Exame clínico das mamas e mamografia: desigualdades nas regiões Sul e Nordeste do Brasil / Clinical breast examination and mammography: inequalities in Southern and Northeast Brazilian regions

RESUMO: Objetivo: Avaliar a prevalência e os fatores associados à realização do exame clínico das mamas (ECM) e da mamografia (MMG) nas regiões Sul e Nordeste do Brasil, focando em algumas desigualdades sociais. Métodos: Estudo transversal, utilizando dados da Pesquisa Nacional por Amostra de Domicílios, de 2008. Foram avaliadas as prevalências de realização de ECM durante o último ano e de MMG nos últimos dois anos e analisadas conforme variáveis demográficas (idade, cor da pele e estado civil) e socioeconômicas (renda e escolaridade). As razões de prevalência brutas e ajustadas foram obtidas através de regressão de Poisson. As análises foram estratificadas por região. Resultados: Foram avaliadas 27.718 mulheres, entre 40 e 69 anos. Menos da metade das mulheres seguiu a recomendação de realização anual de ECM em ambas as regiões. A prevalência de realização de MMG nos últimos 2 anos foi de 58,6 e 45,5% para a região Sul e a Nordeste, respectivamente. Mais de um quarto das mulheres avaliadas de ambas as regiões nunca realizaram MMG (26,5% no Sul e 40,6% no Nordeste). Nunca ter realizado ambos os exames foi quase duas vezes mais prevalente na região Nordeste (29,7%) do que na região Sul (15,9%). O risco para a não realização de ambos os exames foi maior em mulheres com idades entre 60 e 69 anos, não brancas, com menor escolaridade e com menor renda familiar. Conclusão: Importantes desigualdades foram observadas entre as regiões Sul e Nordeste para o ECM e a MMG. Políticas públicas de saúde devem priorizar grupos mais vulneráveis para reduzi-las.

ABSTRACT: Objective: To evaluate the prevalence and associated factors of doing clinical breast examinations (CBE) and mammogram (MMG) in the Southern and Northeast Brazilian regions, focusing on some social inequalities. Methods: This is a cross-sectional study using data from the 2008 National Household Sampling Survey (PNAD). We evaluated the prevalence of CBE during the last year and of the MMG in the last two years, which were analyzed based on demographic (age, skin color, and marital status) and socioeconomic (income and schooling) variables. Gross and adjusted prevalence ratios were obtained using Poisson regression models. All analyses were stratified by region. Results: The sample comprised 27,718 women aged 40 to 69 years. Less than a half of the women followed the recommendation of annual CBE performance in both the regions. The MMG prevalence during the last two years was 58.6 and 45.5% for the Southern and Northeast regions, respectively. More than a quarter of the women had never had a MMG (26.5% in the Southern and 40.6% in the Northeast regions). Not having performed both examinations was almost two times higher in the Northeast region (29.7%) when compared with the Southern (15.9%). The risk for not having performed both examinations was greater among nonwhite women, aged 60 to 69 years, with lower schooling level and family income. Conclusion: Important inequalities were seen between the Southern and Northeast regions for CBE and MMG. Health public policies should prioritize the most vulnerable groups to reduce these inequalities.

Inter-Observer Variation in Ultrasound Measurement of the Volume and Diameter of Thyroid Nodules

OBJECTIVE: Thyroid nodule measurement using ultrasonography (US) is widely performed in various clinical scenarios. The purpose of this study was to evaluate inter-observer variation in US measurement of the volume and maximum diameter of thyroid nodules. MATERIALS AND METHODS: This retrospective study included 73 consecutive patients with 85 well-defined thyroid nodules greater than 1 cm in their maximum diameter. US examinations were independently performed by using standardized measurement methods, conducted by two clinically experienced thyroid radiologists. The maximum nodule diameter and nodule volume, calculated from nodule diameters using the ellipsoid formula, were obtained by each reader. Inter-observer variations in volume and maximum diameter were determined using 95% Bland-Altman limits of agreement. The degree of inter-observer variations in volumes and the maximum diameters were compared using the Student's t test, between nodules or = 2 cm. RESULTS: The mean inter-observer difference in measuring the nodule volume was -1.6%, in terms of percentage of the nodule volume, and the 95% limit of agreement was +/- 13.1%. For maximum nodule diameter, the mean inter-observer difference was -0.6%, in terms of percentage of the nodule diameter, and the 95% limit of agreement was +/- 7.3%. Inter-observer variation in volume was greater in nodules of 1 cm should not be considered as a real change in size.

Reliability of the Balance Evaluation Systems Test (BESTest) and BESTest sections for adults with hemiparesis

BACKGROUND: The Balance Evaluation Systems Test (BESTest) was recently created to allow the development of treatments according to the specific balance system affected in each patient. The Brazilian version of the BESTest has not been specifically tested after stroke. OBJECTIVE: To evaluate the intra- and inter-rater reliability and concurrent and convergent validity of the total score of the BESTest and BESTest sections for adults with hemiparesis after stroke. METHOD: The study included 16 subjects (61.1±7.5 years) with chronic hemiparesis (54.5±43.5 months after stroke). The BESTest was administered by two raters in the same week and one of the raters repeated the test after a one-week interval. Intraclass correlation coefficient (ICC) was calculated to assess intra- and interrater reliability. Concurrent validity with the Berg Balance Scale (BBS) and convergent validity with the Activities-specific Balance Confidence scale (ABC-Brazil) were assessed using Pearson's correlation coefficient. RESULTS: Both the BESTest total score (ICC=0.98) and the BESTest sections (ICC between 0.85 and 0.96) have excellent intrarater reliability. Interrater reliability for the total score was excellent (ICC=0.93) and, for the sections, it ranged between 0.71 and 0.94. The correlation coefficient between the BESTest and the BBS and ABC-Brazil were 0.78 and 0.59, respectively. CONCLUSIONS: The Brazilian version of the BESTest demonstrated adequate reliability when measured by sections and could identify what balance system was affected in patients after stroke. Concurrent validity was excellent with the BBS total score and good to excellent with the sections. The total scores but not the sections present adequate convergent validity with the ABC-Brazil. However, other psychometric properties should be further investigated. .

Comparison between a Pediatric Health Promotion Center and a Pediatric Obesity Clinic in Detecting Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease in Children

This study was done to evaluate the efficacy of health check-ups in children in detecting metabolic syndrome and non-alcoholic fatty liver disease (NAFLD) by comparing the pediatric health promotion center with the pediatric obesity clinic. Children who visited a pediatric health promotion center (n=218) or a pediatric obesity clinic (n=178) were included. Anthropometric data, blood pressure, laboratory tests, and abdominal ultrasonography were evaluated. Two different criteria were applied to diagnose metabolic syndrome. The prevalence of metabolic syndrome in the 2 units was 3.2%-3.7% in a pediatric health promotion center and 23%-33.2% in a pediatric obesity clinic. Significant differences were observed in the prevalence of each component of metabolic syndrome between the 2 units including abdominal adiposity, blood pressure, serum triglycerides, and fasting blood glucose (P<0.05). The prevalence of NAFLD was 8.7% and 71.9% in the 2 units according to liver enzymes and 5.9% and 61.8% according to ultrasonography (P<0.05). The prevalence of metabolic syndrome and NAFLD was higher among patients visiting the obesity clinic targeting obese children than that among patients visiting the health promotion center offering routine check-ups. An obesity-oriented approach is required to prevent obesity-related health problems in children.

Scoliometer measurements of patients with idiopathic scoliosis

BACKGROUND: Patients with idiopathic scoliosis are exposed to approximately 25 radiographic examinations of their spine throughout the clinical follow-up using the Cobb angle. Several non-invasive and radiation-free methods have been proposed to measure scoliotic deformities, including the scoliometer. OBJECTIVES: To measure the intra- and interrater reliability of the scoliometer measurements, to assess the correlation of the values obtained by the scoliometer measurements with the Cobb angles obtained by radiography, and to assess the sensitivity and specificity of the scoliometer measurements for the different diagnostic criteria for the referral of idiopathic scoliosis. METHOD: Sixty-four patients were selected for the study: half with idiopathic scoliosis and half without. The 17 levels of the spine of each volunteer were measured with a scoliometer in the forward bending position. The measurements were performed three times on 42 volunteers by two different raters to obtain data for calculating the reliability values. Anteroposterior radiographs were taken to determine the Cobb angles, which were then compared with the highest trunk rotation value. Sensitivity and specificity were evaluated using radiograph criteria for referral: a Cobb angle of 10º and axial trunk rotation values between 5º and 10º. RESULTS: Excellent intrarater reliability values and very good interrater reliability values were obtained. The correlation between the scoliometer measurements and radiograph analyses was considered good (r=0.7, p<0.05). The highest sensitivity value was for a trunk rotation of 5º at 87%. CONCLUSIONS: The scoliometer measurements showed a good correlation with the radiographic measurements. .

Força de preensão palmar em idosos com demência: estudo da confiabilidade / Handgrip strength in elderly with dementia: study of reliability

CONTEXTUALIZAÇÃO: Instrumentos de medida devem ser analisados quanto a sua utilidade clínica e científica em diferentes populações. Apesar de o teste da força de preensão palmar (FPP) ser amplamente utilizado, pouco foi investigado quanto a sua confiabilidade ao ser utilizado em idosos com demência e em qual grau de demência seria inviabilizado o seu uso. OBJETIVO: Avaliar a confiabilidade teste-reteste da FPP em idosos com diferentes graus de demência. MÉTODO: Realizou-se uma avaliação dos aspectos cognitivos de 76 idosos com demência e uma entrevista com o cuidador, permitindo a classificação do idoso segundo os critérios da Escala Clínica de Demência (Clinical dementia rating - CDR). Para essas avaliações, foram utilizados o Miniexame do Estado Mental e os questionários Pfeffer, Lawton e Katz. Vinte idosos foram classificados como grau questionável (83,4±5,8 anos); 19, como leve (82,4±6,8 anos); 19, como moderado (85,8±5,6 anos) e 18, como grave (84,0±5,1 anos). Os idosos tiveram a FPP avaliada por meio de um dinamômetro hidráulico JAMAR e, após uma semana, foram reavaliados. A confiabilidade foi estimada pelo Coeficiente de Correlação Intraclasse (ICC). O nível de significância foi α=0,05. RESULTADOS: A confiabilidade teste-reteste foi excelente para os grupos que apresentaram o CDR questionável (ICC=0,975; p=0,001), leve (ICC=0,968; p=0,002) e moderado (ICC=0,964; p=0,001). A análise do grupo com CDR grave mostrou não haver uma significância estatística e um ICC baixo (ICC=0,415; p=0,376). CONCLUSÃO: O teste de FPP apresenta excelente confiabilidade ao ser utilizado em idosos com demências questionável, leve e moderada, viabilizando seu uso em pesquisas. Já em idosos classificados como graves, seu uso não é recomendado visto que a confiabilidade da medida é baixa e, portanto, sem relevância clínica para uso na prática.

BACKGROUND: Measuring instruments should have their scientific and clinical value evaluated in different populations. The handgrip strength test is widely used, however little has been investigated about its reliability when used in elderly with dementia and the right stage wich its use should be avoided. OBJECTIVES: To evaluate the test-retest reliability of the handgrip strength test in elderly with different ratings of dementia. METHOD: The cognitive function of 76 elderly subjects with dementia was measured, and the caregivers were interviewed to allow classification by the Clinical dementia rating (CDR). For these assessments the Mini-Metal State Examination and the Pfeffer, Lawton, and Katz scales were used. Twenty subjects were classified as borderline (83.4± 5.8 years), 19 as mild (82.4±6.8 years), 19 as moderate (85.8±5.6 years) and 18 as severe dementia (84.0±5.1 years). Handgrip strength was assessed with a JAMAR hydraulic dynamometer and after one week it was reevaluated. Reliability was analyzed by Intraclass Correlation Coefficient (ICC). The significance level was set at α=0.05. RESULTS: Test-retest reliability was excellent for groups with borderline (ICC=0.975; p=0.001), mild (ICC=0.968; p=0.002), and moderate (ICC=0.964; p=0.001) dementia. The analysis of the group with a severe CDR showed no statistical significance and a low ICC (ICC=0.415; p=0.376). CONCLUSION: The handgrip strength test has excellent reliability when used in elderly with borderline, mild, and moderate dementia, which enables its use in research. However, its use is not recommended in elderly classified with severe dementia due to the measure’s low reliability and subsequent irrelevance in clinical practice.

Correlação entre a Visual Gait Assessment Scale, Edinburgh Visual Gait Scale e Escala Observacional da Marcha em crianças com paralisia cerebral diparética espástica / Correlation among the Visual Gait Assessment Scale, Edinburgh Visual Gait Scale and Observational Gait Scale in children with spastic diplegic cerebral palsy

CONTEXTUALIZAÇÃO: Desordens da marcha são comuns em crianças com paralisia cerebral (PC) diparética espástica. Com o intuito de aprimorar a marcha dessas crianças e quantificar os desfechos de tal intervenção, torna-se necessário que se faça uma análise instrumentada pré e pós-intervenção. OBJETIVOS: Correlacionar a Edinburgh Visual Gait Scale (EVGS), a Visual Gait Assessment Scale (VGAS) e a Escala Observacional de Marcha (EOM). MÉTODOS: Estudo transversal de análise da marcha por meio das escalas EVGS, VGAS e EOM, envolvendo oito crianças com PC diparética espástica, nível I ou II do Gross Motor Function Classification System (GMFCS), avaliadas por três examinadores. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da Universidade Estadual de Campinas - UNICAMP. Os dados foram analisados pelo índice Kappa ponderado, considerando um nível de significância de 5%. RESULTADOS: O estudo intra-avaliadores mostrou que a concordância entre os métodos na classificação dos sujeitos foi de moderada a excelente (k=0,41, 1,00), sendo a comparação entre a VGAS e a EVGS a de maior índice de concordância, enquanto a EOM obteve grande discordância em comparação com as outras escalas. A concordância interavaliadores se mostrou predominantemente alta. CONCLUSÃO: Os resultados fornecem evidências de que a VGAS e a EVGS são mais adequados para avaliação da marcha de crianças com PC diparética quando comparadas à EOM.

BACKGROUND: Gait disorders are very common in children with spastic diplegia cerebral palsy (CP). In order to improve the CP children's gait and to quantify the outcomes of this intervention it becomes essential to perform an instrumented analysis before and after the intervention. OBJECTIVES: To analyze the correlation among the Edinburgh Visual Gait Scale (EVGS), the Visual Gait Assessment Scale (VGAS) and the Observational Gait Scale (OGS). METHODS: Cross sectional study aiming to analyze the gait of 8 children with spastic diplegia CP with level I or II in the Gross Motor Function Classification System (GMFCS) through the EVGS, VGAS and OGS scales performed by 3 examiners. This study was approved by the Research Ethics Committee of the Universidade Estadual de Campinas (UNICAMP). Weighted Kappa scores were used to analyze the data considering a significance level of 5%. RESULTS: The intra-rater analyses showed a moderate to excellent agreement (k=0.41, 1.00) among the methods of the children's classification, being the comparison between VGAS and the EVGS scales presented the highest level of agreement, while the OGS scale presented a considerable disagreement in comparison with other scales. The inter-rater agreement showed to be predominantly high. CONCLUSIONS: The results provide evidence that the VGAS and the EVGS scales are more suitable for children's spastic diplegia CP gait assessment when compared to OGS.

Tradução, adaptação e confiabilidade interexaminadores do manual de administração da escala de Fugl-Meyer / Translation, adaptation and inter-rater reliability of the administration manual for the Fugl-Meyer assessment

CONTEXTUALIZAÇÃO: Recentemente a confiabilidade da versão brasileira da Escala de Fugl-Meyer (EFM) foi avaliada pela pontuação dada pela observação de um único examinador que aplicou a escala. Quando diferentes examinadores aplicam a escala, a confiabilidade pode depender da interpretação dada à ficha de avaliação. Nesse caso, um manual de administração claro é fundamental para garantir homogeneidade na aplicação. OBJETIVOS: Traduzir e adaptar para o português-Brasil a versão do Manual de Administração em francês-canadense da EFM e avaliar a confiabilidade interexaminadores quando diferentes examinadores aplicam a EFM com base nas informações contidas no manual. MÉTODOS: Participaram do estudo 18 adultos (59±10 anos) com hemiparesia crônica (38±35 meses pós-Acidente Vascular Encefálico). Oito sujeitos participaram da primeira parte do estudo e dez, da segunda parte. Baseada na análise dos resultados da parte 1, desenvolveu-se uma versão adaptada à qual foram adicionadas informações e fotos para ilustrar a posição do paciente e do examinador. A confiabilidade interexaminadores foi avaliada com o Coeficiente de Correlação Intraclasse (CCI). RESULTADOS: A confiabilidade da EFM baseada na versão adaptada do manual foi excelente para o escore motor total do membro superior (MS, CCI=0,98) e membro inferior (MI, CCI=0,90), sentido de movimento (CCI=0,98), amplitude de movimento (ADM) passiva do MS (CCI=0,84) e do MI (CCI=0,90) e moderada para a sensibilidade tátil (0,75). A avaliação da dor articular apresentou baixa confiabilidade. CONCLUSÃO: Os resultados mostram que, com exceção da avaliação da dor, a aplicação da EFM com base na versão adaptada do manual de aplicação em português-Brasil apresenta adequada confiabilidade interexaminadores.

BACKGROUND: Recently, the reliability of the Brazilian version of the Fugl-Meyer Assessment (FMA) was assessed through the scoring given according to observations made by a single evaluator who applied the test. When different raters apply the scale, the reliability may depend on the interpretation given to the assessment sheet. In such cases, a clear administration manual is essential for ensuring homogeneity of application. OBJECTIVES: To translate and adapt the French Canadian version of the FMA administration manual into Brazilian Portuguese and to evaluate the inter-rater reliability when different evaluators apply the FMA on the basis of the information contained in the manual. METHODS: Eighteen adults (59±10 years) with chronic hemiparesis (38±35 months after a stroke) took part in this study. Eight patients participated in the first part of the study and 10 in the second part. Based on analyzing the results from part 1, an adapted version was developed, in which information and photos were added to illustrate the positions of the patient and evaluator. The inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: The reliability of the FMA based on the adapted version of the manual was excellent for the total motor scores for the upper limbs (ICC=0.98) and lower limbs (ICC=0.90), as well as for movement sense (ICC=0.98) and upper and lower-limb passive range of motion (ICC=0.84 and 0.90, respectively). The reliability was moderate for tactile sensitivity (0.75). The joint pain assessment presented low reliability. CONCLUSIONS: The results showed that, except for pain assessment, application of the FMA based on the adapted version of the application manual for Brazilian Portuguese presented adequate inter-rater reliability.

Adaptação transcultural para o Brasil do Sistema de Classificação da Função Motora Grossa (GMFCS) / Cross-cultural adaptation of the Gross Motor Function Classification System into Brazilian-Portuguese (GMFCS)

CONTEXTUALIZAÇÃO: Em função da complexidade das manifestações clínicas da paralisia cerebral (PC) e das dificuldades na sua classificação baseada apenas nos tipos motores e topografia de distribuição corporal, estudiosos canadenses propuseram o Gross Motor Function Classification System (GMFCS). Apesar de esse sistema de classificação estar sendo bastante utilizado no Brasil, ele ainda não havia sido adapatado transculturalmente para tal. OBJETIVOS: Realizar a adaptação transcultural para o Brasil do Sistema de Classificação da Função Motora Grossa (GMFCS) para a PC e verificar a confiabilidade entre observadores do instrumento adaptado com crianças brasileiras. MÉTODOS: Este estudo consistiu em duas etapas, sendo a primeira relacionada com o processo de adaptação transcultural, e a segunda referente à testagem do instrumento. A adaptação transcultural do instrumento foi feita por meio da tradução, retrotradução, análise semântica, análise de conteúdo, retrotradução da versão final e aprovação dos autores do instrumento. A testagem do instrumento ocorreu junto a 40 crianças com PC, as quais foram avaliadas por dois examinadores para verificar a confiabilidade entre observadores. RESULTADOS: Os resultados demonstram que as etapas de tradução e retrotradução não apresentaram dificuldades, e a equivalência semântica e a conceitual foram obtidas. A confiabilidade entre examinadores demonstrou que as avaliações quase não diferiam e que havia excelente correlação e consistência interna do constructo, com coeficiente de correlação intraclasse (ICC) de 0,945 (com intervalo de 0,861 a 0,979) e a de Cronbach de 0,972. CONCLUSÕES: A versão final do GMFCS mostrou bom potencial de aplicabilidade por graduandos e profissionais da área de neuropediatria.

BACKGROUND: Due to the complexity of clinical symptoms of cerebral palsy and the difficulties in classifying it based upon the motor types and the topography of the body distribution only, Canadian researchers have proposed the Gross Motor Function Classification System (GMFCS). Although this classification system has been largely used in Brazil, it has not been cross culturally adapted yet. OBJECTIVES: To perform the cross adaptation of the Gross Motor Function Classification System for the Cerebral Palsy (GMFCS) into Brazilian-Portuguese and to verify the reliability among observers of the adapted instrument in Brazilian children. METHODS: This study was performed in two stages; the first stage was related to the process of cross-cultural adaptation and the second stage tested the instrument. Translation, back-translation, semantic and content analysis, back-translation of the final version and the approval of the authors were used for the cross-cultural adaptation. The test of the instrument was performed in 40 children with cerebral palsy, who were evaluated by two raters to verify the reliability among the observers. RESULTS: The results showed that the stages of translation and back-translation did not present any difficulties and the semantic and conceptual equivalence was achieved. The reliability among the observers showed that the evaluations do not differ and that there is an excellent correlation and internal consistency of the construct with an ICC of 0.945 (95 percent CI 0.861 to 0.979) and a Cronbach a of 0.972. CONCLUSIONS: The final version of the GMFCS showed good potential of applicability for undergraduate students and professionals of the neuropediatric area.

Confiabilidade intra e interexaminador da análise por padrões de impressão de plantigrafias de pessoas diabéticas obtidas com o Harris Mat / Inter- and intra-examiner reliability of footprint pattern analysis obtained from diabetics using the Harris Mat

INTRODUÇÃO: A hiperpressão plantar é um fator de risco comprovado para a ulceração em portadores de diabetes mellitus. O "Harris and Beath Footprinting Mat" é um dos instrumentos usados nas avaliações para rastreamento do risco de ulceração nos pés desses pacientes. Não há relatos na literatura sobre estudos da confiabilidade da análise das impressões plantares usando o critério de padrões de impressão. OBJETIVO: O objetivo deste estudo foi avaliar a confiabilidade inter e intraexaminador da análise dos padrões de impressão plantar obtida com o "Harris and Beath Footprinting Mat". MÉTODOS: As impressões plantares de 41 sujeitos foram obtidas usando o plantígrafo. As imagens foram submetidas à análise de três examinadores independentes. Para verificar a confiabilidade intraexaminador, um dos examinadores repetiu a análise após uma semana. RESULTADOS: O coeficiente de Kappa ponderado foi excelente (Kp>0,80) para as análises inter e intraexaminador para a maioria dos pontos estudados em ambos os pés. CONCLUSÃO: O critério de análise por padrões de impressão plantar obtidas com o "Harris and Beath Footprinting Mat" apresentou boa confiabilidade e de alta a excelente concordância para as condições inter e intraexaminador. Esse método é confiável para análises que envolvam um ou mais examinadores.

INTRODUCTION: High plantar pressure is a proven risk factor for ulceration among individuals with diabetes mellitus. The Harris and Beath footprinting mat is one of the tools used in screening for foot ulceration risk among these subjects. There are no reports in the literature on the reliability of footprint analysis using print pattern criteria. OBJECTIVE: The aim of this study was to evaluate the inter- and intra-examiner reliability of the analysis of footprint patterns obtained using the Harris and Beath footprinting mat. METHODS: Footprints were taken from 41 subjects using the footprinting mat. The images were subjected to analysis by three independent examiners. To investigate the intra-examiner reliability, the analysis was repeated by one of the examiners one week later. RESULTS: The weighted kappa coefficient was excellent (Kw>0.80) for the inter- and intra-examiner analyses for most of the points studied on both feet. CONCLUSIONS: The criteria for analyzing footprint patterns obtained using the Harris and Beath footprinting mat presented good reliability and high to excellent inter- and intra-examiner agreement. This method is reliable for analyses involving one or more examiners.

Concordância e confiabilidade de dois métodos não-invasivos para a avaliação da amplitude de movimento cervical em adultos jovens / Agreement and reliability of two non-invasive methods for assessing cervical range of motion among young adults

CONTEXTUALIZAÇÃO: A amplitude de movimento (ADM) cervical é fundamental na avaliação funcional e na intervenção fisioterapêutica. O Cervical Range of Motion (CROM) destaca-se por ser um método confiável, não invasivo e de fácil manuseio, porém de alto custo. Na prática clínica, opta-se por aparelhos mais acessíveis, como o Flexímetro, cuja confiabilidade ainda não foi adequadamente testada para o segmento cervical. OBJETIVOS: Comparar o Flexímetro com o CROM na análise da ADM cervical e verificar a confiabilidade intra e interexaminadores de ambas as ferramentas. MÉTODOS: Os movimentos cervicais de flexão, extensão, inclinação lateral e rotação foram mensurados, com ambas as ferramentas, por três examinadores em 20 indivíduos jovens, do sexo feminino, assintomáticos. A análise estatística foi realizada pelo Coeficiente de Correlação Intraclasse (ICC). RESULTADOS: A concordância entre as ferramentas foi considerada moderada nos movimentos de flexão e rotação esquerda (0,71;0,58) e excelente nos demais movimentos (0,76-0,87). A confiabilidade intraexaminadores com o CROM foi moderada para os movimentos de flexão e rotação direita (0,70; 0,69) e excelente para os demais movimentos (0,79-0,88); com o Flexímetro, foi excelente para inclinação e rotação direita (0,80; 0,77) e moderada para os demais movimentos (0,69-0,75). A confiabilidade interexaminadores com o CROM foi excelente em todos os movimentos (0,76-0,93) e, com o Flexímetro, foi moderada para os movimentos de rotação direita e esquerda (0,66; 0,75) e excelente para os demais movimentos (0,81-0,88). CONCLUSÕES: Os valores obtidos na avaliação da ADM cervical feita pelo Flexímetro concordam com aqueles mensurados pelo CROM. Além disso, ambas as ferramentas apresentam confiabilidades aceitáveis para a prática clínica.

BACKGROUND: Cervical range of motion (CROM) is a fundamental component of the functional evaluation in physical therapy interventions. The CROM device stands out as a reliable, non-invasive and easy-to-use method, but it is a very expensive tool. In clinical practice, more affordable tools such as Fleximeters are preferred. However, the reliability of Fleximeters for the cervical spine has not been adequately tested. OBJECTIVES: To compare the Fleximeters and the CROM device for the analysis of CROM, and to investigate the intra- and inter-examiner reliability of both tools. METHODS: Cervical movements (flexion, extension, lateral flexion and rotation) were assessed in 20 asymptomatic young women by three examiners using both tools. The statistical analyses were performed using the intra-class correlation coefficient (ICC). RESULTS: The agreement between the tools was considered moderate for flexion and left rotation (0.71; 0.58) and excellent for all of the other movements (0.76-0.87). The intra-examiner reliability for the CROM device was moderate for flexion and right rotation (0.70; 0.69) and excellent for all of the other movements (0.79-0.88). For the Fleximeter, the agreement was excellent for inclination and right rotation (0.80; 0.77) and moderate for all of the other movements (0.69-0.75). The inter-examiner reliability for the CROM device was excellent for all movements (0.76-0.93) and for the Fleximeter, it was moderate for right and left rotation (0.66; 0.75) and excellent for all of the other movements (0.81-0.88). CONCLUSIONS: There was agreement between the CROM assessments using the Fleximeter and the CROM device. Furthermore, both devices showed acceptable reliability for clinical practice.

Hepatimetria: correlação entre o método clínico e ultra-sonográfico / Liver size: correlation between clinical method and ultrasonography

Introdução: O método clínico é amplamente utilizado para avaliação da hepatimetria, utilizando-se a associaçãodas técnicas de percussão e palpação. Alterações encontradas no exame físico determinam investigações posteriores com exames complementares. Objetivo: Avaliar a correlação da hepatimetria obtida pela semiotécnica de percussão e palpação, com a hepatimetria obtida através da ultra-sonografia. Métodos: Foi realizado um estudo transversal, onde a amostra foi formada por quarenta acadêmicos do Curso de Medicina da Unisul – Tubarão - SC. Os participantes foram submetidos ao exame clínico e ultra-sonográficoabdominal. Resultados: Dos 40 participantes, 20 de cada gênero,a idade média foi de 22,98 (± 2,75) anos. A média final da hepatimetria clínica foi de 9,14 (± 1,99) cm. A diferença das medidas entre os examinadores não foi estatisticamente significativa (p=0,28). A média dahepatimetria obtida através do ultra-som foi de 10,33 (± 2,89) cm. Não foram estatisticamente significativas asdiferenças da hepatimetria entre os gêneros (p=0,11) e entre os biótipos (p=0,082). Para os indivíduos com pesoabaixo de 70Kg o coeficiente de correlação de Pearson foi de 0,75 (IC 95%: 0,23 a 0,78). Para os indivíduoscom peso superior a 70 Kg o coeficiente de correlação de Pearson foi de 0,45 (IC 95%: -0,27 a 0,66). Conclusão: A hepatimetria obtida pelo método clínicoapresenta boa correlação com o método ultrasonográfico, embora subestime o tamanho real do fígado em adultos jovens. A influência das habilidades doexaminador mostram-se nítidas, assim como as características dos pacientes.

Introduction: The clinical method widely is used for evaluation of the liver size.Objectives: To evaluate the correlation of the liver size gotten for the technique semiologic of percussion and palpation, with the liver size obtained byultrasonography. Methods: A transversal study was carried through between-observator, sample was formed by fortyacademics of the Course of Medicine of the Unisul – Tubarão - SC. The participants had been submitted tothe clinical examination and the abdominal ultrasonography. Results: 20 participants had been of each gender,average age were of 22,98 (± 2,75) years. The final average of the clinical liver size was of 9,14 (± 1,99) cm.The difference of the measures between the examiners was not statistically significant (p=0,28). The average ofthe liver size obtained by trasonography was of 10,33 (± 2,89) cm had not been statistically significant the differences of the liver size between genders (p=0,11) and the biotypes (p=0,082). For people which weightbelow of 70Kg we find the following correlation: r = 0,75 (IC 95%: 0,23 0,78). For people which weight above70 kg we find the following correlation r = 0,45 (IC 95%: -0,27 0,66).Conclusion: The liver size obtained by the clinical method presents good correlation with the ultrasonography method, even so underestimate the realsize of the liver in young adults. The influence of the abilities of the examiner reveals clear, as well as thecharacteristics of the patients.

Eficiencia técnica de la atención al paciente con diabetes en el primer nivel / Technical efficiency in primary care for patients with diabetes

OBJETIVO: Cuantificar en un primer nivel la eficiencia técnica de la atención al paciente con diabetes y distinguir la provisión de servicios y los resultados en salud, además de reconocer las fuentes potenciales de variación. MATERIAL Y MÉTODOS: Se incluyeron insumos, actividades clínicas y resultados en salud de 47 clínicas familiares del IMSS Nuevo León. La medida de la eficiencia se realizó mediante el análisis envolvente de datos y se aplicaron modelos de regresión de Tobit. RESULTADOS: Siete clínicas fueron eficientes en cuanto a la provisión de servicios y nueve en salud; dos coincidieron en ambos aspectos. La localización metropolitana y el total de consultas favorecieron la eficiencia en relación con la provisión de servicios, cualesquiera que fueran los atributos del paciente; y la edad del médico, la eficiencia de los resultados en salud. CONCLUSIONES: El desempeño varió en una misma unidad y entre una y otra; algunas fueron eficientes para suministrar servicios y otras para mejorar la salud. Las fuentes de variación también difirieron. Se recomienda incluir ambos productos en el estudio de la eficiencia en diabetes en el primer nivel.

OBJECTIVE: To quantify the technical efficiency of diabetes care in family practice settings, characterize the provision of services and health results, and recognize potential sources of variation. MATERIAL AND METHODS: We used data envelopment analysis with inputs and outputs for diabetes care from 47 family units within a social security agency in Nuevo Leon. Tobit regression models were also used. RESULTS: Seven units were technically efficient in providing services and nine in achieving health goals. Only two achieved both outcomes. The metropolitan location and the total number of consultations favored efficiency in the provision of services regardless of patient attributes; and the age of the doctor, the efficiency of health results. CONCLUSIONS: Performance varied within and among family units; some were efficient at providing services while others at accomplishing health goals. Sources of variation also differed. It is necessary to include both outputs in the study of efficiency of diabetes care in family practice settings.

Correlação entre exame clínico das mamas, exame mamográfico e exame histopatológico de mulheres atendidas em uma clínica de mastologia no Sul do Brasil / Correlation between clinical breast examination, mammography and histopathology examination of women attending in a mastology clinic at the South of Brazil

Objetivos: O objetivo do presente estudo foi correlacionar o exame clínico das mamas, a mamografia e a histopatologia, e verificar a sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo. Métodos: Foram analisados 193 prontuários de pacientes atendidas em uma clínica privada no município de Santo Ângelo, RS. As variáveis identificadas foram a idade das pacientes, os resultados dos exames clínicos, mamográficos e histopatológicos. Resultados: As mulheres apresentaram idade média de 48,5 anos, variando de 18 a 92 anos. Tiveram exame clínico negativo ou com alterações benignas 55,4% no histopatológico com o exame clínico. Quando foi correlacionado o diagnóstico histopatológico com o exame clínico das mamas, foi observada associação significante (p < 0,001), com sensibilidade de 94,2%, especifidade de 33,6%, valor preditivo positivo de 53,3% e valor preditivo negativo de 87,8%. O histopatológico com mamográfico teve maior associação, quando analisada a categoria BI-RADS V com sensibilidade de 54,7%, especificidade de 99,1%, valor preditivo positivo de 97,9% e valor preditivo negativo de 73,1%. Conclusão: A palpação mamária isolada pode ser um simples, rápido e eficiente exame clínico de rastreamento para o câncer de mama. O histopatológico benigno apresenta maior correlação dentro do BI-RADS I, II e III. As pacientes com classificação BI-RADS IV e V devem ser submetidas a exame histopatológico pelo alto risco de doença maligna associada.

Objective: The aim of the present study was to correlate the clinical breast examination, mammography and histopathology, to verify the sensitivity, specificity, negative and positive predictive values. Materials and Methods: Were analized 193 of pacients seen at a private clinic in the city of Santo Ângelo, RS. The variables identified were the pacient's age, the clinical exam results, mammography and histopathological. Results: The average of the women was 48.5 years , varying from 18 to 92. 55.4% had negative exam or benignant alteration on the histopathological. When the histopathological was correlated with the clinical breast examination, a significant association was seen (p < 0.001), with sensitivity 94.2%, specificity 33.6%, negative and positive values 87.8% and 53.3% . The histopathological shows bigger corralation inside BI-RADS V, with sensitivity 54.7%, specificity 99.1%, negative and positive values 73.1% and 97.9%. Conclusion: Mammary touching alone can be a simple, fast and efficient screening clinical examination for breast cancer. The histopathological shows bigger correlation inside BI-RADS 0, I, II, III. Pacients with BI-RADS IV, V must be submitted to histopathological exam for the high risk of associated malignant disease.

Disparities in Participation in Health Examination by Socio-economic Position among Adult Seoul Residents / 예방의학회지

OBJECTIVES: To determine the disparity in the rate people undergo health examinations according to socioeconomic position (SEP) and the changes in this disparity with time. METHODS: Seoul citizens}health profile data from 1997 to 2005 were analyzed. The study subjects were 40 years old and over, and the total number of subjects was 6,601 in 1997, 8,994 in 2001, and 8,819 in 2005. Those aged 60 years and over were eliminated from the analysis of subjects}occupation. We used education, family income and occupation as indicators of SEP. The age-standardized health examination attendance rate for each year was calculated according to the education, family income and occupation. The odds ratios (ORs) from multiple logistic regressions were adjusted for age. RESULTS: The disparity in the rate of attendance according to the SEP decreased from 1997 to 2005 but still existed. Even though the disparities among the subgroups according to education, family income and occupation were not that high, the disparity between the group with the highest SEP and the other groups was considerable. CONCLUSIONS: Our findings suggest that unequal access to health examination services according to socioeconomic position still exists. This disparity has decreased recently but the disparity according to level of education was the greatest.

Socioeconomic Inequalities in Preventive Services among the Elderly: Results from Medical Checkup, Cancer Check, and BP Check / 예방의학회지

OBJECTIVES: Due to the assumptions of homogeneity as well as challenges in the socioeconomic position of the elderly, they have been relatively neglected in studies of health inequalities. Therefore, this study was conducted to investigate the social inequalities in preventive services among elderly men and women. METHODS: Data were obtained from a nationally representative sample of 342 men and 525 women aged 65 and over collected during the 2001 National Health and Nutrition Examination Survey. Age adjusted proportions and logistic regression were used to identify the social patterning of preventive services among elderly Koreans using various social position indicators. RESULTS: The findings of this study generally supported the presence of social gradients in preventive services among the Korean elderly. The likelihood of using the service becomes progressively higher with social position. Educational level, income, and self-rated living status were significantly associated with increased medical checkups and cancer checks. In addition, logistic regression detected educational inequalities only among older women receiving BP checks. After being stratified based on health status and chronic disease status, social disparities still existed when educational level and self-rated living status were considered. Among unhealthy individuals, place of residence was observed as a barrier to medical checkups. CONCLUSIONS: This study demonstrated strong and consistent associations between socioeconomic position and preventive services among the elderly in Korea. The results indicate that public health strategies should be developed to reduce the barriers to preventive services encountered by the elderly.

A Correlation between Low Back Pain and Associated Factors: A Study Involving 772 Patients who Had Undergone General Physical Examination

Many factors are associated with the development of low back pain. Among them, exercise, obesity, smoking, age, educational level and stress are the most common. This study examined the association of these factors with low back pain. An additional aim was to determine a procedure for preventing low back pain. This study analyzed the responses to a questionnaire sent to 772 individuals who had undergone a medical examination at this hospital in 2003 and excluded the individuals who had shown symptoms or their test results indicated a particular disease. Assuming that there were no variables, individuals who exercised regularly 3-4 times per week would have a lower chance of having low back pain than those who did not exercise regularly. The analysis revealed that individuals with a college degree or higher education have a lower chance of experiencing low back pain than those with only a high school education or even college drop-outs. When the other variables were constant, age, extent of obesity (body mass index), smoking and level of stress were not found to affect the development of low back pain. The level of education was associated with the development of low back pain. However, regular exercise 3-4 times per week or more would be most effective in reducing the incidence and duration of low back pain.

Escolares submetidos a videonasofaringoscopia na escola: achados e aceitação / Schoolchildren submitted to nasal fiber optic examination at school: findings and tolerance

OBJETIVO: Verificar a aceitação da videonasofaringoscopia por crianças, no ambiente escolar, para avaliação de vegetações adenoideanas e determinar a sua prevalência nessa população MÉTODO: Estudo transversal realizado em amostra proporcional (n = 368) de escolares da primeira série do ensino fundamental de Aracaju (SE), com idades entre 6 e 13 anos, submetidos a videonasofaringoscopia flexível. Todas se submeteram à mesma rotina de exame, feito na própria escola, sem a necessidade de contenção ou qualquer tipo de sedação. RESULTADOS: As crianças que foram submetidas a avaliação nasofibroscópica aceitaram bem o procedimento, permitindo a adequada avaliação das cavidades do nariz e nasofaringe. A prevalência de hipertrofia adenoideana grau I foi de 50,6 por cento, a de grau II foi de 35,1 por cento e a de grau III foi de 14,3 por cento. As hipertrofias adenoideanas graus II e III apresentam maior número de sintomas obstrutivos. CONCLUSÃO: A videonasofaringoscopia flexível pode ser realizada, com excelente aceitação, fora do ambiente hospitalar ou consultório, como mostra este estudo realizado em ambiente escolar, indicando que sua utilização pode ser mais ampla, tornando-a mais acessível a um maior número de pessoas. A prevalência dos três graus de hipertrofia adenoideana encontrada em Aracaju difere de alguns estudos por ter sido realizada em crianças não triadas para sintomas respiratórios.

Health status of health care workers at Srinagarind Hospital: experience from the Annual Health Check-up Program.

The authors conducted this study to evaluate the efficacy of a health check-up program and the health status of health care workers at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University. The authors reviewed all yearly-check up charts of personnel who worked at Srinagarind Hospital from 2002 to 2003 including history taking, physical examination, and laboratory testings. There were 606 office workers and 1,024 nursing staff enrolled The mean ages of both groups were 38.9 and 36.5 years old, respectively. The office workers visited physicians significantly more often than the nursing staff (553 of 606 vs 271 of 1,024; p-value = 0.00). Obesity was found much more in office workers (127 of 472 versus 129 of 749). There were significant differences between the groups on impaired fasting plasma glucose, DM, HT, high cholesterol level, high triglyceride level, and significant elevation of ALT or AST (all p-value = 0.00). In the obese group, there was also a significantly higher number of cases who had high blood pressure, defined as IFG or DM, high cholesterol level, and high triglyceride level (p-value = 0.00) except the significant elevation of ALT or AST level. Cases of obesity with significant elevation of hepatic enzyme had many atherosclerotic risk factors. Therefore, metabolic derangements are the important problem for health care workers.

Annual laboratory checkup: early signs of health problems in young and middle-age adults.

The objective of this descriptive study was to review the usefulness and relevance of the present parameters provided in an annual laboratory health checkup program. Three hundred sixty-four volunteers were randomly selected, composed of 141 males and 223 females age 15 to 81 years old. Samples from all the volunteers were analyzed for CBC, FBG, BUN, Cr, uric acid, Chol, HDLc, Tg, AST, ALT, ALP, UA and stool examination. More than half the young adults (67.7%, 63 of 93) had abnormal laboratory results. This was higher than in the middle-age group (56.8%, 154 of 271).