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This review describes the germ cell neoplasms that are malignant and most commonly associated with several types of gonadal dysgenesis. The most common neoplasm is gonadoblastoma, while others including dysgerminomas, yolk-sac tumors and teratomas are rare but can occur. The purpose of this review is to evaluate the incidences of these abnormalities and the circumstances surrounding these specific tumors. According to well-established methods, a PubMed systematic review was performed, to obtain relevant studies published in English and select those with the highest-quality data. Initially, the first search was performed using gonadal dysgenesis as the search term, resulting in 12,887 PubMed papers, published, from 1945 to 2017. A second search using ovarian germ cell tumors as the search term resulted in 10,473 papers, published from 1960 to 2017. Another search was performed in Medline, using germ cell neoplasia as the search term, and this search resulted in 7,560 papers that were published between 2003 to 2016, with 245 new papers assessing gonadoblastomas. The higher incidence of germ cell tumors in gonadal dysgenesis is associated with a chromosomal anomaly that leads to the absence of germ cells in these gonads and, consequently, a higher incidence of neoplasms when these tumors are located inside the abdomen. Several hypotheses suggest that increased incidence of germ cell tumors involves all or part of the Y chromosome or different genes.

In this September 2009 issue of Clinics we highlight a study by Meneghini et al. on the effect of Memantine, a N-methyl-d-aspartate (NMDA) glutamate receptor antagonist used to treat Alzheimer’s disease on cardiomyocites. They found that the reduction of nuclear size of rats exposed to a cold stress is effectively prevented by simultaneous treatment with memantine. We publish nine papers on Clinical Science and three other reports on non clinical research. Bueno et al. evaluated the reasons for resubmitting research projects to the Research Ethics Committee of a University Hospital in Sao Paulo Brazil, and found that the main reasons for returning the projects to the researchers were the use of inadequate language and/or difficulty understanding the informed consent form, lack of information about the protocol in the informed consent form, as well as doubts regarding methodological and statistical issues of the protocol. Otherreasons involved lack of accuracy or incomplete documentation, need of clarification, approval for participation of external entities, and lack of information on financial support. Bittencourt et al. evaluated HFE and non-HFE gene mutations in Brazilian patients with hereditary hemochromatosis and found that one-third of Brazilian subjects with the classical phenotype of HH do not carry HFE or other mutations that are currently associated with the disease in Caucasians. This observation suggests a role for other yet unknown mutations in the aforementioned genes or in other genes involved in iron homeostasis in the pathogenesis of hereditary hemochromatosis in Brazil. Kamulegeya et al. investigated the epidemiological characteristics of maxillofacial fractures and associated fractures in 132 patients seen in the Oral Surgery Unit of Mulago Hospital, Kampala, Uganda through a six-month prospective study, which included socio-demographic factors, type and etiology of injury, additional fractures, and post-surgery complications and recommend that anticipated changes in maxillofacial trauma trends necessitate regular epidemiologic studies of facial fractures to allow for development and implementation of timely novel preventive measures. Brandao et al. followed 53 patients with medullar thyroid carcinoma, a neoplasia of intermediate prognosis and differentiation, which does not always respond predictably to known treatments. They found that clinical and pathological aspects of surgically treated patients are predictors of disease progression. Specifically, even treated cervical lymph node metastases are significantly correlated with disease progression. Carvalho et al. evaluated crack cocaine use practices, risk behaviors associated with HIV infection among drug users, and their involvement with violence in 350 drug users attending drug abuse treatment clinics in Sao Paulo, Brazil. A high HIV prevalence and associated risky sexual behaviors were observed among crack cocaine users. The society and the authorities that deal with violence related to crack users and drug trafficking should be aware of these problems. Campos et al. endeavored to identify factors associated with increased levels of self-reported quality of life among HIV-infected patients after four months of antiretroviral therapy. Patients were recruited at two public health referral centers for AIDS in the city of Belo Horizonte, Brazil, for a prospective adherence study. Authors highlight the importance of modifiable factors such as psychiatric symptoms and treatment-related variables that may contribute to a better quality of life among patients initiating treatment. Considering that poor quality of life is related to non-adherence to antiretroviral therapy, careful clinical monitoring of these factors may contribute to ensuring the long-term effectiveness of antiretroviral regimens. Meyer et al. evaluated, by means of the Inflammatory Bowel Disease Questionnaire the quality of life of 36 ulcerative colitis patients submitted to proctocolectomy with sphincter preservation using J-pouch reconstruction over ten years ago. They concluded that the possibility of sphincter preservation should always be taken into account, since patients remain clinically stable and have a high quality of life even after long periods. Miot et al. estimated oculometric parameters of 15 cases of Graves’ ophthalmopathy in comparison to 12 healthy eyes using digital photography and digital image analysis. This comparative analysis suggests that eye proptosis is related to an asymmetric increase in lateral oculometric measures, and that standardized digital photographs can be used in clinical practice to objectively estimate oculometric parameters of Graves’ ophthalmopathy patients. Vaz et al. sought to identify the participation of the coagulation system in the differential diagnosis of pleural effusions through the laboratory profile of coagulation and fibrinolysis in 54 pleural fluids (15 transudates and 39 exudates). The coagulation system was found to play an important role in the development of pleural diseases. Coagulation tests show differences between transudates and exudates but not among exudate subgroups. Understanding the pathophysiological mechanisms of pleural disorders may help to define new diagnostic and therapeutic approaches. Pai et al. studied 98 pelvic halves of embalmed cadavers, in which the origin and course of the obturator artery were traced and noted. The data obtained in this study show that it is more common to find an abnormal obturator artery than was reported previously, and this observation has implications for pelvic surgeons and is of academic interest to anatomists. Surgeons dealing with direct, indirect, femoral, or obturator hernias need to be aware of these variations and their close proximity to the femoral ring. Cardoso et al. identified the scientific production of tenured faculty from the Universidade de Sao Paulo, Faculdade de Medicina performed from 2001 to 2006, and that it is possible to analyze this by the number of papers published by full professors, taking into account not only their academic position and influence, but also the fact that publication is an opportunity to stimulate joint projects with other members of the same institution. Zanoni et al. investigated mesenteric microcirculatory dysfunctions, bacterial translocation phenomenon, and hemodynamic/metabolic disturbances in a rat model of intestinal obstruction and ischemia. They found that Intestinal obstruction and ischemia in rats is a relevant model for the in vivo study of mesenteric microcirculatory dysfunction and the occurrence of bacterial translocation. This model parallels the events implicated in multiple organ dysfunction (MOD) and death. We also publish 3 case reports

This issue of Clinics closes our fourth year of existence and the first in which our impact factor will be formally calculated by the Journal of Citation Reports of ISI Web of Knowledge. During this year we have experienced a 40% increase in the total of submitted papers, with a 400% increase in submissions from outside Brazil, to an all time high approximating 60 out of 400 papers. We have also increased the total number of published papers from 91 (in 2007) to 111, 10 of which were review articles. We shall be starting the year of 2009 by becoming a monthly journal. In this issue we publish 18 original research articles and two review articles. We highlight an article by Costa et al, who evaluated the effects of obesity on the pulmonary function, comparing inspiratory and expiratory reserve volumes, as well as maximal voluntary ventilation of 20 obese (BMI > 35 kg/m2) vs. 20 non-obese women. All were sedentary non-smokers aged 20–35. Results clearly show that although obese women have greater inspiratory reserve, they have smaller expiratory reserve and lower maximal voluntary respiration. This indicates damage to the chest mechanics caused by obesity. Carvalho et al. investigated the relationship between heart rate reserve and oxygen uptake reserve in heart failure patients on optimized and non-optimized beta-blocker therapy. They find that the relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve is reliable in patients on optimized beta-blocker therapy, but unreliable in non-optimized heart failure patients. Colombo et al. report the outcomes of laparoscopic partial cystectomy performed in 6 cases at 3 institutions; 3 cases of urachal adenocarcinoma and 3 cases of bladder transitional cell carcinoma and conclude that in selected cases this procedure is feasible and safe, offering a promising and minimally invasive therapeutic alternative. Conforto et al. investigated changes in excitability of the unaffected hemisphere in chronic stroke patients after somatosensory stimulation of the paretic hand. They find that somatosensory stimulation did not influence excitability as measured by motor threshold, short-interval intracortical inhibition or intracortical facilitation. Thy also find that better motor function was correlated with deeper short-interval intracortical inhibition. Vieira analyzed a Portuguese translation of the postgraduate hospital educational environment measure (PHEEM) questionnaire as a measure of quality of instruction and as a key factor predicting academic achievement, by administering it to 306 medical residents. The conclusion is that the teaching section, or quality of instruction is the best indicator of academic achievement. Moure et al. reviewed the histopathologic diagnoses of 38 cases of primary cicatricial alopecias, sub-typed them into different primary cicatricial alopecias: chronic cutaneous lupus (17), lichen planus pilaris (4), pseudopelade of Brocq (12), folliculitis decalvans (3), dissecting folliculitis (1), and non-specific scarring alopecia (1). They conclude that this approach using systematic criteria allowed for a more accurate diagnosis. Ciolac et al. applied acute aerobic exercises to 50 hypertensive patients monitored for 24h with respect to ambulatory (A) blood pressure after an aerobic exercise session (post-exercise) and a control period (control), in random order. They find that a single bout of aerobic exercise reduced 24h ambulatory blood pressure levels in long-term-treated hypertensive patients and increased the percentage of patients reaching normal ambulatory blood pressure values. They suggest that aerobic exercise may have a potential role in blood pressure management of long-term-treated hypertensive. Kato et al. estimated pretreatment prostate tumor volume based on total serum PSA and define a simple method that allows for estimation of tumor volume before treatment, which can help to establish a better therapeutic strategy for each patient. Cunha et al. experimentally compared conventional static stretching and muscle chain stretching, as proposed by the global posture reeducation method in patients with chronic neck pain. Conventional stretching and muscle chain stretching were equally effective in reducing pain and improving the range of motion and quality of life of 33 female patients with chronic neck pain, both immediately after treatment and after a six-week follow-up period. Munia et al. compared the results of two levels of video-assisted thoracoscopic sympathectomy (T3–T4 vs. T4) for treating axillary sudoresis at the initial and at six and twelve month follow-ups. They conclude that both techniques were effective for treating axillary hyperhidrosis, but that the T4 group showed milder compensatory hyperhidrosis and greater patient satisfaction at the one-year follow-up. Valadares et al. analyzed the prevalence of sexual dysfunction and its associated factors in 315 Brazilian-born women aged 40–65 years, with 11 years or more of formal education, through a cross sectional population based study. They find that sexual dysfunction was positively associated with aging and hot flashes. They also find that having a sexual partner and feeling well were factors associated with lower sexual dysfunction scores. Martinelli et al. evaluate the quality of life and its association with cardiovascular risk factors in a Community Health Care Program population in a study which included 332 individuals that had attended a specific community event on health care education. They conclude that quality of life was decreased in the presence of cardiovascular risk factors, such as diabetes mellitus, dyslipidemia, and obesity. Conversely, male gender and regular physical activity had protective effects on quality of life. Andrade-Alegre et al. review open thoracotomy and decortication for chronic empyema as performed in 85 patients and note that these patients were operated with no mortality, 9% morbidity, no recurrence of empyema and excellent functional results. They suggest that the validation of other surgical approaches should be based on comparative, prospective, and controlled studies. Branco et al. compare hand-assisted and pure laparoscopic techniques in live donor nephrectomy and observed that the latter technique has some advantages in terms of the warm ischemia time, time to first oral intake, length of hospital stay, and post-operative donor complications. Galia et al. evaluated the biocompatibility of lyophilized bovine bone manufactured according to a novel preparation process. The following assessments were performed in vitro cytotoxicity, in vivo acute systemic toxicity, in vivo oral irritation potential, in vitro pyrogenic reaction, and bioburden, yelding an end-product with excellent biocompatibility. They conclude that the protocol changes established by them to prepare lyophilized bovine cancellous bone at a semi-industrial scale is reproducible and yielded a product with excellent biocompatibility. Habib et al. evaluated the effect of ginger extract on the expression of NFκB and TNF-α in liver cancer-induced male Wistar rats and conclude that it significantly reduced the elevated expression of NFκB and TNF-α in rats with liver cancer. They suggest that ginger may act as an anti-cancer and anti-inflammatory agent by inactivating NFκB through the suppression of the pro-inflammatory TNF-α. Potu et al. examined the efficacy of maternally administered petroleum ether extract of the Cissus quadrangularis plant on the development of long bones during the intra-uterine development in rats using alizarin red S, alcian blue staining and morphometric analysis by Scion image software, and showed an osteostimulant role of the above plant. Madhyastha et al. compared vitamin A and leucovorin for the prevention of methotrexate-induced micronuclei production in rat bone marrow through micro nuclei assay of rat bone marrow erythrocytes because it is a predictive assay for chromosomal aberrations, genetic diseases, and carcinogenesis. They conclude that both vitamin A and leucovorin provided significant protection against genetic damage induced by methotrexate and that leucovorin did not differ from vitamin A in its ability to prevent methotrexate-induced micronuclei formation. Reis and Laranjeira provide an interesting narrative review of the concepts, history, functions, methods, development, and theoretical bases for the use of halfway houses for alcohol dependents, from theoretical bases to the implications for the organization of facilities. Azoubel et al. provide a review of 30 clinical studies on the use of hyperosmotic-hyperoncotic solutions during surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions. We also publish three case reports.

Since the outbreak of severe acute respiratory coronavirus 2 (SARS-CoV-2), the coronavirus disease 2019 has had a wide range of effects on human health. This paper summarizes the data related to the effects of the SARS-CoV-2 infection on human reproduction. Both the male and female reproductive tract express high levels of receptors and proteins needed for viral cell entry. There is presently no evidence that gametes are affected by the infection. Male fertility may be temporarily reduced due to inflammatory responses following infection. The endometrium is highly susceptible to SARS-CoV-2 cell entry; however, it remains unclear whether this could alter receptivity and embryo implantation. Menstrual cycle changes were reported in women who experienced severe infection; however, they tended to be reversible. For couples undergoing assisted reproduction treatment, the pandemic led to a significant psychological burden, with changes in lifestyle that could directly affect the success of the treatment. Human reproduction societies recommend screening all patients prior to cycle initiation and avoiding treatment of women with severe comorbidities until the pandemic is under control. Finally, for pregnant women, it is expected that the infection is more severe in women in the third trimester and in those with comorbidities. Those who are symptomatic for SARS-CoV-2 are more likely to have increased rates of prematurity and intrapartum fetal distress than those who are asymptomatic. Vertical transmission cannot be completely ruled out, but neonatal infection rates are low. Vaccination appears to be safe and is indicated for use in pregnant and lactating women because the benefits outweigh the risks.

Although the diagnosis of Graves' orbitopathy is primarily made clinically based on laboratory tests indicative of thyroid dysfunction and autoimmunity, imaging studies, such as computed tomography, magnetic resonance imaging, ultrasound and color Doppler imaging, play an important role both in the diagnosis and follow-up after clinical or surgical treatment of the disease. Imaging studies can be used to evaluate morphological abnormalities of the orbital structures during the diagnostic workup when a differential diagnosis versus other orbital diseases is needed. Imaging may also be useful to distinguish the inflammatory early stage from the inactive stage of the disease. Finally, imaging studies can be of great help in identifying patients prone to develop dysthyroid optic neuropathy and therefore enabling the timely diagnosis and treatment of the condition, avoiding permanent visual loss. In this paper, we review the imaging modalities that aid in the diagnosis and management of Graves' orbitopathy, with special emphasis on the diagnosis of optic nerve dysfunction in this condition.

Recent original scientific contributions published in selected Brazilian periodicals and classifiable under cardiovascular and pulmonary subject categories cover a wide range of sub specialties, both clinical and exprimental. Because they appear in journals with only recently enhanced visibility, we have decided to highlight a number of specific items appeared in four Brazilian journals, because we understand that this is an important subsidy to keep our readership adequately informed. These papers cover extensive sub-areas in both fields.

OBJECTIVES: Liver regeneration is a complex process that has not been completely elucidated. The model most frequently used to study this phenomenon is 70% hepatectomy in adult rats; however, no papers have examined this effect in developing animals. The aims of the present study were: 1) to standardize two models of partial hepatectomy and liver regeneration in newborn suckling and weaning rats, and 2) to study the evolution of remnant liver weight and histological changes of hepatic parenchyma on the days that follow partial hepatectomy. METHODS: Fifty newborn and forty-four weaning rats underwent 70% hepatectomy. After a midline incision, compression on both sides of the upper abdomen was performed to exteriorize the right medial, left medial and left lateral hepatic lobes, which were tied inferiorly and resected en bloc. The animals were sacrificed on days 0 (just after hepatectomy), 1, 2, 3, 4 and 7 after the operation. Body and liver weight were determined, and hepatic parenchyma was submitted to histological analysis. RESULTS: Mortality rates of the newborn and weaning groups were 30% and 0%, respectively. There was a significant decrease in liver mass soon after partial hepatectomy, which completely recovered on the seventh day in both groups. Newborn rat regenerating liver showed marked steatosis on the second day. In the weaning rat liver, mitotic figures were observed earlier, and their amount was greater than in the newborn. CONCLUSIONS: Suckling and weaning rat models of partial hepatectomy are feasible and can be used for studies of liver regeneration. Although similar, the process of hepatic regeneration in developing animals is different from adults.OBJETIVOS: A regeneração hepática é um processo complexo não completamente elucidado. O modelo mais utilizado para o estudo desse fenômeno é a hepatectomia a 70% em ratos adultos. Não há trabalhos utilizando modelos em animais em crescimento. Desta forma, os objetivos deste estudo foram: 1. padronizar dois modelos de hepatectomia parcial e regeneração hepática utilizando ratos recém-nascidos e recém-desmamados; 2. estudar a evolução do peso do fígado remanescente e as alterações histológicas do parênquima hepático nos dias subseqüentes à hepatectomia parcial. MÉTODOS: Cinqüenta ratos recém-nascidos e quarenta e quatro ratos recém-desmamados foram submetidos à hepatectomia a 70%. Após laparotomia mediana, foi realizada compressão bilateral no abdome superior do animal, levando à exteriorização dos lobos hepáticos direito medial, esquerdo medial e esquerdo lateral, que foram ligados na base e ressecados em bloco. Os animais foram sacrificados logo após a hepatectomia e no 1º,2º,3º,4º, e 7º dias após a cirurgia. O peso corpóreo e do fígado foram determinados, e o parênquima hepático submetido à análise histológica. RESULTADOS: Os índices de mortalidade dos animais recém-nascidos e recém-desmamados foram 30% e 0% respectivamente. Em ambos os grupos, houve uma diminuição significativa na massa hepática logo após a hepatectomia, com recuperação completa no sétimo dia de pós-operatório. O parênquima hepático dos animais recém-nascidos apresentou acentuada esteatose no segundo dia. O fígado do animal recém-desmamado exibiu figuras mitóticas mais precoces e mais numerosas que o do recém-nascido. CONCLUSÕES: Os modelos de hepatectomia parcial em ratos recém-nascidos e recém-desmamados são factíveis e podem ser usados para estudos da regeneração hepática. Embora semelhante, o processo de regeneração hepática em animais em crescimento não é igual ao do animal adulto.

PURPOSE: Treatment with curettage, cauterization, and methylmethacrylate of aggressive benign bone lesions is a method now widely accepted in most orthopedic oncology centers. However, one of the controversies regarding this technique is the possible complications that may arise from the use of methylmethacrylate, which has caused some authors to remove it 2 years after the surgery and replace it with bone graft. The objective of this paper is to present a functional and radiographic evaluation of 214 patients presenting with aggressive benign bone lesions treated with curettage, cauterization, and methylmethacrylate from 1974 to 1998, with some of them having 24 years of follow-up. These patients were clinically and radiographically evaluated for the incidence of late osteoarthrosis, range of motion, and pain in the involved joint. METHOD: This study comprised 214 patients, with an average follow-up duration of 10.6 years (range: 2 to 24 years. All cases involved aggressive benign lesions. The patients were evaluated according to the Musculoskeletal Tumor Society Score (MSTS) functional evaluation system, and the complications are described. RESULTS: The MSTS functional evaluation was excellent in 166 cases (78%), good in 26 (12%), fair in 11 (5%), and poor in 11 (5%). The following complications were observed: late osteoarthrosis, 25 cases (12%); infection, 12 (6%); pathologic fracture, 11 (5%); and local recurrence, 19 (9%). CONCLUSION: Based on clinical assessment, no significant deleterious effects directly related to the use of methylmethacrylate were observed. The functional evaluation performed in 1998 (up to 24 years of follow-up) did not show significant change when compared to the evaluation performed in 1985.OBJETIVO: O tratamento com curetagem cauterização e metilmetacrilato de lesões ósseas benignas agressivas é o método agora amplamente aceito em quase todos os Centros Ortopédicos Oncológicos, entretanto uma das controvérsias com relação a esta técnica são as possíveis complicações que podem sugerir com o uso do metilmetacrilato fazendo com que alguns autores o removam dos anos depois da cirurgia e os substituam com o enxerto ósseo. O objetivo deste trabalho é apresentar a avaliação radiográfica e funcional de 214 pacientes apresentando lesões ósseas benignas agressivas tratadas com curetagem, cauterização e metilmetacrilato de 1974 a 1998, sendo que alguns deles tem 12 anos de seguimento. Esses pacientes foram avaliados clínica e radiograficamente para a ocorrência de osteoartrose tardia, amplitude de movimento e dor na articulação envolvida. MÉTODO: Este estudo é constituído de 214 pacientes, com seguimento médio de 10,6 anos (2 a 24 anos). Todos os casos correspondem as lesões benignas agressivas. Os pacientes foram avaliados de acordo com Muscolskeletal Tumor Society Score sendo descritas as complicações. RESULTADOS: A avaliação funcional da (MSTS) foi excelente em 166 casos (78%), bom em 26 (12%), regular em 11(5%) e mal 11 (5%). Foram observadas as seguintes complicações: osteoartrose tardia 25 casos (12%), infecção 12(6%), fratura patológica 11(5%) e rescindiva local 19(9%). CONCLUSÃO: Baseado na abordagem clínica não foi observado efeitos deletérios diretamente relacionados ao uso do metilmetacrilato. A avaliação funcional realizada em 1998 (até 24 anos de seguimento) não apresentou alterações significantes quando comparadas a avaliação realizada em 1985.

The purpose of this paper is to evaluate the effectiveness of low-dose aspirin in the prevention of preeclampsia in low-risk and high-risk women. We identified randomized clinical trials of the use of low-dose aspirin to prevent preeclampsia through the PUBMED search engine, and through the Cochran Library database. Twenty-two studies met our inclusion criteria, and were divided according to the studied population into 2 groups: trials with women at low risk for preeclampsia and trials with women at high risk. Effects were measured through the incidence of preeclampsia in women taking either placebo or aspirin, in studies where the relative risks and the 95% confidence intervals were calculated for both groups. A total of 33,598 women were studied, comprising 5 trials with 16,700 women at low-risk and 17 trials including 16,898 women at high risk. The incidence of preeclampsia was 3.75% (626/17,700), in the low-risk group, 9.01% (1,524/16,898) in the high-risk group, and 6.40% (2,150/33,598) overall. Low-dose aspirin had no statistically significantly effect on the incidence of preeclampsia in the low-risk group (RR = 0.95, 95% CI = 0.81-1.11), but had a small beneficial effect in the high-risk group (RR = 0.87, 95% CI = 0.79-0.96). Therefore, low-dose aspirin is mildly beneficial in terms of reducing the incidence of preeclampsia in women at high risk of developing preeclampsia.Esta revisão busca reúne estudos sobre a eficácia da aspirina em baixas doses na prevenção da pré-eclâmpsia em pacientes de alto e baixo risco. Identificamos estudos clínicos randomizados controlados usando baixas doses de aspirina para prevenir a pré-eclâmpsia, publicados no MEDLINE. Vinte e dois estudos preencheram nossos critérios de inclusão. Dividimos os estudos de acordo com a população estudada em dois grupos: estudos com mulheres de baixo risco para pré-eclâmpsia e estudos com pacientes de alto risco. A principal medida de efeito foi a incidência de pré-eclâmpsia em pacientes que usaram placebo ou aspirina, na qual os riscos relativos e os intervalos de confiança de 95% foram calculados para os grupos de pacientes de baixo e de alto risco para pré-eclâmpsia. Um total de 33.598 pacientes foram estudadas, dentre as quais cinco estudos com 16.700 pacientes de baixo risco e 17 estudos incluindo 16.898 pacientes de alto risco. As incidências de pré-eclâmpsia no geral, no grupo de baixo e no de alto risco foram de 6,40% (2.150/33.598), 3,75% (626/17.700), e 9,01% (1.524/16.898), respectivamente. Baixas doses de aspirina não tiveram efeito estatístico significante na redução da incidência de pré-eclâmpsia em pacientes de baixo risco (RR=0.95, 95%CI = 0.81-1.11), porém apresentaram pequenos benefícios em mulheres de alto risco (RR=0.87, 95%CI=0.79-0.96). Esta análise leva à conclusão de que baixas doses de aspirina têm pequeno efeito na redução da incidência da pré-eclâmpsia em pacientes com alto risco de desenvolver a doença.

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.A farmácia hospitalar permeia e interliga várias ações desenvolvidas em diferentes setores no complexo processo de utilização do medicamento dentro do hospital. Falhas na dispensação significam o rompimento de um dos últimos elos na segurança do uso dos medicamentos. Ainda que grande parte dessas falhas não cause danos aos pacientes, sua existência denuncia fragilidade no processo e indica, em uma relação direta, riscos maiores de ocorrência de acidentes graves. Os conceitos atuais dos incidentes relacionados a medicamentos podem ser categorizados em grupos e incluem as reações adversas, os eventos adversos e os erros de medicação. Dentre estes se inclui os erros de dispensação, cujas causas mais comuns se associam ao caráter inseguro e ineficiente dos próprios sistemas de dispensação. Os fatores associados a estes erros se resumem nas falhas de comunicação, nos problemas relacionados à rotulagem e embalagem dos medicamentos, na sobrecarga de trabalho e na estrutura da área de trabalho, nas distrações e interrupções, no uso de fontes de informação incorretas e desatualizadas e na falta de conhecimento e educação do paciente sobre os medicamentos que utiliza. O erro de dispensação, ainda que em muitos casos possa ser classificado como banal, assume níveis epidemiológicos importantes. Este artigo, parte de um estudo sobre a ocorrência de erros de dispensação na farmácia de um hospital geral de grande porte, visa divulgar uma revisão sobre os principais conceitos que hoje norteiam os estudos sobre eventos adversos, bem como o estágio atual do conhecimento sobre os erros de dispensação.

Despite the high prevalence of depression and hypertension, the relationship between the two diseases has received little attention. This paper reviews the epidemiological, pathophysiological, and prognostic aspects of this association, as well as its implications for treatment. A Medline search was conducted using the following key words: depression, blood pressure, blood pressure variability, physical morbidity, hypertension, mood, stress, hypertension, antidepressive agents, and genetics, from 1980 to 2004. We found descriptions of increased prevalence of hypertension in depressed patients, increased prevalence of depression in hypertensive patients, association between depressive symptomatology and hypotension, and alteration of the circadian variation of blood pressure in depressed patients. There is considerable evidence suggesting that hyperreactivity of the sympathetic nervous system and genetic influences are the underlying mechanisms in the relationship between depression and hypertension. Depression can negatively affect the course of hypertensive illness. Additionally, the use of antidepressive agents can interfere with blood pressure control of patients with hypertension by inducing changes in blood pressure and orthostatic hypotension.Apesar das altas prevalências de hipertensão arterial sistêmica e de depressão, o estudo da relação entre depressão e pressão arterial tem recebido pouca atenção da literatura. Nesse artigo são revisados os aspectos epidemiológicos, patofisiológicos, prognósticos e implicações no tratamento, relacionados à associação entre depressão e hipertensão arterial sistêmica. O método utilizado foi consulta ao banco de dados bibliográficos Medline, utilizando-se as palavras chave depression, blood pressure, blood pressure variability, physical morbidity, hypertension, mood, stress, hypertension, antidepressive agents e genetics, no período de 1980 a 2004. Encontramos descrições de prevalência aumentada de hipertensão em pacientes deprimidos, prevalência aumentada de depressão em pacientes hipertensos, associação entre sintomatologia depressiva e hipotensão e alteração da variação circadiana da pressão arterial de pacientes deprimidos. Acredita-se que mecanismos envolvendo hiperatividade de sistema nervoso simpático e influências genéticas possam ser a base fisiopatológica da relação entre depressão e hipertensão arterial sistêmica. Além disso, a presença de depressão pode piorar o curso da doença hipertensiva, e o uso medicações antidepressivas pode induzir aumento de pressão arterial, diminuição de pressão arterial e hipotensão ortostática, dificultando o manejo de pacientes com hipertensão arterial sistêmica.

PURPOSE: The aim of this paper is to report our experience in the creation of arteriovenous fistulas in children by using microsurgical vascular techniques, with emphasis on the details of the surgical technique. METHODS: The children underwent surgery from July 1997 to March 2004. Operating loupes (magnification: 3.5X) were used by the entire surgical team. After dissection and adequate mobilization, the vein was anastomosed to the artery in an end-to-lateral fashion by using 4 separate 7/0 or 8/0 prolene running sutures. RESULTS: Twenty nine children underwent 33 fistula creations - 21 radiocephalic, 6 brachiocephalic, 4 brachiobasilic, and 2 saphenofemoral. Primary patency was achieved in 17/21 (80.9%) of the radiocephalic fistulas, 5/6(83.3%) of the brachiocephalic, 3/4 (75.0%) of the brachiobasilic, and 2/2 (100%) of saphenofemoral. Two patients developed fistula occlusion and radial artery thrombosis, and in 2 others, radiocephalic fistulas became occluded in the first or second postoperative week. In the late postoperative period, the saphenofemoral fistulas were responsible for significant edema formation in the lower extremity; an aneurysm formed in a brachiocephalic fistula after a long period of utilization. As to the patency of the different sites of fistulas, the brachiocephalic and brachiobasilic fistulas had the same incidence of patency as the radiocephalic fistulas (P >.05). CONCLUSIONS: This experience indicates that the arteriovenous fistulas are a satisfactory method for providing hemodialysis in children. The utilization of microsurgical techniques and some technical refinements herein described permit the attainment of high patency rates of the fistulas.OBJETIVO: Relatar a experiência dos autores na execução de fístulas artério-venosas em crianças, com a utilização dos recursos da microcirurgia vascular, com especial ênfase aos detalhes de técnica cirúrgica. MÉTODOS: Os pacientes foram operados entre julho de 1997 e março de 2004. Foram utilizadas lupas cirúrgicas (aumento de 3,5 vezes). Após a dissecção da veia e da artéria, a anastomose veno-arterial foi realizada de forma término-lateral, com quatro suturas contínuas de fio 7/0 ou 8/0. RESULTADOS: Vinte e nove crianças foram operadas para a realização de 33 fístulas - 21 rádio-cefálicas, 6 bráquio-cefálicas, 4 bráquio-basílicas e 2 safeno-femorais. Obteve-se permeabilidade em 17/21 (80,9%) fístulas rádio-cefálicas, 5/6 (83,3%) bráquio-cefálicas, 3/4 (75,0%) bráquio-basílicas e 2/2 (100%) safeno-femorais. 2 pacientes apresentaram obstrução da fístula e da artéria radial e 2 outras fístulas rádio-cefálicas obstruíram-se entre a primeira e segunda semana de pós-operatório. Tardiamente, verificou-se que as fístulas safeno-femorais causaram edema do membro inferior correspondente e houve formação de aneurisma em uma fístula bráquio-cefálica. Quanto à permeabilidade, verificou-se que as fístulas bráquio-cefálicas e bráquio-basílicas apresentaram a mesma incidência de permeabilidade em comparação com as fístulas rádio-cefálicas (p>0,05). CONCLUSÃO: A presente casuística demonstra que as fístulas artério-venosas persistem como um bom acesso vascular para hemodiálise em crianças. A utilização de microcirurgia e alguns detalhes técnicos aqui descritos permitem a obtenção de bons índices de permeabilidade das fístulas.

Primary tumors of the heart are rare, with an incidence between 0.0017% and 0.19% in unselected patients at autopsy. Approximately 75% of the tumors are benign, and nearly half of them are myxomas (1) Atrial myxoma is the most common benign cardiac neoplasm, and its origin has been ascribed to a multipotential mesenchymal cell (2) Myxomas commonly occur between the third and sixth decades of life and are three times more frequent in women (3) There are two distinctive forms of the tumors: solid and ovoid myxomas and soft and papillary myxomas. Solid tumors are more likely to present with symptoms of congestive heart failure (CHF), while papillary tumors are more likely to embolize to the cerebral and other peripheral vessels (4) At the time of diagnosis, 92% of the patients have symptoms of CHF (5) Atrial myxoma may mimic valvular heart disease, cardiac insufficiency, cardiomegaly, bacterial endocarditis, disturbances of ventricular and supraventricular rhythm, syncope, and systemic or pulmonary embolism (3) The purpose of this paper is to present a case report of atrial myxoma mimicking severe mitral valve stenosis at cardiac auscultation and the importance of echocardiograpy in the diagnosis.

We read the paper titled “Acupuncture and exercise capacity: A case report” by Nascimento RC et al with great interest (1). The results of the study demonstrated that acupuncture is an efficient tool for improving the exercise capacity of an individual. However, some portions of the methodology remain unclear, and we would like to highlight some published data regarding the treadmill cardiopulmonary exercise test. Basically, a treadmill is a piece of equipment used to measure the status of the heart and is used as a diagnostic and prognostic measurement when the appropriate protocol is selected. We are interested in identifying the ramp protocol used by the authors. Additionally, it would be interesting to know whether the subjects completed the protocol before and after acupuncture treatment. For future case reports or studies, we suggest that the subjects recruited for a program to improve health and well-being need to undergo specific protocols, such as the Bruce or modified Bruce protocol, depending on the design of the exercise program (2). Commenting on the results, the authors reported that the patient showed improvement in his exercise capacity following acupuncture treatment. We would like to comment on the effect of the study on two types of clinical subjects. First, when the techniques are applied to neurological subjects (those paralyzed and semiconscious), oxygen consumption and other variables can improve. Similarly, when these techniques are applied to cardiac patients (those diagnosed as hypertensive), negative effects can occur. Physiologically, the amount of oxygen consumption may cause the heart to become stressed following acupuncture therapy. Under such conditions, the heart needs to pump more blood to cope with the demand, which may increase the heart rate and in turn increase blood pressure. Therefore, it can be said that the results of the study would be desirable for a particular population to increase exercise capacity when it is cautiouslxy used for patients with stable vital parameters. Overall, this is an interesting case report for discussion that may benefit individuals who attend a program to improve their well-being. The authors and the editor need to be applauded for highlighting such an innovative treatment for exercise capacity.

Dear Editor, We read with great interest the article by Bueno Filho et al. entitled “Rare association of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome with tuberculous lymphadenitis” that was published in the esteemed journal Clinics. The authors presented an interesting case of cutaneous vasculitis, IgA nephropathy and antiphospholipid antibody syndrome with tuberculous lymphadenitis in a 45-year-old woman (1). I would like to mention a few points regarding this paper. A definitive pathologic IgA nephropathy diagnosis based on immunostaining assays requires the presence of dominant mesangial IgA depositions in the absence of significant C1q depositions to rule out lupus nephritis (2–5), which the authors should note. Moreover, the detection of significant fibrin deposition along with IgA deposits can help differentiate between primary IgA nephropathy and Henoch-Schonlein purpura nephropathy (2–5). Therefore, the authors should also discuss this point. Bueno Filho et al. classified the morphologic lesions of IgA nephropathy in renal biopsies as “focal and segmental sclerosis with mild focal and chronic tubulointerstitial damage”. Indeed, as a result of the publication of the Oxford classification of IgA nephropathy in 2009 (2,5), it is necessary to describe the morphologic lesions of IgA nephropathy according to this classification system (6–8). Furthermore, figure 2C shows a normal glomerulus, which is in contrast to the described morphologic features. The authors reported the final diagnosis as a combination of tuberculous lymphadenitis, cutaneous leukocytoclastic vasculitis, primary IgA nephropathy and anti-phospholipid antibody syndrome. However, the presence of morphologic lesions upon renal biopsy suggests anti-phospholipid syndrome nephropathy and should have been reported (9–11). Anti-phospholipid antibody syndrome is a vaso-occlusive disease (12,13) that affects renal tissue and has various morphologic lesions, some of which are characteristic of the disease (14). Accurate documentation and reporting of such rare cases are necessary to determine the complete spectrum of this disorder and improve the understanding of its pathophysiology. Bueno Filho et al. merit compliments for bringing this interesting case to this journal for discussion. Such discussions may help increase awareness of anti-phospholipid antibody syndrome among pathologists and nephrologists, particularly in developing countries.