Physician turnover in primary health care services in the East Zone of São Paulo City, Brazil: incidence and associated factors.

BACKGROUND: The shortage and high turnover of physicians is a recurrent problem in health care systems; this is especially harmful to the expansion and full operation of primary health care (PHC). The aim of this paper is to analyze incidence and associated factors with physician turnover in primary health care services in the East Zone of São Paulo City. METHODS: This is a retrospective cohort study of 1378 physicians over a 15 years' time period based on physicians' administrative records from two distinct secondary databases. Physicians' individual characteristics were analyzed including graduation and specialization. Survival analysis techniques such Kaplan-Meier and Cox Regression were used to analyze the termination of contract. RESULTS: One thousand three hundred seventy-eight physicians were included in the study of which 130 [9.4%(CI95 8.0-11.1%)] remained in the PHC services. The mean and median time until the occurrence of the physician leaving the service was 2.14 years (CI95% 1.98-2.29 years) and 1.17 years [(CI95% 1.05-1.28 years)]. The probability of contract interruption was 45% in the first year and 68% in the second year. Independent factors associated with TEC were identified: workload of 40 h/week HR = 1.71 [(CI95% 1.4-2.09), p < 0.001]; initial salary ≤1052 BGI HR = 1.87 [(CI95 1.64-2.15), p < 0.001]; time since graduation ≤2 years HR =1.36 [(CI95 1.18-1.56), p < 0.001]; and the conclusion of residency in up to 3 years after leaving the service HR = 1.69 [(CI95 1.40-2.04), p < 0.001]. CONCLUSIONS: The time of employment of the physician in PHC was relatively short, with a high probability of TEC in the first year. Modifiable factors such as working hours, starting salary, time since graduation from medical school and need to enter in a residency program were associated with TEC. In pointing out that modifiable factors are responsible for long term employment or the end of contract of physicians in PHC services of the Unified Health System in the periphery of a metropolitan area, the study provides support for the planning, implementation and management of policies and strategies aimed at attracting and retaining physicians in suburban, priority or underserved regions.

Incidence and associated factors of type 2 diabetes mellitus onset in the Brazilian HIV/AIDS cohort study.

BACKGROUND: People living with HIV (PLH) under combined antiretroviral therapy (cART) are at risk of developing type 2 diabetes mellitus (T2DM). OBJECTIVE: We examined the incidence of T2DM, associated factors and mean time to outcome in PLH under cART. METHOD: Data for this multicenter cohort study were obtained from PLH aged over 18, who started cART in 13 Brazilian sites from 2003 to 2013. Factors associated with incident T2DM were evaluated by Cox multiple regression models. RESULTS: A total of 6724 patients (30,997.93 person-years) were followed from January 2003 to December 2016. A T2DM incidence rate of 17.3/1000 person-years (95%CI 15.8-18.8) was observed. Incidence of isolated hypertriglyceridemia and impaired fasting glucose (IFG) were 84.3 (95%CI 81.1-87.6) and 14.5/1000 person-years (95%CI 13.2-15.9), respectively. Mean time to T2DM onset was 10.5 years (95%CI 10.3-10.6). Variables associated with incident T2DM were age 40-50 [Hazard Ratio (HR) 1.7, 95%CI 1.4-2.1] and ≥ 50 years (HR 2.4, 95%CI 1.9-3.1); obesity (HR 2.1, 95%CI 1.6-2.8); abnormal triglyceride/HDL-cholesterol ratio (HR 1.8, 95%CI 1.51-2.2). IFG predicted T2DM (HR 2.6, 95%CI 1.7-2.5) and occurred on average 3.3 years before diabetes onset. Exposure to stavudine for ≥ 2 years was independently associated with incident T2DM [HR 1.6, 95%CI 1.0-2.2). CONCLUSION: Brazilian PLH under cART are at significant risk of developing T2DM and share risk factors for diabetes onset with the general population, such as older age, obesity, and having metabolic abnormalities at baseline. Moreover, stavudine use was independently associated with incident T2DM. Identifying PLH at a higher risk of T2DM can help caretakers trigger health promotion and establish specific targets for implementation of preventive measures.

Incidence and associated factors of type 2 diabetes mellitus onset in the Brazilian HIV/AIDS cohort study

ABSTRACT Background: People living with HIV (PLH) under combined antiretroviral therapy (cART) are at risk of developing type 2 diabetes mellitus (T2DM). Objective: We examined the incidence of T2DM, associated factors and mean time to outcome in PLH under cART. Method: Data for this multicenter cohort study were obtained from PLH aged over 18, who started cART in 13 Brazilian sites from 2003 to 2013. Factors associated with incident T2DM were evaluated by Cox multiple regression models. Results: A total of 6724 patients (30,997.93 person-years) were followed from January 2003 to December 2016. A T2DM incidence rate of 17.3/1000 person-years (95%CI 15.8-18.8) was observed. Incidence of isolated hypertriglyceridemia and impaired fasting glucose (IFG) were 84.3 (95%CI 81.1-87.6) and 14.5/1000 person-years (95%CI 13.2-15.9), respectively. Mean time to T2DM onset was 10.5 years (95%CI 10.3-10.6). Variables associated with incident T2DM were age 40-50 [Hazard Ratio (HR) 1.7, 95%CI 1.4-2.1] and ≥ 50 years (HR 2.4, 95%CI 1.9-3.1); obesity (HR 2.1, 95%CI 1.6-2.8); abnormal triglyceride/HDL-cholesterol ratio (HR 1.8, 95%CI 1.51-2.2). IFG predicted T2DM (HR 2.6, 95%CI 1.7-2.5) and occurred on average 3.3 years before diabetes onset. Exposure to stavudine for ≥ 2 years was independently associated with incident T2DM [HR 1.6, 95%CI 1.0-2.2). Conclusion: Brazilian PLH under cART are at significant risk of developing T2DM and share risk factors for diabetes onset with the general population, such as older age, obesity, and having metabolic abnormalities at baseline. Moreover, stavudine use was independently associated with incident T2DM. Identifying PLH at a higher risk of T2DM can help caretakers trigger health promotion and establish specific targets for implementation of preventive measures.

Combined liver and multivisceral resections: A comparative analysis of short and long-term outcomes.

BACKGROUND: En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver resections (MLRs). OBJECTIVES: To compare the short and long-term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies. METHODS: From a prospective database, a case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long-term survival. RESULTS: Fifty-three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 [320-525] vs 360 [270-440] minutes, P = .005); higher estimated blood loss (600 [400-800] vs 400 [100-600] mL; P = .011); longer hospital stay (8 [6-14] vs 7 [5-9] days; P = .003); and higher postoperative mortality (9.4% vs 1.9%, P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio [OR], 1 organ = 1.8 [0.54-6.05]; OR ≥ 2, organs = 4.0 [0.35-13.84]) or perioperative mortality (OR, 1, organ = 5.2 [0.91-29.51]; OR ≥ 2, organs = 6.5 [0.52-79.60]). No differences in overall (P = .771) and disease-free survival (P = .28) were observed. CONCLUSION: MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long-term outcomes.

Stray dogs in urban fragments: relation between population's perception of their presence and socio-demographic factors / Cães errantes em fragmentos urbanos: relação entre o relato de visualização de cães errantes e fatores sociodemográficos da população local

Stray dogs are associated with environment and public health impacts. São Paulo is a city with approximately 2.5 million owned dogs and until the time of writing no studies describing the distribution of the stray dog population have been conducted in this city. Therefore, no scientific support for intervention plans is available. The objective of this study was to evaluate the association of local sociodemographic and environmental factors with the population perception of presence of stray dogs in urban fragments of São Paulo city. A convenience sample of six urban fragments was selected. In-depth interviews were performe, using a systematic random sample of households in each study area, between October/2010 and January/2011 to identify socio-demographic factors of interest and determine the population's perception of stray dogs. Additionally, the presence of stray dogs was estimated by photographic mark-recapture method. The degree of human-dog proximity and environmental factors such as waste handling were associated to the sighting of stray dogs. Stray dogs were observed in two of the six study areas, agreeing with the greater population perception of this issue on those areas. Intervention in these factors and encouragement of responsible ownership are two potential solutions for management and reduction of problems associated with the presence of stray dogs.(AU)

A presença de cães errantes está associada a impactos no meio ambiente e na saúde pública. São Paulo é uma cidade com aproximadamente 2.5 milhões de cães domiciliados e até o presente momento, não foram desenvolvidos estudos que descrevam a distribuição da população errante na cidade. Desta forma, não há suporte científico para planejar intervenções. O objetivo deste estudo foi avaliar a associação entre os fatores sociodemográficos e ambientais da população local com a frequência com que relataram a visualização de cães errantes em fragmentos urbanos da cidade de São Paulo. Foi definida uma amostra de conveniência composta por seis fragmentos urbanos, onde um questionário foi aplicado em uma amostra sistemática dos domicílios de cada área de estudo. Este questionário, aplicado entre outubro de 2010 e janeiro de 2011, determinou os fatores socio-econômicos de interesse e a percepção da presença de cães errantes pela população. Também foi estimada a presença de cães pelo método de marcação e recaptura fotográfica. Foi possível estabelecer uma relação entre a visualização de cães errantes pela população local e o grau de proximidade com cães e o manejo de resíduos do domicílio. Cães errantes foram observados em duas das seis áreas trabalhadas, em concordância com a maior percepção da sua presença pela população local. Intervenções nestes fatores e incentivo a guarda responsável são duas ações com potencial de contribuir para redução dos problemas causados pela presença de cães errantes.(AU)

Seroprevalence and modifiable risk factors for Toxocara spp. in Brazilian schoolchildren.

BACKGROUND: Toxocariasis is a worldwide helminthic zoonosis caused by infection with the larvae of the ascarid worms that comprise the Toxocara spp. Children are particularly prone to infection because they are exposed to the eggs in sandboxes and playgrounds contaminated with dog and cat feces. Certain behaviors, such as a geophagy habit, poor personal hygiene, a lack of parental supervision, close contact with young dogs, and ingestion of raw meat, as well as gender, age, and socioeconomic status, affect the prevalence of the disease. However, previous studies of the risk factors for toxocariasis have generally produced inconsistent results. An epidemiological cross-sectional study was conducted to evaluate the seroprevalence of IgG anti-Toxocara spp. antibodies and associated factors in schoolchildren from a region in the southeast of Brazil. METHODOLOGY/PRINCIPAL FINDINGS: A total of 252 schoolchildren aged 1 to 12 years (120 males and 132 females) were assessed. An enzyme-linked immunosorbent assay based on Toxocara canis larval excretory-secretory antigens was used to determine outcomes. A questionnaire was used to collect information on children, family, and home characteristics. Clinical and laboratory data completed the dataset investigated in this study. Seroprevalence was 15.5% (95%CI 11.5-19.8). Geophagy (aPR 2.38 [95%CI 1.36-4.18], p-value 0.029) and the habit of hand washing before meals (aPR 0.04 [95%CI 0.01-0.11], p-value ≤ 0.001) were factors associated with increased and decreased seroprevalence, respectively. The income factor and its related variables lost statistical significance after adjustment with a multiple Poisson regression model. CONCLUSIONS/SIGNIFICANCE: The current study confirms that toxocariasis is a public health problem in the evaluated area; modifiable factors such as soil contact and personal hygiene appear to have a greater influence on the acquisition of infection than sociodemographic attributes, thus representing direct targets for disease prevention and control.