Experiência do programa de saúde do trabalhador de Piracicaba: desafios da vigilância em acidentes do trabalho / Experience of the Piracicaba Worker Health Program: challenges for the surveillance of work-related accidents

Apresenta-se neste estudo a descrição da experiência de saúde do trabalhador no Município de Piracicaba-SP e as propostas de vigilância com ênfase nos acidentes do trabalho graves. O texto representa o esforço coletivo da equipe em sua atuação. Ele mostra a importância de ações interinstitucionais, a parceria entre o Programa de Saúde do Trabalhador - SUS, com membros do Ministério do Trabalho e Emprego (MTE), a integração do serviço com as universidades e com representantes da sociedade civil, na proteção e promoção da saúde. Os dados das Comunicações de Acidentes do Trabalho (CAT) processados em 1997 serviram de base para o planejamento das atividades e mostram que o município possui uma proporção de incidência anual de 5,43 acidentes e doenças do trabalho para 100 trabalhadores expostos (regidos pela Consolidação das Leis do Trabalho - CLT), bem acima da média nacional de 1,62 por 100, ano base de 1996. A rede local de prontos-socorros atende a cerca de 60% dos Acidentes e Doenças Profissionais, o que mostra a importância das ações preventivas do setor público, neste contexto. Propõe-se um sistema de vigilância aos acidentes graves e fatais, nos moldes de eventos sentinela, que inclui um sistema de comunicação, a busca ativa de casos e o registro das ocorrências na rede de pronto atendimento e ações ou negociações coletivas setoriais para prevenção dos riscos mais relevantes.

This study describes a worker's health experience in Piracicaba city and proposes surveillance actions with an emphasis on severe work-related accidents. This text represents our collective work as a team. It reveals the importance of interinstitutional actions in prevention and health promotion, such as: the partnership among the Worker's Health Program of the Unified Health System - SUS, with members of the Ministry of Labour, and the integration of health services with the universities and representatives of the community. Data of the Work Related Accident Register (CAT) of 1997, served as the basis for planning the activities and showed an annual incidence of 5,43 work-related accidents and occupational diseases per 100 exposed workers, much more than the National average (1,62 per 100) registered in 1996. The local emergency services assist about 60% of work-related accidents and professional diseases, showing the importance of these health problems and the potential impact of local preventive actions and workers' health promotion. A sentinel surveillance system for severe occupational accidents is proposed, which would include an information system, active search and reporting of the cases at the local emergency services. Another aspect proposed is the actions or collective negotiations for risk prevention.

[Validity of clinical tests to confirm or exclude the diagnosis of acute myocardial infarction]. / Validez de las pruebas diagnósticas para confirmar o descartar un infarto agudo de miocardio.

BACKGROUND: To know the clinical usefulness of the diagnostic tests habitually used to diagnose an acute myocardial infarction (MI), in a group of patients in which this diagnosis is clinically highly suspected. PATIENTS AND METHODS: A cross sectional study was designed. The sample (n = 114) was randomized and selected by term and specific of days from the patients attending the Emergency Service at Elda General Hospital (Alicante, Spain) in a year period. The method we used was is a validity study, making 2 x 2 tables. The clinical outcome was the gold standard and was cross matched with some of the clinical criteria habitually used to diagnose acute myocardial infarction: thoracic pain character, irradiation, ECG findings and CK-MB levels. RESULTS: Clinical suspicion of MI was confirmed in only 27.8% (IC--95%: 19.3-36.3). The best validity indexes of clinical usefulness to confirm the MI diagnosis were obtained from ECG findings (CP+ = infinity) and CK-MB (CP+ = 24.2 at the end of the observational period and CP = 17.9 at the beginning). The best negative clinical validity indexes were CK values obtained at the end of the observational period (CP- = 0.07) and the ECT findings obtained at the end of the observational period (CP- = 0.10). CONCLUSION: Clinical carefulness is essential to avoid a diagnostic mistakes in MI patients, since the symptoms we used as a diagnostic guide do not offer good validity indexes. Changes in ECG or CK-MB levels could confirm the MI diagnosis but normal findings in both tests did not discard this diagnosis. We should keep the possibility of a mistake till the end of the observational period.

[Validity of clinical tests to confirm or to exclude the diagnosis of acute appendicitis]. / Validez de las pruebas diagnósticas para confirmar o descartar una apendicitis aguda.

AIMS: The clinical usefulness of the diagnostic tests (usually employed to diagnose an acute appendicitis in a group of patients in which this diagnosis is clinically highly suspected). PATIENTS AND METHODS: A cross sectional study was designed. The sample (n = 116) was randomly selected by term and specific days from the patients attending the Emergency Service at Elda General Hospital in a year period. The method used was is a validity study making 2 x 2 tables. We have cross matched the habitual routine tests with: a) the clinical outcome if the patient was not surgically treated, or b) the result of the biopsy for those operated. Being these the gold standard. The validity indexes studied were sensibility (S), specificity (E). The 95% confidence index of the CF were calculated. RESULTS: Acute appendicitis clinical suspicion was confirmed in 29.4% (IC 95%: 20.8-38). The best validity indexes were: a) kind of pain (S = 81.3; E = 33.8); b) peritoneal inflammatory signs (S = 78.5%, E = 45.9%); c) presence of leucocytosis in blood exam (S = 100%, E = 54.5%), and d) a greater difference in axillary-rectum temperature (S = 13.6%, E = 96.6%). Only leucocytosis reached 0 for PP- and CP-; the blood leucocytosis (PP+ = 47.8%, CP+ = 2.20) and the axillary-rectum temperature (PP+ = 60%, CP+ = 4.0) dissociation were the test with most valuable indexes. CONCLUSIONS: Clinical suspicion of acute appendicitis in a group of patients having a great probability of suffering it over estimates this diagnosis. The symptoms or signs routinely used in the diagnosis did not reach high validity indexes in these patients. They are a poor help to stress or reject the diagnosis of acute appendicitis. To be careful is the main tool the doctors have. Blood leucocytosis is the test that has the best agreement indexes of clinical usefulness and it has the best countence with the gold standard.

[Non-compliance of the treatment with antibiotics in non-severe acute infections]. / Incumplimiento del tratamiento con antibióticos en infecciones agudas no graves.

BACKGROUND: To determine the nonfulfillment of antiinfectious therapy in clinical practice. MATERIAL AND METHODS: Fulfillment was quantified by tablet counting (TC) in the homes of 366 patients undergoing antibiotic treatment and the motives and predictive factors were identified. RESULTS: Nonfulfillment was of 61% (95% confidence interval [CI] 55.4-66.6%). Patient improvement was the main reason for discontinuation (54.5%). The predictive factors were greater length of treatment (p = 0.000004), dose (p = 0.0019) and number of tablets (p = 0.0000). CONCLUSIONS: Nonfulfillment of antiinfectious treatment in clinical practice is high, mainly due to clinical improvement and to the greater complexity and length of treatment.

[The validity of basal blood glucose in the control of non-insulin-dependent diabetic patients]. / Validez de la determinación de la glucemia basal en el control de los pacientes diabéticos no dependientes de insulina.

BACKGROUND: To validate basal glucemia as a control method for non-insulin dependent diabetes mellitus, and to determine the cut-off point that best characterizes good control. PATIENTS AND METHODS: A transversal, observational study of 256 patients who participated in a diabetes mellitus follow-up program during 1993. In the study, glucemia validity indicators were evaluated after making 2 X 2 tables and ROC (receiver operating characteristic) curves for the different values. Control values of glycated hemoglobin was used as to define a good (< 6.5%) and moderate (< 8%). RESULTS: The values of glucemia considered to be "good" as regards control (from 80 to 110 mg/dl, 4.4-6.05 mmol/dl) have good sensitivity (from 97.3% to 100%) and negative predictive values (from 85.7% to 100%) but extremely bad specificity (from 3.8% to 22.7%) and only moderate positive predictive values (from 59.5% to 64.1%) in reference to values of glycated hemoglobin of 6.5%. The same occurs for 8% as regards sensitivity (from 98.6% to 100%), negative predictive value (from 96.4% to 100%) and specificity from 2.1% to 14.5%). Positive predictive value worsens (from 27.8% to 30.3%). The most effective and most accurate values of glucemia in the ROC curves are 150 mg/dl (8.25 mmol/l) if the control of glycated hemoglobin is good, and 170 mg/dl (9.35 mmol/l) if it is moderate. CONCLUSIONS: The glucemia control figures recommended by consensus produce false positives when they are compared to glycated hemoglobin. In the analysis of effectiveness and ROC curves greater accuracy is obtained with glucemia values that are slightly higher than those recommended.

[Quality of drug prescriptions by the Spanish internal medicine services]. / La calidad en la indicación de medicamentos por los servicios de Medicina Interna españoles.

Many registered drugs in different countries not always have been tested by clinical assays and their efficacy has no definitively proved. Good clinical practice must assume the prescription of the more efficacy drugs. The aim of this study is to evaluate the quality of the drugs prescribed by spanish general internists. We analyze the treatments prescribed by general internists using their hospital medical records. The records were offered by the Heads of the Internal Medecine Departments of Spanish hospitals with 250 beds or more when required by the Spanish Society of Internal Medecine. A random sample, stratified by the hospital size, was obtained from the whole of the Spanish hospitals. Quality of the drugs was determined using two criteria: A. Their intrinsic value; it was decided it was high if clinical assays showed their efficacy and security, and low of it was not B. The number of different chemical substances in the drug; we considered a high quality criteria if only one chemical substance, or two with proved synergistic efficacy were present, and low if it was more than two, or without proved synergistic efficacy. The sample was 250 clinical records, with 1022 different prescriptions; the records were collected between February and July 1994. We found that 94.06 +/- 1.45 of evaluated treatments have a high intrinsic value, and 96.93 +/- 1.06 have only one chemical component. The drugs without a high intrinsic value were: oral hypoglycaemics, some including several combinations of vit B, drugs acting on the cerebral blood flow and some mucolitics. Spanish general Internists usually prescribed monocomponent drugs with proved efficacy and safety.

[Importance of HDL cholesterol determination in the evaluation of coronary risk in clinical practice]. / Importancia de la determinación del colesterol HDL en la valoración del riesgo coronario en la práctica clínica.

OBJECTIVE: To validate to what extent the isolated determination of total Cholesterol (TC) is effective when seeking to predict coronary risk. DESIGN: An observational crossover study of the analytic determinations of the clinics which systematically request TC and HDL-Cholesterol (HDL)--case-finding method. SETTING: Health Centre. PARTICIPANTS: 631 analytic determinations, with samples from people who attended a Health Centre between May and November 1992, were studied. MEASUREMENTS AND MAIN RESULTS: As proof of certainty the Atherogenic Index (AI) was used for the relative risks (RR) of suffering a coronary event in line with the Framingham study. The confidence limits (CL) were calculated to 95% in order to quantify random error and permit comparison. On varying the cut-off points of TC the indicators changed, being more sensitive (S) and less specific (E) with the lower figures: 180 mg/dl, RR > 1, S = 97.5% (CL: 100-94.7) and E = 30.5% (36.8-24.2); RR > 2, S = 100%, E = 22.1% (26.9-17.3) and RR > 3, S = 100%, E = 20.8% (25.3-16.3). As values of TC increase, S diminishes and E increases: 250 mg/dl, RR > 1, S = 48.3% (57.2-39.4), E = 87.2% (91.8-82.6); RR > 2, S = 58.6% (76.5-40.7), E = 77.2% (82-72.4) and RR > 3, S = 63.6% (92-35.2), E = 75.3% (80.1-70.5). CONCLUSIONS: HDL must be determined if TC is -200 mg/dl. If everyone with RR > 2 is to be detected, HDL-cholesterol from TC > or = 180 mg/dl must be measured.

[The validity of the separate determination of total cholesterol in the primary prevention of coronary risk]. / Validez de la determinación aislada del colesterol total en la prevención primaria del riesgo coronario.

BACKGROUND: The aim of this study was to validate total cholesterol (TC) determination in the primary prevention of coronary risk and evaluate the prevalence of low HDL cholesterol (HDL-C) levels at the different TC cut-off points to thereby determine the TC level at which HDL-C determination is of interest. METHODS: The atherogenic index was used as the reference method in TC evaluation with the values of low HDL-C levels being evaluated at the following TC cut-off points: 160, 180, 200, 220, 240, 250, and 300 mg/dl (4.44; 4.66; 5.18; 5.70; 6.22; 6.48; 7.77 mmol/l). According to the results of the Framingham study the atherogenic index or the existence of low HDL-C levels were considered as abnormal. The sample included 4,162 workers from the province of Alicante (Spain) selected by consecutive sampling and opportunistic search in January and February, 1993. Validity was calculated with confidence interval of 95%. RESULTS: The atherogenic index was high in 43.7% of the sample, ranging from 6% in the population with TC lower than 160 mg/dl (4.14 mmol/l) to 76.4% in those oscillating between 250-299 mg/dl (6.48-7.76 mmol/l). Low HDL-C levels were detected in 20.1% with a prevalence ranging from 38.8% in those with a TC of less than 160 mg/dl (4.14 mmol/l) to 11.9% in those with TC > or = 250 mg/dl (> or = 6.48 mmol/l). The cut-off points for low TC had high sensitivity (S) and low specificity (SP) (160 mg/dl [4.14 mmol/l]: S = 91.1%, SP = 11.5%; 180 mg/dl [4.66 mmol/l]: S = 95.2%, SP = 30.2%). The highest TC points presented very low S and very high SP (250 mg/dl [6.48 mmol/l]: S = 46.3%, SP = 87.7%; 300 mg/dl [6.48 mmol/l]: S = 7.4%, SP = 97%). CONCLUSIONS: The HDL-cholesterol should be determined in people with a total cholesterol of less than 200 mg/dl (5.18 mmol/l) since, in this group there is an important percentage of individuals with an altered atherogenic index and low HDL-C levels.

[Opinion of university professors on the suitability of specific primary care training in medical students]. / Opinión de los profesores universitarios acerca de la conveniencia de una formación específica sobre atención primaria en los alumnos de medicina.

OBJECTIVE: To find the opinion of teachers at the University of Alicante about the appropriateness of a Primary Care Theory-Practice programme within the Medicine curriculum. DESIGN: A descriptive observation study of a crossover nature. SETTING: Teachers of the Departments of Medicine and Public Health who had had contact with the Primary Care Theory-Practice programme. PARTICIPANTS: 44 out of 71 teachers (62%) replied. INTERVENTION: An 11-question survey was answered anonymously between October 1993 and June 1994. MEASUREMENTS AND MAIN RESULTS: 77.3% (95% Confidence Interval 64.9-89.7%) considered appropriate the theoretical content at undergraduate level, where there was an average 18.5 hours teaching (C.I. 15.8-21.2); and 95.5% (C.I.89.4-100%), the practicals at a Health Centre, where there was an average 65.2 hours (C.I. 43.1-87.3) work. 43.9% thought it was appropriate to form a separate subject and 39% favored integrating these themes into other subjects. Theoretical contents would be basically teaching general information about Primary Care; and practical work would be clinical activities. The greatest advantages regarding carrying out practical work in Health Centres were: the student finds pathology more prevalent and learns to provide practical answers. The greatest disadvantages were: the low methodological knowledge and teaching preparation of the Teams. CONCLUSIONS: Those interviewed considered that the teaching at undergraduate level of a Primary Care subject with theoretical-practical content would be useful. The advantages, its contents and some difficulties were noted.

[Validity of four indirect methods which evaluate therapeutic compliance for arterial hypertension]. / Validez de cuatro métodos indirectos que valoran el cumplimiento terapéutico en la hipertensión arterial.

OBJECTIVES: To validate 4 indirect methods for detecting therapeutic non-compliance in 157 patients in a community health center Centro de Salud "Carrus" in Elche, Alicante. MATERIALS AND METHODS: The methods employed are self related compliance (SC), therapeutic gains obtained, Morinsky-Green Test, and the level of knowledge of Batalla disease (LK). For verification purposes, pills were counted, allowing the formation of 2x2 tables to calculate indices of validity. The statistical analysis employed is the calculation of 95% confidence intervals. RESULTS: SC yields significantly the lowest sensitivity (13.7 +/- 7.9%) and the highest specificity (85.7% +/- 7.5%). The LK presents the highest sensitivity 79.5 +/- 9.3%. SC underestimates non-compliance (32.5%) significantly, and the LK overestimates noncompliance (23.6%). CONCLUSIONS: The LK is a good method for detecting problems of low compliance and SC those of high compliance. It is recommended that both methods should be employed in a systematic fashion in clinical practice. However, the LK and SC cannot be used to calculate prevalences of therapeutic noncompliance in population-based studies.

[Medicine at the primary care level (optional undergraduate subject at the University of Alicante): 2 years of experience]. / Medicina en atención primaria (asignatura optativa de pregrado en la Universidad de Alicante): dos años de experiencia.

OBJECTIVE: We want to put on record two years' experience of undergraduate teaching of an optional subject, "Medicine at the Primary Care level". This was given to sixth-year students by Family and Community Medicine specialist doctors within the Department of Medicine. DESIGN AND SETTING: A crossover study carried out at the University of Alicante. PARTICIPANTS: In the first year, 73 out of the 102 students making up the complete course took part (71.6%); and in the second year, 33 out of 93 (35.5%). MEASUREMENTS AND MAIN RESULTS: The methodology employed, the teaching staff and the documents handed out were given high marks by the students in both cases; as were the course contents in the second year. Deficiencies were noted in the presentation of practical hypotheses. In the first course the students criticised the lack of certain points, basically the tackling of the more common chronic pathologies, something which was corrected in the second year. The survey identified students' wishes to spend longer on the subject. CONCLUSIONS: The students valued positively the existence of a theoretical content specific to Primary Care Medicine. In particular, they requested to be taught performance patterns for prevalent pathologies and for seminars to be organised around practical hypotheses.

[Undergraduate training in primary health care: 6 years' experience at the University of Alicante]. / Formación de pregrado en atención primaria: seis años de experiencia en la Universidad de Alicante.

OBJECTIVE: To assess the opinion of medical students on the teaching offered in the Primary Care context (TOPC). DESIGN: Observational and crossover study. The assessment used an opinion questionnaire. PARTICIPANTS: 296 sixth-year medical students between 1987 and 1992. INTERVENTIONS: The TOPC consisted of four weeks stay in a Health Centre with an eminently practical programme. However this also included hour-long theoretical seminars on the most important Primary Care questions and the student's completion of a research project related to Primary Care. RESULTS: The students expressed satisfaction with the TOPC (average score of 4 out of 5). Moreover this satisfaction increased over the five years (from 3.7 to 4.6, p = 0.0001). They believed the TOPC to be useful (3.6 to 4.7, p = 0.0001) and relevant to their future professional activity (3.1 to 4.6, p = 0.0001). They thought that the tutors were very competent (4 out of 5, with no significant variation) and the Health Centres' teaching facilities suitable (3.8 to 4, with no significant variation). Finally, they considered that TOPC should become a compulsory undergraduate subject (3.9 out of 5). CONCLUSIONS: Medical students give a positive rating to the Primary Care teaching offered and believe it should be integrated into the Medicine syllabus as a compulsory subject.