ensino de graduaçäo médica da Escola Paulista de Medicina (EPM), com a qual se implantou amplo processo de avaliaçäo institucional. Metodologia. O estudo, de base amostral, envolve o levantamento de expectativas e opiniöes de docentes, alunos e egressos, constituindo três subprojetos específicos. Resultados. Os autores chamam a atençäo para näo-terminalidade da formaçäo médica na EPM, levando em conta que os egressos näo entram no mercado de trabalho ao final da graduaçäo. Conclusäo. Este resultado aponta para a necessidade de reflexäo em torno do significado da näo-terminalidade por referência ao longo processo de formaçäo médica. Neste caso, a característica apontada näo está associada à ausência de qualidade e, sim, à incorporaçäo, no currículo de graduaçäo, do desenvolvimento de técnicas e procedimentos profissionais que conduzem à inexorável especializaçäo do conhecimento, atingida somente por meio de formaçäo pós-graduada.

[The diaphragm as a contraceptive method in the experience of users in the public health services] / O diafragma como método contraceptivo: a experiência de usuárias de serviços públicos de saúde.

This study, started in August 1989, describes the acceptability of diaphragms as part of the daily routine of 194 women enrolled at five public health care centers in Osasco, (Greater São Paulo). Follow-up of the cohort was performed by semestral home interviews until August 1991. Our data indicate that the diaphragm can be a viable alternative within the public health care setting. Women, including those from low-income groups, are interested in new alternatives to currently available contraceptive practices. Nevertheless, the cumulative rate of continuity for use of the method was only 25.7% (39 women) after a period of 12 months. Only 37.1% of women opting for the diaphragm confirm its use during every act of sexual intercourse. Most of the women (72.7%) only learned about diaphragms during the process of choosing a contraceptive method. The main reasons for discontinued use were partners' complaints, discomfort, and difficulty in handling. The findings point to the need for reformulating family planning activities to provide greater support for women, introduce initiatives to enhance male participation, and promote on-going training of health professionals with regard to the management of the method and support for its users.

[Medical graduation and specialization: an apparent incompatibility]. / Graduação médica e especialização: uma incompatibilidade aparente.

PURPOSE: Partial results of a continuous evaluation process of the undergraduate medical course at Escola Paulista de Medicina (EPM) started in 1989 are presented. METHODS: A survey on expectations and opinions about the medical course of EPM was carried out among faculty members, students and alumni. RESULTS: The authors call into question that the medical formation is non-terminal as indicated by the late entry to labor market. CONCLUSION: The authors consider that the phenomenon is not related to quality aspects but to the specialization process started during the medical course and completed only with graduated studies.

[Evaluation of the Malnourished Children's Recuperation Program in the town of Embu, located in the Metropolitan Area of São Paulo]. / Avaliação do Programa de Recuperação de Desnutridos do Município do Embu, na Região Metropolitana de São Paulo.

The objective of this study is to assess the anthropometric evolution of children who had been assisted by the Malnourished Children's Recuperation Program in the town of Embu, as well as to analyze some variables that interfered in this evaluation. The study included 233 children aged under five, enrolled in the program from January 1984 to December 1985. 201 (86,3%) were undernourished grade II and 32 (13,7%) grade III, according to Gomez. The percentage increase of Weight in relation to Age (W/A) and Height in relation to Age (H/A) - outcome variables, in the first and last examinations in the program - were analyzed, using the multiple linear regression. Younger children and in worse nutritional conditions showed higher W/A and H/A increases. Low birth weight, more frequent examinations, and longer stay in the program were associated to lower W/A increases. The presence of chronical pathologies jeopardized the H/A rate increases. This result strengthens the importance of developing programs for the assistance of undernourished children, due to higher risk of morbi-mortality in this group, mainly in younger children and with worse nutritional conditions.

Mental health of the mothers of malnourished children.

BACKGROUND: The objective of this study is to measure the association between protein-energy malnutrition (PEM) in children and their mothers' mental health, in a low income area in the city of Embú, São Paulo, Brazil. METHODS: A case-control study was performed. Cases were 60 moderately and severely malnourished children (Gomez criteria) selected from two primary health care units. Controls consisted of 45 eutrophic children attending the same units. The main outcome measure was for the mothers to present a mental health score > 6 according with the 'Adult Psychiatric Morbidity Questionnaire' (QMPA), a psychiatric screening instrument. RESULTS: Of mothers of children with PEM, 63% and 38% of mothers in the control group were QMPA positive: odds ratio (OR) = 2.8 (95% confidence interval [CI]: 1.2-6.9). Of PEM children, 27% had low birthweight (LBW = < 2500 g) and 6% of the control group had LBW. Interactions were found between: mothers' mental health and number of children (with > or = 4 children: OR = 20.0 [95% CI: 2.1-274.2], with < or = 3 children: OR = 1.6 [95% CI: 0.6-4.5), as well as mothers' mental health and maternal age (in women > 30: OR = 12.5 [95% CI: 2.0-93.4], in women < or = 30: OR = 1.5 [95% CI: 0.5-4.4]. CONCLUSIONS: Mothers of children with PEM showed a higher rate of mental disturbances than mothers of eutrophic children. Unlike LBW, maternal age and number of children interact with mothers' mental health, increasing the association. Management of poor mental health may lead to mothers being better caretakers of their children and this may have a positive impact on PEM.

[Information systems for the management of local health systems]. / Sistemas de informação para a gestão dos sistemas locais de saúde.

Owing to the diffusion of computers--personal as well as highly sophisticated models--and of modern data bank systems and more accessible programming methods that no longer require hiring professional programmers to develop a variety of applications, administrators are increasingly using this new technology as a basis for making more realistic decisions. Good information systems are of great importance in the management of local health systems; however, in order for them to be truly useful, data collection must be homogeneous so that the data may be subsequently consolidated and compared. In this connection the authors present a model consisting of four stages: strategic planning; analysis of needs; allocation of resources; and selection of alternatives for consideration by project teams and suppliers of equipment and programs.

Geographical stratification by socio-economic status: methodology from a household survey with elderly people in S. Paulo, Brazil.

Considering that in most developing countries there are still no comprehensive lists of addresses for a given geographical area, there has always been a problem in drawing samples from the community, ensuring randomisation in the selection of the subjects. This article discusses the geographical stratification by socio-economic status used to draw a multistage random sample from a community-based elderly population living in a city like S. Paulo-Brazil. Particular attention is given to the fact that the proportion of elderly people in the total population of a certain area appeared to be a good discriminatory variable for such stratification. The validity of the stratification method is analysed in the light of the socio-economic results obtained in the survey.

Comparison of daily and twice-weekly regimens to treat pulmonary tuberculosis.

A randomised controlled trial compared the effectiveness and toxicity in pulmonary tuberculosis of two drug regimens containing rifampicin and isoniazid given daily or twice-weekly for 4 months after a 2-month period of intensive treatment with daily isoniazid, rifampicin, and pyrazinamide. 667 patients with newly diagnosed pulmonary tuberculosis were randomly allocated to continue daily treatment with isoniazid (400 mg) and rifampicin (600 mg) or to twice-weekly treatment with isoniazid (900 mg) and rifampicin (600 mg). 544 of the 667 patients (81%) completed the 6-month course (287 of 337 [85%] treated daily and 257 of 330 [79%] treated twice-weekly). Drug toxicity was not a great problem; the treatment was permanently discontinued in only 2% of patients. There was no significant difference at the end of months 5 and/or 6 of chemotherapy between the groups treated daily and twice-weekly in the proportions with bacteriological failure (at least one positive sputum culture with more than 20 colonies) or who had died from tuberculosis (17 [6%] vs 10 [3%]). Nor was there a significant difference in the relapse rate (17 [7%] treated daily vs 10 [4%] treated twice-weekly) during follow-up of 12 months. Thus, the twice-weekly regimen was at least as effective as the daily regimen for treatment of pulmonary tuberculosis.

Food intake and energy expenditure of male and female farmers from Upper-Volta.

1. The energy balance of eleven male and fourteen female adult farmers was measured for 6 d after the harvest, in December-January. Their energy intake was recorded by weighing their food consumption and their energy expenditure was determined using indirect calorimetry. 2. Body-weight, expressed as percentage of expected weight-for-height was 91 and 86% of the Inter-departmental Committee on Nutrition for National Development (1963) standard for women and men respectively. 3. The staple foods were sorghum (Sorghum vulgare) and millet (Pennisetum typhoïdes); carbohydrates, fat and protein supplied approximately 80, 13 and 12% of the total energy of the diet respectively. 4. In the male group, the mean energy intake (9.0 MJ (2148 kcal)) was in good agreement with the average energy output (8.91 MJ (2130 kcal)). By contrast, in the female group, the mean energy expenditure (8.11 MJ (1941 kcal)) exceeded the mean energy intake (6.3 MJ (1515 kcal)) and the deficit was statistically significant. 5. This study allows an evaluation of the adequacy of food intake for subjects living in a particular hostile environment, by using their actual energy output instead of current standard values. The energy deficit found for female farmers whose energy intake was similar to that reported in other developing countries emphasizes the need for a better understanding of the regulation of energy balance in such conditions.

Energy expenditure of male farmers in dry and rainy seasons in Upper-Volta.

1. Thirty Mossi male farmers from Upper-Volta were investigated, twenty-three in the dry season (March-April) and sixteen in the rainy season (July-August), eight of them being studied twice. A 48 h time-and-motion study was carried out and the daily energy expenditure was computed. 2. The mean height was 1.70 m and the mean weight 58.5 kg. The averaged percentage of body fat calculated from skinfold thickness was 10. 3. During the dry season the subjects could be classified as very moderately active with an energy output of 10.0 MJ (2410 kcal)/d. By contrast, with an energy expenditure of 14.4 MJ (3460 kcal)/d, they were considered as exceptionally active in July-August when performing the agricultural work. 4. In this study we measured the intensity of physical work in a society where human labour is still the main tool of production. The determination of seasonal variations in energy expenditure may be useful to assess the nutritional requirements in arid zones of West Africa.

Duration of activities and energy expenditure of female farmers in dry and rainy seasons in Upper-Volta.

1. Fifteen female farmers (aged 18--47 years) from two villages of the Mossi Plateau in Upper-Volta participated in a survey in which their daily activity pattern and their energy expenditure were assessed. Eight of the subjects were investigated twice, in March (dry season) when there is no agricultural activity, and in July--August (rainy season) when heavy physical work is performed: mostly hoeing, weeding and replanting sorghum (Sorghum vulgare) and millet (Pennisetum typhoïdes). 2. The mean height was 1.57 m and the mean weight 50.6 kg. The average percentage of body fat, calculated from skinfold thickness, was comparable to that of European females but the triceps skinfold was more than 60% below the standard value (Jelliffe, 1969). The type of activities and the period of time spent on each activity changed significantly with the season. The mean energy output rose from 9.7 MJ (2320 kcal) in March to 12.1 MJ (2890 kcal) in July--August for a 55 kg standard weight. 3. In this paper, the extent of both the daily activity pattern of women living in a subsistence agriculture and their energy output is estimated. The results suggest that during the rainy season, the energy requirements of female farmers are much higher than usually estimated.