THE EFFECTS OF DEMOGRAPHIC AND ENVIRONMENTAL FACTORS ON ADULT HEALTH IN BRAZIL

Very little is known about the effects on adult health of environmental conditions in developing countries. Most studies have focused on child health and few have included environmental factors. The shortcomings are associated with difficulties in measuring health status for adults and the limited availability of data on environmental conditions in developing countries. Schultz and Tansel conclude their study stating "the next step in this field of research is to distinguish what variations in public policies or natural variations in environmental conditions combine to explain existing variation in adult morbidity among wage earners." According to UNICEF, over half the population of Brazil live in an unsanitary environment. Worldwide, nearly three billion people do not have access to even a minimally sanitary toilet. This study assesses the effects of demographic factors and key environmental conditions on adult health in Brazil. The research focuses on morbidity among wage earners and the impact of specific environmental conditions. The analysis is based on a household model developed by Schultz and Tansel and treats work absence due to health problems as a measure of adult health status. The data used are from the 1989 Brazilian National Health and Nutrition Survey and 1989 National Basic Sanitation Condition Survey. The first is a household survey that measured individual health and nutrition. The second survey provides data on basic environmental and sanitary conditions at the municipality level.Health Economics and Policy,

O ENSINO E APRENDIZAGEM NO CURSO DE EDUCAÇÃO FÍSICA NA MODALIDADE A DISTÂNCIA

A finalidade desta pesquisa versa em compreender como são construídas as ações didáticas que envolvem o curso de Educação Física na modalidade a distância, oferecido pela Universidade Federal do Amazonas, no Campus do município de Parintins-AM. A metodologia adotada foi baseada no paradigma qualitativo, mediante a análise e discussão dos dados foram amparados pela técnica da análise de conteúdo. Os sujeitos da pesquisa foram dezesseis estudantes que cursam o último período do curso e um tutor presencial. Apesar de ter na unidade universitária professores presenciais e tutores onlines, optamos, pois, em trabalhar apenas com as categorias estudantes e tutor presencial.  Os dados apontaram para fragilidades que atentam diretamente à qualidade do curso pesquisado. Dentre as fragilidades mais recorrentes estão a falta de acompanhamento sistemático no ambiente online e nos estágios supervisionados no campo de atuação desses estudantes e a falta de diálogo entre professores e estudantes nas interfaces.   PALAVRAS-CHAVE: Educação Física a distância. Ensino Superior. Formação Inicial.   ABSTRACTThe purpose of this research is to understand, in a well-founded way, the didactic actions that involve the Physical Education course in the distance modality, offered by the Federal University of Amazonas, in the Campus of the municipality of Parintins-AM. The methodology adopted was based on the qualitative paradigm, through the analysis and discussion of data were supported by the technique of content analysis. The subjects of the research were sixteen students who attended the last period of the course and one tutor in person. Although we have faculty and online tutors at the university unit, we have chosen to work only with the categories of students and tutor in person. The data pointed to weaknesses that directly affect the quality of the course studied. Among the most recurrent weaknesses are the lack of systematic monitoring in the online environment and supervised internships in the field of these students' activities and the lack of dialogue between teachers and students in the interfaces.   KEYWORDS: Distance Physical Education. Higher Education. Initial Formation.     RESUMEN La finalidad de esta investigación versa en comprender cómo se construyen las acciones didácticas que envuelven el curso de Educación Física en la modalidad a distancia, ofrecido por la Universidad Federal del Amazonas, en el Campus del municipio de Parintins-AM. La metodología adoptada fue basada en el paradigma cualitativo, mediante el análisis y discusión de los datos fueron amparados por la técnica del análisis de contenido. Los sujetos de la investigación fueron dieciséis estudiantes que cursan el último período del curso y un tutor presencial. A pesar de tener en la unidad universitaria profesores presenciales y tutores onlines, optamos, pues, en trabajar sólo con las categorías estudiantes y tutor presencial. Los datos apuntaron a fragilidades que atentan directamente a la calidad del curso investigado. Entre las fragilidades más recurrentes están la falta de seguimiento sistemático en el ambiente online y en las etapas supervisadas en el campo de actuación de esos estudiantes y la falta de diálogo entre profesores y estudiantes en las interfaces.   PALABRAS CLAVE: Educación física a distancia. Enseñanza superior. Formación Inicial

Safety and efficacy of protease inhibitors to treat hepatitis C after liver transplantation: A multicenter experience

Background & Aims: Protease inhibitors (PI) with peginterferon/ ribavirin have significantly improved SVR rates in HCV G1 patients. Their use to treat HCV recurrence after liver transplantation (LT) is a challenge. Methods: This cohort study included 37 liver transplant recipients (male, 92%, age 57 ± 11 years), treated with boceprevir (n = 18) or telaprevir (n = 19). The indication for therapy was HCV recurrence (fibrosis stage PF2 (n = 31, 83%) or fibrosing cholestatic hepatitis (n = 6, 16%). Results: Eighteen patients were treatment-naive, five were relapsers and fourteen were non-responders to dual therapy after LT. Twenty-two patients received cyclosporine and fifteen tacrolimus. After 12 weeks of PI therapy, a complete virological response was obtained in 89% of patients treated with boceprevir, and 58% with telaprevir (p = 0.06). The end of treatment virological response rate was 72% (13/18) in the boceprevir group and 40% (4/10) in the telaprevir group (p = 0.125). A sustained virological response 12 weeks after treatment discontinuation was observed in 20% (1/5) and 71% (5/7) of patients in the telaprevir and boceprevir groups, respectively (p = 0.24). Treatment was discontinued in sixteen patients (treatment failures (n = 11), adverse events (n = 5)). Infections occurred in ten patients (27%), with three fatal outcomes (8%). The most common adverse effect was anemia (n = 34, 92%), treated with erythropoietin and/ or a ribavirin dose reduction; thirteen patients (35%) received red blood cell transfusions. The cyclosporine dose was reduced by 1.8 ± 1.1-fold and 3.4 ± 1.0-fold with boceprevir and telaprevir, respectively. The tacrolimus dose was reduced by 5.2 ± 1.5-fold with boceprevir and 23.8 ± 18.2-fold with telaprevir. Conclusions: Our results suggest that triple therapy is effective in LT recipients, particularly those experiencing a severe recurrence. The occurrence of anemia and drug-drug interactions, and the risk of infections require close monitoring.

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

THE EFFECTS OF DEMOGRAPHIC AND ENVIRONMENTAL FACTORS ON ADULT HEALTH IN BRAZIL

Very little is known about the effects on adult health of environmental conditions in developing countries. Most studies have focused on child health and few have included environmental factors. The shortcomings are associated with difficulties in measuring health status for adults and the limited availability of data on environmental conditions in developing countries. Schultz and Tansel conclude their study stating "the next step in this field of research is to distinguish what variations in public policies or natural variations in environmental conditions combine to explain existing variation in adult morbidity among wage earners." According to UNICEF, over half the population of Brazil live in an unsanitary environment. Worldwide, nearly three billion people do not have access to even a minimally sanitary toilet. This study assesses the effects of demographic factors and key environmental conditions on adult health in Brazil. The research focuses on morbidity among wage earners and the impact of specific environmental conditions. The analysis is based on a household model developed by Schultz and Tansel and treats work absence due to health problems as a measure of adult health status. The data used are from the 1989 Brazilian National Health and Nutrition Survey and 1989 National Basic Sanitation Condition Survey. The first is a household survey that measured individual health and nutrition. The second survey provides data on basic environmental and sanitary conditions at the municipality level

Multicenter Experience with Boceprevir or Telaprevir to Treat Hepatitis C Recurrence after Liver Transplantation: When Present Becomes Past, What Lessons for Future?

International audienceBACKGROUND AND AIMS: First generation protease inhibitors (PI) with peg-interferon (PEG-IFN) and ribavirin (RBV) have been the only therapy available for hepatitis C virus (HCV) genotype 1 infection in most countries for 3 years. We have investigated the efficacy and tolerance of this triple therapy in transplanted patients experiencing a recurrence of HCV infection on the liver graft. PATIENTS: This cohort study enrolled 81 liver transplant patients (Male: 76%, mean age: 55.8±9.7 years) with severe HCV recurrence (F3 or F4: n = 34 (42%), treatment experienced: n = 44 (54%)), treated with boceprevir (n = 36; 44%) or telaprevir (n = 45; 56%). We assessed the percentages of patients with sustained virological responses 24 weeks after therapy (SVR24), and safety. RESULTS: The SVR24 rate was 47% (telaprevir: 42%; boceprevir: 53%, P = ns). At baseline, a normal bilirubin level (p = 0.0145) and albumin level \textgreater35g/L (p = 0.0372) and an initial RBV dosage of ≥800 mg/day (p = 0.0033) predicted SVR24. During treatment, achieving an early virological response after 12 weeks was the strongest independent factor to predict SVR24 (p\textless0.0001). A premature discontinuation of anti-HCV therapy due to a serious adverse event (SAE) was observed in 22 patients (27%). Hematological toxicity, infections and deaths were observed in 95%, 28% and 7% of patients, respectively. A history of post-LT antiviral therapy and thrombocytopenia (\textless50G/L) during treatment were both independent predictors of the occurrence of infections or SAE (p = 0.0169 and p = 0.011). CONCLUSIONS: The use of first generation PI after liver transplantation enabled an SVR24 rate of 47% in genotype 1 patients, but induced a high rate of SAE. The identification of predictive factors for a response to treatment, and the occurrence of SAE, have enabled us to establish limits for the use of this anti-HCV therapy in the transplant settin