Predictive value of functional disability scales among stroke survivors: A long-term mortality evaluation in a Brazilian stroke cohort.

OBJECTIVE: To assess the influence of two functional scales- Modified Rankin Scale (m-RS) and Modified Katz Index (m-Katz Index) on long-term mortality in a stroke cohort. MATERIAL AND METHODS: Among 760 stroke survivors (median age: 66 (IQR:56-75), 56.4 % women) m-Katz Index and m-RS scales applied at 1 and 6 months after stroke, were investigated in relation to 12-years of all-cause mortality. Kaplan-Meier survival curves were computed, and time-varying covariate Cox regression models were fitted to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs) in all sample and by sex. The prognostic ability of the fitted models was computed for each model by six different measures. RESULTS: After 12 years of follow-up (median survival time: 7.3 years), 311 participants died. Overall survival curves show lower survival rates among those with the highest levels of disability/dependence (all log-rank p-values <0.0001). These findings were confirmed in all regression models for both sexes, particularly in men who had higher levels of dependence on Activities of Daily Living (ADLs) by m-Katz Index and severe disability by m-RS and presented the highest HR of dying (HR: 3.34 (95 %CI: 2.27-4.92) and HR: 4.94 (95 % CI: 3.15-7.75), respectively). CONCLUSIONS: Both the m-Katz Index and the m-RS scale were good predictors of long-term mortality, which is of importance for guiding the functional rehabilitation of stroke patients. Besides, high levels of disability and dependence were implicated with high mortality risks, regardless of sex.

Forecasting Covid-19 in the United Kingdom: A dynamic SIRD model.

Making use of a state space framework, we present a stochastic generalization of the SIRD model, where the mortality, infection, and underreporting rates change over time. A new format to the errors in the Susceptible-Infected-Recovered-Dead compartments is also presented, that permits reinfection. The estimated trajectories and (out-of-sample) forecasts of all these variables are presented with their confidence intervals. The model only uses as inputs the number of reported cases and deaths, and was applied for the UK from April, 2020 to Sep, 2021 (daily data). The estimated infection rate has shown a trajectory in waves very compatible with the emergence of new variants and adopted social measures. The estimated mortality rate has shown a significant descendant behaviour in 2021, which we attribute to the vaccination program, and the estimated underreporting rate has been considerably volatile, with a downward tendency, implying that, on average, more people are testing than in the beginning of the pandemic. The evolution of the proportions of the population divided into susceptible, infected, recovered and dead groups are also shown with their confidence intervals and forecast, along with an estimation of the amount of reinfection that, according to our model, has become quite significant in 2021. Finally, the estimated trajectory of the effective reproduction rate has proven to be very compatible with the real number of cases and deaths. Its forecasts with confident intervals are also presented.

Self-reported versus actigraphy-assessed sleep duration in the ELSA-Brasil study: analysis of the short/long sleep duration reclassification.

PURPOSE: This study was aimed to determine the magnitude and predictors of self-reported short/long sleep duration (SDUR) reclassifications using objective measurements. METHODS: Adult participants from the ELSA-Brasil study performed self-reported SDUR, 7-day wrist actigraphy, and a portable sleep study. We explored two strategies of defining self-reported SDUR reclassification: (1) short and long SDUR defined by <6 and ≥8h, respectively; (2) reclassification using a large spectrum of SDUR categories (<5, 5-6, 7-8, 8-9, and >9 h). RESULTS: Data from 2036 participants were used in the final analysis (43% males; age: 49±8 years). Self-reported SDUR were poorly correlated (r=0.263) and presented a low agreement with actigraphy-based total sleep time. 58% of participants who self-reported short SDUR were reclassified into the reference (6-7.99 h) or long SDUR groups using actigraphy data. 88% of participants that self-reported long SDUR were reclassified into the reference and short SDUR. The variables independently associated with higher likelihood of self-reported short SDUR reclassification included insomnia (3.5-fold), female (2.5-fold), higher sleep efficiency (1.35-fold), lowest O2 saturation (1.07-fold), higher wake after sleep onset (1.08-fold), and the higher number of awakening (1.05-fold). The presence of hypertension was associated with a 3.4-fold higher chance of self-reported long SDUR reclassification. Analysis of five self-reported SDUR categories revealed that the more extreme is the SDUR, the greater the self-reported SDUR reclassification. CONCLUSION: In adults, we observed a significant rate of short/long SDUR reclassifications when comparing self-reported with objective data. These results underscore the need to reappraise subjective data use for future investigations addressing SDUR.

The impact of atrial fibrillation and long-term oral anticoagulant use on all-cause and cardiovascular mortality: A 12-year evaluation of the prospective Brazilian Study of Stroke Mortality and Morbidity.

BACKGROUND: Atrial fibrillation is a predictor of poor prognosis after stroke. AIMS: To evaluate atrial fibrillation and all-cause and cardiovascular mortality in a stroke cohort with low socioeconomic status, taking into consideration oral anticoagulant use during 12-year follow-up. METHODS: All-cause mortality was analyzed by Kaplan-Meier survival curve and Cox regression models to estimate hazard ratios and 95% confidence intervals (95% CI). For specific mortality causes, cumulative incidence functions were computed. A logit link function was used to calculate odds ratios (OR) with 95% CIs. Full models were adjusted by age, sex, oral anticoagulant use (as a time-dependent variable) and cardiovascular risk factors. RESULTS: Of 1121 ischemic stroke participants, 17.8% had atrial fibrillation. Overall, 654 deaths (58.3%) were observed. Survival rate was lower (median days, interquartile range-IQR) among those with atrial fibrillation (531, IQR: 46-2039) vs. non-atrial fibrillation (1808, IQR: 334-3301), p-log rank < 0.0001). Over 12-year follow-up, previous atrial fibrillation was associated with increased mortality: all-cause (multivariable hazard ratios, 1.82; 95% CI: 1.43-2.31) and cardiovascular mortality (multivariable OR, 2.07; 95% CI: 1.36-3.14), but not stroke mortality. In the same multivariable models, oral anticoagulant use was inversely associated with all-cause mortality (oral anticoagulant time-dependent effect: multivariable hazard ratios, 0.47; 95% CI: 0.30-0.50, p = 0.002) and stroke mortality (oral anticoagulant time-dependent effect ≥ 6 months: multivariable OR, 0.09; 95% CI: 0.01-0.65, p-value = 0.02), but not cardiovascular mortality. CONCLUSIONS: Among individuals with low socioeconomic status, atrial fibrillation was an independent predictor of poor survival, increasing all-cause and cardiovascular mortality risk. Long-term oral anticoagulant use was associated with a markedly reduced risk of all-cause and stroke mortality.

Work-Family Conflict and Ideal Cardiovascular Health Score in the ELSA-Brasil Baseline Assessment.

Background There are few data about the association between work-related stress and the American Heart Association ideal cardiovascular health (CVH) metrics. We studied the association between work-family conflict (WFC) and ideal CVH scores in the ELSA-Brasil (Brazilian Longitudinal Study of Adult Health) baseline study. Methods and Results We analyzed data of active workers (5424 men and 5967 women), aged 35 to 74 years, from 2008 to 2010. Ideal CVH scores were calculated based on the lifestyle and health metrics proposed by the American Heart Association, using data from questionnaires and clinical and laboratory examinations from the ELSA-Brasil study baseline. The WFC questionnaire was based on the Frone model, validated for Brazilian Portuguese. WFC domains (time and strain-based work interference with family, family interference with work, and lack of time for personal care and leisure) and frequency (never to rarely, sometimes, or frequently) were self-reported. Main models were adjusted for age, sex, race, educational level, income, and study site. Positive relative predicted score differences (rPSDs) indicate higher predicted scores. We found lower lifestyle ideal CVH scores among men (rPSD, -5.7%; P=0.002) and women (rPSD, -10.2%; P<0.001) with frequent lack of time for personal care and leisure. We found lower lifestyle ideal CVH scores among women with frequent strain-based work interference with family (rPSD, -5.1%; P=0.002), and family interference with work (rPSD, -8.6%; P=0.001). We found higher health ideal CVH scores among men with frequent WFC, which may be attributable to reverse causation. Conclusions We found significant associations between WFC and ideal CVH scores. These associations were heterogeneous according to sex.

Prognostic value of carotid intima-media in the short- and long-term mortality in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study.

BACKGROUND AND AIMS: Atherosclerotic in carotids can determinate a poor prognosis in individuals after acute coronary syndrome (ACS). Thus, we aimed to evaluate mortality associated to carotid intima media thickness (CIMT) in the participants from the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. METHODS: Carotid intima media thickness was evaluated by B-mode ultrasound for mortality risk assessment in 180 days, 1-3 years. We performed Kaplan-Meier survival curves and Cox logistic regression models to evaluate all-cause, cardiovascular (CVD) and coronary heart disease (CHD) mortality by CIMT tertiles in crude, age and sex- and multivariate models. RESULTS: Among 644 ACS individuals (median age 61-year old), we observed a median CIMT of 0.74 mm. Besides aging, low education, hypertension, diabetes, and dyslipidemia were associated with the 3rd tertile of CIMT values. During 3 years of follow-up, we observed 65 deaths (10.1%), crude case-fatality rates were progressively higher across the CIMT tertiles in all periods, being the highest rates observed in participants with the highest CIMT (3rd tertile) (180-day: 6.6% vs 1-year: 9.0% vs 2-year:12.3% vs 3-year:16.0%, P < .05). In crude analyses, lowest survival rates (all-cause, CVD and CHD, p log-rank values <0.005) and higher hazard ratios of dying for all-cause and CVD (from 1 to 3 years) and for CHD (2 and 3 years) were observed. However, we kept no significant results after adjusting for age. CONCLUSION: Carotid intima media thickness was mainly influenced by aging. CIMT was not a good predictor of all-cause, CVD or CHD mortality in the ERICO study.

Job Strain and Cardiovascular Health Score (from the Brazilian Longitudinal Study of Adult Health [ELSA-Brasil] Baseline).

We aimed to study the association between the American Heart Association cardiovascular health (CVH) score and job strain in the Brazilian Longitudinal Study of Adult Health baseline. We analyzed data from 11,351 active workers (aged 35 to 74 years) without overt cardiovascular disease and who had complete data. Job strain was assessed using the 17-item Brazilian version of the Swedish Job Demand-Control-Support Questionnaire. Clinical (fasting plasma glucose, total cholesterol, and blood pressure) and lifestyle (diet, physical activity, smoking, and body mass index) components of CVH score were assessed according to the American Heart Association criteria. We used quasi-Poisson and multinomial regression models, adjusted for age, gender, race, educational level and income, and positive relative predicted score differences (rPSDs) indicate greater predicted scores. Subjects with low skill discretion scores had lower global (rPSD: -1.8%; p = 0.021) and lifestyle (rPSD: -3.6%; p = 0.018) CVH scores. Participants with low decision authority (rPSD: -2.4%; p = 0.029) and low social support scores (rPSD: -3.3%; p = 0.001) also had lower lifestyle CVH scores. In conclusion, we found significant associations between job strain and CVH scores in this large multicenter sample.

Morphological and morphometric analysis of the effects of intralesional tamoxifen on keloids.

The aim of this study was to evaluate the effect of intralesional tamoxifen on keloids, particularly on the concentration of fibroblasts, dermal inflammatory infiltrate, and collagen degeneration. A prospective study was carried out to evaluate keloids in 13 patients of both genders pre- and post-treatment with intralesional tamoxifen. Two samples of keloid lesions were obtained by 4-mm punch biopsies during the study: the first at the time of diagnostic confirmation of keloid and the other eight weeks later at the end of intralesional tamoxifen treatment. The biopsy samples were placed in 10% buffered formalin for HE staining and morphological and morphometric study. The degree of collagen fiber reduction and inflammatory infiltration were analyzed. Student's t-test was used for statistical analysis of the mean number of fibroblasts before and following tamoxifen treatment ( P < 0.05). The degree of collagen fiber reduction and inflammatory infiltration were absent before treatment and present in 100% of cases after treatment, while the mean number of fibroblasts was significantly lower after intralesional tamoxifen treatment ( P < 0.0001). We conclude that intralesional administration of tamoxifen promoted an inflammatory stimulus and collagen fiber reduction as well as a significant reduction in the number of fibroblasts that produce collagen. Impact statement Effective treatment of keloid that is a commonly recurrent dermatosis is very difficult, even after standard treatment. Standard treatment consists of partial resection of the lesion (shaving excision), in addition to local corticosteroid injection. Therefore, there is interest in alternative forms of topical treatment, e.g., selective estrogen receptor modulators, particularly tamoxifen has demonstrated in vitro studies to be a promising drug. Nevertheless, there is scarcity of publications on the effects of intralesional tamoxifen on keloids have been found, leading us to the conception of the present study. In this study, tamoxifen has proven to be an interesting alternative drug for the topical treatment of keloid, allowing us to conclude that the intralesional application of tamoxifen in keloids promotes a variable but ever-present inflammatory stimulus, associated with intense reduction of collagen fiber, in addition to a significant decrease in the number of fibroblasts that produce collagen and are involved in disease maintenance.

Evaluation of Ki-67 antigen expression in the vaginal epithelium of castrated female rats treated with raloxifene and tamoxifen: a comparative study.

OBJECTIVE: The aim of this study was to evaluate the effects of raloxifene and tamoxifen on Ki-67 antigen expression in the vaginal epithelium of castrated rats. MATERIAL AND METHODS: Thirty-nine virgin, adult, castrated female Wistar-Hannover rats were randomly divided into three groups: Group I (control, n = 13), Group II (raloxifene, n = 13) and Group III (tamoxifen, n = 13). After confirmation of their hypoestrogenic state, the rats were given 0.5 ml of propylene glycol (vehicle), 750 µg of raloxifene or 250 µg of tamoxifen, respectively, by gavage, for 30 days. On the 31st day, the rats were euthanized and their vaginas removed and fixed in 10% buffered formalin for of Ki-67 immunohistochemical evaluation. Data were analyzed using Levene's test and Tukey's method (p < 0.05). RESULTS: Mean Ki-67 expression in groups I, II and III was 27 ± 2.6, 32.3 ± 1.9 and 43.7 ± 3.5, respectively. In Group III (tamoxifen), there was a greater proportion of stained cells compared to Groups I and II (p < 0.0003), with no statistically significant difference between Groups I and II (p = 0.3626). CONCLUSIONS: The present results show that tamoxifen significantly increased cell proliferation in the vaginal epithelium of the castrated rats and no difference between the raloxifene and control groups.

Burden of influenza-associated deaths in the Americas, 2002-2008.

BACKGROUND: Influenza disease is a vaccine-preventable cause of morbidity and mortality. The Pan American Health Organization (PAHO) region has invested in influenza vaccines, but few estimates of influenza burden exist to justify these investments. We estimated influenza-associated deaths for 35 PAHO countries during 2002-2008. METHODS: Annually, PAHO countries report registered deaths. We used respiratory and circulatory (R&C) codes from seven countries with distinct influenza seasonality and high-quality mortality data to estimate influenza-associated mortality rates by age group (0-64, 65-74, and ≥ 75 years) with a Serfling regression model or a negative binomial model. We calculated the percent of all R&C deaths attributable to influenza by age group in these countries (etiologic fraction) and applied it to the age-specific mortality in 13 countries with good mortality data but poorly defined seasonality. Lastly, we grouped the remaining 15 countries into WHO mortality strata and applied the age and mortality stratum-specific rate of influenza mortality calculated from the 20 countries. We summed each country's estimate to arrive at an average total annual number and rate of influenza deaths in the Americas. RESULTS: For the 35 PAHO countries, we estimated an annual mean influenza-associated mortality rate of 2·1/100,000 among <65-year olds, 31·9/100 000 among those 65-74 years, and 161·8/100,000 among those ≥ 75 years. We estimated that annually between 40,880 and 160,270 persons (mean, 85,100) die of influenza illness in the PAHO region. CONCLUSION: Influenza remains an important cause of mortality in the Americas.

Low Impact of Traditional Risk Factors on Carotid Intima-Media Thickness: The ELSA-Brasil Cohort.

OBJECTIVE: There is little information about how much traditional cardiovascular risk factors explain common carotid artery intima-media thickness (CCA-IMT) variance. We aimed to study to which extent CCA-IMT values are determined by traditional risk factors and which commonly used measurements of blood pressure, glucose metabolism, lipid profile, and adiposity contribute the most to this determination in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort baseline. APPROACH AND RESULTS: We analyzed 9792 individuals with complete data and CCA-IMT measurements. We built multiple linear regression models using mean left and right CCA-IMT as the dependent variable. All models were stratified by sex. We also analyzed individuals stratified by 10-year coronary heart disease risk and, in separate, those with no traditional risk factors. Main models' R(2) varied between 0.141 and 0.373. The major part of the explained variance in CCA-IMT was because of age and race. Indicators of blood pressure, lipid profile, and adiposity that most frequently composed the best models were pulse pressure, low-density lipoprotein/high-density lipoprotein ratio, and neck circumference. The association between neck circumference and CCA-IMT persisted significant even after further adjustment for vessel sizes and body mass index. Indicators of glucose metabolism had smaller contribution. CONCLUSIONS: We found that >60% of CCA-IMT were not explained by demographic and traditional cardiovascular risk factors, which highlights the need to study novel risk factors. Pulse pressure, low-density lipoprotein/high-density lipoprotein ratio, and neck circumference were the most consistent contributors.

Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996-2011.

BACKGROUND: It is not clear the relationship between stroke mortality trends and socioeconomic inequalities in low- and middle-income countries. AIMS: We compared differences of trends in stroke mortality by socioeconomic status in the city of Sao Paulo, Brazil. METHODS: We analyzed the intra-urban distribution of stroke death rates from 1996 to 2011 for persons aged 35-74 years old according to income using joinpoint regression. RESULTS: We confirmed 77 848 stroke deaths in the period, 51·4% of them among persons aged 35-74 years old. For all areas, there was parallelism between genders, and the average annual percent changes combined was -5·2 (-5·7 to -4·6) from 1996 to 2005 and -3·0 (-4·3 to -1·7) from 2005 to 2011. The full period average annual percent changes of age-adjusted rates between persons living in the high- and low-income area were, respectively, -5·4 and -4·2 (P = 0·002) for men and -5·9 vs. -4·9 (P = 0·017) for women. Differences in the risk of stroke between the high- and low-income areas increased more than twofold in the period in both genders. CONCLUSIONS: The risk of stroke death is decreasing in all regions, but the faster decline in mortality rates in the wealthiest area contributes to further greater inequalities.

Trends in mortality from respiratory disease in Latin America since 1998 and the impact of the 2009 influenza pandemic.

OBJECTIVE: To determine trends in mortality from respiratory disease in several areas of Latin America between 1998 and 2009. METHODS: The numbers of deaths attributed to respiratory disease between 1998 and 2009 were extracted from mortality data from Argentina, southern Brazil, Chile, Costa Rica, Ecuador, Mexico and Paraguay. Robust linear models were then fitted to the rates of mortality from respiratory disease recorded between 2003 and 2009. FINDINGS: Between 1998 and 2008, rates of mortality from respiratory disease gradually decreased in all age groups in most of the study areas. Among children younger than 5 years, for example, the annual rates of such mortality - across all seven study areas - fell from 56.9 deaths per 100,000 in 1998 to 26.6 deaths per 100,000 in 2008. Over this period, rates of mortality from respiratory disease were generally highest among adults older than 65 years and lowest among individuals aged 5 to 49 years. In 2009, mortality from respiratory disease was either similar to that recorded in 2008 or showed an increase - significant increases were seen among children younger than 5 years in Paraguay, among those aged 5 to 49 years in southern Brazil, Mexico and Paraguay and among adults aged 50 to 64 years in Mexico and Paraguay. CONCLUSION: In much of Latin America, mortality from respiratory disease gradually fell between 1998 and 2008. However, this downward trend came to a halt in 2009, probably as a result of the (H1N1) 2009 pandemic.

Predictors of long-term survival among first-ever ischemic and hemorrhagic stroke in a Brazilian stroke cohort.

BACKGROUND: Few studies have examined both ischemic and hemorrhagic stroke to identify prognostic factors associated to long-term stroke survival. We investigated long-term survival and predictors that could adversely influence ischemic and hemorrhagic first-ever stroke prognosis. METHODS: We prospectively ascertained 665 consecutive first-ever ischemic and hemorrhagic stroke cases from "The Study of Stroke Mortality and Morbidity" (The EMMA Study) in a community hospital in São Paulo, Brazil. We evaluated cardiovascular risk factors and sociodemographic characteristics (age, gender, race and educational level). RESULTS: We found a lower survival rate among hemorrhagic cases compared to ischemic stroke cases at the end of 4 years of follow-up (52% vs. 44%, p = 0.04). The risk of death was two times higher among people with ischemic stroke without formal education. Also, we found consistently higher risk of death for diabetics with ischemic stroke (HR = 1.45; 95% CI = 1.07-1.97) compared to no diabetics. As expected, age equally influenced on the high risk of poor survival, regardless of stroke subtype. CONCLUSIONS: For ischemic stroke, the lack of formal education and diabetes were significant independent predictors of poor long-term survival.

The influence of the day of the week of hospital admission on the prognosis of stroke patients.

This study aimed to evaluate the weekday and weekend distribution of stroke case hospital admissions and their respective prognosis based on a sample from the Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA), a cohort of stroke patients admitted to a community hospital in the city of São Paulo, Brazil. We ascertained all consecutive cases of first-time strokes between April 2006 and December 2008 and performed a subsequent one-year follow-up. No association was found between frequency of hospital admissions due to ischemic and hemorrhagic strokes and the specific day of the week on which the admission occurred. However, ten-day and twelve-month case-fatality was higher in hemorrhagic stroke patients admitted at the weekend. We also found that intracerebral hemorrhage patients admitted on weekends had a worse survival rate (50%) compared with those admitted during weekdays (25.6%, P log-rank = 0.03). We found a multivariate hazard ratio of 2.49 (95%CI: 1.10-5.81, P trend = 0.03) for risk of death at the weekend compared to weekdays for intracerebral hemorrhage cases. No difference in survival was observed with respect to the overall sample of stroke or ischemic stroke patients.

The influence of the day of the week of hospital admission on the prognosis of stroke patients / O dia da semana de admissão hospitalar influenciando o prognóstico de pacientes com acidente vascular cerebral / Influencia del día de la semana de admisión hospitalaria en el pronóstico de pacientes con accidente vascular cerebral

This study aimed to evaluate the weekday and weekend distribution of stroke case hospital admissions and their respective prognosis based on a sample from the Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA), a cohort of stroke patients admitted to a community hospital in the city of São Paulo, Brazil. We ascertained all consecutive cases of first-time strokes between April 2006 and December 2008 and performed a subsequent one-year follow-up. No association was found between frequency of hospital admissions due to ischemic and hemorrhagic strokes and the specific day of the week on which the admission occurred. However, ten-day and twelve-month case-fatality was higher in hemorrhagic stroke patients admitted at the weekend. We also found that intracerebral hemorrhage patients admitted on weekends had a worse survival rate (50%) compared with those admitted during weekdays (25.6%, P log-rank = 0.03). We found a multivariate hazard ratio of 2.49 (95%CI: 1.10-5.81, P trend = 0.03) for risk of death at the weekend compared to weekdays for intracerebral hemorrhage cases. No difference in survival was observed with respect to the overall sample of stroke or ischemic stroke patients.

O estudo avaliou a distribuição de casos incidentes de acidente vascular cerebral (AVC) que procuraram hospital de 2ª a 6ª feira ou nos finais de semana no Estudo de Mortalidade e Morbidade do AVC (EMMA). O EMMA é uma coorte de pacientes com AVC em hospital comunitário da cidade de São Paulo, Brasil. Casos consecutivos de primeiro episódio de AVC internados entre abril de 2006 e dezembro de 2008 foram seguidos prospectivamente por um ano. Não houve diferença na frequência das internações por AVC isquêmico ou hemorrágico pelos dias da semana. Entretanto, a letalidade em dez dias e após um ano estava aumentada no AVC hemorrágico. Na análise da sobrevida de um ano, pacientes admitidos nos finais de semana por hemorragia intraparenquimatosa apresentaram menor sobrevida (50%) quando comparados aos admitidos de 2ª a 6ª (22%) (p log-rank = 0.03). Encontrou-se uma razão de risco multivariada de 2,49 (IC95%: 1,10-5,81, p tendência = 0,03) de morrer nos fins de semana em comparação ao período de 2ª a 6ª feira para hemorragia intracerebral. Não houve diferença na sobrevida para amostra total de AVC nem para AVC isquêmico.

El estudio evaluó la distribución de casos incidentes de accidente vascular cerebral (AVC) que fueron al hospital de lunes a viernes o durante los fines de semana en el Estudio de Mortalidad y Morbilidad del AVC (EMMA). El EMMA es una cohorte de pacientes con AVC en un hospital comunitario de la ciudad de São Paulo, Brasil. Casos consecutivos de primer episodio de AVC internados, entre abril de 2006 y diciembre de 2008, fueron seguidos prospectivamente durante un año. No hubo diferencia en la frecuencia de las internaciones por AVC isquémico o hemorrágico durante los días de la semana. Sin embargo, la letalidad en 10 días y tras un año había aumentado en el AVC hemorrágico. En el análisis de supervivencia de un año, pacientes admitidos los fines de semana por hemorragia intraparenquimatosa presentaron menor supervivencia (50%), comparados con los admitidos de Lunes hasta Viernes (22%, p log-rank = 0.03). Se encontró una razón de riesgo multivariada de un 2,49 (IC95%: 1,10-5,81; p tendencia = 0,03) de morir los fines de semana en comparación con los lunes y viernes para la hemorragia intracerebral. No hubo diferencia en la supervivencia para la muestra total de AVC ni para el AVC isquémico.

Income and heart disease mortality trends in Sao Paulo, Brazil, 1996 to 2010.

BACKGROUND: Reductions in heart disease mortality rates are variable according to socioeconomic status. METHODS: We performed a time trend analysis of all heart diseases (all circulatory diseases, except rheumatic, cerebrovascular, and aortic diseases) comparing three different household income levels (high, middle, and low) in the city of Sao Paulo from 1996 to 2010. RESULTS: A total of 197,770 deaths were attributed to heart diseases; 62% of them were due to coronary diseases. The rate of death due to heart diseases declined for the city as a whole. The annual percent change (APC) and 95% confidence intervals for men living in the high, middle and low income areas were -4.1 (-4.5 to -3.8), -3.0 (-3.5 to -2.6), and -2.5 (-2.8 to -2.1), respectively. The decline in death rate was greatest among men in the wealthiest area. The trend rates of women living in the high-income area had one joinpoint; APC was -4.4 (-4.8 to -3.9) from 1996-2005 and -2.6 (-3.8 to -1.4) from 2005-2010. Middle and low income areas had an APC of -3.6 (-4.1 to -3.1) and -3.0 (-3.2 to -2.7) from 1996-2010, respectively. During the last 5years of observation, there was a gradient of the decline of the risk of death, faster for people living in the wealthiest area and slower for people living in the more deprived neighborhoods. CONCLUSION: Reduction in deaths due to heart diseases is greatest for men and women living in the wealthiest neighborhoods.

Educational levels and the functional dependence of ischemic stroke survivors.

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. ≥ 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.