Maria Ângela Reis de Góes Monteiro Antonio

Determinantes do baixo peso ao nascer a partir das Declarações de Nascidos Vivos

Este estudo teve como objetivos conhecer a distribuicao do peso de nascimento das criancas de Campinas (SP) e indicar fatores de risco para baixo peso. Realizou-se estudo transversal no qual foram utilizados dados das 14.444 Declaracoes de Nascidos Vivos de 2001. A variavel dependente foi o peso de nascimento, e as independentes as caracteristicas maternas, gestacionais, do parto e do recem-nascido. Na avaliacao da associacao entre variaveis empregou-se teste de qui-quadrado e calculou-se valores de odds ratio brutos (OR) e ajustados (ORaj). A media do peso de nascimento foi 3.142g, variando de 285 a 5.890g; 65,1% das criancas pesaram 3.000g ou mais, 25,7% entre 2.500 e 2.999g e 9,1% menos de 2.500g. Os determinantes para baixo peso em prematuros foram cesariana, gemelaridade, recem-nascidos femininos e os de mulheres com menos de sete consultas de pre-natal. Para criancas a termo os riscos foram gestacao dupla, tripla ou mais, filhos de mulheres com mais de 34 anos, das com ate sete anos de estudo, com oito a onze e das com menos de sete consultas de pre-natal. A distribuicao de peso de nascimento em Campinas foi inadequada e a proporcao de baixo peso foi mais que o dobro dos paises desenvolvidos. Os recem-nascidos prematuros que nasceram por cesariana, os prematuros e os a termo de gestacao multipla, os femininos, os de mulheres com pre-natal inadequado e os a termo daquelas com maior idade e baixa escolaridade apresentaram maior chance de nascer com baixo peso.

Desenvolvimento cerebral em recém-nascidos prematuros

OBJECTIVE:To review the current literature about brain growth and development of premature children, as well as the motor and cognitive changes that may result from prematurity. DATA SOURCES: Medline and Lilacs were searched between 2000 and 2007 along with textbooks whose content was relevant. DATA SYNTHESIS: The development of preterm infants differs from term neonates. Studies have shown that children born prematurely have anatomical changes related to cognitive impairments in the central nervous system. Some regions seem vulnerable, such as white and gray matter, corpus callosum, caudate nucleus, hippocampus and cerebellum, when evaluated by volumetric neuroimaging techniques. Thus, one would expect some functional and/or learning impairment in children, adolescents and adults born prematurely. When evaluated in late childhood and adolescence, they show deficits in the intelligence quotient, memory, calculations skills and in the overall cognitive function. Motor coordination, attention, planning and association deficits are also reported in the literature. CONCLUSIONS: Prematurity can lead to structural and anatomical changes of the brain due to interruption of the prenatal development. These changes can cause functional deficits and children born prematurely are more vulnerable to cognitive and motor problems as well as its effects on their daily activities, even in adolescence and adulthood.Objective: To review the current literature about brain growth and development of premature children, as well as the motor and cognitive changes that may result from prematurity. Data sources: Medline and Lilacs were searched between 2000 and 2007 along with textbooks whose content was relevant. Data synthesis: The development of preterm infants differs from term neonates. Studies have shown that children born prematurely have anatomical changes related to cognitive impairments in the central nervous system. Some regions seem vulnerable, such as white and gray matter, corpus callosum, caudate nucleus, hippocampus and cerebellum, when evaluated by volumetric neuroimaging techniques. Thus, one would expect some functional and/ or learning impairment in children, adolescents and adults born prematurely. When evaluated in late childhood and adolescence, they show deficits in the intelligence quotient, memory, calculations skills and in the overall cognitive function. Motor coordination, attention, planning and association deficits are also reported in the literature. Conclusions: Prematurity can lead to structural and anatomical changes of the brain due to interruption of the prenatal development. These changes can cause functional deficits and children born prematurely are more vulnerable to cognitive and motor problems as well as its effects on their daily activities, even in adolescence and adulthood.

The Impact of Simulated Medical Consultations on the Empathy Levels of Students at One Medical School

Purpose To examine the impact of simulated medical consultations using standardized patients (SPs) on the empathy levels of fourth- and sixth-year students at the Unicamp medical school in Brazil. Method Throughout 2011 and 2012, the authors conducted this study with two classes of fourth-year (n = 124) and two classes of sixth-year (n = 123) medical students. Students completed the medical student version of the Jefferson Scale of Physician Empathy before and after simulated medical consultations with SPs, followed by an in-depth debriefing dealing with the feelings of the patient about the disease, such as fear, guilt, anger, and abandonment; the feelings of the doctor towards the patient; and other topics as they arose. Results The simulation activity increased the empathy scores of the fourth-year students (from 115.8 to 121.1, P < .001, effect size = 0.61) and of the sixth-year students (from 117.1 to 123.5, P < .001, effect size = 0.64). Conclusions Although the study results were obtained via self-report—a limitation—they suggest that the effective simulation of medical consultations with SPs may improve medical students’ empathy levels. One unexpected result was that this activity, during the debriefing, became a forum for debating topics such as the doctor–patient relationship, the hidden curriculum, negative role models, and emotionally significant experiences of students in medical school. This kind of activity in itself may influence young doctors to become more empathetic and compassionate with their patients and foster a more meaningful way of practicing medicine.

Factors associated with insufficient birth weight

OBJECTIVE To identify risk factors for insufficient birth weight, in the Brazilian city of Campinas from the Live Birth Certificates. METHODS A cross-sectional study was conducted consulting data from 14,444 Live Birth Certificates from the year 2001. These newborn birth weights ranged from 285g to 5,890g (mean 3,142g), 65.1% of them weighted 3,000g or more, while 25.7% had insufficient weight. A sample of 12,779 term newborn from single pregnancies, with a birth weight > 2,500g was selected. Birth weight was the dependent variable and maternal, pregnancy, delivery and newborn characteristics were the independent variables. Association among variables was assessed by Chi-square test, crude odds-ratio (OR) was calculated. For adjusted odds-ratio (adjOR) values, a logistic regression model was used. RESULTS Results showed association between insufficient birth weight and newborn of the female gender (adjOR = 1.57 [95%CI 1.44 - 1.70]), birth from primiparous mothers (adjOR = 1.47 [95%CI 1.35 - 1.60]), inadequate prenatal care (adjOR = 1.42 [95%CI 1.29 - 1.58]) and vaginal delivery (adjOR = 1.23 [95%CI 1.13 - 1.34]). CONCLUSION The risk for insufficient birth weight was higher for female newborn, offspring of primiparous women, of women who had inadequate prenatal care and had vaginal delivery.

Obesidade e fatores de risco cardiovascular em estudantes de Sorocaba, SP

OBJETIVO: Verificar a prevalencia de obesidade, hipertensao arterial sistemica (HAS), aumento de cintura e acanthosis nigricans em estudantes da cidade paulistana de Sorocaba em 2009, associando aos fatores de risco. METODOS: Amostra probabilistica com 680 criancas (7-11 anos) de 13 escolas municipais de Sorocaba. Um questionario avaliou a pratica de atividade fisica, tempo com televisao, videogame e computador (TV/VG/PC), antecedentes do aluno e dos pais para hipertensao arterial, doenca renal e cardiaca e nivel economico. Foram realizadas medidas de peso, altura, cintura, pressao arterial (PA) e verificado acanthosis nigricans. Determinou-se a prevalencia de alteracao nutricional, HAS, aumento da cintura e acanthosis nigricans. Para a associacao do indice de massa corporea (IMC) IMC > P85 e da PA > P90 com outras variaveis, empregou-se o teste do qui-quadrado ou exato de Fisher (p P85 foi 22,1% [IC 95%: 19,0-25,3%], de PA > P90 10,9% [IC 95%: 8,6-13,5%], aumento da cintura 15,4% [IC 95%: 12,9-17,9%] e acanthosis nigricans 3,8% [IC 95%: 2,6-5,6%]. Foi encontrada associacao do excesso de peso com antecedentes do pai (RCP: 1,76; IC 95%:1,05-2,95; p = 0,02) em ambas as analises. A elevacao de PA associou-se ao sexo feminino (RCP: 1,90; IC 95%:1,12-3,23; p = 0,010), ao maior tempo na TV/VG/PC (RCP: 1,82; IC 95%:1,00-3,36; p = 0,030), a presenca de acanthosis nigricans (RCP: 8,18; IC 95%:3,37-19,80; p < 0,00), a obesidade (RCP: 4,09; IC 95%:2,416,94; p < 0,00) e a cintura (RCP: 4,83; IC 95%:2,77-8,41; p < 0,00). Apos analise multivariada, permaneceram como fatores associados o sexo feminino (RCP ajustada = 2,15; IC 95%:1,17-3,93) e a obesidade (RCP ajustada = 9,51; IC 95%: 4,77-18,97). CONCLUSAO: A prevalencia de excesso de peso, HAS, aumento da cintura e acanthosis nigricans foi relevante, o que justifica a realizacao dessas medidas.

Association of Sleep Deprivation With Reduction in Insulin Sensitivity as Assessed by the Hyperglycemic Clamp Technique in Adolescents

IMPORTANCE The association between short sleep duration and decreased insulin sensitivity in adolescents has been described. However, to our knowledge, no studies have investigated this association measuring insulin sensitivity by the hyperglycemic clamp technique. OBJECTIVES To compare the distributions of parameters of insulin resistance in adolescents with sleep deprivation vs adequate sleep, and to investigate the association between sleep deprivation and insulin sensitivity. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional multicenter study using data from the Brazilian Metabolic Syndrome Study conducted from June 29, 2011, to December 3, 2014, at an obesity outpatient clinic at the University of Campinas and public schools, with a convenience sample of 615 adolescents aged 10 to 19.9 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) for age and sex at the fifth percentile or higher. A subsample of 81 adolescents underwent the hyperglycemic clamp technique. MAIN OUTCOMES AND MEASURES The self-reported sleep duration was used to classify the population into 2 groups: adolescents with sleep deprivation (<8 hours/night) and adolescents with adequate sleep (≥8 hours/night). Insulin sensitivity was assessed using the hyperglycemic clamp technique. RESULTS Among the 615 adolescents (56.3% female; median age, 15.9 years [interquartile range, 12.9-17.8 years]) included in the sample, the mean (SD) sleep duration was 7.9 (1.7) hours/night. The adolescents with sleep deprivation (n = 257) compared with those with adequate sleep (n = 358) had a higher median (interquartile range) age (17.0 [15.4-18.3] vs 14.1 [11.8-16.9] years), BMI (25.0 [21.2-29.3] vs 23.1 [19.5-27.6]), waist circumference (83.0 [73.5-95.4] vs 79.0 [68.5-91.0] cm), sagittal abdominal diameter (17.9 [15.8-20.8] vs 17.0 [15.0-19.8] cm), neck circumference (35.2 [33.0-38.0] vs 33.0 [30.0-35.5] cm), uric acid level (4.9 [4.0-5.8] vs 4.5 [3.7-5.5] mg/dL), and white blood cell count (7000 [5900-8200] vs 6600 [5600-7800] cells/μL) (all P < .05). Moreover, the adolescents with sleep deprivation had a lower median (interquartile range) insulin sensitivity index compared with those with adequate sleep (0.10 [0.05-0.21] vs 0.21 [0.09-0.33] mg · kgfat-free mass-1 · min-1 · mU/L × 100, respectively; difference, -0.01; 95% CI, -0.01 to -0.00; P = .02). After controlling for age and sex in the multivariate regression model, sleep deprivation remained an independent predictor for those variables. In the sleep deprivation group, BMI and central distribution of fat were higher in all categories of adiposity. CONCLUSIONS AND RELEVANCE Sleep deprivation (<8 hours of sleep per night) is associated with centripetal distribution of fat and decreased insulin sensitivity in adolescents. Therefore, investigations of sleep duration and sleep quality in adolescents should be included in clinical practice to promote, through health education, the eradication of the health risks associated with sleep restriction.

Neck circumference as a new anthropometric indicator for prediction of insulin resistance and components of metabolic syndrome in adolescents: Brazilian Metabolic Syndrome Study

OBJECTIVE: To evaluate the correlation between neck circumference and insulin resistance and components of metabolic syndrome in adolescents with different adiposity levels and pubertal stages, as well as to determine the usefulness of neck circumference to predict insulin resistance in adolescents. METHODS: Cross-sectional study with 388 adolescents of both genders from ten to 19 years old. The adolescents underwent anthropometric and body composition assessment, including neck and waist circumferences, and biochemical evaluation. The pubertal stage was obtained by self-assessment, and the blood pressure, by auscultation. Insulin resistance was evaluated by the Homeostasis Model Assessment-Insulin Resistance. The correlation between two variables was evaluated by partial correlation coefficient adjusted for the percentage of body fat and pubertal stage. The performance of neck circumference to identify insulin resistance was tested by Receiver Operating Characteristic Curve. RESULTS: After the adjustment for percentage body fat and pubertal stage, neck circumference correlated with waist circumference, blood pressure, triglycerides and markers of insulin resistance in both genders. CONCLUSIONS: The results showed that the neck circumference is a useful tool for the detection of insulin resistance and changes in the indicators of metabolic syndrome in adolescents. The easiness of application and low cost of this measure may allow its use in Public Health services.OBJETIVO: Avaliar a correlacao da circunferencia do pescoco com resistencia a insulina e com os componentes da sindrome metabolica em adolescentes com diferentes niveis de adiposidade e estadios puberais, bem como determinar a utilidade da circunferencia do pescoco como um parâmetro na predicao de resistencia a insulina em adolescentes.METODOS:Estudo transversal no qual se avaliaram 388 adolescentes de ambos os sexos, de dez a 19 anos. Os adolescentes foram submetidos a avaliacao antropometrica e de composicao corporal, incluindo circunferencias do pescoco e da cintura, e a avaliacao bioquimica. O estadio puberal foi obtido por meio de autoavaliacao e a pressao arterial, pelo metodo auscultatorio. Analisou-se a resistencia a insulina pelo Homeostasis Model Assessment-Insulin Resistance. A correlacao entre duas variaveis foi verificada com o coeficiente de correlacao parcial ajustado para o percentual de gordura corporal e o estadio puberal. O desempenho da circunferencia do pescoco para identificar resistencia a insulina foi testado pela Receiver Operating Characteristic Curve.RESULTADOS: Apos ajuste para o percentual de gordura corporal e estadio puberal, a circunferencia do pescoco correlacionou-se com circunferencia da cintura, pressao arterial, triglicerides e marcadores de resistencia a insulina em ambos os sexos.CONCLUSOES:Os resultados demonstraram que a circunferencia do pescoco e uma ferramenta util para detectar a resistencia a insulina e a alteracao nos indicadores de sindrome metabolica em adolescentes. A facilidade de aplicacao e o baixo custo podem viabilizar sua utilizacao em servicos de Saude Publica.

Crianças e adolescentes obesos: dois anos de acompanhamento interdisciplinar

OBJECTIVE: To study two years follow-up of obese children and adolescents from a specialized out-patient clinic. METHODS: This cohort study with retrospective collection of data enrolled 150 patients (1 to 19 years old, 53% males, 63% from Campinas, Sao Paulo, Brazil, and at mean age of 4.3 years when they started the weight gain). All patients were followed at the Obesity Out-Patient Clinic of the Clinical Hospital of Campinas University. Out of the 150 patients, 128 returned once and weight, height, body mass index (BMI) measurements and Z scores were obtained. Laboratory exams were colleted: hemoglobin, lipids, fasting glucose and fasting insulin. Glucose/insulin ratio was calculated. Patients were divided in two groups, if they returned or not to the clinic. Difference between both groups were analyzed regarding age, gender, city of origin, age when the weight gain started, acanthosis nigricans, weight, height, BMI Z score and proportion of altered laboratory exams. The difference in BMI Z score in relation to the first visit was also analyzed. RESULTS: Among the 128 patients, 57% continued to be followed in the clinic and 114 returned at least once. Comparing groups, patients from Campinas fail more to return. There were no differences in the clinical, anthropometric and laboratory variables. Both groups showed lower mean BMI Z score in the return visit compared to the first visit. CONCLUSIONS: The obese children and adolescents from the follow-up clinic showed a reduction in the mean BMI Z score similar to published data. The rate of dropping follow-up was high, but no variable could explain it, except for the patient origin.

Obesity and cardiovascular risk factors in school children from Sorocaba, SP.

OBJECTIVE To verify the prevalence of obesity, systemic arterial hypertension (SAH), waist circumference and acanthosis nigricans (AN) in school children from Sorocaba, in 2009 and associate them with risk factors. METHODS A probabilistic sample study was carried out with 680 children (7-11 years) from 13 public schools from the city of Sorocaba, SP. A questionnaire containing questions on physical activity, time spent watching television, playing with video games and computers (TV/VG/PC), student and parental antecedents of arterial hypertension, renal or cardiac disease, and economic level was applied. On physical examination, weight, height, waist circumference (WC) and blood pressure (BP) were measured; presence of AN was observed. The prevalence of nutritional disorders, SAH, WC increase and presence of AN were calculated. To associate body mass index (BMI) > P85 and BP > P90 with the other variables, chi square or Fishers exact test (significance p < 0.05) and crude and adjusted prevalence odds ratio (POR) were used. RESULTS The prevalence of BMI > P85 was 22.1% [95% CI: 19.0-25.3%], of BP > P90 10.9% [95% CI: 8.6- 13.5%], increased WC 15.4% [95% CI: 12.9-17.9%] and AN 3.8% [95% CI: 2.6-5.6%]. Paternal antecedents were associated with weight excess in both analysis (POR: 1.76; 95% CI: 1.05-2.95; p = 0.02). High blood pressure was associated with female sex (POR: 1.90; 95% CI: 1.12-3.23; p = 0.01), more time spent with TV/VG/PC (POR: 1.82; 95% CI: 1.00-3.36; p = 0.03), AN (POR: 8.18; 95% CI: 3.37-19.80; p < 0.00), obesity (POR: 4.09; 95% CI: 2.41-6.94; p < 0.00) and WC (POR: 4.83; 95% CI: 2.77-8.41; p < 0.00). After the multivariate analysis, the female sex (adjusted POR = 2.15; 95% CI: 1.17-3.93) and obesity (adjusted POR = 9.51; 95% CI: 4.77-18.97) remained. CONCLUSION The prevalence of weight excess, SAH, increased WC and AN in these school children was relevant. This fact justifies the use of these measurements.

Childhood and adolescent obesity: how many extra calories are responsible for excess of weight?

Objective: To review the main articles on energy imbalance and obesity in order to quantify the daily energy surplus associated with weight gain in children and adolescents. Data sources: Articles published in the last ten years, indexed in electronic databases Medline (Pubmed) and SciELO-Br. In the Medline database, the descriptor “energy gap” was used and describes the energy values associated with changes in body weight in individuals or populations. In SciELO-Br database, the descriptors “obesity”, “energy metabolism”, “energy balance”, and “energy imbalance” were used, once it was not possible to find national articles discussing the energy gap. Data synthesis: In the pediatric population, four studies were performed and indicate that children and adolescents are gradually gaining weight due to a small, but persistent, daily positive energy balance of 70 to 160kcal above the total energy suitable for growth. The results suggest that small changes in daily eating behavior as well as physical activity would be enough to prevent future weight gain in this population.