Cause-specific mortality for 249 causes in Brazil and states during 1990-2015: a systematic analysis for the global burden of disease study 2015

Estimation and probabilistic projection of age- and sex-specific mortality rates across Brazilian municipalities between 2010 and 2030

BACKGROUND

Mortality rate estimation in small areas can be difficult due the low number of events/exposure (i.e. stochastic error). If the death records are not completed, it adds a systematic uncertainty on the mortality estimates. Previous studies in Brazil have combined demographic and statistical methods to partially overcome these issues. We estimated age- and sex-specific mortality rates for all 5,565 Brazilian municipalities in 2010 and forecasted probabilistic mortality rates and life expectancy between 2010 and 2030.

METHODS

We used a combination of the Tool for Projecting Age-Specific Rates Using Linear Splines (TOPALS), Bayesian Model, Spatial Smoothing Model and an ad-hoc procedure to estimate age- and sex-specific mortality rates for all Brazilian municipalities for 2010. Then we adapted the Lee-Carter model to forecast mortality rates by age and sex in all municipalities between 2010 and 2030.

RESULTS

The adjusted sex- and age-specific mortality rates for all Brazilian municipalities in 2010 reveal a distinct regional pattern, showcasing a decrease in life expectancy in less socioeconomically developed municipalities when compared to estimates without adjustments. The forecasted mortality rates indicate varying regional improvements, leading to a convergence in life expectancy at birth among small areas in Brazil. Consequently, a reduction in the variability of age at death across Brazil's municipalities was observed, with a persistent sex differential.

CONCLUSION

Mortality rates at a small-area level were successfully estimated and forecasted, with associated uncertainty estimates also generated for future life tables. Our approach could be applied across countries with data quality issues to improve public policy planning.

Temporal-spatial analysis of mortality from cardiovascular diseases in the State of Ceará, Brazil, between 2009-2019

OBJECTIVE

To analyze the spatial distribution of mortality from cardiovascular diseases in the municipalities of the state of Ceará, Brazil, between 2009-2019.

METHODS

This is an ecological study with a spatial focus on the state of Ceará, considering the period from 2009 to 2019. Death data from the Brazilian Mortality Information System and population data from the Brazilian Institute of Geography and Statistics were used to calculate crude and standardized mortality rates from cardiovascular diseases. Temporal analysis was carried out using the Joinpoint Regression Program 4.9.0 software and spatial analysis of the municipalities' average mortality. The values were smoothed by the local empirical Bayesian method using QGIS 3.16. For spatial clusters, the Global and Local Moran Index was used through Moran Map and LISA Map, with analyses carried out in TerraView 4.2.2.

RESULTS

A total of 132,145 deaths from cardiovascular diseases were recorded in the period, with an average increase of 3% per year. Higher mortality rates were observed in men, people aged ≥80 years, mixed-race ethnicity/skin color, married, and with lower level of education. There was the formation of clusters of municipalities with high mortality rates in the regions of Vale do Jaguaribe, Sertão Central, Centro Sul, Sertão dos Inhamuns and Serra da Ibiapaba.

CONCLUSION

This study identified municipalities with high mortality and exposed the need for strategies aligned with the reality and particularities of these locations.

Prevalence and associated factors of structural congenital anomalies in resource limited setting, 2023: a systematic review and meta-analysis

Background

Several studies have been conducted on structural congenital anomalies (CA). However, there is a paucity of studies that provide a comprehensive review of structural anomalies. We aimed to verify the available research articles to pool the possible risk factors of structural CA in resource-limited settings.

Setting

The research articles were genuinely searched using PubMed, Scopus, Cochrane Library, Web of Science, free Google database search engines, Google Scholar, and ScienceDirect databases. Published studies were searched and screened for inclusion in the final analysis, and studies without sound methodologies and review and meta-analysis were not included in the analysis.

Participants

This review analyzed data from 95,755 women who gave birth as reported by primary studies. Ten articles were included in this systematic review and meta-analysis. The articles that had incomplete information and case reports were excluded from the study.

Results

The overall pooled effect estimate (EI) of structural CA was 5.50 (4.88-6.12) per 100 births. In this systematic review and meta-analysis, maternal illness EI with odds ratio (OR) = 4.93 (95% CI: 1.02-8.85), unidentified drug use with OR = 2.83 (95% CI: 1.19-4.46), birth weight with OR = 4.20 (95% CI: 2.12-6.28), chewing chat with OR = 3.73 (95% CI: 1.20-6.30), chemical exposure with OR = 4.27 (95% CI: 1.19-8.44), and taking folic acid tablet during pregnancy with OR = 6.01 (95% CI: 2.87-14.89) were statistically significant in this meta-regression.

Conclusions

The overall pooled effect estimate of structural CA in a resource-limited setting was high compared to that in countries with better resources. Maternal illness, unidentified drug use, birth weight, chewing chat, chemical exposure, and never using folic acid were found to be statistically significant variables in the meta-regression. Preconception care and adequate intake of folic acid before and during early pregnancy should be advised.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022384838.

Effect Of Persistent Organic Pollutants In Patients With Ischemic Stroke And All Stroke: A Systematic Review And Meta-Analysis

The role of environmental contaminants and their association with stroke is still being determined. Association has been shown with air pollution, noise, and water pollution; however, the results are inconsistent across studies. A systematic review and meta-analysis of the effect of persistent organic pollutants (POP) in ischemic stroke patients were conducted; a comprehensive literature search was carried out until 30^th June 2021 from different databases. The quality of all the articles which met our inclusion criteria was assessed using Newcastle-Ottawa scaling; five eligible studies were included in our systematic review. The most studied POP in ischemic stroke was polychlorinated biphenyls (PCBs), and they have shown a trend for association with ischemic stroke. The study also revealed that living near a source of POPs contamination constitutes a risk of exposure and an increased risk of ischemic stroke. Although our study provides a strong positive association of POPs with ischemic stroke, more extensive studies must be conducted to prove the association.

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil

OBJECTIVE

 To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital.

METHODS

 Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression.

RESULTS

 In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36).

CONCLUSION

 there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Social inequalities in the temporal trend of mortality from sickle cell disease in Brazil, 1996-2019

Contrary to international trends, the mortality rate of sickle cell disease increased in Brazil after the implementation of the neonatal screening program, probably due to improving access to diagnosis. This study aimed to assess differences in the temporal trend of the mortality rate and median age at death from sickle cell disease in Brazil, considering implemented measures to expand diagnosis, and improve health care access in-country and in the international scenario. Time series were extracted from the Brazilian Mortality Information System from 1996 to 2019. Changes in the mortality rate and median age at death were verified via segmented regression models, which were stratified by sex, region of residence, and age. Most deaths occurred in non-white people, young adults, and the Southeast and Northeast population. Sickle cell disease mortality rate increased until 2010 (13.31%; 95%CI: 6.37; 20.70), particularly in individuals aged 30 years or more (12.78%; 95%CI: 2.98; 23.53) and in the Northeast (12.27%; 95%CI: 8.92; 15.72). Most deaths occurred in the second decade of life (3.01 deaths/million), with a 59% increase in the median age of death in Brazil, from 27.6 to 30.3 years, more pronounced in females and the North Region. The observed gain in the survival of sickle cell disease in Brazil is still much lower than in developed countries and presents regional disparities, probably due to the lack of access to health care and recent treatments, such as hydroxyurea, still restricted to hematological referral centers in Brazilian capitals.

Real-World Treatment of Patients Newly Diagnosed with Chronic Obstructive Pulmonary Disease: A Retrospective German Claims Data Analysis

Purpose

This study aimed to describe the real-world treatment of German incident COPD patients, compare that treatment with clinical guidelines, and provide insight into disease development after incident diagnosis. In addition, the economic burden of the disease by assessing COPD-related healthcare costs was described.

Patients and Methods

Based on a German claims dataset, continuously insured individuals (04/2014-03/2019) aged 40 years or older with at least two incident pulmonologist's diagnoses or one inpatient diagnosis of COPD (ICD-10-GM code J44.-; no respective diagnosis in a 12-month baseline period) were selected. Treatment patterns after incident diagnosis considering inhaled maintenance therapies identified by ATC codes (outpatient prescriptions) were analyzed. Prescription patterns were compared with recommendations of German COPD treatment guidelines. Severe exacerbations were assessed as hospitalizations with main diagnosis ICD-10-GM code J44.1. COPD-associated costs from the perspective of the health insurance fund AOK PLUS were calculated per patient-year (PY).

Results

The sample comprised 17,464 incident COPD patients with a mean age of 71.5 years. 58.9% were male and the mean Charlson-Comorbidity-Index was 5.3. During follow-up (median: 2.0 years), 57.1% of the patients received at least one prescription of an inhaled maintenance therapy, whereas 42.9% did not. Among treated patients, 35.2% started their treatment with LABA/LAMA, 25.3% with LAMA monotherapy, 16.2% with LABA/ICS, and 7.8% with LABA/LAMA/ICS therapy. Within four weeks after initial diagnosis, ICS-containing therapies were prescribed in 14.1% of patients. Of all patients with a prescribed triple therapy, 68.9% had no corresponding exacerbation history documented. On average, 0.16 severe exacerbations and 0.19 COPD-related hospitalizations were observed per PY during available follow-up. Direct COPD-related costs were 3,693 €/PY, with COPD-related hospitalizations being responsible for about 79.2% of these costs.

Conclusion

Long-acting bronchodilators are the mainstay of pharmacological treatment of incident COPD patients in Germany, in line with guideline recommendations. Yet, a considerable proportion of incident COPD patients did not receive any inhaled maintenance therapy.

Marble Dust Effect on the Air Quality: An Environmental Assessment Approach

All over the world, increasing anthropogenic activities, industrialization, and urbanization have intensified the emissions of various pollutants that cause air pollution. Marble quarries in Pakistan are abundant and there is a plethora of small- and large-scale industries, including mining and marble-based industries. The air pollution caused by the dust generated in the process of crushing and extracting marble can cause serious problems to the general physiological functions of plants and it affects human life as well. Therefore, the objectives of this study were to assess the air quality of areas with marble factories and areas without marble factories, where the concentration of particulate matter in terms of total suspended particles (TSP) was determined. For this purpose, EPAM-5000 equipment was used to measure the particulate levels. Besides this, a spectrophotometer was used to analyze the presence of PM2.5 and PM10 in the chemical composition of marble dust. It was observed that the TSP concentrations in Darmangi and Malagori areas of Peshawar, Pakistan—having marble factories—were 626 µg/m3 and 5321 µg/m3 respectively. The (PM2.5, PM10) concentration in Darmangi was (189 µg/m3, 520 µg/m3) and in Malagori, it was recorded as (195 µg/m3, 631 µg/m3), which was significantly higher than the non-marble dust areas and also exceeded WHO recommended standards. It was concluded that the areas with the marble factories were more susceptible to air pollution as the concentration of TSP was significantly higher than the recommended TSP levels. It is recommended that marble factories should be shifted away from residential areas along with strict enforcement. People should be instructed to use protective equipment and waste management should be ensured along with control mechanisms to monitor particulate levels.

Translation, cross-cultural adaptation, and validation of the Los Angeles Prehospital Stroke Screen for use in Brazil

ABSTRACT Background: Stroke is one of the leading causes of death and neurological disability in the world. Several scales help professionals in the early recognition of the disease. However, none of these were developed in Brazil. Objectives: To translate the Los Angeles Prehospital Stroke Screen (LAPSS) into Brazilian Portuguese, and cross-culturally adapt and validate the scale in a representative sample of the Brazilian population. Methods: This study was carried out in two phases: the first consisted in the translation and cross-cultural validation of the LAPSS, and the second in a cross-sectional study with prospectively collected data in patients with suspected stroke treated in a Brazilian prehospital and referred to a stroke center. Statistical analysis was used to assess the sensitivity, specificity, and accuracy of the scale. Cohen's Kappa coefficient (κ) was used for psychometric assessment. Results: After translation and cross-cultural adaptation, the scale was applied to 86 patients. The scale presented a sensitivity of 83.8%, positive predictive value of 79.50%, specificity of 40.70%, negative predictive value of 47.80%, and accuracy of 77%. Cohen’s kappa coefficient was calculated using data from 26 (30.23%) patients and the results showed excellent inter-rater reliability in the majority of the items (52.96%). Conclusions: The scale was translated and cross-culturally adapted for use in Brazil. The scale presented high sensitivity and accuracy but low specificity, and the Cohen’s kappa demonstrated inter-rater reliability. The greatest difficulties occurred when the evaluation included subjective identifications. The scale excluded patients < 45 years old as stroke suspects.

The increasing burden of pancreatic cancer in Brazil from 2000 to 2019: estimates from the Global Burden of Disease Study 2019

INTRODUCTION:

Pancreatic cancer is increasing worldwide. The burden of pancreatic cancer in Brazil and its states was analyzed and compared with that from the USA and China.

METHODS:

This is a descriptive study of the incidence and mortality estimates from the Global Burden of Disease 2019 study, from 2000 to 2019. The Brazilian states presenting the highest and lowest socio-demographic index (SDI) were selected from each of the five regions. The SDI consists of the per capita income, education, and fertility rate of each population.

RESULTS:

A significant increase was found in age-standardized incidence and mortality of pancreatic cancer in all three countries, with differences in magnitude and annual increases. In Brazil, this incidence rose from 5.33 [95% Uncertainty Interval (UI): 5.06- 5.51] to 6.16 (95% UI: 5.68- 6.53) per 100,000 inhabitants. China and the Brazilian states with the lowest SDI, such as Pará and Maranhão, showed lower incidence and mortality rates, although presenting the highest annual increases. No difference was found between the sexes. A higher mortality rate was observed for those individuals of 70+ years, which was three to four times higher than those aged 50 to 69 years.

CONCLUSIONS:

The increasing burden of pancreatic cancer in the studied countries, and the higher estimates for the elderly in a fast-aging country such as Brazil, indicates that more resources and health policies will be necessary. The greatest increase in the states with lower SDI reflects inequalities in the access to diagnosis and registries of this cancer.

Trend of the Burden of Larynx Cancer in Brazil, 1990 to 2019

INTRODUCTION:

Larynx cancer is one of the most common head and neck cancers, whose main risk factors are smoking and alcohol use, and its occurrence and prognosis depend on adequate and timely preventive measures. This study aimed to investigate the burden of larynx cancer in Brazil and its states.

METHODS:

Using estimates from the Global Burden of Disease Study 2019, this study analyzed the trends of incidence, mortality, and disability-adjusted life years (DALYs) for larynx cancer between 1990 and 2019, besides the mortality-to-incidence ratio and the socio demographic index.

RESULTS:

Incidence and mortality due to larynx cancer in Brazil, which are approximately eight-fold higher for men, showed a declining trend between 1990 and 2019 (APPC: -0.4% and -1.0%, respectively). The DALYs also showed negative variation between 1990 and 2019 for both sexes in Brazil, mainly due to the decrease in premature deaths, with the greatest reduction in the state of São Paulo. For the states of Brazil in 2019, the higher age-standardized incidence rate (Rio Grande do Sul, 3.83 cases per 100,000 inhabitants) is twice the lowest rate (Piauí, 1.56 cases per 100,000 inhabitants).

CONCLUSIONS:

A fall in the burden of larynx cancer was observed in Brazil over the past 30 years, which may be attributed to a reduction in smoking and to an improvement in treatment. However, the regional inequalities in the country remain evident, especially for males. This data can guide public policy priorities to control the disease in Brazil.

Associations of plasma lipids, lipoproteins, and cardiovascular outcomes with climatic variations in a large Brazilian population of Campinas, São Paulo state: an eight-year study

In this eight-year retrospective study, we evaluated the associations between climatic variations and the biological rhythms in plasma lipids and lipoproteins in a large population of Campinas, São Paulo state, Brazil, as well as temporal changes of outcomes of cardiovascular hospitalizations. Climatic variables were obtained at the Center for Meteorological and Climatic Research Applied to Agriculture (University of Campinas - Unicamp, Brazil). The plasma lipid databases surveyed were from 27,543 individuals who had their lipid profiles assessed at the state university referral hospital in Campinas (Unicamp). The frequency of hospitalizations was obtained from the Brazilian Public Health database (DATASUS). Temporal statistical analyses were performed using the methods Cosinor or Friedman (ARIMA) and the temporal series were compared by cross-correlation functions. In normolipidemic cases (n=11,892), significantly different rhythmicity was observed in low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol (C) both higher in winter and lower in summer. Dyslipidemia (n=15,651) increased the number and amplitude of lipid rhythms: LDL-C and HDL-C were higher in winter and lower in summer, and the opposite occurred with triglycerides. The number of hospitalizations showed maximum and minimum frequencies in winter and in summer, respectively. A coincident rhythmicity was observed of lower temperature and humidity rates with higher plasma LDL-C, and their temporal series were inversely cross-correlated. This study shows for the first time that variations of temperature, humidity, and daylight length were strongly associated with LDL-C and HDL-C seasonality, but moderately to lowly associated with rhythmicity of atherosclerotic outcomes. It also indicates unfavorable cardiovascular-related changes during wintertime.

Epidemiology, Biodiversity, and Technological Trajectories in the Brazilian Amazon: From Malaria to COVID-19

The Amazon biome is under severe threat due to increasing deforestation rates and loss of biodiversity and ecosystem services while sustaining a high burden of neglected tropical diseases. Approximately two thirds of this biome are located within Brazilian territory. There, socio-economic and environmental landscape transformations are linked to the regional agrarian economy dynamics, which has developed into six techno-productive trajectories (TTs). These TTs are the product of the historical interaction between Peasant and Farmer and Rancher practices, technologies and rationalities. This article investigates the distribution of the dominant Brazilian Amazon TTs and their association with environmental degradation and vulnerability to neglected tropical diseases. The goal is to provide a framework for the joint debate of the local economic, environmental and health dimensions. We calculated the dominant TT for each municipality in 2017. Peasant trajectories (TT1, TT2, and TT3) are dominant in ca. fifty percent of the Amazon territory, mostly concentrated in areas covered by continuous forest where malaria is an important morbidity and mortality cause. Cattle raising trajectories are associated with higher deforestation rates. Meanwhile, Farmer and Rancher economies are becoming dominant trajectories, comprising large scale cattle and grain production. These trajectories are associated with rapid biodiversity loss and a high prevalence of neglected tropical diseases, such as leishmaniasis, Aedes-borne diseases and Chagas disease. Overall, these results defy simplistic views that the dominant development trajectory for the Amazon will optimize economic, health and environmental indicators. This approach lays the groundwork for a more integrated narrative consistent with the economic history of the Brazilian Amazon.

Validated quantitative needs assessment differences in the management of children with central nervous system cancer between Brazil, an upper middle-income country, and the United States of America, a high income country

BACKGROUND

Pediatric cancer cure rates differ among high-income countries (HIC) and upper middle-income countries (UMIC). We have compared individual capacities of two major referral pediatric centers from a HIC and an UMIC caring for children with central nervous system (CNS) cancer.

METHODS

A quantitative needs assessment questionnaire and key informant interviews, distributed in March of 2017, were used to evaluate the treatment of children with CNS cancer at Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC) children's cancer center in São Paulo, Brazil and Nationwide Children's Hospital (NCH) in Columbus, Ohio, United States of America (USA).

RESULTS

Both hospitals had 24-hour pediatric oncology, nursing and intensivist coverage. Supportive care available at both institutions included social workers, psychologists, child life specialists, and physical/occupational/speech therapists. Differences included two part-time neuroradiologists and one pathologist specializing in neuropathology at IOP/GRAACC/UNIFESP, whereas eight full-time neuroradiologists and two neuropathologists at NCH/OSU. There were four pediatric neurosurgeons on staff at each hospital; however, there were only 2 operative days per week at IOP/GRAACC/UNIFESP, compared with 7 days at NCH/OSU. Additionally, time to initiation of radiation therapy at IOP/GRAACC/UNIFESP extended 2-4 weeks compared with less than 1 week at NCH/OSU.

CONCLUSIONS

Center-specific differences in resources exist in highly specialized hospitals caring for children with CNS cancer in HIC and UMIC. This quantitative needs assessment may facilitate the development of targeted strategies for effective interventions to improve on the management of children with CNS cancers.

Recent Trends in Cardiovascular Mortality in Rio de Janeiro State Health Regions and Capital

Fundamento:

A mortalidade por doenças cardiovasculares (DCV) vem mostrando tendência à estabilização em alguns países, incluindo o Brasil e o estado do Rio de Janeiro, após décadas de queda. Não encontramos análises detalhadas dessa tendência para o estado do Rio de Janeiro.

Objetivo:

Analisar as tendências da mortalidade prematura e tardia por doenças do aparelho circulatório (DAC), doença isquêmica do coração (DIC) e doença cerebrovascular (DCBV) por sexo nas regiões de saúde do estado do Rio de Janeiro e capital (1996-2016).

Métodos:

Dados de óbitos e população foram obtidos no DATASUS/MS. Taxas foram compensadas por códigos mal definidos, corrigidos pelos códigos cardiovasculares mal definidos e ajustadas por sexo e idade pelo método direto. O Joinpoint Trend Analysis Software foi empregado para calcular a variação percentual anual (APC) e variação percentual anual média (AAPC). Foram consideradas para o estudo APC e AAPC significativamente diferentes de zero, calculadas por um teste de student com significância de 5%.

Resultados:

A mortalidade por DIC estabilizou ou até aumentou em pelo menos 50% das localidades analisadas (EAPC ≥0). Nas regiões Norte e Noroeste, nenhuma mudança foi observada. Para DCBV, apenas uma região apresentou estabilidade na mortalidade (EAPC próximo a 0). Para as outras regiões, a taxa continuou a diminuir (APC <0) até 2016.

Conclusão:

Esses resultados observados no Rio de Janeiro devem se repetir em várias regiões brasileiras e apontam para a necessidade de uma resposta na abordagem dos comportamentos no estilo de vida. Os médicos da atenção primária devem estar familiarizados com a tendência desfavorável da doença isquêmica do coração entre os adultos mais jovens e rastrear ativamente os fatores de risco para DCV, com atenção especial às mulheres.

Regional Distribution of Causes of Death for Small Areas in Brazil, 1998-2017

Background: What is the spatial pattern of mortality by cause and sex in Brazil? Even considering the main causes of death, such as neoplasms, cardiovascular diseases, external causes, respiratory diseases, and infectious diseases, there are still important debate regarding the spatial pattern of mortality by causes in Brazil. Evidence shows that there is an overlap in transitional health states, due to the persistence of infectious diseases (e.g., dengue, cholera, malaria, etc.,) in parallel with the increase in chronic degenerative diseases. The main objective of this paper is to analyze the spatio-temporal evolution of three groups of causes of death in Brazil across small areas from 1998 to 2017, by sex. Methods: We use publicly available data from the System Data Mortality Information (SIM-DATASUS) from 1998 to 2017. We focus on this period due to the better quality of information, in addition to all deaths are registered following the Tenth Revision of the International Classification of Diseases (ICD-10). We estimate standardized mortality rates by sex and cause aggregated into three main groups. We use a ternary color scheme to maximize all the information in a three-dimensional array of compositional data. Results: We find improvements in mortality from chronic degenerative diseases; faster declines are observed in the Southern regions of the country; but the persistence of high levels of mortality due to infectious diseases remained in the northern parts of the country. We also find impressive differences in external causes of deaths between males and females and an increase in mortality from these causes in the interior part of the country. Conclusions: This study provides useful information for policy makers in establishing effective measures for the prevention of deaths and public health planning for deaths from external and non-communicable causes. We observed how the distribution of causes of death varies across regions and how the patterns of mortality also vary by gender.

Spatial pattern of COVID-19 deaths and infections in small areas of Brazil

As of mid-August 2020, Brazil was the country with the second-highest number of cases and deaths by the COVID-19 pandemic, but with large regional and social differences. In this study, using data from the Brazilian Ministry of Health, we analyze the spatial patterns of infection and mortality from Covid-19 across small areas of Brazil. We apply spatial autoregressive Bayesian models and estimate the risks of infection and mortality, taking into account age, sex composition of the population and other variables that describe the health situation of the spatial units. We also perform a decomposition analysis to study how age composition impacts the differences in mortality and infection rates across regions. Our results indicate that death and infections are spatially distributed, forming clusters and hotspots, especially in the Northern Amazon, Northeast coast and Southeast of the country. The high mortality risk in the Southeast part of the country, where the major cities are located, can be explained by the high proportion of the elderly in the population. In the less developed areas of the North and Northeast, there are high rates of infection among young adults, people of lower socioeconomic status, and people without access to health care, resulting in more deaths.

The Effect of Continuous Low-Intensity Exposure to Electromagnetic Fields from Radio Base Stations to Cancer Mortality in Brazil

Background: this study aims to estimate the rate of death by cancer as a result of Radio Base Station (RBS) radiofrequency exposure, especially for breast, cervix, lung, and esophagus cancers. Methods: we collected information on the number of deaths by cancer, gender, age group, gross domestic product per capita, death year, and the amount of exposure over a lifetime. We investigated all cancer types and some specific types (breast, cervix, lung, and esophagus cancers). Results: in capitals where RBS radiofrequency exposure was higher than 2000/antennas-year, the average mortality rate was 112/100,000 for all cancers. The adjusted analysis showed that, the higher the exposure to RBS radiofrequency, the higher cancer mortality was. The highest adjusted risk was observed for cervix cancer (rate ratio = 2.18). The spatial analysis showed that the highest RBS radiofrequency exposure was observed in a city in southern Brazil that also showed the highest mortality rate for all types of cancer and specifically for lung and breast cancer. Conclusion: the balance of our results indicates that exposure to radiofrequency electromagnetic fields from RBS increases the rate of death for all types of cancer.

Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil

BACKGROUND

It has been suggested that cardiovascular disease exhibits a 'social cross-over', from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.

METHODS

We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).

RESULTS

In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.

CONCLUSIONS

Our results do not support a 'social crossover' in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.

Mortality Due to Acute Myocardial Infarction in Brazil from 1996 to 2016: 21 Years of Disparities in Brazilian Regions

Fundamento:

O infarto agudo do miocárdio (IAM), principal causa de morte no Brasil, apresenta disparidades regionais nas tendências temporais das taxas de mortalidade dos últimos anos. Estudos anteriores de tendências temporais não fizeram correção para os códigos-lixo de causas de mortalidade, o que pode ter enviesado as estimativas.

Objetivo:

Analisar as desigualdades regionais e por sexo na tendência de mortalidade por IAM no Brasil no período de 1996 a 2016.

Métodos:

Estudo de séries temporais de 21 anos (1996 a 2016). Os dados são do Sistema de Informações sobre Mortalidade (SIM) e das estimativas populacionais do Instituto Brasileiro de Geografia e Estatística (IBGE). Foram feitas correções de óbitos por causas mal definidas, códigos-lixo e sub-registro. As séries temporais desagregadas por grandes regiões, sexo, capitais e interior foram analisadas utilizando a técnica de regressão linear segmentada por Jointpoint. O nível de significância estatística adotado foi de 5%.

Resultados:

No período, a mortalidade diminuiu mais acentuadamente no sexo feminino (–2,2%; IC 95%: –2,5; –1,9) do que no masculino (–1,7%; IC 95%: –1,9; –1,4), e mais nas capitais (–3,8%; IC 95%: –4,3; –3,3) do que no interior (–1,5%; IC 95%: –1,8; –1,3). Foram verificadas desigualdades regionais com aumento para homens residentes no interior do Norte (3,3; IC 95%: 1,3; 5,4) e Nordeste (1,3%; IC 95%: 1,0; 1,6). O nível de significância estatística adotado foi de 5%. As taxas de mortalidade após correções, principalmente pela redistribuição dos códigos-lixo, apresentaram expressiva diferença em relação às estimativas sem correções.

Conclusões:

Embora a mortalidade por IAM apresente redução no Brasil nos últimos anos, essa tendência é desigual segundo região e sexo. Desse modo, as correções dos números de óbitos são essenciais para estimativas mais fidedignas.

Mortality by road traffic injuries in Brazil (2000-2016): capital cities versus non-capital cities

OBJECTIVES

To compare the magnitude and trend of mortality by road traffic injuries (RTI) in the capitals and other municipalities of each Brazilian state between 2000 and 2016.

METHODS

A time series analysis of mortality rates by RTI standardized by age was performed, comparing the capitals and the cluster of non-capital municipalities in each state. Data on deaths were obtained from the Sistema de Informações sobre Mortalidade (SIM - Mortality Information System). RTI deaths were considered to be those, whose root cause was designated by ICD-10 codes V01 to V89, with redistribution of garbage codes. To estimate mortality rates, we used the population projections of the Brazilian Institute of Geography and Statistics (IBGE) from 2000 to 2015 and the population estimated by polynomial interpolation for 2016. The trend analysis was performed using the Prais-Winsten method, using the Stata 14.0 program.

RESULTS

There were 601,760 deaths due to RTI in the period (114,483 of residents in capital cities). Mortality by RTI did not present an increasing trend in any of the Capitals in the period under study. Among non-capital municipalities, the trend was growing in 14 states. The greatest increase was observed in Piaui (AIR = 7.50%; 95%CI 5.50 - 9.60). There was a decreasing trend in RTI mortality in 14 capitals, among which Curitiba showed the greatest decrease (AIR = -4.82%; 95%CI -6.61 - -2.92). Only São Paulo and Rio Grande do Sul showed a decreasing trend in mortality by RTI in non-capital cities (AIR = 2.32%; 95%CI -3.32 - -1.3 and AIR = 1.2%, 95%CI -2.41 - 0.00, respectively).

CONCLUSIONS

We conclude that RTI mortality rates in non-capital cities in Brazil showed alarming trends when compared with those observed in capital cities. The development of effective traffic safety actions is almost always limited to Brazilian capitals and large cities. Municipalities with higher risk should be prioritized to strengthen public policies for prevention and control.

Temporal and spatial trends of adult mortality in small areas of Brazil, 1980–2010

To determine the variations and spatial patterns of adult mortality across regions, over time, and by sex for 137 small areas in Brazil, we first apply TOPALS to estimate and smooth mortality rates and then use death distribution methods to evaluate the quality of the mortality data. Lastly, we employ spatial autocorrelation statistics and cluster analysis to identify the adult mortality trends and variations in these areas between 1980 and 2010. We find not only that regions in Brazil’s South and Southeast already had complete death registration systems prior to the study period, but that the completeness of death count coverage improved over time across the entire nation—most especially in lesser developed regions—probably because of public investment in health data collection. By also comparing adult mortality by sex and by region, we document a mortality sex differential in favor of women that remains high over the entire study period, most probably as a result of increased morbidity from external causes, especially among males. This increase also explains the concentration of high male mortality levels in some areas.

The burden of disease among Brazilian older adults and the challenge for health policies: results of the Global Burden of Disease Study 2017

BACKGROUND

Brazil is the world's fifth most populous nation, and is currently experimenting a fast demographic aging process in a context of scarce resources and social inequalities. To understand the health profile of older adults in Brazil is fundamental for planning public policies.

METHODS

The estimates were derived from data obtained through the collaboration between the Brazilian Ministry of Health and the Institute of Health Metrics and Evaluation of the University of Washington. The Brazilian Institute of Geography and Statistics provided the population estimates. Data on causes of death came from the Mortality Information System. To calculate morbidity, population-based studies on the prevalence of diseases in Brazil were comprehensively searched, in addition to information obtained from national databases such as the Hospital Information System, the Outpatient Information System, and the Injury Information System. We presented the Global Burden of Disease (GBD) 2017 estimates among Brazilian older adults (60+ years old) for life expectancy at birth (LE), healthy life expectancy (HALE), cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs), from 2000 to 2017.

RESULTS

LE at birth significantly increased from 71.3 years (95% UI to 70.9-71.8) to 75.2 years (95% UI 74.7-75.7). There was a trend of increasing HALE, from 62.2 years (95% UI 59.54-64.5) to 65.5 years (95% UI 62.6-68.0). The proportion of DALYs among older adults increased from 7.3 to 10.3%. Chronic noncommunicable diseases are the leading cause of death among middle aged and older adults, while Alzheimer's disease is a leading cause only among older adults. Mood disorders, musculoskeletal pain, and hearing or vision losses are among the leading causes of disability.

CONCLUSIONS

The increase in LE and the decrease of the DALYs rates are probably results of the improvement of social conditions and health policies. However, the smaller increase of HALE than LE means that despite living more, people spend a substantial time of their old age with disability and illness. Preventable or potentially controllable diseases are responsible for most of the burden of disease among Brazilian older adults. Health investments are necessary to obtain longevity with quality of life in Brazil.

Changes in the quality of cause-of-death statistics in Brazil: garbage codes among registered deaths in 1996-2016

BACKGROUND

Registered causes in vital statistics classified as garbage codes (GC) are considered indicators of quality of cause-of-death data. Our aim was to describe temporal changes in this quality in Brazil, and the leading GCs according to levels assembled for the Global Burden of Disease (GBD) study. We also assessed socioeconomic differences in the burden of different levels of GCs at a regional level.

METHODS

We extracted data from the Brazilian Mortality Information System from 1996 to 2016. All three- and four-digit ICD-10 codes considered GC were selected and classified into four categories, according to the GBD study proposal. GC levels 1 and 2 are the most damaging unusable codes, or major GCs. Proportionate distribution of deaths by GC levels according selected variables were performed. Age-standardized mortality rates after correction of underreporting of deaths were calculated to investigate temporal relationships as was the linear association adjusted for completeness between GC rates in states and the Sociodemographic Index (SDI) from the GBD study, for 1996-2005 and 2006-2016. We classified Brazilian states into three classes of development by applying tertiles cutoffs in the SDI state-level estimates.

RESULTS

Age-standardized mortality rates due to GCs in Brazil decreased from 1996 to 2016, particularly level 1 GCs. The most important GC groups were ill-defined causes (level 1) in 1996, and pneumonia unspecified (level 4) in 2016. At state level, there was a significant inverse association between SDI and the rate of level 1-2 GCs in 1996-2005, but both SDI and completeness had a non-expected significant direct association with levels 3-4. In 2006-2016, states with higher SDIs tended to have lower rates of all types of GCs. Mortality rates due to major GCs decreased in all three SDI classes in 1996-2016, but GC levels 3-4 decreased only in the high SDI category. States classified in the low or medium SDI groups were responsible for the most important decline of major GCs.

CONCLUSION

Occurrence of major GCs are associated with socioeconomic determinants over time in Brazil. Their reduction with decreasing disparity in rates between socioeconomic groups indicates progress in reducing inequalities and strengthening cause-of-death statistics in the country.

Changes in malaria patterns in Brazil over 28 years (1990-2017): results from the Global Burden of Disease Study 2017

Background

This study presents the malaria burden in Brazil from 1990 to 2017 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), by analyzing disease burden indicators in federated units of the Legal Amazon and Extra-Amazon regions, as well as describing malaria cases according to Plasmodium species occurring in the country.

Methods

We used estimates from the GBD 2017 to report years of life lost due to premature death (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) for malaria in Brazil, grouped by gender, age group, and Brazilian federated unit, from 1990 to 2017. Results are presented as absolute numbers and age-standardized rates (per 100,000 inhabitants) with 95% uncertainty intervals (UI).

Results

At the national level, the age-standardized DALYs rate due to malaria decreased by 92.0%, from 42.5 DALYs per 100,000 inhabitants (95% UI 16.6–56.9) in 1990 to 3.4 DALYs per 100,000 inhabitants (95% UI 2.7–4.7) in 2017. The YLLs were the main component of the total DALYs rate for malaria in 1990 (67.3%), and the YLDs were the main component of the metric in 2017 (61.8%). In 2017, the highest sex–age DALYs rate was found among females in the “< 1-year-old” age group, with a 6.4 DALYs per 100,000 inhabitants (95% UI 1.8–14.7) and among males in the age group of “20 to 24 years old”, with a 4.7 DALYs per 100,000 inhabitants (95% UI 3.3–9.9). Within the Brazilian Amazon region, the three federated units with the highest age-standardized DALYs rates in 2017 were Acre [28.4 (95% UI 14.2–39.1)], Roraima [28.3 (95% UI 13.5–40.2)], and Rondônia [24.7 (95% UI 11.4–34.8)]. Concerning the parasite species that caused malaria, 73.5% of the total of cases registered in the period had Plasmodium vivax as the etiological agent.

Conclusions

The results of the GBD 2017 show that despite the considerable reduction in the DALYs rates between 1990 and 2017, malaria remains a relevant and preventable disease, which in recent years has generated more years of life lost due to disability than deaths. The states endemic for malaria in the Amazon region require constant evaluation of preventive and control measures. The present study will contribute to the direction of current health policies aimed at reducing the burden of malaria in Brazil, as knowing the geographical and temporal distribution of the risk of death and disability of this disease can facilitate the planning, implementation, and improvement of control strategies aimed at eliminating the disease.

The burden of tuberculosis and attributable risk factors in Brazil, 1990-2017: results from the Global Burden of Disease Study 2017

Background

Tuberculosis (TB) continues to be an important cause of fatal and non-fatal burden in Brazil. In this study, we present estimates for TB burden in Brazil from 1990 to 2017 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017).

Methods

This descriptive study used GBD 2017 findings to report years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) of TB in Brazil by sex, age group, HIV status, and Brazilian states, from 1990 to 2017. We also present the TB burden attributable to independent risk factors such as smoking, alcohol use, and diabetes. Results are reported in absolute number and age-standardized rates (per 100,000 inhabitants) with 95% uncertainty intervals (UIs).

Results

In 2017, the number of DALYs due to TB (HIV-negative and HIV-positive combined) in Brazil was 284,323 (95% UI: 240,269–349,265). Among HIV-negative individuals, the number of DALYs was 196,366 (95% UI: 189,645–202,394), while 87,957 DALYs (95% UI: 50,624–146,870) were estimated among HIV-positive individuals. Between 1990 and 2017, the absolute number and age-standardized rates of DALYs due to TB at the national level decreased by 47.0% and 68.5%, respectively. In 2017, the sex–age-specific TB burden was highest among males and in children under-1 year and the age groups 45–59 years. The Brazilian states with the highest age-standardized DALY rates in 2017 were Rio de Janeiro, Pernambuco, and Amazonas. Age-standardized DALY rates decreased for all 27 Brazilian states between 1990 and 2017. Alcohol use accounted for 47.5% of national DALYs due to TB among HIV-negative individuals in 2017, smoking for 17.9%, and diabetes for 7.7%.

Conclusions

GBD 2017 results show that, despite the remarkable progress in reducing the DALY rates during the period, TB remains as an important and preventable cause of health lost to due premature death and disability in Brazil. The findings reinforce the importance of strengthening TB control strategies in Brazil through integrated and multisectoral actions that enable the access to prevention, early diagnosis, and timely treatment, with emphasis on high-risk groups and populations most vulnerable to the disease in the country.

Depressive disorders in Brazil: results from the Global Burden of Disease Study 2017

BACKGROUND

Depression is one of the major causes of disability worldwide. The objective of this study was to analyze the results of the Global Burden of Disease Study 2017 (GBD-2017) for depressive disorders in Brazil and its Federated Units (FUs) in 1990 and 2017.

METHODS

We used GBD-2017 study methodology to evaluate the prevalence estimates, the disability-adjusted life-year (DALY), and the years lived with disability (YLDs) for depressive disorders, which include major depressive disorder and dysthymia. The YLD estimates and the position of these disorders in the DALY and YLD rankings were compared to those of seven other countries. The observed versus expected YLD, based on the sociodemographic index (SDI), were compared.

RESULTS

In GBD-2017, the prevalence of depressive disorders in Brazil was 3.30% (95% uncertainty interval [UI]: 3.08 to 3.57), ranging from 3.79% (3.53 to 4.09) in Santa Catarina to 2.78% in Pará (2.56 to 3.03), with significant differences between the Federated Units. From 1990 to 2017, there was an increase in number of YLD (55.19%, 49.57 to 60.73), but a decrease in the age-standardized rates (- 9.01%, - 11.66 to - 6.31). The highest proportion of YLD was observed in the age range of 15-64 years and among females. These disorders rank 4th and 13th as leading causes of YLD and DALY, respectively, in Brazil. In the other countries evaluated, the ranking of these disorders in the YLD classification was close to Brazil's, while in the DALY classification, there was higher variability. All countries had YLD rates similar to the overall rate. The observed/expected YLD ratio ranged from 0.81 in Pará to 1.16 in Santa Catarina. Morbidity of depressive disorders was not associated with SDI.

CONCLUSIONS

Depressive disorders have been responsible for a high disability burden since 1990, especially in adult women living in the Southern region of the country. The number of people affected by these disorders in the country tends to increase, requiring more investment in mental health aimed at advancements and quality of services. The epidemiological studies of these disorders throughout the national territory can contribute to this planning and to making the Brazilian health system more equitable.

Vulnerable road-user deaths in Brazil: a Bayesian hierarchical model for spatial-temporal analysis

Reducing the road traffic injuries burden is relevant to many sustainable development goals (SDG), in particular SDG3 - to establish good health and well-being. To describe the spatial-temporal trends and identify hotspot regions for fatal road traffic injuries, a Bayesian hierarchical Poisson model was used to analyze data on vulnerable road users (bicyclist, motorcyclist and pedestrians) in Brazil from 1999 to 2016. During the study period, mortality rates for bicyclists remained almost unchanged (0.6 per 100,000 people) but rose dramatically for motorcyclists (from 1.0 in 1999 to 6.0 per 100,000 people in 2016) and decreased for pedestrians (from 6.3 to 3.0 per 100,000 people). Spatial analyses accounting for socio-economic factors showed that the central and northeastern microregions of Brazil are hotspot areas for fatal injuries among motorcyclists while the southern areas are for pedestrians.

Trends and predictions for survival and mortality in individuals with Down syndrome in Brazil: A 21-year analysis

BACKGROUND

Regional heterogeneities and sociodemographic characteristics affect mortality and population survival in Brazil. However, for individuals with Down syndrome (DS) this information remains unknown. In this study, we analysed survival and mortality rates among DS individuals in the five Brazilian geographic regions. In addition, we investigated whether there is an association between mortality and sociodemographic factors across administrative regions.

METHODS

Data between 1996 and 2016, comprising 10 028 records of deaths of individuals with DS, were collected from database records of the Department of Informatics of the Unified Health System. Data on race/ethnicity, sex, age and years of schooling were defined for the association analyses. Survival data were analysed according to the Kaplan-Meier method and Cox regression model.

RESULTS

The number of deaths among people with DS has increased in recent years. Children are more susceptible to death, especially in the first years of life. Individuals living in the northern region, Indigenous women and people with no years of schooling have higher mortality. In the Southeast and South region, for White and Yellow, survival is related to a higher level of education. Ethnic factors and years of schooling influence risk for mortality across the administrative regions.

CONCLUSIONS

These findings show that sociodemographic characteristics affect survival and are associated with the risk of mortality for people with DS. In addition, this suggests that differences in access to health services among Brazilian regions, especially in the first years of life, may affect the survival of individuals with DS.

Effect of a Multifaceted Quality Improvement Intervention on the Prescription of Evidence-Based Treatment in Patients at High Cardiovascular Risk in Brazil: The BRIDGE Cardiovascular Prevention Cluster Randomized Clinical Trial

Importance

Studies have found that patients at high cardiovascular risk often fail to receive evidence-based therapies in community practice.

Objective

To evaluate whether a multifaceted quality improvement intervention can improve the prescription of evidence-based therapies.

Design, Setting, and Participants

In this 2-arm cluster randomized clinical trial, patients with established atherothrombotic disease from 40 public and private outpatient clinics (clusters) in Brazil were studied. Patients were recruited from August 2016 to August 2017, with follow-up to August 2018. Data were analyzed in September 2018.

Interventions

Case management, audit and feedback reports, and distribution of educational materials (to health care professionals and patients) vs routine practice.

Main Outcomes and Measures

The primary end point was prescription of evidence-based therapies (ie, statins, antiplatelet therapy, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) using the all-or-none approach at 12 months after the intervention period in patients without contraindications.

Results

Of the 1619 included patients, 1029 (63.6%) were male, 1327 (82.0%) had coronary artery disease (843 [52.1%] with prior acute myocardial infarction), 355 (21.9%) had prior ischemic stroke or transient ischemic attack, and 197 (12.2%) had peripheral vascular disease, and the mean (SD) age was 65.6 (10.5) years. Among randomized clusters, 30 (75%) were cardiology sites, 6 (15%) were primary care units, and 26 (65%) were teaching institutions. Among eligible patients, those in intervention clusters were more likely to receive a prescription of evidence-based therapies than those in control clusters (73.5% [515 of 701] vs 58.7% [493 of 840]; odds ratio, 2.30; 95% CI, 1.14-4.65). There were no differences between the intervention and control groups with regards to risk factor control (ie, hyperlipidemia, hypertension, or diabetes). Rates of education for smoking cessation were higher among current smokers in the intervention group than in the control group (51.9% [364 of 701] vs 18.2% [153 of 840]; odds ratio, 11.24; 95% CI, 2.20-57.43). The rate of cardiovascular mortality, acute myocardial infarction, and stroke was 2.6% for patients from intervention clusters and 3.4% for those in the control group (hazard ratio, 0.76; 95% CI, 0.43-1.34).

Conclusions and Relevance

Among Brazilian patients at high cardiovascular risk, a quality improvement intervention resulted in improved prescription of evidence-based therapies.

Trial Registration

ClinicalTrials.gov identifier: NCT02851732.

Modifiable risk factors for 9-year mortality in older English and Brazilian adults: The ELSA and SIGa-Bagé ageing cohorts

To quantify and compare 9-year all-cause mortality risk attributable to modifiable risk factors among older English and Brazilian adults. We used data for participants aged 60 years and older from the English Longitudinal Study of Ageing (ELSA) and the Bagé Cohort Study of Ageing (SIGa-Bagé). The five modifiable risk factors assessed at baseline were smoking, hypertension, diabetes, obesity and physical inactivity. Deaths were identified through linkage to mortality registers. For each risk factor, estimated all-cause mortality hazard ratios (HR) and population attributable fractions (PAF) were adjusted by age, sex, all other risk factors and socioeconomic position (wealth) using Cox proportional hazards modelling. We also quantified the risk factor adjusted wealth gradients in mortality, by age and sex. Among the participants, 659 (ELSA) and 638 (SIGa-Bagé) died during the 9-year follow-up. Mortality rates were higher in SIGa-Bagé. HRs and PAFs showed more similarities than differences, with physical inactivity (PAF 16.5% ELSA; 16.7% SIGa-Bagé) and current smoking (PAF 4.9% for both cohorts) having the strongest association. A clear graded relationship existed between the number of risk factors and subsequent mortality. Wealth gradients in mortality were apparent in both cohorts after full adjustment, especially among men aged 60-74 in ELSA. A different pattern was found among older women, especially in SIGa-Bagé. These findings call attention for the challenge to health systems to prevent and modify the major risk factors related to non-communicable diseases, especially physical inactivity and smoking. Furthermore, wealth inequalities in mortality persist among older adults.

Association between C reactive protein and all-cause mortality in the ELSA-Brasil cohort

Background

High-sensitivity C reactive protein (hsCRP) has been proposed as a marker of incident cardiovascular disease and vascular mortality, and may also be a marker of non-vascular mortality. However, most evidence comes from either North American or European cohorts. The present proposal aims to investigate the association of hsCRP with the risk of all-cause mortality in a multiethnic Brazilian population.

Methods

Baseline data (2008–2010) of a cohort of 14 238 subjects participating in the Brazilian Longitudinal Study of Adult Health were used. hsCRP was assayed with immunochemistry. The association of baseline covariates with all-cause mortality was calculated by Cox regression for univariate model and adjusted for different confounders after a mean follow-up of 8.0±1.1 years. The final model was adjusted for age, sex, self-rated race/ethnicity, schooling, health behaviours and prevalent chronic disease.

Results

The risk of death increased steadily by quartiles of hsCRP, from 1.45 (95% CI 1.05 to 2.01) in quartile 2 to 1.95 (95% CI 1.42 to 2.69) in quartile 4, compared with quartile 1. Furthermore, the persistence of a significant graded association after the exclusion of deaths in the first year of follow-up suggests that these results are unlikely to be due to reverse causality. Finally, the HR was unaffected by the exclusion of participants who had self-reported medical history of diabetes, cancer and chronic obstructive pulmonary disease.

Conclusions

Our study shows that hsCRP level is associated with mortality in a highly admixed population, independent of a large set of lifestyle and clinical variables.

How large should a cause of death be in order to be included in mortality trend analysis? Deriving a cut-off point from retrospective trend analyses in 21 European countries

OBJECTIVES

The International Classification of Diseases (ICD-10) distinguishes a large number of causes of death (CODs) that could each be studied individually when monitoring time-trends. We aimed to develop recommendations for using the size of CODs as a criterion for their inclusion in long-term trend analysis.

DESIGN

Retrospective trend analysis.

SETTING

21 European countries of the WHO Mortality Database.

PARTICIPANTS

Deaths from CODs (3-position ICD-10 codes) with ≥5 average annual deaths in a 15-year period between 2000 and 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Fitting polynomial regression models, we examined for each COD in each country whether or not changes over time were statistically significant (with α=0.05) and we assessed correlates of this outcome. Applying receiver operating characteristicROC curve diagnostics, we derived COD size thresholds for selecting CODs for trends analysis.

RESULTS

Across all countries, 64.0% of CODs had significant long-term trends. The odds of having a significant trend increased by 18% for every 10% increase of COD size. The independent effect of country was negligible. As compared to circulatory system diseases, the probability of a significant trend was lower for neoplasms and digestive system diseases, and higher for infectious diseases, mental diseases and signs-and-symptoms. We derived a general threshold of around 30 (range: 28-33) annual deaths for inclusion of a COD in trend analysis. The relevant threshold for neoplasms was around 65 (range: 61-70) and for infectious diseases was 20 (range: 19-20).

CONCLUSIONS

The likelihood that long-term trends are detected with statistical significance is strongly related to COD size and varies between ICD-10 chapters, but has no independent relation to country. We recommend a general size criterion of 30 annual deaths to select CODs for long-term mortality-trends analysis in European countries.

Profile of female deaths by homicide in the city of Goiânia

ABSTRACT Objectives: to identify the female homicide profile in the city of Goiânia. Methods: a cross-sectional, descriptive study that characterized female deaths by homicide from 2008 to 2015. They occurred in Goiânia, and registered in the Mortality Information System. Cases of homicide of women aged ≥ 10 years were eligible. Other causes of death were excluded. Descriptive statistical analysis with frequencies. Results: three hundred seventy-six women died from assault, with an increase in the percentage of deaths annually. Most of the victims were young (57.5%), single (78.8%), mixed-ethnicity (61.1%) and with low education (58.4%). The most frequent means of assault was firearm (64.0%). The health districts with the highest record of female deaths due to assault were southwest, center and northwest. Conclusions: the predominant profile of women victims of femicide was young, mixed-ethnicity, single, with low level of education and living in less favored regions.

Evaluation study of the garbage codes research project in the Northern region of Brazil

INTRODUCTION

The term "garbage code" (GC) is used to designate an underlying cause of death that is not very useful for the health policy, since it does not adequately identify actions to prevent and control diseases and health problems.

OBJECTIVE

To evaluate the results of GC investigation on changing causes of death in 17 municipalities in the Brazilian Northern region in 2017.

METHODS

This is a cross-sectional study on the results of the investigation of deaths with GC in selected hospitals in 17 cities in the seven states of the Northern region, as part of the Data for Health Initiative of the Ministry of Health (MH). In these hospitals, the underlying causes of deaths occurring in 2017 were reviewed, and the GC investigation protocol was applied to deaths with GC.

RESULTS

In 2017, 37,082 deaths occurred in the 17 municipalities studied, of which 29.3% (n = 10,878) were GC and 83.2% were priority GC. Among the priority GCs, 25.9% were investigated, of which 79.1% had a change in the underlying cause.

DISCUSSION

There is great variation among the 17 municipalities in relation to the proportion of GC. In 13 of the municipalities studied, the underlying cause of death was reclassified in at least 70% of the cases investigated for the priority GC.

CONCLUSION

Despite the improvement in reducing the proportion of underlying causes of death with GC in this study, there is still a need for greater investment in training professionals and increasing services to carry out death investigations, in order to ensure the sustainability of the project in the region.

Long-term outcomes after hepatectomy of huge hepatocellular carcinoma: A single-center experience in China

BACKGROUND

Currently, hepatectomy remains the first-line therapy for hepatocellular carcinoma (HCC). However, surgery for patients with huge (>10 cm) HCCs is controversial. This retrospective study aimed to explore long-term survival after hepatectomy for patients with huge HCC.

METHODS

The records of 188 patients with pathologically confirmed HCC who underwent curative hepatectomy between 2007 and 2017 were reviewed; patients were divided into three groups according to tumor size: huge (>10 cm; n = 84), large (5-10 cm; n = 51) and small (<5 cm; n = 53) HCC. Kaplan-Meier analysis was used to assess overall survival (OS) and disease-free survival (DFS), and log-rank analysis was performed for pairwise comparisons among the three groups. Risk factors for survival and recurrence were analyzed using the Cox proportional hazard model.

RESULTS

The median follow-up period was 20 months. Although the prognosis of small HCC was better than that of huge and large HCC, OS and DFS were not significantly different between huge and large HCC (P = 0.099 and P = 0.831, respectively). A family history of HCC, poor Child-Pugh class, vascular invasion, diolame, pathologically positive margins, and operative time ≥240 min were identified as independent risk factors for OS and DFS in a multivariate model. Tumor size (>10 cm) had significant effect on OS, and postoperative antiviral therapy and postoperative complications also had significant effects on DFS.

CONCLUSIONS

Huge HCC is not a contraindication of hepatectomy. Although most of these patients experienced recurrence after surgery, OS and DFS were not significantly different from those of patients with large HCC after resection.

Association Between the Change of Serum Copper and Ischemic Stroke: a Systematic Review and Meta-Analysis

Ischemic stroke is the most common stroke subtypes with all strokes. More and more studies found that serum copper was related to the ischemic stroke. However, the correlation between serum copper and ischemic stroke was inconsistent. We performed the meta-analysis to assess the association between the change of serum copper and ischemic stroke. Electronic databases were identified to search for relevant studies about serum copper and ischemic stroke from inception to February 28, 2019. Eight studies with a total of 777 participants were included into this meta-analysis. Because of high heterogeneity (I² = 71%), we chose a random effect model. Our results showed the serum copper levels were significantly higher in ischemic stroke group compared with controls group (pooled mean difference, 1.25; 95% confidence intervals (CIs), 0.07-2.43; P = 0.04), in particular studies after the year of 2009 (I² = 0%; pooled mean difference, 2.16; 95% CI, 1.37-2.95; P < 0.00001). Serum copper was associated with ischemic stroke, and it may be one of the risk factors of ischemic stroke.

Exercise-induced changes of gene expression in the cerebellum of aged mice

PURPOSE

Exercise has been prescribed to the elderly based on its effect on increasing muscle strength and protein synthesis that prevent sense of balance and/or cognitive functions. However, a few molecular mechanism researches has been conducted on how the vestibular organs, cerebellum, and hippocampus, which are responsible for the deterioration and balance of spatial learning memory due to aging, are affected by exercise.

METHODS

The 9-week old and 84-week old C57Bl/6 were assigned randomly to Young-Control (YC), Young-Exercise (YE), Old-Control (OC) and Old-Exercise (OE) groups for 4 -week treadmill running. A Rotarod test was used to evaluate motor coordination function. Moreover, a high-throughput whole transcript expression RNA array approach was applied to the cerebellum of aged mice to explain the novel molecular mechanism of beneficial effect of exercise.

RESULTS

As results, the motor coordination function was significantly improved in exercise-aged mice. The RNA sequencing analysis showed that the expression of cerebellar genes was significantly changed by aging rather than exercise. Especially, Cers1 was up-regulated in sedentary aged mice and down-regulated in exercise aged mice. Fumonisin B1, inhibition of Cers1, mitigates neuronal cell death induced by doxorubicin.

CONCLUSION

These results provide unraveling specific transcripts and understanding of the exercise-related cerebellum transcriptome in aged mice. Well-designed exercise program might prevent the motor coordination defect in aged model, which development of the exercise protocol for elderly population based on these markers.

Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial

Importance

Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries.

Objective

To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA.

Design, Setting and Participants

This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle.

Interventions

The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster.

Main Outcomes and Measures

The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale).

Results

A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01).

Conclusions and Relevance

A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies.

Trial Registration

ClinicalTrials.gov identifier: NCT02223273.

Assessing the causes of under-five mortality and proportion associated with pneumococcal diseases in Cameroon. A case-finding retrospective observational study: 2006-2012

BACKGROUND

Vital registration data outlining causes of deaths (CoD) are important for a sustainable health system, targeted interventions and other relevant policies. There is data paucity on vital registration systems in developing countries. We assessed the leading causes and proportions of under-five deaths, and particularly those related to pneumococcal infections in Yaoundé, Cameroon, using hospital registration data.

METHODS

A retrospective case-finding observational study design was used to access and identify data on 817 death cases in children under-five years of age recorded in health facilities in Yaoundé, within the period January 1, 2006 and December 31, 2012. Patients' files were randomly selected and needed information including demographic data, date of admission, clinical and laboratory diagnosis, principal and/or underlying causes of death were abstracted into structured case report forms. The International Classification of Diseases and Clinical Modifications 10th revision (ICD-10-CM) codes (ICD10Data.com 2017 edition) were used to classify the different CoD, retrospectively. Ascertainment of CoD was based on medical report and estimates were done using the Kaplan-Meier procedure and descriptive statistics.

RESULTS

Of the 817 death records assessed, malaria was the leading CoD and was responsible for 17.5% of cases. Meningitis was the second largest CoD with 11.0%; followed by sepsis (10.0%), Streptococcus pneumoniae infections (8.3%), malnutrition (8.3%), gastro-enteritis / diarrhoea (6.2%), anaemia (6.1%) and HIV (3.5%), respectively.

CONCLUSION

The main CoD in this population are either treatable or vaccine-preventable; a trend consistent with previous reports across developing countries. Besides, the health effects from non-communicable infections should not be neglected. Therefore, scaling-up measures to reduce causes of under-five deaths will demand sustainable efforts to enhance both treatment and disease prevention strategies, to avoid a decline in the progress towards reducing under-five deaths by 2/3 from the 1990 baseline.