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PURPOSE: Although physical examination is a fundamental component of medical decision making, relatively few studies have evaluated how physicians quantify clinical signs and whether different methods of assessment have different effects on clinical practice. OBJECTIVES: To evaluate a possible impact of clinical experience when attending physicians, medical residents and medical students quantify qualitative signs of physical examination in a teaching hospital. SETTING: Hospital das Clínicas, University of São Paulo, Brazil. SUBJECTS: A total of 244 randomly selected physicians and medical students completed a reliable and consistent eight-item questionnaire. MAIN OUTCOME MEASURES: To compare how they quantified clinical signs of cyanosis, anaemia, jaundice, oedema and dehydration, why they used the method(s) they described, and whether the method used could affect diagnosis, further testing or patient management. A chi-square test was used to calculate differences between the groups. RESULTS: Whilst the majority of those surveyed tended to use a four-level evaluation for these clinical signs, attending staff physicians were more likely to employ two-level evaluations than were residents or medical students. For all five signs, attending physicians' use of dichotomous evaluations was significantly higher than that of residents or medical students: anaemia (P = 0.004), cyanosis (P < 0.001), oedema (P = 0.005), dehydration (P < 0.001) and jaundice (P = 0.002). CONCLUSION: Although medical students and residents are routinely taught to use a four-level evaluation for these clinical signs, many of those surveyed tend to abandon this experience for a dichotomous approach. Given that the clinicians in this survey tended not to change their initial approach to a patient based on the intensity of this semi-quantitative method, increased emphasis on teaching dichotomous approach evaluations in medical school should be encouraged.

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The objective was to examine the association between high blood pressure (BP) and chronic daily headache using 24-h ambulatory blood pressure monitorization (24-h ABPM). This was a cross sectional study in an out-patient clinic. Women were selected among patients referred for first evaluation, 62 with chronic daily headache and 57 without chronic daily headache. The main outcome measures were mean office systolic and diastolic blood pressure (BP), mean systolic and diastolic daytime and night-time BP and BP load, and mean systolic and diastolic nocturnal fall. Office systolic BP was 138.2 mmHg for women with chronic daily headache and 141.7 mmHg for women without headache (P = 0.36). Office diastolic BP was 88.9 mmHg for women with headache and 92.7 mmHg for women without headache (P = 0.17). Mean daytime and mean night-time systolic BP was, respectively, 122.2 mmHg and 108.8 mmHg for women with headache and 122.9 mmHg and 109.5 for women without headache (P = 0.82 and P = 0.80, respectively). Mean daytime and mean night-time diastolic BP was, respectively, 78.6 mmHg and 65.4 mmHg for women with headache and 79.9 mmHg and 67.1 mmHg for the women without headache (P = 0.80 and P = 0.45, respectively). There was no difference between the two groups regarding systolic and diastolic BP load and nocturnal systolic and diastolic fall. No significant difference in BP values was observed in women with chronic daily headache compared with women without headache using 24-h ABPM.

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OBJECTIVE: To determine if abnormal laboratory findings are more common in individuals with hypertension and in those with other risk factors, such as obesity, smoking and alcohol ingestion. METHODS: A study was carried out in the general outpatient clinics of a university hospital (145 individuals without previous diagnosis of hypertension) and the following variables were assessed: high blood pressure (as defined by the VI Joint National Committee on Prevention, Detection and Treatment of High Blood Pressure--VI JNC), obesity [calculated using body mass index (BMI)], tobacco use, and alcoholic ingestion. The laboratory examinations consisted of the following tests: hemogram, glycemia, uric acid, potassium, total/HDL-fraction cholesterol, triglycerides, calcium and creatinine. RESULTS: High blood pressure was not associated with a higher number of abnormal laboratory tests. Hypertensive individuals with a BMI > or = 25 kg/m2 or normotensive obese individuals, however, had a higher frequency of diabetes (12X), hypertriglyceridemia (3X), and hypercholesterolemia (2X), as compared with hypertensive individuals with BMI < 25 kg/m2 and preobese/normal weight normotensive individuals. CONCLUSION: High blood pressure is not associated with a higher frequency of abnormal laboratory tests. The association of high blood pressure and obesity, however, increases the detection of diabetes and dyslipidemias.

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Headache is a common complaint with a high prevalence in ambulatory settings. The physical and neurological examinations are frequently normal. The use of questionnaires as a screening methods for patients with primary headache could facilitate the diagnosis in non-specialized medical centers. In the present study, we used a questionnaire, based on the IHS criteria and modified by the authors, applied to 204 patients from the outpatient clinic of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Half of the patients were submitted to a clinical interview. We compared the results of the questionnaire with the results of the medical interview (gold standard). Most of the headaches we studied were primary headaches (89.6%). The questionnaire revealed a sensitivity of 90.2% and specificity of 57.9% for migraine detection with a chance corrected agreement (kappa) of 0.47 and a positive predictive (PPV) value of 65.7% and a negative predictive value (NPV) de 86.8%. The sensitivity for tension-type headache detection was 60.8% and the specificity 87.1% with a kappa value of 0.49 and a PPV of 77.8% and a NPV of 75.9%. We conclude that this questionnaire can be used as a screening method for diagnosing headache and that it can be applied by non-medical personnel. This questionnaire could also be used for population studies.

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PURPOSE: To test the efficaccy of primary prevention in detecting a cluster of cardiovascular risk factors in a low income population and unaware individuals with hypertension, diabetes mellitus and hypercholesterolemia in the district of Butantã (São Paulo, Brazil). METHODS: We studied 156 people older than 40 years-old, 126 (80.8%) female, mean age 53 years and observed their cardiovascular risk factors. RESULTS: The proportion of unaware hypertensive patients was of 46.4% among hypertensive women and 40.0% among hypertensive men; and about diabetes, the proportion of unawareness was 22.2% among diabetic women and 50.0% among diabetic men, although the total number of diabetics and of hypertensive men was very small. CONCLUSION: People with the following attributes: female, overweight, hypertensive and with glucose intolerance were those with more concern about health and prevention. In other hand, men and smokers were absent of those activities showing a low self-concern with health and disease.

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Objetivo - testar a eficácia da prevençäo primária na detecçäo de subpopulaçöes de alto risco para doenças cardiovasculares em uma populaçäo de baixa renda familiar, detectando casos de hipertensäo arterial, diabetes metllitus e hipercolesterolemia, no Distrito de Saúde do Butantä (Säo Paulo, SP). Métodos - Durante a semana do coraçäo de 1993 foram estudados 156 indivíduos acima dos 40 anos, sendo 126 (80,8 por cento) mulheres, com média de idade de 53 anos e tiveram seus fatores de risco cardiovaslares quantificados. Resultados - O percentual de fatores de risco foi: fumantes (19,2 por cento), obesidade (27,8 por cento), hpercolesterolemia (50 por cento), diabetes mellitus (15,2 por cento) e hipertensäo arterial sistêmica (HAS) (25,8 por cento). O diagnóstico de HAS e diabetes mellitus era desconhecido, respectivamente, entre 46,4 por cento e 22,2 por cento das mulheres e em 45 por cento e 50 por cento dos homens. Conclusäo - a utilizaçäo da Semana do Coraçäo como atividade para busca de alto ric em populaçào de baixa renda é uma atividade exequível, porém limitada a mulheres, obesos, hipertensos, hipercolesterolêmicos e diabéticos, näo atingindo os fumantes.

Purpose - To test the efficaccy of primary prevention in detecting a cluster of cardiovascular risk factors in a low income population and unaware individuals with hypertension, diabetes mellitus and hypercholesterolemia in the district of Butantã (São Paulo, Brazil). Methods - We studied 156 people older than 40 yearsold, 126 (80.8%) female, mean age 53 years and observed their cardiovascular risk factors. Results - The proportion of unaware hypertensive patients was of 46.4% among hypertensive women and 40.0% among hypertensive men; and about diabetes, the proportion of unawareness was 22.2% among diabetic women and 50.0% among diabetic men, although the total number of diabetics and of hypertensive men was very small. Conclusion - People with the following attributes: female, overweight, hypertensive and with glucose intolerance were those with more concern about health and prevention. In other hand, men and smokers were absent of those activities showing a low self-concern with health and disease

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Mortality from asthma has shown important variations over time in several countries. In Brazil, a mortality study performed in the 60s, covering the cities of S. Paulo and Ribeirão Preto, and other ten cities showed that S. Paulo presented the lowest death rate from asthma among of them all. It was decided to study the time trends of deaths from asthma and from the whole set of respiratory diseases from 1970 to 1992, in the population aged 15-34 yrs. old in the State of S. Paulo, as well as to compare them with those of other countries. Asthma mortality rates during the 23 years of observation since 1975, showed an oscillatory declining pattern with a peak of deaths in the initial years. The linearization of the curve allows the calculation of Pearson's correlation coefficient that was significantly negative, suggesting a decline in the mortality over this period, mainly in the 5-9 yrs. old and 30-34 yrs. old strata. The segmentation of data between the period of ICD-9, 1970 to 1978, and of ICD-9, 1979 and subsequent years, shows that there is stability within each period, in all age-groups, except for that of 5-9 yr. olds between 1970-1978. Comparing the rates of the population aged 15-34 yrs. old for the State of S. Paulo, Brazil, with trends observed in 14 other countries, an intermediate pattern for the first triennial period (1970-1972) as well as for the subsequent triennial periods, emerges. A prevalence study of asthma, a follow up program meant for using emergency rooms and a surveillance of deaths due to all respiratory diseases and specifically to asthma are strongly recommended.

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AIM: The role of smoking as risk factor for stroke is controversial. An ecological design study was performed to test the association between stroke mortality and smoking in Brazil. Lung cancer mortality was used as a surrogate for smoking habit. METHODS: The mortality rate for stroke (ICD-9:430-438) and lung cancer (ICD-9: 162) were determined in the following metropolitan areas: Belém, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo, Curitiba and Porto Alegre for males and females between 30 years-old and 69 years-old. ANOVA test was used to compare both age-adjusted mortality rates. RESULTS: A negative association by ANOVA was determined between age-adjusted rates and age-specific rates, except among males with 40-49 years-old. CONCLUSION: These results may be on account of three causes: the different smoking role as a risk factor in the distinct stroke subtypes analyzed; the competitive risk between coronary heart disease and stroke; and the high prevalence of arterial hypertension in the Brazilian metropolitan areas.

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PURPOSE: An ecological study was performed to test the association between coronary heart disease (CHD) mortality and smoking in Brazil. Lung cancer mortality was used as a surrogate for smoking habit. METHODS: The mortality rate for CHD (ICD-9:410-414) and lung cancer (ICD-9: 162) were determined in the following metropolitan areas: Belém, Recife, Salvador, Belo Horizonte, Rio de Janeiro, São Paulo, Curitiba and Porto Alegre for males and females between 30 and 69 year old. ANOVA test was used to compare both age-adjusted mortality rates. RESULTS: A positive association by ANOVA was determined only for males ages 60-69 and to age-adjusted rates. CONCLUSION: The relationship between smoking and CHD mortality as determined in Brazilian cities, among men, mainly in the older ages, is a proof that tobacco control would contribute to downward trends in CHD mortality rates.

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BACKGROUND: Trends of peptic ulcer mortality rates were studied in São Paulo State (Brazil) among 1970 and 1989. MATERIAL: Deaths from PU, ICD-9 531-534. RESULTS: The PU rates in São Paulo are comparable with those in Europe and rank second place for males and in third place for females. During this period there was a downward trend either for males or females. CONCLUSIONS: For women, the decline was less impressive and the male/female ratio decreased. A cohort effect was suspected for the explanation of female mortality trends.

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