Implementation of a systematic approach to diabetes in primary care in Bahia, Brazil improves metabolic outcomes: PRODIBA-Programa de Interiorização da Assistência ao Diabetes na Bahia (Project for Dissemination of Diabetes Care in the State of Bahia).

BACKGROUND: Staged Diabetes Management (SDM) improves glycaemic control and reduces diabetes-related complications in primary care. METHODS: An 18-month randomized controlled cohort study was conducted in two municipalities in the state of Bahia, Brazil, involving 100 patients with Type 2 diabetes in each municipality. In one municipality, healthcare professionals were trained to use SDM customized protocols for clinical decisions and, in the other municipality, no protocols for diabetes care were implemented. We hypothesized that, in the municipality with SDM trained professionals, patients would have better outcomes, including a fall in glycated haemoglobin (HbA(1c)). RESULTS: Improvements in some metabolic parameters were observed in the SDM group, including a 22% decrease in mean random glucose, a significant 15% decrease in mean HbA(1c), a 6% decrease in systolic blood pressure and an 11% decrease in diastolic blood pressure. There were no differences in body mass index and lipid profile. CONCLUSIONS: SDM customized algorithms are effective, practical and easy to use in primary healthcare teams with very limited resources.

[Social aspects of premature mortality (15 to 59 years old) caused by cerebrovascular diseases]. / Aspectos sociais da mortalidade precoce (15 a 59 anos) por doenças cerebrovasculares.

The loss of productive years for premature death (15-59 years) due to cerebrovascular diseases (CVD) was estimated on the basis of official mortality statistics for Brasil, 1985. Estimations were made for the 5 macro-regions of the country--North, Northeast, Southeast, South and Midwest, as well as for selected capital cities located in each of the regions, respectively: Belém, Salvador, São Paulo, Porto Alegre and Brasília. Men lost 158,194 years of productive life while the loss for women was 128,905 years. The average of years lost/person varied between 11.5 (South) and 13.4 (Midwest) for males and between 12.9 (North) and 14.1 (Midwest) for females. The proportions of productive years lost were greater for women in all five regions. In the capital cities, the average loss of years were similar to the respective macro-regions, although for Salvador there was an increase for both genders as compared to the Northeast. The social costs of such premature deaths is then discussed, estimating a potential reduction of 200,000 years from the total losses, in case of treatment and control of high blood pressure in the Brazilian population.

[Epidemiology of cerebrovascular accidents in the city of Salvador: clinical aspects]. / Epidemiologia dos acidentes vasculares encefálicos na cidade do Salvador: aspectos clínicos.

The major clinical findings of acute cerebrovascular accidents (CVA) were analyzed for 1089 patients from Salvador City (Bahia, Brazil) who attended to medical services from 1 July 1979 to 30 June 1980. Data were collected from all hospitals and emergency services, from private and public sectors, which admitted patients with CVA. Hemiplegies and speech disturbances were the most commonly observed findings in both sexes. In 167 patients (23.03%) a reference to an early episode of CVA was found; 34.93% of the patients were in coma at the time of admission and the lethality rate in this group was 80.87%. The quality of the medical attention provided to these patients was commented. A better organization of the services for tertiary prevention is needed in order to improve patient's adhesion and quality of life.

[Estimated prevalence of cerebral neoplasm of childhood from the capture-recapture method]. / Estimativa da prevalência de neoplasia cerebral na faixa etária pediátrica pelo método de captura-recaptura.

The aim of the study was to estimate the prevalence and fatality rate of primary cerebral neoplasms among children between 1 and 15 years old, State of Bahia, Brazil, 1995. It was a cross-sectional study which includes all cases of brain tumors diagnosed by several sources. From these cases the capture-recapture method was used to estimate the probable number of cases and measure the prevalence and confidence intervals at 95%. By this method it was estimated the existence of 87 cases (CI = 64; 111) of brain tumors in the State, being 72 (CI = 54; 91) in the capital. The estimated prevalence was 1.85/100,000 for children between 1 to 15 years old (CI = 1.36; 2.36/100,000) for the State, and 10.1/100,000 (CI = 7.58; 12.77/100,000) for the capital. The fatality rate was 5.4 percent (CI = 4%; 8%), and 8.9% (CI = 7%; 13%) for the capital and the State respectively. The capture-recapture method showed high precision to estimate the total number of cases. Possible causes of no diagnostic nor treatment of cerebral neoplasms are discussed.

[Clinical epidemiological aspects of cerebral neoplasms in childhood in the State of Bahia, Brazil]. / Aspectos clínico-epidemiológicos das neoplasias cerebrais na faixa etária pediátrica no estado da Bahia, Brasil.

The aim of this study is to describe the relevant aspects of the medical treatment and epidemiology of brain tumors in children between 1 and 15 years old in the State of Bahia, Brazil, first semester of 1995. A cross-sectional design was used for the survey of all new cases and preexisting cases of brain tumors diagnosed through neuroimage among all the children who completed these examinations. Forty eight out of 2,128 were diagnosed as brain tumors, 19 of which being incident cases. In the clinical epidemiological study, the prevalence was 2.3 percent, and the incidence was 0.9 percent. In the prevalent cases, males predominated (1.4:1), and the average age of 10-15 years old (65%). Among the 1-4 years old group predominated incident cases. The astrocytoma was the most frequent brain tumor (41%), and the supratentorial localization predominated by 52%. The ataxia and/or paralysis of cranial nerve and the endocrine and/or visual disturbance symptomatic groups were the most prevalent (82% and 43%, respectively). We discuss the supratentorial localization and the adolescent group predomination in cerebral neoplasms in childhood.

[Cerebrovascular diseases as multiple cause of death in Salvador: magnitude and space differences of mortality omitted in official statistics]. / Doenças cerebrovasculares como causa múltipla de morte em Salvador. Magnitude e diferenças espaciais da mortalidade omitida nas estatísticas oficiais.

Social inequalities and the excess (%) in mortality by cerebrovascular diseases (CVD) unregistered in the official death statistics were studied in Salvador, Brazil, 1988. In an ecological spacial (aggregate) desing, all death mentioning CVD as basic and as associated cause of death were reviewed and distributed, according to their addresses by 66 geographical zones. The mortality rates by CVD (basic+associated) ranged from 22.94 to 376.62/10,000 adults. The mortality fraction not included in the official statistics was 29.1% for Salvador with means between 16.12 and 33.72% in the group of zones of very low to those in the high mortality levels. Seven out of 16 zones included in the 4th quantil showed exceptionally high mortality rates (above those of Salvador + 1.64 x standard deviation corrected by the zones population). The authors discuss possible explanations for the social differences in the mortality profile.

HTLV-1 and myelopathy in Salvador (northeastern Brazil): a case control study.

The principal aim of the study was to determine the degree of association between cerebrospinal fluid (CSF) that is positive for HTLV-1 and myelopathy in Salvador, Brazil. From the same hospital, twenty-eight cases of myelopathy and twenty-eight cases showing no neurological disorder were studied using blind selection matched 1:1 by age and sex. The twenty-eight pairs underwent HTLV-1 serology tests. In those with a positive result, anti-HTLV-1 antibodies were investigated in the CSF. The ELISA method was used, complemented by the Western-blot test. Myelopathy was considered associated with HTLV-1 only when the CSF was positive indicating neurotropism of the virus. The mean age of the cases was 44.6 +/- 15.6 years and the control group was 43.5 +/- 16.0 (p > 0.05). An OR of 9.0 was detected with a reliability interval (95%) of 1.652-48.866 and chi-square significant at the 0.02 level. Despite a strong degree of association and considering the low level of precision, there is a need for analytical studies with larger samples which besides improving the precision will allow for greater control of the confounding variables.

[Characteristics of the demand for cranial computerized tomography: reasons and costs of the exam]. / Características da demanda por tomografia computadorizada crânio-encefálica. Motivos e custos dos exames.

It was reviewed a series of 2860 cerebral computed tomography (CCT) in order to compare the main reasons at referral to investigation with the CCT results and the costs with normal and abnormal CCT. It was also studied the age and sex of the patients. Data were collected from one out of three diagnostic centers in Salvador, Brasil, for a three years period. The 2860 CCT exclude all investigation carried out for the follow-up of a previously diagnosed abnormality. CCT abnormalities were detected in 1152 (40.3%). The following reasons showed the highest proportion of abnormal CCT, for males and females respectively: demential syndrome (91.7 and 83.3%); cerebrovascular accidents (85.1 and 73.6%); infectious and parasitary diseases (76.5 and 78.6%); tumors (65.8 and 55.4%); and head injuries, 63.6% for males. In the female group, 65.0% of the CCT were normal, in a range of 65.0 to 80.0% for the age groups under 54 years old. In the male group, the highest proportion of normal CCT was found in the age groups: 25-34 (68.4%), < 15 (62.9%) and 35-44 (62.7%). The most common reasons for normal CCT for males and females were: headache (81.3 and 87.5%); dizziness/vertigo (79.3 and 78.6%); seizures (67.3 and 70.0%); psychomotor deficiency (72.0 and 67.7%) and "endocrine disorders", 75.0% for each sex. The highest proportion of normal CCT (65.3%) was requested by medical "convenios". The cost with normal CCT reached US$565,225 and with the abnormal ones, US$381,247. Costs with normal CCT were 2.2 higher for medical "convenios" as compared to those of the National Institute of Security requests and 2.8 more than those of private medicine.

[Race, compliance to treatment and/or consultation and control of arterial hypertension]. / Raça, aderência ao tratamento e/ou consultas e controle da hipertensão arterial.

PURPOSE: To compare racial differences on hypertension (Hy) control and compliance to appointments and/or treatment. METHODS: Between November/94 to January/95, 200 low social strata hypertensive outpatients were interviewed (cross-sectional clinical-epidemiologic study) and had their blood-pressure measured (double-blind) in Salvador, Brazil. Compliance to treatment criteria: > or = 50% appointments/year; compliance to treatment = Hy control-WHO and NIH criteria. Means, frequency ratios (FR) and chi 2 were used in the analysis. RESULTS: Most of the hypertensives (88%) were women. Race: 45.5% were mulatoes (M) and 40.5% blacks (B). Compliance to appointments and treatment (A + T) was 30.5%, to treatment (T) 11%, to appointments, 37%, and noncompliance = 21.5%. Compliance was 53.6% for whites (W) and 19.7% for B (p < 0.001); 40% of hypertensives were controlled by WHO criteria and 24% by the NIH (p < 0.001). Frequency ratios for SBP, NIH criteria: W/B = 2.9, W/M = 2.6; WHO: W/B and B/M = 1.7 and for DBP, NIH criteria: W/B = 1.6, W/M = 1.9 and WHO = W/B and W/M = 1.4. Main reason for compliance = Hy control; main reason for noncompliance forgetting the appointment date and/or disease in the appointment day. CONCLUSION: Compliance to appointment did not seem an advantage for treatment adherence and the results pointed out some characteristics of patients that need special attention to improve appointments and treatment compliance.

[Race and left ventricle hypertrophy without hypertension and pulmonary heart disease]. / Raça e hipertrofia do ventrículo esquerdo na ausência de hipertensão e de doenças cardiopulmonares.

PURPOSE: To analyze the association between black people and left ventricular hypertrophy (LVH) in the absence of hypertension and/or other cardiopulmonar disease. METHODS: Data were collected from necropsies carried out in the Anatomopathologic Service (APS). Hospital Edgard Santos from 1970 to 1986, Salvador. It were included only subjects at ages > or = 20 years and free of hypertension and any cardiopulmonar disease. A LV wall > 1.6cm was considered as LVH (standardized criteria of the APS). Controls variables were age, sex, and absence of the mentioned diseases. It was used a case-control epidemiological study design and the association measured by "odds ratio" (OR) for no matched case-control study. RESULTS: From the 208 subjects studied, 48 (23.1%) had LVH. There was no difference in the frequency of right ventricular hypertrophy between cases and controls (p > 0.05). The mean of heart weight was higher for LVH cases (p < 0.001), but there was no evidence of association between blacks and LVH (OR = 1.05, p > 0.05 and confidence interval at 95% = 0.8, 1.31. The highest odds possible for the association in this study (assuming that all 3 LVH losses were black subjects) would be 1.5, also no statistically significant. CONCLUSION: In the absence of hypertension and other cardiopulmonar diseases, LHV is common in necropsies in Salvador, Brazil, with similar frequencies in blacks, whites and mullatos and seems not be a risk factor for hypertension in black people.

Mortality attributed to myocardial infarction in the male and female population of Salvador, BA, between 1981 and 1996.

OBJECTIVE: To describe according to gender the trend in mortality attributed to myocardial infarction (MI) in the population of Salvador, Bahia between 1981 and 1996. METHODS: This study was on mortality due to MI estimates by period and gender of the city of Salvador, Bahia. Data from 1981 to 1996 were stratified by quadrienia, and the percentage reduction in death rate due to MI relative to the preceding period (PRR) was determined. Comparisons between genders were expressed by the male/female death ratio (DR) based on the gender-related PPR. RESULTS: An overall increase of approximately 8% was observed in the death rate attributed to MI for the period 1985-1988 (89.2/10 5 individuals / year) versus the period 1981-1984 (82.1/10(5)/ year). In the subsequent periods, overall reductions of 10% and 20.3% were observed for the periods 1989-1992 and 1993-1996, respectively. For men, the PPRs were 11.1 in the period 1989-1992 and 22.7% in the period 1993-1996. The PPRs in women were lower: 8.6% and 17.4% between 1989 and 1992, and 1993 and 1996, respectively. Death rate reduction was greater for men than women, then the male/female DR decreased from 1.66 in 1981-1984 to 1.35 in 1993-1996. CONCLUSION: The results indicate a trend towards a reduction in the death rate attributed to myocardial infarction in the city of Salvador from the second half of the 1980s onwards, striking in men.

[Acute embolic stroke treated with rt-PA during elective coronary angiography]. / Acidente vascular cerebral isquêmico agudo embólico tratado com rt-PA durante cinecoronariografia eletiva.

A 56-year-old female with unstable angina, presented an acute embolic ischaemic stroke of right medium cerebral artery during elective coronary angiography. Complete patency was achieved after an intraarterial infusion of rt-PA (60mg/60min) with important functional improvement.

[Prevalence of dyslipidemias in adult ambulatory laboratory tests from different health care providers]. / Prevalência de dislipidemias na demanda laboratorial de três diferentes prestadores de assisência.

OBJECTIVE: To detect differences in the prevalence of dyslipidemia in adult ambulatory laboratory tests from three different health care providers, in Salvador-Brazil, 1995. METHODS: The study was carried out using a probabilistic sample of 24 out of 104 laboratories (approximately equal to 25%) which performed the same enzymatic method for lipid tests with the same quality control. Laboratory tests results were separated into three groups, according to health care provider: Sistema Unico de Saúde (SUS, governamental), Health Maintenance Organizations (HMO), and Private or Patients Health Insurance (PHI). Criteria for dyslipidemias in mg/dl were: total cholesterol > or = 240; LDL-c > or = 160; HDL-c < 35 and triglycerides > or = 200. Prevalence rates, 95% confidence intervals (CI) and chi (2) test were used in the analysis. RESULTS: From the 5464 adult subjects, 14.8% were from SUS, 31.6%. from HMO and 53.6% PHI. The highest prevalence for hypercholesterolemia--28.0% (CI 24.0; 32.0) and for LDL-c > or = 160mg/dL--30.4% (CI 27.6; 33.2), were found in the HMO group. PHI had the highest prevalence for HDL-c < 35mg/dL--12.3% (CI 10.0; 13.8), and for hypertrygliceridemia--17.8% (CI 16.3; 19.3). Most of the differences among health providers were statistically significant. CONCLUSION: The best lypid profile observed in subjects from SUS suggests social differences in the prevalence of dyslipidemias. As compared to other dyslipidemias, HDL-c < 35mg/dL prevalence was lower than expected in all three groups. The data may provide insights to medical doctors and other health care professionals regarding the questions of dyslipidemias. It can also provide objective information to the patients and encourage them to change their life styles.

[Prevalence of dyslipidemias in adults in laboratory tests from Salvador, Brazil]. / Prevalência de dislipidemias em adultos da demanda laboratorial de Salvador, Brasil.

PURPOSE: To determine the prevalence of dyslipidemia in non-hospital laboratory tests of adults from Salvador, Brazil. METHODS: The study was carried out in subjects from a probabilistic sample of 25% of a total of 104 local laboratories that used the same enzymatic method for lipid analysis with the quality control as recommended by the Brazilian Society of Clinical Analyses. These represented 93% of all non-hospital laboratories of Salvador in 1995. The odd months of 1995 were selected for sampling in the present study. Criteria for dyslipidemias were: total cholesterol > or = 240; LDL > or = 160; HDL < 35 and triglycerides > or = 200 mg/dl. Prevalence rates and their 95% confidence intervals (CI) and chi 2 test were used in the analyses. RESULTS: Tests from two of the 26 laboratories were not used in the analyses due to file problems or refusal. 7,392 adults were screened, 65% female. We observed prevalence (95% CI) of hypercholesterolemia in 30.0 (27.8; 32.2)%, high LDL in 30.1 (30.8; 35.4)% and hypertriglyceridemia in 30.4 (29.0; 31.4)% of the females. As to the male subjects, prevalences were; 24.0 (20.5; 27.5)% for hypercholesterolemia, 26.1 (22.4; 29.3)% for high LDL, 27.6 (25.7; 29.5)% for hypertriglyceridemia. All gender differences were significant. Low HDL occurred in 15.9 (14.2; 17.8)% of males and in 8.0 (7.1; 8.9)% of females. CONCLUSION: Dyslipidemia is an important risk factor observed in non-hospital laboratory tests of men and women in Salvador. Our data may provide physicians and other health care professionals with objective information to encourage life-style changes.

[Differences in blood pressure measurement in the first consultations before and after implementation of the National Program of Hypertension Control]. / Diferenças na medida da pressão arterial em primeiras consultas pré e pós-implantação do Programa Nacional de Controle da Hipertensão.

This study was carried out in order to compare differences in blood pressure measurements (BPM) before and after the implementation of the program of hypertension control in Salvador, Brazil. Data concerning BPM following the program were obtained from medical records of all 846 adult patients who were seen in a first consultation basis in 5/16/91 in 23 health services. Data for the 1982 year-before the program--were published in 1984. Both studies had the same methodology. In 1991 the BP was measured in 29.1% of the 846 patients. Taking into account the same services included in both studies, the frequency of BPM in 1991 reached 35.9%, 92.0% more than the 18.7% observed in 1982. Lower frequencies of BPM were seen in the State health services all showing reduction in the BPM frequencies as compared to 1982 data. The two hospitals associated to the "Sistema Unico de Saúde" had a bad performance. Patients with ill defined diseases and those surveyed about previous history of hypertension reached the highest frequencies of BPM (85.4 and 83.3% respectively). Strategies in order to improve the BPM in the routine medical work as contributor to the reduction of morbidity and mortality by the complications of hypertension are suggested.

Modelling the population control of the domestic cat: an example from an island in Brazil.

The domestic cat is an invasive species that often causes great impacts where introduced due to its high predatory and reproductive potential, especially on islands. In this study, carried out on Ilha Grande (RJ, Brazil), we aimed to: i) estimate the population density of domestic cats, ii) calculate the number of animals preyed upon annually by domestic cats, and iii) evaluate the efficiency of methods to control the cat population. We used the Vortex program to project the population growth of domestic cats in fifty years, and simulated different scenarios of population control (without control, castration, spay and harvest). Population density of owned cats was 662 cats/km². The annual predation rate was 1.97 prey animals/cat which is an average of 1497.96 prey/year. The population would only be reduced if 70% of females were spayed or removed annually. Measures to control the domestic cat population must be undertaken urgently, since uncontrolled growth of this predator has the potential to seriously impact the biodiversity of Ilha Grande.