A decision support system to facilitate management of patients with acute gastrointestinal bleeding

Objective: To develop a model to predict the bleeding source and identify the cohort amongst patients with acute gastrointestinal bleeding (GIB) who require urgent intervention, including endoscopy. Patients with acute GIB, an unpredictable event, are most commonly evaluated and managed by non-gastroenterologists. Rapid and consistently reliable risk stratification of patients with acute GIB for urgent endoscopy may potentially improve outcomes amongst such patients by targeting scarce health-care resources to those who need it the most. Design and methods: Using ICD-9 codes for acute GIB, 189 patients with acute GIB and all. available data variables required to develop and test models were identified from a hospital medical records database. Data on 122 patients was utilized for development of the model and on 67 patients utilized to perform comparative analysis of the models. Clinical data such as presenting signs and symptoms, demographic data, presence of co-morbidities, laboratory data and corresponding endoscopic diagnosis and outcomes were collected. Clinical data and endoscopic diagnosis collected for each patient was utilized to retrospectively ascertain optimal management for each patient. Clinical presentations and corresponding treatment was utilized as training examples. Eight mathematical models including artificial neural network (ANN), support vector machine (SVM), k-nearest neighbor, linear discriminant analysis (LDA), shrunken centroid (SC), random forest (RF), logistic regression, and boosting were trained and tested. The performance of these models was compared using standard statistical analysis and ROC curves. Results: Overall the random forest model best predicted the source, need for resuscitation, and disposition with accuracies of approximately 80% or higher (accuracy for endoscopy was greater than 75%). The area under ROC curve for RF was greater than 0.85, indicating excellent performance by the random forest model Conclusion: While most mathematical models are effective as a decision support system for evaluation and management of patients with acute GIB, in our testing, the RF model consistently demonstrated the best performance. Amongst patients presenting with acute GIB, mathematical models may facilitate the identification of the source of GIB, need for intervention and allow optimization of care and healthcare resource allocation; these however require further validation. (c) 2007 Elsevier B.V. All rights reserved.

Left main stenting: do we need another study?

Coronary artery bypass graft (CABG) surgery has long been adopted as the treatment of choice for patients with left main (LM) coronary obstructions. In the past, randomised trials and observational studies have shown an advantage in survival of CABG against medical treatment. Recent studies comparing CABG with percutaneous coronary intervention (PCI) suggested that angioplasty may play a role as an alternative choice. However, well designed randomised trials to evaluate the relative merits of both therapeutic approaches are lacking. In this article, we review the current scientific evidences and outline issues that currently still need to be addressed in comparing CABG versus PCI for the treatment of LM disease.

Anxiety and Depression in Mothers of Preterm Infants and Psychological Intervention During Hospitalization in Neonatal ICU

The objective of this study was to evaluate and compare symptoms of anxiety and depression before and after psychological intervention in mothers of babies born preterm with very low birth weight, hospitalized in the Neonatal Intensive Care Unit. Fifty nine mothers, without psychiatric antecedents, were distributed into two groups according to the type of psychological intervention received. Group G1 included 36 mothers who received routine psychological treatment associated with initial structured intake using support materials (video and guidance manual). Group G2 included 23 mothers who received routine psychological intervention without support material. The STAI and BDI, respectively. were used to evaluate maternal indicators of anxiety and depression. The results revealed that both groups showed a reduction in levels of state or trait anxiety and depression after psychological intervention and discharge of the baby from the hospital. In regard to the emotional symptoms at a clinical level, a statistically significant reduction in the level of state-anxiety was verified in G1. The findings confirmed the need for psychological support for mothers of preterm infants and the use of materials focusing on ""prematurity"" for reduction of the situational anxiety on a clinical level.

Telehealth in audiology: The need and potential to reach underserved communities

Permanent hearing loss is a leading global health care burden, with 1 in 10 people affected to a mild or greater degree. A shortage of trained healthcare professionals and associated infrastructure and resource limitations mean that hearing health services are unavailable to the majority of the world population. Utilizing information and communication technology in hearing health care, or tele-audiology, combined with automation offer unique opportunities for improved clinical care, widespread access to services, and more cost-effective and sustainable hearing health care. Tele-audiology demonstrates significant potential in areas such as education and training of hearing health care professionals, paraprofessionals, parents, and adults with hearing disorders; screening for auditory disorders; diagnosis of hearing loss; and intervention services. Global connectivity is rapidly growing with increasingly widespread distribution into underserved communities where audiological services may be facilitated through telehealth models. Although many questions related to aspects such as quality control, licensure, jurisdictional responsibility, certification and reimbursement still need to be addressed; no alternative strategy can currently offer the same potential reach for impacting the global burden of hearing loss in the near and foreseeable future.

Políticas de saúde bucal no Brasil e seu impacto sobre as desigualdades em saúde

Sistematiza-se o conhecimento disponível sobre o estágio atual de efetivação das principais políticas de saúde bucal no Brasil e seu impacto sobre as desigualdades em saúde. Embora a fluoretação da água de abastecimento público no Brasil seja uma determinação legal, sua implantação tem sofrido marcantes desigualdades regionais. São apresentados dados sobre o grau de efetivação da medida e são revisados estudos que avaliaram seu impacto sobre a ampliação da desigualdade na experiência de cárie dentária. A oferta de atendimento público odontológico, ampliada consideravelmente após a implantação do Sistema Único de Saúde, também é discutida em relação à provisão do serviço e seu impacto sobre a redução da desigualdade no acesso a tratamento dentário. A discussão do efeito diferencial dessas medidas propiciou a proposição de estratégias focais (direcionar a fluoretação para as áreas com maiores necessidades), visando a reduzir a desigualdade na experiência de cárie no País.

Effects of an intervention in eating habits and physical activity in Japanese-Brazilian women with a high prevalence of metabolic syndrome in Bauru, São Paulo State, Brazil

We evaluated the impact of a lifestyle intervention on the cardiometabolic risk profile of women participating in the Study on Diabetes and Associated Diseases in the Japanese-Brazilian Population in Bauru. This was a non-controlled experimental study including clinical and laboratory values at baseline and after a 1-year intervention period. 401 Japanese-Brazilian women were examined (age 60.8±11.7 years), and 365 classified for metabolic syndrome (prevalence = 50.6%). Subjects with metabolic syndrome were older than those without (63.0±10.0 vs. 56.7±11.6 years, p < 0.01). After intervention, improvements in variables were found, except for C-reactive protein. Body mass index and waist circumference decreased, but adiposity reduction was more pronounced in the abdominal region (87.0±9.7 to 84.5±11.2cm, p < 0.001). Intervention-induced differences in total cholesterol, LDL, and post-challenge glucose were significant; women who lost more than 5% body weight showed a better profile than those who did not. The lifestyle intervention in Japanese-Brazilian women at high cardiometabolic risk improved anthropometric and laboratory parameters, but it is not known whether such benefits will persist and result in long-term reduction in cardiovascular events.

Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção

A great challenge for the primary healthcare system, implemented by the strategy called the Family Health Program, is to incorporate actions for facing situations of violence and mental health problems. This study analyzed the care delivered to 411 children between five and eleven years of age in a primary care unit in the city of São Paulo. The clinical findings were compared to a standard inventory of symptoms (CBCL). In addition, semi-structured interviews were held with pediatricians. The study shows low capacity of the pediatricians to recognize mental health problems in children. This is mainly due to deficiencies in their training and lack of possibilities for concrete intervention to face a complaint or diagnostic hypothesis. The reorganization process of primary care will need to provide specific technical support in mental health, incorporating more appropriate technologies for intervention such as a humanized approach and qualified listening. The inclusion of psychosocial aspects in the everyday practice of primary care will make it possible to broaden the concept of health and open way for an integrated approach to situations of violence related to children assisted by the primary care network of the Brazilian Health System.

The need for adequate ethical guidelines for qualitative health research

O artigo discute a adequação de aplicar a Resolução 196/961 do Conselho Nacional de Saúde - CNS, às pesquisas qualitativas em saúde, que se baseiam em paradigmas não positivistas. Nestas pesquisas, freqüentemente as decisões sobre a pesquisa são tomadas conjuntamente com a comunidade em estudo. Há a preocupação de favorecer a justiça e a mudança social. E, uma vez que a subjetividade pode ser considerada seu instrumento privilegiado, busca-se o balanço entre objetividade e subjetividade, e discute-se como superar a visão do pesquisador. Estudamos o âmbito de aplicação e a concepção de pesquisa presentes nas diretrizes éticas internacionais e brasileiras. Verificamos que elas adotam uma concepção positivista de pesquisa, que prevê: teste de hipótese, definição prévia de todos os procedimentos pelo pesquisador e neutralidade do pesquisador e do conhecimento produzido. Serão apresentadas algumas características das pesquisas qualitativas, as implicações éticas da maneira como a pesquisa qualitativa é concebida nos paradigmas não positivistas e um breve histórico dos documentos sobre ética em pesquisa. Concluímos que não é adequado analisar estas pesquisas com base nestes documentos e sugerimos a elaboração de diretrizes específicas

Methods and Participant Characteristics of a Randomized Intervention to Promote Physical Activity and Healthy Eating Among Brazilian High School Students: The Saude na Boa Project

Background: A cross-cultural, randomized study was proposed to observe the effects of a school-based intervention designed to promote physical activity and healthy eating among high school students in 2 cities from different regions in Brazil: Recife and Florianopolis. The objective of this article is to describe the methodology and subjects enrolled in the project. Methods: Ten schools from each region were matched and randomized into intervention and control conditions. A questionnaire and anthropometry were used to collect data in the first and last month of the 2006 school year. The sample (n = 2155 at baseline; 55.7% females; 49.1% in the experimental group) included students 15 to 24 years, attending nighttime classes. The intervention focused on simple environmental/organizational changes, diet and physical activity education, and personnel training. Results: The central aspects of the intervention have been implemented in all 10 intervention schools. Problems during the intervention included teachers' strikes in both sites and lack of involvement of the canteen owners in schools. Conclusions: The Saude no Boa study provides evidence that public high schools in Brazil represent an important environment for health promotion. Its design and simple measurements increase the chances of it being sustained and disseminated to similar schools in Brazil.

Effectiveness of a School-Based Intervention on Physical Activity for High School Students in Brazil: The Saude na Boa Project

Background: We evaluated the effectiveness of a school-based intervention on the promotion of physical activity among high school students in Brazil: the Saude no Boa project. Methods: A school-based, randomized trial was carried out in 2 Brazilian cities: Recife (northeast) and Florianopolis (south). Ten schools in each city were matched by size and location, and randomized into intervention or control groups. The intervention included environmental/organizational changes, physical activity education, and personnel training and engagement. Students age 15 to 24 years were evaluated at baseline and 9 months later (end of school year). Results: Although similar at baseline, after the intervention, the control group reported significantly fewer d/wk accumulating 60 minutes+ moderate-to-vigorous physical activity (MVPA) in comparison with the intervention group (2.6 versus 3.3, P < .001). The prevalence of inactivity (0 days per week) rose in the control and decreased in the intervention group. The odds ratio for engaging at least once per week in physical activity associated with the intervention was 1.83 (95% CI = 1.24-2.71) in the unadjusted analysis and 1.88 (95% CI = 1.27-2.79) after controlling for gender. Conclusion: The Saude no Boa intervention was effective at reducing the prevalence of physical inactivity. The possibility of expanding the intervention to other locations should be considered.

Predictive factors of non-deterioration of glucose tolerance following a 2-year behavioral intervention

Aim: To identify predictive factors associated with non-deterioration of glucose metabolism following a 2-year behavioral intervention in Japanese-Brazilians. Methods: 295 adults (59.7% women) without diabetes completed 2-year intervention program. Characteristics of those who maintained/improved glucose tolerance status (non-progressors) were compared with those who worsened (progressors) after the intervention. In logistic regression analysis, the condition of non-progressor was used as dependent variable. Results: Baseline characteristics of non-progressors (71.7%) and progressors were similar, except for the former being younger and having higher frequency of disturbed glucose tolerance and lower C-reactive protein (CRP). In logistic regression, non-deterioration of glucose metabolism was associated with disturbed glucose tolerance impaired fasting glucose or impaired glucose tolerance - (p < 0.001) and CRP levels <= 0.04 mg/dL (p = 0.01), adjusted for age and anthropometric variables. Changes in anthropometry and physical activity and achievement of weight and dietary goals after intervention were similar in subsets that worsened or not the glucose tolerance status. Conclusion: The whole sample presented a homogeneous behavior during the intervention. Lower CRP levels and diagnosis of glucose intolerance at baseline were predictors of non-deterioration of the glucose metabolism after a relatively simple intervention, independent of body adiposity.

DOES THE CHRONOTYPE CLASSIFICATION NEED TO BE UPDATED? PRELIMINARY FINDINGS

Traditionally, chronotype classification is based on the Morningness-Eveningness Questionnaire (MEQ). It is implicit in the classification that intermediate individuals get intermediate scores to most of the MEQ questions. However, a small group of individuals has a different pattern of answers. In some questions, they answer as ""morning-types"" and in some others they answer as ""evening-types,"" resulting in an intermediate total score. ""Evening-type"" and ""Morning-type"" answers were set as A(1) and A(4), respectively. Intermediate answers were set as A(2) and A(3). The following algorithm was applied: Bimodality Index = (Sigma A(1) x Sigma A(4))(2) - (Sigma A(2) x Sigma A(3))(2). Neither-types that had positive bimodality scores were classified as bimodal. If our hypothesis is validated by objective data, an update of chronotype classification will be required. (Author correspondence: brunojm@ymail.com)

Cardiac and peripheral adjustments induced by early exercise training intervention were associated with autonomic improvement in infarcted rats: role in functional capacity and mortality

Aims To test the effects of early exercise training (ET) on left ventricular (LV) and autonomic functions, haemodynamics, tissues blood flows (BFs), maximal oxygen consumption (VO(2) max), and mortality after myocardial infarction (MI) in rats. Methods and results Male Wistar rats were divided into: control (C), sedentary-infarcted (SI), and trained-infarcted (TI). One week after MI, TI group underwent an ET protocol (90 days, 50-70% VO2 max). Left ventricular function was evaluated noninvasively and invasively. Baroreflex sensitivity, heart rate variability, and pulse interval were measured. Cardiac output (CO) and regional BFs were determined using coloured microspheres. Infarcted area was reduced in TI (19 +/- 6%) compared with SI (34 +/- 5%) after ET. Exercise training improved the LV and autonomic functions, the CO and regional BF changes induced by MI, as well as increased SERCA2 expression and mRNA vascular endothelial growth factor levels. These changes brought about by ET resulted in mortality rate reduction in the TI (13%) group compared with the SI (54%) group. Conclusion Early aerobic ET reduced cardiac and peripheral dysfunctions and preserved cardiovascular autonomic control after MI in trained rats. Consequently, these ET-induced changes resulted in improved functional capacity and survival after MI.

The Absence of Coronary Calcification Does Not Exclude Obstructive Coronary Artery Disease or the Need for Revascularization in Patients Referred for Conventional Coronary Angiography

Objectives This study was designed to evaluate whether the absence of coronary calcium could rule out >= 50% coronary stenosis or the need for revascularization. Background The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients. Methods A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before. Results In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 +/- 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of >= 50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 >= 50% stenosis. The overall sensitivity for CS = 0 to predict the absence of >= 50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with >= 50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium. Conclusions The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218) (J Am Coll Cardiol 2010;55:627-34) (C) 2010 by the American College of Cardiology Foundation