Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial

Abstract Introduction Several studies have shown that maximizing stroke volume (or increasing it until a plateau is reached) by volume loading during high-risk surgery may improve post-operative outcome. This goal could be achieved simply by minimizing the variation in arterial pulse pressure (ΔPP) induced by mechanical ventilation. We tested this hypothesis in a prospective, randomized, single-centre study. The primary endpoint was the length of postoperative stay in hospital. Methods Thirty-three patients undergoing high-risk surgery were randomized either to a control group (group C, n = 16) or to an intervention group (group I, n = 17). In group I, ΔPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10% or less by volume loading. Results Both groups were comparable in terms of demographic data, American Society of Anesthesiology score, type, and duration of surgery. During surgery, group I received more fluid than group C (4,618 ± 1,557 versus 1,694 ± 705 ml (mean ± SD), P < 0.0001), and ΔPP decreased from 22 ± 75 to 9 ± 1% (P < 0.05) in group I. The median duration of postoperative stay in hospital (7 versus 17 days, P < 0.01) was lower in group I than in group C. The number of postoperative complications per patient (1.4 ± 2.1 versus 3.9 ± 2.8, P < 0.05), as well as the median duration of mechanical ventilation (1 versus 5 days, P < 0.05) and stay in the intensive care unit (3 versus 9 days, P < 0.01) was also lower in group I. Conclusion Monitoring and minimizing ΔPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital. Trial registration NCT00479011

Prevalence and correlates of dizziness in community-dwelling older people: a cross sectional population based study

Abstract Background Dizziness is a common complaint among older adults and has been linked to a wide range of health conditions, psychological and social characteristics in this population. However a profile of dizziness is still uncertain which hampers clinical decision-making. We therefore sought to explore the relationship between dizziness and a comprehensive range of demographic data, diseases, health and geriatric conditions, and geriatric syndromes in a representative sample of community-dwelling older people. Methods This is a cross-sectional, population-based study derived from FIBRA (Network for the Study of Frailty in Brazilian Elderly Adults), with 391 elderly adults, both men and women, aged 65 years and older. Elderly participants living at home in an urban area were enrolled through a process of random cluster sampling of census regions. The outcome variable was the self-report of dizziness in the last year. Several feelings of dizziness were investigated including vertigo, spinning, light or heavy headedness, floating, fuzziness, giddiness and instability. A multivariate logistic regression analysis was conducted to estimate the adjusted odds ratios and build the probability model for dizziness. Results The complaint of dizziness was reported by 45% of elderly adults, from which 71.6% were women (p=0.004). The multivariate regression analysis revealed that dizziness is associated with depressive symptoms (OR = 2.08; 95% CI 1.29–3.35), perceived fatigue (OR = 1.93; 95% CI 1.21-3.10), recurring falls (OR = 2.01; 95% CI 1.11-3.62) and excessive drowsiness (OR = 1.91; 95% CI 1.11–3.29). The discrimination of the final model was AUC = 0.673 (95% CI 0.619-0.727) (p< 0.001). Conclusions The prevalence of dizziness in community-dwelling elderly adults is substantial. It is associated with other common geriatric conditions usually neglected in elderly adults, such as fatigue and drowsiness, supporting its possible multifactorial manifestation. Our findings demonstrate the need to expand the design in future studies, aiming to estimate risk and identify possible causal relations.

PReS-FINAL-2170: Work disability in adult patients with juvenile idiopathic arthritis (JIA)

Introduction Approximately 20% JIA patients enters adulthood with clinically active disease and disabled, therefore work condition may be affected. Objectives To assess the prevalence of work disability among adult patients with JIA regularly attending a tertiary heumatology center and to determine possible associated risk factors. Methods This was a cross-sectional study that enrolled 43 JIA patients according to 2004 revised ILAR criteria. A questionnaire was developed in order to evaluate working status and labor activity: occupation, current/previous work, employment status and withdrawal rate were actively searched. Demographic data, JIA characteristics, clinical activity (DAS28>2.6), therapeutic intervention, comorbidities, physical activity, sedentarism (WHO definitions), functional class (1991 ACR criteria), HAQ and SF-36 were recorded. The prevalence of work disability was calculated using 95% confidence interval, and compared to all parameters; qualitative variables were analyzed using tests of association (chi-square test) and quantitative variables by Mann-Whitney or student test. Results Patients' mean age was 29+7.4 yrs (range 19-41) with mean JIA duration = 17.2+12.3 yrs (range 3-33); 63% were males and 37% females. JIA subtypes were 64% polyarticular, 11% oligoarticular, 9% systemic, 9% ERA, 2% extended oligoarticular, 2% psoriatic arthritis; 7% had uveitis. Serum RF was positive in 21% and ANA in 21%. The majority (72%, n = 31) of JIA patients were employed, whereas 28% (n = 12) were currently not working. In the latter group, 83% (10/12) were retired due to JIA related disability. Further analysis comparing those currently working vs. Those not working revealed similar age (25,3 yrs vs.29,5 yrs, p = 0,09). Although not significantly, most patients currently working had Poly onset JIA (22 vs. 6 p = 0,37), higher frequencies of good education level >12 yrs of school (31 vs.9, p = 0,38), functional class I (p = 0,96), practiced regular physical activity (9 vs. 0, p = 0,89), were singles (26 vs. 8, p = 0,15). Both groups had comparable HAQ and DAS 28 scores (0,62 vs. 0.59, p = 0,47 and 2,51 vs.2,07, p = 0,64) and similar arthroplasty rate (8 vs. 4, p = 0,427). Frequencies of hypertension (3 vs.1, p = 0,999), dyslipidemia (1 vs. 1, p = 0,125), diabetes (1 vs. 0 p = 0,999), depression (1 vs. 0, p = 0,999) and smokers (3 vs. 1, p = 0,99) were alike in both groups. Remarkably, employed patients had higher SF 36 mental health component (84.0 vs. 70.42, P = 0.01). Conclusion High prevalence of almost 1/3 work disability and of retirement due to disease related incapacity remain major problems for adult JIA individuals. We also identified worse mental health in employed patients indicating that further research is needed, in addition to intense affirmative disability actions in order to remove possible disabling barriers and to adapt restrictive environments for these patients. Moreover, enhanced strategies and policy for inclusion of JIA patients in the job market is urged.

Survey of Trachoma within School Students in the State of Roraima, Brazil

Purpose: Trachoma, a blinding conjunctivitis, is the result of repeated infection with Chlamydia trachomatis. There are no recent data for the state of Roraima, Brazil, where it was thought that trachoma no longer existed. These data are derived from school children sampled in this state, with additional data collected from the contacts of children with trachoma. Design: A population-based cross-sectional study with random sampling of students in grades 1 through 4 of all public schools within municipalities where the human development index was less than the national average in 2003. The sample was stratified according to population size. Participants: A sample size of 7200 was determined and a total of 6986 (93%) students were examined, along with an additional 2152 contacts. Methods: All students were examined for trachoma according to World Health Organization criteria. Demographic data and contact information also was collected. The family and school contacts of students with trachoma then were located and examined. Main Outcome Measures: Prevalence and grade of trachoma, age, gender, race, and municipality location. Results: The overall prevalence of trachoma was 4.5% (95% confidence interval [CI], 3.7%–5.3%), but there were municipalities within the state where the prevalence of inflammatory trachoma was more than 10%. The prevalence was greater in rural areas (4.9%; 95% CI, 3.7%–6.0%) compared with urban areas (3.9%; 95% CI, 2.9%–4.9%). Living in indigenous communities was associated with trachoma (odds ratio, 1.6; 95% CI, 0.9 –2.6). An additional 2152 contacts were examined, and the overall trachoma prevalence was 9.3% (95% CI, 8.1–10.5). Conclusions: Trachoma continues to exist in Roraima, Brazil, where there are municipalities with a significant prevalence of disease. The indigenous population is highly mobile, crossing state and international borders, raising the possibility of trachoma in neighboring countries. Trachoma prevalence among the contacts of students with trachoma was higher than the school population, highlighting the importance of contact tracing.

Instrumental activities of daily living performance in healthy and cognitively intact seniors from a Brazilian sample and its relation to age and other socio-demographic variables

Background: Studies on functional capacity in community-dwelling older people have shown associations between declines in instrumental activities of daily living (IADL) and several factors. Among these, age has been the most consistently related to functional capacity independent of other variables. We aimed at evaluating the performance of a sample of healthy and cognitively intact Brazilian older people on activities of daily living and to analyze its relation to social-demographic variables. Methods: We conducted a secondary analysis of data collected for previous epidemiological studies with community-dwelling subjects aged 60 years or more. We selected subjects who did not have dementia or depression, and with no history of neurological diseases, heart attack, HIV, hepatitis or arthritis (n = 1,111). Functional capacity was assessed using the Brazilian version of the Older American Resources and Services Questionnaire (BOMFAQ). ADL performance was analyzed according to age, gender, education, and marital status (Pearson's chi(2), logistic regression). Results: IADL difficulties were present in our sample, especially in subjects aged 80 years or more, with lower levels of education, or widowed. The logistic regression analysis results indicated that "higher age" and "lower education" (p <= 0.001) remained significantly associated with IADL difficulty. Conclusions: Functional decline was present in older subjects even in the absence of medical conditions and cognitive impairment. Clinicians and researchers could benefit from knowing what to expect from older people regarding IADL performance in the absence of medical conditions.

Demographic processes in the montane Atlantic rainforest: Molecular and cytogenetic evidence from the endemic frog Proceratophrys boiei

Historical climatic refugia predict genetic diversity in lowland endemics of the Brazilian Atlantic rainforest. Yet, available data reveal distinct biological responses to the Last Glacial Maximum (LGM) conditions across species of different altitudinal ranges. We show that species occupying Brazil's montane forests were significantly less affected by LGM conditions relative to lowland specialists, but that pre-Pleistocene tectonics greatly influenced their geographic variation. Our conclusions are based on palaeoclimatic distribution models, molecular sequences of the cytochrome b, 16S, and RAG-1 genes, and karyotype data for the endemic frog Proceratophrys boiei. DNA and chromosomal data identify in P. boiei at least two broadly divergent phylogroups, which have not been distinguished morphologically. Cytogenetic results also indicate an area of hybridization in southern Sao Paulo. The location of the phylogeographic break broadly matches the location of a NW-SE fault, which underwent reactivation in the Neogene and led to remarkable landscape changes in southeastern Brazil. Our results point to different mechanisms underpinning diversity patterns in lowland versus montane tropical taxa, and help us to understand the processes responsible for the large number of narrow endemics currently observed in montane areas of the southern Atlantic forest hotspot. (C) 2011 Elsevier Inc. All rights reserved.

THE SOCIOECONOMIC AND DEMOGRAPHIC CHARACTERIZATION OF CHILDREN AND ADOLESCENTS WHO STUDY AND WORK OUTSIDE THEIR HOME

The objective of this study was to identify the socioeconomic and demographic characteristics of children and adolescents who study and work outside their home. This non-experimental, correlational, cross-sectional study was performed using questionnaires applied to primary education students, enrolled in public schools in Ribeirao Preto (Brazil). Two schools were selected through a draw. Data analysis was performed using Statistical Package for Social Sciences, version 14.0. Of the 133 students who answered the questionnaire, 36 (27.7%) reported working outside their home, 20.6% were between 11 and 13 years of age, and 66.7% were male (p=0.000) and had started working early to help with the family income (p=0.003). The salary they received helped comprise the family income, and it was found that as the family income increased, the need for the youngsters to work was reduced. It was found that many factors contribute to these subjects' early start at work, including family size, structure and poverty.

Infant mortality in Brazil, 1980-2000: A spatial panel data analysis

Background: Infant mortality is an important measure of human development, related to the level of welfare of a society. In order to inform public policy, various studies have tried to identify the factors that influence, at an aggregated level, infant mortality. The objective of this paper is to analyze the regional pattern of infant mortality in Brazil, evaluating the effect of infrastructure, socio-economic, and demographic variables to understand its distribution across the country. Methods: Regressions including socio-economic and living conditions variables are conducted in a structure of panel data. More specifically, a spatial panel data model with fixed effects and a spatial error autocorrelation structure is used to help to solve spatial dependence problems. The use of a spatial modeling approach takes into account the potential presence of spillovers between neighboring spatial units. The spatial units considered are Minimum Comparable Areas, defined to provide a consistent definition across Census years. Data are drawn from the 1980, 1991 and 2000 Census of Brazil, and from data collected by the Ministry of Health (DATASUS). In order to identify the influence of health care infrastructure, variables related to the number of public and private hospitals are included. Results: The results indicate that the panel model with spatial effects provides the best fit to the data. The analysis confirms that the provision of health care infrastructure and social policy measures (e. g. improving education attainment) are linked to reduced rates of infant mortality. An original finding concerns the role of spatial effects in the analysis of IMR. Spillover effects associated with health infrastructure and water and sanitation facilities imply that there are regional benefits beyond the unit of analysis. Conclusions: A spatial modeling approach is important to produce reliable estimates in the analysis of panel IMR data. Substantively, this paper contributes to our understanding of the physical and social factors that influence IMR in the case of a developing country.

Phylogeography of an Atlantic forest passerine reveals demographic stability through the last glacial maximum

In this study we analyzed the phylogeographic pattern and historical demography of an endemic Atlantic forest (AF) bird, Basileuterus leucoblepharus, and test the influence of the last glacial maximum (LGM) on its population effective size using coalescent simulations. We address two main questions: (i) Does B. leucoblepharus present population genetic structure congruent with the patterns observed for other AF organisms? (ii) How did the LGM affect the effective population size of B. leucoblepharus? We sequenced 914 bp of the mitochondrial gene cytochrome b and 512 bp of the nuclear intron 5 of beta-fibrinogen of 62 individuals from 15 localities along the AF. Both molecular markers revealed no genetic structure in B. leucoblepharus. Neutrality tests based on both loci showed significant demographic expansion. The extended Bayesian skyline plot showed that the species seems to have experienced demographic expansion starting around 300,000 years ago, during the late Pleistocene. This date does not coincide with the LGM and the dynamics of population size showed stability during the LGM. To further test the effect of the LGM on this species, we simulated seven demographic scenarios to explore whether populations suffered specific bottlenecks. The scenarios most congruent with our data were population stability during the LGM with bottlenecks older than this period. This is the first example of an AF organism that does not show phylogeographic breaks caused by vicariant events associated to climate change and geotectonic activities in the Quaternary. Differential ecological, environmental tolerances and habitat requirements are possibly influencing the different evolutionary histories of these organisms. Our results show that the history of organism diversification in this megadiverse Neotropical forest is complex. Crown Copyright (c) 2012 Published by Elsevier Inc. All rights reserved.

Suicide rates and trends in Sao Paulo, Brazil, according to gender, age and demographic aspects: a joinpoint regression analysis

Objective: To evaluate suicide rates and trends in Sao Paulo by sex, age-strata, and methods. Methods: Data was collected from State registry from 1996 to 2009. Population was estimated using the National Census. We utilized joinpoint regression analysis to explore temporal trends. We also evaluated marital status, ethnicity, birthplace and methods for suicide. Results: In the period analyzed, 6,002 suicides were accrued with a rate of 4.6 per 100,000 (7.5 in men and 2.0 in women); the male-to-female ratio was around 3.7. Trends for men presented a significant decline of 5.3% per year from 1996 to 2002, and a significant increase of 2.5% from 2002 onwards. Women did not present significant changes. For men, the elderly (> 65 years) had a significant reduction of 2.3% per year, while younger men (25-44 years) presented a significant increase of 8.6% from 2004 onwards. Women did not present significant trend changes according to age. Leading suicide methods were hanging and poisoning for men and women, respectively. Other analyses showed an increased suicide risk ratio for singles and foreigners. Conclusions: Specific epidemiological trends for suicide in the city of Sao Paulo that warrant further investigation were identified. High-risk groups - such as immigrants - could benefit from targeted strategies of suicide prevention.

Suicide rates and trends in São Paulo, Brazil, according to gender, age and demographic aspects: a joinpoint regression analysis

OBJECTIVE: To evaluate suicide rates and trends in São Paulo by sex, age-strata, and methods. METHODS: Data was collected from State registry from 1996 to 2009. Population was estimated using the National Census. We utilized joinpoint regression analysis to explore temporal trends. We also evaluated marital status, ethnicity, birthplace and methods for suicide. RESULTS: In the period analyzed, 6,002 suicides were accrued with a rate of 4.6 per 100,000 (7.5 in men and 2.0 in women); the male-to-female ratio was around 3.7. Trends for men presented a significant decline of 5.3% per year from 1996 to 2002, and a significant increase of 2.5% from 2002 onwards. Women did not present significant changes. For men, the elderly (> 65 years) had a significant reduction of 2.3% per year, while younger men (25-44 years) presented a significant increase of 8.6% from 2004 onwards. Women did not present significant trend changes according to age. Leading suicide methods were hanging and poisoning for men and women, respectively. Other analyses showed an increased suicide risk ratio for singles and foreigners. CONCLUSIONS: Specific epidemiological trends for suicide in the city of São Paulo that warrant further investigation were identified. High-risk groups - such as immigrants - could benefit from targeted strategies of suicide prevention.