Predictive value of the ankle-brachial index in the evaluation of intermittent claudication

The purpose of this study was to determine whether the ankle-brachial index (ABI) could be used to predict the prognosis for a patient with intermittent claudication (IC). We studied 611 patients prospectively during 28 months of follow-up. We analyzed the predictive power of using various levels of ABI - 0.30 to 0.70 at 0.05 increments - in terms of the measure's specificity (association with a favorable outcome after exercise rehabilitation therapy) and sensitivity (association with a poor outcome after exercise rehabilitation therapy). We found that using an ABI of 0.30 as a cut-off value produced the lowest margin of error overall, but the predictive power was still low with respect to identifying the patients with a poor prognosis after non-aggressive therapeutic treatment. Further study is needed to perhaps identify a second factor that could increase the sensitivity of the test.

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.

Sexing the human skull through the mastoid process

OBJECTIVE: The purpose of this study was to evaluate the significance for sex determination of the measurement of the area formed by the xerographic projection of 3 craniometric points related to the mastoid process: the porion, asterion, and mastoidale points. METHOD: Sixty skulls, 30 male and 30 female, were analyzed. A xerographic copy of each side of the skull was obtained. On each xerographic copy, the craniometric points were marked to demarcate a triangle. The area (mm²) of the demarcated triangle for each side of the skull (right (D) and left (E) sides) was determined, and the total value of these measures (T) was calculated. RESULTS: Concerning the right area of the male and female skulls, 60% of the values overlapped; for the left area, 51.67% overlapped, and for the total area, 36.67% overlapped. The analysis of the differences between the sexes in the areas studied was significant for the 3 areas. Regarding the total area, which is the preferred measurement because of the asymmetry between the sides of the skull, the value of the mean was 1505.32 mm² for male skulls, which was greater than the maximum value obtained in the female skulls. The value of the mean for female skulls was 1221.24 mm², less than the minimum value obtained for the male skulls. CONCLUSIONS: This study demonstrates a significant result in the 3 studied areas, (D), (E), and (T). The total area values show less overlapping of values between the sexes, and therefore can be used for sexing human skulls. For the population studied, values of the total area that were greater than or equal to 1447.40 mm² belonged to male crania (95% confidence). Values for this area that were less than or equal to 1260.36 mm² belonged to female crania (95% confidence).

Color Doppler sonography with contrast in the differentiation of ovarian tumors

The objective of this study was to differentiate benign ovarian tumors from malignant ones before surgery using color and pulsed Doppler sonography, and to compare results obtained before and after use of contrast medium, thereby verifying whether contrast results in an improvement in the diagnostic sensitivity. METHODS: Sixty two women (mean age 49.9 years) with ovarian tumors were studied, 45 with benign and 17 with malignant tumors. All women underwent a transvaginal color Doppler ultrasonographic exam. A study of the arterial vascular flow was made in all tumor areas, as well as an impedance evaluation of arterial vascular flow using the resistance index. RESULT: Localization of the vessels in the tumor revealed a greater proportion of malignant tumors with detectable internal vascular flows (64%) than benign tumors with such flows (22%). There was a considerable overlap of these findings. The use of contrast identified a greater number of vessels with confirmation in the totality of tumors, but did not improve the Doppler capacity in tumoral differentiation. Malignant tumors presented lower values of resistance index than the benign ones, whether or not contrast was used. The cutoff value for resistance index that better maximized the Doppler sensitivity and specificity was 0.55. Through this value, an increase of the sensitivity after contrast use was obtained, varying from 47% to 82%, while specificity remained statistically unchanged. CONCLUSION: Although the injection of a microbubble agent improved the sensitivity of the method detecting vascularization of tumors, a positive finding for vascularization by this method was not clinically useful in the differentiation of benign and malignant ovarian tumors.

Evolução, a curto prazo, do perfil do estado de nutrição no transplante hepático, em adultos : contributo para otimização da abordagem clínica e nutricional

RESUMO:Contexto: A avaliação do estado de nutrição do doente com indicação para transplante hepático (TH) deve ser abrangente, considerando o amplo espetro de situações clínicas e metabólicas. As alterações metabólicas relacionadas com a doença hepática podem limitar a aplicação de métodos de avaliação nutricional, subestimando a desnutrição. Após o TH, é expectável a reversão dos distúrbios metabólicos da doença hepática, pela melhoria da função do fígado. No entanto, algumas complicações metabólicas podem surgir após o TH, relacionadas com a má-nutrição, a desnervação hepática e o uso prolongado de imunossupressão, comprometendo os resultados clínicos a longo-prazo. A medição longitudinal e confiável do metabolismo energético e dos compartimentos corporais após o TH, avaliada em conjunto com fatores influentes no estado de nutrição, pode identificar precocemente situações de risco e otimizar e individualizar estratégias clínicas e nutricionais com vantagens no prognóstico. Objetivo: Avaliar longitudinalmente, a curto prazo, o estado de nutrição após o TH em doentes com insuficiência hepática por doença crónica e identificar os fatores, para além da cirurgia, que determinam diferentes evoluções do metabolismo energético e da composição corporal. Métodos: Foi estudada uma coorte de indivíduos com indicação para TH por doença hepática crónica, admitidos consecutivamente para TH ortotópico eletivo, durante 2 anos. Foram programados 3 momentos de avaliação: na última consulta pré-TH (T0), logo que adquirida autonomia respiratória e funcional após o TH (T1) e um mês após o TH (T2). Nesses momentos, foram medidos no mesmo dia: o suprimento nutricional por recordatório das últimas 24 horas, o estado de nutrição por Avaliação Subjetiva Global (ASG), o gasto energético em repouso (GER) por calorimetria indireta, a antropometria, a composição corporal por bioimpedância elétrica tetrapolar multifrequências e a força muscular por dinamometria de preensão palmar. O índice de massa magra (IMM) e a massa celular corporal (MCC) foram usados como indicadores do músculo esquelético e a percentagem de massa gorda (%MG) e o índice de massa gorda (IMG) como indicadores de adiposidade. O GER foi comparado com o estimado pelas fórmulas de Harris-Benedict para classificação do estado metabólico em:hipermetabolismo (GER medido >120% do GER estimado), normometabolismo (GER medido entre 80 e 120% do GER estimado) e hipometabolismo (GER medido <80% do GER estimado). Foi utilizada análise multivariável: por regressão logística, para identificar variáveis associadas à possibilidade (odds ratio – OR) de pertencer a cada grupo metabólico pré-TH; por regressão linear múltipla, para identificar variáveis associadas à variação dos compartimentos corporais no período pós-TH; e por modelos de efeitos mistos generalizados, para identificar variáveis associadas à evolução do GER e dos compartimentos corporais entre o período pré- e pós-TH. Resultados: Foram incluídos 56 indivíduos com idade, média (DP), 53,7 (8,5) anos, 87,5% do sexo masculino, 23,2% com doença hepática crónica de etiologia etanólica. Após o TH, em 60,7% indivíduos foi administrado regime imunossupressor baseado no tacrolimus. Os indivíduos foram avaliados [mediana (AIQ)] 90,5 (P25: 44,2; P75: 134,5) dias antes do TH (T0), 9,0 (P25: 7,0; P75: 12,0) dias após o TH (T1) e 36,0 (P25: 31,0; P75: 43,0) dias após o TH (T2). Após o TH houve melhoria significativa do estado de nutrição, com diminuição da prevalência de desnutrição classificada pela ASG (37,5% em T0, 16,1% em T2, p<0,001). Antes do TH, 41,1% dos indivíduos eram normometabólicos, 37,5% hipometabólicos e 21,4% hipermetabólicos. A possibilidade de pertencer a cada grupo metabólico pré-TH associou-se à: idade (OR=0,899, p=0,010) e desnutrição pela ASG (OR=5,038, p=0,015) para o grupo normometabólico; e índice de massa magra (IMM, OR=1,264, p=0,049) e etiologia viral da doença hepática (OR=8,297, p=0,019) para o grupo hipermetabólico. Não se obteve modelo múltiplo para o grupo de hipometabólico pré-TH, mas foram identificadas associações univariáveis com a história de toxicodependência (OR=0,282, p=0,047) e com a sarcopénia pré- TH (OR=8,000, p=0,040). Após o TH, houve normalização significativa e progressiva do estado metabólico, indicada pelo aumento da prevalência de normometabolismo (41,1% em T0, 57,1% em T2, p=0,040). Foram identificados diferentes perfis de evolução do GER após o TH, estratificado pelo estado metabólico pré-TH: no grupo hipometabólico pré-TH, o GER (Kcal) aumentou significativa e progressivamente (1030,6 em T0; 1436,1 em T1, p=0,001; 1659,2 em T2, p<0,001); no grupo hipermetabólico pré-TH o GER diminuiu significativa e progressivamente (2097,1 em T0; 1662,5 em T1, p=0,024; 1493,0 em T2, p<0.001); no grupo normometabólico não houve variações significativas. Os perfis de evolução do GER associaram-se com: peso corporal (β=9,6, p<0,001) e suprimento energético (β=13,6, p=0,005) na amostra total; com peso corporal (β=7,1, p=0,018) e contributo energético dos lípidos (β=18,9, p=0,003) no grupo hipometabólico pré-TH; e com peso corporal (β=14,1, p<0,001) e desnutrição pela ASG (β=-171,0, p=0,007) no grupo normometabólico pré-TH.Houve redução transitória dos compartimentos corporais entre T0 e T1, mas a maioria destes recuperou para valores semelhantes aos pré-TH. As exceções foram a água extracelular, que diminuiu entre T0 e T2 (média 18,2 L e 17,8 L, p=0,042), a massa gorda (média 25,1 Kg e 21,7 Kg, p<0,001) e o IMG (média 10,6 Kg.m-2 e 9,3 Kg.m-2, p<0,001) que diminuíram entre T1 e T2. Relativamente à evolução dos indicadores de músculo esquelético e adiposidade ao longo do estudo: a evolução do IMM associou-se com força de preensão palmar (β=0,06, p<0,001), creatininémia (β=2,28, p<0,001) e número total de fármacos administrados (β=-0,21, p<0,001); a evolução da MCC associou-se com força de preensão palmar (β=0,16, p<0,001), creatininémia (β=4,17, p=0,008) e número total de fármacos administrados (β=-0,46, p<0,001); a evolução da %MG associou-se com força de preensão palmar (β=-0,11, p=0,028), história de toxicodependência (β=-5,75, p=0,024), creatininémia (β=-5,91, p=0,004) e suprimento proteico (β=-0,06, p=0,001); a evolução do IMG associou-se com história de toxicodependência (β=- 2,64, p=0,019), creatininémia (β=-2,86, p<0,001) e suprimento proteico (β=-0,02, p<0,001). A variação relativa (%Δ) desses compartimentos corporais entre T1 e T2 indicou o impacto da terapêutica imunossupressora na composição corporal: o regime baseado na ciclosporina associou-se positivamente com a %Δ do IMM (β=23,76, p<0,001) e %Δ da MCC (β=26,58, p<0,001) e negativamente com a %Δ MG (β=-25,64, p<0,001) e %Δ do IMG (β=-25,62, p<0,001), relativamente ao regime baseado no tacrolimus. Os esteróides não influenciaram a evolução do GER nem com a dos compartimentos corporais. Conclusões: O estado de nutrição, avaliado por ASG, melhorou significativamente após o TH, traduzida pela diminuição da prevalência de desnutrição. O normometabolismo pré-TH foi prevalente e associou-se à menor idade e à desnutrição pré- TH. O hipometabolismo pré-TH associou-se à história de toxicodependência e à sarcopénia pré-TH. O hipermetabolismo pré-TH associou-se ao maior IMM e à etiologia viral da doença hepática. Após o TH, houve normalização progressiva do estado metabólico. Foram identificados três perfis de evolução do GER, associando-se com: peso corporal e suprimento energético na amostra total; peso corporal e contributo energético dos lípidos no grupo hipometabólico pré- TH; e peso corporal e desnutrição pela ASG no grupo normometabólico pré-TH. Foram identificados diferentes perfis de evolução da composição corporal após TH. A evolução do músculo esquelético associou-se positivamente com a força de preensão palmar e a creatininémia e negativamente com o número total de fármacos administrados. A evolução da adiposidade (%MG e IMG) associou-se inversamente com a história de toxicodependência, a creatininémia e o suprimento proteico; adicionalmente, a %MG associou-se inversamente com a força de preensão palmar. O regime baseado na ciclosporina associou-se independentemente com diminuição da adiposidade e aumento do músculo esquelético, comparativamente ao regime baseado no tacrolimus.---------------------------ABSTRACT:Background: The assessment of nutritional status in patients undergoing liver transplantation (LTx) should be comprehensive, accounting for the wide spectrum of the clinical and metabolic conditions. The metabolic disturbances related to liver disease may limit the precision and accuracy of traditional nutritional assessment methods underestimating the undernourishment. After LTx, it is expected that many metabolic derangements improve with the recovery of liver function. However, some metabolic complications arising after LTx, related to nutritional status, hepatic denervation, and prolonged immunosuppression, may compromise the longterm outcome. A reliable longitudinal assessment of both energy metabolism and body compartments after LTx, combined with assessments of other factors potentially affecting the nutritional status, may enable a better interpretation on the relationship between the metabolic and the nutritional status. These reliable assessments may precociously identify nutritional risk conditions and optimize and customize clinical and nutritional strategies improving the prognosis. Objective: To assess longitudinally the nutritional status shortly after orthotopic LTx in patients with chronic liver disease, and identify factors, beyond surgery, determining different energy metabolism and body composition profiles.Methods: A cohort of consecutive patients who underwent LTx due to chronic liver disease was studied within a period of two years. The assessments were performed in three occasions: at the last visit before LTx (T0), after surgery as soon as respiratory and functional autonomy was established (T1), and approximately one month after surgery (T2). On each occasion all assessments were performed on the same day, and included: the dietary assessment by 24- hour dietary recall, nutritional status by the Subjective Global Assessment (SGA), the resting energy expenditure (REE) by indirect calorimetry, anthropometry, body composition by multifrequency bioelectrical impedance analysis, and muscle strength by handgrip strength. Both the lean mass index (LMI) and body cell mass (BCM) were used as surrogates of skeletal muscle, and both the percentage of fat mass (%FM) and fat mass index (FMI) of adiposity. The REE was predicted according to the Harris and Benedict equation. Hypermetabolism was defined as a measured REE more than 120% of the predicted value; normometabolism as a measured REE within 80-120% of the predicted value; and hypometabolism as a measured REE less than 80% of the predicted value. Multiple regression analysis was used: by logistic regression to identify variables associated with odds of belong each pre-LTx metabolic groups; by linear multiple regression analysis to identify variables associated with body compartments relative variations (%Δ) in the post-LTx period; and by mixed effects models to identify variables associated with the REE and body compartments profiles pre- and post-LTx. Results: Fifty six patients with a mean (SD) of 53.7 (8.5) years of age were included, 87.5% were men and 23.2% with alcoholic liver disease. After LTx 60.7% individuals were assigned to tacrolimus-based immunosuppressive regimen. The patients were assessed at a median time (inter-quartil range) of 90.5 (P25 44.2; P75 134.5) days before LTx (T0), at a median time of 9.0 (P25 7.0; P75 12.0) (T1) and 36 (P25 31.0; P75 43.0) (T2) days after LTx. After LTx the nutritional status significantly improved: the SGA-undernourishment decreased from 37.5% (T0) to 16.1% (T2) (p<0.001). Before LTx, 41.1% patients were normometabolic, 37.5% hypometabolic, and 21.4% hypermetabolic. The predictors of each pre-LTx metabolic group were: age (OR=0.899, p=0.010) and SGA-undernourishment (OR=5.038, p=0.015) for the normometabolic group; and LMI (OR=1.264, p=0.049) and viral etiology of liver disease (OR=8.297, p=0.019) for the hypermetabolic group. No multiple model was found for the pre-LTx hypometabolic group, but univariate association was found with history of drug addiction (OR=0.282, p=0.047) and pre- LTx sarcopenia (OR=8.000, p=0.040). After LTx a significant normalization of the metabolic status occurred, indicated by the increase in the prevalence of normometabolic patients (from T0: 41.1% to T2: 57.1%, p=0.040). Different REE profiles were found with REE stratified by preoperative metabolic status: in the hypometabolic group a significant progressive increase in mean REE (Kcal) was observed (T0: 1030.6; T1: 1436.1, p=0.001; T2: 1659.2, p<0.001); in the hypermetabolic group, a significant progressive decrease in mean REE (Kcal) was observed (T0: 2097.1; T1: 1662.5, p=0.024; T2: 1493.0, p<0.001); and in the normometabolic group, no significant differences were found. The REE profiles were associated with: body weight (β- estimate=9.6, p<0.001) and energy intake (β-estimate=13.6, p=0.005) in the whole sample; with body weight (β-estimate=7.1, p=0.018) and %TEV from lipids (β-estimate=18.9, p=0.003) in the hypometabolic group; and with body weight (β-estimate=14.1, p<0.001), and SGAundernourishment (β-estimate=-171, p=0.007) in the normometabolic group. A transient decrease in most body compartments occurred from T0 to T1, with subsequent catch-up to similar preoperative values. Exceptions were the extracellular water, decreasing from T0 to T2 (mean 18.2 L to 17.8 L, p=0.042), the fat mass (mean 25.1 Kg to 21.7 Kg, p<0.001) and FMI (mean 10.6 Kg.m-2 to 9.3 Kg.m-2, p<0.001), decreasing from T1 to T2. Significant predictors of skeletal muscle and adiposity profiles were found: LMI evolution was associated with handgrip strength (β-estimate=0.06, p<0.001), serum creatinine (β- estimate=2.28, p<0.001) and number of medications (β-estimate=-0.21, p<0.001); BCM evolution was associated with handgrip strength (β-estimate=0.16, p<0.001), serum creatinine (β-estimate=4.17, p<0.001) and number of medications (β-estimate=-0.46, p<0.001); the %FM evolution was associated with handgrip strength (β-estimate=-0.11, p=0.028), history of drug addiction (β-estimate=-5.75, p=0.024), serum creatinine (β-estimate=-5.91, p=0.004) and protein intake (β-estimate=-0.06, p=0.001); and FMI evolution was associated with history of drug addiction (β-estimate=-2.64, p=0.019), serum creatinine (β-estimate=-2.86, p<0.001) and protein intake (β-estimate=-0.02, p<0.001). The %Δ of the aforementioned body compartments from T1 to T2 indicated the influence of immunosuppressive agents on body composition: the cyclosporine-based regimen, compared with tacrolimus-based regimen, was positively associated with %Δ LMI (β-estimate=23.76, p<0.001) and %Δ BCM (β- estimate=26.58, p<0.001), and inversely associated with %Δ FM (β-estimate=-25.64, p<0.001) and %Δ FMI (β-estimate=-25.62, p<0.001). No significant changes in REE or body composition were observed associated with dose or duration of steroid therapy. Conclusions: The SGA-assessed nutritional status improved shortly after LTx, with significant decrease in prevalence undernourished individuals. XXI Preoperative normometabolism was prevalent and was associated with younger age and SGAundernourishment before LTx. Preoperative hypometabolism was associated with history of drug addiction and pre-LTx sarcopenia. Preoperative hypermetabolism was associated with higher LMI and viral etiology of liver disease. A significant normalization of the metabolic status was observed after LTx. The REE profiles were positively predicted by body weight and energy intake in the whole sample, by body weight and percentage of energy intake from lipids in the preoperative hypometabolic patients, and by body weight and SGA–undernourishment in the preoperative normometabolic patients. Different body composition profiles were found after LTx. Skeletal muscle profile was positively associated with handgrip strength and serum creatinine, and inversely with the number of medications. The adiposity profile was inversely associated with history of drug addiction, serum creatinine and protein intake. Additionally, the %FM evolution was inversely associated with handgrip strength. The cyclosporine-based regimen, compared with tacrolimus-based regimen, was independently associated with skeletal muscle increase and adiposity decrease.

On the isotopic composition of precipitation in tropical stations (*).

Some of the trends and characteristics of the isotopic composition oh precipitation in tropical stations are discussed. Stations in small Pacific islands show a variation with latitude, with lower 8-values between 15°N and 1S°S and higher values at higher. Inland stations are depleted in heavy isotopes with respect to coastal stations but sometimes this continental effect is rather complex, as f,or instance in África. Mean monthly 8-values show a remarkable correlation with the amount of precipitation, but the slope variations do not show a clear dependence on the mean long term 8-value,as should be expected theoretically. In Southern American stations the seasonal variations of the meanmonthly 5-values are correlated and they are greater in inland stations due to con-tinentaly. The possible effects of recycling of water vapour by evapotranspiration are also discussed.