Hospitalizaciones evitables por problemas de salud sensibles a cuidados ambulatorios: construcción y validación de la lista Uruguaya de patologías

Introducción: Las hospitalizaciones por Ambulatory Care Sensitive Conditions es un indicador que mide la utilización de los servicios hospitalarios por problemas de salud que podrían haber sido prevenidos en el primer nivel de atención. El concepto se refiere a los procesos en que la atención ambulatoria efectiva puede ayudar a disminuir los riesgos de hospitalización, en un segundo nivel de atención. El objetivo del estudio fue construir y validar una lista uruguaya de problemas de salud sensibles a cuidados ambulatorios (PSSCA) según CIE-10. Metodología: Para la construcción de la lista inicial de códigos de PSSCA se realizó una revisión de los listados existentes y se propuso un listado inicial que fue validado a través del Método Delphi. Se propone un listado de 99 códigos diagnósticos de PSSCA adaptado a nuestro entono sanitario. Los mismos permiten identificar y cuantificar problemas de salud que pueden producir hospitalizaciones potenciamente evitables mediante cuidados ambulatorios accesibes y oportunos en el primer nivel de atención. Resultados: Se conformó un panel de 12 expertos. A partir de los datos obtenidos, considerando los 99 diagnósticos clasificados por CIE-10, éstos se pueden subclasificar en función de si la patología es infecciosa o no, obteniendo un resultado general de 62 patologías en un total de 99 que pueden ser clasificadas como infecciosas, lo que se corresponde a un 62 %. Discusión: De la comparación de la lista uruguaya de PSSCA a la que hemos arribado y las listas validadas utilizadas para la construcción inicial del listado de patologías propuesto, podemos decir que la primera presenta un mayor porcentaje de coincidencia con la lista de patologías de Bello Horizonte. Podemos mencionar que la mayoría de los problemas de salud identificados con base en el listado de PSSCA, son sensibles de ser resueltos con la atención primaria oportuna y de calidad que podría evitar o disminuir de una manera significativa su hospitalización. Conclusiones: Este trabajo describe el proceso de construcción y validación de una lista de códigos de PSSCA adaptados al contexto uruguayo a través del método Delphi. Hemos arribado a un listado que comprende un total de 99 diagnósticos, agrupadas en un total de diecinueve categorías que considera la especificidad del contexto uruguayo del indicador.

Introduction: Hospitalizations for Ambulatory Care Sensitive Conditions is an indicator that measures the use of hospital services for health problems that could have been prevented at the first level of care. The concept refers to the processes in which effective outpatient care can help reduce the risks of hospitalization, at a second level of care. The objective of the study was to build and validate a Uruguayan list of health problems sensitive to outpatient care (PSS-CA) according to ICD-10. Methodology: To construct the initial list of PSSCA codes, a review of the existing lists was carried out and an initial list was proposed that was validated through the Delphi Method. A list of 99 PSSCA diagnostic codes adapted to our healthcare environment is proposed. They make it possible to identify and quantify health problems that can lead to potentially avoidable hospitalizations through accessible and timely outpatient care at the first level of care. Results: A panel of 12 experts was formed. From the data obtained, considering the 99 diagnoses classified by ICD-10, these can be subclassified depending on whether the pathology is infectious or not, obtaining a general result of 62 pathologies in a total of 99 that can be classified as infectious, which corresponds to 62%. Discussion: From the comparison of the Uruguayan list of PSSCA that we have arrived at and the validated lists used for the initial construction of the proposed list of pathologies, we can say that the first presents a higher percentage of coincidence with the list of pathologies of Bello Horizonte . We can mention that most of the health problems identified based on the PSSCA list are sensitive to being resolved with timely and quality primary care that could prevent or significantly reduce hospitalization. Conclusions: This work describes the process of construction and validation of a list of PSSCA codes adapted to the Uruguayan context through the Delphi method. We have arrived at a list that includes a total of 99 diagnoses, grouped into a total of nineteen categories that consider the specificity of the Uruguayan context of the indicator.

Introdução: As Internações por Condições Sensíveis à Atenção Ambulatorial são um indicador que mede a utilização de serviços hospitalares para problemas de saúde que poderiam ter sido evitados no primeiro nível de atenção. O conceito refere-se aos processos em que um atendimento ambulatorial eficaz pode auxiliar na redução dos riscos de internação, em um segundo nível de atenção. O objetivo do estudo foi construir e validar uma lista uruguaia de problemas de saúde sensíveis à atenção ambulatorial (PSS-CA) segundo a CID-10. Metodologia: Para construir a lista inicial de códigos PSSCA foi realizada uma revisão das listas existentes e foi proposta uma lista inicial que foi validada através do Método Delphi. É proposta uma lista de 99 códigos de diagnóstico PSSCA adaptados ao nosso ambiente de saúde. Permitem identificar e quantificar problemas de saúde que podem levar a hospitalizações potencialmente evitáveis ​​através de cuidados ambulatórios acessíveis e oportunos no primeiro nível de cuidados. Resultados: Foi formado um painel de 12 especialistas. A partir dos dados obtidos, considerando os 99 diagnósticos classificados pela CID-10, estes podem ser subclassificados consoante a patologia seja infecciosa ou não, obtendo-se um resultado geral de 62 patologias num total de 99 que podem ser classificadas como infecciosas, o que corresponde para 62%. Discussão: A partir da comparação da lista uruguaia de PSSCA a que chegamos e das listas validadas utilizadas para a construção inicial da lista de patologias proposta, podemos dizer que a primeira apresenta um maior percentual de coincidência com a lista de patologias de Belo Horizonte. Podemos mencionar que a maioria dos problemas de saúde identificados com base na lista PSSCA são sensíveis para serem resolvidos com cuidados primários oportunos e de qualidade que possam prevenir ou reduzir significativamente a hospitalização. Conclusões: Este trabalho descreve o processo de construção e validação de uma lista de códigos PSSCA adaptados ao contexto uruguaio através do método Delphi. Chegamos a uma lista que inclui um total de 99 diagnósticos, agrupados em um total de dezenove categorias que consideram a especificidade do contexto uruguaio do indicador.

Irritable bowel syndrome in celiac disease - relationships to celiac disease antibodies and levels of pro-inflammatory cytokines.

BACKGROUND: Evidence indicates that low-grade inflammation can alter gastrointestinal motor and sensory function and might contribute to the genesis of symptoms in IBS. OBJECTIVE: To examine relationships between IBS, disease antibodies and cytokine titers in celiac patients and a control group. MATERIALS AND METHODS: IBS, CD activity and serum levels of IL-6, IL-8 and IL12/23p40 were determined in celiac patients and controls. RESULTS: 123 celiac patients were included, 89% were female. 59% demonstrated disease activity and 32% met IBS criteria. Prevalence of IBS was not different between patients who adhered or did not adhere to GFD as well as between patients with or without positive antibodies. Celiac patients had increased levels of IL-6, IL-8 and IL12/23p40 as compared to controls. Higher levels of cytokines were found in celiac patients with IBS than in those without IBS. No difference in levels of cytokines was found between patients with and without CD positive antibodies. A significant negative correlation between the mental component of QoL and IL-6 and IL12/23p40 levels was found, but not with IL-8. CONCLUSION: Higher levels of inflammatory cytokines were found in CD patients with IBS than in either those without IBS or controls, indicating that IBS symptoms are associated with an increase in the inflammatory response and a decrease in quality of life of CD patients. These differences in cytokine levels were not related to CD antibodies status suggesting that IBS, in CD, is related to a different inflammatory process than that which is relevant to CD.

Irritable bowel syndrome in celiac disease - relationships to celiac disease antibodies and levels of pro-inflammatory cytokines / Síndrome del intestino irritable en la enfermedad celíaca: relaciones con los anticuerpos contra la enfermedad celíaca y los niveles de citocinas proinflamatorias

ABSTRACT Background: Evidence indicates that low-grade inflammation can alter gastrointestinal motor and sensory function and might contribute to the genesis of symptoms in IBS. Objective: To examine relationships between IBS, disease antibodies and cytokine titers in celiac patients and a control group. Materials and methods: IBS, CD activity and serum levels of IL-6, IL-8 and IL12/23p40 were determined in celiac patients and controls. Results: 123 celiac patients were included, 89% were female. 59% demonstrated disease activity and 32% met IBS criteria. Prevalence of IBS was not different between patients who adhered or did not adhere to GFD as well as between patients with or without positive antibodies. Celiac patients had increased levels of IL-6, IL-8 and IL12/23p40 as compared to controls. Higher levels of cytokines were found in celiac patients with IBS than in those without IBS. No difference in levels of cytokines was found between patients with and without CD positive antibodies. A significant negative correlation between the mental component of QoL and IL-6 and IL12/23p40 levels was found, but not with IL-8. Conclusion: Higher levels of inflammatory cytokines were found in CD patients with IBS than in either those without IBS or controls, indicating that IBS symptoms are associated with an increase in the inflammatory response and a decrease in quality of life of CD patients. These differences in cytokine levels were not related to CD antibodies status suggesting that IBS, in CD, is related to a different inflammatory process than that which is relevant to CD.

RESUMEN Antecedentes: la evidencia indica que la inflamación de bajo grado puede alterar la función motora y sensorial gastrointestinal y puede contribuir a la aparición de síntomas en el SII. Objetivo: Examinar la relación entre SII, anticuerpos contra enfermedades y títulos de citocinas en pacientes celíacos y un grupo de control. Materiales y métodos: se determinaron los síntomas de SII, actividad de CD y niveles séricos de IL-6, IL-8 e IL12 / 23p40 en pacientes celíacos y controles. Resultados: se incluyeron 123 pacientes celíacos, el 89% eran mujeres. El 59% demostró actividad de la enfermedad y el 32% cumplió con los criterios del SII. La prevalencia del SII no fue diferente entre los pacientes que se adhirieron o no se adhirieron a GFD, así como entre los pacientes con o sin anticuerpos positivos. Los pacientes celíacos tenían niveles aumentados de IL-6, IL-8 e IL12 / 23p40 en comparación con los controles. Se encontraron niveles más altos de citocinas en pacientes celíacos con SII que en aquellos sin SII. No se encontraron diferencias en los niveles de citocinas entre pacientes con y sin anticuerpos CD positivos. Se encontró una correlación negativa significativa entre el componente mental de la calidad de vida y los niveles de IL-6 e IL12 / 23p40, pero no con IL-8. Conclusión: Se encontraron niveles más altos de citocinas inflamatorias en pacientes con EC con SII que en aquellos sin SII o controles, lo que indica que los síntomas del SII están asociados con un aumento en la respuesta inflamatoria y una disminución en la calidad de vida de los pacientes con CD. Estas diferencias en los niveles de citocinas no estaban relacionadas con el estado de los anticuerpos contra la CD, lo que sugiere que el SII, en la CD, está relacionado con un proceso inflamatorio diferente al que es relevante para la CD.

Incidencia de tuberculosis en pacientes que reciben fármacos anti-TNF( / Incidence of tuberculosis in patients receiving tumor necrosis factor-( blockers / Incidência de tuberculose em pacientes que recebem fármacos anti-TNF(

Resumen: Introducción: la tuberculosis (TB) es una complicación frecuente del uso de fármacos anti-TNF(. Ocurre por reactivación de una infección latente o por progresión de una infección reciente. Objetivos: conocer la incidencia de TB en la población que recibió fármacos anti- TNF(, analizar las formas de presentación y la realización de pesquisa de infección latente previo al inicio del tratamiento. Método: estudio de cohorte retrospectiva. Se incluyeron los pacientes que recibieron fármacos anti- TNF( entre 2010 y 2016. Los datos se obtuvieron de los sistemas informáticos del Fondo Nacional de Recursos y del Programa Nacional de Tuberculosis. Se calculó la incidencia de TB y se describieron los casos que desarrollaron TB. Resultados: se incluyeron 991 tratamientos para un total de 980 pacientes. Se reportaron nueve casos de TB. La incidencia global fue de 419,9 (IC 95% 191,9-591,2) por 100.000 personas/año. Solo hubo casos de TB en pacientes tratados con adalimumab. El cribado de infección tuberculosa latente (ITBL) previo al inicio del fármaco fue heterogéneo y predominaron las formas de TB diseminadas (6/9) sobre la afectación pulmonar aislada (3/9). En todos los casos se suspendió el anti- TNF( al diagnóstico de TB y en ningún caso se retomó. Conclusiones: la incidencia de TB en la población de pacientes bajo tratamiento con anti- TNF( fue 16,5 veces mayor que en la población general. Predominaron las formas de TB diseminadas y se dieron casos en sujetos que habían recibido tratamiento de ITBL previo al inicio del fármaco, sugiriendo que el riesgo persiste mientras exista exposición a éste.

Summary: Introduction: tuberculosis (TB) is a frequent complication in patients receiving tumor necrosis factor-alpha (TNF-() blockers. It occurs upon the reactivation of a latent infection or the progression of a recent infection. Objective: to learn about the incidence of TB in a population receiving tumor necrosis factor-alpha (TNF-() blockers, to analyze the presentation of this condition and to conduct a latent infection research prior to the initiation of therapy. Method: retrospective cohort study. Patients receiving tumor necrosis factor-alpha (TNF-() blockers between 2010 and 2016 were included in the study. Data were obtained from the IT systems of the National Resources Fund and the National Tuberculosis Program. The incidence of TB was calculated and the cases developing TB were described. Results: 991 treatments were included for 980 patients in total. 9 cases of TB were reported. Global incidence was 419.9 (IC 95% 191.9-591.2) out of 100,000 people per year. Cases of TB were only seen in patients treated with adalimumab. Screening for LTBI upon initiation of the drug was heterogeneous and the disseminated forms of TB prevailed (6/9) over isolated pulmonary affectation (3/9). In all cases anti- TNF( was suspended when TB was diagnosed, and it was not reinitiated. Conclusions: the incidence of TB in patients receiving tumor necrosis factor-alpha (TNF-() blockers was 16.5 times greater than in the general population. Disseminated forms of TB prevailed, and some cases occurred in individuals who had received LTBI therapy prior to the initiation of the drug, suggesting the risk persists as long as there is exposure to the drug.

Resumo: Introdução: a tuberculose (TB) é uma complicação frequente do uso de fármacos anti- TNF(. É causada pela reativação de uma infecção latente ou pela evolução de uma infecção recente. Objetivos: conhecer a incidência de TB na população que recebeu fármacos anti- TNF(, analisar as formas de apresentação e a realização de pesquisa de infecção latente prévia ao início do tratamento. Método: estudo de coorte retrospectivo. Foram incluídos todos os pacientes que receberam fármacos anti- TNF( no período 2010-2016. Os dados foram obtidos dos registros informatizados do Fondo Nacional de Recursos e do Programa Nacional de Tuberculosis. A incidência de TB foi calculada e foram descritos os casos que desenvolveram esta patologia. Resultados: foram incluídos 991 tratamentos para um total de 980 pacientes. Nove casos de TB foram registrados. A incidência global foi de 419,9 (IC 95% 191,9-591,2) por 100.000 pessoas/ano. Somente foram registrados casos de TB em pacientes tratados com adalimumab. A triagem de infecção tuberculosa latente (ITBL) prévia ao início do fármaco foi heterogênea e predominaram as formas de TB disseminadas (6/9) sobre a pulmonar isolada (3/9). Em todos os casos o uso de anti- TNF( foi suspenso definitivamente quando o diagnóstico de TB foi realizado. Conclusões: a incidência de TB na população de pacientes em tratamento com anti- TNF( foi 16,5 vezes maior que na população em geral. Predominaram as formas disseminadas de TB e foram registrados casos em pacientes que haviam recebido tratamento para ITBL prévio ao início do fármaco, sugerindo que o risco persiste enquanto houver exposição a este.

¿Coartación de aorta en el recién nacido? No siempre es lo que parece: a propósito de un caso / Coarctation of aorta in a neonate? It is not always what it seems: an illustrative case

La coartación de aorta en neonatos se puede manifestar como insuficiencia cardíaca según el grado de obstrucción. Hay situaciones que pueden simular una coartación de aorta en los recién nacidos. Limitarse a la imagen típica de muesca aórtica en la ecocardiografía para diagnosticar una coartación de aorta puede inducir a error y demorar el diagnóstico adecuado. Se presenta el caso de un recién nacido con insuficiencia cardíaca con diagnóstico inicial de coartación de aorta y, posteriormente, de malformación arteriovenosa cerebral. Se debe considerar la malformación arteriovenosa en el diagnóstico diferencial de un recién nacido con insuficiencia cardíaca.

Coarctation of the aorta in neonates can manifest as heart failure when there is a certain degree of obstruction. There are some situations that can simulate a coarctation of the aorta in newborns. Diagnosis of coarctation of the aorta based solely on the typical aortic arch image on echocardiography can be misleading and delay an accurate diagnosis. We describe an unusual case of a newborn with heart failure who was initially diagnosed with coarctation of the aorta and then with cerebral arteriovenous malformation. We must consider the cerebral arteriovenous malformation in the differential diagnosis of a newborn with heart failure.

Modelos epidemiológicos en la pandemia por SARS-CoV-2: concepto, aplicaciones y alcance / Epidemiological models in the SARS-CoV-2 pandemic: concept, applications and scope / Modelos epidemiológicos na pandemia de SARS-CoV-2: conceito, aplicações e escopo

Resumen: La pandemia por SARS-CoV-2, un nuevo coronavirus surgido en 2019, ha determinado una emergencia sanitaria y social mundial. Cada país optó por tomar acciones teniendo en cuenta su experiencia, analizando el impacto en las áreas de la salud, en lo económico y social, y aprendiendo de las experiencias comunicadas por otros países. El desarrollo de modelos epidemiológicos para obtener curvas estimativas de la situación de la enfermedad en la población y poder proyectar su evolución, adquiere especial importancia en un contexto de extrema incertidumbre, complejidad y dinamismo.

Abstract: The SARS-CoV-2 pandemic, a new coronavirus that emerged in 2019, has led to a global health and social emergency. Each country chose to take actions taking into account their experience, analyzing the impact in the areas of health, economically and socially, and learning from the experiences reported by other countries. The development of epidemiological models to obtain estimating curves of the disease situation in the population and to project its evolution, acquires special importance in a context of extreme uncertainty, complexity and dynamism.

Resumo: A pandemia de SARS-CoV-2, um novo coronavírus que surgiu em 2019, levou a uma emergência social e de saúde global. Cada país optou por tomar ações levando em consideração sua experiência, analisando o impacto nas áreas da saúde, econômica e socialmente, e aprendendo com as experiências relatadas por outros países. O desenvolvimento de modelos epidemiológicos para obter curvas de estimativa da situação da doença na população e projetar sua evolução, adquire importância especial em um contexto de extrema incerteza, complexidade e dinamismo.

A systematic review and meta-analysis of cesarean delivery and other uterine surgery as risk factors for placenta accreta.

BACKGROUND: The incidence of placenta accreta has increased in recent years and it has been suggested that the rising trend in cesarean delivery and other uterine surgery is the underlying cause. OBJECTIVE: To explore the magnitude of the effect of performing single and repeat cesarean deliveries or other uterine surgery on the incidence of placenta accreta. SEARCH STRATEGY: Relevant databases were searched for papers published before August 1, 2018, using terms including "accreta" and "cesarean." SELECTION CRITERIA: Cohort studies assessing the risk of placenta accreta according to women's history of uterine surgery. DATA COLLECTION AND ANALYSIS: Meta-analyses were performed to assess the risks associated between uterine surgery and placenta accreta, hysterectomy, and uterine rupture. The I2 statistic was used to examine between-study heterogeneity. MAIN RESULTS: The risk of placenta accreta in a second pregnancy increased for women who had undergone a cesarean in their first pregnancy compared with vaginal delivery (OR 3.02; 95% CI, 1.50-6.08). Absolute risk of placenta accreta increased with the number of previous cesareans. The risk of uterine rupture and hysterectomy was also associated with the number of cesareans. CONCLUSIONS: Risk of placenta accreta, hysterectomy, and uterine rupture increases with the number of previous cesarean deliveries. PROSPERO: CRD42016050646.

Efectos de una intervención de reducción del estrés basada en Mindfulness (MBSRP) sobre parámetros clínicos en la Artritis Reumatoidea / Effects of a Mindfulness-based stress reduction intervention (MBSRP) on clinical parameters in Rheumatoid Arthritis / Efeitos de uma intervenção de redução do estresse baseada em Mindfulness (MBSRP) sobre parâmetros clínicos na artrite reumatóide

Resumen: La artritis reumatoide es un trastorno autoinmune sistémico que causa inflamación extensa y persistente de las articulaciones. La inflamación persistente da lugar a muchas manifestaciones sistémicas y extraarticulares que afectan a la mayoría de los sistemas orgánicos, dando lugar a complicaciones graves y comorbilidades. El estrés psicológico es un factor provocador importante de los síntomas en las enfermedades inflamatorias crónicas. En los últimos años, el interés por abordar la respuesta al estrés a través de prácticas como la meditación ha aumentado asombrosamente, a pesar de la escasez de pruebas de que los beneficios reportados son específicos de esa práctica. La presente revisión sistemática se propone como objetivo evaluar la eficacia y seguridad de técnicas de meditación como tratamiento complementario de la AR. Se llevó a cabo una revisión sistemática de la literatura. Se consultaron las bases de datos Colaboración Cochrane, MEDLINE, Organización Mundial de la Salud, Plataforma de Registro Internacional de Ensayos clínicos para todos los ensayos registrados y en curso de realización y Clinicaltrials.gov Los datos extraídos se incluyeron en el kit de herramientas COVIDENCE y en el software REVMAN de la colaboración Cochrane. No pudo realizarse meta-análisis realizándose una síntesis narrativa de los resultados. Conclusiones: la técnica de Atención Plena (MBSR) es beneficiosa como tratamiento complementario de la Artritis Reumatoide, modificándose parámetros clínicos, pero con resultados heterogéneos en cuanto a los marcadores séricos de inflamación.

Abstract: Rheumatoid arthritis is a systemic autoimmune disorder that causes extensive and persistent inflammation of the joints. Persistent inflammation leads to many systemic and extra-articular manifestations that affect most of the organ systems, leading to serious complications and comorbidities. Psychological stress is a major provocative factor of symptoms in chronic inflammatory diseases. In recent years, interest in addressing the stress response through practices such as meditation has increased dramatically, despite the paucity of evidence that the benefits reported are specific to that practice. The present systematic review aims to evaluate the effectiveness and safety of meditation techniques as a complementary treatment of RA. A systematic review of the literature was carried out. The databases Cochrane Collaboration, MEDLINE, World Health Organization, International Registry Platform of Clinical Trials for all the trials registered and in progress and Clinicaltrials.gov were consulted. extracted data were included in the COVIDENCE toolkit and in the REVMAN software of the Cochrane collaboration. Meta-analysis could not be performed, making a narrative synthesis of the results. Conclusions: the technique of Full Attention (MBSR) is beneficial as a complementary treatment of Rheumatoid Arthritis, modifying clinical parameters, but with heterogeneous results in terms of serum markers of inflammation.

Resumo: A artrite reumatóide é um distúrbio auto-imune sistêmico que causa inflamação generalizada e persistente das articulações. A inflamação persistente leva a muitas manifestações sistêmicas e extra-articulares que afetam a maioria dos sistemas orgânicos, levando a sérias complicações e comorbidades. O estresse psicológico é um dos principais fatores desencadeantes dos sintomas nas doenças inflamatórias crônicas. Nos últimos anos, o interesse em abordar a resposta ao estresse por meio de práticas como a meditação aumentou dramaticamente, apesar da escassez de evidências de que os benefícios relatados são específicos dessa prática. A presente revisão sistemática tem como objetivo avaliar a eficácia e segurança das técnicas de meditação como tratamento complementar para AR. Uma revisão sistemática da literatura foi realizada. os bancos de dados Cochrane Collaboration, MEDLINE, Organização Mundial da Saúde, Plataforma de Registo Internacional de Ensaios Clínicos para todos os ensaios registrados e em andamento e consultou dados Clinicaltrials.gov extraído incluído no kit de ferramentas e Covidence no software REVMAN da colaboração Cochrane. Meta-análise não pôde ser realizada, fazendo uma síntese narrativa dos resultados. Conclusões técnica Mindfulness (MBSR) é benéfico como tratamento adjuvante de artrite reumatóide, modificando os parâmetros clínicos, mas com heterogénea em marcadores séricos de inflamação resulta.

Humo de tabaco en vehículos: medición de partículas de materia 2. 5 micras / Smoking in vehicles: measurement of 2. 5 PM matter particles

Introducción: proteger a la población del humo de segunda mano (HSM) es uno de los principios de la Organización Mundial de la Salud en el marco del control del tabaco. Existen pocos datos acerca de la exposición de HSM en vehículos en América del Sur. Este estudio tuvo como objetivo determinar el nivel de dicha exposición. Materiales y método: se midieron niveles de micropartículas de materia de 2,5 micras de diámetro (PM2,5) que vehiculizan el HSM en la vía aérea, en modelos experimentales en autos de fumadores y no fumadores. Resultados: la media de la concentración de PM2,5 fue de 181 µg/m3 en los autos de fumadores y de 0 µg/m3 en los autos de no fumadores (p <0,001). La máxima concentración fue de 2.900 µg/m3 en un auto de fumador estacionado con la ventanilla del conductor parcialmente abierta. Conclusiones: las concentraciones de PM2,5 en vehículos en los que se fuma alcanzó niveles altos, similares a los que se encuentran en ciertos países con políticas de control de tabaco débiles. Este hecho determina la necesidad de nuevas políticas públicas para eliminar el HSM de los vehículos para proteger la salud pública. (AU)

Introduction: Protection from second-hand smoke (SHS) is one of the main principles of the World Health Organization Framework Convention for Tobacco Control. Limited data is available on SHS exposure in vehicles in South America. This study aimed to assess the levels of exposure. Methods: Levels of respirable and fine suspended particles with 2.5 micrometres or less (PM2.5) diameter were measured in different models in smokers' and non-smoker´s vehicles. Results: Median PM2.5 concentration was 181 µg/m3 in "smoking vehicles" and 0 µg/m3 in "non-smoking vehicles" (p<0.001). The highest concentration reached 2.900 µg/m3 in a parked car with the driver's window partially open. Conclusions: Concentration of PM2.5 in vehicles reached high levels, similar to those at certain sites in countries with weak tobacco control policies. These facts underscore a need for new public policies to eliminate SHS in vehicles to protect public health.

Introdução: um dos princípios da Organização Mundial da Saúde no contexto do controle do tabaquismo é proteger a população da fumaça de segunda-mão (HSM). Existem poucos dados sobre a exposição de HSM em veículos na América do Sul. O objetivo deste estudo foi identificar um mecanismo para determinar o nível desta exposição. Materiais e métodos: utilizando modelos experimentais em veículos de fumantes e não fumantes foram medidos os níveis de micropartículas de matéria de 2,5 micras de diâmetro (PM2,5) transportados pela HSM na via aérea. Resultados: á concentração média de PM2,5 foi 181 µg/m3 nos automóveis de fumantes e 0 µg/m3 nos automóveis de não fumantes (p<0.001). A concentração máxima de 2.900 µg/m3 foi encontrada no automóvel estacionado de um fumante com a janela do motorista parcialmente aberta. Conclusões: as concentrações de PM2,5 em veículos de fumantes alcançou níveis altos, similares aos encontrados em alguns países com políticas de controle de tabaco débeis. Este fato determina a necessidade de novas políticas públicas para eliminar a HSM dos veículos para proteger a saúde pública.

Carga de enfermedad de los adolescentes en Uruguay y su comparación con la de América Latina y el Caribe / Global burden of disease among teenagers in Uruguay and its comparison with Latin America and the Caribbean

Resumen Introducción. La adolescencia es considerada una etapa de buena salud y por tanto poco estudiada. El objetivo de este estudio es describir la evolución de la mortalidad en adolescentes en Uruguay y analizar la carga de enfermedad en esta etapa de la vida, a través de la medida de los Años de Vida Perdidos por Muerte Prematura en Uruguay y su comparación con los de América Latina y el Caribe según sexo, causa y subregión. Metodología. Se utilizaron fuentes de datos secundarias: el registro nacional de defunciones del Uruguay, el primer estudio de Carga Global de Enfermedad en Uruguay y la información presentada por la página de visualización de datos del Instituto de Métricas y Evaluación en Salud. Resultados. La mortalidad en los adolescentes se ha mantenidos aproximadamente estable entre 1997 y 2015. Loa años perdidos por muerte prematura para el Uruguay son más en los hombres y sus principales causas son los accidentes de tránsito, heridas auto infringidas y violencia. El mismo comportamiento se presenta en la región. Conclusiones. Los determinantes sociales de la salud vinculados a la pobreza e inequidad tienen un rol en el desarrollo de depresión, conductas riesgosas y violentas que posiblemente expliquen la perdida de años por muerte prematura en esta etapa de la vida.

Abstract Introduction. Adolescence is considered a healthy stage of life and therefore little studied. This study described mortality over time in teenagers in Uruguay and analysed the burden of disease at this stage of life by the measure of Years of Life Lost by Premature Death in Uruguay and by comparison with rates in Latin America and the Caribbean by sex, cause and sub-region. Methodology. Secondary data sources used were the national registry of deaths in Uruguay, the first Global Burden of Disease study in Uruguay and the information on the data visualisation page of the Institute of Metrics and Health Evaluation. Data were extracted by the authors and displayed in tables and graphs. Results. Teenager mortality held roughly stable between 1997 and 2015. More years were lost to premature death among Uruguayan men, the main causes being traffic accidents, self-inflicted injuries and violence. The same behaviour occurs throughout the region. Conclusions. The social determinants of health connected with poverty and inequality play a role in the development of depression, risky and violent behaviour, which possibly explain the loss of years due to premature death in adolescence.

Anemia, estado nutricional y parasitosis intestinales en niños pertenecientes a hogares vulnerables de Montevideo / Anemia, nutritional status and intestinal parasites in children from vulnerable homes of Montevideo / Anemia, estado nutricional e parasitoses intestinais em crianças de lares vulneráveis em Montevidéu

Resumen: Introducción: la anemia ferropénica, las alteraciones nutricionales y las parasitosis intestinales, principalmente giardiasis y helmintiasis transmitidas por el suelo (HTS) son problemas prevalentes en Uruguay, que determinan consecuencias en la salud individual y colectiva. Objetivo: determinar prevalencia de anemia, alteraciones nutricionales y enteroparasitosis en niños de 6-48 meses, de una población vulnerable de Montevideo, establecer posibles sinergismos y analizar presencia de factores de riesgo. Material y métodos: estudio descriptivo, transversal. Población: niños de 6-48 meses pertenecientes a un programa de apoyo a hogares vulnerables de Montevideo. Estudiantes y docentes de Medicina y Nutrición capacitados concurrieron a los domicilios y mediante encuestas recolectaron variables demográficas, ambientales, epidemiológicas, clínicas y hábitos, entre octubre/2014 a mayo/2015. Realizaron medidas antropométricas, hemoglobina capilar y coproparasitario. Análisis de datos: EPIinfo2000 complementada con SPSS19. Análisis estadístico: uni o multivariados. Asociaciones entre dos variables: test de Z o chi². Asociaciones entre más de dos variables: regresiones múltiples. Protocolo aprobado por el Comité de Ética de la Facultad de Medicina. Resultados: N: 136 niños. Prevalencia de anemia: 33%, bajo peso: 3,7%, retraso de talla: 18% y sobrepeso/obesidad: 4,5%. Albergaban parásitos patógenos: 60% de los estudiados; giardiasis: 46% y HTS: 23%, poliparasitados: 13%. Condiciones que presentaron asociación con HTS: zona inundable, alternativas de saneamiento no mejorado y eliminación de residuos a cielo abierto. Asociaciones significativas encontradas: entre HTS y anemia; y entre HTS y déficit de talla (grupo de 1-2 años). Conclusiones: los resultados son preocupantes dada la alta prevalencia de anemia, alteraciones nutricionales y parasitosis en esta población. Urge la planificación y ejecución de medidas con participación multidisciplinaria, interinstitucional y comunitaria.

Summary: Introduction: iron deficiency anemia, nutritional alterations and intestinal parasitic diseases, mainly giardiasis and soil-transmitted helminthiasis (HTS) are prevalent problems in Uruguay, which determine consequences for individual and collective health. Objective: to determine the prevalence of anemia, nutritional alterations and enteroparasitosis in children of 6-48 months of a vulnerable population of Montevideo, to establish possible synergisms and to analyze the presence of risk factors. Material and methods: descriptive, cross-sectional study. Population: children aged 6-48 months belonging to a program to support vulnerable homes in Montevideo. Students and teachers of Medicine and Nutrition trained, attended the homes and through surveys, collected demographic, environmental, epidemiological, clinical and habits variables, between October / 2014-May / 2015. They performed anthropometric measures, capillary hemoglobin and coproparasitary. Data analysis: EPIinfo2000 complemented with SPSS19. Statistical analysis: uni or multivariate. Associations between 2 variables: test of Z or chi². Associations between more than 2 variables: multiple regressions. Protocol approved by the Ethics Committee of the School of Medicine. Results: N: 136 children. Prevalence of anemia: 33%, low weight: 3.7%, size retardation: 18% and overweight / obesity: 4.5%. They harbored pathogenic parasites: 60% of those studied; Giardiasis: 46% and HTS: 23%, polyparasites: 13%. Conditions that presented association with HTS: flood zone, alternatives of sanitation not improved and elimination of open pit. Significant associations found: between HTS and anemia; and between HTS and height deficit (group of 1-2 years). Conclusions: the results are worrying given the high prevalence of anemia, nutritional alterations and parasites in this population. The planning and implementation of measures with multidisciplinary, inter-institutional and community participation is urgently needed.

Resumo: Introdução: a anemia ferropênica, as alterações nutricionais e as parasitoses intestinais, principalmente giardíase e helmintíase transmitida pelo solo (HTS) são problemas prevalentes no Uruguai e têm consequências para a saúde individual e coletiva. Objetivo: determinar a prevalência de anemia, alterações nutricionais e enteroparasitoses em crianças de 6 a 48 meses numa população vulnerável em Montevidéu, estabelecer possíveis sinergias e analisar a presença de fatores de risco. Material e métodos: estudo descritivo, transversal. População: crianças de 6 a 48 meses pertencentes a um programa de apoio a famílias vulneráveis em Montevidéu. Alunos e professores de Medicina e Nutrição foram treinados, frequentaram as residências e por meio de pesquisas coletaram variáveis demográficas, ambientais, epidemiológicas, clínicas e de hábito, entre outubro de 2014 e maio de 2015. Realizaram medidas antropométricas, hemoglobina capilar e coproparasitológico. Análise de dados: EPIinfo2000 complementado com SPSS19. Análise estatística: uni ou multivariada. Associações entre duas variáveis: teste de Z ou chi². Associações entre mais de duas variáveis: regressões múltiplas. Protocolo aprovado pelo Comitê de Ética da Faculdade de Medicina. Resultados: N: 136 crianças. Prevalência de anemia: 33%, baixo peso: 3,7%, atraso na altura: 18% sobrepeso / obesidade: 4,5%. Parásitos patogênicos: 60%; Giardíase: 46% e HTS: 23%, poliparasitizados: 13%. Condições que apresentaram associação com HTS: zonas de inundação, alternativas precárias de saneamento e disposição de resíduos a céu aberto. Associações significativas encontradas: entre HTS e anemia; e entre HTS e déficit de altura (grupo de 1-2 anos). Conclusões: os resultados são preocupantes, dada a alta prevalência de anemia, alterações nutricionais e parasitoses nessa população. É fundamental o planejamento e execução de medidas tais como participação multidisciplinar, interinstitucional e comunitária.

Prevalence of invehicle smoking and secondhand smoke exposure in Uruguay.

INTRODUCTION: Protection from secondhand smoke (SHS) is one of the fundamental principles of the WHO Framework Convention for Tobacco Control. Objective data on SHS exposure in vehicles in South America is scarce. This study aimed to estimate prevalence of smoking inside vehicles. METHODS: The point prevalence of smoking in vehicles was observed, and a method for estimating smoking prevalence was piloted. RESULTS: We observed 10 011 vehicles. In 219 (2.2%; 95% CI 1.91 to 2.49) of them, smoking was observed, and in 29.2% of these, another person was exposed to SHS. According to the 'expansion factor' we constructed, direct observation detected one of six to one to nine vehicles in which smoking occurred. The observed prevalence of smoking in vehicles (2.2%) could reflect a real prevalence between 12% and 19%. In 29.2% (95% CI 23.6 to 35.5) and 4.6% (95% CI 2.2 to 8.3) of vehicles in which smoking was observed, another adult or a child, respectively, was exposed to SHS. CONCLUSIONS: Smoking was estimated to occur in 12%-19% of vehicles, with involuntary exposure in one of three of vehicles observed. These data underscore a need for new public policies to eliminate SHS in vehicles to protect public health.

IMPACT OF HEALTH TECHNOLOGY ASSESSMENT IN LITIGATION CONCERNING ACCESS TO HIGH-COST DRUGS.

OBJECTIVES: The impact of health technology assessment (HTA) in the judicialization of the right of health has not been deeply studied in Latin American countries. The purpose of this study is to review the process of judicialization of the access to high cost drugs in Uruguay and assess the impact HTAs have had on this process. METHODS: The methodology used for this study included a comprehensive literature search in electronic databases, local journals, internal documents developed in the Ministry of Health, as well as conducting interviews with key informants. RESULTS: Judicialization of the access of high cost drugs has been increasing since 2010. The strategy of the Ministry of Health of Uruguay to decrease this problem included the organization of roundtables with judges and other stakeholders on the basis of HTA, the training of defense lawyers in the use and interpretation of HTA, and the participation of a professional who develops HTA in the preparation of the defense arguments. A year after the implementation of this strategy, 25 percent of writs of protection were won by the Ministry of Health. CONCLUSIONS: Even though the strategy implemented was effective in reducing the loss of litigations, it was not effective in reducing the growing number of writs of protection. It is essential to address this problem in a broad debate and to promote understanding between the parties.

Brief Counseling on Secondhand Smoke Exposure in Pregnant Women in Argentina and Uruguay.

Argentina and Uruguay have a high prevalence of smoking during pregnancy, as well as of secondhand smoke (SHS) exposure. In this secondary analysis of a trial to implement brief smoking cessation counseling during antenatal care in Argentina and Uruguay, we aim to evaluate the effects of the intervention on the rates of self-reported SHS exposure at home and at work, and on attitudes recalled by non-smoker women enrolled in the intervention group compared with the control group. We randomly assigned (1:1) 20 antenatal care clusters in Argentina and Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling, which also included questions and counseling regarding SHS exposure, or to receive the standard of care. There was not a statistically significant difference between groups of the intervention's effect (reduction of exposure to SHS) on any of the three exposure outcome measures (exposure at home, work or other indoor areas) or on the attitudes of women regarding exposure (avoiding breathing SHS and having rooms where smoking is forbidden). This analysis shows that we should not expect reductions in SHS exposure with this modest intervention alone. To achieve such reductions, strategies engaging partners and other household members may be more effective.

Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay.

INTRODUCTION: The 5A's (Ask, Advise, Assess, Assist, and Arrange) strategy, a best-practice approach for cessation counseling, has been widely implemented in high-income countries for pregnant women; however, no studies have evaluated implementation in middle-income countries. The study objectives were to assess smoking patterns and receipt of 5A's among pregnant women in Buenos Aires, Argentina and Montevideo, Uruguay. METHODS: Data were collected through administered questionnaires to women at delivery hospitalizations during October 2011-May 2012. Eligible women attended one of 12 maternity hospitals or 21 associated prenatal care clinics. The questionnaire included demographic data, tobacco use/cessation behaviors, and receipt of the 5A's. Self-reported cessation was verified with saliva cotinine. RESULTS: Overall, of 3400 pregnant women, 32.8% smoked at the beginning of pregnancy; 11.9% quit upon learning they were pregnant or later during pregnancy, and 20.9% smoked throughout pregnancy. Smoking prevalence varied by country with 16.1% and 26.7% who smoked throughout pregnancy in Argentina and Uruguay, respectively. Among pregnant smokers in Argentina, 23.8% reported that a provider asked them about smoking at more than one prenatal care visit; 18.5% were advised to quit; 5.3% were assessed for readiness to quit, 4.7% were provided assistance, and 0.7% reported follow-up was arranged. In Uruguay, those percentages were 36.3%, 27.9%, 5.4%, 5.6%, and 0.2%, respectively. CONCLUSIONS: Approximately, one in six pregnant women smoked throughout pregnancy in Buenos Aires and one in four in Montevideo. However, a low percentage of smokers received any cessation assistance in both countries. Healthcare providers are not fully implementing the recommended 5A's intervention to help pregnant women quit smoking.

A Multifaceted Strategy to Implement Brief Smoking Cessation Counseling During Antenatal Care in Argentina and Uruguay: A Cluster Randomized Trial.

INTRODUCTION: Argentina and Uruguay have a high prevalence of smoking during pregnancy. However, and despite national recommendations, pregnant women are not routinely receiving cessation counseling during antenatal care (ANC). We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who received a brief smoking cessation counseling based on the 5As (Ask, Advise, Assess, Assist, and Arrange). METHODS: We randomly assigned (1:1) 20 ANC clusters in Buenos Aires, Argentina and Montevideo, Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling into routine ANC, or to receive no intervention. The primary outcome was the frequency of women who recalled receiving the 5As during ANC at more than one visit. Frequency of women who smoked until the end of pregnancy, and attitudes and readiness of ANC providers towards providing counseling were secondary outcomes. Women's outcomes were measured at baseline and at the end of the 14- to 18-month intervention, by administering questionnaires at the postpartum hospital stay. Self-reported cessation was verified with saliva cotinine. The trial took place between October 03, 2011 and November 29, 2013. RESULTS: The rate of women who recalled receiving the 5As increased from 14.0% to 33.6% in the intervention group (median rate change, 22.1%), and from 10.8% to 17.0% in the control group (median rate change, 4.6%; P = .001 for the difference in change between groups). The effect of the intervention was larger in Argentina than in Uruguay. The proportion of women who continued smoking during pregnancy was unchanged at follow-up in both groups and the relative difference between groups was not statistically significant (ratio of odds ratios 1.16, 95% CI: 0.98-1.37; P = .086). No significant changes were observed in knowledge, attitudes, and self-confidence of ANC providers. CONCLUSIONS: The intervention showed a moderate effect in increasing the proportion of women who recalled receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention. IMPLICATIONS: No implementation trials of smoking cessation interventions for pregnant women have been carried out in Latin American or in middle-income countries where health care systems or capacities may differ. We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who receive brief smoking cessation counseling based on the 5As in Argentina and Uruguay. We found that the intervention showed a moderate effect in increasing the proportion of women receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention.

Prevalencia de cáncer colorrectal en pacientes en valoración preoperatoria de hernia de la pared abdominal / Prevalence of colorectal cancer in patients in preoperative assessment of abdominal wall herniation

Introducción: el cáncer colorrectal (CCR) es la tercera causa de muerte por cáncer en hombres y la segunda causa de muerte por cáncer en mujeres de nuestro país. Se ha sugerido que los pacientes con hernias de pared abdominal tendrían más posibilidades de asociar CCR, lo que ha llevado a recomendar por parte de numerosas sociedades científicas la realización de videocolonoscopía (VCC) para búsqueda de CCR previo a la resolución quirúrgica de las hernias. Estudios más recientes han cuestionado esta indicación, no recomendando la realización de VCC en pacientes con hernias de la pared abdominal sin otra sintomatología. Objetivo: Específico. Establecer la prevalencia de CCR y lesiones preneoplásicas en pacientes en valoración preoperatoria de hernias de pared abdominal. Secundario. Establecer si existe asociación estadística entre CCR y la aparición de hernias abdominales. Material y método: se realizó un estudio retrospectivo de casos controles que incluyó a pacientes que concurrieron en el período comprendido entre enero de 2006 y febrero de 2014 al servicio de Endoscopía Digestiva del Hospital de Clínicas. Se definieron como casos los pacientes a quienes se les había indicado una VCC previa a la reparación quirúrgica de su hernia de pared abdominal y se definieron como controles al grupo de pacientes que concurrió al mismo servicio en el mismo período a realizarse VCC para tamizaje de cáncer de colon. Resultados: en el grupo de casos se incluyeron 225 pacientes. En este, 55 VCC (24,4%) fueron incompletas por diversos motivos (56,4% por intolerancia). Se encontraron dos pacientes (0,9%) con cáncer de colon (uno cáncer de colon ascendente y el otro cáncer de colon descendente). En el grupo control se incluyeron 230 pacientes. En este grupo, un paciente (0,43%) presentó cáncer de colon ascendente; 21 VCC (9,1%) fueron parciales debido a intolerancia en el mayor porcentaje de los casos. Discusión: está demostrada la relación entre patologías que aumentan la presión intraabdominal y la posterior aparición de hernias, por lo que se podría pensar que un CCR sintomático pueda desencadenar la aparición de las mismas; sin embargo, no existe fundamento que sustente que un CCR asintomático pueda provocar lo mismo. En este estudio no hubo diferencias significativas en la frecuencia de CCR entre el grupo de casos y controles. Conclusiones: la decisión de realizar o no una VCC debería seguir los lineamientos habituales recomendados por las sociedades científicas respecto al screening de CCR y no basarse en la sola presencia de las hernias para realizar dicho estudio.

Abstract Introduction: colorectal cancer is the third cause of death for cancer in men and the second cause of cancer in women in our country. It has been suggested that patients with abdominal wall hernias would have more chances of associating colorectal cancer, what has led many scientific societies to recommend patients to undergo a video colonoscopy to look for colorectal cancer prior to the surgical treatment of the hernia. More recent studies have questioned such indication, and do not recommend the video colonoscopy I patients with abdominal wall hernias in the absence of other symptoms. Objective: Specific. To determine the prevalence of colorectal cancer and pre-neoplastic lesions in patients during preoperative assessment of abdominal wall hernias. Secondary. To determine if there is a statistical connection between colorectal cancer and abdominal wall hernias. Method: we conducted a retrospective study of control cases, which included patients who were seen at the Digestive Endoscopy Unit of the University Hospital between January 2006 and February 2014. Cases were defined between when a colonoscopy had been indicated prior to the surgical repair of their abdominal wall hernia, and the control group was made up of patients who were seen at the same unit, during the same period of time, seeking for a video colonoscopy for a colorectal cancer screening. Results: 225 patients were included in the cases group. Within this group, 55 video colonoscopies (24.4%) were incomplete for several reasons (56.4% due to intolerance). Two patients (0.9%) were diagnosed with colorectal cancer (one of cancer in the ascending colon and the other one cancer in the descending colon). 230 patients were included in the control group. In this group, one patient (0.43%) presented cancer in the ascending colon, 21 colorectal cancer (9.1%) were partial given to intolerance, in most cases. Discusion: the association between conditions that increase intra-abdominal pressure and result in hernias has been proved; and for this reason it could be thought that a symptomatic colorectal cancer could cause them. However, there is no evidence that indicates that an asymptomatic colorectal cancer could cause the same. In this study there were no meaning differences in the frequency of colorectal cancer between the case and the control groups. Conclusions: the decision as to whether to perform a video colonoscopy or not should follow the usual guidelines recommended by the scientific societies regarding the colorectal cancer screening instead of basing the decis0ion on the presence of hernias.

Resumo Introdução: a radio-quimioterapia é uma opção de tratamento curativo do carcinoma de cérvix, particularmente em pacientes do meio hospitalar uruguaio cujo diagnóstico é feito em estádios localmente avançados. O objetivo deste trabalho é analisar os resultados terapêuticos e a toxicidade crônica deste tratamento no Centro Hospitalario Pereira Rossell (CHPR). Método: foram incluídas 164 pacientes portadoras de carcinoma cérvico-uterino que completaram o tratamento de radio-quimioterapia no período junho de 2006 - novembro de 2008. A radioterapia externa (RTE) foi feita por irradiação pélvica (concomitante com cisplatina semanal) e braquiterapia (BT) útero-vaginal. A dose biológica efetiva para tumor, reto e bexiga foi calculada. A taxa de controle loco-regional e a sobrevida aos cinco anos foram calculadas e também as complicações crônicas utilizando o método de Kaplan-Meier. Resultados: a sobrevida global obtida foi de 67% aos cinco anos, mostrando diferenças significativas entre o estádio II (78%) e o estádio III (49%) (Log-rank test, p = 0,0002). A taxa de complicações crônicas graus 3-4, de acordo com a RTOG (Radiation Therapy Oncology Group), foi 1,8% para as urinarias e 3,7% para as digestivas. O controle local inicial foi de 89% e a persistência da lesão de 10,3%; recidiva loco-regional (RL) em todo o período: 19,5%; metástases com ou sem RL: 10,3%. Conclusões: a eficácia terapêutica da radioquimioterapia no câncer de cérvix no nosso meio foi confirmada. A maioria das recidivas ou persistências foi devida a falta de controle loco-regional depois do tratamento inicial. O tratamento foi bem tolerado, com baixa porcentagem de complicações crônicas, comparável a referências internacionais.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. METHODS: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. FINDINGS: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. INTERPRETATION: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. FUNDING: Bill & Melinda Gates Foundation.

Aceptabilidad de Incentivos y reemplazo nicotínico entre embarazadas / Acceptability of incentives and nicotinic replacement in pregnant smokers

El objetivo de este estudio exploratorio fue obtener información sobre la aceptabilidad en el uso de incentivos y de terapia de reemplazo nicotínico (TRN) como estrategia para apoyar la cesación tabáquica en mujeres que continúan fumando durante el embarazo. Se implementó un estudio descriptivo de corte transversal basado en un cuestionario administrado durante la internación hospitalaria en el posparto por encuestadoras entrenadas. Tres cuartos de las mujeres respondió que participarían en un estudio para probar la efectividad de los parches o chicles para dejar de fumar durante el embarazo y casi la mitad manifestó que sería de utilidad recibir una recompensa como incentivo para dejar de fumar durante el embazo.

The purpose of this exploratory study was to obtain information regarding acceptably to use incentives and Nicotine replacement therapy (NRT) as a smoking cessation strategy for women who continue smoking during pregnancy. A descriptive cross sectional study was implemented based on a questionnaire during hospital stay after delivering which was administered by trained data collector. Three quarter of women declared that they would participate in a study designed to test the effectiveness of the patches and gum to quit smoking, and almost half of the women declared that receiving a reward as an incentive to quit smoking, would be useful.