Pulmonary Hypertension in Latin America Pulmonary Vascular Disease: The Global Perspective

Latin America is here defined as all of the Americas south of the United States. In the setting of pulmonary hypertension, there are social inequalities and geophysical aspects in this region that account for a high prevalence of certain etiologies. This review aimed to analyze some of these factors. Data were collected from the existing literature. Information also was obtained from local tertiary-care centers to where patients with pulmonary hypertension generally are referred. Further, local experience and expertise was taken into consideration. Three etiologies of pulmonary hypertension were found to be the most prevalent: schistosomiasis (similar to 1 million affected people in Brazil), high altitude (particularly in the Andes), and congenital heart disease (late diagnosis of congenital left-to-right shunts leading to development of pulmonary vasculopathy). The diversity in terms of ancestries and races probably accounts for the differences in phenotype expression of pulmonary hypertension when a given region is considered (eg, schistosomiasis-, high-altitude-, or congenital heart disease-associated pulmonary hypertension). Governmental measures are needed to improve social and economic inequalities with an obvious impact on certain etiologies, such as schistosomiasis and congenital heart disease. Early diagnosis of pulmonary hypertension and access to medication remain important challenges all over Latin America. CHEST 2010; 137(6)(Suppl):78S-84S

Is the wearing of elastic stockings for half a day as effective as wearing them for the entire day?

P>Background There is good evidence for the use of compression for some clinical indications but little is known about dosimetry in compression. Objective The aim of this work was to evaluate whether or not the use of compression stockings during part of the day would help in the reduction of evening oedema in patients with clinical, epidemiological, anatomical and physiopathological (CEAP) classifications C0 and C1. Methods The effects of elastic compression stockings on volumetric variations during the working day were evaluated for the legs of two men and 18 women (40 legs). The inclusion criterion was classification as C0 (10 legs) or C1 (30 legs) according to the CEAP criteria. Participants used three-quarter-length elastic compression stockings (20-30 mmHg) on three consecutive days for the entire day or only for the morning or they did not use the stockings at all. Volumetry using the water displacement technique was performed in the morning and in the evening. When the patients wore the stockings only during the morning, volumetry was also performed at 13:00 h. Results Significant increases in volume were observed for both legs when stockings were not used compared with the use of stockings in the morning only. After removing the stockings, both legs had significant increases in volume in the afternoon. However, use for half the day was better than not using the stockings at all. Conclusions The use of elastic compression stockings can reduce volumetric variations during working hours, with the use of stockings for the entire day being better than for just half the day.

Laparoscopic resection of uncinate process of the pancreas

Solid pseudopapillary neoplasm of the pancreas is an uncommon but distinctive pancreatic neoplasm with low metastatic potential [1]. Therefore, whenever feasible, an organ-preserving operation should be performed. As previously reported, women with solid pseudopapillary neoplasm of the pancreas may be best treated by more conservative procedures [2]. Recently, laparoscopic pancreatic resections became more common and are being performed in highly specialized centers. There are only six cases of laparoscopic resection for solid pseudopapillary neoplasm of pancreas published in the English literature and, to our knowledge, laparoscopic resection of uncinate process of the pancreas has never been reported [3-6]. This video demonstrates the technical aspects of a totally laparoscopic resection of the uncinate process of the pancreas in a patient with solid pseudopapillary neoplasm. A 26-year-old woman with a 4-cm solid pseudopapillary pancreatic neoplasm was referred for surgical treatment. According to preoperative echoendoscopy, there was a safe margin between neoplasm and main pancreatic duct. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, one 10-mm and three 5-mm, were used. At inspection, the inferior vena cava, transverse colon, duodenum, and pancreas are clearly identified. A Kocher maneuver was performed with complete exposure of pancreatic head and uncinate process. The uncinate process was dissected from the superior mesenteric vein and venous branches were divided between metallic clips or by use of laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA). Blood supply of the duodenum was preserved by ligature of small pancreatic branches from inferior pancreatoduodenal artery. Transection of pancreatic parenchyma was performed using laparoscopic coagulation shears, which is an effective tool for cutting the pancreas [7, 8]. Surgical specimen was removed through a suprapubic incision inside a retrieval bag. A hemostatic absorbable tissue (Surgicel; Ethicon Inc., Cincinnati, OH) was placed in the cutting pancreatic surface, and one round 19F Blake abdominal drain (Ethicon) was left in place. Operative time was 180 minutes and blood loss estimated in 40 ml with no blood transfusion. Hospital stay was 4 days. The patient did not have postoperative pancreatitis or pancreatic leakage, and the abdominal drain was removed on the tenth postoperative day. Final pathology confirmed the diagnosis of solid pseudopapillary neoplasm of pancreas with free surgical margins. The patient was well and asymptomatic 2 months after the procedure. Laparoscopic resection of uncinate process of the pancreas is safe and feasible and should be considered for patients suffering from pancreatic neoplasms.

FREQUENCY OF HUMAN RHINOVIRUS SPECIES IN OUTPATIENT CHILDREN WITH ACUTE RESPIRATORY INFECTIONS AT PRIMARY CARE LEVEL IN BRAZIL

This study assessed the occurrence of human rhinovirus (HRV) species in outpatient children attending day-care in Sao Paulo, Brazil. HRV reverse transcriptase polymerase chain reaction and amplicon sequencing were done in 120 samples collected in 2008. HRV was detected in 27.5% of samples. HRV C was detected in 60.7% of wheezers, a frequency not different from that observed in nonwheezers (69.6%).

Psychometric qualities of the Brazilian versions of the Fagerstrom Test for Nicotine Dependence and the Heaviness of Smoking Index

This study examined the psychometric properties of the Brazilian versions of the Fagerstrom Test for Nicotine Dependence (FTND) and the Heaviness of Smoking Index (HSI). The test-retest reliability of the FTND was assessed in a sample of 61 smoking university students, with a 15-day interval between assessments. The interrater reliability was examined in 30 smoking patients of a psychosocial care center for alcohol and drug users (PCC-AD). The reliability coefficient was estimated by the kappa and intraclass correlation coefficients. The predictive validity, internal consistency, and factor structure of the FTND and the HSI were evaluated by factor analysis in 271 smokers treated at an emergency unit and at the PCC-AD. The gold standard was the nicotine dependence criteria of DSM-IV, as assessed by the Structured Clinical Interview for DSM-IV. The FTND showed high reliability, with correlation coefficients of .92 for test-retest reliability and .99 for interrater reliability. Both the FTND and the HSI presented high levels of sensitivity and specificity. The internal consistency evaluation yielded a Cronbach`s alpha coefficient of .83 for the FTND and of .56 for the HSI. An exploratory factor analysis found 2 factors in the FTND, which were validated by a confirmatory factor analysis. The results obtained in this study confirm the validity and reliability of the Brazilian versions of the FTND and the HSI.

Study of the Discriminative Validity of the PHQ-9 and PHQ-2 in a Sample of Brazilian Women in the Context of Primary Health Care

PURPOSE. This study aimed to assess the discriminative validity of the Brazilian version of the Patient Health Questionnaire (PHQ-9) and of its reduced version (PHQ-2). DESIGN AND METHODS. The sample consisted of 177 women (60 cases of depression and 117 noncases). The SCID-IV was used as the gold standard. FINDINGS. For the PHQ-9, a cutoff score equal to or higher than 10 proved to be the most adequate for the screening of depression, whereas the best cutoff score for the PHQ-2 was found to lie between 3 and 4. PRACTICE IMPLICATIONS. The systematic use of these instruments in nursing and in the context of primary health care could favor the early detection of depression.

Indicators of lean body mass catabolism: emphasis on the creatinine excretion rate

Background: The major stress response to critical illness leads to a catabolic state and loss of lean body mass. Aims: To test whether an increased rate of creatinine excretion might provide unique and timely information to monitor cell catabolism; to relate this information to balances of cell constituents (nitrogen, potassium, phosphate and magnesium); to evaluate the effectiveness of nutritional therapy to reverse this catabolic process. Design: Prospective observational study. Methods: Children with severe traumatic brain injury admitted to the paediatric critical care units of The Hospital for Sick Children, Toronto, Canada and Hospital das Clnicas, Faculty of Medicine of Ribeiro Preto, University of So Paulo, Brazil were studied. Complete 24 h urine collections were obtained for measurement of creatinine excretion rate and daily balances of nitrogen, potassium, phosphate and magnesium. Results: Seventeen patients were studied for 310 days. On Day 1, all had negative balances for protein and phosphate. Balances for these intracellular constituents became positive when protein intake was >= 1 g/kg/day and energy intake was >= 50% of estimated energy expenditure (P < 0.0001). Creatinine excretion rate was positively correlated with the urea appearance rate (r = 0.60; P < 0.0001), and negatively with protein balance (r = -0.45; P < 0.0001). Sepsis developed in four patients; before its clinical detection, there were negative balances for all intracellular markers and an abrupt rise in the excretion of creatinine. Conclusions: Negative balances of intracellular components and an increase in rate of creatinine excretion heralded the onset of catabolism.

The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery

The diagnosis and treatment for paediatric and congenital cardiac disease has undergone remarkable progress over the last 60 years. Unfortunately, this progress has been largely limited to the developed world. Yet every year approximately 90% of the more than 1,000,000 children who are born with congenital cardiac disease across the world receive either suboptimal care or are totally denied care. While in the developed world the focus has changed from an effort to decrease post-operative mortality to now improving quality of life and decreasing morbidity, which the focus of this Supplement, the rest of the world still needs to develop basic access to congenital cardiac care. The World Society for Pediatric and Congenital Heart Surgery [http://www.wspchs.org/] was established in 2006. The Vision of the World Society is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The Mission of the World Society is to promote the highest quality comprehensive care to all patients with pediatric and/or congenital heart disease, from the fetus to the adult, regardless of the patient`s economic means, with emphasis on excellence in education, research and community service. We present in this article an overview of the epidemiology of congenital cardiac disease, the current and future challenges to improve care in the developed and developing world, the impact of the globalization of cardiac surgery, and the role that the World Society should play. The World Society for Pediatric and Congenital Heart Surgery is in a unique position to influence and truly improve the global care of children and adults with congenital cardiac disease throughout the world [http://www.wspchs.org/].

The Building Partnerships Program: An Approach to Community-based Learning for Medical Students in Australia

The Building Partnerships Program at the University of Queensland, Australia seeks to address the dual challenge of preparing doctors who are responsive to the community while providing a meaningful context for social sciences learning. Through partnerships with a diverse range of community agencies, the program offers students opportunities to gain non-clinical perspectives on health and illness through structured learning activities including: family visits; community agency visits and attachments; and interview training. Students learn first-hand about psychosocial influences on health and how people manage health problems on a day-to-day basis. They also gain insights into the work of community agencies and how they as future doctors might work in partnership with them to enhance patient care. We outline the main components of the program, identify challenges and successes from student and community agency perspectives, and consider areas that invite further development.

The efficacy of a psychosocial intervention for HIV/AIDS caregiving dyads and individual caregivers: a controlled treatment outcome study

The present study examined the comparative efficacy of intervening at the caregiver/care-recipient dyadic level, versus the individual caregiver level, for caregivers and their care-recipients with HIV/AIDS. Participants were randomly assigned to a Dyad Intervention (DI), a Caregiver Intervention (CI) or Wait List Control group (WLC), and assessed by interview and self-administered scales immediately before treatment and eight weeks later. Participants in the intervention groups also completed a four-month follow-up assessment. Dependent variables included global distress, social adjustment, dyadic adjustment, subjective health status, HIV/AIDS knowledge and target problem ratings. Results showed that caregivers in the DI group showed greater improvement from pre- to post-treatment on global distress, dyadic adjustment and target problems than the CI and WLC caregivers. The CI and DI caregivers showed greater improvement than the WLC group on all dependent variables except social adjustment. Care-recipients in the DI group improved significantly from pre- to post-treatment on dyadic adjustment, social adjustment, knowledge, subjective health status and Target Problem 1, whereas the CI and WLC care-recipients failed to improve on any of these measures. The treatment gains made by the DI caregivers and care-recipients on most dependent variables were maintained at a four-month follow-up. Findings support a reciprocal determinism approach to the process of dyadic adjustment and suggest that intervening at the caregiver/care-recipient level may produce better outcomes for both the caregiver and care-recipient than intervening at the individual caregiver level.

Managing urinary incontinence across the lifespan

In the 1996 baseline surveys of the Australian Longitudinal Study of Women's Health (ALSWH), 36.1% of mid-age women (45-50) and 35% of older women (70-75) reported leaking urine. This study aimed to investigate (a) the range of self-management strategies used to deal with urinary incontinence (UI); (b) the reasons why many women who report leaking urine do not seek help for UI; and (c) the types of health professionals consulted and treatment provided, and perceptions of satisfaction with these, among a sample of women in each age group who reported leaking urine often' at baseline. Five hundred participants were randomly selected from women in each of the mid-age and older cohorts of the ALSWH who had reported leaking urine often in a previous survey. Details about UI (frequency, severity, and situations), self-management behaviors and help-seeking for UI, types of health professional consulted, recommended treatment for the problem, and satisfaction with the service provided by health care professionals and the outcomes of recommended treatments were sought through a self-report mailed follow-up survey. Most respondents had leaked urine in the last month (94% and 91% of mid-age and older women, respectively), and 72.2% and 73. 1% of mid-aged and older women, respectively, had sought help or advice about their UI. In both age groups, the likelihood of having sought help significantly increased with severity of incontinence. The most common reasons for not seeking help were that the women felt they could manage the problem themselves or they did not consider it to be a problem.. Many women in both cohorts had employed avoidance techniques in an attempt to prevent leaking urine, including reducing their liquid consumption, going to the toilet just in case, and rushing to the toilet the minute they felt the need to. Strategies are needed to inform women who experience UI of more effective management techniques and the possible health risks associated with commonly used avoidance behaviors. There may be a need to better publicize existing incontinence services and improve access to these services for women of all ages.

Ambivalent implications of health care information systems: a study in the Brazilian public health care system

This article evaluates social implications of the "SIGA" Health Care Information System (HIS) in a public health care organization in the city of São Paulo. The evaluation was performed by means of an in-depth case study with patients and staff of a public health care organization, using qualitative and quantitative data. On the one hand, the system had consequences perceived as positive such as improved convenience and democratization of specialized treatment for patients and improvements in work organization. On the other hand, negative outcomes were reported, like difficulties faced by employees due to little familiarity with IT and an increase in the time needed to schedule appointments. Results show the ambiguity of the implications of HIS in developing countries, emphasizing the need for a more nuanced view of the evaluation of failures and successes and the importance of social contextual factors.

Detection of psychiatric morbidity in the primary medical care setting in Brazil

The aims of this study were a) to assess the ability of primary care doctors to make accurate ratings of psychiatric disturbance and b) to evaluate the use of a case-finding questionnaire in the detection of psychiatric morbidity. The estudy took place in three primary care clinics in the city of São Paulo, Brazil, during a six-month survey. A time sample of consecutive adult attenders were asked to complete a case-finding questionnaire for psychiatric disorders (the Self Report Questionnaire - SRQ) and a subsample were selected for a semi-structured psychiatric interview (the Clinical Interview Schedule - CIS). At the end of the consultation the primary care doctors were asked to assess, in a standardized way, the presence or absence of psychiatric disorder; these assessments were then compared with that ratings obtained in the psychiatric interview. A considerable proportion of minor psychiatric morbidity remained undetected by the three primary care doctors: the hidden morbidity ranged from 22% to 79%. When these were compared to those of the case-finding questionnaire, they were consistently lower, indicating that the use of these instruments can enhance the recognition of psychiatric disorders in primary care settings. Four strategies for adopting the questionnaire are described, and some of the clinical consequences of its use are discussed.

Demographic profile and health conditions of the elderly in a community in an urban area of Southeastern Brazil

Some specific characteristics of the aging of the Brazilian population in different areas, states and communities all over the country, have shown significant variations. Historical series of demographic and health indicators for the population in their sixties and over in Brazil, state of S. Paulo and in the municipal district of Araraquara are listed as follows: level of education and urban population growth rate, income distribution, mortality rates and main causes of death. In 1991 the aged constituled were 7,8% of the Brazilian population and 9,7% in Araraquara community. The elderly population (of 70 years of aged and above) as a proportion of the whole, has increased and already stands for 40%. The same trend holds good for both the proportion of aged within the urban population and their level of education wich increased to 90% in 1991. The main causes of death are chronic degenerative diseases which have replaced the infectious illness: firts, the diseases of the circulatory sistem (which account for more than 40% of all deaths) and the neoplasms (which let to 15% of the deaths). On the basis of these health and demographic data relating to people of 60 years of age and over, this study suggests some procedures for the improvement of the quality of the assistance given to the target population: a) the assistance give to the aged should be improved by providing gerontological training for general physicians and nurses, both of public and private clinics; b) the already exixting educational activities for the aged, for health workers and for teachers of secundary education should be further developed; c) the number of day-hospitals should be increased for the purpose of avoiding unnecessary confinement so as maintain the low rate of institutionalization in homes for the elderly (0,7% in Araraquara). It is reported that at least 35% of the aged population in this area is entitled to private health assistance, wich brings out the importance of including such services in the local health programs for this group.