Ronir Raggio Luiz

Sepse Brasil: estudo epidemiológico da sepse em Unidades de Terapia Intensiva brasileiras

BACKGROUND AND OBJECTIVES: Sepsis represents the major cause of death in the ICUs all over the world. Many studies have shown an increasing incidence over time and only a slight reduce in mortality. Many new treatment strategies are arising and we should define the incidence and features of sepsis in Brazil. METHODS: Prospective cohort study in sixty-five hospitals all over Brazil. The patients who were admitted or who developed sepsis during the month of September, 2003 were enrolled. They were followed until the 28th day and/or until their discharge. The diagnoses were made in accordance to the criteria proposed by ACCP/SCCM. It were evaluated demographic features, APACHE II score, SOFA (Sepsis-related Organ Failure Assessment) score, mortality, sources of infections, microbiology, morbidities and length of stay (LOS). RESULTS: Seventy-five ICUs from all regions of Brazil took part in the study.3128 patients were identified and 521 (16.7%) filled the criteria of sepsis, severe sepsis or septic shock. Mean age was 61.7 (IQR 39-79), 293 (55.7%) were males, and the overall 28-day mortality rate was 46.6%. Average APACHE II score was 20 and SOFA score on the first day was 7 (IQR 4-10). SOFA score in the mortality group was higher on day 1 (8, IQR 5-11), and had increased on day 3 (9, IQR 6-12). The mortality rate for sepsis, severe sepsis and septic shock was 16.7%, 34.4% and 65.3%, respectively. The average LOS was 15 days (IQR 5-22). The two main sources of infection were the respiratory tract (69%) and the abdomen one (23.1%). Gram-negative bacilli were more prevalent (40.1%). Gram-positive cocci were identified in 32.8% and fungi infections in 5%. Mechanical ventilation was observed in 82.1% of the patients, Swan-Ganz catheter in 18.8%, vasopressors in 66.2% and hemotransfusion in 44.7%. CONCLUSIONS: It was observed a high mortality of sepsis in the ICUs in Brazil. The high frequency of septic shock demonstrated a group at high risk of death. In order to have a better use of the resources and reduce in mortality during the next 5 years, it is very important to identify our specific features related to this syndrome.

McNemar χ2 test revisited: comparing sensitivity and specificity of diagnostic examinations

When evaluating a novel diagnostic examination for clinical use, it should be compared with a reference standard, defined as the best available examination, which may include clinical and laboratory criteria. The novel examination and reference standards results are usually presented in the form of a 2×2 table, which allows calculation of sensitivity, specificity and accuracy. It has been recommended that the measures of statistical uncertainty should be reported, such as the 95% confidence interval, when evaluating the accuracy of diagnostic examinations. Comparing the difference in sensitivity or specificity of a novel examination with the reference standard is important when evaluating its usefulness. The McNemar χ2 test, used to compare discordance of two dichotomous responses, can be applied for this purpose. However, applying the McNemar test to a 2×2 table for comparing the accuracy of examinations is not recommended, since this test is sensitive to the proportion of positive versus negative subjects. Moreover, if the novel examination has higher sensitivity than the one considered as the reference standard, constructing a classic 2×2 table would result in low specificity of the novel examination. Thus, in order to compare sensitivities and specificities between examinations, this table is inappropriate and an independent reference standard is necessary. In this article, we propose the use of the McNemar χ2 test to compare sensitivities between examinations using a 2×2 table exclusively among diseased patients, defined by a set of criteria and follow‐up of patients. Likewise, specificities can be compared applying the McNemar test among healthy individuals.

Autopercepção da imagem corporal entre estudantes de nutrição: um estudo no município do Rio de Janeiro

OBJETIVO: Identificar a autopercepcao da imagem corporal entre estudantes de nutricao no municipio do Rio de Janeiro. METODOS: Estudo seccional junto a estudantes de nutricao do sexo feminino. Para dimensionar a prevalencia de distorcao de imagem corporal, utilizou-se o Body Shape Questionaire (BSQ) em sua versao para o portugues, adotando-se o intervalo de confianca de 95%. Para o estudo das associacoes, empregou-se o teste qui-quadrado. RESULTADOS: A amostra foi de193 estudantes, tendo como media de idade 20,9 anos (± 2). O escore medio do BSQ foi 81,2 pontos (± 33,6), correspondendo a preocupacao leve com a auto-imagem corporal. A prevalencia de universitarias com distorcao grave da imagem corporal foi de 6,2% (IC 95%; 3,2%-10,6%). Observou-se associacao estatisticamente significativa (p < 0,026) entre o BSQ e o indice de massa corporal (IMC) categorizado. Tambem foi significativa a associacao entre BSQ moderado ou grave e insatisfacao com o peso (p < 0,001). CONCLUSAO: Os resultados encontrados evidenciam que o ideal de corpo magro imposto pela sociedade prevalece, pois mulheres com peso adequado apresentaram insatisfacao com sua imagem corporal, desejando altera-la para se adequar aos padroes sociais. Em se tratando de futuras nutricionistas, o impacto desse achado e ainda mais relevante, tendo em vista seu papel no manejo desses quadros.

Association of red complex, A. actinomycetemcomitans and non-oral bacteria with periodontal diseases

OBJECTIVE Pathogens related to systemic infections have been detected in the periodontal microbiota. The relationship amongst these pathogens, periodontal bacteria and periodontal clinical status is poorly understood. This study evaluated the association amongst red complex, A. actinomycetemcomitans (A.a) and non-oral pathogenic bacteria in subjects with good periodontal health (PH), gingivitis (G), chronic (CP) and aggressive (AP) periodontitis. METHODS Subgingival biofilm samples were obtained from 51 PH, 42 G, 219 CP and 90 AP subjects. The presence and levels of A.a, red complex (Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola), Acinetobacter baumannii, Escherichia coli, Enterococcus faecalis, Pseudomonas aeruginosa, and Staphylococcus aureus were determined by DNA probes and DNA-DNA hybridization technique. RESULTS CP and AP subjects presented significantly higher prevalence and levels of A.a, red complex and A. baumannii than G and PH individuals (p<0.01), whereas S. aureus was detected in lower frequency and counts in AP as compared to the other groups (p<0.001). The predictor variables age, prevalence of red complex, and the presence of A. baumannii and P. aeruginosa were strongly associated with the frequency of sites with PD and CAL ≥5 mm. Increasing age (OR 1.08), high frequency of red complex (OR 6.10), and the presence of A.a with P. aeruginosa (OR 1.90) were associated with periodontal disease (p<0.001). Subjects harbouring a high prevalence of A.a, A. baumannii, and red complex with P. aeruginosa were more likely to have AP than CP (p<0.001). CONCLUSION Putative periodontal pathogens and non-oral bacteria alone or in association were strongly associated with periodontitis.

Comportamento alimentar e imagem corporal entre estudantes de educação física

OBJECTIVE: To characterize eating practices and possible risk factors associated with eating disorders among physical education students in a public university of the Municipality of Rio de Janeiro, Brazil. METHODS: Sectional study, electing as target population a risk group for the emergence of eating disorders. The questionnaires Bulimic Investigatory Test Edinburgh (BITE), Eating Attitudes Test (EAT-26), Body Shape Questionnaire (BSQ) and a variety that considers related issues were applied. RESULTS: A positive result was detected in 6.9% of cases (IC95%: 3.6-11.7%) on EAT-26. On BITE, for elevated symptoms and severe cases, a prevalence of 5% was found (IC95%: 2.4-9.5%) and 2.5% (IC95%: 0.7-6.3%), respectively. It was evidenced that 26.29% of students presented abnormal eating behavior. CONCLUSION: The results of this study demonstrate the need to pay attention to risk eating behaviors in this group, being justified to take special care with these future health care educators.

Acute kidney injury network criteria as a predictor of hospital mortality in cirrhotic patients with ascites.

Background: Acute kidney injury (AKI) is frequent in cirrhotic patients but its best definition is unclear. Recently, the Acute Kidney Injury Network (AKIN) proposed criteria to define AKI. The aims of this study were to apply AKIN criteria to cirrhotic patients with ascites and to evaluate its association to hospital mortality. Study: In this retrospective study, cirrhotic patients with ascites admitted to a university hospital in Brazil between November 2003 and December 2007 were included. AKIN criteria were applied in the first 48 hours of hospitalization, considering 2 values of creatinine in this period. Association of AKI at admission and hospital mortality was analyzed. Results: Of the 198 patients in the study, 91 (46%) presented AKI at hospital admission. Overall hospital mortality was 40.4%. Patients without AKI had a hospital mortality rate of 29.9%, whereas the same rate for patients with this complication was 52.7% (odds ratio=2.6; 95% confidence interval, 1.5-4.7; P=0.001). In a logistic regression analysis, 4 variables were independently associated to hospital mortality: infection, hepatic encephalopathy, Child score, and AKI. A receiver operating characteristic curve analysis revealed that the variation in creatinine proposed by AKIN had the best combination of sensitivity and specificity in relation to hospital mortality. Conclusions: In cirrhotic patients with ascites, prevalence of AKI at hospital admission is high. Patients with renal dysfunction defined by AKIN have significant higher hospital mortality. AKIN criteria are useful in cirrhotic patients with ascites, as it identifies earlier patients with worse prognosis.

Genetic variation in MMP20 contributes to higher caries experience

UNLABELLED Matrix metalloproteinases play an important role during the initial process of enamel development and therefore may play a role in caries. OBJECTIVES To evaluate the association between MMP20 and caries experience in Brazilian children. METHODS Eligible unrelated children with or without caries were evaluated using a cohort design. Demographic data and oral health habits were obtained though a questionnaire. Caries data was collected by clinical examination. Genotyping of the selected polymorphism was carried out by real-time PCR from genomic DNA. Allele and genotype frequencies were compared between groups with distinct caries experience and oral health habits. RESULTS Of 388 subjects, 161 were caries free children. There were no differences between caries levels and genotype distribution in the total cohort. When ethnic background was considered, differences in genotype distribution were observed in caries free children vs. children with caries in Caucasians (p=0.03). Differences could also be seen when poor oral hygiene was used to stratify the analysis (p=0.02). Regression analysis, adjusted for genotype and ethnicity, confirmed that ingestion of sweets between meals increases the risk of presenting carious lesions (p=0.00001; OR=2.33; 95%CI 1.53-3.54). CONCLUSION Variation in MMP20 may be associated with caries experience mainly in Caucasian subjects with poor oral health habits.

Anemia em crianças menores de cinco anos que freqüentam creches públicas do município do Rio de Janeiro, Brasil

OBJETIVOS: estimar a prevalencia de anemia em criancas matriculadas em creches municipais do Rio de Janeiro e identificar os subgrupos de maior risco. METODOS: foram avaliadas 865 criancas. A hemoglobina (Hb) foi dosada em fotometro portatil (HemoCue) e a anemia foi definida quando Hb <11g/dL e <9,5g/dL para maiores e menores de seis meses, respectivamente. Foram obtidas informacoes biologicas e socioeconomicas atraves de questionarios aplicados as maes. RESULTADOS: A prevalencia de anemia foi de 47,3%. As criancas anemicas apresentaram medias de z escore de peso para a idade (-0,239) e a altura para a idade (-0,548) mais baixas do que as nao-anemicas. O risco de anemia foi maior para as criancas com idade abaixo de dois anos (razao de prevalencia [RP]=1,73; intervalo de confianca [IC95%: 1,52-1,97), para as que tinham pais com menos de quatro anos de estudo (RP=1,57; IC95%:1,24-1,99) e moravam em domicilios com mais de oito moradores (RP=1,45; IC95%:,1,07-1,95). . CONCLUSOES: a prevalencia de anemia foi elevada. As criancas com mais baixo peso e estatura para a idade, menores de dois anos, que moravam em residencias com numero elevado de pessoas e que tinham pais com baixa escolaridade foram as mais vulneraveis a anemia, devendo ser alvo de politicas de controle e prevencao.

Photorejuvenation with Topical Methyl Aminolevulinate and Red Light: A Randomized, Prospective, Clinical, Histopathologic, and Morphometric Study

BACKGROUND Photodynamic therapy (PDT) is an option for skin rejuvenation. Although many studies report clinical improvement with PDT in photodamaged skin, histologic and morphometric evidence is not documented in most cases. OBJECTIVE To evaluate clinical and histopathologic changes induced by methyl aminolevulinate (MAL)‐PDT and to morphometrically quantify collagen and elastic fibers in skin remodeling induced by MAL‐PDT in photodamaged skin. METHODS AND MATERIALS Fourteen patients were treated with two sessions of MAL‐PDT. The light source was a light‐emitting diode: 635 nm, 37 J/cm2. Skin biopsies were performed before and 3 and 4 months after treatment. All fragments were stained using the hematoxylin‐eosin, orcein, and picrosirius techniques. Morphometric studies were done of three samples from each patient. RESULTS Global clinical improvement was observed in 10 of 14 patients. The histopathologic study showed increased collagen fibers 3 and 6 months after treatment. The decrease in the amount of elastic fiber was statistically significant 3 (p=.016) and 6 (p=.008) months after treatment. The increase in the amount of collagen fiber was statistically significant 6 months after treatment (p=.048). CONCLUSION Clinical improvement with regard to texture, firmness, wrinkle depth, skin coloration, and clearance of actinic keratoses was observed. Histopathologic and morphometric studies were consistent with the clinical findings. Dr. M. Issa is a consultant to Galderma (Brazil). Galderma Industries provided the Metvix used in this study.

Effect of weekly rice fortification with iron on anemia prevalence and hemoglobin concentration among children attending public daycare centers in Rio de Janeiro, Brazil

This was a double-blind, placebo-controlled, community-based trial. For 16 weeks, children in the intervention group (n = 180) received iron-fortified rice, while children in the control group (n = 174) received rice with placebo. Anemia was defined as hemoglobin < 11.0g/dL. Students t-test was used to compare mean variation in hemoglobin between the groups. Hemoglobin concentration improved in both groups, with a mean increase of 0.42g/ dL in the intervention group (11.28+/-1.23g/dL to 11.75+/-1.16g/dL, p < 0.001), and 0.49g/dL in controls (11.06+/-1.13g/dL to 11.51+/-1.16g/dL, p < 0.001). Anemia decreased (p < 0.01) in both groups (37.8% to 23.3% in the intervention group and 45.4% to 33.3% in controls), with no significant difference between the two. Hemoglobin increase was significantly higher in children that received total iron = 53.76mg from fortified rice, compared to those who received less than this cut-off value (0.94g/dl vs. 0.39g/dl, p = 0.03). The findings suggest that this type of intervention can be useful in anemia control as long as fortified food intake is adequate.