Validation of physician certified verbal autopsy using conventional autopsy: a large study of adult non-external causes of death in a metropolitan area in Brazil.

BACKGROUND: Reliable mortality data are essential for the development of public health policies. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death (CoD) is not even among Brazilian regions, with a high proportion of ill-defined CoD. Verbal autopsy (VA) is an alternative to improve mortality data. This study aimed to evaluate the performance of an adapted and reduced version of VA in identifying the underlying causes of non-forensic deaths, in São Paulo, Brazil. This is the first time that a version of the questionnaire has been validated considering the autopsy as the gold standard. METHODS: The performance of a physician-certified verbal autopsy (PCVA) was evaluated considering conventional autopsy (macroscopy plus microscopy) as gold standard, based on a sample of 2060 decedents that were sent to the Post-Mortem Verification Service (SVOC-USP). All CoD, from the underlying to the immediate, were listed by both parties, and ICD-10 attributed by a senior coder. For each cause, sensitivity and chance corrected concordance (CCC) were computed considering first the underlying causes attributed by the pathologist and PCVA, and then any CoD listed in the death certificate given by PCVA. Cause specific mortality fraction accuracy (CSMF-accuracy) and chance corrected CSMF-accuracy were computed to evaluate the PCVA performance at the populational level. RESULTS: There was substantial variability of the sensitivities and CCC across the causes. Well-known chronic diseases with accurate diagnoses that had been informed by physicians to family members, such as various cancers, had sensitivities above 40% or 50%. However, PCVA was not effective in attributing Pneumonia, Cardiomyopathy and Leukemia/Lymphoma as underlying CoD. At populational level, the PCVA estimated cause specific mortality fractions (CSMF) may be considered close to the fractions pointed by the gold standard. The CSMF-accuracy was 0.81 and the chance corrected CSMF-accuracy was 0.49. CONCLUSIONS: The PCVA was efficient in attributing some causes individually and proved effective in estimating the CSMF, which indicates that the method is useful to establish public health priorities.

Influence of pH change and water storage on the sealing ability of two resin-based root-filling materials.

AIM: To evaluate the Influence of pH change and water storage up to 90 days on the sealing ability of two resin-based root-filling materials. MATERIALS AND METHODS: Forty-four human mandibular single-rooted teeth were instrumented and filled with gutta-percha/ AH Plus or Resilon/Epiphany SE (n=20 per group). Two teeth each were used as positive and negative controls. Specimens were set for 7 days under 100% humidity at 37°C. They were allocated into two subgroups (n=10) according to whether they were tested immediately or stored for up to 90 days in water before testing. Sealing ability was evaluated by passive dye penetration. Absorbance at 630 nm (in µg/ml) was measured by spectrophotometry. The pH values were obtained in triplicate. Data were submitted to ANOVA by post-hoc Tukey's test (α=0.05). RESULTS: Specimens filled with Resilon/Epiphany SE exhibited more leakage than specimens filled with gutta-percha/AH Plus at the immediate time point (p<0.001). No differences were detected between the groups after storage, or between the materials with pH changes after 30, 60 and 90 days (p>0.05). CONCLUSION: Gutta-percha/AH Plus provided superior sealing at the immediate time point. Water storage and pH changes did not Influence the sealing ability of tested materials. CLINICAL SIGNIFICANCE: These results suggest that Resilon/ Epiphany SE sealer offered no apparent advantage over the more conventional gutta-percha/AH Plus sealer technique in terms of sealing ability.

Body checking and obsessive-compulsive symptoms in Brazilian outpatients with eating disorders.

OBJECTIVE: Compare obsessive-compulsive symptoms in patients with anorexia nervosa (AN) and bulimia nervosa (BN), and assess the association of these symptoms and body checking in each of these groups of patients. METHODS: Eighty-five female outpatients with eating disorders (ED) completed body checking and obsessive-compulsive questionnaires. RESULTS: Body checking was more prevalent in the BN group. Among patients with AN, the highest mean body-checking scores were found in patients with somatic obsessions related to body areas and eating rituals (p = 0.003 and 0.018, respectively). DISCUSSION: Patients with eating disorders are believed to be included in the obsessive-compulsive spectrum, and may experience intrusive thoughts about behavior. The results of our work suggest that obsessive symptoms and body checking should be further investigated and properly managed in patients with ED.

Psychometric evaluation of the Body Checking Cognitions Scale (BCCS) Portuguese version.

The aim of this study is evaluate the psychometric results and validity of the Brazilian Portuguese language version of the Body Checking Cognitions Scale (BCCS). Factor analysis and concurrent validity were checked on assessments from participants with and without eating disorders. The scale had good internal consistency. Factor analysis confirmed four components. Control and Eating Disorders groups were discriminated, and results correlated well with the Eating Attitudes Test and Body Shape Questionnaire. The results for the Portuguese version of the BCCS were similar to the original version, and its use is recommended for evaluation of body-checking cognitions in the Brazilian population with or without eating disorders.

Could a lipid oxidative biomarker be applied to improve risk stratification in the prevention of cardiovascular disease?

There is significant evidence demonstrating the influence of oxidative stress on atherosclerosis and cardiovascular diseases (CVD). However, oxidative biomarkers have not been applied to follow patients under primary or secondary prevention. Many factors can explain this paradox: the higher complexity of the methods applied to quantify oxidative markers, the high variability observed among the studies, the lack of reference values, and the weak correlation with clinical endpoints. This review presents the role of the major reactive oxygen species (ROS) involved in cardiovascular pathophysiology and how they can be neutralized by endogenous and exogenous antioxidants based on classical and recent studies, highlighting the importance of the secondary products of fatty acid oxidation as potential biomarkers. Furthermore, we discuss the great variability of oxidative stress biomarkers, using as an example data obtained from 55 studies. Among the molecules directly formed from lipid oxidation, such as malondialdehyde (MDA), oxidized LDL (oxLDL), and isoprostanes (F2-IsoP), and those associated with general oxidative conditions (ferric-reducing antioxidant power (FRAP), superoxide dismutase (SOD), glutathione (GSH)), MDA was the most lipid biomarker evaluated in the treatments and proved to be an independent factor compared with traditional markers used in the algorithms to stratify the patient's risk. Finally, this review suggests four steps to follow, aiming to include MDA in the algorithms applied to estimate CVD risk.

Mortality after discharge from a public tertiary cardiovascular referral hospital.

It is critically important for stakeholders with distinct foci of attention on healthcare to understand patient evolution in the presence of an established diagnosis or with a suspected diagnosis of various diseases, specially considering death as an outcome. To study the long-term mortality of patients at a cardiovascular referral hospital. Deterministic binding (selection of pairs of registers from the hospital electronic health records and the mortality records of São Paulo state) from 2002 to 2017 was performed. Studied variables were: age, sex, hospital treatment unit where the first visit occurred (Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostics Services), treatment type, elapsed time between the first visit and death, diagnosis at first and last visits and variables related to death. Statistical Methods: descriptive, survival (with Kaplan-Meier method), correspondence and competitive risks analyses; in case of nonoccurrence of death until the end of 2017, the patients were considered alive. Statistical significance was set at values of P < .05. Median age at the first visit to the Hospital was 51.9 years. Birth locations included 4496 cities, 17.33% in São Paulo, 0.41% in Rio de Janeiro, 0.40% in Osasco, 24.04% in other cities. Sex included females (46.7%), males (44.2%), not defined (6.3%), and other (2.8%). We observed an association between diseases in ICD-10 Chapter 16 (certain conditions originating in the perinatal period) and Chapter 17 (congenital malformations, deformations, and chromosomal abnormalities), both as diagnoses and underlying causes of death, as well as between neoplasms as diagnoses and as the underlying cause of death. In this sample, there was an association between admission diagnoses and underlying causes of death, such as neoplasms, cardiovascular diseases, and congenital heart malformations. Additionally, patients who underwent a cardiac intervention had a smaller less mortality rate than those who were not operated on. There were also differences in cardiovascular mortality between distinct treatment units of the hospital ((Emergency Unit, Outpatient Unit, Hospital Admissions, Diagnostic Services).

Effect of resveratrol supplementation on biomarkers associated with atherosclerosis in humans.

Previous studies have suggested the beneficial effects of resveratrol against cardiovascular disease (CVD). However, there are inconsistent results on cardiovascular-related biomarkers mainly because of variable dosage, intervention time and baseline characteristics of the population. Thus, the exact effect of resveratrol remains unclear. We conducted a review to classify the studies that applied resveratrol to supplement humans according to the major biomarkers and identify which protocol characteristics would be associated with each result profile. Randomized clinical trials that assessed resveratrol effect on biomarkers related to atherosclerosis were searched in databases. Biochemical data were collected from 27 studies on the baseline and post-intervention time. We selected 12 biomarkers to compose the matrix, based on their clinical relevance and higher variation level. A total of 32 assays were obtained from these 27 studies. The net change (%) was calculated for each biomarker. Applying multivariate analysis, the assays were grouped into 3 clusters. Studies that composed Cluster II were characterized by a mean dose of 454.14 mg/day for 74.21 days and showed higher reduction of triglyceride concentration and blood pressure, while those composing Cluster III applied doses around 273.75 mg/day for about 175.33 days and showed the highest HDL increase. Thus, interventions with resveratrol could be customized according to the patient condition, in terms of "dose/time of intervention". This information can be applied to combine resveratrol with drugs to reduce blood pressure or improve lipid profile in further clinical studies.

Validation of SmartVA using conventional autopsy: A study of adult deaths in Brazil.

Background: Accurate cause of death data are essential to guide health policy. However, mortality surveillance is limited in many low-income countries. In such settings, verbal autopsy (VA) is increasingly used to provide population-level cause of death data. VAs are now widely interpreted using the automated algorithms SmartVA and InterVA. Here we use conventional autopsy as the gold standard to validate SmartVA methodology. Methods: This study included adult deaths from natural causes in São Paulo and Recife for which conventional autopsy was indicated. VA was conducted with a relative of the deceased using an amended version of the SmartVA instrument to suit the local context. Causes of death from VA were produced using the SmartVA-Analyze program. Physician coded verbal autopsy (PCVA), conducted on the same questionnaires, and Global Burden of Disease Study data were used as additional comparators. Cause of death data were grouped into 10 broad causes for the validation due to the real-world utility of VA lying in identifying broad population cause of death patterns. Findings: The study included 2,060 deaths in São Paulo and 1,079 in Recife. The cause specific mortality fractions (CSMFs) estimated using SmartVA were broadly similar to conventional autopsy for: cardiovascular diseases (46.8% vs 54.0%, respectively), cancers (10.6% vs 11.4%), infections (7.0% vs 10.4%) and chronic respiratory disease (4.1% vs 3.7%), causes accounting for 76.1% of the autopsy dataset. The SmartVA CSMF estimates were lower than autopsy for "Other NCDs" (7.8% vs 14.6%) and higher for diabetes (13.0% vs 6.6%). CSMF accuracy of SmartVA compared to autopsy was 84.5%. CSMF accuracy for PCVA was 93.0%. Interpretation: The results suggest that SmartVA can, with reasonable accuracy, predict the broad cause of death groups important to assess a population's epidemiological transition. VA remains a useful tool for understanding causes of death where medical certification is not possible.

Evaluation of three different adhesive systems using a bacterial method to develop secondary caries in vitro.

PURPOSE: To assess the effects of three different dental adhesive systems on the formation of secondary root caries, in vitro, with a standardized interfacial gap in a filled cavity model. METHODS: 40 sound human molars were selected and randomly assigned to four experimental groups: Clearfil SE Bond (CSEB), Xeno III (X-III), Scotchbond Multi-Purpose Plus (SBMP) and negative control (NC) without an adhesive system. After the standardized Class V cavity preparations on the buccal and lingual surfaces, restorations were placed with resin composite (Filtek Z250) using a standardized interfacial gap, using a 3 x 2 mm piece of 50 microm metal matrix. The teeth were sterilized with gamma irradiation and exposed to a cariogenic challenge using a bacterial system with Streptococcus mutans. Depth and extension of wall lesions formed and the depth of outer lesions were measured by software coupled with light microscopy. RESULTS: For wall lesion extension the ANOVA test showed differences between groups except between X-III and SBMP (P=0.294). The Tukey's test of confidence intervals indicated smaller values for the CSEB group than for the others. For wall lesion depth the CSEB group also presented the smallest mean values of wall lesion depth when compared to the others (P<0.0001) for all comparisons using Tukey's test. Regarding outer lesion depth, all adhesives showed statistically similar behavior. SEM evaluation of the morphologic appearance of caries lesions confirmed the statistical results showing small caries lesion development for cavities restored with CSEB adhesive system, which may suggest that this adhesive system interdiffusion zone promoted a good interaction with subjacent dentin protecting the dental tissues from recurrent caries.

Neuropsychological assessment of current and past crack cocaine users.

BACKGROUND: Cognitive changes due to crack cocaine consumption remain unclear. METHODS: For clarification, 55 subjects were assigned to three groups: control group, crack cocaine current users, and ex-users. Participants were submitted to Mini-Mental State Examination (MMSE) and tasks evaluating executive functioning and verbal memory. Mood state was also measured. Intergroup comparisons were carried out. RESULTS: Control group performance on the MMSE was better than that of users and ex-users. Verbal memory performance for logical memory of users was impaired. Ex-users scored lower on DSST and Trail Making Test (Part B). CONCLUSION: Chronic crack cocaine use seems to disrupt general cognitive functioning (MMSE), verbal memory, and attentional resources, but findings suggest that some of these effects could be reversed by abstinence.

Drug consumption among medical students in São Paulo, Brazil: influences of gender and academic year.

OBJECTIVE: To analyze alcohol, tobacco and other drug use among medical students. METHOD: Over a five-year period (1996-2001), we evaluated 457 students at the Universidade de São Paulo School of Medicine, located in São Paulo, Brazil. The students participated by filling out an anonymous questionnaire on drug use (lifetime, previous 12 months and previous 30 days). The influence that gender and academic year have on drug use was also analyzed. RESULTS: During the study period, there was an increase in the use of illicit drugs, especially inhalants and amphetamines, among the medical students evaluated. Drug use (except that of marijuana and inhalants) was comparable between the genders, and academic year was an important influencing factor. DISCUSSION: Increased inhalant use was observed among the medical students, especially among males and students in the early undergraduate years. This is suggestive of a specific behavioral pattern among medical students. Our findings corroborate those of previous studies. CONCLUSION: Inhalant use is on the rise among medical students at the Universidade de São Paulo School of Medicine. Because of the negative health effects of illicit drug use, further studies are needed in order to deepen the understanding of this phenomenon and to facilitate the development of preventive measures.

[Reliability of the instrument for classifying elderly people's capacity for self-care]. / Confiabilidade do Instrumento para Classificação de Idosos quanto à Capacidade para o Autocuidado.

OBJECTIVE: To evaluate the reliability of an instrument for classifying elderly people regarding their capacity for self-care, which was developed to assist occupational therapists in attending elderly people at primary healthcare units. METHODS: Stability and internal consistency tests were carried out. To validate the instrument, tests were applied to a sample of 30 individuals aged 60 years and over, on two occasions. The statistical analysis was performed after careful grouping of the responses. This led to the formulation of a simplified version of the instrument. The stability of this version was assessed using the kappa coefficient and the internal consistency by Cronbach's alpha coefficient. RESULTS: The stability ranged from moderate to excellent. The internal consistency was checked only for areas that were shown to be appropriate for using the methodology, based on calculations of Cronbach's alpha: three of the six questions in the "social profile" area and the blocks of basic and instrumental activities of daily living in the "functional capacity" area, which respectively consisted of nine and eight activities. CONCLUSIONS: Following the stability and internal consistency tests, the instrument made it possible to succinctly and simply classify elderly people with regard to their functional capacity for basic and instrumental activities, and to characterize them regarding other aspects of self-care. The evidence regarding its reliability and validity could be expanded by means of new studies.

Effect of chlorhexidine-thymol varnish on caries lesion development in first permanent molars.

OBJECTIVE: The aim of this study was to investigate the caries prevention efficacy of chlorhexidine-thymol (CHX-T) varnish on newly erupted permanent first molars. METHODS: Fifty-seven six- to eight-year-old school children were included in a program of sequential CHX-T varnish application. For inclusion, they had to have at least two homologous, newly erupted first permanent molars with visually sound occlusal surfaces. A clinical examination was used to determine the molar eruption stage, biofilm presence, and whole caries status. There were 99 pairs of molars in the study population. A split-mouth design was used where each child randomly had one first molar treated with six applications of CHX-T varnish, and the other with a placebo varnish, every 15 days for 75 days. The children were then revaluated for caries one year following the conclusion of treatment. RESULTS: Fourteen pairs of teeth presented incipient enamel caries lesions in both molars (one CHX-T and one placebo varnish), four developed lesions in the placebo-treated molars only, and eight developed lesions in CHX-T varnish-treated molar only. No significant statistical differences were found between the two groups with regard to caries increment (p = 0.20). CONCLUSION: Six applications of CHX-T varnish had no protective effect against caries development.

Labeling disorder--the relationship between conduct problems and drug use in adolescents.

OBJECTIVE: To verify how conduct disorder and conduct problems are associated with gender, age at onset of drug use and categories of drugs used. METHOD: A test of association was conducted between the presence of comorbidity and gender. Mean age of first use of each drug was compared to mean age of first arrest, of first robbery/theft, and of first drug dealing. RESULTS: In this sample, approximately 59% of adolescents had already robbed and/or stolen, 38.6% had already been arrested, 32.3% had prior history of drug dealing, 24.1% had depression, and 9.6% had conduct disorder. Prevalence of conduct problems was 65.2%. Tobacco, alcohol, marijuana and cocaine were used before the first robbery and/or theft, first drug dealing, and first arrest. DISCUSSION: The fact that drug use onset preceded illegal acts suggests that the latter are the consequence of the consumption of the former, or perhaps, the consequence of "social invisibility" (feeling of not belonging to anything or to anybody) by which these youths undergo. CONCLUSIONS: Labeling these youths as conduct-disordered adolescents may cloud a rather different reality, and it may submit them to more social isolation and stigmatization as well.

Alcohol and drug use among university students: gender differences.

OBJECTIVE: This study compared the pattern of alcohol, legal and illegal drugs use among students of the Universidade de São Paulo (Brazil) in 1996 and 2001. METHOD: Samples of 2.564 (1996) and 2.837 (2001) students answered a questionnaire proposed by the World Health Organization, which characterizes the consumption of alcohol, legal and illegal drugs in lifetime, in the last 12 months and in the last 30 days. RESULTS: Men showed a significant increase in lifetime use of tobacco (44.8% to 50.9%), marijuana (33.7% to 39.5%) and hallucinogens (6.6% to 14.1%) between 1996 and 2001. No significant change was observed among women between 1996 and 2001 in tranquilizer use. Concerning the consumption reported in the last 12 months, both genders displayed significant increases in the consumption of marijuana (22.3% to 27.1% for men and 12.9% to 16.9% for women), amphetamines (1.9% to 5.0% for men and 3.4% to 5.6% for women), and inhalants (9.8% to 15.7% for men and 5.4% to 10.6% for women). The greatest gender difference was observed in consumption reported in the last 30 days with significant increases in male use of tobacco (19.6% to 23.5%), marijuana (15.8% to 20.5%), amphetamines (1.1% to 3.2%), and inhalants (4.0% to 7.9%). Substance use reported in the last 30 days remained stable among women between the 2 surveys. CONCLUSION: Rates of substance use among university students increased. These gender differences in substance consumption should be taken into account in the development of preventive and treatment strategies for undergraduate university students.

Prevalence of at-risk drinking among Brazilian truck drivers and its interference on the performance of executive cognitive tasks.

BACKGROUND: Binge drinking (BD) has been associated with an increase in the risk of alcohol-related injuries. Alcohol continues to be the main substance consumed by truck drivers, a population of special concern, since they are often involved in traffic accidents. The aim of this study was to estimate the prevalence of BD and its interference in the executive functioning among truck drivers in Sao Paulo, Brazil. METHODS: A non-probabilistic sample of 684 truck drivers was requested to answer a structured research instrument on their demographic data and alcohol use. They performed cognitive tests to assess their executive functioning and inventories about confounding variables. The participants were then divided according to their involvement in BD. RESULTS: 17.5% of the interviewees have reported being engaged in BD. Binge drinkers showed a better performance on one test, despite having done so at the expense of more mistakes and lower accuracy. More interestingly, binge drinkers took three seconds longer than non-binge drinkers to inhibit an inadequate response, which is worrisome in the context of traffic. Overall, the deleterious effect of BD on performance remained after controlling for the effects of confounding variables in regression logistic models. CONCLUSIONS: As the use of alcohol among truck drivers may be as a way to get by with their work conditions, we believe that a negotiation between their work organization and public authorities would reduce such use, preventing negative interferences on truck drivers' cognitive functioning, which by its turn may also prevent traffic accidents.

Truck drivers' traffic accidents in the State of São Paulo: prevalence and predictors. / Acidentes de trânsito envolvendo motoristas de caminhão no Estado de São Paulo: prevalência e preditores.

Abstract The mortality rate of traffic accidents (TA) is high in Brazil. Trucks are the second category of motor vehicles most often involved in TA. However, few studies have addressed the issue of TA among these professionals. The study aimed to estimate the prevalence of TA and their predictors in a sample of 684 truck drivers recruited in the state of São Paulo during 2012 and 2013. We requested participants to answer a research instrument on their personal and occupational data and their involvement in TA and traffic violations. A logistic regression model was developed to identify TA predictors. Almost 11% of the respondents suffered at least one TA in that timeframe. We identified the following TA predictors: having few years of experience as professional drivers (OR = 1.86; CI 95% = 1.05-3.38; p = 0.036); receiving some traffic tickets (OR = 1.91; CI 95% = 1.04-3.66; p = 0.043) and working more than 12 hours daily (OR = 1.84; CI 95% = 1.04-3.24; p = 0.034). Given those results, we suggest the development of a joint action among all the involved social stakeholders in order to negotiate truck drivers' work organization aiming at reducing behaviors that may lead to traffic accidents.

Comparison of intra- and intertooth resin-dentin bond strength variability.

PURPOSE: The aim of this study was to investigate the intra- and intertooth microtensile bond strength variability of two adhesive systems applied to dentin. MATERIALS AND METHODS: Twenty human third molars were ground to expose a flat dentin surface. Two adhesive systems (Single Bond and One Step) were applied according to the manufacturers' instructions and composite resin crowns were constructed incrementally. After 24 h in distilled water at 37 degrees C, each tooth was longitudinally sectioned in both "x" and "y" directions under 300 rpm to obtain sticks with a cross-sectional area of 0.8 mm2. The sticks from each tooth were tested at a crosshead speed of 0.5 mm/min. The fracture pattern of each stick was microscopically analyzed after debonding (400X). A mixed model with adhesive as a fixed variable, tooth as a random variable, and bonded area included as a covariate, was employed for the data treatment. In this model, all observations have the same variance, which is the sum of two components: the variance of the random effect (intertooth) and the variance of the errors (intratooth). RESULTS: The intratooth variability was greater than the intertooth variability. CONCLUSION: The intratooth variability is higher than the intertooth variability. Sticks from the same tooth cannot be considered as an experimental unit, since it does not fulfill all ANOVA requirements.

Comparative study of drug use among undergraduate students at the University of São Paulo--São Paulo campus in 1996 and 2001.

OBJECTIVE: To compare the rate of drug use prevalence and to investigate opinions regarding such use among undergraduate students at the University of São Paulo--São Paulo campus in 1996 and again in 2001. METHODS: Both studies followed the same procedures of sampling and data collection. A random sample of undergraduate students, divided into the areas Humanities, Exact Sciences and Biologic Sciences, responded to an anonymous and self-report survey regarding the use of licit and illicit drugs within the last 30 days, within the last 12 months and over the lifetime of the subject. The two surveys were compared through the construction of (95%) confidence intervals for the prevalence differences for each substance by area and by total number of students. The Wald test for homogeneity was applied in order to compare the prevalences. RESULTS: High approval of regularly trying and using cocaine, crack, amphetamines and inhalants was observed. The drugs that showed statistic significant increasing were:lifetime use: alcohol, tobacco, marijuana, inhalants, hallucinogens, amphetamines, anti cholines, barbiturics and any illicit drug;last-12-month use: marijuana, inhalants, amphetamines, hallucinogens and any illicit drug;last-30-day use: marijuana, inhalants, amphetamines and any illicit drug. DISCUSSION: The observed difference in the use of some drugs between the two surveys appears to be a consequence of the higher rates of favorable opinions regarding trying and regularly using some psychoactive substances, a finding that mirrors global trends in drug use.