Experience with the first Internet-based course at the Faculty of Medicine, University of São Paulo

PURPOSE: The Internet expands the range and flexibility of teaching options and enhances the ability to process the ever-increasing volume of medical knowledge. The aim of this study is to describe and discuss our experience with transforming a traditional medical training course into an Internet-based course. METHOD: Sixty-nine students were enrolled for a one-month course. They answered pre- and post-course questionnaires and took a multiple-choice test to evaluate the acquired knowledge. RESULTS: Students reported that the primary value for them of this Internet-based course was that they could choose the time of their class attendance (67%). The vast majority (94%) had a private computer and were used to visiting the Internet (75%) before the course. During the course, visits were mainly during the weekends (35%) and on the last week before the test (29%). Thirty-one percent reported that they could learn by reading only from the computer screen, without the necessity of printed material. Students were satisfied with this teaching method as evidenced by the 89% who reported enjoying the experience and the 88% who said they would enroll for another course via the Internet. The most positive aspect was freedom of scheduling, and the most negative was the lack of personal contact with the teacher. From the 80 multiple-choice questions, the mean of correct answers was 45.5, and of incorrect, 34.5. CONCLUSIONS: This study demonstrates that students can successfully learn with distance learning. It provides useful information for developing other Internet-based courses. The importance of this new tool for education in a large country like Brazil seems clear.

The influence of patient's consciousness regarding high blood pressure and patient's attitude in face of disease controlling medicine intake

OBJECTIVE: To assess the relation between blood pressure control and the following: the Morisky-Green test, the patient's consciousness regarding high blood pressure, the patient's attitude in face of medicine intake, the patient's attendance at medical consultations, and the subjective physician's judgment. METHODS: We studied 130 hypertensive patients with the following characteristics: 73% females, 60±11 years, 58% married, 70% white, 45% retired, 45% with incomplete elementary schooling, 64% had a familial income of 1 to 3 minimum wages, body mass index of 30±7 kg/m², consciousness regarding the disease for a mean period of 11±9.5 years, and mean treatment duration of 8 ±7 years. RESULTS: Only 35% of the hypertensive individuals had blood pressure under control and a longer duration of treatment (10±7 vs 7±6.5 years; P<0.05). The retiree predominated. The result of the Morisky-Green test did not relate to blood pressure control. In evaluating the attitude in face of medicine intake, the controlled patients achieved significantly higher scores than did the noncontrolled patients (8±1.9 vs 7 ±2, P<0.05). The hypertensive patients had higher levels of consciousness regarding their disease and its treatment, and most (70%) patients attended 3 or 4 medical consultations, which did not influence blood pressure control. The physicians attributed significantly higher scores regarding adherence to treatment to controlled patients (6±0.8 vs 5±1.2; P<0.05). CONCLUSION: Consciousness regarding the disease, the Morisky-Green test, and attendance to medical consultations did not influence blood pressure control.

Factors associated to medicine use among children from the 2004 Pelotas Birth Cohort (Brazil)

OBJECTIVE: To identify factors associated to medicine use among children from the 2004 Pelotas Birth Cohort, Brazil. METHODS: Prospective study to evaluate medicine use in children aged 3, 12 and 24 months regardless of the reasons, therapeutic indication or class. The study included 3,985 children followed up at three months of age, 3,907 at 12 months, and 3,868 at the last follow-up time of 24 months. Mothers were interviewed to collect information on medicine use during the recall period of 15 days prior to the interview. The outcome was studied according to sociodemographic and perinatal variables, mother's perception of child's health and breastfeeding status. Crude and adjusted analyses were performed by Poisson regression following a hierarchical model. RESULTS: The prevalence of medicine use ranged from 55% to 65% in the three follow-ups. After controlling for confounders, some variables remained associated to medicine use only at the three-month follow-up with greatest use among children of younger mothers, those children who had intrapartum complications, low birthweight, were never breastfed and were admitted to a hospital. Greatest medicine use was also associated with being a firstborn child at 3 and 12 months; mother's perception of their child health as fair or poor and children whose mothers have private health insurance at 12 and 24 months; highest maternal education level at all follow-up times. CONCLUSIONS: Different variables influence medicine use among children during the first two years of life and they change as the child ages especially maternal factors and those associated to the child's health problems.

A case of human rabies in the Urban Area of Ribeirão Preto, SP, Brazil

A 39-year old male patient was admitted to the University Hospital of the Faculty of Medicine of Ribeirão Preto with signs and symptoms of sudden dyspnea, generalized myalgia and behavioral disorders. The initial suspicion was alcohol abstinence syndrome and the patient was referred for psychiatric and neurologic care. The evolution of the patient with a worsening of signs and symptoms, presence of crises of tachypnea, agitation, difficulty to swallow, irritability and hydrophobia, and his report of having been bitten by a suspected dog raised the hypothesis of rabies. The diagnosis was confirmed by examination of a corneal impression, biological tests in the cerebrospinal fluid (CSF) and saliva and visualization of Negri bodies in nervous tissue (direct immunofluorescence). The patient evolved with agitation, aggressiveness, and worsening tachypnea intercalating with apnea, and died on the 4th day after admission

Neutralizing antibodies in Brazilian sera against three strains of human immunodeficiency virus type 1 (HIV-1)

The MN strain of HIV-1 is known to be more prevalent in Brazil, the BRU strain is more prevalent in Europe, and the NDK strain in Africa. It has been suggested in the literature to include different strains in the same vaccine against HIV-1. To contribute to the studies for the development of a universal vaccine, the occurrence of antibodies (Ab) against three HIV-1 strains (MN, BRU and NDK) was determined in serum samples from 85 HIV-1-positive patients, adult volunteers seen at the University Hospital of the Faculty of Medicine of Ribeirão Preto-USP. One-hundred tissue culture infective unit (TCIU) of the viruses reacted with serial dilutions of the sera (2x) and with MT4 cells added at a final concentration of 0.3 × 106 cells/ml, and a cytopathic effect was observed on the 7th and 11th days of incubation. Titres of less than 1/50 were considered to be negative. In 129 tests, the sera were negative for one of the three strains: 40 for MN, 29 for BRU and 60 for NDK. There was a predominance of strains MN and BRU, most of them presenting titres from 1/50 to 1/200. Titres for NDK were detected in 25 sera. We conclude that there seems to be a predominance of strains MN and BRU among the individuals from the region tested; however, the detection of sera with positive NKD titres indicates the need for further studies of this strain in other populations and regions of Brazil

Proposal of abolition of the skin sensitivity test before equine rabies immune globulin application

An epizootic outbreak of rabies occurred in 1995 in Ribeirão Preto, SP, with 58 cases of animal rabies (54 dogs, 3 cats and 1 bat) confirmed by the Pasteur Institute of São Paulo, and one human death. The need to provide care to a large number of people for the application of equine rabies immune globulin (ERIG) prevented the execution of the skin sensitivity test (SST) and often also the execution of desensitization, procedures routinely used up to that time at the Emergency Unit of the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (EU-UHFMRP-USP), a reference hospital for the application of heterologous sera. In view of our positive experience of several years with the abolition of SST and of the use of premedication before the application of antivenom sera, we used a similar schedule for ERIG application. Of the 1489 victims of animal bites, 1054 (71%) received ERIG; no patient was submitted to SST and all received intravenously anti-histamines (anti-H1 + anti-H2) and corticosteroids before the procedure. The patients were kept under observation for 60 to 180 minutes and no adverse reaction was observed. On the basis of these results, since December 1995 ERIG application has been decentralized in Ribeirão Preto and has become the responsibility of the Emergency Unit of the University Hospital and the Central Basic Health Unit, where the same routine is used. Since then, 4216 patients have received ERIG (1818 at the Basic Health Unit and 2398 at the EU-UHFMRP), with no problems. The ideal would be the routine use of human rabies immune globulin (HRIG) in public health programs, but this is problematic, because of their high cost. However, while this does not occur, the use of SST is no longer justified at the time of application of ERIG, in view of the clinical evidence of low predictive value and low sensitivity of SST involving the application of heterologous sera. It is very important to point out that a negative SST result may lead the health team to a feeling of false safety that no adverse reaction will occur, but this is not true for the anaphylactoid reactions. The decision to use premedication, which is based on knowledge about anaphylaxis and on the pharmacology of the medication used, is left to the judgment of health professionals, who should always be prepared for eventual untoward events.

Endemic Pemphigus foliaceus ("Fogo selvagem"): a series from the Northeastern region of the State of São Paulo, Brazil, 1973-1998

Endemic Pemphigus Foliaceus (EPF) is a bullous autoimmune skin disease whose incidence used to be high in the State of São Paulo (SP), Brazil, during the forties, but has declined thereafter. OBJECTIVES: to report a series of EPF patients from the northeastern region of SP. METHODS: a retrospective study concerning demographic and epidemiological data of patients seen from 1973 to 1998 was conducted at the University Hospital, Faculty of Medicine of Ribeirão Preto, SP. RESULTS: bullous disease was diagnosed in 340 patients, 245 with EPF (72.1%), 9.4 cases per year, 60.4% females, and 70.2% white, 7 to 82 year-old (29.4% in their teens); 46.9% lived in the rural zone. Concerning profession, housewives predominated among women (67.6%) and agricultural workers among men (40.2%). The time of disease was less than 1 year in 62.0% of cases, followed by 1 and 5 years (27%), and more than 5 years for the remaining patients (11%). 36.7% of patients were referred by the Direção Regional de Saúde (DIR) XVIII of Ribeirão Preto, with the largest number of cases being from Ribeirão Preto and Batatais: 33.3% and 23.3%, respectively; 22% from DIR XIII (Franca); 13.5% from DIR VII (Araraquara); 2.9% from DIR IX (Barretos); 4.1% from other DIRs of SP, and 20.8% from other States (16.7% from Minas Gerais). Thirteen (5.3%) patients reported occurrence of the disease in some relative, and 4 (1.6%) in neighbors. CONCLUSIONS: the present data characterize the northeastern region of the state of São Paulo as a remaining endemic focus of EPF.

A retrospective study of histopathological findings in 894 cases of megacolon: what is the relationship between megacolon and colonic cancer?

Patients with megaesophagus (ME) have increased prevalence of cancer of the esophagus. In contrast, a higher incidence of colorectal cancer is not observed in patients with megacolon (MC). MC is very common in some regions of Brazil, where it is mainly associated with Chagas disease. We reviewed the pathology records of surgical specimens of all patients submitted for surgical resection of MC in the Hospital das Clínicas of the Faculty of Medicine of Ribeirão Preto (HC-FMRP), from the University of São Paulo. We found that 894 patients were operated from 1952 until 2001 for MC resection. Mucosal ulcers, hyperplasia and chronic inflammation were frequently found, while polyps were uncommon. No patients with MC presented any type of colonic neoplasm. This observation reinforces the hypothesis that MC has a negative association with cancer of the colon. This seems to contradict the traditional concept of carcinogenesis in the colon, since patients with MC presents important chronic constipation that is thought to cause an increase in risk for colon cancer. MC is also associated with other risk factors for cancer of colon, such as hyperplasia, mucosal ulcers and chronic inflammation. In ME these factors lead to a remarkable increase in cancer risk. The study of mucosal cell proliferation in MC may provide new insights and useful information about the role of constipation in colonic carcinogenesis.

Dermatophyte agents in the city of São Paulo, from 1992 to 2002

Dermatophytosis are superficial mycoses caused by fungi that can invade stratum corneum and keratinized tissues. In order to study the frequency of dermatophytes species and the clinical manifestations caused by these fungi, in São Paulo, SP, Brazil, the authors analyzed cultures isolated at the Mycology Laboratory from a selected population (15,300 out-patients of the Hospital das Clínicas, Department of Dermatology, Faculty of Medicine of University of São Paulo) from January 1992 to June 2002. The most prevalent dermatophyte was Trichophyton rubrum (48.7%), followed by Microsporum canis (20.9%), Trichophyton tonsurans (13.8%), Trichophyton mentagrophytes (9.7%), Epidermophyton floccosum (4.1%), and Microsporum gypseum (2.5%). These agents determined more than one clinical manifestation, i.e., tinea corporis (31.5%), tinea capitis (27.5%), tinea unguium (14.8%), tinea cruris (13.9%), tinea pedis (9.9%), and tinea manuum (1.9%). Clinical variants of dermatophytosis and their relationship to the etiologic agents were studied and the results were compared to those obtained in previous studies in other regions of Brazil and in other countries.

On an acute case of Chagas disease in a region under vector control in the state of São Paulo, Brazil

No vector transmitted cases of Chagas disease had been notified in the state of São Paulo since the 1970s. However, in March, 2006, the death of a six-year-old boy from the municipality of Itaporanga was notified to the Center for Epidemiological Survey of the São Paulo State Health Secretariat: an autochthonous case of acute Chagas disease. The postmortem histopathological examination performed in the Hospital das Clínicas of the Botucatu School of Medicine confirmed the diagnosis. Reference to hospital records, consultation with the health professionals involved in the case and interviews with members of the patient's family supplied the basis for this study. We investigated parasite route of transmission, probable local reservoirs and vectors. No further human cases of acute Chagas disease were diagnosed. No locally captured vectors or reservoirs were found infected with Trypanosoma cruzi. Alternative transmission hypotheses - such as the possible ingestion of foods contaminated with vector excreta - are discussed, as well as the need to keep previously endemic regions and infested houses under close surveillance. Clinicians should give due attention to such signs as uni- or bilateral palpebral edema, cardiac failure, myocarditis, pericarditis, anasarca and atypical signs of nephrotic syndrome or nephritis and consider the diagnostic hypothesis of Chagas disease.

A retrospective study of 40 victims of Crotalus snake bites: analysis of the hepatic necrosis observed in one patient

Forty patients with a diagnosis of snake bite were studied at the Infectious and Parasitic Disease Service of the Faculty of Medicine of Botucatu. Thirty were males and 10 females, ranging in age from 16 to 70 years. All were farm laborers and 35 of them were bitten in the lower limbs. Two of the 9 patients seen more than 6 hours after the bite died. The low mortality rate (5%) observed could be explained by the early care provided, by the use of appropriate doses of anti-crotalus serum, parenteral hydration, urine alkalinization with sodium bicarbonate and induction of osmotic diuresis with a mannitol solution. Anatomopathological examination of one of the patients who died revealed extensive hepatic necrosis. The authors discuss the possibility of the effect of a factor of snake venom in the genesis of hepatic necrosis and in the increased transaminase levels.

Use of a condom in sex relations by HIV carriers

The frequency with which condoms are used in sex relations by subjects with HIV was determined by interviewing 132 individuals, 82 men and 50 women, most of them from São Paulo state and some from other regions of the country, all of them seen at an outpatient clinic of the School of Medicine in Botucatu. The women were younger, were of lower educational level and had poorer professional qualification than men. Also, a greater proportion of women were widowed, separated or divorced. We observed that 43.9% of men and 72% of women had been contaminated by the sexual route, but only 41.2% of the men and 31.8% of the women reported the use of a condom after the diagnosis of infection, with most men and women preferring sexual abstinence. The results enable the conclusion that there is still a need to continue to provide information about the use of condoms and to guarantee their free-of-charge distribution due to the low levels of education and professional qualification of the individuals studied. The data also suggest that campaigns for the dissemination of preventive measures should consider the social and cultural differences of infected women.

Diagnosis of hantavirus infection in humans and rodents in Ribeirão Preto, State of São Paulo, Brazil

INTRODUCTION: Hantavirus pulmonary and cardiovascular syndrome (HPCS) is an emerging serious disease in the Americas. Hantaviruses (Bunyaviridae) are the causative agents of this syndrome and are mainly transmitted through inhalation of aerosols containing the excreta of wild rodents. In the Ribeirão Preto region (state of São Paulo, Brazil), HPCS has been reported since 1998, caused by the Araraquara virus (ARAV), for which Necromys lasiurus is the rodent reservoir. This study aimed to show diagnostic results relating to infection in humans and rodents, obtained at the Virology Research Center of the Ribeirão Preto School of Medicine, University of São Paulo, between 2005 and 2008. METHODS: HPCS was diagnosed by means of ELISA and/or RT-PCR in 11 (21.2%) out of 52 suspected cases, and 54.4% of these were fatal. Furthermore, 595 wild rodents (Necromys lasiurus, Akodon sp, Calomys tener and Oligoryzomys sp) were caught between 2005 and 2008. RESULTS: Fifteen (2.5%) of these rodents presented antibodies for hantavirus, as follows: Necromys lasiurus (4%), Calomys tener (1.9%) and Akodon sp (1.5%). Nucleotide sequences obtained through RT-PCR from one HPCS patient and one Calomys tener rodent were compared with hantavirus sequences from GenBank, which showed that both were homologous with ARAV. CONCLUSIONS: This work corroborates previous studies showing that ARAV is the hantavirus causing HPCS in the Ribeirão Preto region. It also shows that rodents infected with hantavirus represent a constant risk of transmission of this virus to man.