Relationship between OSA pathophysiological phenotypes and treatment response to mandibular advancement devices: a pilot study.

STUDY OBJECTIVES: To assess whether critical pathophysiological phenotypes predict treatment response in patients with obstructive sleep apnea (OSA) using a mandibular advancement device (MAD). METHODS: Thirty-one OSA patients were treated with a MAD. Individuals were categorized and graded into four pathophysiological phenotypes based on polysomnographic features (anatomical, ventilatory control, arousal threshold and muscle responsiveness). Morphoanthropometric data were additionally assessed. Patients were classified as responders or nonresponders. Associations between polysomnographic phenotypes and treatment response were documented, as was morphoanthropometric data and their impact on therapeutic success. RESULTS: There was a male predominance (64.5%), with a median age of 49 years (25p:40; 75p:55), BMI=27.4 kg/m2 (26; 28.8) and apnea-hypopnea index (AHI) of 18.2 (25p:11.7; 75p: 27.6). The majority of patients treated with a MAD (58%) were good responders (68.0% mild and moderate versus 16.7% severe). Treatment response was associated with shorter intermolar and interpremolar distances in the lower arch (p = 0.0092 and 0.0129). Rapid eye movement sleep AHI (REMAHI) and MAD-related treatment response were inversely correlated (p = 0.0013). Favorable anatomical (p = 0.0339) and low muscle response (p = 0.0447) phenotypes were correlated with outcomes. CONCLUSIONS: According to our results, a favorable response occurred in a better 'anatomical phenotype' and in the worse 'muscular responsiveness phenotype' according to polysomnographic data. Furthermore, other favorable predictors, such as a REMAHI <16 and a smaller distance between lower molars and premolars, were found. These findings indicate that clinical and polysomnographic aspects can discriminate phenotypes that may guide decisions on MAD treatment for OSA.

Hospitalizations of children and adolescents with complex chronic conditions in Brazil: a temporal analysis from 2009 to 2020.

Access to advanced and sophisticated health technologies made it possible to increase the survival of children with complex chronic conditions. Thus, the profile of pediatric patients admitted to hospitals has changed in recent decades. In Brazil, there are few epidemiological studies on this subject. This study aims to evaluate the main characteristics and temporal trend of hospital admissions of children and adolescents with complex chronic conditions in Brazil, 2009-2020. This is a cross-sectional study with data on hospitalizations of children and adolescents with complex chronic conditions, extracted from the Hospital Information System of the Unified Health System, 2009-2020, in the 26 Brazilian states and the Federal District. The analysis included descriptive statistics and a generalized linear model. From 2009 to 2020, there were 1,337,120 hospitalizations of children and adolescents with complex chronic conditions, and of these, 735,820 (55.0%) were male. The percentage of hospital deaths during the analyzed period was 4.0%. The most recurrent diagnostic category was malignancy (41.0%), with an annual incidence increase of 2.61 (95% CI: 1.16-4.05). Between 2009 and 2019, the increase in hospitalizations for complex chronic conditions was 27.4% for boys and 25.2% for girls, and the reductions in the number of hospitalizations for other causes were 15.4% and 11.9% for boys and girls, respectively.  Conclusions: Hospitalizations for complex chronic conditions in pediatrics are increasing in Brazil. This increase is a new challenge for the Brazilian public health system. What is Known: • The profile of pediatric patients admitted to hospitals has changed in recent decades, with a reduction in the total number of hospitalizations, but with an increase in the complexity and costs of these hospitalizations. • The world's scientific production on CCC is concentrated in the United States health care system. Epidemiological studies on the topic in universal health care systems are scarce. What is New: • This is the first study that evaluated the temporal trend of hospitalizations of children and adolescents with CCC in Brazil. • Hospitalizations for CCC in pediatrics are increasing in Brazil, with emphasis on the condition of malignancy, higher incidence in males and in children under one year of age. Furthermore, our study found a decrease in hospitalizations for other pediatric causes.

Association of health predictors with quality of life in children and adolescents.

OBJECTIVES: To evaluate the association of health-related quality of life (HRQOL) with physical activity, food consumption, sleep duration and screen time in children and adolescents. METHODS: Cross-sectional study with 268 students aged 10-17 years from a public school in Brazil. The outcome variable was HRQOL score, evaluated by the Pediatric Quality of Life Inventory™ (PedsQL™). Exposure variables were habitual physical activity, food consumption, sleep duration, and screen time. A general linear model was used to estimate age-adjusted means and 95 % confidence interval (95 % CI) of HRQOL scores, and a multivariable analysis of variance to identify factors associated with lower/higher HRQOL scores. The study was approved by the Human Research Ethics Committee of the Pontifical Catholic University of Campinas. RESULTS: Overall HRQOL score was 70.3 (95 % CI: 68.0-72.6). Multivariable analyses showed lower HRQOL scores for those adolescents who: 1-were physically inactive (67.3; p=0.014); 2-sleep less than 6 h per night (66.8; p=0.003); 3-eat fruits and vegetables less than five days/week (68.9; p=0.027); and 4-eat fast food twice/week or more (68.6; p=0.036) when compared to their opposite groups. Screen time was not statistically significantly associated with total HRQOL. CONCLUSIONS: The joint association found in our study suggests that at least three habits must change to improve the HRQOL of children and adolescents (physical activity, food consumption, and sleep duration). Therefore, interventions in schools to promote a healthy lifestyle to achieve a better HRQOL should include a multidisciplinary team to properly guide children and adolescents about these habits simultaneously.

Self-Reported Chronic Back Pain and Current Depression in Brazil: A National Level Study.

There is limited literature investigating the association between chronic back pain (CBP) and depression in Brazil. This study evaluates the association between CBP, CBP-related physical limitations (CBP-RPL), and self-reported current depression (SRCD), in a nationally representative sample of Brazilian adults. The data for this cross-sectional study came from the 2019 Brazilian National Health Survey (n = 71,535). The Personal Health Questionnaire depression scale (PHQ-8) was used to measure the SRCD outcome. The exposures of interest were self-reported CBP and CBP-RPL (none, slight, moderate, and high limitation). Multivariable weighted and adjusted logistic regression models were used to investigate these associations. The weighted prevalence of SRCD among CBP was 39.5%. There was a significant weighted and adjusted association between CBP and SRCD (weighted and adjusted odds ratio (WAOR) 2.69 (95% CI: 2.45-2.94). The WAOR of SRCD among individuals with high, moderate, and slight levels of physical limitation was significantly greater than for those without physical limitation due to CBP. Among Brazilian adults with high levels of CBP-RPL, there was over a five-fold increased risk of SRCD compared to those without CBP-RPL. These results are important for increasing awareness of the link between CBP and SRCD and for informing health services policies.

Parental Justifications for Not Vaccinating Children or Adolescents against Human Papillomavirus (HPV).

Vaccination coverage against Human Papillomavirus (HPV) is low compared with uptake of other vaccines in many countries, including Brazil. The aim of this study was to examine the main reasons provided by parents or guardians of a target population that did not have the first dose of HPV vaccine in a small rural Brazilian municipality, and to verify the factors associated with the reasons for non-vaccination. This is a cross-sectional study with interviews based on the Health Belief Model (HBM), conducted with parents and guardians of 177 unvaccinated children or adolescents. The outcome of interest was the main reason for not vaccinating the child/adolescent. The exposure factors of interest were knowledge about HPV and its prevention as well as sociodemographic characteristics. The main justifications for not vaccinating were lack of information (62.2%), fear or refusal (29.9%), and logistical issues (7.9%). The justifications associated with adolescents' sex, fear, or refusal were mentioned by 39.3% (95% CI: 28.8-50.6%) of parents or guardians of girls and by 21.5% (95% CI: 13.7-31.2%) of parents or guardians of boys. The main barrier to HPV vaccination is lack of information. Further training of health professionals in clarifying the benefits of vaccination and differentiating the risks between boys and girls could encourage uptake.

Association of Weight Perception, Body Satisfaction, and Weight Loss Intention With Patterns of Health Risk Behaviors in Adolescents With Overweight and Obesity.

Obesity is a public health issue and childhood is a critical window in which to establish healthy eating patterns and modify risk factors for overweight. This study aims to verify the association of weight perception, body satisfaction, and weight loss intention with patterns of health risk behaviors in adolescents with overweight and obesity. We analyzed health risk behavior from a school-based national survey conducted in 2015 in Brazil (n = 2,703 students with overweight or obesity, aged 13-17 years). We performed latent class analysis of alcohol consumption, tobacco use, physical activity, screen time, and eating habits for adolescents with overweight and identified four distinct health behavior patterns. The association of these patterns with weight perception, body satisfaction, and weight loss intention was analyzed through multinomial logistic regression. Adolescents who perceived themselves as "fat" or "very fat" were more likely to have a sedentary lifestyle and low consumption of fruit and vegetables. Body satisfaction was a protective factor against sedentary lifestyle. Students who reported weight loss intention were less likely to be in high-health-risk behavior groups (low consumption of fruit and vegetables; sedentary lifestyle; tobacco and alcohol use). Self-perception as overweight had detrimental associations, while body satisfaction was a protective factor for a healthy lifestyle. Weight loss intention still requires rigorous analysis due to inconsistencies in the literature. The complexity of the relationship between body image and obesity needs to be highlighted. Multicomponent strategies are required to control the global obesity pandemic.

How are children with medical complexity being identified in epidemiological studies? A systematic review.

BACKGROUND: There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies. METHODS: PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths. RESULTS: Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles). CONCLUSIONS: CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.

Factors associated with not adopting healthy behavior among hypertensive individuals: a population-based study in Brazil.

Adoption of a healthy lifestyle is strongly recommended for the control of hypertension, but professional advice alone does not ensure uptake of healthy behavior. Therefore, this study aimed to investigate the factors-associated with non-adoption of healthy behaviors among individuals with a medical diagnosis of hypertension. It was a cross-sectional study using data from the National Health Survey (PNS) carried out in Brazil in 2013, based on interviews with adults (≥18 years) (n = 60,202). The outcome variable was the non-adoption-two or fewer-of healthy behaviors (regular physical activity, recommended consumption of fruit and vegetables, no excessive alcohol consumption, no smoking, and very low/low salt intake [self-perceived]). A logistic regression model was used to verify the factors-associated with non-adoption of healthy behaviors. Approximately 64% of the study sample did not adopt healthy behaviors, i.e., they adopted two or fewer healthy habits. The most frequently mentioned healthy behaviors were not drinking excessively (91.5%), followed by not smoking (86%). Short time since disease diagnosis (OR = 1.20, 95% CI: 1.01-1.43), not using antihypertensive medication (OR = 1.38, 95% CI: 1.13-1.68), not making regular doctor visits (OR = 1.43, 95% CI: 1.23-1.65), and good self-rated health (OR = 1.16, 95% CI: 1.01-1.36) increased the chance of individuals not adopting healthy behaviors compared with their respective reference categories, independently of gender, age, schooling, and economic status. Counseling strategies should consider patient particularities, and health professionals need to be aware of issues that can interfere with the adoption of healthy behaviors of hypertensive patients.

Prevalence of metabolic syndrome and its associated factors in overweight and obese adolescents.

Background Metabolic syndrome (MetS) is not only a problem of adulthood but is already present in children and adolescents. The aim of this study was to estimate the prevalence of MetS in adolescents and to identify the associated factors. Methods This was a cross-sectional study with 354 overweight and obese school-aged adolescents (10-19 years). Sociodemographic, anthropometric, clinical, biochemical and lifestyle variables were collected. MetS was identified according to the criteria proposed by the International Diabetes Federation (IDF). Multivariate logistic regression models were used to examine the associations between risk variables and MetS. Results The prevalence of MetS was 9.6%. Among adolescents with MetS, all of them had low high-density lipoprotein cholesterol (HDL-c), while 76.5% had hyperglycemia and 38.2% had hypertriglyceridemia. Only 12.1% did not present any component of MetS, while 40% had at least two components. Multivariate analysis showed that being a girl was a protective factor (odds ratio [OR] = 0.29, confidence interval [CI] = 0.13-0.65) for the presence of MetS, while obesity (OR = 3.63, CI = 1.62-8.17) and being insufficiently active (OR = 4.60, CI = 1.01-20.96) were the risk factors for MetS. Conclusions Obese and insufficiently active male adolescents are more likely to have MetS. Early identification of MetS components, especially among obese adolescents, is an important tool for the prevention of cardiovascular complications in adult life.

The association between obesity and self-reported current depression among adult cancer survivors residing in Brazil.

BACKGROUND: The purpose of the current study was to investigate the association between obesity and self-reported current depression (SRCD) in a population-based sample of adult Brazilian cancer survivors. METHODS: The sample for this study (N=930) was based on the 2013 Brazilian National Health Survey. SRCD was assessed using the 8-item Patient Health Questionnaire (PHQ-8). Obesity was defined as a body mass index ≥30 kg/m2. Multivariable weighted logistic regression models were conducted to investigate the association between obesity and SRCD among Brazilian adult cancer survivors. RESULTS: The weighted prevalence of obesity and SRCD among adult cancer survivors was 26.4% (95% confidence interval [CI] 22.5 to 30.3%) and 13.7% (95% CI 10.4 to 17.1%), respectively. Overall there was no significant weighted and adjusted association between obesity and SRCD among cancer survivors (adjusted odds ratio [AOR] 0.99 [95% CI 0.56 to 1.73]). Nevertheless, among cancer survivors of working age (18-59 y), this association was significant (AOR 2.19 [95% CI 1.28 to 3.73]) and therefore obesity is significantly associated with a 119% increase in the odds of SRCD among Brazilian adult cancer survivors of working age. CONCLUSIONS: Since both obesity and depression may lead to worse health and quality of life outcomes in this young and middle-aged population, further investigations are needed in order to establish the causality and directionality of this association.

Gender and schooling inequalities in risk and protective factors for chronic diseases among Brazilian adults.

Background: There is consistent evidence showing that low socioeconomic level, both at the individual and contextual levels, is an important predictor of morbidity and mortality due to noncommunicable diseases. Objective: To identify gender and schooling inequalities in the distribution of risk and protective factors for chronic diseases among Brazilian adults. Methods: This study included data from 97 468 individuals interviewed in 2012 and 2013 from the Surveillance System of Risk and Protective Factors for Chronic Diseases (VIGITEL). Age-adjusted prevalence ratios at different schooling levels were calculated using Poisson regression. Results: Tobacco use, alcohol abuse and the consumption of meat with visible fat were more frequent among men, while the medical diagnosis of diseases such as diabetes, high blood pressure and dyslipidaemia was more frequent among women. In both genders, the highest level of education was associated with a lower prevalence of tobacco use, excessive consumption of soft drinks and excessive TV time, as well as increased alcohol abuse. Conclusion: The results of this study represent a challenge for public health policies in Brazil, since sociodemographic inequalities reflect differences in the prevalence of risk factors and, consequently, in the prevalence of chronic noncommunicable diseases.

The association between physical activity and depression among individuals residing in Brazil.

PURPOSE: There is very limited literature investigating the association between physical activity (PA) and depression in South American countries such as Brazil. The purpose of the current study was to evaluate the prevalence of depression and its association with PA in a very large, representative sample of young adults (ages 18-39 years) (YA), middle-aged adults (ages 40-59 years) (MAA) and older adults (ages ≥ 60 years) (OA) residing in Brazil. METHODS: The sample for this cross-sectional study was based on the Brazilian National Health Survey conducted in 2013. The Personal Health Questionnaire depression scale (PHQ-8) was applied to measure current (past 2 weeks) depression as the outcome of interest, and the exposure was self-reported PA for leisure. Multivariable weighted logistic regression models were conducted to investigate the association between PA and depression while adjusting for socio-demographic characteristics and number of health comorbidities among YA, MAA and OA. RESULTS: The final study sample size was 59,399 (33,480 females; 25,919 males). After adjusting for the covariates of interest, the lack of PA for leisure was associated with a significant increase in depression only among males (YA: OR 1.45, 95% CI 1.02-2.06; MAA: OR 2.38, 95% CI 1.40-4.03; OA: OR 5.35, 95% CI 2.14-13.37). There was no significant association between PA for leisure and depression among females of all age groups. CONCLUSIONS: Although PA for leisure is not associated with depression among Brazilian females, the obtained results suggest that this association is significant among Brazilian males, who may be able to benefit from PA for leisure to reduce their symptoms of depression.

Age at menarche in schoolgirls with and without excess weight / Idade da menarca em escolares com e sem excesso de peso

OBJECTIVE: To evaluate the age at menarche of girls, with or without weight excess, attending private and public schools in a city in Southeastern Brazil. METHODS: This was a cross-sectional study comparing the age at menarche of 750 girls from private schools with 921 students from public schools, aged between 7 and 18 years. The menarche was reported by the status quo method and age at menarche was estimated by logarithmic transformation. The girls were grouped according to body mass index (BMI) cut-off points: (thin + normal) and (overweight + obesity). In order to ensure that they belonged to different strata, 328 parents of these schools answered a questionnaire to rate the student's socioeconomic level. RESULTS: Menarche was reported by 883 girls. Although they belonged to different classes (p < 0.001), there was no difference in the nutritional diagnosis (p = 0.104) between them. There was also no difference in age at menarche between the girls studying in private (12.1 years, 95% CI: 12.0-12.2) and public schools (12.2 years, 95% CI:12.1-12.3; p = 0.383). When evaluated by nutritional status, there was difference only in the age at menarche between girls from private schools with excess weight and without excess weight (11.6 and 12.3 years; p < 0.001). The girls with excess weight attending private schools also had earlier an menarche than those attending public schools (respectively, 11.6 and 12.1 years; p = 0.016). CONCLUSIONS: Although the students from private schools belonged to a higher socioeconomic status, there is currently no longer a large gap between them and girls from public schools regarding nutritional and socioeconomic factors that may influence the age at menarche. .

OBJETIVO: Avaliar a idade da menarca em meninas, com e sem excesso de peso, que frequentam escolas particulares e públicas de uma cidade do sudeste do Brasil. MÉTODOS: Estudo transversal que comparou a idade da menarca de 750 meninas de escolas particulares com 921 alunas de escolas públicas, com idades entre sete e 18 anos. A menarca foi relatada pelo método status quo e a idade da mesma estimada pelo logito. As meninas foram agrupadas pelos pontos de corte do IMC em (magreza + eutrofia) e (sobrepeso + obesidade). Com o intuito de certificar que elas pertenciam a classes diferentes, 328 pais responderam a um questionário para classificar o nível econômico dos alunos. RESULTADOS: A menarca foi referida por 883 meninas. Embora elas pertençam a classes econômicas distintas (p < 0,001), não houve diferença quanto ao diagnóstico nutricional (p = 0,104). Também não houve diferença na idade da menarca entre as que estudam em escolas particulares (12,1 anos; IC95%%: 12,0-12,2) e públicas (12,2 anos; IC95%%: 12,1-12,3); p = 0,383. Quando avaliadas pelo diagnóstico nutricional só houve diferença na idade da menarca das meninas com e sem excesso de peso de escolas particulares (11,6 e 12,3 anos; p < 0,001). As meninas com excesso de peso das escolas particulares também menstruaram mais cedo do que as das escolas públicas (respectivamente, 11,6 e 12,1 anos; p = 0,016). CONCLUSÕES: Embora as alunas das escolas particulares ainda pertençam a classes mais altas, atualmente, não existe mais um abismo nutricional e socioeconômico tão grande entre elas quanto a fatores que podem influenciar na idade da menarca. .

Age at menarche in schoolgirls with and without excess weight.

OBJECTIVE: To evaluate the age at menarche of girls, with or without weight excess, attending private and public schools in a city in Southeastern Brazil. METHODS: This was a cross-sectional study comparing the age at menarche of 750 girls from private schools with 921 students from public schools, aged between 7 and 18 years. The menarche was reported by the status quo method and age at menarche was estimated by logarithmic transformation. The girls were grouped according to body mass index (BMI) cut-off points: (thin + normal) and (overweight + obesity). In order to ensure that they belonged to different strata, 328 parents of these schools answered a questionnaire to rate the student's socioeconomic level. RESULTS: Menarche was reported by 883 girls. Although they belonged to different classes (p<0.001), there was no difference in the nutritional diagnosis (p=0.104) between them. There was also no difference in age at menarche between the girls studying in private (12.1 years, 95% CI: 12.0-12.2) and public schools (12.2 years, 95% CI:12.1-12.3; p=0.383). When evaluated by nutritional status, there was difference only in the age at menarche between girls from private schools with excess weight and without excess weight (11.6 and 12.3 years; p<0.001). The girls with excess weight attending private schools also had earlier an menarche than those attending public schools (respectively, 11.6 and 12.1 years; p=0.016). CONCLUSIONS: Although the students from private schools belonged to a higher socioeconomic status, there is currently no longer a large gap between them and girls from public schools regarding nutritional and socioeconomic factors that may influence the age at menarche.

Spatial distribution of the risk for metabolic complications: an application in south-east Brazil, 2006-2007.

OBJECTIVE: To identify spatial variation in the risk for metabolic complications (RMC) by means of a semi-parametric approach for multinomial data. DESIGN: Cross-sectional study. SETTING: We visited 730 households selected in the first of a two-stage sample in South health district in Campinas, São Paulo, Brazil, 2006-2007. SUBJECTS: We interviewed 651 individuals and obtained their respective anthropometric measures and geographical coordinates of their house location. They were classified according to a combination of BMI and abdominal circumference as having no risk, increased, high or very high RMC. RESULTS: Gender, age and schooling were associated with RMC. Crude spatial risk for the three levels of RMC in relation to the absence of risk suggested different patterns in each level. Adjusted spatial risk for the RMC showed smaller significant areas, but the pattern remained similar to crude risk. CONCLUSIONS: Spatial point analysis with a multinomial approach improves the understanding of differences in RMC found, as we could identify specific areas in which to intervene. The public health significance of these findings may lie in the additional evidence provided that spatial location and its features can influence patterns of RMC.

Spatial distribution of the risk of dengue fever in southeast Brazil, 2006-2007.

BACKGROUND: Many factors have been associated with circulation of the dengue fever virus and vector, although the dynamics of transmission are not yet fully understood. The aim of this work is to estimate the spatial distribution of the risk of dengue fever in an area of continuous dengue occurrence. METHODS: This is a spatial population-based case-control study that analyzed 538 cases and 727 controls in one district of the municipality of Campinas, São Paulo, Brazil, from 2006-2007, considering socio-demographic, ecological, case severity, and household infestation variables. Information was collected by in-home interviews and inspection of living conditions in and around the homes studied. Cases were classified as mild or severe according to clinical data, and they were compared with controls through a multinomial logistic model. A generalized additive model was used in order to include space in a non-parametric fashion with cubic smoothing splines. RESULTS: Variables associated with increased incidence of all dengue cases in the multiple binomial regression model were: higher larval density (odds ratio (OR) = 2.3 (95%CI: 2.0-2.7)), reports of mosquito bites during the day (OR = 1.8 (95%CI: 1.4-2.4)), the practice of water storage at home (OR = 2.5 (95%CI: 1.4, 4.3)), low frequency of garbage collection (OR = 2.6 (95%CI: 1.6-4.5)) and lack of basic sanitation (OR = 2.9 (95%CI: 1.8-4.9)). Staying at home during the day was protective against the disease (OR = 0.5 (95%CI: 0.3-0.6)). When cases were analyzed by categories (mild and severe) in the multinomial model, age and number of breeding sites more than 10 were significant only for the occurrence of severe cases (OR = 0.97, (95%CI: 0.96-0.99) and OR = 2.1 (95%CI: 1.2-3.5), respectively. Spatial distribution of risks of mild and severe dengue fever differed from each other in the 2006/2007 epidemic, in the study area. CONCLUSIONS: Age and presence of more than 10 breeding sites were significant only for severe cases. Other predictors of mild and severe cases were similar in the multiple models. The analyses of multinomial models and spatial distribution maps of dengue fever probabilities suggest an area-specific epidemic with varying clinical and demographic characteristics.

Initial impact and cost of a nationwide population screening campaign for diabetes in Brazil: a follow up study.

BACKGROUND: In 2001 Brazilian citizens aged 40 or older were invited to participate in a nationwide population screening program for diabetes. Capillary glucose screening tests and procedures for diagnostic confirmation were offered through the national healthcare system, diagnostic priority being given according to the severity of screening results. The objective of this study is to evaluate the initial impact of the program. METHODS: Positive testing was defined by a fasting capillary glucose >or= 100 mg/dL or casual glucose >or= 140 mg/dL. All test results were tabulated locally and aggregate data by gender and clinical categories were sent to the Ministry of Health. To analyze individual characteristics of screening tests performed, a stratified random sample of 90,106 tests was drawn. To describe the actions taken for positive screenees, a random sub-sample of 4,906 positive screenees was actively followed up through home interviews. Main outcome measures considered were the number of diabetes cases diagnosed and cost per case detected and incorporated into healthcare. RESULTS: Of 22,069,905 screening tests performed, we estimate that 3,417,106 (95% CI 3.1 - 3.7 million) were positive and that 346,168 (290,454 - 401,852) new cases were diagnosed (10.1% of positives), 319,157 (92.2%) of these being incorporated into healthcare. The number of screening tests needed to detect one case of diabetes was 64. As many cases of untreated but previously known diabetes were also linked to healthcare providers during the Campaign, the estimated number needed screen to incorporate one case into the healthcare system was 58. Total screening and diagnostic costs were US$ 26.19 million, the cost per diabetes case diagnosed being US$ 76. Results were especially sensitive to proportion of individuals returning for diagnostic confirmation. CONCLUSION: This nationwide population-based screening program, conducted through primary healthcare services, demonstrates the feasibility, within the context of an organized national healthcare system, of screening campaigns for chronic diseases. Although overall costs were significant, cost per new case diagnosed was lower than previously reported. However, cost-effectiveness analysis based on more clinically significant outcomes needs to be conducted before this screening approach can be recommended in other settings.

Prenatal weight gain following smoking cessation.

OBJECTIVE: To evaluate the association of changes in smoking habit with maternal weight gain. STUDY DESIGN: We questioned 4000 pregnant women > or =20 years about previous and current smoking habits during a second trimester visit to general prenatal clinics in 6 Brazilian cities, from 1991 to 1995, and followed their weight, through chart review, to term. RESULTS: Of women who reported stopping smoking (915, 23% of the total), 240 (26.2%) stopped during pregnancy. The median number of cigarettes smoked/day among those who reported continued smoking (717, 18%) decreased from 10 to 5 with pregnancy. In linear regression models adjusting for age, educational attainment, ethnicity, prepregnancy body mass index, parity and clinical center, ex-smokers gained 1.03 kg (95%CI 0.59-1.46) more than those reporting never smoking, this difference being greater: 1.54 kg (95%CI 0.78-2.30) in those who reported quitting while pregnant. The size of weight gain in both continuing smokers and ex-smokers was proportional to the reduction in daily number of cigarettes smoked during pregnancy, being 0.38 kg (95%CI 0.07-0.68) greater for each 10 cigarettes reduced (p=0.007). CONCLUSION: Decreasing the quantity of cigarettes smoked in pregnancy, although important for maternal and child health, is associated with maternal weight gain.

A nationwide population screening program for diabetes in Brazil

OBJETIVOS: En 2001, se invitó a los habitantes del Brasil de 40 años de edad o mayores a participar en un programa para el tamizaje de la diabetes sacarina como parte del Plan de Reorganización de la Atención de la Hipertensión Arterial y la Diabetes Mellitus, del Ministerio de Salud del Brasil. En este informe se describen los porcentajes totales de participación y de resultados positivos obtenidos en la campaña de tamizaje, así como los factores asociados con el grado de participación en las distintas municipalidades del Brasil. MÉTODOS: Se definió como resultado positivo una glucemia en ayunas = 100 mg/dL o una glucemia casual = 140 mg/dL. Los resultados del tamizaje se obtuvieron del Ministerio de Salud y se analizaron por municipalidad. RESULTADOS: De las 5 561 municipalidades del Brasil, 5 301 (95,3%) participaron y notificaron los resultados. De los 30,2 millones de personas que integraban la población destinataria, 22,1 millones (73,0%) recibieron la prueba, y de estas últimas, 3,5 millones (15,7%) tuvieron resultados positivos. Las probabilidades de un buen porcentaje de participación (> 80%) fueron mayores en las municipalidades pequeñas (razón de riesgos (RR) = 5,0, al compararse los valores extremos), en las situadas en la parte norte del país (RR = 1,8), en las ubicadas a las afueras de una zona metropolitana (RR = 1,4) y en aquellas donde era mayor el porcentaje de la población que había completado la escuela primaria (RR = 1,2) (P < 0,05). En todo el país aumentó el uso de la prueba de glucosa inmediatamente después de la campaña, quizá debido en parte a la necesidad de confirmar el diagnóstico de los casos identificados mediante el tamizaje. CONCLUSIONES: La respuesta entusiasta a la campaña ilustra que este tipo de programa puede servir para crear mayor conciencia en torno al problema de la diabetes y para sentar las bases del fortalecimiento de la capacidad en el contexto de la atención primaria de salud.