Avaliação da função pulmonar em obesos mórbidos com sonolência diurna excessiva

Background: Obesity impairment to the pulmonary function related to the magnitude of adiposity and is associated with excessive daytime sleepiness (EDS) and snoring, among others symptoms of respiratory disorders related to sleep. It is possible that obese individuals with excessive daytime sleepiness may make changes in lung function on spirometry monitored during the day as a consequence of fragmented sleep or episodes of nocturnal hypoventilation that cause respiratory and changes that can persist throughout the day. The combination of these findings alone sleepiness observed by subjective scales with pulmonary function in obese patients is unknown. Objective: To assess the influence of EDS and snoring on pulmonary function in morbidly obese and distinguish between different anthropometric markers, the snoring and sleepiness which the best predictors of spirometric function and respiratory muscle strength and endurance of these patients. Methods: We evaluated 40 morbidly obese markers on the anthropometric, spirometric respiratory variables, maximal inspiratory and expiratory pressures (MIP and MEP) and maximal voluntary ventilation (MVV) and the measured excessive daytime sleepiness (the Epworth sleepiness scale) and snoring (snoring scale of Stanford). The data were treated when the differences between the groups of obese patients with and without sleepiness, whereas the anthropometric variables, respiratory and snoring. Pearson's correlation was performed, and multiple regression analysis assessed the predictors of pulmonary function. For this we used the software SPSS 15.0 for windows and p <0.05. Results: 39 obese patients were included (28 women), age 36.92+11.97y, body mass index (BMI) 49.3+5.1kg/m², waist-hip ratio (WHR) 0.96+0.07 and neck circumference (NC) 44.1+4.2 cm. Spirometric values and respiratory pressures were up 80% of predicted values, except for endurance (MVV <80%). Obese with EDS have lower tidal volume. Positive correlation was observed between BMI and EDS, EDS and NC and between snoring and BMI, and negative correlation between EDS and tidal volume (TV), and between snoring and snoring FVC and FEV1. In linear regression the best predictor of pulmonary function was snoring, followed by NC. NC has more obese with higher strength (MEP, p = 0.031) and endurance (MVV p = 0.018) respiratory muscle. Conclusion: Obese with EDS tend to have lower TV. In addition, snoring and NC can better predict pulmonary function in obese when compared with other anthropometric markers or EDS. Obese patients with higher NC tend to have greater capacity for overall strength of respiratory muscles, but may have low muscle endurance

Funcionalidade em pacientes após acidente vascular encefálico: relação com o sono e ritmo de atividade-repouso

It is known that sleep plays an important role in the process of motor learning. Recent studies have shown that the presence of sleep between training a motor task and retention test promotes a learning task so than the presence of only awake between training and testing. These findings also have been reported in stroke patients, however, there are few studies that investigate the results of this relationship on the functionality itself in this population. The objective of this study was to evaluate the relationship between functionality and sleep in patients in the chronic stage of stroke. A cross-sectional observational study was conducted. The sample was composed of 30 stroke individuals in chronic phase, between 6 and 60 months after injury and aged between 55 and 75 years. The volunteers were initially evaluated for clinical data of disease and personal history, severity of stroke, through the National Institute of Health Stroke Scale, and mental status, the Mini-Mental State Examination. Sleep assessment tools were Pittsburgh Sleep Quality Index, the Questionnaire of Horne and Ostberg, Epworth Sleepiness Scale, the Berlin questionnaire and actigraphy, which measures were: real time of sleep, waking after sleep onset, percentage of waking after sleep onset, sleep efficiency, sleep latency, sleep fragmentation index, mean activity score. Other actigraphy measures were intraday variability, stability interdiária, a 5-hour period with minimum level of activity (L5) and 10-hour period with maximum activity (M10), obtained to evaluate the activity-rest rhythm. The Functional Independence Measure (FIM) and the Berg Balance Scale (BBS) were the instruments used to evaluate the functional status of participants. The Spearman correlation coefficient and comparison tests (Student's t and Mann-Whitney) were used to analyze the relationship of sleep assessment tools and rest-activity rhythm to measures of functional assessment. The SPSS 16.0 was used for analysis, adopting a significance level of 5%. The main results observed were a negative correlation between sleepiness and balance and a negative correlation between the level of activity (M10) and sleep fragmentation. No measurement of sleep or rhythm was associated with functional independence measure. These findings suggest that there may be an association between sleepiness and xii balance in patients in the chronic stage of stroke, and that obtaining a higher level of activity may be associated with a better sleep pattern and rhythm more stable and less fragmented. Future studies should evaluate the cause-effect relationship between these parameters

Desfechos clínicos e mortalidade de sujeitos submetidos à cirurgia bariátrica no Rio Grande do Norte

Introduction: Actually the obesity is a public health problem throughout the world. Bariatric surgery has been an efficient method of weight reduction body in severe obesity, reducing its associated effects and presenting low levels of immediate and late postoperative complications. In Brazil, bariatric surgery asa recent therapeutic that has been growing recently. Being Brazil a country with continental dimensions and with a huge diversity socioeconomic and cultural, it is essential to understand the reality of patients undergoing bariatric surgery in less economically privileged regions of Brazil. Objectives: To evaluate the epidemiological, clinical outcomes and mortality of patients undergoing videolaparoscopic bariatric surgery through the public health system in the Brazilian state of Rio Grande do Norte- Brazil. Methods: Observational descriptive study of a prospective, carried out from February 2009 to February 2011, the Clinic Obesity and Bariatric Surgery at Universitary Hospital Onofre Lopes - Federal University of Rio Grande do Norte (HUOL-UFRN). Anthropometric measures, comorbidity and deaths register were made in the postoperative period. Results: Seventy patients (54 women) with low income aged 22 to 63 years completed the study. We recorded the death of three patients during the study period. The results show significant decrease anthropometric parameters, especially in relation to body weight, waist circumference and hipin both sexes. Only Waist / Hip ratio showed no difference after intervention in male patients It had a resolution of comorbidities. No significant differences in reports of daily sleepiness and the snoring male patients. Conclusion: Our findings attest laparoscopic bariatric surgery as an effective method reducing weight and comorbidities in morbidly obese patients

Controle circadiano e homeostático do sono-virgília em pacientes com acidente vascular encefálico e correlações com a qualidade de vida e o nível de atividade física

The cerebral vascular accident is a neurological dysfunction of vascular origin that leds to development of motor sensibility, cognitive, perceptive and language deficits. Despite the fact that the main sleep disorders in stroke patients are well known, it is still necessary to analyze which mechanisms of regulation of sleep and wakefulness are affected. The objective of this study was to evaluate the changes in the circadian and homeostatic control of sleep-wakefulness in stroke patients and the correlations with quality of life and level of physical activity. The study analyzed 22 stroke patients (55± 12 years old) and 24 healthy subjects (57 ±11 years old). The instruments used in this study were questionnaires on sleep quality, daytime sleepiness, quality of life, physical activity level and the actigraphy. The data were analyzed using the Student `t test, Mann-Whitney test, ANOVA and Spearman's correlation tests. The results showed stability in the sleep-wake circadian expression with changes in the amplitude of the rhythm. However, significant changes were found related to the homeostatic component characterized by increased sleep duration, increased latency, fragmented sleep and lower sleep efficiency. Additional data showed decreased quality of sleep and increased daytime sleepiness, as well as decreased quality of life and level of physical activity. The results indicate that the interaction of circadian and homeostatic control of sleep-wake is compromised and the main reason might be because of the homeostatic component and the lower activity level resulting from the brain damage. Thus, further studies may be developed to evaluate whether behavioral interventions such as increased daytime activity and restriction of sleep during the day can influence the homeostatic process and its relation to circadian component, resulting in improved quality of nocturnal sleep in stroke patients

Estratégias para ajuste do ciclo vigília-sono de adolescentes aos horários escolares matutinos: a educação sobre o sono e a exposição a luz solar

In adolescents, who tend to sleep and wake-up later, the school schedule in the morning is associated with sleep advancement and shortening besides bedtime and wake-up time irregularity between week and weekend days. As a result, there is an increase in daytime sleepiness and a drop in cognitive performance that interfer in students performance in classroom. These consequences reinforce the need to evaluate alternatives that help the adolescent to adapt their sleep needs to the time of start of classes in the morning. Accordingly, the general aim of this study was to evaluate the effects of a sleep program education and sunlight exposure in early morning on sleep-wake cycle (SWC) and daytime sleepiness of adolescents. The students chronotype were evaluated by the Horne-Ostberg questionnaire and the health and usual sleep habits by "the health and the sleep questionnaire. The SWC patterns were assessed by sleep log, the daytime sleepiness by Karolinska Sleepiness Scale (KSS) and the alertness by the Psychomotor Vigilance Test (PVT). These parameters were compared before and after a sleep education program and before and during the sunlight exposure. The sleep program was effective in increasing sleep knowledge of adolescents, in promoting a reduction of bedtime and wake-up time irregularity and increasing the sleep duration in school days. The sunlight exposure effect was evaluated in the return to classes after vacation due to the difference in sleep patterns between school and vacation days. During the intervention week it was observed an advance of sleep schedules, an increase on sleep duration and alertness at the end of the morning. Assessed separately, sleep education and sunlight exposure should contribute to minimize adolescents partial sleep deprivation, but daytime sleepiness effect must be better investigated. These strategies should be used jointly by school members to improve health and performance of their students

Efeito do exercício físico matinal realizado sob luz solar no ciclo vigília-sono de adolescentes

The sleep onset and offset delay at adolescence in relation to childhood. Besides biological causes, some external factors as academic obligations and socialization contributes, increasing the burden of school and socialization. However, morning school schedules reduce sleep duration. Besides light strong effect, studies in humans have indicated that exercise influence circadian synchronization. To evaluate the effect of the morning exercise under sunlight on sleep-wake cycle (SWC) of adolescents, 160 high school students (11th year) were exposed to the following conditions: lesson in usual classroom (Group C), lesson in swimming pool exposed to sunlight (Group E), half of them carrying through physical activity (EE) and the other resting (EL). Each experimental group met two stages: assessment of SWC 1 week before and 1 week during the intervention, which was held in Monday and Wednesday between 7:45 and 8:30 am. In the baseline, there were applied the questionnaires "Health and Sleep" and cronotype evaluation (H & O). In addition, students were evaluated before and during the intervention by "Sleep Diary", "Karolinska Sleepiness Scale" (KSS), Psychomotor Vigilance Test (PVT) and actimetry. During the intervention, there was a delay in wake-up time on the weekend and a trend to greater sleep duration on week for the three groups. At the weekend, only the groups EE and EL increased sleep duration. There was no difference in bedtime, irregularity of sleep schedules and nap variables. The sleepiness showed a circadian pattern characterized by higher alertness levels at 11:30 am and sleepiness levels at bedtime and wake-up time on week. On weekends there were higher levels of alertness in these times. In the days of intervention, there was an increase of sleepiness at 11:30 am for groups EL and EE, which may have been caused by a relaxing effect of contact with the water of the pool. In addition, the group EE showed higher alert levels at 14:30 pm on Monday and at 8:30 am in the Wednesday, possibly caused by exercise arousal effect. The reaction time assessed through the TPV did not vary between the stages. The sleep quality improved in the three groups in the second stage, making impossible the evaluation of intervention effect. However, the sleep quality increased on Monday and Tuesday only on the group EE. From the results, it is suggested that the intervention promoted effects on the sleepiness at some day hours. In other SWC variables there were no effects, possibly due to a large SWC irregularity on weekends. Thus, the evaluation of higher weekly frequency EF is necessary, since only two days were insufficient to promote greater effect on adolescents SWC

Caracterização do ciclo sono/vigília de professores do ensino médio em natal/rn

In the school environment is fundamental the knowledge about the sleep-wake cycle (SWC), because we find children and adolescents with excessive sleepiness and learning difficulties. Furthermore, teachers with high demand and with different work schedule, which may contribute to changes in SWC. The aim of this study was to describe the SWC of high school teachers in Natal/RN. Habits and knowledge about sleep, chronotype, SWC, daytime sleepiness, sleep quality and job satisfaction were described in 98 high school teachers from public and private school. These parameters were compared according to the characteristics of work, family structure and gender. Data collection was performed with the use of questionnaires in two stages: 1) "health and sleep" (general characterization of sleep habits), Horne & Ostberg questionnaire (characterization of chronotype), Epworth Sleepiness Scale and the Index of Pittsburg Sleep Quality, 2) The sleep diary for 14 days. From the results, we observe that the teachers woke up and went to bed earlier in the week and showed a reduction of time in bed around 42min comparing to weekend. This reduction in time in bed during the week was accompanied by an increase in nap duration on weekend. In addition the teachers woke up earlier on Saturdays than on Sundays, probably due to housework and leisure. The teachers' knowledge about sleep was low in relation to individual differences and effect of alcoholic beverages on sleep, and high in the consequences of sleep deprivation. The differences found in comparisons on the characteristics of work, family structure and gender were punctual, except concerning the work schedule. The teacher who started work in the morning and finished in the night, woke up earlier, went to bed later and had less time in bed, when compared to teachers who work only in two shifts. In addition, teachers with late chronotypes who begin the work in the morning had a greater irregularity in the wake up time compared to teachers with earlier and intermediate chronotypes. Half of teachers have excessive sleepiness, which was positive correlated with work dissatisfaction. In general, teachers showed IPSQ averages equivalent to poor sleep quality and the women showed worst averages. From the results, it is suggested that the SWC of teachers varies according to work schedule, leading to irregularity and partial sleep deprivation in the week, although these responses vary according to chronotype. These changes are accompanied by excessive daytime sleepiness and poor sleep quality. However, it is necessary to expand the sample to clarify the influence of variables related to work, family structure and gender together

Avaliação do padrão do ciclo sono-vigília e a cognição em estudantes de medicina com diferentes esquemas de horários de aulas

The sleep patterns of students entering the university, is accompanied by many factors that can lead to changes in sleep habits, such as academic demands, new social opportunities, reduced parental care and irregular teaching schedules. The irregular pattern of sleep-wake cycle is usually accompanied by several daytime consequences, for example, reduced levels of motivation, performance, concentration, alertness and mood as well as increased fatigue and sleepiness.Thus, there are numerous reasons to support the fact that these students may suffer damage in their academic performance. The aim of this study was to evaluate the sleep-wake cycle (SWC) and cognition in medical students with different schemes teaching schedules. One group started classes at 08am, while the other started at 07am. We analyzed the data from 88 volunteers, 39 from each group. However, only those who participated in both stages of the study (n = 78) underwent cognitive testing. For subjective evaluation of the SWC was used questionnaires to check the quality of sleep, chronotype, daytime sleepiness and sleep habits. For objective evaluation was used actigraphy. For cognitive assessment was used the test MoCA (Montreal Cognitive Assessment). The results indicate that the group has class earlier had a greater irregularity of the SWC and a worse performance in cognitive testing. There was a difference between the schedules the week and weekend in the subjective variables, bedtime, wake up and sleep duration in both groups. The objective variables, time in bed showed difference between the schedules the week and weekend to the group started class at 08am and the variables bedtime, get up time, actual sleep time, time in bed and wake bouts in the class at 07am. In the cognitive test, there were differences between the groups in overall score and in the areas of executive function and memory recall. Thus, it is suggested that the class starting time may cause irregularity of the SWC and the irregularity may cause mild cognitive impairment. Moreover, cognitive testing MoCA was sensitive to detect differences among students, although the difference between the schedules is small

Injeção inadvertida de metoclopramida no espaço subaracnóideo: relato de caso

JUSTIFICATIVA E OBJETIVOS: Injeção inadvertida de medicamentos de uso não espinhal nos espaços peridural e subaracnóideo é uma complicação anestésica passível de ocorrer. Este relato apresenta um caso de injeção inadvertida de metoclopramida no espaço subaracnóideo. RELATO do CASO: Paciente do sexo feminino, 17 anos, 69 kg, IMC de 26.2, estado físico ASA I, 36 semanas e 4 dias de gestação, com diagnóstico de sofrimento fetal agudo, e indicação de cesariana. Apresentava freqüência cardíaca de 82 bpm, pressão arterial de 130 x 70 mmHg, SpO2 de 97%, ritmo cardíaco sinusal regular. A anestesia foi por via subaracnóidea com a associação de anestésico local e opióide, 15 mg de bupivacaína hiperbárica a 0,5% e 25 µg de fentanil. Após 5 minutos da instalação do bloqueio, a paciente referiu mal estar inespecífico. Aferidas pressão arterial, 190 x 120 mmHg, freqüência cardíaca, 145 bpm, e SpO2, 95%. Verificando-se as ampolas cujos conteúdos foram administrados encontrou-se uma de bupivacaína e uma de metoclopramida. O quadro se apresentou com cefaléia frontal intensa, visão turva, náuseas, vômitos e agitação inicial, que evoluiu para sonolência e torpor, além de hipertensão arterial e taquicardia. Foram administrados tramadol, dipirona, ondansetron e medidas de suporte. Após 30 minutos, a paciente apresentava-se assintomática, com PA de 150 x 100 mmHg e FC de 120 bpm. Recebeu alta para a enfermaria 140 minutos após permanência na SRPA, com total reversão dos bloqueios motor, sensitivo e autonômico, e normalização dos parâmetros hemodinâmicos. Recebeu alta hospitalar 48 horas após, sem apresentar seqüelas neurológicas, juntamente com o recém-nascido. CONCLUSÕES: Máxima atenção deve ser dada a qualquer medicamento administrado, seja qual for à via utilizada. Padronização de cores de ampolas, e dos locais de depósito, com o intuito de diminuir este tipo de acidente é recomendável.

Treatment of snoring and sleep apnea syndrome with a removable mandibular advancement device in patients without TMD

INTRODUCTION: Among the sleep disorders reported by the American Academy of Sleep, the most common is obstructive sleep apnea-hypopnea syndrome (OSAHS), which is caused by difficulties in air passage and complete interruption of air flow in the airway. This syndrome is associated with increased morbidity and mortality in apneic individuals. OBJECTIVE: It was the objective of this paper to evaluate a removable mandibular advancement device as it provides a noninvasive, straightforward treatment readily accepted by patients. METHODS: In this study, 15 patients without temporomandibular disorders (TMD) and with excessive daytime sleepiness or snoring were evaluated. Data were collected by means of: Polysomnography before and after placement of an intraoral appliance, analysis of TMD signs and symptoms using a patient history questionnaire, muscle and TMJ palpation. RESULTS: After treatment, the statistical analysis (t-test, and the before and after test) showed a mean reduction of 77.6% (p=0.001) in the apnea-hypopnea index, an increase in lowest oxyhemoglobin saturation (p=0.05), decrease in desaturation (p=0.05), decrease in micro-awakenings or EEG arousals (p=0.05) and highly significant improvement in daytime sleepiness (p=0.005), measured by the Epworth Sleepiness Scale. No TMD appeared during the monitoring period. CONCLUSION: The oral device developed in this study was considered effective for mild to moderate OSAHS.

Evaluation of obstructive sleep apnea in obese patients scheduled for bariactric surgery

PURPOSE: To evaluate the frequency of obstructive sleep apnea (OSA) in obese patients scheduled for bariatric surgery and their identification for risk of OSA by Berlin Questionnaire (BQ) and excessive daytime sleepiness by Epworth Sleepiness Scale (ESS). METHODS: Fifty nine patients were evaluated by BQ and ESS. Out of these individuals, 35 performed a full-night sleep study using a type 3 portable monitoring (PM). The questionnaire results were compared for gender and BMI. The presence and severity of OSA was correlated with gender and both questionnaires. RESULTS: 94.75% of the respondents presented high risk for OSA by BQ and 59.65% presented positivity by ESS. Taking into account the AHI> 5 per hour for OSA diagnosis, all of them presented OSA, average AHI of 45.31±26.3 per hour and 68.6% have severe OSA (AHI>30). The male patients had a higher AHI (p<0.05). There was a positive correlation between the positivity in both questionnaires as well as the severity of OSA measured by AHI (p<0.05). CONCLUSION: The frequency and severe obstructive sleep apnea in the studied group is high. The Berlin Questionnaire and Epworth Sleepiness Scale had a positive correlation with the diagnosis of OSA in the group studied.

Sleep-wake patterns of student workers and non-workers

Adolescents usually exhibit late sleep phase and irregular sleep patterns. As a result, they do not get enough sleep and report daytime sleepiness. This condition could be aggravated in working students who have a more limited time for sleep. In this survey, we investigated the impact of evening classes and employment on the sleep patterns of adolescents. We compared female (n = 17) and male (n = 14) non-worker students to female (n = 28) and male (n = 20) worker students who attended the same high school. The volunteers (aged 17.4 years +/- 11 months) answered a sleep log during a 16-day period. Worker students slept and woke up earlier, had a shorter nocturnal sleep length and a shorter daily (nocturnal plus diurnal) sleep length compared to non-working pupils. The four groups of students delayed sleep onset time on weekends, but only worker students delayed wake-up time on Sundays. The wake-up time was similar among groups on Sundays. While student workers tended to increase the sleep length in the weekends, non-working students increased it on Mondays and/or Tuesdays. The results showed that sleep schedules and sleep length were different according to the work status. Going to bed later on Saturday by the four groups of students suggests the influence of social activities, while a later wake-up time on Sundays could result from a shorter sleep length on workdays.

Observational study on efficacy of negative expiratory pressure test proposed as screening for obstructive sleep apnea syndrome among commercial interstate bus drivers - protocol study

Background: Obstructive sleep apnea (OSA) is a respiratory disease characterized by the collapse of the extrathoracic airway and has important social implications related to accidents and cardiovascular risk. The main objective of the present study was to investigate whether the drop in expiratory flow and the volume expired in 0.2 s during the application of negative expiratory pressure (NEP) are associated with the presence and severity of OSA in a population of professional interstate bus drivers who travel medium and long distances.Methods/Design: An observational, analytic study will be carried out involving adult male subjects of an interstate bus company. Those who agree to participate will undergo a detailed patient history, physical examination involving determination of blood pressure, anthropometric data, circumference measurements (hips, waist and neck), tonsils and Mallampati index. Moreover, specific questionnaires addressing sleep apnea and excessive daytime sleepiness will be administered. Data acquisition will be completely anonymous. Following the medical examination, the participants will perform a spirometry, NEP test and standard overnight polysomnography. The NEP test is performed through the administration of negative pressure at the mouth during expiration. This is a practical test performed while awake and requires little cooperation from the subject. In the absence of expiratory flow limitation, the increase in the pressure gradient between the alveoli and open upper airway caused by NEP results in an increase in expiratory flow.Discussion: Despite the abundance of scientific evidence, OSA is still underdiagnosed in the general population. In addition, diagnostic procedures are expensive, and predictive criteria are still unsatisfactory. Because increased upper airway collapsibility is one of the main determinants of OSA, the response to the application of NEP could be a predictor of this disorder. With the enrollment of this study protocol, the expectation is to encounter predictive NEP values for different degrees of OSA in order to contribute toward an early diagnosis of this condition and reduce its impact and complications among commercial interstate bus drivers.

Sleep apnea and automobile accidents: Review of regulation for drivers

Several studies show a crescent association between sleep-disordered breathing, excessive sleepiness and automobile accidents. Many countries already discussed about specific regulations for drivers with these conditions, including questionnaire and/or investigation by a qualified specialist. In Brazil, these discussions have barely begun. In view of that, we suggest some items to be included in our traffic law.

Pediatras e os distúrbios respiratórios do sono na criança

OBJECTIVES. assessment of opinions and practices of pediatricians concerning sleep-disordered breathing (SDB) in children. Methods. randomly 516 pediatricians were selected in the state of São Paulo, Brazil. A survey mailed to them included questions regarding: their professional profile, knowledge about SDB in childhood, opinions and practices for diagnosis and treatment of these diseases. RESULTS. 112 anonymous completed surveys were returned (21.7%). The teaching of SDB during medical school and pediatric residency training was considered unsatisfactory respectively by 65.2% and 34.8% of the pediatricians. Forty-nine respondents (43.8%) rated their knowledge about SDB in children as regular, 39 (34.8%) as good and 17 (15.2%) as unsatisfactory. The most important sleep-related questions were: mouth breathing, breathing pauses, sleep amount, excessive daytime sleepiness and nocturnal wheezing. Clinical aspects regarded as the most significant for suspecting obstructive sleep apnea syndrome (OSAS) were: breathing pauses, adenoid hypertrophy, mouth breathing, craniofacial anomaly and snoring. The most frequent practices for evaluation of OSAS in children were: cavum radiography with referral to an otorhinolarnygologist (25%) and nocturnal pulse oximetry (14.2%). Only 11.6% of pediatricians recommended overnight polysomnography and 4.5%, nap polysomnography. The most effective practices for SDB were considered to be: adenoidectomy and adenotonsillectomy, parents counseling, weight loss and sleep hygiene. CONCLUSIONS. there is a gap between research on SDB in childhood and pediatric practice. © 2006 Associação Médica Brasileira.