COVID-19 death risk predictors in Brazil using survival tree analysis: a retrospective cohort from 2020 to 2022

PURPOSE

This study analyses the survival of hospitalized patients with Severe Acute Respiratory Syndrome (SARS) due to COVID-19 and identifies the risk groups for death due to COVID-19 from the identification of potential interactions between its predictors.

METHODS

This was a retrospective longitudinal study with data from 1,756,917 patients reported in the Influenza Epidemiological Surveillance Information System from 26 February 2020 to 31 December 2022. In this study, all adult and older (≥ 20 years) patients were hospitalized with SARS due to COVID-19, with death as the outcome. Survival tree analysis was used to identify potential interactions between the predictors. A model was built for each year of study.

RESULTS

Hospital lethalitywas 33.2%. The worst survival curve was observed among those who underwent invasive mechanical ventilation and were aged 80 years or older in the three years of the pandemic. Black and brown race/color were predictors of deaths in the years 2020 and 2021 when there was greater demand from the health system due to the greater number of cases.

CONCLUSION

By applying survival tree analysis we identified several numbers of homogeneous subgroups with different risks for mortality from COVID-19. These findings show the effects of wide inequalities of access by the population, requiring effective policies for the reduction and adequate management of the disease.

Equations for Prediction of Body Adiposity in Patients With Chronic Kidney Disease Undergoing Hemodialysis

OBJECTIVES

The prevalence of obesity in the population has increased and excess body adiposity is one of the main nutritional disorders in patients with chronic kidney disease (CKD) on hemodialysis (HD). The objective of this study was to develop equations using anthropometric measurements to predict the total and abdominal body adiposity of patients with CKD on HD.

METHODS

This is a cross-sectional study evaluating 323 patients with CKD on HD in city in northeastern Brazil. Measurements and anthropometric indicators were correlated with percentage of body fat (%BF) and visceral fat (VF, in kg) measured by dual energy X-ray absorptiometry. Multiple linear regression models based on different combinations of anthropometric measurements were adjusted to develop the equations, with subsequent cross-validation.

RESULTS

Of the 323 patients, 62.2% were male and 46.5% were aged between 40 and 59 years. The equation selected to estimate %BF included weight, height, waist and hip circumferences, and triceps and suprailiac skin folds, presenting high predictive capacity (R2 = 0.771). The equation selected to estimate VF included weight, height, waist circumference, hip circumference, and sum of skin folds (R22 = 0.796).

CONCLUSIONS

The proposed equations efficiently predicted the %BF and VF (kg) of patients with CKD on HD, thereby serving as viable indicators in clinical practice.

Prediction of deciduous teeth eruption in Brazilian children: A cross-sectional study nested in a prospective birth cohort (BRISA)

BACKGROUND

Dental eruption is part of a set of children´s somatic growth phenomena. The worldwide accepted human dental eruption chronology is still based on a small sample of European children. However, evidence points to some population variations with the eruption at least two months later in low-income countries, and local standards may be useful. So, this study aimed to predict deciduous teeth eruption from 12 months of age in a Brazilian infant population.

METHODS

We developed a cross-sectional study nested in four prospective cohorts - the Brazilian Ribeirão Preto and São Luís Cohort Study (BRISA) - in a sample of 3,733 children aged 12 to 36 months old, corrected by gestational age. We made a reference curve with the number of teeth erupted by age using the Generalized Additive Models for location, scale, and shape (GAMLSS) technique. The explanatory variable was the corrected children´s age. The dependent variable was the number of erupted teeth, by gender, evaluated according to some different outcome distributional forms. The generalized Akaike information criterion (GAIC) and the model residuals were used as the model selection criterion.

RESULTS

The Box-Cox Power Exponential method was the GAMLSS model with better-fit indexes. Our estimation curve was able to predict the number of erupted deciduous teeth by age, similar to the real values, in addition to describing the evolution of children's development, with comparative patterns. There was no difference in the mean number of erupted teeth between the sexes. According to the reference curve, at 12 months old, 25% of children had four erupted teeth or less, while 75% had seven or fewer and 95% had 11 or fewer. At 24 months old, 5% had less than 12, and 75% had 18 or more. At 36 months old, around 50% of the population had deciduous dentition completed (20 teeth).

CONCLUSION

The adjusted age was an important predictor of the number of erupted deciduous teeth. This outcome can be a variable incorporated into children's growth and development curves, such as weight and height curves for age to help dentists and physicians in the monitoring the children's health.

Spatial analysis of hospital-related mortality due to COVID-19 among children and adolescents in Brazil

The objective was to perform a spatial analysis of the hospital mortality rate (HMR) due to severe acute respiratory syndrome (SARS) attributed to COVID-19 among children and adolescents in Brazil from 2020 to 2021. A cluster method was used to group federal units (FUs) based on HMR. In 2020, clusters with high HMRs were formed by north/northeast FUs. In 2021, there was a reduction in HMR. Clusters with higher rates remained in the N/NE region. Regional differences were observed in the HMR. The findings may reflect social inequalities and access to hospital care, especially in the under 1-year-old age group due to the severity of the disease in this group.

Comparison of beriberi cases in indigenous and non-indigenous people, Brazil, 2013 to 2018

Beriberi is the clinical manifestation of severe and prolonged thiamine (vitamin B1) deficiency. It is a neglected disease that affects low-income populations facing food and nutrition insecurity. The aim of this study was to compare cases of beriberi among indigenous and non-indigenous people in Brazil. We conducted a cross-sectional study using data on cases of beriberi during the period July 2013-September 2018 derived from beriberi notification forms available on the FormSUS platform. Cases in indigenous and non-indigenous patients were compared using the chi-squared test or Fisher's exact test, adopting a significance level of 0.05. A total of 414 cases of beriberi were reported in the country during the study period, 210 of which (50.7%) were among indigenous people. Alcohol consumption was reported by 58.1% of the indigenous patients and 71.6% of the non-indigenous patients (p = 0.004); 71.0% of the indigenous patients reported that they consumed caxiri, a traditional alcoholic drink. Daily physical exertion was reported by 76.1% of the indigenous patients and 40.2% of the non-indigenous patients (p < 0.001). It is concluded that beriberi disproportionately affects indigenous people and is associated with alcohol consumption and physical exertion.

Prevalence of metabolic syndrome in adolescents based on three diagnostic definitions: a cross-sectional study

Objective

There is no consensus as to the best criterion for the evaluation of metabolic syndrome (MS), impairing the estimation of its prevalence. This study aims to compare MS estimates using three recommended definitions for adolescents based on a cross-sectional study nested in the Consortium of Brazilian Birth Cohorts in São Luís, Maranhão.

Subjects and methods

A total of 2,515 adolescents aged between 18 and 19 years were evaluated. The criteria of International Diabetes Federation (IDF) and National Cholesterol Education Program Panel III (NCEP-ATP) modified by Cook and cols. (2003) and De Ferranti and cols. (2004) defined SM. To compare the estimates of MS prevalence, the chi-square, Fisher´s exact and Cohen´s Kappa index tests were used.

Results

Among the 2,064 participants evaluated in the final sample. The prevalence of MS ranged from 4.2% (95% CI: 3.3-5.1) to 10.2% (95% CI: 8.8-11.4). When comparing the estimates of MS prevalence in the total sample and by sex, a statistically significant difference was observed. The agreement between the criteria ranged from 0.42 (CI 95%: 0.35-0.49) to 0.55 (CI 95%: 0.48-0.62) in the total sample, 0.33 (CI 95%: 0.24-0.42) to 0.59 (95%CI: 0.47-0.71) among boys and 0.39 (95% CI: 0.26-0.52) to 0.54 (95% CI: 0.44-0.64) among girls.

Conclusion

Different criteria provide different estimates for the prevalence of MS in adolescents, reflecting the importance of establishing a consensus.

Factors associated with the occurrence of upright birth in Brazil

OBJECTIVE

To identify the factors associated with Upright Delivery (UD) performed in hospitals linked to the Rede Cegonha (RC) in Brazil.

METHODS

Cross-sectional study with 3,073 parturients who had vaginal delivery in 606 health facilities in Brazil, located in health regions with a regional action plan approved in the RC. Socioeconomic, demographic, and obstetric characteristics of the parturients, organizational and management aspects of maternity hospitals, and work processes in childbirth care were evaluated. The multivariate logistic regression model with a hierarchical approach was adjusted to identify the variables associated with UD (outcome), estimating Odds Ratios (OR) with a significance level of 5%.

RESULTS

Of the evaluated parturient, 6.7% gave birth in the vertical position. The following were associated with a greater chance of PPV: being black (OR=2.07); having 13 or more years of study (OR=3.20); giving birth in a high-risk hospital (OR=1.58); giving birth in PPP rooms (which assisted with labor, delivery, and puerperium in the same environment) in Obstetric Centers (OR=2.07) or in-hospital Normal Delivery Centers (OR=1.62); being assisted by an obstetrician nurse (OR=1.64) or by a midwife (OR=7.62) when compared to a doctor; receiving massage during labor and delivery (OR=1.89); using a stool (OR=4.16) and among women who did not ask for/not receive analgesia (OR=3.15).

CONCLUSION

The UD is an event related to racial aspects and the education of the parturient, being stimulated in health establishments where good practices of childbirth care are implemented, with adequate ambiance, and with multidisciplinary teams comprising midwives and obstetric nurses.

Prevalence of self-medication and associated factors in adolescents aged 18-19 years: the 1997/1998 cohort in São Luís-MA, Brazil

This article aims to assess the prevalence and factors associated with self-medication in adolescents. Cross-sectional study, nested in cohort, with 2,515 adolescents aged 18-19 years born in São Luís-MA. The use of medication in the last 15 days without a medical prescription or by a qualified professional was considered self-medication. Factors associated with self-medication were evaluated using Poisson regression with robust variances and hierarchical selection of variables. Medicines were used in the last 15 days by 48.05% of adolescents. Among these, 70.09% use it without a prescription or indication from another health professional. The most used medications for self-medication were "over the counter" (93.68%). Self-medication was positively associated with female gender (PR: 1.41; 95%CI: 1.25-1.59), screen time ≥5h/day (PR: 1.32; 95%CI: 1.05-1.67) and self-reported diagnosis of allergic rhinitis (PR: 1.19; 95%CI: 1.02-1.39); however, negatively associated with self-satisfaction with health (PR: 0.79; 95%CI: 0.67-0.94) and hospitalization in the previous year (PR: 0.70; 95%CI: 0.50-0.97). Self-medication was common among adolescents and to reduce this practice, greater attention should be given to women, individuals with intense exposure to meshes and allergic diseases.

The role of skin-to-skin contact in exclusive breastfeeding: a cohort study

OBJETIVE

To understand the role of exposure to skin-to-skin contact and its minimum duration in determining exclusive breastfeeding at hospital discharge in infants weighing up to 1,800g at birth.

METHODS

A multicenter cohort study was carried out in five Brazilian neonatal units. Infants weighing ≤ 1,800g at birth were eligible. Skin-to-skin contact time was recorded by the health care team and parents on an individual chart. Maternal and infant data was obtained from maternal questionnaires and medical records. The Classification Tree, a machine learning method, was used for data analysis; the tree growth algorithm, using statistical tests, partitions the dataset into mutually exclusive subsets that best describe the response variable and calculates appropriate cut-off points for continuous variables, thus generating an efficient explanatory model for the outcome under study.

RESULTS

A total of 388 infants participated in the study, with a median of 31.6 (IQR = 29–31.8) weeks of gestation age and birth weight of 1,429g (IQR = 1,202–1,610). The exclusive breastfeeding rate at discharge was 61.6%. For infant’s weighting between 1,125g and 1,655g, exposed to skin-to-skin contact was strongly associated with exclusive breastfeeding. Moreover, infants who made an average > 149.6 min/day of skin-to-skin contact had higher chances in this outcome (74% versus 46%). In this group, those who received a severity score (SNAPPE-II) equal to zero increased their chances of breastfeeding (83% versus 63%).

CONCLUSION

Skin-to-skin contact proved to be of great relevance in maintaining exclusive breastfeeding at hospital discharge for preterm infants weighing 1,125g–1,655g at birth, especially in those with lower severity scores.

[Supply of best childbirth practices in maternity units of Rede Cegonha according to Item Response Theory]

This study aimed to develop an intelligible scale to measure the level of supply of best practices in labor, childbirth and delivery in maternity units in the Rede Cegonha (RC) based on the workers' perception. The scale consisted of seventeen items related to best practices, based on the instrument used in the "Evaluation of care during delivery and birth in maternity hospitals in the RC" research The three-parameter logistic model of Item Response Theory was used to create the scale and analyze the items. The scale consisted of three levels. In the first level, there are maternity hospitals that adequately offered strategies for welcoming and encouraging the pregnant woman to circulate during labor. The second level maternity wards also included the adequate offer of the right to a companion of choice, massage, ball and different birth positions. Finally, the third level maternity hospitals also offered an adequate delivery stool, as well as the items already mentioned. The findings of this study showed the contribution of each item in measuring the level of supply of best practices in care for labor, childbirth and delivery and the construction of an intelligible scale to assess RC maternity hospitals.

Presence of a full-time companion in Brazilian maternities linked to the Rede Cegonha

The objective was to estimate the proportion of women with a full-time companion in Brazilian maternities linked to the Rede Cegonha (RC) and to compare them between the macro-regions in Brazil. A nationwide study, carried out from December/2016 to October/2017. 10,665 puerperal women from all regions of Brazil participated in the study, who gave birth at one of 606 maternity hospitals with a regional action plan approved by RC. Proportions and respective 95% confidence intervals were estimated, adjusted for the cluster effect, by comparing the macro-regions using Wald's chi-square test. The presence of a full-time companion occurred in 71.2% of maternities, being higher among women aged 20-35 years, brown-skinned, with higher education, married, and assisted in vaginal delivery. Almost 30% of puerperal women did not have a full-time companion. In the Southeast and Midwest regions, self-declared black women, with less schooling and unmarried women were less accompanied. The moment of delivery had less presence of the companion (29.2%). Despite the advances, this right is still not fully fulfilled, pointing to the occurrence of social inequities among Brazilian macro-regions.

[Proposal for measuring the level of urbanicity of Brazilian cities based on the 2010 demographic census data]

The scope of this study is to present a proposal for measuring the level of urbanicity in Brazilian cities based on data from the 2010 census. It is an ecological study, which used the official (urban rural) classification of IBGE (Instituto Brasileiro de Geografia e Estatística, in portuguese) and that of small, medium and large cities of Veiga (2002). A classification tree was used for prediction with Cross Validation. Two models of analysis were tested. In model 1, the independent variables were the physical and social characteristics of the cities, and the outcome was classification in accordance with IBGE criteria. In model 2, in addition to the variables used in model 1, the Veiga (2002) criterion was included as a covariate. Sensitivity, specificity and accuracy were then calculated. Model 2 showed statistically significant gains in the prediction of the level of urbanicity, increasing the sensitivity and accuracy estimates in the sets used for testing. Large cities were automatically classified as urban in model 2. However, to predict the urbanicity of other cities, Veiga (2002) criteria were combined with other physical and social characteristics of cities. The combination of indicators in model 2 enabled the definition of quantitative criteria to create typologies for classifying the urban rural definition in the Brazilian municipal territory.

[Association between psychological violence and posttraumatic stress disorder in a cohort of Brazilian adolescents]

The study analyzed the impact of psychological violence on the development of posttraumatic stress disorder (PTSD). This was a cross-sectional study nested in a cohort in which the second follow-up was conducted in 2016. A questionnaire was applied to 2,486 adolescents and approached individual, family, and social aspects and experience with psychological violence. Propensity score was used to create inverse probability weighting (IPW). Thus, a probability was assigned to each adolescent, where 1/IPW represent those in the exposed group and 1/(1-IPW) those in the unexposed group. This procedure made the two groups more homogeneous and mutually comparable. The association between the occurrence of psychological violence and PTSD was estimated by odds ratios (OR) and 95% confidence intervals (95%CI) via crude binary logistic regression and adjusted logistic regression (weighted by IPW). According to the results, 30.3% reported having suffered severe violence. Prevalence of PTSD was 4.8% among exposed and 1.5% in unexposed to psychological violence. An association was observed between severe violence and PTSD in the two analyses, but the magnitude in the model structured by the propensity score (OR = 1.97; 95%CI: 1.08-3.56) indicated an adjustment to the measure from the crude analysis (OR = 3.40; 95%CI: 2.03-5.69). The current study contributes to the scarce literature on exposure to psychological violence and its association with the development of PTSD, confirming the negative impact of this form of abuse on the individual´s mental health.

Excess deaths from all causes and by COVID-19 in Brazil in 2020

OBJECTIVE

To estimate the 2020 all-cause and COVID-19 excess mortality according to sex, age, race/color, and state, and to compare mortality rates by selected causes with that of the five previous years in Brazil.

METHODS

Data from the Mortality Information System were used. Expected deaths for 2020 were estimated from 2015 to 2019 data using a negative binomial log-linear model.

RESULTS

Excess deaths in Brazil in 2020 amounted to 13.7%, and the ratio of excess deaths to COVID-19 deaths was 0.90. Reductions in deaths from cardiovascular diseases (CVD), respiratory diseases, and external causes, and an increase in ill-defined causes were all noted. Excess deaths were also found to be heterogeneous, being higher in the Northern, Center-Western, and Northeastern states. In some states, the number of COVID-19 deaths was lower than that of excess deaths, whereas the opposite occurred in others. Moreover, excess deaths were higher in men aged 20 to 59, and in black, yellow, or indigenous individuals. Meanwhile, excess mortality was lower in women, in individuals aged 80 years or older, and in whites. Additionally, deaths among those aged 0 to 19 were 7.2% lower than expected, with reduction in mortality from respiratory diseases and external causes. There was also a drop in mortality due to external causes in men and in those aged 20 to 39 years. Moreover, reductions in deaths from CVD and neoplasms were noted in some states and groups.

CONCLUSION

There is evidence of underreporting of COVID-19 deaths and of the possible impact of restrictive measures in the reduction of deaths from external causes and respiratory diseases. The impacts of COVID-19 on mortality were heterogeneous among the states and groups, revealing that regional, demographic, socioeconomic, and racial differences expose individuals in distinct ways to the risk of death from both COVID-19 and other causes.

Autoregressive spatial modeling of possible cases of dengue, chikungunya, and Zika in the capital of Northeastern Brazil

INTRODUCTION:

Dengue, chikungunya, and Zika are a growing global health problem. This study analyzed the spatial distribution of dengue, chikungunya, and Zika cases in São Luís, Maranhão, from 2015 to 2016 and investigated the association between socio-environmental and economic factors and hotspots for mosquito proliferation.

METHODS:

This was a socio-ecological study using data from the National Information System of Notifiable Diseases. The spatial units of analysis were census tracts. The incidence rates of the combined cases of the three diseases were calculated and smoothed using empirical local Bayes estimates. The spatial autocorrelation of the smoothed incidence rate was measured using Local Moran's I and Global Moran's I. Multiple linear regression and spatial autoregressive models were fitted using the log of the smoothed disease incidence rate as the dependent variable and socio-environmental factors, demographics, and mosquito hotspots as independent variables.

RESULTS:

The findings showed a significant spatial autocorrelation of the smoothed incidence rate. The model that best fit the data was the spatial lag model, revealing a positive association between disease incidence and the proportion of households with surrounding garbage accumulation.

CONCLUSIONS:

The distribution of dengue, chikungunya, and Zika cases showed a significant spatial pattern, in which the high-risk areas for the three diseases were explained by the variable "garbage accumulated in the surrounding environment,” demonstrating the need for an intersectoral approach for vector control and prevention that goes beyond health actions.

Delay in death reporting affects timely monitoring and modeling of the COVID-19 pandemic

This study describes the COVID-19 death reporting delay in the city of São Luís, Maranhão State, Brazil, and shows its impact on timely monitoring and modeling of the COVID-19 pandemic, while seeking to ascertain how nowcasting can improve death reporting delay. We analyzed COVID-19 death data reported daily in the Epidemiological Bulletin of the State Health Secretariat of Maranhão and calculated the reporting delay from March 23 to August 29, 2020. A semi-mechanistic Bayesian hierarchical model was fitted to illustrate the impact of death reporting delay and test the effectiveness of a Bayesian Nowcasting in improving data quality. Only 17.8% of deaths were reported without delay or the day after, while 40.5% were reported more than 30 days late. Following an initial underestimation due to reporting delay, 644 deaths were reported from June 7 to August 29, although only 116 deaths occurred during this period. Using the Bayesian nowcasting technique partially improved the quality of mortality data during the peak of the pandemic, providing estimates that better matched the observed scenario in the city, becoming unusable nearly two months after the peak. As delay in death reporting can directly interfere with assertive and timely decision-making regarding the COVID-19 pandemic, the Brazilian epidemiological surveillance system must be urgently revised and notifying the date of death must be mandatory. Nowcasting has proven somewhat effective in improving the quality of mortality data, but only at the peak of the pandemic.

A mhealth application for automated detection and diagnosis of strabismus

BACKGROUND AND OBJECTIVE

Amblyopia is a public health problem, and strabismus is its primary cause. Our objective is to evaluate the concordance of the diagnosis of strabismus between strabismus expert ophthalmologist and the mhealth application developed for this purpose.

METHODS

We evaluated the concordance of the diagnosis of strabismus between the expert ophthalmologist and the mhealth application by screening 224 children and adolescents in the 5-15 years age group, with snapshots of patients' eyes and their analysis thereof. We were using a multifunctional cell phone with Android and the ophthalmologist's clinical evaluation by analyzing the ocular deviations using simple cover and prism and alternate cover.

RESULTS

Fraction measurements were used with two cutoff points of 6 and 11 prismatic diopters (PD). Results were compared according to their concordances, with a fair Kappa equal to 0.43 (95%CI = [0.38; 0.48]), which was statistically significant (p < 0.0001) at the cutoff point of 6 PD and Kappa equal to 0.49 (95% CI = [0.35; 0.61]), which was statistically significant (p < 0.042) in the cutoff point of 11 PD.

CONCLUSIONS

The cutoff point of 6 PD was chosen for screening by this mhealth application since it caused the loss of only two patients with strabismus, whereas, in the case of 11 PD, the loss was five patients in the universe of 224. These results are promising for the use of this software as a screening method for patients with strabismus.

Beriberi in Brazil: A Disease That Affects Indigenous People

BACKGROUND

Beriberi is the clinical manifestation of thiamine deficiency. It is multicausal and typically associated with poverty and food insecurity among vulnerable populations, such as indigenous people.

OBJECTIVE

The objective of this study was to carry out a spatial analysis of reported cases of beriberi among indigenous people in Brazil.

METHODS

Cross-sectional study using time series data on suspected cases of beriberi reported to the Ministry of Health via the FormSUS between July 2013 and September 2018. Indigenous villages were georeferenced, and Kernel density estimation was used to identify patterns of the spatial distribution of beriberi cases.

RESULTS

A total of 414 cases of beriberi were reported in the country of which 210 (50.7%) were indigenous people. All the cases in indigenous people occurred in states located in the Legal Amazon (Maranhão, Roraima, and Tocantins). Kernel density estimation showed high-density areas in Tocantins and Roraima.

CONCLUSIONS

This is the first nationwide study of reported cases of beriberi. The findings can be used to guide actions that contribute to the monitoring and prevention of beriberi among indigenous people.

Correlation Between Parathyroid Hormone Levels with Urinary Magnesium Excretion in Patients with Non-Dialysis Dependent Chronic Kidney Disease

Background

Disorders of mineral metabolism occur in most patients with chronic kidney disease (CKD). The aim of this work was to correlate parathyroid hormone (PTH) levels with urinary magnesium excretion in patients with non-dialysis dependent CKD.

Methods

Cross-sectional study. Concentrations of creatinine, magnesium, calcium, phosphate, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH)D] and alkaline phosphatase (ALP) were determined in blood samples. The assessment of urinary magnesium levels was performed by means of total daily excretion and by the excretion fraction (FEMg).

Results

The study evaluated 163 patients with a mean age of 60.7 ± 11.7 years and 51.0% were male. In the highest quartile of PTH (>89.5pg/mL), the mean levels of FEMg and ALP were higher (p<0.05). In the unadjusted regression analysis, the following variables were related to serum PTH levels: FEMg (odds ratio (OR) = 1.12; 95% confidence intervals (CI): 1.02–1.23), calcium (OR = 0.45; 95% CI: 0.22–0.90), ALP (OR = 1.02; 95% CI: 1.00–1.03) and eGFR (OR = 0.92; 95% CI: 1.00–1.03). After an adjusted analysis, only one FEMg and ALP will remain correlated with PTH.

Conclusion

In patients with non-dialysis dependent CKD, FEMg and ALP were some variables that remained associated with PTH.

Racial inequality in obstetric good practices and interventions in labor and birth care in Rede Cegonha

This study aimed to evaluate the racial inequality on childbirth care at the Rede Cegonha (Stork Network) using obstetric good practice and interventions indicators. Racial inequality, measured by the total effect of ethnicity/skin color in the crude model, was seen in many indicators. After adjusting for mediators, such as age, schooling, parity, high-risk hospital, and geographic macro-regions, the persistent direct effect suggests racial discrimination against black women with lower partograph completion (PR 0.88; 95% CI 0.80-0.95). Black women stayed less in lithotomy (PR 0.93; 95% CI 0.89-0.98), performed less episiotomy (PR 0.81; 95% CI 0.68 - 0.96), and had less episiotomy suturing pain (PR 0.66; 95% CI 0.51 - 0.87) when compared to white women, suggesting more good practice applied to black women. However, according to the interventionist care model still adopted by many professionals, these practices are routine, and lower achievement in black women would be better interpreted as evidence of racial discrimination against these women. For other outcomes, the ethnicity/skin color effect disappeared after adjusting for mediators, suggesting mitigation or disappearance of the skin color effect in some practices/interventions in childbirth.

Erythropoietin Resistance in Patients with Chronic Kidney Disease: Current Perspectives

Anemia is a frequent complication of chronic kidney disease, and its primary cause is erythropoietin deficiency. After diagnosis, treatment begins with administration of an erythropoiesis-stimulating agent (ESA). However, some patients present with resistance to ESA, which needs to be reversed, as it can increase the risk of death in patients with kidney disease. Therefore, we provide a discussion of the current literature regarding the factors that can modify the response to this class of drugs and the strategies that can be considered to optimize the benefits of treating anemia.

Prevalence of sarcopenia in kidney transplants and their association with determinant factors of muscle homeostasis

INTRODUCTION

Sarcopenia is characterized by the involuntary loss of lean body mass associated with a progressive reduction of muscle strength.

OBJECTIVE

To determine the prevalence of sarcopenia in kidney transplant recipients and its association with the determining factors that control muscle homeostasis.

METHODS

We evaluated renal transplant recipients undergoing follow-up at the University Hospital of the Federal University of Maranhão from June 2017 to July 2018 and who met the inclusion criteria. Sarcopenia was defined according to the European criteria. The skeletal muscle mass index was measured by dual-energy radiological absorptiometry; the values <7,26 kg/m2 for men and <5,5 kg/m2 for women were adopted for muscle depletion. For handgrip strength, values of <30 kg for men and <20 kg for women were considered as reduced muscle strength. In both sexes, the cutoff point for walking speed was <0,8 m/s.

RESULTS

We evaluated 83 renal transplant recipients with a mean age of 48.8 ± 12,1 years and predominantly males (57,8%). The prevalence of sarcopenia was 19,3%. Among individuals without sarcopenia, 17,9% had a decrease in handgrip strength and 40,3% has altered gait speed.

DISCUSSION

Individuals submitted to renal transplant may develop sarcopenia while still young and already present altered muscle function and strength even before the depletion of lean body mass.

CONCLUSION

Early diagnosis may allow the prevention of sarcopenia and provide a better quality of life for patients.

Recurrent Violence, Violence with Complications, and Intimate Partner Violence Against Pregnant Women and Breastfeeding Duration

Background: Few studies have investigated the association between violence against pregnant women in terms of recurrence, complications, and perpetrators of violence, and breastfeeding duration. This study verifies whether recurrent violence, violence with pregnancy complications, and intimate partner violence (IPV) against pregnant women are associated with shorter exclusive breastfeeding up to the infant's 6th month and breastfeeding up to the 12th month of life. Materials and Methods: A cohort study with a convenience sample of 1,146 pregnant women was performed. Follow-up assessments were conducted at birth, and at 12-36 months. Survival analysis was used to verify whether recurrent violence, violence with pregnancy complications, and IPV were associated with reduced duration of exclusive breastfeeding and breastfeeding. Results: The adjusted Cox regression revealed no difference regarding exclusive breastfeeding duration among mothers exposed or not exposed to violence and according to who perpetrated the violence. The risk of an infant not being breastfed within the first 12 months of life increased in cases of violence before/during pregnancy (95% confidence interval [CI] = 1.03-1.88), recurrent psychological/physical/sexual violence during pregnancy (95% CI = 1.11-1.92), recurrent psychological violence (95% CI = 1.05-1.96), and recurrent physical/sexual violence (95% CI = 1.01-2.39). Violence with pregnancy complications (95% CI = 0.94-2.22) was not associated with breastfeeding interruption. Similar risks of breastfeeding interruption were observed for IPV (95% CI = 0.96-1.87) and violence perpetrated by other family members (95% CI = 0.83-1.89). Conclusions: We observed a shorter breastfeeding duration up to 12 months of life in cases of recurrent violence.

Association between the FTO gene polymorphism and obesity in Brazilian adolescents from the Northeast region

OBJECTIVE

To investigate the association between the FTO gene polymorphism with obesity in Brazilian adolescents from the Northeast region.

METHOD

This was a case-control study with adolescents aged 18 to 19 years. The case group consisted of 378 obese individuals and the control group of 378 non-obese individuals. Obesity was measured by percentage of body fat using the air displacement plethysmography technique. The study variables included data on socioeconomics, demographics, lifestyle, physical activity, waist circumference, waist-to-height ratio, and body mass index. To identify the rs9939609 polymorphism of the FTO gene, blood samples were obtained for genomic DNA extraction by the real-time PCR (Polymerase Chain Reaction) technique. Categorical variables were compared between the groups by the chi-squared test. The normality of the anthropometric measurements body mass index, waist circumference, waist-to-height ratio, and percentage of body fat was evaluated by the Shapiro-Wilk test. Comparison of the anthropometric measurements, stratified by the polymorphism genotypes, was performed by the Kruskal-Wallis test. The Hardy-Weinberg equilibrium was calculated. The significance level was set at 5%.

RESULTS

The variables gender, age, and physical activity showed significant differences between the groups (p<0.001). The samples of obese and non-obese adolescents were in Hardy-Weinberg equilibrium (p=0.0515). There was no significant difference between the genotypic (p=0.719) and allelic frequencies (p=0.812) regarding the case and control groups. When comparing the anthropometric measurements according to the genotypes (AA, AT, and TT), no significant difference was observed for body mass index (p=0.337), waist circumference (p=0.3473), percentage of body fat (p=0.7096), and waist-to-height ratio (p=0.2584).

CONCLUSION

The excess adiposity of the study adolescents was not influenced by their genotype.

Labor and childbirth care in maternities participating in the "Rede Cegonha/Brazil": an evaluation of the degree of implementation of the activities

Using a judgment framework, this article analyzes the degree of implementation of the best practices in labor and childbirth care contained in the guidelines of the Rede Cegonha (RC) across Brazil. The study eligibility criteria were public and mixed hospitals located in a health region with a RC action plan in place in 2015, resulting in a total of 606 facilities distributed across the country. Three different data collection methods were used: face-to-face interviews with managers, health professionals and puerperal women; document analysis; and on-site observation. The framework was built around the five guidelines of the Labor and Childbirth component of the RC. Degree of implantation was rated as follows: adequate; partially adequate and inadequate. The performance of maternity facilities was rated as partially adequate for all guidelines except for hospital environment, which was rated as inadequate. A huge variation in degree of implementation was observed across regions, with the South and Southeast being the best-performing regions in most items. The results reinforce the need for an ongoing evaluation of the actions developed by the RC to inform policy-making and the regulation of labor and childbirth care.

Spatial analysis of probable cases of dengue fever, chikungunya fever and zika virus infections in Maranhao State, Brazil

Dengue fever, chikungunya fever, and zika virus infections are increasing public health problems in the world, the last two diseases having recently emerged in Brazil. This ecological study employed spatial analysis of probable cases of dengue fever, chikungunya fever, and zika virus infections reported to the National Mandatory Reporting System (SINAN) in Maranhao State from 2015 to 2016. The software GeoDa version 1.10 was used for calculating global and local Moran indices. The global Moran index identified a significant autocorrelation of incidence rates of dengue (I=0.10; p=0.009) and zika (I=0.07; p=0.03). The study found a positive spatial correlation between dengue and the population density (I=0.31; p<0.001) and a negative correlation with the Performance Index of Unified Health System (PIUHS) by basic care coverage (I=-0.08; p=0.01). Regarding chikungunya fever, there were positive spatial correlations with the population density (I=0.06; p=0.03) and the Municipal Human Development Index (MHDI) (I=0.10; p=0.002), and a negative correlation with the Gini index (I=-0.01; p<0.001) and the PIUHS by basic care coverage (I=-0.18; p<0.001). Lastly, we found positive spatial correlations between Zika virus infections and the population density (I=0.13; p=0.005) and the MHDI (I=0.12; p<0.001), as well as a negative correlation with the Gini index (I=-0.11; p<0.001) and the PIUHS by basic care coverage (I=-0.05; p=0.03). Our results suggest that several socio-demographic factors influenced the occurrence of dengue fever, chikungunya fever, and zika virus infections in Maranhao State.

Abdominal obesity and reduction of glomerular filtration

The objective was to evaluate the association between nutritional status and the glomerular filtration rate (GFR) in remaining quilombolas. Cross-sectional study carried out on 32 remaining quilombola communities in the municipality of Alcântara-MA. The nutritional indicators (IN) used were: body mass index (BMI); Waist circumference (WC); Waist-to-hip ratio (WHR); Waist-to-height ratio (WHtR); conicity index (CI) and estimated visceral adipose tissue (VAT). GFR was estimated from the CKD-EPI creatinine-cystatin C formula. The Shapiro Wilk test was used to evaluate the normality of the quantitative variables. In order to compare the second IN sex, the chi-square test was applied. The Anova or Kruskal-Wallis tests were used to verify the association between IN and GFR. Of the 1,526 remaining quilombolas studied, 89.5% were black or brown, 51.2% were women, 88.6% belonged to economic classes D and E and 61.2% were farmers or fishermen. Clinical investigation revealed 29.2% of hypertensive patients, 8.5% of diabetics and 3.1% with reduced GFR. The BMI revealed 45.6% of the remaining quilombolas with excess weight. When compared to men, women presented a higher prevalence of overweight by BMI (56.6% vs 33.8%, p <0.001) and abdominal obesity CC (52.3% vs 4.3%), WHR (76,5% vs 5.8%), WHtR (82.3% vs 48.9%) and VAT (27.1% vs 14.5%) (p <0.001). Comparing the means of IN according to the GFR, it was observed that the higher the mean value of the IN lower the GFR (p <0.05). The GFR reduced with increasing mean values of nutritional indicators of abdominal obesity, regardless of sex.

Effectiveness of Acupuncture as Auxiliary Treatment for Chronic Headache

OBJECTIVES

To assess the effectiveness of acupuncture as an auxiliary analgesic treatment for chronic headaches and the influence of this treatment on the quality of life, as the effectiveness of acupuncture in chronic headache is still controversial.

METHODS

Thirty-four patients selected from a University Hospital Clinic on Chronic Pain were divided into two groups: True acupuncture (Group 1), in which the recommended points of the Traditional Chinese Medicine were used for each type of headache and sham acupuncture (Group 2), in which the needles were inserted into a device (the stick-on moxa), at the same points as Group 1. Both groups used the prescribed preventive medication for pain. The verbal numeric scale before (VNS0) and after (VNS1) treatment, the number of crisis, and the number of analgesics used during the first and second months of treatment were used for assessment. Quality of life was also assessed before and after treatment with the Brazilian version of the Quality of Life Questionnaire: SF-6D, 2002.

RESULTS

The true acupuncture group showed greater effectiveness in controlling pain in chronic headache, which was statistically significant in all domains compared to the sham acupuncture group, including quality of life.

CONCLUSIONS

Acupuncture can be considered an auxiliary treatment for chronic headache, reducing the intensity of pain, the number of crisis, the quantity of analgesics used, and improving the quality of life in patients with this painful condition.

Association between estimated glomerular filtration rate and sodium excretion in urine of African descendants in Brazil: a population-based study

INTRODUCTION

Excessive salt intake is a risk factor for the development of chronic kidney disease (CKD). Objective: To evaluate the association between estimated glomerular filtration rate (eGFR) and sodium excretion in urine samples of Brazilians of African ancestry.

METHODS

Cross-sectional, population-based study of 1,211 Brazilians of African ancestry living in Alcântara City, Maranhão, Brazil. Demographic, nutritional, clinical, and laboratory data were analyzed. The urinary excretion of sodium was estimated using the Kawasaki equation. Calculations of eGFR were based on the Chronic Kidney Disease Epidemiology Collaboration equation. Multivariate linear-regression model was used to identify the relationship between sodium excretion and eGFR.

RESULTS

Mean age was 37.5±11.7 years and 52.8% were women. Mean urinary excretion of sodium was 204.6±15.3 mmol/day and eGFR was 111.8±15.3 mL/min/1.73m2. According to multivariate linear regression, GFR was independently correlated with sodium excretion (β=0.11; p<0.001), age (β=-0.67; p<0.001), female sex (β=-0.20; p<0.001), and body mass index (BMI; β=-0.09; p<0.001).

CONCLUSIONS

The present study showed that age, female sex, BMI, and correlated negatively with eGFR. Sodium excretion was the only variable that showed a positive correlation with eGFR, indicating that high levels of urinary sodium excretion may contribute to hyperfiltration with potentially harmful consequences.

Effect of exercise on pain and functional capacity in breast cancer patients

PURPOSE

To assess the influence of combined training on pain, fatigue, maximal oxygen uptake (VO₂ max), body mass index (BMI), flexibility, and strength in patients with breast cancer.

METHODS

A controlled pilot study with 28 patients undergoing chemotherapy, radiation therapy, and clinical observation in a renowned cancer treatment center; the patients were aged from 30 to 59 years old and were not engaged in physical training for three months previously. The Study Group (SG) underwent 12 weeks of training, including three 60-min sessions of aerobic exercise and resistance training, and two sessions of flexibility training per week; each flexibility exercise lasted 20 s and was performed in sets of three repetitions. The Control Group (CG) received only the standard hospital treatment. Participants were evaluated at the beginning of the study to establish a baseline and reevaluated at the end of 12 weeks.

RESULTS

Patients in the SG showed a significant decrease in total pain points (p = 0.0047), pain intensity (p = 0.0082), and the extent to which pain interfered with their daily life (p = 0.0047). There was an increase in maximum oxygen uptake (p = 0.0001), flexibility (p = 0.0001), and strength on both sides (right p = 0.0001 and left p = 0.0008). No significant differences were observed in fatigue (p = 0.0953) or BMI (p = 0.6088).

CONCLUSION

Combined training was effective in decreasing pain and increasing VO₂ max, flexibility and static strength in patients with breast cancer.

TRIAL REGISTRATION

NCT03061773 . Registered on February 19, 2017, 'retrospectively registered'.

Evidence of validity of the Stress-Producing Life Events (SPLE) instrument

OBJECTIVE Evaluate the construct validity of a list of eight Stressful Life Events in pregnant women. METHODS A cross-sectional study was conducted with 1,446 pregnant women in São Luís, MA, and 1,364 pregnant women in Ribeirão Preto, SP (BRISA cohort), from February 2010 to June 2011. In the exploratory factorial analysis, the promax oblique rotation was used and for the calculation of the internal consistency, we used the compound reliability. The construct validity was determined by means of the confirmatory factorial analysis with the method of estimation of weighted least squares adjusted by the mean and variance. RESULTS The model with the best fit in the exploratory analysis was the one that retained three factors with a cumulative variance of 61.1%. The one-factor model did not obtain a good fit in both samples in the confirmatory analysis. The three-factor model called Stress-Producing Life Events presented a good fit (RMSEA < 0.05; CFI/TLI > 0.90) for both samples. CONCLUSIONS The Stress-Producing Life Events constitute a second order construct with three dimensions related to health, personal and financial aspects and violence. This study found evidence that confirms the construct validity of a list of stressor events, entitled Stress-Producing Life Events Inventory.

Diagnosis of latent Mycobacterium tuberculosis infection: tuberculin test versus interferon-gamma release

INTRODUCTION

The treatment of individuals with active tuberculosis (TB) and the identification and treatment of latent tuberculosis infection (LTBI) contacts are the two most important strategies for the control of TB. The objective of this study was compare the performance of tuberculin skin testing (TST) with QuantiFERON-TB Gold In TUBE(r) in the diagnosis of LTBI in contacts of patients with active TB.

METHODS

Cross-sectional analytical study with 60 contacts of patients with active pulmonary TB. A blood sample of each contact was taken for interferon-gamma release assay (IGRA) and subsequently performed the TST. A receiver operating characteristic curve was generated to assess the cutoff points and the sensitivity, predictive values, and accuracy were calculated. The agreement between IGRA and TST results was evaluated by Kappa coefficient.

RESULTS

Here, 67.9% sensitivity, 84.4% specificity, 79.1% PPV, 75% NPV, and 76.7% accuracy were observed for the 5mm cutoff point. The prevalence of LTBI determined by TST and IGRA was 40% and 46.7%, respectively.

CONCLUSIONS

Both QuantiFERON-TB Gold In TUBE(r) and TST showed good performance in LTBI diagnosis. The creation of specific diagnostic methods is necessary for the diagnosis of LTBI with higher sensitivity and specificity, preferably with low cost and not require a return visit for reading because with early treatment of latent forms can prevent active TB.