Paulo University Medical School Research Articles

BRAZILIAN-PORTUGUESE VERSION AND APPLICABILITY QUESTIONNAIRE OF THE MOBILITY INDEX FOR ANKYLOSING SPONDYLITIS

To translate and adapt the Bath Ankylosing Spondylitis Methodology Index (BASMI) - a metrological measurement for the assessment of patients with ankylosing spondylitis to Brazilian-Portuguese and to analyze the applicability of the questionnaire. The Brazilian-Portuguese version of the Bath Ankylosing Spondylitis Methodology Index was achieved through a translation and back-translation process. This new Bath Ankylosing Spondylitis Methodology Index version was administered to 25 consecutive patients with ankylosing spondylitis who met the 1984 New York criteria for ankylosing spondylitis and were followed in the Soronegative Spondyloarthropathy Unit of the Rheumatology Division, São Paulo University Medical School, from May to November 2005. In order to evaluate the applicability of the questionnaire, it was administered to patients by 2 separate observers, A and B (Rheumatologists), enabling inter-observer test analysis. After 2 weeks, the second interview was administered to the same patients by observer A only to analyze the intra-observer test. All interviews were conducted in the morning. The Pearson coefficient correlation was used to evaluate applicability. There was no conflict stemming from translation and re-translation of Bath Ankylosing Spondylitis Methodology Index questionnaire, and cross-cultural adaptation proved unnecessary. All components had statistically significant coefficients for intra- and inter-observational applicability, with scores ranging from 0.85 to 1.00 and 0.80 to 0.94, respectively. The Brazilian-Portuguese version of the Bath Ankylosing Spondylitis Methodology Index proved to be an applicable instrument for analyzing the mobility index of Brazilian patients with ankylosing spondylitis.

AUTOPSY-PROVEN CAUSES OF DEATH IN LUNGS OF PATIENTS IMMUNOCOMPROMISED BY SECONDARY INTERSTITIAL PNEUMONIA

To present the more frequent associations found in autopsies of immunocompromised patients who developed secondary interstitial pneumonia as well as the risk of death (odds ratio) in having specific secondary interstitial pneumonia according to the cause of immunocompromise. From January 1994 to March 2004, 17,000 autopsies were performed at Hospital das Clínicas, São Paulo University Medical School. After examining the pathology report review, we selected 558 of these autopsies (3.28%) from patients aged 15 years or more with primary underlying diseases who developed radiologically diffuse infiltrates of the lung during their hospital course and died after secondary interstitial pneumonia (bronchopneumonia, lobar pneumonia, interstitial pneumonia, diffuse alveolar damage, pulmonary recurrence of underlying disease, drug-induced lung disease, cardiogenic pulmonary edema, or pulmonary embolism). Histology slides were reviewed by experienced pathologists to confirm or not the presence of secondary interstitial pneumonia. Statistical analysis included the Fisher exact test to verify any association between histopathology and the cause of immunocompromise; a logistic regression was used to predict the risk of death for specific histological findings for each of the independent variables in the model. Secondary interstitial pneumonia was histologically represented by diffuse interstitial pneumonitis ranging from mild nonspecific findings (n = 213) to a pattern of diffuse alveolar damage (n = 273). The principal causes of immunocompromise in patients with diffuse alveolar damage were sepsis (136 cases), neoplasia (113 cases), diabetes mellitus (37 cases), and transplantation (48 cases). A high risk of death by pulmonary edema was found for patients with carcinoma of colon. Similarly, in patients with lung cancer or cachexia, A high risk of death by bronchopneumonia (OR = 3.6; OR = 2.6, respectively) was found. Pulmonary thromboembolism was associated with an appreciable risk of death (OR = 2.4) in patients with arterial hypertension. The risk of death was also high in patients presenting hepatic cancer (OR = 2.5) or steroid therapy (OR = 2.4) who developed pulmonary hemorrhage as the histological pattern of secondary interstitial pneumonia . The risk of death by lung metastasis was also elevated (OR = 1.6) for patients that were immunosuppressed after radiotherapy. Patients with secondary immunosuppression who developed secondary interstitial pneumonia during treatment in hospital should be evaluated to avoid death by diffuse alveolar damage, pulmonary edema, bronchopneumonia, lung hemorrhage, pulmonary thromboembolism, or lung metastasis. The high-risk patients are those immunosuppressed by hematologic disease; those under steroid treatment; or those with colon or hepatic carcinoma, cachexia, or arterial hypertension.

MULTILOCUS GENOTYPING OF CRYPTOSPORIDIUM HOMINIS ASSOCIATED WITH DIARRHEA OUTBREAK IN A DAY CARE UNIT IN SÃO PAULO

A number of species of Cryptosporidium are associated with diarrhea worldwide. Little data exists regarding the genotypes and species of Cryptosporidium associated with cases of infections in Brazil. In the present study, we ascertained by molecular methods the species and the genotype of Cryptosporidium sp from a diarrhea outbreak diagnosed in a day care at the Hospital Clínicas, São Paulo University Medical School. Specific identification and typing of the isolates associated with the outbreak was done by DNA sequencing analysis of fragments amplified by polymerase chain reaction (PCR) from 3 different Cryptosporidium loci: the SSUrRNA coding region, the Cryptosporidium oocyst wall protein (COWP) gene, and the microsatellite locus 1 (ML1), a tandem GAG-trinucleotide repeat containing substitutions that differentiate the genotypes of Cryptosporidium parvum and Cryptosporidium hominis. A total of 29 positive samples from the outbreak were studied by the molecular methods described. Our study revealed the presence of a single genotype of Cryptosporidium hominis in all samples. The molecular analysis reinforced the hypothesis that the transmission of Cryptosporidium hominis during the period the samples were collected occurred in an outbreak pattern, possibly by person-to-person contact through the fecal-oral route. As far as we know, this is the first time that molecular tools have been used to identify the species and the genotype of isolates showing the presence of the ML1 genotype in samples from Brazilian patients.

FOLLOW-UP OF THE ANEURYSMAL SAC AFTER EXCLUSION AND BYPASS OF POPLITEAL ARTERY ANEURYSMS

Popliteal artery aneurysms are frequent and may lead to thromboembolic events and limb loss. To evaluate clinical and ultrasonographic follow-up of patients who underwent exclusion of a popliteal artery aneurysm using the technique proposed by Edwards. Data of all patients who underwent surgery to repair a popliteal artery aneurysm at Hospital das Clinicas, the São Paulo University Medical School between 1996 and 2004 were reviewed. Inclusion criteria were repair with aneurysm exclusion and bypass using the technique proposed by Edwards, as well as the existence of preoperative and postoperative measurements of the aneurysmal sac. Data of 16 patients who underwent 20 procedures for popliteal artery aneurysm exclusion and bypass were available to analysis. The preoperative diameter of the popliteal artery aneurysms ranged from 1.3 cm to 6.1 cm (mean = 3.1 cm). Patients underwent duplex ultrasound scanning 1 month to 7 years after surgical repair. Follow-up of the 20 cases revealed that 10 aneurysms exhibited decreased mean transverse diameters, ranging from 0.2 to 2.3 cm, while 7 had increased in diameter, ranging 0.3 to 3.3 cm, and 3 remained unchanged. Flow was observed only in 5 out of the 20 procedures, 3 of which (60%) had increased diameters. Although exclusion is a widely accepted procedure for the repair of popliteal artery aneurysms, data in the literature and the results of this study, which did not include cases of rupture or compression, suggest that strict follow-up of patients who undergo aneurysm exclusion is necessary.

PRENATAL DIAGNOSIS AND PERINATAL OUTCOME OF 38 CASES WITH CONGENITAL DIAPHRAGMATIC HERNIA: 8-YEAR EXPERIENCE OF A TERTIARY BRAZILIAN CENTER

To evaluate the perinatal results for neonates with congenital diaphragmatic hernia diagnosed prenatally. We reviewed data from 38 cases of congenital diaphragmatic hernia diagnosed prenatally from January 1995 to December 2003 in the Fetal Medicine Unit of the Department of Obstetrics and Gynecology, São Paulo University Medical School. The main data analyzed were gestational age at diagnosis, fetal karyotyping, side of diaphragmatic defect, presence of associated structural malformations, hepatic herniation, and severe mediastinal shift. Perinatal outcomes were obtained by reviewing hospital documents or by directly calling the patients' immediate relatives. Mean gestational age at diagnosis was 29 weeks (range, 16-37 weeks). Thirty (79%) cases had a left diaphragmatic defect and 8 (21%) had a right lesion. Associated structural malformations were observed in 21 (55%) cases, in which 12 fetuses had a normal karyotype and 9 had chromosomal abnormalities. Isolated congenital diaphragmatic hernia was confirmed in 17 (45%) cases. The overall perinatal mortality rate was 92%. Rates of fetal deaths, early neonatal deaths, late neonatal deaths, and survival were 42%, 50%, 0%, and 8%, respectively, in cases with associated structural malformations but normal karyotyping; 56%, 44%, 0%, and 0% for cases with chromosomal abnormalities; and, 0%, 76%, 12%, and 12% in cases with isolated congenital diaphragmatic hernia. The neonatal mortality rate was 89% in cases with isolated congenital diaphragmatic hernia. Perinatal mortality was very high in prenatally diagnosed cases of congenital diaphragmatic hernia. Earlier perinatal deaths are associated with the presence of other structural defects or chromosomal abnormalities. In cases of isolated congenital diaphragmatic hernia, mortality is related to the presence of herniated liver, right-sided lesion, and major mediastinal shift.

Hermafroditismo verdadeiro: experiência com 36 casos

To show data on true hermaphrodites (TH) followed in two reference centers in the state of São Paulo. Twenty-six TH patients have been followed from 1975 to 2004 in the Pediatric Endocrinology Unit, São Paulo University Medical School, and the other 10 patients from 1989 to 2004 in the GIEDDS-UNICAMP. Clinical and pathological data were retrospectively analyzed, as well as the decision about the sex of rearing. Genital ambiguity was the most frequent complaint (34/36 cases) and the age at the first appointment was 20 mo (median). In 55.6% of the patients the female option was taken. The most frequent karyotype was 46,XX (47.2%), followed by mosaicisms (27.8%). SRY was negative in all 46,XX TH patients and the prevalent gonad was ovotestis (OT-47%), followed by ovary (OV-27%) and testis (TT-24%). The prevalent gonadal associations were OV+TT (30.5%), OT+OT (22.2%) and OT+OV (22.2%). The decision about the sex of rearing did not depend on karyotype, phallus size, and testosterone levels. However, the location of the urethral meatus was taken into account in this decision: 20 (80%) patients out of the 25 with perineal urethra were reared as females while all 11 with "non-perineal" urethra were reared as males. In five 46,XX patients reared as females it was possible to maintain the ovarian portion of the ovotestis. TH keeps on defying clinicians and investigators since most patients are 46,XX and SRY-negative, and yet they are able to develop testicular and ovarian tissues. The female sex of rearing seems to be the most adequate, and it is important to try to preserve, in these cases, the ovarian portion of the ovotestis, allowing the patient to have normal puberty and fertility.

Tuberculosis affecting the oral cavity in Brazilian HIV-infected patients

Tuberculosis (TB) affecting the oral cavity is a very rare disease. We reviewed the medical data of 18 HIV(1)-infected patients referred to the Stomatology Group, Ear, Nose, and Throat Department, São Paulo University Medical School, who had a diagnosis of oral tuberculosis, between 1991 and 2002. This retrospective study aimed to analyze the relationship between oral tuberculosis and HIV infection. The clinical records of the patients were reviewed to note age and gender, symptoms, and site and type of the lesions in the oral mucosa. Results of CD4+ T-lymphocyte count, sputum analysis, tuberculin skin test, histopathologic characteristics, cultures of the specimens (that were taken during the biopsy), chest x-ray findings, and the type of treatment they received were also reviewed. The most affected sites were palate and tongue. All patients had culture confirming tuberculosis. Patients with HIV and nonhealing oral lesions or papillomatous masses in the oral mucosa should be screened for the presence of pulmonary tuberculosis.

Clinical presentation, treatment and outcome of patients with cerebral metastases: the University of São Paulo series.

Secondary neoplasias are the most common tumors affecting the central nervous system and several clinical aspects of this disease are still controversial. Forty-seven consecutive patients with the diagnosis of cerebral metastases (CM) were retrospectively studied at the Clinical Hospital of Sao Paulo University Medical School. Mean age was 53.9 years and 25 patients were female. The most frequent primary sites were breast, lung and skin. Symptoms were related to increased intracranial pressure (ICP) in 48.9%, focal neurological events in 27.7% and both in 17.0%. Single brain metastases were found in 57.4% of those cases, the frontal lobe being most frequently affected. Surgical treatment was performed in 68.1%, radiotherapy in 40.4% and chemotherapy in 17.0%. After statistical analysis, there was a trend towards prolonged survival of female patients, patients with ICP symptoms and the surgical group. Data from different centers are essential to establish the best management of CM.

Beneficial effects of a phosphodiesterase type 5 inhibitor (Sildenafil) on exercise, neurohormonal activation, and erectile dysfunction in patients with congestive heart failure-$alpha; double-blind placebo-controlled cross-over randomized study Edimar A. Bocchi, Guilherme Guimar�es, Giovanni Bellotti, Jose A. F. Ramires. Heart Institute of S�o Paulo University Medical School, S�o Paulo, Brazil

Beneficial effects of a phosphodiesterase type 5 inhibitor (Sildenafil) on exercise, neurohormonal activation, and erectile dysfunction in patients with congestive heart failure-$alpha; double-blind placebo-controlled cross-over randomized study Edimar A. Bocchi, Guilherme Guimar�es, Giovanni Bellotti, Jose A. F. Ramires. Heart Institute of S�o Paulo University Medical School, S�o Paulo, Brazil

Squamous cell carcinoma of the esophagus and multiple primary tumors of the upper aerodigestive tract.

Squamous cell carcinoma of the esophagus is frequently associated with other, synchronous or metachronous tumors, in the upper aerodigestive tract. All 264 patients with squamous cell carcinoma of the esophagus, treated in the Gastrointestinal Surgery, Esophagus section, of the "Hospital das Clínicas" (São Paulo University Medical School, Brazil), between 1979 and 1989 were analyzed retrospectively with regards to the occurrence of multiple primary tumors in the upper aerodigestive tract. Multiple primary tumors were encountered in 10 (3.8%) patients. All patients were male and the mean age at the time of the first primary was 52.2 years. Tobacco smoke and alcohol were the principal carcinogens in these patients (n = 10). The sites of the tumors were: larynx (n = 4), tongue (n = 4), lung (n = 2), and oral cavity (n = 1). Two simultaneous, three synchronous and five metachronous multiple primary carcinomas were detected. The esophagus was the second primary tumor in nine patients. The mean overall survival after the diagnosis of the second primary was 2.8 months (SD = 0.89). Inquiry regarding other malignancies, associated with panendoscopy should be carry out prior to the treatment of the first primary to diagnose simultaneous or synchronous primary tumors, and careful follow-up should be performed after treatment of the first primary to detect new tumors in these high-risk patients.

The Use of Ultrasound Evaluation in the Diagnosis of Peritonsillar Abscess

Peritonsillar Abscess (PTA) and Peritonsillar Cellulitis (PTC) are very similar clinical conditions. The differential diagnosis between them is made by needle aspiration, a very painful and invasive method. This study was performed at the Department of Otolaryngology at the Clinical Hospital of São Paulo University Medical School. It's aim was to evaluate the use of ultrasound as a noninvasive and inexpensive method of diagnosis, differentiating abscess from cellulitis. Twenty-one consecutive patients with a clinical diagnosis of peritonsillar infection were evaluated in the emergency service with a probable diagnosis of PTA. These patients were evaluated with intraoral and percutaneous ultrasound. Needle aspiration was used to compare and confirm the diagnosis. The sensitivity was 92.3% and specificity was 62.3%. The authors conclude that ultrasound is a good method to evaluate the differences between PTA and PTC.

True hermaphroditism: clinical aspects and molecular studies in 16 cases.

Although true hermaphroditism (TH) accounts for less than 10% of intersex patients, it stands as a diagnostic challenge and has allowed a better understanding of the mechanisms involved in sexual differentiation. In this paper we review the clinical and laboratory data as well as molecular biology findings on 16 TH patients followed up at the Pediatric Endocrine Unit, Instituto da Criança, Hospital das Clínicas. São Paulo University Medical School. They were of a mean age of 3 years 8 months and nine of them were black. All the patients had ambiguous external genitalia as the main complaint. The 46,XX karyotype accounted for 50% of the cases and the ovotestis was the most frequent gonad found (59%). In the eight TH patients with a 46,XX karyotype, the sex-determining region of the Y chromosome (SRY) was negative, posing an intriguing question about the testicular differentiation mechanisms involved in these cases. In 7/19 ovotestes, the ovarian portion of the gonad has been preserved, keeping open the possibility of fertility. The female sex option was made in 10/16 cases (62.5%) and three patients exhibited spontaneous puberty. The mechanism through which testicular tissue develops without SRY has not yet been completely clarified, suggesting the involvement of the X chromosome as well as autosomal genes in the process.

Present trends in clinical experience with dynamic cardiomyoplasty.

Dynamic cardiomyoplasty has been performed to reinforce the myocardium in the treatment of patients with severe cardiomyopathies. At the Heart Institute of São Paulo University Medical School, 36 patients were submitted to cardiomyoplasty between May 1988 and December 1993. The indications were idiopathic dilated cardiomyopathy in 31, ischemic cardiomyopathy in 3, and Chagas' disease cardiomyopathy in 2 patients. Twenty-eight patients were categorized in New York Heart Association (NYHA) Class III and 8 in Class IV despite the use of maximal medical therapy. There were no hospital deaths, and patients were followed up from 2 to 70 months (mean, 24 months). Besides the improvement of NYHA functional class from 3.2 +/- 0.6 to 1.6 +/- 0.9 at 6 months of follow-up, patients also presented significant changes in the left ventricular systolic and diastolic functions. Nevertheless, 16 patients died, and 2 patients were submitted to heart transplantation during late follow-up. Actuarial survival rates were 82.3% at 1 year, 61.5% at 2 years, and 38.8% at 5 years of follow-up. Otherwise, the analysis of factors influencing the outcome showed that long-term survival was significantly affected by preoperative functional class and by pulmonary vascular resistance. The 26 patients operated in NYHA functional Class III and with pulmonary vascular resistance below 4 Wood units presented survival rates of 72.7% at 2 years and of 63% at 5 years of follow-up. In conclusion dynamic cardiomyoplasty improves functional class and left ventricular function in patients with severe cardiomyopathies. However, the long-term survival after this surgical procedure may be limited by the patients' condition before the operation.

Clinical experience of emergency coronary artery bypass grafting following failed percutaneous transulminal coronary angioplasty

From July, 1981 to December, 1988, 2431 percutaneous transluminal coronary angioplasties were performed on 1901 patients at the Heart Institute of São Paulo University Medical School. Seventy-six patients (4.0 per cent) underwent emergency coronary artery bypass grafting for failed angioplasty. The incidence of failed angioplasty was significantly higher in the impending myocardial infarction group (11.5 per cent) than in the angina group (4.8 per cent) and the acute myocardial infarction group (1.3 per cent). The mean age of the seventy-six patients was 54.4 years, and 54 patients were male. The operative mortality was 15.8 per cent, being 9 males and 3 females. Patients who had had a left main trunk dissection during angioplasty and those who were hemodynamically unstable following the failed angioplasty or who had had a cardiac arrest necessitating a cardiac massage during transportation to the operating room, had a higher mortality than patients in whom the failure occurred in other sites and those who were hemodynamically stable. Perioperative myocardial infarction was documented in 50 per cent of the patients. Patients who had had a cardiac arrest during the procedure had a higher rate of perioperative myocardial infarction than those whose preoperative hemodynamic condition was stable.

Intolerance to enteral nutrition in critically ill patients : [formula omitted],N.J.E.Pizzotti. Hospital das Clínicas,São Paulo University Medical School,São Paulo,S.P.,Brazil

Intolerance to enteral nutrition in critically ill patients : [formula omitted],N.J.E.Pizzotti. Hospital das Clínicas,São Paulo University Medical School,São Paulo,S.P.,Brazil

Non‐oestrogen therapy of the menopausal syndrome

AbstractA double‐blind study of cyclofenil plus diazepam compared to placebo was carried out in 30 postmenopausal patients at the Gynaecologic Clinic of São Paulo University Medical School. All patients had had amenorrhoea for at least one year before the trial. Kupperman Menopausal Index (KMI), FSH, LH, prolactin and oestradiol blood levels and vaginal smears were the data analysed.Cyclofenil 400 mg plus diazepam 10 mg po daily was the prescribed standard dose, which relieved the main symptoms of the menopausal syndrome. With the dose schedule used, neither blood hormone levels nor vaginal smears data showed any statistical difference before and after treatment. Also, no important side‐effects were observed.

Cancer-induced changes in body composition not reflected by carcass weight. Serum albumin or total body nitrogen : [formula omitted], J.Faintuch, E.L.Gonçalves, C.Lee Rocha, F.S. Goffi. Depto. of Surgical Technique, São Paulo University Medical School, São Paulo. BRASIL

Cancer-induced changes in body composition not reflected by carcass weight. Serum albumin or total body nitrogen : [formula omitted], J.Faintuch, E.L.Gonçalves, C.Lee Rocha, F.S. Goffi. Depto. of Surgical Technique, São Paulo University Medical School, São Paulo. BRASIL