PURPOSE:To investigate the effect of Botulinum toxin A (BoNTA) on skin flap viability in healthy, tobacco-exposed and diabetic rats.METHODS: Ninety male Wistar rats (250-300g) were randomly divided into six groups: control+saline (C1), control+BoNTA (C2), tobacco-exposed+saline (T1), tobacco-exposed+BoNTA (T2) diabetes+saline (D1) and diabetes+BoNTA (D2). A dorsal cutaneous flap (3×10cm) was performed. Survival area and total area of the flaps were measured. Lumen diameter, external arterial diameter and lumen/wall thickness ratio were recorded.RESULTS: Survival area increased in control group with BoNTA injection compared with control animals injected with saline (C2 x C1; 0.9±0.1 vs0.67±0.15, p= 0.001). A similar result was found in diabetes group injected with BontA (D2 x D1; 0.97±0.2 vs0.61±0.24, p=0.018). No difference was observed in skin flap viability in tobacco-exposed groups (T2 x T1; 0.74±0.24 vs 0.64±0.21, p=0.871). Lumen diameter (p= 0.004), external arterial diameter (p = 0.0046,) and lumen/wall thickness ratio (p= 0.003) were increased in diabetes+BoNTA-treated animals. This effect was not observed in control or in tobacco-exposed groups.CONCLUSIONS:Botulinum toxin A increased skin flap viability in control and diabetic rats on the seventh post-operative day. Increased lumen diameter, external arterial diameter, and lumen/wall thickness ratio were observed in the diabetes+BoNTA group. BoNTA had no effect in the tobacco-exposed group on the seventh postoperative day.

OBJETIVO: Determinar a prevalência de broncoespasmo induzido por exercício em corredores brasileiros de longa distância de elite e se há uma diferença na carga de treinamento entre atletas com e sem broncoespasmo induzido por exercício. MÉTODOS: Estudo transversal com corredores de longa distância de elite sem sintomas atuais de asma e sem diagnóstico de broncoespasmo induzido por exercício. Todos os participantes foram submetidos ao teste de hiperventilação voluntária eucápnica e ao teste cardiopulmonar de esforço máximo e responderam a questionários sobre sintomas de asma e atividade física para monitorizar sua carga de treinamento semanal. RESULTADOS: Dos 86 atletas do sexo masculino recrutados, 20 concordaram em participar do estudo, dos quais 5 (25%) foram diagnosticados com broncoespasmo induzido por exercício. Não foram evidenciadas diferenças entre os atletas com e sem broncoespasmo induzido por exercício em relação a características antropométricas, consumo de oxigênio de pico, valores basais de função pulmonar ou sintomas de asma relatados. A carga de treinamento semanal foi significativamente menor nos atletas com broncoespasmo induzido por exercício do que naqueles sem esse diagnóstico. CONCLUSÕES: Nesta amostra de corredores de longa distância brasileiros, a prevalência de broncoespasmo induzido por exercício foi alta.

OBJECTIVE: To determine the prevalence of exercise-induced bronchoconstriction among elite long-distance runners in Brazil and whether there is a difference in the training loads among athletes with and without exercise-induced bronchoconstriction. METHODS: This was a cross-sectional study involving elite long-distance runners with neither current asthma symptoms nor a diagnosis of exercise-induced bronchoconstriction. All of the participants underwent eucapnic voluntary hyperpnea challenge and maximal cardiopulmonary exercise tests, as well as completing questionnaires regarding asthma symptoms and physical activity, in order to monitor their weekly training load. RESULTS: Among the 86 male athletes recruited, participation in the study was agreed to by 20, of whom 5 (25%) were subsequently diagnosed with exercise-induced bronchoconstriction. There were no differences between the athletes with and without exercise-induced bronchoconstriction regarding anthropometric characteristics, peak oxygen consumption, baseline pulmonary function values, or reported asthma symptoms. The weekly training load was significantly lower among those with exercise-induced bronchoconstriction than among those without. CONCLUSIONS: In this sample of long-distance runners in Brazil, the prevalence of exercise-induced bronchoconstriction was high.

INTRODUCTION: Patient safety is seldom assessed using objective evaluations during undergraduate medical education. OBJECTIVE: To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure. METHODS: In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated. RESULTS: A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59 ± 1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains. CONCLUSIONS: An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship.

JUSTIFICATIVA E OBJETIVOS: A circulação extracorpórea (CEC) pode causar disfunção pulmonar. As alterações inflamatórias podem afetar a liberação de óxido nítrico (NO). Objetivou-se avaliar o NO exalado em pacientes submetidos à revascularização do miocárdio (RM) com CEC. MÉTODO:Foram estudados prospectivamente nove pacientes adultos submetidos à RM com CEC. Inicialmente, foi coletada amostra de ar para análise de NO no sistema que alimenta o aparelho de anestesia. A seguir, anestesia iniciada por via venosa com etomidato (0,3 mg.kg-1), sufentanil (0,3 µg.kg-1), pancurônio (0,08 mg.kg-1) e mantida com isoflurano (0,5 a 1,0 CAM) e sufentanil (0,5 µg.kg-1.h-1). O volume corrente fixado a 8 mL.kg-1, com FIO2 de 0,6, exceto durante a CEC. Trinta minutos depois da indução, e trinta após a CEC, três amostras sequenciais de ar exalado foram colhidas para análise de NO, por quimioluminescência. Os dados foram analisados por meio do teste t de Student. RESULTADOS: O valor do NO do ar ambiente foi de 5,05 ± 3,37 ppb. O NO exalado decresceu após a CEC, variando de 11,25 ± 5,65 ppb para 8,37 ± 3,17 ppb (p = 0,031). CONCLUSÕES: A redução do NO exalado pós-CEC observada nesse estudo não permite confirmar o papel dessa molécula como marcador de lesão pulmonar. Entretanto, os variados graus de colapso do parênquima pulmonar, o método de obtenção dos dados, os fármacos utilizados, dentre outros, podem ter contribuído para a redução.

BACKGROUND AND OBJECTIVES: Cardiopulmonary bypass (CPB) can cause pulmonary dysfunction. Inflammatory changes may affect the release of nitric oxide (NO). The objective of this study was to evaluate exhaled NO in patients undergoing myocardial revascularization (MR) with CPB. METHODS: This is a prospective study with nine adult patients undergoing MR with CPB. Initially, air samples were collected to analyze the presence of NO in the system that feeds the anesthesia equipment. Intravenous anesthesia was then initiated with ethomidate (0.3 mg.kg-1), sufentanil (0.3 µg.kg-1), and pancuronium (0.08 mg.kg-1), and maintained with isoflurane (MAC from 0.5 to 1.0) and sufentanil (5 µg.kg-1.h-1). Tidal volume was fixed at 8 mL.kg-1 and FiO2 0.6, except during CPB. Thirty minutes after induction and 30 minutes after CPB, three sequential samples of exhaled air were collected for NO analysis by chemiluminescence. Data were analyzed by the Student t test. RESULTS: The level of NO in room air was 5.05 ± 3.37 ppb. Levels of exhaled NO decreased after CPB, varying from 11.25 ± 5.65 ppb to 8.37 ± 3.71 ppb (p = 0.031). CONCLUSIONS: The reduction of exhaled NO after CPB observed in this study does not confirm the role of this molecule as a marker of pulmonary lesion. However, the different degrees of pulmonary parenchymal collapse, the method used to collect the data, and the drugs, among others, could have contributed for this reduction.

JUSTIFICATIVA Y OBJETIVOS: La circulación extracorpórea (CEC), puede causar una disfunción pulmonar. Las alteraciones inflamatorias pueden afectar la liberación de óxido nítrico (NO). Se buscó evaluar el NO exhalado en pacientes sometidos a la revascularización del miocardio (RM) con CEC. MÉTODO: Se estudiaron prospectivamente nueve pacientes adultos sometidos a la RM con CEC. Inicialmente fue recolectada una muestra de aire para el análisis de NO en el sistema que alimenta el aparato de anestesia. A continuación, se inició la anestesia por vía venosa con etomidato (0,3 mg.kg-1), sufentanil (0,3 µg.kg-1), pancuronio (0,08 mg.kg-1) y se mantiene con isoflurano (0,5 a 1,0 CAM) y sufentanil (0,5 µg.kg-1.h-1). El volumen corriente fijado fue 8 mL.kg-1, con FiO2 de 0,6 excepto durante la CEC. Treinta minutos después de la inducción y treinta minutos después de la CEC, tres muestras secuenciales de aire exhalado fueron recogidas para análisis de NO, por quimioluminescencia. Los datos fueron analizados por medio del test t Student. RESULTADOS: El valor del NO del aire ambiente fue de 5,05 ± 3,37 ppmm. El NO exhalado se redujo después de la CEC, variando de 11,25 ± 5,65 ppmm para 8,37 ± 3,17 ppmm (p = 0,031). CONCLUSIONES: La reducción del NO exhalado pos-CEC, observada en este estudio, no permite confirmar el papel de esta molécula como marcador de lesión pulmonar. Sin embargo, los variados grados de colapso del parénquima pulmonar, el método de obtención de los datos, y los fármacos utilizados, entre otros, pueden haber contribuido para esa reducción.

OBJETIVO: Avaliar a Qualidade de Vida relacionada à saúde em pacientes submetidos à Diálise Peritoneal Automatizada (DPA) e Hemodiálise em um centro de diálise satélite no Município de São Paulo. MÉTODOS: Este estudo observacional transversal, incluiu 101 pacientes com idade entre 18-75 anos, em terapia há mais de 90 dias e que compreenderam o questionário. RESULTADOS: O grupo em Hemodiálise (n=79) estava em terapia há mais tempo (p=0.001) e tinha albumina sérica maior (p<0.001) comparado ao grupo em DPA (n=22). Os escores do SF-36 foram semelhantes em várias dimensões, exceto pelo escore de Aspectos Físicos que foi maior nos pacientes em Hemodiálise (p=0.03). Não houveram interações significativas entre SF-36 e as demais variáveis que explicassem esta diferença. CONCLUSÃO: A Qualidade de Vida foi semelhante entre as modalidades, porém o escore de Aspectos Físicos foi menor para pacientes em Diálise Peritoneal Automatizada.

OBJECTIVE: To evaluate the health-related quality of life in patients from a satellite dialysis center in São Paulo city undergoing Automated Peritoneal Dialysis (APD) or Hemodialysis. METHODS: This cross-sectional descriptive study included 101 patients with ages ranging from 18 to 75 years-old, who were in dialysis treatment over 90 days and able to understand the items of the SF-36 questionnaire in Portuguese. RESULTS: The Hemodialysis group (n=79) had been in dialysis treatment longer (p=0.001) and had higher serum albumin level (p<0.001) than the APD group (n=22). The SF-36 scores of the two groups were similar in all dimensions, except for the physical functioning dimension, on which the hemodialysis group had higher scores than the APD group (p=0.03). There were no statistically significant interactions between the SF-36 score and the other variables of the study. CONCLUSION: There were no differences in quality of life between patients on APD and patients on hemodialysis, except for the physical functioning dimension.

OBJETIVO: Evaluar la Calidad de Vida relacionada a la salud de pacientes sometidos a Diálisis Peritoneal Automatizada (DPA) y Hemodiálisis en un centro de diálisis del Municipio de Sao Paulo. MÉTODOS: Este estudio observacional transversal, incluyó a 101 pacientes con edades comprendidas entre los 18 y 75 años, que se encontraban en terapia hace más de 90 días y que comprendieran el cuestionario. RESULTADOS: El grupo en Hemodiálisis (n=79) estaba en terapia hace más de un tiempo (p=0.001) y tenía albúmina sérica mayor (p<0.001) comparado al grupo en DPA (n=22). Los escores del SF-36 fueron semejantes en varias dimensiones, excepto para el escore de Aspectos Físicos que fue mayor en los pacientes en Hemodiálisis (p=0.03). No hubo interacciones significativas entre SF-36 y las demás variables que explicaran esta diferencia. CONCLUSIÓN: La calidad de Vida fue semejante entre las modalidades, no obstante el escore de Aspectos Físicos fue menor para pacientes en Diálisis Peritoneal Automatizada.

OBJECTIVE: To evaluate the health-related quality of life in patients from a satellite dialysis center in São Paulo city undergoing Automated Peritoneal Dialysis (APD) or Hemodialysis. METHODS: This cross-sectional descriptive study included 101 patients with ages ranging from 18 to 75 years-old, who were in dialysis treatment over 90 days and able to understand the items of the SF-36 questionnaire in Portuguese. RESULTS: The Hemodialysis group (n=79) had been in dialysis treatment longer (p=0.001) and had higher serum albumin level (p<0.001) than the APD group (n=22). The SF-36 scores of the two groups were similar in all dimensions, except for the physical functioning dimension, on which the hemodialysis group had higher scores than the APD group (p=0.03). There were no statistically significant interactions between the SF-36 score and the other variables of the study. CONCLUSION: There were no differences in quality of life between patients on APD and patients on hemodialysis, except for the physical functioning dimension.

OBJETIVO: Evaluar la Calidad de Vida relacionada a la salud de pacientes sometidos a Diálisis Peritoneal Automatizada (DPA) y Hemodiálisis en un centro de diálisis del Municipio de Sao Paulo. MÉTODOS: Este estudio observacional transversal, incluyó a 101 pacientes con edades comprendidas entre los 18 y 75 años, que se encontraban en terapia hace más de 90 días y que comprendieran el cuestionario. RESULTADOS: El grupo en Hemodiálisis (n=79) estaba en terapia hace más de un tiempo (p=0.001) y tenía albúmina sérica mayor (p<0.001) comparado al grupo en DPA (n=22). Los escores del SF-36 fueron semejantes en varias dimensiones, excepto para el escore de Aspectos Físicos que fue mayor en los pacientes en Hemodiálisis (p=0.03). No hubo interacciones significativas entre SF-36 y las demás variables que explicaran esta diferencia. CONCLUSIÓN: La calidad de Vida fue semejante entre las modalidades, no obstante el escore de Aspectos Físicos fue menor para pacientes en Diálisis Peritoneal Automatizada.

OBJETIVO: Avaliar a Qualidade de Vida relacionada à saúde em pacientes submetidos à Diálise Peritoneal Automatizada (DPA) e Hemodiálise em um centro de diálise satélite no Município de São Paulo. MÉTODOS: Este estudo observacional transversal, incluiu 101 pacientes com idade entre 18-75 anos, em terapia há mais de 90 dias e que compreenderam o questionário. RESULTADOS: O grupo em Hemodiálise (n=79) estava em terapia há mais tempo (p=0.001) e tinha albumina sérica maior (p<0.001) comparado ao grupo em DPA (n=22). Os escores do SF-36 foram semelhantes em várias dimensões, exceto pelo escore de Aspectos Físicos que foi maior nos pacientes em Hemodiálise (p=0.03). Não houveram interações significativas entre SF-36 e as demais variáveis que explicassem esta diferença. CONCLUSÃO: A Qualidade de Vida foi semelhante entre as modalidades, porém o escore de Aspectos Físicos foi menor para pacientes em Diálise Peritoneal Automatizada.

OBJECTIVE: To investigate the recognition of depressive symptoms of major depressive disorder (MDD) by general practitioners. INTRODUCTION: MDD is underdiagnosed in medical settings, possibly because of difficulties in the recognition of specific depressive symptoms. METHODS: A cross-sectional study of 316 outpatients at their first visit to a teaching general hospital. We evaluated the performance of 19 general practitioners using Primary Care Evaluation of Mental Disorders (PRIME-MD) to detect depressive symptoms and compared them to 11 psychiatrists using Structured Clinical Interview Axis I Disorders, Patient Version (SCID I/P). We measured likelihood ratios, sensitivity, specificity, and false positive and false negative frequencies. RESULTS: The lowest positive likelihood ratios were for psychomotor agitation/retardation (1.6) and fatigue (1.7), mostly because of a high rate of false positive results. The highest positive likelihood ratio was found for thoughts of suicide (8.5). The lowest sensitivity, 61.8%, was found for impaired concentration. The sensitivity for worthlessness or guilt in patients with medical illness was 67.2% (95% CI, 57.4-76.9%), which is significantly lower than that found in patients without medical illness, 91.3% (95% CI, 83.2-99.4%). DISCUSSION: Less adequately identified depressive symptoms were both psychological and somatic in nature. The presence of a medical illness may decrease the sensitivity of recognizing specific depressive symptoms. CONCLUSIONS: Programs for training physicians in the use of diagnostic tools should consider their performance in recognizing specific depressive symptoms. Such procedures could allow for the development of specific training to aid in the detection of the most misrecognized depressive symptoms.

INTRODUÇÃO: A relação entre asma e refluxo gastroesofágico permanece pouco compreendida. O reflexo vagal e a microaspiração estão entre os mecanismos propostos para explicar a piora da asma pelo refluxo gastroesofágico. OBJETIVO: Avaliar o volume expirado forçado no primeiro segundo após a acidificação esofágica. MÉTODO: O estudo investigou os efeitos da infusão ácida em treze voluntários portadores de asma moderada e refluxo gastroesofágico. Foram realizadas espirometrias antes e depois da inserção esofágica de uma sonda nasogástrica 8F e um cateter de pHmetria. Outras medidas de volume expirado forçado no primeiro segundo foram realizadas depois de quinze minutos de infusão de solução salina no ponto médio entre o esfíncter esofágico superior e o inferior, e depois de quinze minutos da acidificação esofágica, a cada cinco minutos mantida a acidificação, até a obtenção de um valor estável (variação < 5%). RESULTADOS: O volume expirado forçado no primeiro segundo (média do grupo) apresentou-se estável durante os procedimentos de sondagem, infusão de solução salina, infusão de ácido clorídrico e manutenção de ácido clorídrico (p = 0,72). Dois casos apresentaram queda do volume expirado forçado no primeiro segundo (de 11% e 22%) devida à sondagem, outros dois pela infusão de solução salina (13% e 14%) e um caso após a infusão ácida (de 22%). CONCLUSÃO: A acidificação esofágica por pequenos períodos não desencadeia alterações espirométricas num grupo de asmáticos com refluxo gastroesofágico. Entretanto, há casos em que a simples manipulação esofágica ou infusões causam broncoespasmo.

BACKGROUND: The relationship between asthma and gastroesophageal reflux is, as yet, not completely understood. Among the mechanisms thought to be responsible for gastroesophageal reflux-related worsening of asthma symptoms are the vagovagal reflex and microaspiration. OBJECTIVE: To assess forced expiratory volume in one second after acid infusion. METHOD: This study investigated the effect of acid infusion in 13 volunteers with moderate asthma and gastroesophageal reflux. Spirometry was performed before and after insertion of an 8F nasogastric tube and a pH meter. After 15 minutes of saline solution infusion into the midpoint between the upper esophageal sphincter and lower esophageal sphincter, and again after 15 minutes of esophageal acidification (with hydrochloric acid) of the same area, forced expiratory volume in one second was reassessed. Acidification was repeated every 5 minutes until forced expiratory volume in one second values stabilized (variation: < 5%). RESULTS: Mean forced expiratory volume in one second values remained stable during the tube insertion, saline infusion, initial hydrochloric acid infusion and subsequent hydrochloric acid infusion procedures (p = 0.72). Lower forced expiratory volume in one second values were seen resulting from the tube insertion in two patients (drops of 11% and 22%, respectively), after saline infusion in another two (drops of 13% and 14%) and after acid infusion in 1 (a drop of 22%). CONCLUSION: Esophageal acidification over short periods does not lead to spirometric alterations in a group of asthmatics with gastroesophageal reflux. However, in some cases, simple esophageal procedures or infusions result in bronchospasm.