Liver transplant outcome: a comparison between high and low MELD score recipients

OBJECTIVE: To compare low and high MELD scores and investigate whether existing renal dysfunction has an effect on transplant outcome. METHODS: Data was prospectively collected among 237 liver transplants (216 patients) between March 2003 and March 2009. Patients with cirrhotic disease submitted to transplantation were divided into three groups: MELD > 30, MELD < 30, and hepatocellular carcinoma. Renal failure was defined as a ± 25% decline in estimated glomerular filtration rate as observed 1 week after the transplant. Median MELD scores were 35, 21, and 13 for groups MELD > 30, MELD < 30, and hepatocellular carcinoma, respectively. RESULTS: Recipients with MELD > 30 had more days in Intensive Care Unit, longer hospital stay, and received more blood product transfusions. Moreover, their renal function improved after liver transplant. All other groups presented with impairment of renal function. Mortality was similar in all groups, but renal function was the most important variable associated with morbidity and length of hospital stay. CONCLUSION: High MELD score recipients had an improvement in the glomerular filtration rate after 1 week of liver transplantation.

The use of severity indexes to estimate the risk of death in Intensive Care

The Simplified Acute Physiology Score II (SAPS II) and Logistic Organ Dysfunction System (LODS) are instruments used to classify Intensive Care Unit (ICU) inpatients according to the severity of their condition and risk of death, and evaluate the quality of nursing care. The objective of this study is to evaluate and compare the performance of SAPS II and LODS to predict the mortality of patients admitted to the ICU. The participants were 600 patients from four ICUs located in Sao Paulo, Brazil. Receiver Operator Characteristic (ROC) curves were used to compare the performance of the indexes. Results: The areas under the ROC curves of LODS (0.69) and SAPS II (0.71) indicated moderate discriminatory capacity to identify death or survival. No statistically significant differences were found between these areas (p=0.26). In conclusion, there was equivalence between SAPS II and LODS to estimate the risk of death of ICU patients.

Desempenho de índices de gravidade para estimar risco de morte em Unidades de Terapia Intensiva

O Simplified Acute Physiology Score II (SAPS II) e o Logistic Organ Dysfunction System (LODS) são instrumentos utilizados para classificar pacientes internados em Unidades de Terapia Intensiva (UTI) conforme a gravidade e o risco de morte, sendo um dos parâmetros da qualidade da assistência de enfermagem. Este estudo teve por objetivo avaliar e comparar as performances do SAPS II e do LODS para predizer mortalidade de pacientes admitidos em UTI. Participaram do estudo 600 pacientes de quatro diferentes UTIs de São Paulo, Brasil. A curva Receiver Operator Characteristic (ROC) foi utilizada para comparar o desempenho discriminatório dos índices. Os resultados foram: as áreas sob a curva do LODS (0.69) e do SAPS II (0.71) apresentaram moderada capacidade discriminatória para predizer mortalidade. Não foi encontrada diferença estatisticamente significativa entre as áreas (p=0,26). Concluiu-se que houve equivalência entre SAPS II e LODS para estimar risco de morte de pacientes em UTI.

Construction and validation of an instrument that breaks the silence: the impact of domestic and/or sexual violence on women's health, as shown during climacterium

Objective: The aim of this study was to construct and to validate a measure of the consequences of domestic violence on women's health during climacterium. Methods: A questionnaire was administered at the Outpatient Climacterium Clinic to 124 women aged 40 to 65 years who were the victims of domestic and/or sexual violence (experimental group). They were divided into three groups: (1) those who were victims of violence exclusively during childhood/adolescence, (2) those who were victims of violence exclusively during adulthood, and (3) those who were victims of violence throughout their lives. The instrument included 34 items evaluating the beginning, frequency, and type of violence; the search for health assistance and reporting of the violence; the violence and the number of comorbidities; and violence and the Kupperman Menopausal Index. We also included a control group composed of perimenopausal and postmenopausal women who did not experience any violence (n = 120). Results: The instrument presented a Cronbach alpha = 0.82, good reliability among the examiners (+0.80), and a good possibility of reproducibility. The mean age of menopause was 45.4 years, and the mean age in the control group was 48.1 years. Group 1 showed a mean of 5.1 comorbidities, Group 2 had 4.6, and Group 3 had 4.4. Sexual violence (43.5%) and other types of violence both presented average comorbidities (4.60) but represented a significant impairment in the victim's sexual life. There were significant associations in group 3 and a high Kupperman Menopausal Index score. In the experimental group, 80.6% did not seek health services for the violence they experienced. Conclusions: The questionnaire presented good internal consistency and a validated construction. It can be easily reproduced and is indicated to evaluate the consequences of domestic and/or sexual violence on women's health during climacterium.

The role of pneumonia scores in the emergency room in patients infected by 2009 H1N1 infection

Despite the severity of pneumonia in patients with pandemic influenza A infection (H1N1), no validated risk scores associated with H1N1 pneumonia were tested. In this prospective observational study, we analyzed data of consecutive patients in our emergency room, hospitalized because of pneumonia between July and August 2009 in a public hospital in Brazil. The following pneumonia scoring systems were applied: the SMART-COP rule; the Pneumonia Severity Index; and the CURB-65 rule. Of 105 patients with pneumonia, 53 had H1N1 infection. Among them, only 9.5% that had a low risk according to SMART-COP were admitted to ICU, compared with 36.8% of those with the Pneumonia Severity Index score of 1-2 and 49% of those with CURB-65 score of 0-1. The SMART-COP had an accuracy of 83% to predict ICU admission. The SMART-COP rule presented the best performance to indicate ICU admission in patients with H1N1 pneumonia. European Journal of Emergency Medicine 19: 200-202 (C) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Revisão analítica das escalas de disfagia

INTRODUÇÃO: Instrumento eficiente para medição da disfagia, facilmente reprodutível e estatisticamente consistente, deveria fornecer dados mais consistentes sobre os resultados e acompanhamento de doenças com disfagia. As propostas existentes mostram ampla cobertura na avaliação do sintoma disfágico. OBJETIVOS: Analisar as escalas de disfagia disponíveis sugerindo as que permitem avaliação mais objetiva e estatisticamente consistente, e não apenas ferramenta de mensuração, e sugerir as que melhor quantificam o sintoma e úteis para seguimento dos pacientes. MÉTODO: Foram pesquisados os seguintes descritores no Pubmed: "disfagia", "escala", "index", "score". Dez artigos foram selecionados entre 1995 e 2012 com propostas de escalas para a disfagia. RESULTADOS: A maioria das escalas não atingiram os requisitos para serem classificadas como ferramenta completa na avaliação de qualquer disfagia. Muitas são específicas para uma única doença, e poucas com maior abrangência, não têm consistência estatística. Para disfagia orofaríngea (cervical), as escalas FOIS e ASHA são citadas com mais frequência. Na disfagia motora (cervical), a de Zaninotto e Youssef têm aplicabilidade prática, mas ambas necessitam de validação estatística. A de Zaninotto parece ser mais precisa por incluir mais variáveis (disfagia, dor no peito e azia). As escalas que cobrem as duas formas de disfagia (ASHA e DHI) são bem diferentes em seus objetivos. A DHI é escala publicada recentemente examina os dois tipos de disfagia e tem validação estatística bem estruturada. Importante passo no futuro seria testar essa nova proposta com amostra mais expressiva e representativa, provavelmente consagrando esse novo instrumento de avaliação. CONCLUSÃO: As escalas mais frequentes de disfagia relatadas nos últimos 17 anos têm propósito e estruturas diferentes. As escalas FOIS e ASHA são muitas vezes utilizadas para a avaliação da disfagia orofaringeana (região cervical), ambas focadas em terapia nutricional. Para a avaliação motora baixa, a escala de Zaninotto e Youssef tem aplicação prática, e a DHI parece representar a ferramenta mais promissora na avaliação global da disfagia.

Estudo multicêntrico sobre escalas para grau de comprometimento em disfagia orofaríngea neurogênica

OBJETIVO: Analisar a concordância entre distintas escalas para grau de comprometimento em disfagia orofaríngea neurogênica. MÉTODOS: Foi realizado estudo clínico transversal. Participaram 200 indivíduos com disfagia orofaríngea neurogênica, 108 do gênero masculino e 92 do gênero feminino, com idades de 3 meses a 91 anos. Foram aplicadas quatro escalas para classificar o grau de comprometimento da disfagia orofaríngea, sendo duas escalas clínicas e duas videofluoroscópicas. Análises estatísticas foram realizadas para verificar a concordância entre as escalas clínicas e objetivas. RESULTADOS: Os resultados mostraram concordância muito boa entre as escalas clínicas estudadas (Kappa=0,92) e concordância moderada entre as escalas objetivas (Kappa=0,52). CONCLUSÃO: Embora a concordância entre as escalas clínicas tenha sido muito boa e entre as escalas objetivas tenha sido moderada, ainda é necessária ampla discussão e possível revisão dos parâmetros que definem o grau de comprometimento da disfagia orofaríngea em pacientes neurológicos.

Medidas fonológicas em crianças com transtorno fonológico

OBJETIVO: Comparar o desempenho de crianças com e sem transtorno fonológico (TF) quanto às habilidades de consciência fonológica (CF), índice de Porcentagem de Consoantes Corretas - Revisada (PCC-R) e Índice de Inconsistência de Fala (IIF), além de correlacionar estes resultados entre si. MÉTODOS: Participaram 36 sujeitos, entre 5 anos e 7 anos de idade, divididos em: Grupo Pesquisa (GP): 18 crianças com TF; e Grupo Controle (GC): 18 crianças em desenvolvimento típico de linguagem. Foi calculado o PCC-R, aplicado o IIF e o Teste de Sensibilidade Fonológica-Visual (TSF-V): aliteração igual (AI), diferente (AD) e total (AT), rima igual (RI), diferente (RD) e total (RT). Os resultados foram analisados estatisticamente. RESULTADOS: Foram encontradas diferenças na comparação dos grupos em todos os índices, com melhores desempenhos no GC. Neste, houve correlação negativa do IIF com todas as habilidades de CF e com o PCC-R, exceto com RI. Em todos os subtestes do TSF-V houve correlações positivas entre si. No GP, foram encontradas correlações positivas entre o PCC-R e as provas de aliteração; não foram encontradas correlações entre IFF e PCC-R, nem com as provas de CF. Houve correlações no TSF-V: AI com AT; AD com AT; AD com RD; RI com RT e RD com RT. CONCLUSÃO: Crianças com TF apresentam pior desempenho; as do GC, na medida em que estabilizam a produção de fala, desenvolvem as habilidades de rima e aliteração. As crianças do GP são mais inconsistentes e parecem desenvolver as habilidades de CF de forma desorganizada.

Does the neonatal clinical risk for illness severity influence pain reactivity and recovery in preterm infants?

Background: The biobehavioural pain reactivity and recovery of preterm infants in the neonatal period may reflect the capacity of the central nervous system to regulate neurobiological development. Objective: The aim of the present study was to analyse the influence of the neonatal clinical risk for illness severity on biobehavioural pain reactivity in preterm infants. Methods: Fifty-two preterm infants were allocated into two groups according to neonatal severity of illness, as measured by the Clinical Risk Index for Babies (CRIB). The low clinical risk (LCr) group included 30 neonates with CRIB scores <4, and the high clinical risk (HCr) group included 22 neonates with CRIB scores >= 4. Pain reactivity was assessed during a blood collection, which was divided into five phases (baseline, antisepsis, puncture, recovery-dressing and recovery-resting). Behavioral pain reactivity was measured using the scores, and magnitude of responses in Neonatal Facial Coding System (NFCS) and Sleep-Wake States Scale (SWS). The heart rate was continuously recorded. Results: The HCr demonstrated a higher magnitude of response on the SWS score from the baseline to the puncture phase than the LCr. Also, the HCr exhibited a higher mean heart rate and minimum heart rate than the LCr in the recovery-resting phase. In addition, the HCr exhibited a higher minimum heart rate from the baseline to the recovery-resting phase than the LCr. Conclusion: The infants exhibiting a high neonatal clinical risk showed high arousal during the puncture procedure and higher physiological reactivity in the recovery phase.

Body temperature, Aldrete-Kroulik index, and patient discharge from the Post-Anesthetic Recovery Unit

Patient discharge from post-anesthetic recovery (PAR) depends, among other factors, on normothermia and the patient's score on the Aldrete-Kroulik index. The objective of this study was to verify the relationship between the Aldrete-Kroulik index and body temperature in patients. This study was performed at the University of Sao Paulo University Hospital. Convenience sampling was used, and the sample consisted of 60 patients of ages between 18 and 60 years who underwent general anesthesia. The patients' body temperature was obtained by tympanic measurement, and the Aldrete-Kroulik index was measured on admission and at discharge from post-anesthetic recovery. The data were processed using SPSS, considering a significance level of 5%, and the Spearman and Wilcoxon tests were applied. In conclusion, no significant correlation was found between the two parameters for discharge.

Cross-cultural adaptation and assessment of the reliability and validity of the Core Outcome Measures Index (COMI) for the Brazilian-Portuguese language

The use of patient-orientated questionnaires is of utmost importance in assessing the outcome of spine surgery. Standardisation, using a common set of outcome measures, is essential to aid comparisons across studies/in registries. The Core Outcome Measures Index (COMI) is a short, multidimensional outcome instrument validated for patients with spinal disorders. This study aimed to produce a Brazilian-Portuguese version of the COMI. A cross-cultural adaptation of the COMI into Brazilian-Portuguese was carried out using established guidelines. 104 outpatients with chronic LBP (> 3 months) were recruited from a Public Health Spine Medical Care Centre. They completed a questionnaire booklet containing the newly translated COMI, and other validated symptom-specific questionnaires: Oswestry Disability Index (ODI) and Roland Morris disability scale (RM), and a pain visual analogue scale. All patients completed a second questionnaire within 7-10 days to assess reproducibility. The COMI summary score displayed minimal floor and ceiling effects. On re-test, the responses for each individual domain of the COMI were within 1 category in 98% patients for the domain 'function', 96% for 'symptom-specific well-being', 97% for 'general quality of life', 99% for 'social disability' and 100% for 'work disability'. The intraclass correlation coefficients (ICC2,1) for COMI pain and COMI summary scores were 0.91-0.96, which compared favourably with the corresponding values for the RM (ICC, 0.99) and ODI (ICC, 0.98). The standard error of measurement for the COMI was 0.6, giving a "minimum detectable change" (MDC95%) of approximately 1.7 points i.e., the minimum change to be considered "real change" beyond measurement error. The COMI scores correlated as hypothesised (Rho, 0.4-0.8) with the other symptom-specific questionnaires. The reproducibility of the Brazilian-Portuguese version of the COMI was comparable to that of other language versions. The COMI scores correlated in the expected manner with existing but longer symptom-specific questionnaires suggesting good convergent validity for the COMI. The Brazilian-Portuguese COMI represents a valuable tool for Brazilian study-centres in future multicentre clinical studies and surgical registries.

A Spatial Propensity Score Matching Evaluation of the Social Impacts of Sugarcane Growing on Municipalities in Brazil

The expansion of sugarcane growing in Brazil, spurred particularly by increased demand for ethanol, has triggered the need to evaluate the economic, social, and environmental impacts of this process, both on the country as a whole and on the growing regions. Even though the balance of costs and benefits is positive from an overall standpoint, this may not be so in specific producing regions, due to negative externalities. The objective of this paper is to estimate the effect of growing sugarcane on the human development index (HDI) and its sub-indices in cane producing regions. In the literature on matching effects, this is interpreted as the effect of the treatment on the treated. Location effects are controlled by spatial econometric techniques, giving rise to the spatial propensity score matching model. The authors analyze 424 minimum comparable areas (MCAs) in the treatment group, compared with 907 MCAs in the control group. The results suggest that the presence of sugarcane growing in these areas is not relevant to determine their social conditions, whether for better or worse. It is thus likely that public policies, especially those focused directly on improving education, health, and income generation/distribution, have much more noticeable effects on the municipal HDI.

Validation of the Duke Religion Index: DUREL (Portuguese Version)

The purpose of the current study was to examine the psychometric properties of the Portuguese version of the Duke Religion Index (PDUREL) in a community setting. PDUREL was translated and adapted for administration to 383 individuals from a population-based study of low-income community-dwelling adults. The PDUREL intrinsic subscale and total scores demonstrated high internal consistency (alphas ranging from 0.733 for the total scale score to 0.758 for the intrinsic subscale). Correlations among the DUREL subscales were also examined for evidence of discriminant validity. Correlations were ranging from 0.36 to 0.46, indicating significant overlap between the scales without marked redundancy. PDUREL is a reliable and valid scale. The availability of a comprehensive, but brief measure of religiousness can help to study the role of religiousness in health by researchers from countries that speak the Portuguese language.

Predicting pH at birth in pregnancies with abnormal pulsatility index and positive end-diastolic velocity in the umbilical artery

Objectives: To identify potential associations between fetal surveillance tests and acidosis at birth in pregnancies with abnormal but positive end-diastolic velocity in the umbilical artery. Methods: A prospective case-control study [group 1: pH < 7.2; group 2: pH >= 7.2] including 46 fetuses with abnormal but positive end-diastolic velocity in the umbilical artery was conducted between February 2007 and March 2009. Outcome variables were evaluated by univariate analysis and compared between the two groups. Clinically relevant and statistically significant variables were analyzed by logistic regression. Results: Abnormal nonstress test, presence of deceleration, and absent fetal breathing movements were statistically significant. Logistic regression analysis revealed that fetal heart rate (FHR) deceleration in the nonstress test is the only predictor of fetal acidosis at birth (p = 0.024; OR = 8.2; 95% CI: 1.2-52). Conclusions: In fetuses with positive end-diastolic flow velocity, acute variables of the antenatal surveillance tests are correlated with acidosis at birth and FHR deceleration in the nonstress test is the only predictor of fetal acidosis.

TRANSLATION AND VALIDATION OF THE KNEE SOCIETY SCORE - KSS FOR BRAZILIAN PORTUGUESE

Objective: To translate, culturally adapt and validate the "Knee Society Score"(KSS) for the Portuguese language and determine its measurement properties, reproducibility and validity. Method: We analyzed 70 patients of both sexes, aged between 55 and 85 years, in a cross-sectional clinical trial, with diagnosis of primary osteoarthritis,undergoing total knee arthroplasty surgery. We assessed the patients with the English version of the KSS questionnaire and after 30 minutes with the Portuguese version of the KSS questionnaire, done by a different evaluator. All the patients were assessed preoperatively, and again at three, and six months postoperatively. Results: There was no statistical difference, using Cronbach's alpha index and the Bland-Altman graphical analysis, for the knees core during the preoperative period (p=1), and at three months (p=0.991) and six months postoperatively (p=0.985). There was no statistical difference for knee function score for all three periods (p=1.0). Conclusion: The Brazilian version of the Knee Society Score is easy to apply, as well providing as a valid and reliable instrument for measuring the knee score and function of Brazilian patients undergoing TKA. Level of Evidence: Level I - Diagnostic Studies Investigating a Diagnostic Test- Testing of previously developed diagnostic criteria on consecutive patients (with universally applied 'gold' reference standard).