Análise retrospectiva dos fatores associados à distribuição da tuberculose bovina no estado do Rio de Janeiro / Retrospective analysis of the factors associated to the distribution of bovine tuberculosis in the State of Rio de Janeiro

Fatores associados à ocorrência da tuberculose bovina (TB), em dados de 209 fazendas, foram avaliados por meio de análise de variância. Os dados utilizados foram provenientes do levantamento epidemiológico por demanda, realizado nos rebanhos do estado do Rio de Janeiro, no período de 1959 até 1989. As variáveis significativas na análise bivariada foram incluídas no modelo e analisadas conjuntamente pelo método do modelo linear generalizado. A taxa de prevalência da TB nos rebanhos foi de 49,8 por cento. As variáveis detectadas no estudo como as mais importantes para a ocorrência de TB foram: aleitamento (P=0,03) e as interações densidade x aleitamento (P=0,04) e produtividade x período (P=0,02). A importância da organização econômica da produção pecuária na ocorrência da TB pode ser evidenciada pelos resultados obtidos neste estudo. Este é um fator relevante em decorrência dos danos à saúde humana e animal.

The factors associated to the occurrence of bovine tuberculosis (TB) in 209 farms were evaluated by variance analysis. Data came were colleted in an epidemiological investigation from herds in the State of Rio de Janeiro, examined from 1959 to 1989. The significant variables were analyzed and submitted to generalized linear model. The prevalence rate of TB in herds was 49.8 percent. The most important variations detected in this study for occurrence of TB were: sucking (P=0.03) and interactions density vs. sucking system (P=0.04) and productivity vs. sucking period (P=0.02). The influence of the economical aspects of the farming systems on the occurrence of TB was confirmed by the results of this study. This is an important factor due to human and animal health hazards.

[Cardiac effects of acute poisoning with tricyclic antidepressants: systematic review of the literature -- Part II]. / Os efeitos cardíacos da intoxicação aguda por antidepressivos tricíclicos: revisão sistemática da literatura--Parte II.

Tricyclic antidepressant overdose is a frequent diagnosis in the emergency room. It is responsible for a significant percentage of hospital admissions for observation and treatment. This is due to its cardiac (as well as neurologic) toxicity, and the difficulty in predicting its clinical gravity. The authors present this paper with two objectives in mind: 1) information about a common and significant cardiological emergency; 2) presentation of the methodology concerning systematic reviews of the literature. In this second (of four) articles, the clinical presentation and diagnosis of tricyclic antidepressant overdose are presented (in the first article--published in the previous issue of the Journal--we discussed the epidemiological aspects). In the remaining two papers we will present its management, prognosis and prevention. NOTE: This is the second of a series of four articles on the cardiac toxicity of tricyclic antidepressant overdose; the next two articles will be presented in the September and October issues of the Revista.

[Clinical guidelines and the practice of scientific evidence-based cardiology. Part I]. / As normas de orientação clínica (guidelines) e a prática da cardiologia baseada na evidência científica. Parte I.

Scientific medical information presents special characteristics, particularly its huge quantity as well as the speed with which it evolves as a result of cardiological research. These facts create difficulties in transferring research results into practice, thereby delaying the benefits of medical advances to patients. One of the possible solutions to this problem is the development, dissemination and implementation of clinical practice guidelines, as a clinical decision support system as well as a quality assurance methodology. The process of developing clinical practice guidelines involves a needs assessment, individual formulations, implementation and evaluation, as well as periodic revisions. It constitutes a complex activity, requiring technical and scientific resources for a good design and an efficacious practical implementation. In this article--as well as the next--we will present and discuss the methodology of creation, structure, evaluation and implementation of clinical practice guidelines, as a clinical decision support system as well as a quality assurance methodology in cardiology.

[Glossary of terms and concepts used in scientific evidence based cardiology. Part II: clinical trials]. / Glossário de termos e conceitos utilizados pela cardiologia baseada na evidência científica. Parte II: Ensaios clínicos.

The papers published by the Revista about Evidence-Based Cardiology (EBC) have, so far, discussed general aspects of the theory as well as practice of EBC, using simple terms and concepts. We need a detailed description of the general, as well as specific, concepts applicable to EBC, in order to understand better this methodology and to facilitate the reading. In this second article (the first--on general aspects--was published in the last issue of the Revista) we present a glossary of terms applicable to clinical trials and systematic reviews.

[Glossary of terms and concepts used in scientific evidence based cardiology. Part I: diagnosis, therapy, iatrogenesis, generalities]. / Glossário de termos e conceitos utilizados pela cardiologia baseada na evidência científica. Parte I: Diagnóstico, terapêutica, iatrogenia, generalidades.

The papers published by the Revista about Evidence-Based Cardiology (EBC) have, so far, discussed general aspects of the theory as well as practice of EBC, using simple terms. We need a detailed description of the general, as well as specific, concepts applicable to EBC, in order to understand this methodology better and to facilitate the reading. In this first article we present a glossary of terms applicable to general aspects of the methodology, including terms found in papers about diagnosis, treatment, risk/harm, etc. A second paper, to be published in the next issue of the Revista, will present concepts regarding clinical trials (types, methodology, etc.) and systematic reviews.

[Cardiac effects of acute poisoning with tricyclic antidepressants: systematic review of the literature -- Part IV]. / Os efeitos cardíacos da intoxicação aguda por antidepressivos tricíclicos: Revisão sistemática da literatura--Parte IV.

Tricyclic antidepressant overdose is a frequent diagnosis in the emergency room. It is responsible for a significant percentage of hospital admissions for observation and treatment. This is due to its cardiac (as well as neurologic) toxicity, and the difficulty in predicting its clinical gravity. The authors present this paper with two objectives in mind: 1) information about a common and significant cardiological emergency; 2) presentation of the methodology concerning systematic reviews of the literature. In this fourth article (the last in a series), we present the prevention and management of tricyclic antidepressant overdose (in the three previous articles--published in previous issues of the Revista--we discussed the epidemiological aspects as well as the clinical presentation and the diagnosis, and the prognosis). Note: this is the fourth and last article on the cardiac toxicity of tricyclic antidepressant overdose.

[Basic principles of selection and use of diagnostic tests: analysis of the results of diagnostic studies]. / Princípios básicos de selecção e uso de testes diagnósticos: análise dos resultados dos estudos diagnósticos.

In clinical practice, in order to design and implement a specific therapeutic plan, as well as communicating an appropriate prognosis, the doctor needs to establish a precise diagnosis of the condition. Sometimes all one needs is a clinical impression. More often, however, the definition of an accurate diagnosis will need the interpretation of specific diagnostic tests as well. The rational use of diagnostic tests in cardiology--whether laboratorial or imagiologic--should be based on three factors: 1) validity of the study results about the test; 2) diagnostic properties of the test and 3) applicability of the test in the clinical setting. The rational use and correct interpretation of diagnostic tests are based on these three factors. In this article we present the basic principles concerning the validity of the results from the study that defined the specific test, and what level of evidence that constitutes. Other articles will address diagnostic properties of tests (sensitivity, specificity, positive and negative predictive values, likelihood ratios) as well as the applicability of the test in clinical practice.

[Cardiac effects of acute poisoning with tricyclic antidepressants: systematic review of the literature -- Part III]. / Os efeitos cardíacos da intoxicação aguda por antidepressivos tricíclicos: revisão sistemática da literatura--Parte III.

Tricyclic antidepressant overdose is a frequent diagnosis in the emergency room. It is responsible for a significant percentage of hospital admissions for observation and treatment. This is due to its cardiac (as well as neurologic) toxicity, and the difficulty in predicting its clinical gravity. The authors present this paper with two objectives in mind: 1) information about a common and significant cardiological emergency; 2) presentation of the methodology concerning systematic reviews of the literature. In this third (of four) articles, the prognosis of tryciclic antidepressant overdose is presented (in the two previous articles--published in previous issues of the Revista--we discussed the epidemiological aspects as well as the clinical presentation and the diagnosis). In the remaining paper we will present its management, and prevention. Note: this is the third of a series of four articles on the cardiac toxicity of tricyclic antidepressant overdose; the final article will be presented in the October issue of the Revista.

Basic principles on selection and use of diagnostic tests: properties of diagnostic tests.

In clinical practice, in order to design and implement a specific therapeutic plan, as well as communicating an appropriate prognosis, the doctor needs to establish a precise diagnosis of the condition. Sometimes all one needs is a clinical impression. More often, however, the definition of an accurate diagnosis will mandate the interpretation of specific diagnostic tests as well. The rational use of diagnostic tests in cardiology--whether laboratorial or imaging--should be based on three factors: 1) validity of results of studies on the test; 2) diagnostic properties of the test; and 3) applicability of the test in the clinical setting. The rational use and the correct interpretation of diagnostic tests are based on these three factors. In a previous article we presented the basic principles concerning the validity of the results from the study that defined the specific test, and what level of evidence that constitutes. In this article we present the diagnostic properties of tests (sensitivity, specificity, positive and negative predictive values, likelihood ratios, odds). Finally, in a forthcoming paper we will discuss the applicability of the test in clinical cardiological practice.

[Levels of scientific evidence and grades of recommendations: methodological considerations]. / Níveis de evidência científica e graus de recomendação: considerações metodológicas.

The role of practical clinical guidelines has been increasing over the last few years, and a progressive number of them have been published in mainstream medical journals. The issue of methodological quality of the guidelines, in the context, assumes major importance. We present what is considered to be the most advanced and reliable method of guideline development, through definition of the levels of scientific evidence upon which the grades of recommendations are constructed. As an example, we present a framework of evidence on therapy, diagnosis and prognosis. Finally, the four main principles referring to the translation of the results from the original studies into clinical recommendations are presented.

[Scientific evidence-based cardiology: the principles and practice]. / A cardiologia baseada na evidência científica: princípios e prática.

Every clinical cardiologist, no matter what the clinical work (invasive or non-invasive), has to face several problems concerning clinical knowledge and medical information in everyday practice. Diagnostic and therapeutic advances in cardiology are occurring at an increasing pace and every cardiologist responsible for patient care in hospitals, clinics or emergency rooms needs to be up-to-date in order to provide the best possible medical care. On the other hand, society is increasingly making doctors accountable for the provision of good quality care in a cost-effective way. In the context of scarce resources, this situation requires a rigorous and rational approach by the individual cardiologist. These apparent contradictions can be solved by practicing evidence-based cardiology (EBC). This review introduces the concept of EBC, its principles, practice, and methodological steps: 1) formulation of a structured clinical activity; 2) scientific evidence; 3) critical appraisal of this evidence using explicit methods; and 4) synthesis and practical application of this evidence. In this sense, EBC arises from the patient, and after the best possible scientific evidence is selected, it is applied to the individual case. EBC allows the individual cardiologist to keep up with the medical literature while improving reading habits and the form in which relevant clinical information is selected. It also increases confidence in the clinical decisions, reducing practice variation as well as improving doctor-patient communication. Lastly EBC can be used as a powerful tool for pre, post and continuous medical education.

[The Cochrane Collaboration and the practice of evidence-based cardiology]. / A Cochrane Collaboration e a prática da cardiologia baseada na evidência científica.

Evidence-based Cardiology (EBC) permits a rational and updated clinical approach to patients. The EBC practice needs credible, independent and scientifically solid information, but the sheer volume of the medical bibliography precludes individual solutions: we have too much information and what is relevant is sunk within what is irrelevant or useless. Selection, critical appraisal and synthesis of the best scientific evidence constitutes the basis of EBC. The Cochrane Collaboration is the best source of independent, updated and valid information: through published systematic reviews, the evidence is available in the format of CD-ROM, and can serve as the basis for a modern, efficient and rational cardiological practice.

[Evidence based medicine. A new paradigm for medical practice]. / A medicina baseada na evidência. Um novo paradigma para a prática Médica.

Modern medical practice is an ever-changing process, and the doctor's need for information has been partially met by continuous medical education (CME) activities. It has been shown that CME activities have not prevented clinical knowledge, as well as medical practice, from deteriorating with time. When faced with the need to get the most recent and relevant information possible, the busy clinician has two major problems: most of the published medical literature is either irrelevant or not useful; and there is little time to read it. Evidence-based medicine constitutes a new paradigm for medical practice in the sense that it tries to transform clinical problems into well formulated clinical questions, selecting and critically appraising scientific evidence with predefined and rigorous rules. It combines the expertise of the individual clinician with the best external evidence from clinical research for rational, ethical and efficacious practice. Evidence-based medicine can be taught and practiced by physicians with different degrees of autonomy, with several subspecialties, working in the hospital or in outpatient clinics, alone or in groups.

[The correct formulation of clinical questions for the practice of evidence based medicine]. / A formulação de questões clínicas como passo inicial para a prática da medicina baseada na evidência.

Evidence-based medicine is the conscientious, explicit, and judicious use of the best evidence available to make decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. The good practice of EBM begins with a well formulated clinical question, meaning that it should be clear, directly relevant to the problem at hand and answerable by searching in medical literature. This paper begins by presenting the central tasks of clinical work from which clinical questions arise. The components of well formulated clinical questions are then presented. Finally, some of the steps for the correct formulation of questions are discussed.

[Risk stratification and prognosis in critical surgical patients using the Acute Physiology, Age and Chronic Health III System (APACHE III)]. / Estratificação de risco e prognóstico em doentes cirúrgicos críticos utilizando o Sistema Acute Physiology, Age and Chronic Health III (APACHE III).

INTRODUCTION: Outcome prediction in critical surgical patients admitted to intensive care units (ICU) has been established using several scoring systems. To evaluate the predictive performance of the Acute Physiology, Age and Chronic Health Evaluation (APACHE III) scoring system in these patients, we studied a population admitted to a surgical ICU in our University Hospital. METHODS: We collected prospective data on 220 consecutive patients admitted over a period of 12 months. APACHE III (A3) scores were obtained over the first 24 hours of ICU admission (APACHE II scores were also calculated); data also included age, sex, acute and chronic diseases, ICU and hospital length of stay (LOS), patient location prior to ICU admission and outcome. The relationship of hospital mortality with A3 scores was analyzed using logistic regression, with the discriminatory power of these systems being assessed by the area under the ROC curve and percentage of correct classification. RESULTS: Patient's mean age was 57 +/- 17 years and 44% were male; 53.6% were elective and 46.4% were emergency postoperative patients; 5% of patients had co-morbidities; ICU mortality rate was 10% and in-hospital mortality rate (HMR) was 15%; mean ICU LOS was 3.9 +/- 5.6 days and mean hospital LOS was 9.4 +/- 8.2 days; mean scores were: APACHE III = 33 +/- 2 and APACHE II = 9 +/- 6 points. There was a significant relationship between ascending A3 scores and HMR. APACHE III had a correct classification rate of 87.3% and an area under the ROC curve of 0.830. CONCLUSIONS: In a population of critical surgical patients admitted to our ICU the APACHE III scoring system demonstrated an excellent prognostic performance as measured by contingency tables and areas under the ROC curve; this system can be a useful tool for outcome prediction in critical surgical patients.

[Rational distribution of resources in intensive medicine. Analysis of admission and discharge criteria at intensive care units]. / Distribuição racional de recursos em medicina intensiva. Análise de critérios de admissão e alta de unidades de cuidados intensivos.

Cost-containment in health care has become a major issue in today's practice of medicine. With its needs in advanced technologies and skilled personnel, intensive care is among the most expensive of all hospital activities. This fact makes the analysis of indications for intensive care unit admission, as well as early discharge, of paramount importance: patients who are not likely to benefit from intensive care are at the extremes of disease severity, since low-risk patients are not ill enough to need ICU admission and high-risk patients have a very high mortality, irrespective of intensive care treatment. In this paper we discuss, based on published evidence, the formulation of recommendations for admission and early discharge from ICUs, and also present the Society of Critical Care Medicine guidelines, on this subject.

[Prognostic systems in intensive care: general principles, development, and clinical applications]. / Sistemas de prognóstico em cuidados intensivos: princípios gerais, desenvolvimento e aplicações clínicas.

In this review article, we present the need for prognostic scoring in clinical medicine, specially in Intensive Care Medicine (ICM). The general principles of prognostication in ICM are discussed, and three general scoring systems are presented: ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) in its 3 versions, SIMPLIFIED ACUTE PHYSIOLOGY SCORE (SAPS) and MORTALITY PREDICTION MODEL (MPM). The use of these prognostic systems is then evaluated not only as a support for medical decision-making, and resource allocation, but also as a tool for clinical studies in terms of patient randomization. Finally, the future developments and clinical application of these risk stratification systems are presented and discussed.

Herpes zoster and controlateral hemiplegia in an African patient infected with HIV-1.

One of the neurologic complications of human immunodeficiency virus infection are cerebrovascular accidents. In HIV infected patients, ischemic strokes have been reported secondary to nonbacterial thrombotic endocarditis and cerebral arteritis. We describe an unusual cause of stroke in HIV-1 infection: Herpes Zoster ophtalmicus with contralateral hemiplegia.

PIP: A rare case of ischemic stroke related to Herpes zoster infection of the eye and documented arteritis in an HIV-positive patient is analyzed. The woman, aged 32, who was born in Angola and lived in Zaire, was diagnoses at the Hospital Universitario de Santa Maria, Lisbon. She presented with a 5-month history of sudden hemiplegia, 4 months after onset of herpes zoster ophthalmicus. Among extensive diagnosis tests, she was positive for HIV by ELISA and Western blot, hepatomegaly, and generalized lymphadenopathy. She has left Herpes zoster ophthalmicus with ptosis bulbi and mottled discoloration of the skin over the distribution of the 1st division of the left trigeminal nerve, and right spastic hemiparesis. Her helper T-cell count was 952/cubic mm, and her T-cell ratio was 0.9. She had anemia, hypoalbuminemia, positive serology for cytomegalovirus, Herpes simplex, Epstein Barr virus, and hepatitis B. She had no bacterial infections, but her stool contained Trichuris trichiura eggs and giardia lamblia cysts. Her cardiovascular system and cerebrovascular fluid were negative. Computed tomography of the head showed an old left capsular infarct. Cerebral angiography showed arteritis of the left choroidal artery with occlusion. She was treated with metronidazole and mebendazole, and had surgery for removal of the left eye with a prosthetic replacement. Strokes are common in AIDS patients, resulting from fungal infections, endocarditis, infectious or non-infectious emboli, or arteritis from herpes zoster infections. This is the 1st published case of hemiplegia and Herpes zoster in a European or African patient with HIV-1.

Normal diet NaCl variation can affect the renal set-point for plasma pH-(HCO3-) maintenance.

In humans who are ingesting abundant NaCl, blood pH (pHb) and plasma bicarbonate concentration [HCO3-)p) change little or imperceptibly in response to the ingestion of alkali salts. We tested the hypothesis that such tight homeostatic regulation is an artifact of eating a culturally imposed NaCl-enriched diet, not a fundamental physiological trait of humans. In five normal men ingesting a constant acid-producing diet with a low intrinsic NaCl content (0.15 mEq/kg of body weight per day), we measured plasma and urine acid-base composition during four 7-day periods in which the diet was supplemented as follows: no supplements----NaHCO3 only----NaHCO3 plus NaCl----NaCl only. Each sodium supplement was 2.0 mmol/kg body weight per day. With no supplements, pHb was 7.43 +/- 0.005 and (HCO3-)p was 25.0 +/- 0.4 mEq/L. When NaHCO3 only was added, pHb rose 0.02 (to 7.45 +/- 0.004; P less than 0.01) and (HCO3-)p rose nearly 4 mEq/L (to 28.9 +/- 0.6 mEq/L, P less than 0.001). The rise in (HCO3-)p was sustained predominantly by an increased rate of renal bicarbonate reabsorption. When NaCl was added, (HCO3-)p returned to the earlier level, despite continued NaHCO3 supplementation (24.9 +/- 0.6 mEq/L), and remained there when NaHCO3 supplementation was subsequently stopped (24.1 +/- 0.5 mEq/L). Thus, tight homeostatic regulation of plasma acid-base composition in response to a change in dietary base occurred only when dietary NaCl was abundant. To our knowledge, this is the first study in normal humans that demonstrates that diet NaCl variations within the normal range significantly influence plasma acid-base composition.(ABSTRACT TRUNCATED AT 250 WORDS)