Elaboration and psychometric analysis of a questionnaire to evaluate the knowledge of community health workers about breastfeeding / Elaboração e análise psicométrica de um questionário para avaliar o conhecimento de agentes comunitários de saúde sobre amamentação

Abstract Objectives: to develop and analyze the psychometric properties of a questionnaire to assess community health workers' knowledge on breastfeeding. Methods: this is a methodological study for the development of an instrument and analysis of validity and reliability. For the elaboration of items and identification of dimensions, a literature review was conducted. The items were submitted to the evaluation of a committee of judges, for apparent and content analysis. Construct validation was conducted through hypothesis test, with the participation of 282 community health workers and 19 pediatricians and obstetric nurses. For analysis and comparison of scores, the Mann-Whitney U test was used, assuming a significance level of 5%. Reliability was assessed using Cronbach's alpha coefficient and temporal consistency of the instrument was assessed using test-retest and Kappa analysis. Results: the final instrument presented a favorable opinion from the committee of judges. The hypothesis test showed that the questionnaire has discriminatory power to assess professionals with a higher level of knowledge (p<0.001). The Kappa test revealed that 63% of the items showed substantive to almost perfect agreement. The 32-item questionnaire showed a Cronbach's alpha of 0.794. Conclusion: the instrument developed was valid and reliable, allowing effective measurement of community health workers' knowledge on breastfeeding.

Resumo Objetivos: elaborar e analisar propriedades psicométricas de um questionário para avaliação do conhecimento de agentes comunitários de saúde sobre amamentação. Métodos: trata-se de estudo metodológico de elaboração de instrumento e análise de validade e confiabilidade. Para a elaboração dos itens e identificação das dimensões, realizou-se revisão da literatura. Os itens foram submetidos à apreciação de comitê de juízes, para análise aparente e de conteúdo. A validação de construto foi conduzida pelo teste de hipóteses, com participação de 282 agentes comunitários de saúde e 19 pediatras e enfermeiras obstetras. Para comparação dos escores, utilizou-se o teste U de Mann-Whitney, assumindo-se um nível de significância de 5%. A confiabilidade foi aferida por meio do coeficiente alfa de Cronbach e a consistência temporal do instrumento por meio do teste-reteste e análise de Kappa. Resultados: o instrumento final apresentou parecer favorável do comitê de juízes. O teste de hipóteses evidenciou que o instrumento tem poder discriminatório para aferir profissionais com maior nível de conhecimento (p<0,001). O teste Kappa revelou que 63% dos itens apresentaram concordância de substantiva a quase perfeita. O questionário, com 32 itens, apresentou um alfa de Cronbach de 0,794. Conclusão: o instrumento apresentou-se válido e confiável que permitirá mensurar de forma eficaz o conhecimento de agentes comunitários de saúde sobre amamentação.

O tempo de percurso a cidades polos regionais influencia na mortalidade em pequenos municípios gaúchos? / Does time spent traveling to regional hub cities to receive healthcare influence mortality in small towns in Rio Grande do Sul State, Brazil? / ¿El tiempo de desplazamiento a ciudades que son polos regionales tiene influencia en la mortalidad en los municipios pequeños del Rio Grande do Sul, Brasil?

Resumo: O presente estudo objetiva responder se o tempo de viagem a municípios polos regionais possui efeito na taxa de óbitos por causas evitáveis (TOCE) e na taxa bruta de mortalidade padronizada (TBMP) em municípios com até 5 mil habitantes do Rio Grande do Sul, Brasil. Sem a utilização de variáveis controles, o maior tempo de percurso até municípios com 100 mil habitantes ou mais está associado com um aumento de ambas as taxas. No entanto, enquanto que o comportamento da TOCE permanece similar após a inserção dos controles, a TBMP inverte seu sinal, sugerindo que, mantendo as demais características socioeconômicas e de atendimento de saúde constantes, a distância a municípios polos está associada, ao mesmo tempo, a uma redução dos óbitos por causas evitáveis e a um aumento nas demais causas de morte.

Abstract: The current study aims to determine whether the time spent travelling to regional hub cities to receive healthcare affects mortality from avoidable causes and the standardized crude mortality rate in towns with up to 5,000 inhabitants in Rio Grande do Sul State, Brazil. Without adjusting for control variables, the longest time spent to reach cities with 100,000 inhabitants or more was associated with an increase in both rates. However, while the pattern in the avoidable mortality rate was similar after including controls, the standardized crude mortality rate reversed its signal. This suggests that if other socioeconomic and healthcare characteristics are kept constant, the distance to reference cities is associated with both a reduction in deaths from avoidable causes and an increase in other causes of death.

Resumen: El objetivo del presente estudio es responder si el tiempo de viaje a municipios que son polos regionales posee un efecto en la tasa de óbitos por causas evitables y en la tasa bruta de mortalidad estandarizada en municipios con hasta 5.000 habitantes del estado de Rio Grande do Sul, Brasil. Sin la utilización de variables de control, el mayor tiempo de desplazamiento -hasta municipios con 100 mil habitantes o más- está asociado con un aumento de ambas tasas. No obstante, mientras que el comportamiento de la tasa de óbitos evitables permanece similar tras la inclusión de los controles, la tasa bruta de mortalidad estandarizada invierte su señal, sugiriendo que manteniendo constantes las demás características socioeconómicas y de atención de salud, la distancia a municipios polos regionales está asociada simultáneamente a una reducción de los óbitos por causas evitables y a un aumento en las demás causas de muerte.

Resina fluida com baixa contração e tensão de polimerização para preenchimento de cavidades Classe I e II / Fluid resin with low shrinkage and tension of polymerization for filling cavities Class I and II

A utilização de resinas com baixo módulo de elasticidade permite a confecção de uma camada que diminui as tensões geradas pela tensão de contração, pois têm a capacidade de deformação elástica. Geralmente, as resinas fluidas podem contrair até 6%. O caso clínico ilustrado relata a utilização de uma resina fluida que possibilita espessura de até 4 milímetros, com baixa contração e tensão de polimerização.

The use of resins with low elastic modulus allows the preparation of a layer that reduces the tensions caused by shrinkage stress due to its elastic deformation. Normally, fluid resins can shrink until 6%. The illustrated case reports the use of a fluid resin that allows up to 4mm thickness, with low shrinkage and polymerization tension.

Study of testosterone as a predictor of tumor aggressiveness in patients with prostate cancer

Purpose A growing body of evidence suggests that low testosterone can be an independent predictor of adverse clinicopathological features and worse prognosis in prostate cancer (PCa) patients. However, this association is still incompletely understood and the results are divisive. The aim of this study was to analyze testosterone as a predictor of aggressive disease in subjects with clinically localized PCa. Materials and Methods A cohort was conducted including the patients submitted to radical prostatectomy in our institution during a period of four years. The patients had clinically localized disease and their total testosterone (TT) was routinely measured preoperatively in the morning before surgery. They were stratified in groups with low (< 300 ng/dL) and normal TT (≥ 300 ng/dL). Tumor aggressiveness was inferred based on preoperative PSA levels, pathological Gleason score (lower, equal or greater than 7), TNM stage and surgical margins status. Results After analyzing 164 patients we found a significant association between mean preoperative TT and extraprostatic disease (379 for pT3 vs. 421 ng/for pT2 - p < 0.001, AUC > 0.99). Conversely, men with high Gleason score had similar mean TT compared to those with lower scores. Preoperative low TT (defined as TT < 300 ng/dL) could not be statistically correlated with either preoperative PSA levels, pathological Gleason score, extraprostatic extension, positive surgical margins or seminal vesicles involvement. Conclusions This study indicates that testosterone may be a useful predictive tool once pathological extraprostatic extension was somewhat signaled by lower TT levels preoperatively. However, it does not consolidate a clear association between aggressive tumor biology and hypogonadism. .

Prognostic value of urethral mobility and valsalva leak point pressure for female transobturator sling procedure

PURPOSE: To analyze the influence of urethral mobility and Valsalva leak point pressure on postoperative outcomes of transobturator sling (TOT) for female stress urinary incontinence. MATERIALS AND METHODS: A prospective cohort was conducted including 66 patients submitted to TOT from March 2006 to May 2009. Urethral hypermobility was defined as mobility ≥ 30º on Q-tip test, and Valsalva leak point pressure (VLPP) was classified as greater than 60 cmH2O or 60 and less on preoperative urodynamics. These parameters were compared through well defined postoperative objective and subjective success criteria. Intensity of urinary leakage and quality of life was analysed by ICIQ-SF. Statistical analysis was accomplished and the results rendered significant if p < 0.05. RESULTS: Mean follow up was 10 months (3 to 28). Mean age was 55 years (33 to 80), 70% were white and 30% African descendent, mean body mass index was 27 (21 to 38), average vaginal and abdominal deliveries were 2.8 and 0.5 respectively. A quarter had prior stress incontinence surgery. Patients with urethral hypermobility had higher objective success rates (98% versus 81.25%, p = 0.04). The subjective success rate was also greater in the hypermobility group (84% versus 62.5%), but statistical significance was not reached (p = 0.07). VLPP had no influence on either objective or subjective postoperative success rates (p = 0.17 and 0.34, respectively). In the subgroup analysis, those with low mobility and high VLPP had worse objective success rates in comparison to the group with hypermobility and low VLPP (p = 0.04) and also in relation to the remaining of the studied population. Other possible prognostic factors (previous surgery, mixed incontinence, gestational status) had no influence on success rates. CONCLUSIONS: High urethral mobility, regardless of the sphincteric status indicated by VLPP, is a favorable prognostic factor for tension-free transobturator tape procedure. No relationship was demonstrated between postoperative success rates and VLPP.

Estudo retrospectivo de ferimentos cardíacos ocorridos em Manaus/AM / Retrospective study of heart injuries occurred in Manaus - Amazon

OBJETIVO: Avaliar as formas de tratamento empregadas e os principais aspectos relacionados à morbidade e à mortalidade dos ferimentos cardíacos.. MÉTODOS: Estudo retrospectivo de 102 doentes com lesão cardíaca, atendidos nos dois prontos socorros de Manaus (Pronto Socorro Municipal 28 de Agosto e Hospital Pronto Socorro Dr. João Lúcio P. Machado) no período de janeiro de 1998 a junho de 2006. RESULTADOS: Dos 102 doentes, 95,1% eram homens; a média de idade foi 27 anos; ferimentos por arma branca representaram 81,4% dos casos, contra 18,6% por arma de fogo; cardiorrafia foi realizada em 98,1% dos casos. As câmaras cardíacas atingidas foram: VD: 43,9% (36,2% isoladamente e 7,7% associada a outras câmaras); VE: 37,2%; AD: 8,5% e AE: 10,4%, com mortalidades específicas de 21%, 23%, 22% e 45%, respectivamente. Lesões de duas câmaras associadas alcançaram mortalidade de 37,5%, sendo 20% para VD+AD, 100% para VD+VE e zero para VD+AE. O pulmão correspondeu a 33,7% de 89 lesões associadas. Os tempos médios de cirurgia e de internação foram de 121 minutos e 8,2 dias, respectivamente. Cerca de 22,5% complicaram representando 41 complicações. A mortalidade foi 28,4%. Lesões grau IV e V corresponderam a 55% e 41% dos casos, com mortalidade específica de 26% e 15%, respectivamente. Todos os doentes com lesão grau VI morreram. CONCLUSÃO: O ferimentos cardíacos por arma branca estiveram associados a menor mortalidade, as lesões cardíacas grau IV estiveram associadas à maior mortalidade e um menor tempo operatório esteve associado à maior gravidade e mortalidade.

OBJECTIVE: To evaluate the forms of treatment employed to heart injuries and the main aspects related to their morbidity and mortality. METHODS: A retrospective study of 102 patients with cardiac injuries treated in the two emergency rooms in Manaus (Dr. John Lucio Pereira Machado Emergency Hospital and August 28 County Emergency Hospital) from January 1998 to June 2006. RESULTS: Of the 102 patients, 95.1% were men; mean age was 27 years; stab wounds accounted for 81.4% of cases and gunshot wounds for 18.6%; cardiorrhaphy was performed in 98.1% of cases. The heart chambers affected were: Right Ventricle (RV): 43.9% (36.2% isolated and 7.7% associated with other chambers); Left Ventricle (LV): 37.2%; Right Atrium (RA): 8.5%; and Left Atrium (LA): 10.4%; specific mortalities were of 21%, 23%, 22% and 45%, respectively. The mortality injuries to two associated chambers was 37.5%, 20% being for RA + RV, 100% for RV + LV, and zero for RV + LA. The lung accounted for 33.7% of the 89 associated lesions. Mean time of surgery and hospital stay were 121 minutes and 8.2 days, respectively. About 22.5% of patients displayed 41 complications. The mortality rate was 28.4%. Lesions grade IV and V corresponded to 55% and 41% of cases, with specific mortality of 26% and 15%, respectively. All patients with grade injuries VI died. CONCLUSION: Cardiac stab wounds were associated with lower mortality, cardiac lesions grade IV were associated with higher mortality and a shorter operative time was associated with greater severity and mortality.

Needlescopic versus laparoscopic cholecystectomy: a prospective study of 60 patients / Colecistectomia agulhascópica versus colecistectomia laparoscópica: um estudo prospectivo de 60 pacientes

PURPOSE: To test the hypothesis that needlescopic cholecystectomies (NC) offer superior outcomes in comparison to common laparoscopic cholecystectomies (LC). METHODS: Sixty consecutive patients with gallbladder disease undergoing either LC or NC were evaluated with respect to differences in operative time, frequency of per-operative incidents, post-operative pain, late postoperative symptoms, length of scars and level of postoperative satisfaction. RESULTS: Mean operative time was similar in both groups. Most of the patients, irrespective of the technique, informed mild postoperative pain. NC patients had lower levels of pain on the 7th postoperative day (PO7) (p<0.01) and decreased need for additional analgesia. Less frequency of epigastric wound pain was observed in NC patients until PO4 (p<0.01). Aesthetic result was far superior after NC (total length of scars less than half after LC). No differences regarding postoperative satisfaction with the operation were observed between the studied groups. CONCLUSIONS: Both techniques were safe and effective, presenting similar operative times and low levels of postoperative pain. Downsizing the ports to 2-3 mm was associated with significantly less frequency of postoperative pain only in the epigastric wound until PO4. Aesthetic outcome of NC was significantly superior to LC, although this advantage did not influence patient level of satisfaction.

OBJETIVO: Testar a hipótese de que colecistectomias agulhascópicas oferecem resultados superiores aos da colecistectomia laparoscópica usual (CL). MÉTODOS: Sessenta pacientes consecutivos com colecistopatia submetidos à CA ou CV foram avaliados quanto ao tempo operatório, freqüência de acidentes peroperatórios, dor pós-operatória, sintomas pós-operatórios tardios, comprimento das cicatrizes e grau de satisfação. RESULTADOS: O tempo operatório médio foi semelhante em ambos os grupos. A maioria dos pacientes, independentemente da técnica, relataram dor pós-operatória leve. Aqueles operados por CA tiveram menores níveis de dor no 7º dia de pós-operatório (PO7) (p<0.01) e menor necessidade de analgesia adicional. Menor freqüência de dor epigástrica foi observada no grupo CA até o PO4 (p<0.01). O resultado estético foi amplamente superior após CA (comprimento total das cicatrizes menor que a metade após CL). Não houve diferença quanto ao grau de satisfação entre os grupos. CONCLUSÕES: As duas técnicas foram seguras e eficazes, apresentando tempos operatórios semelhantes e baixos níveis de dor pós-operatória. A redução dos portais para 2-3 mm associou-se a menor freqüência de dor pós-operatória apenas na incisão epigástrica até o PO4. O resultado estético da agulhascopia foi significantemente superior ao da laparoscopia, apesar desta vantagem não ter influenciado o grau de satisfação dos doentes.

Initial experience with hand replantation after traumatic amputation in a nonspecialized center

Traumatic amputation of the hand is an incapacitating injury, requiring skilled surgical care. Achieving functional recovery in addition to salvage of the amputated extremity should be the goal of the patient care team, after the life of the patient is secured. This is a report of the first five cases of hand replantation after complete traumatic amputation in Manaus (Amazonas, Brazil), carried out at Hospital Pronto-Socorro Dr. João Lúcio Pereira Machado. The patients were all young males, mean age of 22.8 years, presenting at the emergency room with complete sharp amputation of the hand. After initial procedures according to the ATLS® protocol, the following surgical actions were taken: heparinization of the blood vessels of the amputated extremity, fixation of the bones, wide opening of the carpal tunnel, primary vascular anastomoses and repair of nerves and tendons. In four cases, viability and partial functional recovery of the replanted hands were achieved. The unsuccessful case was due to extensive venous thrombosis.Through this preliminary experience, we can state that hand replantation can be performed successfully in a nonspecialized hospital and that optimal results depend on adequate prehospital care, multidisciplinary surgical treatment and careful postoperative assistance.

A amputação traumática de mão é uma lesão incapacitante, requerendo tratamento cirúrgico hábil. Alcançar recuperação funcional além de salvar a extremidade amputada deve ser o objetivo da equipe médica, depois de resguardada a vida do paciente. Este é o relato dos cinco primeiros casos de reimplante de mão após amputações traumáticas completas na cidade de Manaus (AM), realizados no Hospital Pronto-Socorro Dr. João Lúcio Pereira Machado. Todos os pacientes eram homens jovens, média das idades de 22,8 anos, sendo admitidos na sala de emergência com amputação completa da mão por trauma inciso. Após medidas iniciais de acordo com o protocolo do ATLS®, foram realizados os seguintes tempos cirúrgicos: heparinização dos vasos sangüíneos da extremidade amputada, fixação óssea, abertura ampla do túnel do carpo, anastomoses vasculares primárias e sutura de nervos e tendões. Em quatro casos, ocorreu recuperação parcial dos movimentos das mãos reimplantadas. O caso de insucesso foi devido à extensa trombose venosa.A partir desta experiência inicial, podemos afirmar que o reimplante de mão pode ser realizado com sucesso em um hospital não-especializado e que os resultados ideais dependem de cuidados pré-operatórios adequados, tratamento cirúrgico multidisciplinar e assistência pós-operatória cuidadosa.