Antonio Carlos Pereira Martins

Incontinência urinária no idoso

The prevalence of urinary incontinence in the elderly varies from 8 to 34% according to the criteria or method of investigation. The etiology or main associated factors are: aging tissular degeneration that compromise the lower urinary tract and pelvic floor, changes of peripheric and central nervous system, hormonal alterations such as menopause, nocturnal polyuria, benign prostate hyperplasia, concomitant diseases and side effects of medical drugs. The incontinence may be transitory or permanent. Besides a criterious medical history for a better characterization of the urinary loss, a search for associated or concomitant causes and the miccional diary, one oftenly may rely on specialized exams such as urodynamics. A specific diagnosis is of utmost value for correct management that may require only conservative measures based on changes of behaviour or counceiling, drugs prescription, or invasive methods including surgical procedures.

Immunoexpression of p53 protein and proliferating cell nuclear antigen in penile carcinoma.

PURPOSE We examined p53 protein and proliferating cell nuclear antigen immunoexpression as prognostic factors to the outcome of squamous cell carcinoma of the penis in 50 patients. MATERIALS AND METHODS Penectomy and lymphadenectomy were performed in 14 patients with clinically positive nodes while 36 with cN0 disease were treated with penectomy and kept under surveillance that resulted in subsequent lymphadenectomy due to nodal relapse in 8. Of 21 patients with confirmed nodal metastases 18 died of disease. Immunohistochemical reactions were performed via the avidin-biotin-immunoperoxidase method and the results were compared with tumor pT stage, grade, nodal status and cause specific death. RESULTS In univariate analysis proliferating cell nuclear antigen staining showed association only with nodal metastasis (p = 0.04) while p53 staining exhibited correlation with tumor pT stage (p = 0.0005), grade (p = 0.02), lymphatic spread (p = 0.02) and cause specific survival (p = 0.003). Multivariate analysis showed that p53 immunoreactivity was the only factor with prognostic significance for disease progression and cause specific survival. Tumor pT stage, grade and proliferating cell nuclear antigen staining had no significance for nodal metastases and cause specific death. CONCLUSIONS Proliferating cell nuclear antigen staining had no prognostic value for disease progression. Since p53 over expression was associated with tumor progression and cause specific death, perhaps it should be evaluated in staging and therapeutic planning for patients with squamous cell carcinoma of the penis.

Prevalence and bacterial susceptibility of hospital acquired urinary tract infection

PURPOSE: Urinary tract infection is the most common nosocomially acquired infection. It is important to know the etiology and antibiotic susceptibility infectious agents to guide the initial empirical treatment. OBJECTIVE: To determine the prevalence of bacterial strains and their antibiotic susceptibility in nosocomially acquired urinary tract infection in a university hospital between January and June 2003. METHODS: We analyzed the data of 188 patients with positive urine culture (= 105 colony-forming units/mL) following a period of 48 hours after admission. RESULTS: Half of patients were male. Mean age was 50.26 ± 22.7 (SD), range 3 months to 88 years. Gram-negative bacteria were the agent in approximately 80% of cases. The most common pathogens were E. coli (26%), Klebsiella sp. (15%), P. aeruginosa (15%) and Enterococcus sp. (11%). The overall bacteria susceptibility showed that the pathogens were more sensible to imipenem (83%), second or third generation cephalosporin and aminoglycosides; and were highly resistant to ampicillin (27%) and cefalothin (30%). It is important to note the low susceptibility to ciprofloxacin (42%) and norfloxacin (43%). CONCLUSION: This study suggests that if one can not wait the results of urine culture, the best choices to begin empiric treatment are imipenem, second or third generation cephalosporin and aminoglycosides. Cefalothin and ampicillin are quite ineffective to treat these infections.

Chronic Ethanol Consumption Induces Cavernosal Smooth Muscle Dysfunction in Rats

OBJECTIVES To investigate the effects of chronic ethanol consumption on nitric oxide (NO)-mediated relaxation in rat cavernosal smooth muscle (CSM). METHODS Male wistar rats were divided into 2 groups: control and ethanol. CSM obtained from both groups were mounted in organ chambers for measurement of isometric tension. Contraction of the strips was induced by electrical field stimulation (EFS, 1-32 Hertz) and phenylephrine. We also evaluated the effect of ethanol consumption on the relaxation induced by acetylcholine (0.01-1000 micromol L(-1)), sodium nitroprusside (SNP, 0.01-1000 micromol L(-1)), or EFS (1-32 Hz) in strips precontracted with phenylephrine (10 micromol L(-1)). Blood ethanol, serum testosterone levels, and basal nitrate generation were determined. Immunoexpression of endothelial NO synthase (eNOS) and inducible NO synthase (iNOS) was also accessed. RESULTS Ethanol intake for 4 weeks significantly increased noradrenergic nerve-mediated contractions of CSM in response to EFS. The endothelium-dependent relaxation induced by acetylcholine decreased after the ethanol treatment. Ethanol consumption decreased serum testosterone levels but did not affect the nitrate levels on rat CSM. The mRNA and protein levels for eNOS and iNOS receptors were increased in CSM from ethanol-treated rats. CONCLUSIONS Ethanol consumption reduces endothelium-dependent relaxation induced by acetylcholine, but does not affect SNP or EFS-induced relaxation, suggesting that ethanol disrupts the endothelial function. Despite the overexpression of eNOS and iNOS in ethanol-treated rats, the impaired relaxation induced by acetylcholine may suggest that chronic ethanol consumption induces endothelial dysfunction.

Ensino superior no Brasil: da descoberta aos dias atuais

As primeiras escolas de ensino superior foram fundadas no Brasil em 1808 com a chegada da família real portuguesa ao país. Neste ano, foram criadas as escolas de Cirurgia e Anatomia em Salvador (hoje Faculdade de Medicina da Universidade Federal da Bahia), a de Anatomia e Cirurgia, no Rio de Janeiro (atual Faculdade de Medicina da UFRJ) e a Academia da Guarda Marinha, também no Rio. Dois anos após, foi fundada a Academia Real Militar (atual Escola Nacional de Engenharia da UFRJ). Seguiram-se o curso de Agricultura em 1814 e a Real Academia de Pintura e Escultura1. Até a proclamação da república em 1889, o ensino superior desenvolveu-se muito lentamente, seguia o modelo de formação dos profissionais liberais em faculdades isoladas, e visava assegurar um diploma profissional com direito a ocupar postos privilegiados em um mercado de trabalho restrito além de garantir prestígio social. Ressalte-se que o caráter não universitário do ensino não constituía demérito para a formação superior uma vez que o nível dos docentes devia se equiparar ao da Universidade de Coimbra, e os cursos eram de longa duração2. Com a independência política em 1822 não houve mudança no formato do sistema de ensino, nem sua ampliação ou diversificação. A elite detentora do poder não vislumbrava vantagens na criação de universidades. Contam-se 24 projetos propostos para criação de universidades no período 1808-1882, nenhum dos quais aprovado3. Depois de 1850 observou-se uma discreta expansão do número de instituições educacionais com consolidação de alguns centros científicos como o Museu Nacional, a Comissão Imperial Geológica e o Observatório Nacional. A ampliação do ensino superior, limitado às profissões liberais em poucas instituições públicas, era contida pela capacidade de investimentos do governo central e dependia de sua vontade política. Até o final do século XIX existiam apenas 24 estabelecimentos de ensino superior no Brasil com cerca de 10.000 estudantes3. A partir daí, a iniciativa privada criou seus próprios estabelecimentos de ensino superior graças à possibilidade legal disciplinada pela Constituição da República (1891). As instituições privadas surgiram da iniciativa das elites locais e confessionais católicas. O sistema educacional paulista surgiu nesta época e representou a primeira grande ruptura com o modelo de escolas submetidas ao controle do governo central. Dentre os cursos criados em São Paulo neste período, constam os de Engenharia Civil, Elétrica e Mecânica (1896), da atual Universidade Mackenzie, que é confessional presbiteriana. Nos 30 anos seguintes, o sistema educacional apresentou uma expansão considerável, passando de 24 escolas isoladas a 133, 86 das quais criadas na década de 19203. A idéia de universidade mobilizou gerações de propositores e críticos desta forma de ensino. O projeto elaborado pela elite intelectual laica defendia a universidade pública em oposição ao modelo de instituições isoladas e propunha a institucionalização da pesquisa em seu interior. Alguns países da América Hispânica dispunham de universidades no período colonial, sendo a primeira delas criada no México em 1553, graças à concepção imperial da Espanha diversa da de Portugal. Em contraposição, o pragmatismo português não permitiu que o Brasil dispuzesse de universidades no período colonial, e a formação do núcleo de ensino superior só teve início com a vinda da família real portuguesa. O seu desenvolvimento foi voltado para a formação profissional sob controle do Estado. O modelo adotado combinou o pragmatismo da reforma pombalina em Portugal (para libertar o ensino dos entraves conservadores tidos como responsáveis pelo atraso do país em relação aos demais europeus), e o modelo napoleônico que contemplava o divórcio entre o ensino e a pesquisa científica. Na década de 1920 o debate sobre a criação de universidades não se restringia mais a questões estritamente políticas (grau de controle estatal) como no passado, mas ao conceito de universidade e suas funções na sociedade. As funções definidas foram as de abrigar a ciência, os cientistas e promover a pesquisa. As universidades não seriam apenas meras instituições de ensino mas centros de saber desinteressado. Na ENSINO SUPERIOR NO BRASIL: DA DESCOBERTA AOS DIAS ATUAIS

Intermittent alpha-blocker therapy in the treatment of men with lower urinary tract symptoms

OBJECTIVES To determine the safety and efficacy of intermittent alpha-blocker therapy in men with lower urinary tract symptoms (LUTS) in a prospective study. Alpha-blockers have been demonstrated to be safe and effective in the treatment of men with LUTS. To date, the role of varying dosing regimens in responding patients has not been well studied. METHODS Men with LUTS were entered into this prospective open label, parallel, randomized trial. In phase 1, patients were treated with alfuzosin, 2.5 mg three times daily for 3 months. In phase 2, those patients who had a significant therapeutic response were randomized into one of the following three groups: (1) maintenance of alfuzosin; (2) alfuzosin every other day; and (3) discontinuation of alfuzosin (ie, no treatment). Patients were followed up for a total of 6 months. Parameters of evaluation included the International Prostate Symptom Score (IPSS), global satisfaction, peak urinary flow rate (Qmax), and adverse events. RESULTS At 3 months, there were 79 patients who were categorized as having obtained a therapeutic response: IPSS decreased to 7.6 +/- 3.2 and Qmax increased to 11.3 +/- 2.9 mL/s. After randomization, IPSS was 7.1 +/- 2.9 and 6.5 +/- 2.5 for group 1; 6.5 +/- 3.2 and 6.7 +/- 2.1 for group 2; and 11.4 +/- 4.8 and 12.3 +/- 4.9 for group 3 at 3 and 6 months, respectively. Qmax was 12.7 +/- 4.8 and 11.7 +/- 5.2 mL/s for group 1; 12.2 +/- 3.9 and 11.9 +/- 3.7 mL/s for group 2; and 9.7 +/- 2.5 and 9.3 +/- 2.1 mL/s for group 3 at 3 and 6 months, respectively. Global satisfaction at 6 months was the same for groups 1 and 2. There were no differences in adverse events among the three groups. CONCLUSIONS In men with LUTS who responded to alfuzosin, changing the dosing regimen from daily to once every other day resulted in similar efficacy and safety at 3 and 6 months. By contrast, complete cessation of alfuzosin resulted in recurrence of both symptoms and impaired urinary flow. These data provide evidence that in responding patients, intermittent alpha-blocker therapy may be a reasonable therapeutic regimen. The role of intermittent alpha-blocker therapy using other agents, as well as in a large cohort of men with LUTS, remains to be determined.

Community acquired urinary tract infection: etiology and bacterial susceptibility

PURPOSE: Urinary tract infections (UTI) are one of the most common infectious diseases diagnosed. UTI account for a large proportion of antibacterial drug consumption and have large socio-economic impacts. Since the majority of the treatments begins or is done completely empirically, the knowledge of the organisms, their epidemiological characteristics and their antibacterial susceptibility that may vary with time is mandatory. OBJECTIVE: The aim of this study was to report the prevalence of uropathogens and their antibiotic susceptibility of the community acquired UTI diagnosed in our institution and to provide a national data. METHODS: We analyzed retrospectively the results of urine cultures of 402 patients that had community acquired urinary tract infection in the year of 2003. RESULTS: The mean age of the patients in this study was 45.34 ± 23.56 (SD) years. There were 242 (60.2%) females and 160 (39.8%) males. The most commonly isolated organism was Escherichia coli (58%). Klebsiella sp. (8.4%) and Enterococcus sp.(7.9%) were reported as the next most common organisms. Of all bacteria isolated from community acquired UTI, only 37% were sensitive to ampicillin, 51% to cefalothin and 52% to trimethoprim/sulfamethoxazole. The highest levels of susceptibility were to imipenem (96%), ceftriaxone (90%), amikacin (90%), gentamicin (88%), levofloxacin (86%), ciprofloxacin (73%), nitrofurantoin (77%) and norfloxacin (75%). CONCLUSION: Gram-negative agents are the most common cause of UTI. Fluoroquinolones remains the choice among the orally administered antibiotics, followed by nitrofurantoin, second and third generation cephalosporins. For severe disease that require parenteral antibiotics the choice should be aminoglycosides, third generation cephalosporins, fluoroquinolones or imipenem, which were the most effective.

Racial influence on the prevalence of prostate carcinoma in Brazilian volunteers

PURPOSE To investigate the prevalence of prostate carcinoma in a sample of volunteers known to have a large proportion of Bantu African ancestors, and the performance of total PSA (tPSA), PSA density (PSAD) and free-to-total PSA ratio (f/tPSA) on the diagnosis. MATERIALS AND METHODS A total of 473 volunteers (range: 40 - 79 years) were screened for prostate carcinoma. Those with tPSA >2 ng/ml and/or abnormal digital rectal examination were submitted to a transrectal ultrasound-directed biopsy (10 cores). The volunteers were classified as White, Mulatto or Black according to physical characteristics and to ancestors race reference. The following variable number of tandem repeats (VNTR) were analyzed in the blood of 120 volunteers without cancer and in 27 patients with prostate cancer: D4S43, PAH, F13A1, APOB and vW-1. RESULTS The biopsies performed in 121 volunteers revealed cancer in 27 (5.7% of 473). The proportions of cancer in White, Mulatto and Black were respectively: 0.6% (1/148), 6.7% (6/90) and 8.5% (20/235) (p = 0.006). The VNTRs analysis revealed heterogeneity in White, Mulatto and Black anthropologic phenotypes with the following admixture of Caucasian, African and Amerindian gene lineages: 67.5 +/- 8%, 20.8 +/- 8%, 11.7 +/- 7%; 54.8 +/- 9%, 36.3 +/- 5%, 8.9 +/- 7%; and, 45.3 +/- 3%, 45.9 +/- 4%, 8.8 +/-7%. Such a mixture was 50.5 +/- 9%, 49 +/- 8% and 0.5 +/- 4% in volunteers bearing cancer, and 59.1 +/- 7%, 31.7 +/- 8% and 9.2 +/- 5% in those without cancer. The sensitivity and specificity of tPSA at cut-off levels of 2, 2.5 and 4 ng/ml for volunteers with tPSA </= 10 ng/ml were respectively: 100% and 6,6%, 100% and 36,6%, 69,2% and 62,2%. PSAD at a cut-off level of 0.08 or 0.10, and f/tPSA at a cut-off level of 20% were able to increase significantly tPSA specificity without loss on sensitivity. CONCLUSIONS The tumor prevalence was higher in Non-White than in White phenotype. The association of tPSA at a cut-off level of 2.5 ng/ml with a PSAD of 0.08 or a f/tPSA of 20% for biopsy indication deserves further investigations as an alternative to tPSA cut-off level of 4 ng/ml.

Use of a Latex Biomembrane for Bladder Augmentation in a Rabbit model: Biocompatibility, Clinical and Histological Outcomes

PURPOSE To investigate histological features and biocompatibility of a latex biomembrane for bladder augmentation using a rabbit model. MATERIAL AND METHODS After a partial cystectomy, a patch of a non-vulcanized latex biomembrane (2x4 cm) was sewn to the bladder with 5/0 monofilament polydioxanone sulfate in a watertight manner. Groups of 5 animals were sacrificed at 15, 45 and 90 days after surgery and the bladder was removed. The 5-mum preparations obtained from grafted area and normal bladder were stained with hematoxylin-eosin. Immunohistochemical staining was performed with a primary antibody against alpha-actin to assess muscle regeneration. RESULTS No death, urinary leakage or graft extrusion occurred in any group. All bladders showed a spherical shape. Macroscopically, after 90 days, the latex biomembrane was not identifiable and the patch was indistinguishable from normal bladder. A bladder stone was found in one animal (6.6%). On the 90th day, histology revealed continuity of transitional epithelium of host bladder tissue on the patch area. At this time, the muscle layers were well organized in a similar fashion to native bladder muscle layers. The inflammatory process was higher on grafted areas when compared to controls: 15 days--p < 0.0001, 45 days--p < 0.001, and 90 days--p < 0.01. The anti alpha-actin immunoexpression peaked at 45 days, when the graft was observed covered by muscle cells. CONCLUSION The latex biomembrane is biocompatible and can be used in models for bladder augmentation in rabbits. It promotes epithelium and muscle regeneration without urinary leakage.

Cyclosporine action on kidneys of rats submitted to normothermic ischaemia and reperfusion

PURPOSE To verify if rat kidneys lesioned by ischaemia followed by reperfusion are affected by cyclosporine A (CsA). METHODS Male Wistar rats were randomly divided into three groups, control (GS) and experimental (G1 and G2). G1 was subdivided in two: G1A composed of animals submitted to 60 minutes ischaemia and G1C with the same ischaemic procedure associated to 20 mg/kg/day CsA. Group G2 was subdivided and treated in the same way as G1 except that ischaemia was applied only for 40 minutes. Clamping the left renal artery followed by right side nephrectomy induced kidney ischaemia. Serum urea and creatinine were quantified on the day of surgery (D0) and in the following day (D1). Twenty four hours after reperfusion the left kidney was removed and histologically analyzed. RESULTS Group GS had normal values for urea and creatinine both on D0 and D1 and did not show structural alterations. Renal function was not significantly different when G2C was compared to GS (p>0.05). Tissue lesions were smaller in G2C than in the other groups. CONCLUSIONS Renal function was protected by CsA, which also reduced tissue lesions in the kidneys of rats submitted to 40 minutes ischaemia.