Prevalence and risk factors of psychiatric symptoms and diagnoses before and during the COVID-19 pandemic: findings from the ELSA-Brasil COVID-19 mental health cohort.

BACKGROUND: There is mixed evidence on increasing rates of psychiatric disorders and symptoms during the coronavirus disease 2019 (COVID-19) pandemic in 2020. We evaluated pandemic-related psychopathology and psychiatry diagnoses and their determinants in the Brazilian Longitudinal Study of Health (ELSA-Brasil) São Paulo Research Center. METHODS: Between pre-pandemic ELSA-Brasil assessments in 2008-2010 (wave-1), 2012-2014 (wave-2), 2016-2018 (wave-3) and three pandemic assessments in 2020 (COVID-19 waves in May-July, July-September, and October-December), rates of common psychiatric symptoms, and depressive, anxiety, and common mental disorders (CMDs) were compared using the Clinical Interview Scheduled-Revised (CIS-R) and the Depression Anxiety Stress Scale-21 (DASS-21). Multivariable generalized linear models, adjusted by age, gender, educational level, and ethnicity identified variables associated with an elevated risk for mental disorders. RESULTS: In 2117 participants (mean age 62.3 years, 58.2% females), rates of CMDs and depressive disorders did not significantly change over time, oscillating from 23.5% to 21.1%, and 3.3% to 2.8%, respectively; whereas rate of anxiety disorders significantly decreased (2008-2010: 13.8%; 2016-2018: 9.8%; 2020: 8%). There was a decrease along three wave-COVID assessments for depression [ß = -0.37, 99.5% confidence interval (CI) -0.50 to -0.23], anxiety (ß = -0.37, 99.5% CI -0.48 to -0.26), and stress (ß = -0.48, 99.5% CI -0.64 to -0.33) symptoms (all ps < 0.001). Younger age, female sex, lower educational level, non-white ethnicity, and previous psychiatric disorders were associated with increased odds for psychiatric disorders, whereas self-evaluated good health and good quality of relationships with decreased risk. CONCLUSION: No consistent evidence of pandemic-related worsening psychopathology in our cohort was found. Indeed, psychiatric symptoms slightly decreased along 2020. Risk factors representing socioeconomic disadvantages were associated with increased odds of psychiatric disorders.

Adherence to the EAT-Lancet sustainable reference diet and cardiometabolic risk profile: cross-sectional results from the ELSA-Brasil cohort study.

PURPOSE: The EAT-Lancet Commission released a reference sustainable diet to improve human health and respect the planetary boundaries. The Planetary Health Diet Index (PHDI) was developed with the purpose of evaluate the adherence to this reference diet. The aim of the present study was to evaluate the association between adherence to the EAT-Lancet diet with cardiometabolic risk profile. METHODS: We used the cross-sectional baseline data from 14,155 participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multicenter ongoing cohort study. Dietary data were collected using a 114-item validated food frequency questionnaire. The PHDI was used to assess the adherence to the EAT-Lancet diet. It consists of 16 components and the total score can range from 0 to 150 points. Linear, logistic and quasi-Poisson regression models were built to evaluate the associations between PHDI and the outcomes. RESULTS: Individuals with higher adherence to EAT-Lancet diet (PHDI, 5th quintile) had lower values for systolic blood pressure (ß - 0.84; 95% CI - 1.66: - 0.01), diastolic blood pressure (ß - 0.70; 95% CI - 1.24: - 0.15), total cholesterol (ß - 3.15; 95% CI - 5.30: - 1.01), LDL-c (ß - 4.10; 95% CI - 5.97: -  2.23), and non-HDL-cholesterol (ß - 2.57; 95% CI - 4.62: - 0.52). No association was observed for HDL-c, triglycerides and HOMA-IR. CONCLUSIONS: Our results indicate that higher adherence to the EAT-Lancet diet is associated with lower levels of blood pressure, total cholesterol, LDL-c, and non-HDL-c.

Association between dietary patterns and carotid intima-media thickness: cross-sectional analysis of ELSA-Brasil study.

PURPOSE: We aimed to perform a cross-sectional evaluation of the association between dietary patterns and carotid intima-media thickness (cIMT), using baseline data from the Brazilian Longitudinal Study of Adult Health. METHODS: The participants with measurement of the cIMT were included (n = 9,624). cIMT was evaluated in a continuous way and categorized as < 75th and ≥ 75th and ≤ 0.9 mm and > 0.9 mm. Dietary patterns (DPs) were identified by principal component factor analysis. Linear and logistic regression models were used to evaluate the association between cIMT and DPs. RESULTS: Three DPs were derived. For each unit increase in the convenience DP score, the odds for cIMT ≥ 75th increased by 13% (OR 1.13; 95% CI 1.05: 1.22) and for cIMT > 0.9 mm increased by 14% (OR 1.14; 95% CI 1.07: 1.22) in the fully adjusted model. In contrast, each unit increase in the prudent DP score decreased by 8% the odds of having cIMT ≥ 75th (OR 0.92; 95% CI 0.86: 0.98) and by 11% of cIMT > 0.9 mm (OR 0.89; 95% CI 0.84: 0.95). Furthermore, each increase in the convenience DP score was associated with increase in the cIMT (ß 0.01; 95% CI 0.01: 0.02), while each increase in the prudent DP score was associated with decrease in the cIMT (ß -0.01; -0.01; -0.01) in linear regression models. CONCLUSIONS: Our results demonstrate that those individuals with adherence to the convenience dietary pattern are more likely to have high cIMT, while those with adherence to a prudent dietary pattern have lower odds for this characteristic.

Biomarkers of Fruit Intake Using a Targeted Metabolomics Approach: an Observational Cross-Sectional Analysis of the ELSA-Brasil Study.

BACKGROUND: Advances in technology have led to the identification of a greater number of metabolites related to diet. Although fruit intake biomarkers have been reported in some studies, these findings require further replication, considering the relevance of fruits for diet quality and health. OBJECTIVES: The aim of this study was to explore the associations of a set of potential urinary biomarkers of diet, assessed using a targeted metabolomics approach, with self-reported fruit intake data in participants of a computer-assisted 24-h dietary recall (GloboDiet software) validation study. METHODS: A total of 93 individuals aged 43-72 y, 54% female, participated in this study. The subjects were a subsample of the Longitudinal Study of Adult Health (ELSA-Brasil). A 24-h dietary recall was obtained with the aid of GloboDiet software matching a 24-h urine sample from each participant. Candidate biomarkers were selected in a literature search and identified in urine by LC coupled to high-resolution MS. Spearman correlation analyses were performed between fruit intake and each biomarker. RESULTS: Spearman correlation analysis showed that total fruits intake was significantly correlated with citric acid (ρ = 0.213, P = 0.041), ferulic acid sulfate I (ρ = 0.240, P = 0.020), hesperetin glucuronide/homoeriodictyol glucuronide (ρ = 0.303, P = 0.003), hydroxyhippuric acid (ρ = 0.239, P = 0.021), homovanillic alcohol sulfate (ρ = 0.339, P = 0.001), methylgallic acid sulfate (ρ = 0.268, P = 0.009), naringenin glucuronide (NG; ρ = 0.278, P = 0.007), proline betaine (PB; ρ = 0.305, P = 0.003), syringic acid sulfate (ρ = 0.210, P = 0.044), and sinapic acid sulfate (ρ = 0.412, P < 0.001). Among them, 3 have been described in literature as promising biomarkers for intake of total fruit, oranges, and citrus fruit: NG, hesperetin glucuronide, and PB. CONCLUSIONS: Associations of total fruits intake with urinary measurements indicate the potential usefulness of dietary biomarkers in the Brazilian population as a complement to self-reported dietary assessments.

Different statistical methods identify similar population-specific dietary patterns: an analysis of Longitudinal Study of Adult Health (ELSA-Brasil).

In recent decades, different data-driven approaches have emerged to identify dietary patterns (DP) and little is discussed about how these methods are able to capture diet complexity within the same population. This study aimed to apply three statistical methods to identify the DP of the Longitudinal Study of Adult Health (ELSA-Brasil) population and evaluate the similarities and differences between them. Dietary data were assessed at baseline in the ELSA-Brasil study using a FFQ. DP were identified by applying three statistical methods: (1) factor analysis (FA), (2) treelet transform (TT) and (3) reduced rank regression (RRR). The characteristics of individuals classified in the last tertile of each DP were compared. Cross-classification and Pearson's correlation coefficients were assessed to evaluate the agreement between individuals' adherence to DP of the three methods. A similar convenience DP was identified for all three methods. FA and TT also identified a similar prudent DP and a DP highly loaded for the food groups rice and beans. Individuals classified in the third tertile of similar DP of each method presented similar socio-demographic and nutrient intake characteristics. Regarding the cross-classification, prudent DP from FA and TT presented a higher level of agreement (75 %), while convenience DP from TT and RRR presented the lowest agreement (44·8 %). The different statistical methods were able to capture the populations' DP in a similar way while highlighting the particularities of each method.

Clustering analysis and machine learning algorithms in the prediction of dietary patterns: Cross-sectional results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Machine learning investigates how computers can automatically learn. The present study aimed to predict dietary patterns and compare algorithm performance in making predictions of dietary patterns. METHODS: We analysed the data of public employees (n = 12,667) participating in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The K-means clustering algorithm and six other classifiers (support vector machines, naïve Bayes, K-nearest neighbours, decision tree, random forest and xgboost) were used to predict the dietary patterns. RESULTS: K-means clustering identified two dietary patterns. Cluster 1, labelled the Western pattern, was characterised by a higher energy intake and consumption of refined cereals, beans and other legumes, tubers, pasta, processed and red meats, high-fat milk and dairy products, and sugary beverages; Cluster 2, labelled the Prudent pattern, was characterised by higher intakes of fruit, vegetables, whole cereals, white meats, and milk and reduced-fat milk derivatives. The most important predictors were age, sex, per capita income, education level and physical activity. The accuracy of the models varied from moderate to good (69%-72%). CONCLUSIONS: The performance of the algorithms in dietary pattern prediction was similar, and the models presented may provide support in screener tasks and guide health professionals in the analysis of dietary data.

Moderate coffee consumption is associated with lower risk of mortality in prior Acute Coronary Syndrome patients: a prospective analysis in the ERICO cohort.

This study examined the association between coffee consumption and all-cause mortality in patients with a prior acute myocardial infarction or unstable angina. Data were from the prospective study ERICO, totalising 928 patients with Acute Coronary Syndrome (ACS). During 4 years' follow-up, a total of 111 deaths occurred. Moderate coffee consumption (1-2 and 2-3 cups/day) was inversely associated with total mortality (HR 0.13, 95% CI: 0.06-0.29 and 0.22, 95% CI: 0.13-0.39, respectively). For patients with higher coffee consumption (>3 cups/day), there was a positive association with mortality (HR 2.12, 95% CI: 1.06-4.24). After stratification by smoking status, the analysis revealed lower risk of mortality in never and former smokers, drinking 1-2 and 2-3 cups/day. Among current smokers there was a positive association between >3 cups/day and mortality. The moderate consumption of coffee was associated with lower risk of all-cause mortality in patients with a prior ACS, particularly in non-smokers.

Major Depression as a Predictor of Poor Long-Term Survival in a Brazilian Stroke Cohort (Study of Stroke Mortality and Morbidity in Adults) EMMA study.

BACKGROUND: The influence of poststroke depression on long-term survival is poorly investigated. Thus, we aimed to evaluate the influence of major depression disorder (MDD) on long-term survival in the participants from The Study of Stroke Mortality and Morbidity in Adults (EMMA Study) in São Paulo, Brazil. METHODS: We prospectively evaluated ischemic and hemorrhagic stroke (HS) cases from the EMMA Study. Baseline and stroke characteristics and cardiovascular risk factors were evaluated according to MDD assessed by the Patient Health Questionnaire, which was applied 30 days after index event and periodically during 1-year follow-up. We performed Kaplan-Meier survival analysis, as well as crude and multiple Cox proportional hazards models. RESULTS: In this subset of the EMMA Study, we evaluated 164 (85.9%) patients with ischemic stroke and 27 (14.1%) with HS. Among these, overall incidence of MDD was 25.1% during 1 year of follow-up, regardless stroke subtype. The peak rate of major depression postacute event was beyond 1 month. We observed a lower survival rate among individuals who developed poststroke MDD than among those who did not develop this condition after 1 year of follow-up (85.4% versus 96.5%, log rank P = .006). After multiple analysis, we kept a higher risk of all-cause mortality among those who developed MDD compared to participants without MDD (hazard ratio = 4.60, 95% confidence interval = 1.36-15.55, P = .01). CONCLUSION: Our findings suggest that incident MDD is a potential marker of poor prognosis 1 year after stroke.

The bipolar depression electrical treatment trial (BETTER): design, rationale, and objectives of a randomized, sham-controlled trial and data from the pilot study phase.

BACKGROUND: Bipolar depression (BD) is a prevalent condition, with poor therapeutic options and a high degree of refractoriness. This justifies the development of novel treatment strategies, such as transcranial direct current stimulation (tDCS) that showed promising results in unipolar depression. METHODS: We describe a randomized, sham-controlled, double-blinded trial using tDCS for refractory, acutely symptomatic BD (the bipolar depression electrical treatment trial, BETTER). Sixty patients will be enrolled and assessed with clinical and neuropsychological tests. The primary outcome is change (over time and across groups) in the scores of the Hamilton Depression Rating Scale (17 items). Biological markers such as blood neurotrophins and interleukins, genetic polymorphisms, heart rate variability, and motor cortical excitability will be assessed. Twelve anodal-left/cathodal-right 2 mA tDCS sessions over the dorsolateral prefrontal cortex will be performed in 6 weeks. RESULTS: In the pilot phase, five patients received active tDCS and were double-blindly assessed, two presenting clinical response. TDCS was well-tolerated, with no changes in cognitive scores. CONCLUSION: This upcoming clinical trial will address the efficacy of tDCS for BD on different degrees of refractoriness. The evaluation of biological markers will also help in understanding the pathophysiology of BD and the mechanisms of action of tDCS.

Stroke in the rain forest: prevalence in a ribeirinha community and an urban population in the Brazilian Amazon.

BACKGROUND: Our objective was to determine the cerebrovascular prevalence in a town in the Brazilian Amazon basin and compare the ribeirinhos (riparians) to the urban population in the same municipality. METHODS: From May to October 2011, 6,216 residents over 35 years of age in the town of Coari were interviewed using a screening questionnaire, the Stroke Symptom Questionnaire. Cerebrovascular prevalence rates (PRs) from the door-to-door surveillance were calculated according to the location of the home. RESULTS: Respondent totals were 4,897 in the urban area and 1,028 in the rural area. The crude prevalence of stroke was 6.3% in rural and 3.7% in urban areas with differences maintained after sex and age adjustment. Among stroke cases, the ribeirinhos were those with less access to medical care in comparison to the urban area (32.1 vs. 52.5%, p = 0.01), and a positive association between rural area and no medical care for stroke remained (PR, 1.33; 95% confidence interval, 1.03-1.71), independently of age, sex, education and functional impairment. CONCLUSIONS: This study provides the first population-based cerebrovascular prevalence comparison between an urban and a rural population in the Amazon rain forest. The PRs were higher in the ribeirinha compared to the urban population in the same municipality.

Dietary acid load and the risk of events of mortality and kidney replacement therapy in people with chronic kidney disease: the Progredir Cohort Study.

BACKGROUND/OBJECTIVES: The association between dietary acid load (DAL) and chronic kidney disease (CKD) progression remains controversial. Also, there is a gap in the literature on the association between DAL and mortality. In this study, we evaluated the association between NEAP (net endogenous acid production) and PRAL (potential renal acid load) and the risk of events of all-cause mortality and kidney replacement therapy (KRT) in people with CKD. SUBJECTS/METHODS: We included 442 patients (250 diabetics) from the Progredir Cohort Study, based in São Paulo, Brazil. We estimated NEAP and PRAL from dietary intake. Events of death before KRT and KRT were ascertained after a median follow-up of 5.8 and 5.1 years, respectively. Cox proportional hazards regression, Weibull regression, and competing risk models were performed. RESULTS: Median NEAP and PRAL were 49.5 and 4.8 mEq/d. There were 200 deaths and 75 KRT events. Neither NEAP nor PRAL were associated with mortality or KRT when all participants were analyzed. After stratification for diabetes, both estimates were positively related to the risk of KRT even after adjustment for age, sex, weight status, glomerular filtration rate, serum bicarbonate, and intakes of protein, phosphorus, and energy (HR 1.31; 95% CI 1.07, 1.60 for NEAP, and HR 1.27; 95% CI 1.04, 1.57 for every 10 mEq/d increments). Competing risk analyses confirmed these findings. CONCLUSIONS: DAL estimates were associated with the risk of KRT in people with CKD and diabetes but not in non-diabetics. There was no association between all-cause mortality and DAL.

Religion and sociodemographic characteristics at baseline of the Brazilian Longitudinal Study of Adult Health study.

OBJECTIVE: The aim of this study was to investigate whether sex, age, race, income, education, and marital status are associated with having a religion in a sample of Brazilian men and women. METHODS: Data were obtained from 15,098 participants of the Brazilian Longitudinal Study of Adult Health, a longitudinal study that ultimately aims to investigate long-term outcomes of chronic diseases. The sociodemographic characteristics and data on religion status were self-reported during interviews conducted by trained personnel. All study procedures followed standard and validated protocols. RESULTS: There was a strong association between being a woman and having a religion (adjusted OR=2.12, 95%CI 1.95-2.31) when compared to men. Regarding age, those with 45-54 years were more likely to have a religion (adjusted OR=1.14, 95%CI 1.03-1.27). Blacks and Browns were more religious (adjusted OR=1.31, 95%CI 1.15-1.49, and OR=1.22, 95%CI 1.10-1.34, respectively) compared to Whites. Those with high income and education were less likely to state having a religion (adjusted OR=0.78, 95%CI 0.70-0.87, and adjusted OR=0.50, 95%CI 0.43-0.59, respectively). Those who did not have a stable conjugal union were found to be less religious (adjusted OR=0.82, 95%CI 0.75-0.89). Stratifying the analysis according to income showed that higher education was inversely associated with religion on both strata: lower and higher annual earnings. CONCLUSION: This study suggests that education is one of the most important socioeconomic characteristics to consider when studying religion. Race, sex, income, and marital status are also important factors; however, there was not a clear association between religion and age.

Association of mental health symptoms with the migraine-tension-type headache spectrum in the Brazilian longitudinal study of adult health.

OBJECTIVE: To investigate the relationship between mental health symptoms and the migraine-tension-type headache (TTH) spectrum in middle-aged adults from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil study). METHODS: In this cross-sectional analysis (baseline data: 2008-2010), it was evaluated the relationship between each mental health symptom assessed by the Clinical Interview Schedule-Revised (CIS-R) questionnaire and headache subtypes (migraine and TTH) according to international criteria. It was performed binary logistic regression models, with estimated odds ratios (OR) with their respective 95% confidence intervals (CI) adjusted for confounders including migraine attack frequency. RESULTS: Among 13,916 participants, 70.1% reported any major primary headache subtype within the last year. The most common subtype was definite TTH (33.4%), followed by probable migraine (21.0%), definite migraine (8.5%), and probable TTH (7.2%). Our main findings indicated positive associations between anxiety-related symptoms and the migraine-tension type headache (TTH) spectrum with a clear trend toward definite migraine more than tension-type headache. The presence of somatic symptoms presented a high likelihood for the associations with headaches, mainly definite migraine (OR: 7.9, 95% CI: 6.4-9.8), probable migraine (OR: 4.5, 95% CI 3.7-5.4) and probable TTH (OR: 3.0, 95% CI: 2.3-3.8). Other symptoms associated with headache disorders included fatigue, panic, irritability, anxiety symptoms, concentration problems, forgetfulness, depressive symptoms, and worry. The effect of associations remained significant after controlling for headache attack frequency. CONCLUSION: This study provides evidence of consistent associations between mental health symptoms and primary headache disorders, with a higher burden of anxiety-based symptoms observed in people with migraine than those with TTH.

Adherence to the planetary health diet and cognitive decline: findings from the ELSA-Brasil study.

The EAT-Lancet Commission proposed a planetary health diet to improve human health within planetary boundaries; however, little is known about the association between adherence to this diet and cognitive decline. We used data from three waves of the Brazilian Longitudinal Study of Adult Health to evaluate the association between the planetary health diet and cognitive decline using linear mixed-effects models. Here we show that in 11,737 participants (mean (s.d.) age 51.6 (9.0) years, 54% women and 53% white), higher adherence to the planetary health diet was associated with slower memory decline (P = 0.046) and that income was a modifier in this association (P < 0.001). Adherence to the planetary health diet was associated with slower decline of memory (P = 0.040) and global cognition (P = 0.009) in high-income participants. No association was found among low-income participants. The results of our study highlight that the promotion of healthy dietary patterns should take into consideration income barriers as well as differences in dietary habits to achieve high adherence.

Potential Determinants of Thyroid Peroxidase Antibodies and Mortality Risk: Results From the ELSA-Brasil Study.

CONTEXT: The presence of thyroid peroxidase antibodies (TPOAbs) may be considered as an indicator of adverse health outcomes. OBJECTIVE: We aimed to investigate the potential determinants of TPOAb levels and to analyze the association between TPOAb titers and the risk of all- and specific-cause mortality. METHODS: Baseline and longitudinal data of 13 187 participants from the ELSA-Brasil Study were analyzed. We investigated the association of TPOAb, detectability, positivity, and persistent positivity with sociodemographic and lifestyle factors using logistic regressions. Cox proportional hazards and Fine-Gray subdistribution hazard regression analyses were used to verify the association of TPOAbs with mortality. RESULTS: The determinants of TPOAb detectability and positivity were younger age, higher body mass index, female sex, and former and current smoking status. Black, mixed, and other self-reported races, intermediate and higher education, and heavy drinking were determinants of detectable and positive TPOAb levels. Female sex, White race, and former smoking were determinants of persistent TPOAb positivity at 2 visits, although only the female sex maintained its association at 3 visits. Moreover, after multivariate adjustment, there were associations between higher levels of TPOAbs and higher risk of cancer-related mortality among men, and TPOAb detectability and mortality by other causes among women. CONCLUSION: Sociodemographic and lifestyle-related factors were determinants of multiple TPOAb categories. TPOAb levels were associated with mortality risk; however, the low mortality rate in this sample might have compromised this finding. We suggest further studies to explore the clinical importance of detectable TPOAb levels, not only its positivity, as a potential marker of inflammation.

The sertraline versus electrical current therapy for treating depression clinical study (select-TDCS): results of the crossover and follow-up phases.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a promising nonpharmacological therapy for major depression. In the Sertraline versus Electrical Current Therapy for Treating Depression Clinical Trial (SELECT-TDCS) trial, phase-I (Brunoni et al., JAMA Psychiatry, 2013) we found that tDCS is effective for the acute episode. Here, we describe tDCS effects during phases II (crossover) and III (follow-up) of this trial (NCTs: 01149889 and 01149213). METHODS: Phase II (n = 25) was the open-label, crossover phase in which phase-I nonresponders who had received sham-tDCS received a 10-day course of active-tDCS. In phase-III (n = 42), all active-tDCS responders (>50% Montgomery-Asberg Depression Rating Scale (MADRS) improvement or MADRS ≤ 12) were enrolled to a 24-week, follow-up phase in which a maximum of nine tDCS sessions were performed-every other week for 3 months and, thereafter, once a month for the subsequent 3 months-sessions would be interrupted earlier whether the subject relapsed. TDCS was applied at 2 mA/30 min, with the anode over the left and the cathode over the right dorsolateral prefrontal cortex. Relapse was the outcome measure. RESULTS: In phase-II, 52% of completers responded to tDCS. In phase-III, the mean response duration was 11.7 weeks. The survival rate per Kaplan-Meier analysis was 47%. Patients with treatment-resistant depression presented a much lower 24-week survival rate as compared to nonrefractory patients (10% vs. 77%, OR = 5.52; P < .01). Antidepressant use (sertraline 50 mg/day, eight patients) was not a predictor of relapse. TDCS was well tolerated and with few side effects. CONCLUSION: Continuation tDCS protocols should be optimized as to prevent relapse among tDCS responders, particularly for patients with baseline treatment-resistant depression.

CYP2C9 and VKORC1 polymorphisms influence warfarin dose variability in patients on long-term anticoagulation.

OBJECTIVES: The main aim of this study was to determine whether CYP2C9 and VKORC1 polymorphisms influence warfarin dose variability during initial dose-finding phase and during maintenance treatment after 360 days. METHODS: Two hundred and six consecutive patients who were beginning warfarin therapy were selected. They were assessed for general and clinical characteristics; prescribed warfarin dose; response to therapy on days 7-10, 30, 60, 180, and 360; adverse events; and CYP2C9 2, 3, 5, 6, 8, 11, and VKORC1 1639G >A assays. RESULTS: During the first 30 days of anticoagulation, the relative variability of warfarin dose was significantly associated with CYP2C9*2 and CYP2C9*3 polymorphisms (p = 0.02) and with VKORC1 1639G >A genotypes (p = 0.04). Warfarin variability was also statistically different according to predicted metabolic phenotype and to VKORC1 genotypes after 360 days of treatment, and in the phase between 180 and 360 days (long-term dose variability). Both CYP2C9 and VKORC1 polymorphisms were associated with the international normalized ratio (INR) made between 7 and 10 days/initial dose ratio, adjusted for covariates (p < 0.01 and p = 0.02, respectively). Patients carrying VKORC1 and CYP2C9 variants presented lower required dose (at the end of follow-up of 360 days) compared to patients carrying wild-type genotypes (p = 0.04 and p = 0.03, respectively). CONCLUSIONS: Genetic information on CYP2C9 and VKORC1 is important both for the initial dose-finding phase and during maintenance treatment with warfarin.

Psoriasis and associated risk factors: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health.

OBJECTIVE: This study investigated the association of psoriasis with cardiovascular risk factors and psychological aspects among participants of the Brazilian Longitudinal Study of Adult Health. METHODS: This is a cross-sectional study from the baseline data of the Brazilian Longitudinal Study of Adult Health cohort, collected between 2008 and 2010 in six state capitals of Brazil (i.e., Belo Horizonte, Porto Alegre, Rio de Janeiro, Salvador, São Paulo, and Vitória). Participants were active and retired civil servants from college and research institutions, aged between 35 and 74 years. Exclusion criteria included the intention to quit working at the institution, pregnancy, severe cognitive impairment, and, if retired, residence outside of a study center's corresponding area. Psoriasis case identification was based on a previous medical diagnosis of psoriasis. Cardiovascular risk profile, psychological aspects, and sociodemographic variables were investigated. RESULTS: Data from 15,105 participants were analyzed (mean age of 52.3 years, 51.3% women). The prevalence of psoriasis was 1.6% (n=236). Psoriasis was associated with higher education (OR 1.94 [CI 1.07-3.52]), health insurance plan (OR 1.56 [CI 1.08-2.25]), central obesity (OR 1.63 [CI 1.10-2.40]), smoking status (former OR 1.40 [CI 1.03-1.88]; current OR 1.61 [CI 1.08-2.40]), and very bad self-perception of health (OR 7.22 [CI 2.41-21.64]), remaining significant even after multivariate adjustment. Self-reported Black participants were less likely to have psoriasis (OR 0.45 [CI 0.26-0.75]). CONCLUSION: In a sample of healthy workers, psoriasis was associated with central obesity, smoking, and a very bad self-perception of health, which may contribute to future cardiovascular disease.

The association between salt intake and blood pressure is mediated by body mass index but modified by hypertension: The ELSA-Brasil study.

High salt intake has been linked to both obesity and high blood pressure (BP). Part of the variability of BP attributed to salt intake might be BMI-mediated. To investigate whether hypertension would be an effect modifier in the complex network including salt intake, obesity, and BP, we tested the hypothesis that salt intake has direct and BMI-mediated effects on systolic (SBP) and diastolic blood pressure (DBP). Data from 9,028 participants (aged 34-75 years, 53.6% women) were analyzed. A validated formula was used to estimate daily salt intake from the sodium excretion (12 h urine collection). A path model adjusted for covariates was designed in which salt intake has both a direct and a BMI-mediated effect on BP. In normotensives, standardized beta coefficients showed significant direct (Men: 0.058 and 0.052, Women: 0.072 and 0,061, P < 0.05) and BMI-mediated (Men: 0.040 and 0.065, Women: 0.038 and 0.067, P < 0.05) effect of salt intake on the SBP and DBP, respectively. However, in hypertensive individuals, neither the direct (Men: 0.006 and 0.056, Women: 0.048 and 0.017) nor the indirect effect (Men: -0.044 and 0.014, Women: 0.011 and 0.050) of salt intake on the SBP and DBP were significant. These data suggest that cardiovascular risk stratification should consider the complex interaction between salt intake and weight gain, and their effects on BP of normotensive and hypertensive individuals.

A pandemic toll in frail older adults: Higher odds of incident and persistent common mental disorders in the ELSA-Brasil COVID-19 mental health cohort.

INTRODUCTION: We aimed to investigate the association of frailty with persistent and incident common mental disorders (CMD) in older adults during the pandemic. METHODS: We included 706 older adults who participated in the onsite wave of the ELSA-Brasil study (2017-2019) and the online COVID-19 assessment (May-July 2020). CMD were assessed in both waves by the Clinical Interview Schedule-Revised. Frailty was defined according to the physical phenotype and Frailty Index in the 2017-2019 wave. Logistic regression was used to investigate the association of frailty with persistent and incident CMD, adjusted for sociodemographics. RESULTS: Frailty according to both definitions were associated with persistent CMD (Frailty Index: OR = 8.61, 95 % CI = 4.08-18.18; physical phenotype: OR = OR = 23.67, 95 % CI = 7.08-79.15), and incident CMD (Frailty Index: OR = 2.79, 95 % CI = 1.15-6.78; physical phenotype OR = 4.37, 95 % CI = 1.31-14.58). The exclusion of exhaustion (that overlaps with psychiatric symptoms) from the frailty constructs did not change the association between frailty and persistent CMD, although the associations with indent CMD were no longer significant. LIMITATIONS: Fluctuations in CMD status were not captured between both assessments. CONCLUSION: Frailty status before the COVID-19 outbreak was associated with higher odds of persistent and incident CMD in older adults during the pandemic first wave. Identifying individuals at higher risk of mental burden can help prioritize resources allocation and management.