Situational analysis of hypertension management at primary health care level in São Paulo, Brazil: population, healthcare professional and health system perspectives.

BACKGROUND: Government-led, population-wide initiatives are crucial for advancing the management of hypertension - a leading cause of cardiovascular disease (CVD) morbidity and mortality. An urban population health initiative was conducted against this backdrop, focussing on hypertension in the primary health system in São Paulo, Brazil. Within the frame of the initiative and under the supervision and leadership of the municipal health authorities, a situational analysis was conducted on the needs in hypertension management, marking the first phase of a Design Thinking process. This article describes the situational analysis process and presents the identified elements to be strengthened considering hypertension diagnosis, treatment and control. METHODS: First, a mixed-methods approach was used, starting with a literature review of municipal hypertension data followed by meetings (N = 20) with the local public health administration to assess health system level components. To investigate activities on hypertension diagnosis, treatment and control, nine primary healthcare units were selected from two districts of São Paulo city- Itaquera and Penha- which received an online form addressed to managers, participated in conversation circles of staff and patients, and underwent shadowing of community health agents. RESULTS: Data gave rise to two main outputs: (i) a patient care journey map; and (ii) a matrix summarizing the identified needs at patient, healthcare professional and health system level for diagnosis, treatment and control of hypertension. Patient awareness and knowledge of hypertension was found to be insufficient and its management needs to be improved. For health professionals, disease awareness, technical training, more time dedicated to patients, and simplified guidelines and clinical decision-making tools for hypertension management were identified as principal needs. The situational analysis found that the healthcare systems efficiency might be improved by establishing defined treatment and care delivery goals with a focus on outcomes and implemented through action plans. CONCLUSIONS: This situational analysis identified several needs related to hypertension control in São Paulo that are in line with global challenges to improve the control of CVD risk factors. Findings were also confirmed locally in an expansion phase of this situational analysis to additional primary care facilities. As a consequence, solutions were designed, promptly taken up and implemented by the municipal health secretariat.

An Intersectoral Approach to Hypertension Care: Solutions for Improving Blood Pressure Control in São Paulo, Brazil.

BACKGROUND: Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and a major public health issue worldwide. In Brazil, it affects approximately 52.5% of the adult population. We describe the solutions package and the impact of a population health initiative in São Paulo city, following the CARDIO4Cities approach for the management of cardiovascular risk. METHODS: Using a design thinking approach, interventions were developed with a coalition of local and international stakeholders to address needs of patients, healthcare professionals, and the health system. The resulting solution package was checked to comply with guidelines for non-communicable disease and hypertension management. Clinical impact was measured by extracting the hypertension cascade of care-monitored, diagnosis, treatment, and control-from medical records. RESULTS: Under the leadership of the municipal health authorities, nine solutions were piloted and scaled across the city. Solutions conform with local and international best-practices. Between October 2017 and December 2021, 11,406 patient records were analyzed. Results showed a 40% increase in monitored patients (patients with at least one blood pressure, BP, measurement); reduced proportions of patients diagnosed among those with available BP measurements (72%-53%) and treated among diagnosed (93%-85%); and an improvement in controlled patients among those receiving treatment (16%-27%). CONCLUSIONS: The solution package described in this study was correlated with increased BP control. The implementation methodology and results add to the body of real-world evidence supporting population health implementation science in Brazil and beyond.

Human leukocyte antigen-G 3' untranslated region polymorphisms are associated with asthma severity.

Asthma is a genetically complex chronic inflammatory airway disorder, and according to disease pathogenesis, clinical manifestations may vary according to asthma severity. A gene region close to the human leukocyte antigen-G (HLA-G) gene was identified as an independent susceptibility marker for asthma. Considering that the HLA-G immune checkpoint molecule may modulate inflammation, we evaluated the diversity of the HLA-G 3' untranslated region (3'UTR) in asthmatic patients stratified according to disease severity. We evaluate the entire HLA-G 3'UTR segment in 115 Brazilian patients stratified into mild (n=29), moderate (n=21) and severe asthmatics (n=65), and in 116 healthy individuals. HLA-G 3'UTR typing was performed using Sanger sequencing. The multiple comparisons among patients stratified according to disease severity revealed several associations; however, after Bonferroni's correction, the following results remained significant: i) the +3010C and +3142G alleles were overrepresented in mild asthma patients when compared to controls; ii) the +3010G and +3142C alleles were overrepresented in severe asthma patients in comparison to patients with mild asthma. In conclusion, the +3010C/G and +3142C/G HLA-G 3'UTR variation sites were differentially associated according to asthma severity.

Interleuquinas 2, 4, 6 y 10 en pacientes con artritis reumatoidea / Interleukins 2, 4, 6 and 10 in patients with rheumatoid arthritis

Las citoquinas juegan un rol primordial en la patogenia de la lesión articular de la artritis reumatoidea (AR). Esto puede verse reflejado en variaciones de sus concentraciones en sangre periférica. Se dosaron los niveles de IL-2, IL-4, IL-6 e IL-10 en el suero de 26 pacientes con AR y compromiso poliarticular, edad media de 50,2 años, tiempo medio de evolución 5,5 años y media de velocidad de sedimentación globular (VSG) 34,6 mm/h y se compararon con los de una población normal pareada por edad y sexo. La concentración media de IL-6 en los pacientes fue de 30,2 ñ 32,3 pg/ml y en controles de 1,3 ñ 1,4 pg/ml, siendo ésta diferencia altamente significativa (p < 0,001). La concentración media de IL-10 en AR fue de 2,2 ñ 2,7 pg/ml y en controles de 0,4 ñ 1,0 pg/ml (p < 0,01). No se hallaron diferencias en las concentraciones séricas de IL-2 e IL-4 entre los pacientes y los controles (p > 0,1). Los pacientes con VSG > 20 mm/hora presentaron también valores más elevados de IL-6 e IL-10 que los de VSG < 20 mm/hora (p < 0,05). También se encontró una correlación positiva estadísticamente significativa entre las concentraciones de IL-6 e IL-10 (r = 0,457; p < 0,05). Si bien la amplia dispersión en las concentraciones de las citoquinas estudiadas y el elevado costo de reactivos no las caracteriza como parámetros aptos para definir inflamación, la importancia futura de su detección probablemente radique en el monitoreo de los pacientes sometidos a las nuevas estrategias terapéuticas destinadas a reducir los efectos de las citoquinas proinflamatorias

Interleuquinas 2, 4, 6 y 10 en pacientes con artritis reumatoidea / Interleukins 2, 4, 6 and 10 in patients with rheumatoid arthritis

Las citoquinas juegan un rol primordial en la patogenia de la lesión articular de la artritis reumatoidea (AR). Esto puede verse reflejado en variaciones de sus concentraciones en sangre periférica. Se dosaron los niveles de IL-2, IL-4, IL-6 e IL-10 en el suero de 26 pacientes con AR y compromiso poliarticular, edad media de 50,2 años, tiempo medio de evolución 5,5 años y media de velocidad de sedimentación globular (VSG) 34,6 mm/h y se compararon con los de una población normal pareada por edad y sexo. La concentración media de IL-6 en los pacientes fue de 30,2 ñ 32,3 pg/ml y en controles de 1,3 ñ 1,4 pg/ml, siendo ésta diferencia altamente significativa (p < 0,001). La concentración media de IL-10 en AR fue de 2,2 ñ 2,7 pg/ml y en controles de 0,4 ñ 1,0 pg/ml (p < 0,01). No se hallaron diferencias en las concentraciones séricas de IL-2 e IL-4 entre los pacientes y los controles (p > 0,1). Los pacientes con VSG > 20 mm/hora presentaron también valores más elevados de IL-6 e IL-10 que los de VSG < 20 mm/hora (p < 0,05). También se encontró una correlación positiva estadísticamente significativa entre las concentraciones de IL-6 e IL-10 (r = 0,457; p < 0,05). Si bien la amplia dispersión en las concentraciones de las citoquinas estudiadas y el elevado costo de reactivos no las caracteriza como parámetros aptos para definir inflamación, la importancia futura de su detección probablemente radique en el monitoreo de los pacientes sometidos a las nuevas estrategias terapéuticas destinadas a reducir los efectos de las citoquinas proinflamatorias (AU)