The influence of the day of the week of hospital admission on the prognosis of stroke patients

This study aimed to evaluate the weekday and weekend distribution of stroke case hospital admissions and their respective prognosis based on a sample from the Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA), a cohort of stroke patients admitted to a community hospital in the city of São Paulo, Brazil. We ascertained all consecutive cases of first-time strokes between April 2006 and December 2008 and performed a subsequent one-year follow-up. No association was found between frequency of hospital admissions due to ischemic and hemorrhagic strokes and the specific day of the week on which the admission occurred. However, ten-day and twelve-month case-fatality was higher in hemorrhagic stroke patients admitted at the weekend. We also found that intracerebral hemorrhage patients admitted on weekends had a worse survival rate (50%) compared with those admitted during weekdays (25.6%, P log-rank = 0.03). We found a multivariate hazard ratio of 2.49 (95%CI: 1.10-5.81, P trend = 0.03) for risk of death at the weekend compared to weekdays for intracerebral hemorrhage cases. No difference in survival was observed with respect to the overall sample of stroke or ischemic stroke patients

Nível de escolaridade e dependência funcional em sobreviventes de acidente vascular cerebral isquêmico

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. >= 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.Foi avaliada a dependência funcional em sobreviventes de acidente vascular cerebral (AVC) do Estudo da Mortalidade e Morbidade do Acidente Vascular Cerebral, utilizando a Escala de Rankin. De 355 sobreviventes com AVC isquêmico (idade média de 67,9 anos), 40% tinham dependência funcional em 28 dias e 34,4% em 6 meses. Os principais indicadores de dependência física foram identificados em 28 dias, e eram: baixa escolaridade (analfabetos vs. > 8 anos de educação, RC = 3,7; IC95%: 1,60-8,54) e localização do AVC (infarto circulação total anterior, RC = 16,9; IC95%: 2,93-97,49). Baixo nível educacional e insulto cerebral isquêmico influenciaram o grau de dependência funcional nesses sobreviventes de AVC. Nossos achados reforçam a necessidade de desenvolvimento de estratégias para reabilitação de pacientes com AVC e formulação de estratégias específicas de atenção e tratamento para essas pessoas, especialmente na população com baixo nível socioeconômico.CNPqFAPES

A Reappraisal in Sao Paulo, Brazil (2008) of "The Ecology of Medical Care:" The "One Per Thousand's Rule"

BACKGROUND AND OBJECTIVES: Medical ecology is a conceptual framework introduced in 1961 to describe the relationship and utilization of health care services by a given population. We applied this conception to individuals enrolled in a private health maintenance organization (HMO) in Sao Paulo, Brazil, with the aim of describing the utilization of primary health care, verifying the frequency of various symptoms, and identifying the roles of different health care sources. METHODS: This was a cross-sectional telephone survey among a random sample of people enrolled in a private HMO. We interviewed a random sample of non-pregnant adults over age 18 using 10 questions about symptoms and health care use during the month prior to interview. RESULTS: The final sample consisted of 1,065 participants (mean age 68 years, 68% female). From this sample, 424 (39.8%) reported the presence of symptoms, 311 (29.2%) had a medical office consult, 104 (9.8%) went directly to an emergency medical department, 63 (5.9%) were hospitalized, 22 (2.1%) used complementary medicine resources, seven (0.7%) were referred to home care, and one (0.1%) was admitted to an academic hospital. CONCLUSIONS: The proportion of study participants referred to an academic care center was similar to that observed in previous "medical ecology" studies in different populations

Suicide rates and income in Sao Paulo and Brazil: a temporal and spatial epidemiologic analysis from 1996 to 2008

Background: In a classical study, Durkheim noted a direct relation between suicide rates and wealth in the XIX century France. Since that time, several studies have verified this relationship. It is known that suicide rates are associated with income, although the direction of this association varies worldwide. Brazil presents a heterogeneous distribution of income and suicide across its territory; however, evaluation for an association between these variables has shown mixed results. We aimed to evaluate the relationship between suicide rates and income in Brazil, State of Sao Paulo (SP), and City of SP, considering geographical area and temporal trends. Methods: Data were extracted from the National and State official statistics departments. Three socioeconomic areas were considered according to income, from the wealthiest (area 1) to the poorest (area 3). We also considered three regions: country-wide (27 Brazilian States and 558 Brazilian micro-regions), state-wide (645 counties of SP State), and city-wide (96 districts of SP city). Relative risks (RR) were calculated among areas 1, 2, and 3 for all regions, in a cross-sectional approach. Then, we used Joinpoint analysis to explore the temporal trends of suicide rates and SaTScan to investigate geographical clusters of high/low suicide rates across the territory. Results: Suicide rates in Brazil, the State of SP, and the city of SP were 6.2, 6.6, and 5.4 per 100,000, respectively. Taking suicide rates of the poorest area (3) as reference, the RR for the wealthiest area was 1.64, 0.88, and 1.65 for Brazil, State of SP, and city of SP, respectively (p for trend <0.05 for all analyses). Spatial cluster of high suicide rates were identified at Brazilian southern (RR = 2.37), state of SP western (RR = 1.32), and city of SP central (RR = 1.65) regions. A direct association between income and suicide were found for Brazil (OR = 2.59) and the city of SP (OR = 1.07), and an inverse association for the state of SP (OR = 0.49). Conclusions: Temporospatial analyses revealed higher suicide rates in wealthier areas in Brazil and the city of SP and in poorer areas in the State of SP. We further discuss the role of socioeconomic characteristics for explaining these discrepancies and the importance of our findings in public health policies. Similar studies in other Brazilian States and developing countries are warranted

Potent Antiretroviral Therapy for Human Immunodeficiency Virus Infection Increases Aortic Stiffness

Background: Highly active antiretroviral therapy for AIDS is known to increase cardiovascular risk, but the effects of potent antiretroviral agents according to gender are unknown. Objective: The present study evaluated the impact of HIV infection treatment on aortic stiffness according to gender. Methods: From university-affiliated hospitals, we recruited 28 AIDS patients undergoing highly active antiretroviral treatment (HAART), 28 treatment-naive HIV-infected patients, 44 patients with type 2 diabetes, and 30 controls. Aortic stiffness was determined by measuring pulse wave velocity (PWV) using a validated and non-invasive automatic device. Results: The crude mean PWV values and 95% confidence intervals (95% CI) for HAART, diabetics, and controls were 9.77 m/s (95% CI 9.17-10.36),, 9.00 m/s (95% CI 8.37-9.63), 9.90 m/s (95% CI 9.32-10.49), and 9.28 m/s (95% CI 8.61-9.95), respectively, for men (P-value for trend = 0.14), and 9.61 m/s (95% CI 8.56-10.66), 8.45 m/s (95% CI 7.51-9.39), 9.83 (95% CI 9.21-10.44), and 7.79 m/s (95% CI 6.99-8.58), respectively, for women (P-value for trend &lt;0.001). Post-hoc analysis revealed a significant difference between the mean PWV values in the HAART group and controls in women (P-value &lt;0.01). After adjusting for other potential covariates, including systolic blood pressure and diabetes, these results did not change. The findings indicate that the impact of HAART treatment on aortic stiffness was amplified in women with hypertension, dyslipidemia, and metabolic syndrome. Conclusion: Potent anti-retroviral agents used in the treatment of HIV infection increases aortic stiffness, mainly among women with higher cardiovascular risk. (Arq Bras Cardiol 2012;99(6):1100-1107)Fundamento: Sabe-se que a terapia antirretroviral altamente potente para Aids reconhecida aumenta o risco cardiovascular, mas os efeitos dos agentes antirretrovirais de acordo com o gênero ainda são desconhecidos. Objetivo: O presente estudo avaliou o impacto do tratamento para o vírus da imunodeficiência humana (HIV) na rigidez\ud aórtica de acordo com o gênero. Métodos: Foram recrutados 28 pacientes com Aids submetidos à terapia antirretroviral altamente potente (HAART), 28 pacientes\ud infectados pelo HIV virgens de tratamento, 44 pacientes com diabetes tipo 2, e 30 controles. A rigidez aórtica foi determinada pela medição da Velocidade da Onda de Pulso (VOP), utilizando um equipamento automático validado e não invasivo. Resultados: Os resultados médios brutos da VOP (e intervalo de confiança de 95%) para participantes nos grupos terapia antirretroviral potente, HIV virgem de tratamento, diabéticos, e controles foram 9,77 m/s (9,17-10,36), 9,00 m/s (8,37-9,63), 9,90 m/s (9,32-10,49) e 9,28 m/s (8,61-9,95), respectivamente, para os homens (p de tendência = 0,14) e 9,61 m/s\ud (8,56-10,66), 8,45 m/s (7,51-9,39), 9,83 (9,21-10,44) e 7,79 m/s (6,99-8,58), respectivamente, para as mulheres (p valor de tendência < 0,001). Análises post-hoc revelaram uma diferença significativa entre os valores médios de VOP no grupo com HAART e controles em mulheres (p < 0,01). Ajustes para as demais covariáveis potenciais, incluindo pressão arterial sistólica e diabetes, não alteraram esses resultados. Os achados indicam que o impacto do tratamento com HAART na rigidez aórtica foi amplificado nas mulheres com hipertensão, dislipidemia e síndrome metabólica. Conclusão: Agentes antirretrovirais potentes utilizados no tratamento da infecção pelo HIV aumentam a rigidez da aorta, especialmente em mulheres com maior risco cardiovascular. (Arq Bras Cardiol 2012;99(6):1100-1107)FAPESPFAPES

Insulin resistance and carotid intima-media thickness mediate the association between resting-state heart rate variability and executive function: A path modelling study

Background: Research has linked high-frequency heart rate variability (HF-HRV) to cognitive function. The present study adopts a modern path modelling approach to understand potential causal pathways that may underpin this relationship. Methods: Here we examine the association between resting-state HF-HRV and executive function in a large sample of civil servants from Brazil (N = 8114) recruited for the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). HF-HRV was calculated from 10-min resting-state electrocardiograms. Executive function was assessed using the trail-making test (version B). Results and conclusions: Insulin resistance (a marker of type 2 diabetes mellitus) and carotid intima-media thickness (subclinical atherosclerosis) mediated the relationship between HRV and executive function in seriatim. A limitation of the present study is its cross-sectional design; therefore, conclusions must be confirmed in longitudinal study. Nevertheless, findings support that possibility that HRV provides a 'spark' that initiates a cascade of adverse downstream effects that subsequently leads to cognitive impairment.Fil: Kemp, Andrew H.. University of Sydney; Australia. Universidade de Sao Paulo; BrasilFil: Rodríguez López, Santiago. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad. Universidad Nacional de Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad; Argentina. University of Sydney; Australia. Universidad Autónoma de Madrid; EspañaFil: Passos, Valeria M. A.. Universidade Federal de Minas Gerais; BrasilFil: Bittencourt, Marcio S.. Universidade de Sao Paulo; BrasilFil: Dantas, Eduardo M.. University of Vale do São Francisco; BrasilFil: Mill, José G.. Universidade Federal do Espírito Santo; BrasilFil: Ribeiro, Antonio L. P.. Universidade Federal de Minas Gerais; BrasilFil: Thayer, Julian F.. Ohio State University; Estados UnidosFil: Bensenor, Isabela M.. Universidade de Sao Paulo; BrasilFil: Lotufo, Paulo A.. Universidade de Sao Paulo; Brasi

Atrial Fibrillation Diagnosis using ECG Records and Self-Report in the Community:Cross-Sectional Analysis from ELSA-Brasil

FUNDAMENTO: A fibrilação ou flutter atrial (FFA) é a arritmia cardíaca sustentada mais comum. Existem poucos dados sobre a epidemiologia da FFA na América do Sul. OBJETIVO: O presente estudo procurou descrever a epidemiologia clínica da FFA e o uso de anticoagulantes na avaliação da linha de base do Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil). MÉTODOS: Foram analisados dados de 13.260 participantes do ELSA-Brasil. A FFA foi definida pelo eletrocardiograma ou por autorrelato. Modelos de regressão logística foram construídos para analisar fatores associados à FFA. Este estudo também analisou se idade e sexo estavam associados ao uso de anticoagulantes para evitar acidente vascular cerebral. O nível de significância foi de 5%. RESULTADOS: A idade mediana foi de 51 anos, e 7.213 (54,4%) participantes eram mulheres. A FFA foi detectada em 333 (2,5%) participantes. O aumento da idade (razão de chances [RC]:1,05; intervalo de confiança de 95% [IC95%]: 1,04-1,07), hipertensão (RC:1,44; IC95%:1,14-1,81) coronariopatia (RC: 5,11; IC95%:3,85–6,79), insuficiência cardíaca (RC:7,37; IC95%:5,00–10,87) e febre reumática (RC:3,38; IC95%:2,28–5,02) foram associadas à FFA. Dos 185 participantes com FFA e pontuação no CHA(2)DS(2)-VASc≥2, apenas 20 (10,8%) usavam anticoagulantes (50,0% entre aqueles com FFA no eletrocardiograma de linha de base). O uso de anticoagulantes nesse grupo foi associado a maior idade (1,8% vs 17,7% naqueles com idade ≤ 54 e ≥ 65 anos, respectivamente; p=0,013). Observou-se uma tendência ao menor uso de anticoagulantes em mulheres (7,1% vs. 16,4% em mulheres e homens, respectivamente; p=0,055). CONCLUSÕES: No recrutamento do ELSA-Brasil, 2,5% dos participantes tinham FFA. O baixo uso de anticoagulantes era comum, o que representa um desafio para os cuidados de saúde nesse cenário

ELSA-Brasil: a 4-year incidence of hearing loss in adults with and without hypertension

OBJECTIVE To compare the incidence of hearing loss among adults stratified by the occurrence of hypertension, and to investigate the association between hypertension and hearing loss. METHODS Longitudinal observational study, part of the Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil, Longitudinal Study on Adult’s Health). Data from the first and second waves were analyzed, including information from audiological assessment and general health of the subjects. As outcome, we considered the presence of hearing loss (hearing thresholds above 25 dBHL at frequencies from 500 Hz to 8 kHz) and, as exposure variable, hypertension (report of medical diagnosis of hypertension; and/or use of drugs to treat hypertension; and/or pressure systolic blood pressure ≥ 140 mmHg; or diastolic blood pressure ≥ 90 mmHg). As covariables for adjustment were considered: sex, age, education, race / ethnicity, income, smoking, diabetes, and occupational exposure to noise. Poisson regression analysis was conducted, estimating the crude and adjusted relative risks, with 95% confidence intervals, in order to assess the factors associated with hearing loss. RESULTS In crude analyses, the incidence of hearing loss was higher for subjects with hypertension (9.7% versus 5.4%). The crude relative risks for hearing loss was almost double (1.93; 95%CI: 1.10–3.39) for subjects with hypertension in the right ear. In the adjusted analyses, the relative risks was not significant for the hypertension variable (1.42; 95%CI: 0.75–2.67). Being 60 years or older (RR: 5.41; 95%CI: 2.79–10.50) showed a statistically significant association with hearing loss, indicating that older adults have higher relative risks for hearing loss. CONCLUSION In the adjusted analyses controlled for multiple risk factors there was no association between hypertension and hearing loss. The dichotomous variable age (being 60 years or older), on the other hand, has shown a significant association with hearing loss

Validation of the Short-Version of Rose Angina Questionnaire in Brazil

Background: Stable angina pectoris is a serious condition with few epidemiological studies in Brazil. Objective: To validate the short-version of the Rose angina questionnaire in Brazilian Portuguese for its implementation in surveys and longitudinal studies. Methods: A total of 116 consecutive patients from an outpatient clinic without prior myocardial infarction and/or coronary revascularization were enrolled for application of three questions of the Rose angina questionnaire addressing chest pain after exertion. We used the treadmill test as the gold standard with the Ellestad protocol. Results: The short-version of the Rose angina questionnaire of the 116 subjects submitted to the exercise treadmill test disclosed 89.7% of accuracy, 25% of sensitivity, 92.0% of specificity, 10.0% of positive predictive value, 97.2% of negative predictive value, and 3.1 of positive likelihood ratio and 0.82 of negative likelihood ratio. Conclusion: The Portuguese version with three items of the Rose angina questionnaire is suitable for epidemiological purposes. (Arq Bras Cardiol 2012; 99(5): 1056-1059