Delay from fracture to hospital admission: a new risk factor for hip fracture mortality?

UNLABELLED: The relationship between surgical timing and hip fracture mortality is unknown in the context of developing countries where large delays to surgery are common. We observed that delay from fracture to hospital admission is associated with decreased survival after a hip fracture. INTRODUCTION: To examine the relationship between the time interval from fracture to surgery as well as its subcomponents (time from fracture to hospital admission and time from admission to surgery) and hip fracture survival. METHODS: The medical records of all patients aged 60 years and older admitted to a public university hospital in the city of Rio de Janeiro with a primary diagnosis of hip fracture between 1995 and 2000 were reviewed. Survival to hospital discharge and at 1 year were examined. RESULTS: Among 343 patients included in the study, there were 18 (5.3%) in-hospital deaths, and 297 (86.6%) patients remained alive 1 year after surgery. Very long delays from the time of fracture to hospital admission (mean 3 days) and from hospital admission to surgery (mean 13 days) were identified. Increased time from fracture to hospital admission was associated with reduced survival to hospital discharge (hazard ratio [HR] 1.09, 95% CI 1.03-1.15, p = 0.005) and reduced survival at 1 year after surgery (HR 1.07, 95% CI 1.03-1.10, p < 0.001). The interval of time from hospital admission to surgery was not associated with reduced survival to hospital discharge (HR 1.03, 95% CI 0.96-1.10, p = 0.379) or at 1 year after surgery (HR 1.03, 95% CI 0.99-1.07, p= 0.185). CONCLUSIONS: If the association estimated in our study is causal, our results provide evidence that some hip fracture-related deaths could be prevented by improved patient access to appropriate and timely hospital care in the context of a developing country.

Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality?

UNLABELLED: This study aims to analyze whether the interval from hospital admission to surgery may be used as a surrogate of the actual gap from fracture to surgery when investigating in-hospital hip fracture mortality. After analyzing 3,754 hip fracture admissions, we concluded that those intervals might be used interchangeably without misinterpretation bias. INTRODUCTION: The debate regarding the influence of time to surgery in hip fracture (HF) mortality is one of the most controversial issues in the HF medical literature. Most previous investigations actually analyzed the time from hospital admission to surgery as a surrogate of the less easily available gap from fracture to surgery. Notwithstanding, the assumption of equivalency between those intervals remains untested. METHODS: We analyzed 3,754 hospital admissions of elderly patients due to HF in Quebec, Canada. We compared the performance as predictors of in-hospital mortality of the delay from admission to surgery and the actual gap from fracture to surgery using univariate and multiple logistic regression analysis. RESULTS: The mean times from fracture to surgery and from admission to surgery were 1.84 and 1.02 days (P < 0.001), respectively. On univariate logistic regression, both times were slightly significant as mortality predictors, yielding similar odds ratios of 1.08 (P < 0.001) for time from fracture to surgery and 1.11 (P < 0.001) for time from admission to surgery. After accounting for other covariates, neither times remained significant mortality predictors. CONCLUSION: The gap from admission to surgery may be used as a surrogate of the actual delay from fracture to surgery when studying in-hospital HF mortality.

Non-malignant consequences of decreasing asbestos exposure in the Brazil chrysotile mines and mills.

AIMS: To investigate the consequences of improvement in the workplace environment over six decades (1940-96) in asbestos miners and millers from a developing country (Brazil). METHODS: A total of 3634 Brazilian workers with at least one year of exposure completed a respiratory symptoms questionnaire, chest radiography, and a spirometric evaluation. The study population was separated into three groups whose working conditions improved over time: group I (1940-66, n = 180), group II (1967-76, n = 1317), and group III (1977-96, n = 2137). RESULTS: Respiratory symptoms were significantly related to spirometric abnormalities, smoking, and latency time. Breathlessness, in particular, was also associated with age, pleural abnormality and increased cumulative exposure to asbestos fibres. The odds ratios (OR) for parenchymal and/or non-malignant pleural disease were significantly lower in groups II and III compared to group I subjects (0.29 (0.12-0.69) and 0.19 (0.08-0.45), respectively), independent of age and smoking status. Similar results were found when groups were compared at equivalent latency times (groups I v II: 30-45 years; groups II v III: 20-25 years). Ageing, dyspnoea, past and current smoking, and radiographic abnormalities were associated with ventilatory impairment. Lower spirometric values were found in groups I and II compared to group III: lung function values were also lower in higher quartiles of latency and of cumulative exposure in these subjects. CONCLUSIONS: Progressive improvement in occupational hygiene in a developing country is likely to reduce the risk of non-malignant consequences of dust inhalation in asbestos miners and millers.

Kinetics of TNF-alpha and IFN-gamma mRNA expression in islets and spleen of NOD mice.

Insulin-dependent diabetes mellitus is caused by autoimmune destruction of pancreatic beta cells. Non-obese diabetic (NOD) mice spontaneously develop diabetes similar to the human disease. Cytokines produced by islet-infiltrating mononuclear cells may be directly cytotoxic and can be involved in islet destruction coordinated by CD4+ and CD8+ cells. We utilized a semiquantitative RT-PCR assay to analyze in vitro the mRNA expression of TNF-alpha and IFN-gamma cytokine genes in isolated islets (N = 100) and spleen cells (5 x 10(5) cells) from female NOD mice during the development of diabetes and from female CBA-j mice as a related control strain that does not develop diabetes. Cytokine mRNAs were measured at 2, 4, 8, 14 and 28 weeks of age from the onset of insulitis to the development of overt diabetes. An increase in IFN-gamma expression in islets was observed for females aged 28 weeks (149 +/- 29 arbitrary units (AU), P<0.05, Student t-test) with advanced destructive insulitis when compared with CBA-j mice, while TNF-alpha was expressed in both NOD and CBA-j female islets at the same level at all ages studied. In contrast, TNF-alpha in spleen was expressed at higher levels in NOD females at 14 weeks (99 +/- 8 AU, P<0.05) and 28 weeks (144 +/- 17 AU, P<0.05) of age when compared to CBA-j mice. The data suggest that IFN-gamma and TNF-alpha expression in pancreatic islets of female NOD mice is associated with beta cell destruction and overt diabetes.

Kinetics of TNF-alpha and IFN-gamma mRNA expression in islets and spleen of NOD mice

Insulin-dependent diabetes mellitus is caused by autoimmune destruction of pancreatic ß cells. Non-obese diabetic (NOD) mice spontaneously develop diabetes similar to the human disease. Cytokines produced by islet-infiltrating mononuclear cells may be directly cytotoxic and can be involved in islet destruction coordinated by CD4+ and CD8+ cells. We utilized a semiquantitative RT-PCR assay to analyze in vitro the mRNA expression of TNF-alpha and IFN-gamma cytokine genes in isolated islets (N = 100) and spleen cells (5 x 10(5) cells) from female NOD mice during the development of diabetes and from female CBA-j mice as a related control strain that does not develop diabetes. Cytokine mRNAs were measured at 2, 4, 8, 14 and 28 weeks of age from the onset of insulitis to the development of overt diabetes. An increase in IFN-gamma expression in islets was observed for females aged 28 weeks (149 ± 29 arbitrary units (AU), P<0.05, Student t-test) with advanced destructive insulitis when compared with CBA-j mice, while TNF-alpha was expressed in both NOD and CBA-j female islets at the same level at all ages studied. In contrast, TNF-alpha in spleen was expressed at higher levels in NOD females at 14 weeks (99 ± 8 AU, P<0.05) and 28 weeks (144 ± 17 AU, P<0.05) of age when compared to CBA-j mice. The data suggest that IFN-gamma and TNF-alpha expression in pancreatic islets of female NOD mice is associated with ß cell destruction and overt diabetes

Are routine preoperative medical tests needed with cataract surgery?

OBJECTIVE: The objective of this study was to investigate whether routine medical testing before cataract surgery reduces the rate of complications during the perioperative period in adults. METHODS: The study was carried out in an academic medical center in Brazil, between 10 February 2000 and 10 January 2001. The scheduled cataract operations were randomly assigned to one of two groups: 1) to be preceded by routine testing (the "routine-testing group") or 2) not to be preceded by routine medical testing (the "selective-testing group"). If the patient was assigned to the selective-testing group, it was requested that no preoperative testing be performed unless the patient presented with a new or worsening medical problem that would warrant medical evaluation with testing. In the case of patients assigned to the routine-testing group, three tests were requested: a 12-lead electrocardiogram, a complete blood count, and measurements of serum glucose. RESULTS: The sample of 1,025 patients scheduled to undergo cataract surgery was comprised of 512 assigned to the routine-testing group and of 513 assigned to the selective-testing group. The two groups had similar proportions of operations canceled and not subsequently rescheduled, 2% in each group. The cumulative rate of medical events was similar in the two groups, 9.6% in the routine-testing group and 9.7% in the selective-testing group (P = 0.923). The types of medical events were also similar in both groups. DISCUSSION: The results of this study suggest that routine medical testing before cataract surgery does not reduce the rate of complications during the perioperative period. The results also suggest it would be more efficient not to request routine preoperative tests unless indicated by patient history or physical examination.

[Treatment abandonment and tuberculosis recurrence: aspects of previous episodes, Brazil, 1993-1994]. / Abandono de tratamento e recidiva da tuberculose: aspectos de episódios prévios, Campinas, SP, Brasil, 1993-1994.

OBJECTIVE: Recurrent patients due to treatment dropout or disease relapse have been congesting health centers and impeding treatment routines and services. The purpose is to study aspects of previous treatment and irregularities concerning the patient, medication and service organization and to evaluate the outcome of retreatment. METHODS: A descriptive study of patient's personal characteristics, previous treatment and retreatment was carried out at Campinas, São Paulo State, in 1993 and 1994. Statistics analyses were performed using 95% confidence interval with Yates correction, exact Fisher test and Mantel Haenszel qui-square for stratification. RESULTS: Retreatment sequence corroborated with the default rates (63%) that were lower, but still high among relapsed cases (28.4%). Only 34.1% of relapsed cases did not present irregularities at previous treatment. CONCLUSIONS: High proportions of retreatment and inadequate previous treatment are favouring drug resistance. Efforts should be taken to improving tuberculosis services efficiency because many irregularities are due to "failures" in health services routine.

Preventing acute respiratory infections and diarrhoea in child care centres.

This study was designed to explore the physical characteristics and child care practices of child care centres as potential risk factors for respiratory infections and diarrhoea in children 3-35 mo of age. A dynamic cohort averaging 667 children from 40 child care centres in Campinas (Brazil) was followed up for 8 mo. Direct structured observations were made to collect information on the centres' physical structure, child activities and child care practices. Despite their good infrastructures, hand washing in the centres was infrequent, and nearly 30% of diaper changes were unhygienic. Risk factors for diarrhoea included the presence of flies during meals, infrequent child hand washing before meals, and infrequent child hand washing after defecation, with relative risks of 1.33, 1.73 and 1.63, respectively. There was 33% less diarrhoea in classes where soap was frequently used during diapering. Contrary to our hypotheses, ventilation, group size and child density were not associated with respiratory infections, as was the case for most other factors studied. Only mixing of groups and a larger classroom area were found to be negatively associated with lower and upper respiratory infections, respectively. The results indicate that improving hygiene practices is the only intervention in child care centre characteristics with good potential to reduce diarrhoea among attendees. For respiratory infections, no modifiable characteristic with intervention potential was identified.

Public awareness and attitudes toward epilepsy in different social segments in Brazil.

PURPOSE: To assess public awareness and attitudes toward epilepsy in Brazilians of different cultural and socioeconomic backgrounds. BACKGROUND: Several studies have examined public awareness and attitudes toward epilepsy in various countries but there are no equivalent data for Brazil or South America. MATERIAL AND METHODS: We have applied the survey proposed by Caveness and Gallup, with some modifications and adaptations to four groups (I-IV) of subjects: I--105 individuals accompanying patients to the Ophthalmologic outpatient clinic of the Hospital das Clínicas of the State University of Campinas (UNICAMP); II--93 students recently admitted to medical and nursing school; III--101 senior non-medical students; and IV--69 senior medical students. Group II, III, and IV were students at UNICAMP. RESULTS: Individuals with a low socioeconomic standing had a poor profile of familiarity, knowledge and attitudes toward epilepsy. The pre-university and university students had a relatively good profile when compared to the published international polls. Senior medical students had an excellent level of familiarity and knowledge, but showed no change in their objection to having a son or a daughter marry an epileptic person. CONCLUSIONS: Our data suggest that there is a clear-cut relationship between the level of education and the individual's familiarity and attitudes toward epilepsy. Effective elimination of the prejudice toward epilepsy requires specific training and not just general, superficial information about the condition.

Characteristics of a pediatric low-vision population.

BACKGROUND: Assessment of the causes of childhood blindness is important to develop preventive and therapeutic strategies that can reduce the incidence of visual impairment. METHODS: A retrospective survey of the clinical records of 395 consecutive children younger than 14 years of age who were attended by the Low Vision Service of State University of Campinas (UNICAMP) was conducted. Data on the age distribution, the causes of low vision, the types of low vision aids prescribed, the follow up of their use, and improvement in visual acuity were obtained. RESULTS: Congenital bilateral toxoplasmic macular scars, optic atrophy, and congenital cataracts were the major causes of low vision in this population. The optical aid most frequently prescribed was a telescope. The improvement of visual acuity with the use of aids was highly significant.

[Back pain and nursing]. / Dores nas costas e enfermagem.

After a clinic specific evaluation performed by a interdisciplinary group, 68 female workers of the nursing staff from a University Hospital were interviewed to evaluate aspects of the back pain in nursing staff.

[Diastolic blood pressure associated with accumulated work time among drivers and collectors]. / Associação da pressão arterial diastólica com o tempo acumulado de trabalho entre motoristas e cobradores.

The relationship between diastolic blood pressure and the variables "total cumulative working time" and "age" was examined by regression analysis. The study was carried out among 839 bus drivers and conductors, users of an occupational health center in Campinas, S. Paulo State, Brazil. The main results were a positive association between diastolic blood pressure and cumulative working time, as well as an interaction between this variable and the bus worker's age.

[Occupation and hypertension]. / Ocupação e hipertensão.

Scientific reports on Arterial Blood Hypertension for the period from 1970 to 1989 are reviewed, with special reference to its epidemiological focusing among workers. The knowledge gained and the theoretical and methodological advances associated with it are assessed.

Biological monitoring of workers occupationally exposed to carbon disulphide in a rayon plant in Brazil: validity of 2-thiothiazolidine-4-carboxylic acid (TTCA) in urine samples taken in different times, during and after the real exposure period.

Fifteen workers from a rayon plant in Brazil were monitored. Air samples were taken during a mean period of 5.8 hours out of an 8 hour workshift, in three different adsorbing tubes. Five urine samples were taken at 4 hour interval from the beginning of the shift, and at the beginning of the next shift in which 2-thiothiazolidine-4-carboxylic acid (TTCA) concentration was analysed. Data from seventeen "individuals" were statistically studied, with the aim of establishing the best and the most practical sampling strategy of biological monitoring for workers occupationally exposed to CS2. For those chronically exposed to CS2, TWA air concentration lower than 30 and higher than 10 mg/m3, it was found that the higher the exposure levels, the lower was TTCA concentration in the end of shift urine samples. The results may be explained by dietary habits and/or by the small number of examined population or even eventual casualty. On the other hand they raise other hypothesis involving the chronicity of exposure which may lead to important changes in metabolism influencing the excretion rate of TTCA.

Contribuiçäo ao estudo epidemiológico das ginecopatias prevalentes no atendimento primário de saúde / Epidemiologic study of gynecological diseases prevalent at the primary health care

Os autores pretendem mostrar a alta prevalência de doenças sem manifestaçöes clínicas aparentes, através de um levantamento feito com 2.200 mulheres de níveis sócio-culturais diferentes e idades entre 15 e 58 anos, a partir de exames clínico-ginecológicos realizados em dois ambulatórios da UNICAMP. O estudo deixa evidente que, do total de pacientes que procuram, por motivos ginecológicos ou näo, a atençäo primária nestes ambulatórios onde foi detectado algum tipo de afecçäo genito-urinária, perto da metade näo apresentou qualquer queixa clínica que pudesse sugerir a existência do problema. Destacam também a influencia do nível sócio-cultural das pacientes no grau de percepçäo dessas doenças e enfatizam a importância da atençäo primária reorganizada de forma mais eficiente com a melhor maneira de solucionar o problema