Early neonatal mortality according to level of hospital complexity in Greater Metropolitan São Paulo, Brazil

O objetivo foi analisar o perfil dos recém-nascidos, mães e mortalidade neonatal precoce, segundo complexidade do hospital e vínculo com o Sistema Único de Saúde (SUS), na Região Metropolitana de São Paulo, Brasil. Estudo baseado em dados de nascidos vivos, óbitos e cadastro de hospitais. Para obter a tipologia de complexidade e o perfil da clientela, empregaram-se análise fatorial e de clusters. O SUS atende mais recém-nascidos de risco e mães com baixa escolaridade, pré-natal insuficiente e adolescentes. A probabilidade de morte neonatal precoce foi 5,6‰ nascidos vivos (65% maior no SUS), sem diferenças por nível de complexidade do hospital, exceto nos de altíssima (SUS) e média (não-SUS) complexidade. O diferencial de mortalidade neonatal precoce entre as duas redes é menor no grupo de recém-nascidos < 1.500g (22%), entretanto, a taxa é 131% mais elevada no SUS para os recém-nascidos > 2.500g. Há uma concentração de nascimentos de alto risco na rede SUS, contudo a diferença de mortalidade neonatal precoce entre a rede SUS e não-SUS é menor nesse grupo de recém-nascidos. Novos estudos são necessários para compreender melhor a elevada mortalidade de recém-nascidos > 2.500g no SUS.The aim of this study was to analyze the profile of newborns, mothers, and early neonatal mortality according to the hospital's complexity and affiliation (or lack thereof) with the Unified National Health System (SUS) in Greater Metropolitan São Paulo, Brazil. The study was based on data for live births, deaths, and hospital registries. Factor and cluster analysis were used to obtain the typology of hospital complexity and user profile. The SUS treats more high-risk newborns and mothers with low schooling, insufficient prenatal care, and teenage mothers. The probability of early neonatal death was 5.6‰ live births (65% higher in the SUS), with no significant differences by level of hospital complexity, except those with extremely high (SUS) and medium (non-SUS) complexity. The difference in early neonatal mortality between the two systems was smaller in the group of newborns with birth weight < 1,500g (22%), but the rate was 131% higher in the SUS for newborns > 2,500g. There was a concentration of high-risk births in the SUS, but the difference in early neonatal mortality between SUS and non-SUS hospitals was smaller in this group of newborns. New studies are needed to elucidate the high mortality rate among newborns with birth weight > 2,500g in the SUS.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Maternal and neonatal characteristics and early neonatal mortality in Greater Metropolitan São Paulo, Brazil

O objetivo foi descrever as características do recém-nascido, da mãe e da mortalidade neonatal precoce, segundo local de parto, na Região Metropolitana de São Paulo, Brasil. Utilizou-se coorte de nascidos vivos vinculados aos respectivos óbitos neonatais precoces, por técnica determinística. Identificou-se o parto domiciliar a partir da Declaração de Nascido Vivo e os ocorridos em estabelecimentos a partir da vinculação com o Cadastro Nacional de Estabelecimentos de Saúde. Foram estudados 154.676 nascidos vivos, dos quais 0,3% dos nascimentos ocorreram acidentalmente em domicílio, 98,7% em hospitais e menos de 1% em outro serviço de saúde. A mortalidade foi menor no Centro de Parto Normal e nas Unidades Mistas de Saúde, condizente com o perfil de baixo risco obstétrico. As taxas mais elevadas ocorreram nos prontos-socorros (54,4 óbitos por mil nascidos vivos) e domicílios (26,7), representando um risco de morte, respectivamente, 9,6 e 4,7 vezes maior que nos hospitais (5,6). Apesar da alta predominância do parto hospitalar, há um segmento de partos acidentais tanto em domicílios como em prontos-socorros que merece atenção, por registrar elevadas taxas de mortalidade neonatal precoce.The objective was to describe maternal and neonatal characteristics and early neonatal mortality rate according to place of delivery in Greater Metropolitan São Paulo, Brazil. The study linked the databases on live births and early neonatal deaths with the national hospital registry. Place of delivery was identified through certificates of live birth. There were a total of 154,676 live births: 98.7% in-hospital; 0.3% home deliveries, and 1% in other health services. Deliveries in birthing centers and small hospital units were associated with low obstetric risk and a low proportion of preterm and low birth weight infants, and as a result these services showed the lowest early neonatal mortality rate. Compared to hospital maternity ward deliveries, the early neonatal mortality rate was 4.7 times higher for home deliveries and 9.6 higher for emergency room deliveries. There is a high rate of hospital delivery care in São Paulo, but there is still a small portion of accidental home births and deliveries occurring in inappropriate health services, probably as a result of obstetric emergencies and difficulties in accessing hospital services.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

Beginning of sexual life of adolescents in Santiago Island, Cape Verde, West Africa

OBJETIVO: estimar a idade de início da atividade sexual de adolescentes e sua associação com fatores sócio-demográficos. MÉTODO: estudo transversal, realizado entre janeiro e março de 2007, com amostra de 368 adolescentes de 13 a 17 anos de idade, sexualmente ativos, provenientes de oito escolas secundárias públicas da Ilha de Santiago, Cabo Verde, escolhidas aleatoriamente. Na análise das variáveis, foi ajustado um modelo de regressão múltipla para variável ordinal com função de ligação probit, considerando-se nível de significância de 5%. RESULTADOS: entre os 368 adolescentes, 31,5% (116) eram meninas e 68,5% (252) meninos. Houve maior freqüência de iniciação sexual protegida entre os jovens que se iniciaram sexualmente com idade mais avançada (16 e 17 anos). A iniciação feminina foi mais tardia do que a masculina e rapazes mais novos (13 anos) relataram o início da vida sexual a partir de dez anos de idade. Após análise múltipla, quatro fatores permaneceram significativamente associados à idade do início da vida sexual no sexo feminino: idade, morar em casa alugada, não estar namorando no período da entrevista e menarca. Para o masculino foram: idade, não estar namorando no período da entrevista e interação entre idade e não namorar. CONCLUSÕES: a maior freqüência de iniciação sexual protegida ocorre entre os jovens que se iniciaram sexualmente com idade mais avançada. Todavia, a influência de morar em casa própria ou cedida e de parceria afetivo-sexual no início da vida sexual revela que a necessidade de ações de prevenção sejam direcionadas para segmentos com piores condições sócio-econômicas e para adolescentes que não namoram.OBJECTIVE: to estimate the age of the first sexual intercourse and the effects of socio-demographic factors among adolescents. METHOD: cross-sectional study with 368 sexually active adolescents aged 13-17 years from eight public elementary and high schools, randomly selected, in Santiago Island, Cape Verde, in Jan-Mar/2007. The analysis was made by means of regression adjusted for ordinal variables with probit link function, with a 5% significance level. RESULTS: among the 368 adolescents, 31.5% (116) were female and 68.5% (252) were male. There was higher prevalence of protected sexual relationship among adolescents who began sexual life later (16 and 17 yrs). Sexual initiation among females occurred later and younger males (13 yrs) reported the first sexual intercourse from 10 years. After multiple analyses, four factors have remained statistically significant associated with the age of first sexual intercourse among females: age, living in rented house, not being dating and age at menarche. The factors included for males were age, not being dating and interaction between age and not being dating. CONCLUSIONS: adolescents who begin sexual life later have safe sexual relationships more frequently. However, the influence of living in their own or donated house and affective-sexual partnership at the beginning of sexual life reveals the necessity (or demand) of preventive actions. These actions must be focused on groups with worse socioeconomic conditions and adolescents who are not dating

Efetividade do serviço móvel de urgência (Samu): uso de séries temporais interrompidas

OBJETIVO: Avaliar o desempenho do serviço de atendimento móvel de urgência (Samu) na região do Grande ABC, utilizando como condição traçadora o infarto agudo do miocárdio. MÉTODOS: A análise de séries temporais interrompidas foi a abordagem de escolha para testar efeitos imediatos e graduais da intervenção na população de estudo. A pesquisa compreendeu séries temporais mensais ajustadas da taxa de mortalidade hospitalar por infarto agudo do miocárdio no período entre 2000 e 2011. Os dados foram extraídos do Sistema de Informações sobre Mortalidade, usando a análise de regressão segmentada para avaliar o nível e tendência da intervenção antes e após sua implementação. Para fortalecer a validade interna do estudo, foi incluída uma região controle. RESULTADOS: A análise de séries temporais interrompidas mostrou redução de 0,04 mortes por 100.000 habitantes na taxa de mortalidade em relação à tendência subjacente desde a implantação do serviço de atendimento médico de urgência (p = 0,0040; IC95% -0,0816 – -0,0162) e uma redução no nível de 2,89 mortes por 100.000 habitantes (p = 0,0001; IC95% -4,3293 – -1,4623), ambos com significância estatística. Em relação à região controle, a Baixada Santista, a diferença da tendência do resultado entre desfecho de intervenção e controle pós-intervenção de -0,0639 mortes por 100.000 habitantes mostrou-se estatisticamente significativa (p = 0,0031; IC95% -0,1060 – -0,0219). Não podemos excluir confundimentos, mas limitamos sua presença no estudo incluindo séries de região controle. CONCLUSÕES: Embora a análise de séries temporais interrompidas tenha limitações, essa modelagem pode ser útil para a análise de desempenho de políticas e programas. Apesar de a intervenção estudada não ser uma condição que por si só implica na efetividade, a efetividade não estaria presente sem essa intervenção, que, integrada a outras condições, gera um resultado positivo. O Samu é uma estratégia cuja expansão precisa ser levada em consideração ao formular e consolidar políticas com foco nas urgências e emergências.OBJECTIVE: To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition. METHODS: The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included. RESULTS: The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: −0.0816 – −0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: −4.3293 – −1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of −0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: −0.1060 – −0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series. CONCLUSIONS: Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care

Qualidade das informações registradas nas declarações de óbito fetal em São Paulo, SP

OBJECTIVE: To evaluate the quality of information registered on fetal death certificates. METHODS: Records were reviewed from 710 fetal deaths registered in the consolidated database of deaths from the State System for Data Analysis and the São Paulo State Secretary of Health, for deaths in São Paulo municipality (Southeastern Brazil) during the first semester of 2008. Completeness was analyzed for variables on fetal death certificates issued by hospitals and autopsy service. The death certificates from a sub-sample of 212 fetal deaths in hospitals of the National Unified Health System (public) were compared to medical records and to the records from Coroners Office. RESULTS: Among death certificates, 75% were issues by Coroners Office, with a greater frequency in public hospitals (78%). Completeness of variables on death certificates issued by hospitals was higher among non-public hospitals. There was greater completeness, agreement and sensitivity in death certificates issued by hospitals. There was low agreement and high specificity for variables related to maternal characteristics. Increased reporting of gender, birth weight and gestational age was observed in certificates issued by Coroners Office. Autopsies did not result in improved ascertainment of cause of death, with 65.7% identified as unspecified fetal death as 24.3% as intrauterine hypoxia, while death certificates by hospitals reported 18.1% as unspecified and 41.7% as intrauterine hypoxia. CONCLUSIONS: Completeness and the ascertainment of cause of fetal death need to be improved. The high proportion of autopsies did not improve information and ascertainment of cause of death. The quality of information generated by autopsies depends on access to hospital records.OBJETIVO: Avaliar a qualidade da informação registrada nas declarações de óbito fetal. MÉTODOS: Estudo documental com 710 óbitos fetais em hospitais de São Paulo, SP, no primeiro semestre de 2008, registrados na base unificada de óbitos da Fundação Sistema Estadual de Análise de Dados e da Secretaria de Estado da Saúde de São Paulo. Foi analisada a completitude das variáveis das declarações de óbito fetal emitidas por hospitais e Serviço de Verificação de Óbitos. Os registros das declarações de óbito de uma amostra de 212 óbitos fetais de hospitais do Sistema Único de Saúde foram comparados com os dados dos prontuários e do registro do Serviço de Verificação de Óbitos. RESULTADOS: Dentre as declarações de óbito, 75% foram emitidas pelo Serviço de Verificação de Óbitos, mais freqüente nos hospitais do Sistema Único de Saúde (78%). A completitude das variáveis das declarações de óbito emitidas pelos hospitais foi mais elevada e foi maior nos hospitais não pertencentes ao Sistema Único de Saúde. Houve maior completitude, concordância e sensibilidade nas declarações de óbito emitidas pelos hospitais. Houve baixa concordância e elevada especificidade para as variáveis relativas às características maternas. Maior registro das variáveis sexo, peso ao nascer e duração da gestação foi observada nas declarações emitidas no Serviço de Verificação de Óbitos. A autópsia não resultou em aprimoramento da indicação das causas de morte: a morte fetal não especificada representou 65,7% e a hipóxia intrauterina, 24,3%, enquanto nas declarações emitidas pelos hospitais foi de 18,1% e 41,7%, respectivamente. CONCLUSÕES: É necessário aprimorar a completitude e a indicação das causas de morte dos óbitos fetais. A elevada proporção de autópsias não melhorou a qualidade da informação e a indicação das causas de morte. A qualidade das informações geradas de autópsias depende do acesso às informações hospitalares.OBJETIVO: Evaluar la calidad de la información registrada en las declaraciones de óbito fetal. MÉTODOS: Estudio documental con 710 óbitos fetales en hospitales de Sao Paulo, Sureste de Brasil, en el primer semestre de 2008, registrados en la base unificada de óbitos de la Fundación Sistema Estatal de Análisis de Datos y de la Secretaria de Estado de la Salud de Sao Paulo. Se analizó la completitud de las variables de las declaraciones de óbito fetal emitidas por hospitales y Servicio de Verificación de Óbitos. Los registros de las declaraciones de óbito de una muestra de 212 óbitos fetales de hospitales del Sistema Único de Salud (público) fueron comparados con los dados de los prontuarios y del registro del Servicio de Verificación de Óbitos. RESULTADOS: Entre as declaraciones de óbito, 75% fueron emitidas por el Servicio de Verificación de Óbitos, más frecuente en los hospitales públicos (78%). La completitud de las variables de las declaraciones de óbito emitidas por los hospitales fue más elevada y fue mayor en los hospitales no-públicos. Hubo mayor completitud, concordancia y sensibilidad en las declaraciones de óbito emitidas por los hospitales. Hubo baja concordancia y elevada especificidad para las variables relativas a las características maternas. Mayor registro de las variables sexo, peso al nacer y duración de la gestación fue observada en las declaraciones emitidas en el Servicio de Verificación de Óbito. La autopsia no resultó en mejoramiento de la indicación de las causas de muerte: la muerte fetal no especificada representó 65,7% y la hipoxia intrauterina, 24,3%, mientras que en las declaraciones emitidas por los hospitales fue de 18,1% y 41,7%, respectivamente. CONCLUSIONES: Es necesario mejorar la completitud y la indicación de las causas de muerte de los óbitos fetales. La elevada proporción de autopsias no mejoró la calidad de la información y la indicación de las causas de muerte. La calidad de las informaciones generadas de autopsias depende del acceso a las informaciones hospitalarias

Analysis of the Ki-67 index in the vaginal epithelium of castrated rats treated with tamoxifen

OBJECTIVES: Vaginal atrophy and breast cancer are common conditions in postmenopausal women and tamoxifen is the standard endocrine treatment for hormone-sensitive tumors. The present study aimed to assess the effect of tamoxifen on Ki-67 protein expression in the vaginal epithelium of castrated rats. MATERIAL AND METHODS: Forty Wistar-Hannover adult, virgin, castrated rats were randomly divided into two groups, group I (control, n=20) and group II (tamoxifen, n=20), receiving 0.5 ml of propylene glycol and 250 µg of tamoxifen diluted in 0.5 ml of propylene glycol, respectively, daily by gavage for 30 days. On the 31st day, the rats were euthanized and their vaginas were removed and fixed in 10% buffered formalin for the immunohistochemical study of Ki-67 protein expression. Data were analyzed by the Levene and Student’s t tests (

Beta-2 adrenergic receptor gene polymorphisms Gln27Glu, Arg16Gly in patients with heart failure

<p>Abstract</p> <p>Background -</p> <p>Beta-2 adrenergic receptor gene polymorphisms Gln27Glu, Arg16Gly and Thr164Ile were suggested to have an effect in heart failure. We evaluated these polymorphisms relative to clinical characteristics and prognosis of alarge cohort of patients with heart failure of different etiologies.</p> <p>Methods -</p> <p>We studied 501 patients with heart failure of different etiologies. Mean age was 58 years (standard deviation 14.4 years), 298 (60%) were men. Polymorphisms were identified by polymerase chain reaction-restriction fragment length polymorphism.</p> <p>Results -</p> <p>During the mean follow-up of 12.6 months (standard deviation 10.3 months), 188 (38%) patients died. Distribution of genotypes of polymorphism Arg16Gly was different relative to body mass index (χ²= 9.797;p = 0.04). Overall the probability of survival was not significantly predicted by genotypes of Gln27Glu, Arg16Gly, or Thr164Ile. Allele and haplotype analysis also did not disclose any significant difference regarding mortality. Exploratory analysis through classification trees pointed towards a potential association between the Gln27Glu polymorphism and mortality in older individuals.</p> <p>Conclusion -</p> <p>In this study sample, we were not able to demonstrate an overall influence of polymorphisms Gln27Glu and Arg16Gly of beta-2 receptor gene on prognosis. Nevertheless, Gln27Glu polymorphism may have a potential predictive value in older individuals.</p

Diagnostic accuracy of a noninvasive hepatic ultrasound score for non-alcoholic fatty liver disease (NAFLD) in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

CONTEXT AND OBJECTIVE: Noninvasive strategies for evaluating non-alcoholic fatty liver disease (NAFLD) have been investigated over the last few decades. Our aim was to evaluate the diagnostic accuracy of a new hepatic ultrasound score for NAFLD in the ELSA-Brasil study. DESIGN AND SETTINGS: Diagnostic accuracy study conducted in the ELSA center, in the hospital of a public university. METHODS: Among the 15,105 participants of the ELSA study who were evaluated for NAFLD, 195 individuals were included in this sub-study. Hepatic ultrasound was performed (deep beam attenuation, hepatorenal index and anteroposterior diameter of the right hepatic lobe) and compared with the hepatic steatosis findings from 64-channel high-resolution computed tomography (CT). We also evaluated two clinical indices relating to NAFLD: the fatty liver index (FLI) and the hepatic steatosis index (HSI). RESULTS: Among the 195 participants, the NAFLD frequency was 34.4%. High body mass index, high waist circumference, diabetes and hypertriglyceridemia were associated with high hepatic attenuation and large anteroposterior diameter of the right hepatic lobe, but not with the hepatorenal index. The hepatic ultrasound score, based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe, presented the best performance for NAFLD screening at the cutoff point ≥ 1 point; sensitivity: 85.1%; specificity: 73.4%; accuracy: 79.3%; and area under the curve (AUC 0.85; 95% confidence interval, CI: 0.78-0.91)]. FLI and HSI presented lower performance (AUC 0.76; 95% CI: 0.69-0.83) than CT. CONCLUSION: The hepatic ultrasound score based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe has good reproducibility and accuracy for NAFLD screening

Chronic inflammatory diseases, subclinical atherosclerosis, and cardiovascular diseases: Design, objectives, and baseline characteristics of a prospective case-cohort study ‒ ELSA-Brasil

Objectives: This analysis describes the protocol of a study with a case-cohort to design to prospectively evaluate the incidence of subclinical atherosclerosis and Cardiovascular Disease (CVD) in Chronic Inflammatory Disease (CID) participants compared to non-diseased ones. Methods: A high-risk group for CID was defined based on data collected in all visits on self-reported medical diagnosis, use of medicines, and levels of high-sensitivity C-Reactive Protein&nbsp;&gt;10&nbsp;mg/L. The comparison group is the Aleatory Cohort Sample (ACS): a group with&nbsp;10% of participants selected at baseline who represent the entire cohort. In both groups, specific biomarkers for DIC, markers of subclinical atherosclerosis, and CVD morbimortality will be tested using weighted Cox. Results: The high-risk group (n&nbsp;=&nbsp;2,949; aged 53.6 ± 9.2; 65.5%&nbsp;women) and the ACS (n=1543; 52.2±8.8; 54.1%&nbsp;women) were identified. Beyond being older and mostly women, participants in the high-risk group present low average income (29.1%&nbsp;vs.&nbsp;24.8%, p &lt; 0.0001), higher BMI (Kg/m2) (28.1&nbsp;vs.&nbsp;26.9, p &lt; 0.0001), higher waist circumference (cm) (93.3&nbsp;vs.&nbsp;91, p &lt; 0.0001), higher frequencies of hypertension (40.2%&nbsp;vs.&nbsp;34.5%, p &lt; 0.0001), diabetes (20.7%&nbsp;vs.&nbsp;17%, p&nbsp;=&nbsp;0.003) depression (5.8%&nbsp;vs.&nbsp;3.9%, p&nbsp;=&nbsp;0.007) and higher levels of GlycA a new inflammatory marker (p &lt; 0.0001) compared to the ACS. Conclusions: The high-risk group selected mostly women, older, lower-income/education, higher BMI, waist circumference, and of hypertension, diabetes, depression, and higher levels of GlycA when compared to the ACS. The strategy chosen to define the high-risk group seems adequate given that multiple sociodemographic and clinical characteristics are compatible with CID