Inequalities in Pap smear screening for cervical cancer in Brazil.

OBJECTIVE: To examine the risk factors associated with never being screened for cervical cancer (CC) in Brazil. METHODS: Using the National Household Sample Survey 2008 (PNAD), we analyzed data from 102,108 Brazilian women ages 25-64years. The patients were analyzed as having been or never having been screened with a Pap smear (Yes/No). Age-adjusted prevalence of never-screening was analyzed using a Chi-squared test. Crude and adjusted models using Poisson regression were performed. RESULTS: The prevalence of never-screened women for CC was 12.9%, 11.5% and 22.2% in Brazil in general, urban and rural areas, respectively. The Brazilian region with the highest prevalence of never-screening was the North (17.4%, 14.7% and 27.3% in general, urban and rural areas, respectively). The factors associated with a higher risk for never being screened were the following: poverty, younger age, lower educational level, non-white skin color, a greater number of children, no supplemental health insurance and not having visited a doctor in the past 12months. CONCLUSION: Socioeconomic and demographic conditions lead to inequalities in access to Pap smear screening in Brazil. Public health policy addressing these risk groups is necessary.

Influence of implementation of a chest pain unit on acute coronary syndrome outcomes.

BACKGROUND: Different strategies have been described to increase promptness and efficiency in the assessment and management of patients with acute chest pain and acute coronary syndrome (ACS) in the emergency department (ED). OBJECTIVE: The objective of this study is to evaluate the results of implementing a Chest Pain Unit (CPU) to assist patients with ACS, and to determine its impact on quality of health care indexes and clinical outcomes. METHODS: A study was conducted with a prospective cohort of patients admitted to the ED with a chief complaint of acute chest pain or suspected ACS at two different time periods: before (n = 663) and after (n = 450) introducing a CPU as part of the ED. Quality-of-care indexes analyzed in this study were adherence to a critical pathway, length of hospital stay, and hospital mortality. RESULTS: There was increased adherence to a critical pathway during the CPU period compared to the period with no designated CPU area, including compliance with prescribing aspirin, beta-blockers, and angiotensin-converting enzyme inhibitor, and performing coronary angiography in high-risk patients. After adjustment to baseline characteristics, admissions to a CPU resulted in a 65% reduction in mortality (odds ratio 0.35; 95% confidence interval 0.14-0.88; p = 0.03). There was no difference in median length of hospital stay, 7 days (interquartile range [IQR] 4-12) before CPU and 6 days (IQR 4-11) after introducing the CPU (p = 0.10). CONCLUSION: In the scenario of a crowded ED, implementation of a CPU was associated with greater adherence to a critical pathway for patients with ACS, with a concomitant reduction in mortality rates.

Glomerular filtration rate measurement and prediction equations.

Chronic kidney disease (CKD) is defined as the presence of kidney damage or a glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) for three or more months. Measurement of serum creatinine is the most commonly used method to evaluated kidney function, but it must be included in formulas to estimate GFR, adjusting for age, gender and ethnicity, such as the Modification of Diet in Renal Disease (MDRD) study equation. The performance of this equation is acceptable for patients with CKD but appears to under-estimate GFR in populations with unknown kidney status. A new formula has been developed recently. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation appears to perform better than the MDRD equation. Cystatin C has been widely evaluated as a marker for GFR and seems to be more sensitive than creatinine. The aim of this review is to discuss the recommendations for detecting CKD, emphasizing the characteristics and limitations of GFR estimating equations and pitfalls in the evaluation of urinary albumin excretion.

Interleukin-18: an independent predictor of cardiovascular events in patients with acute coronary syndrome after 6 months of follow-up.

BACKGROUND: Interleukin-18 (IL-18), a proinflammatory cytokine, has been associated with atherogenesis and plaque rupture in acute coronary syndrome (ACS). Recent studies suggest that IL-18 may have a long-term prognostic value. The aim of this study was to evaluate the relationship between IL-18 levels and major adverse cardiovascular events within 6 months of follow-up in post-ACS patients. METHODS: One hundred and twelve consecutive patients admitted to a university hospital with ACS were included in the study. IL-18 and C-reactive protein were measured within the first 24 h of admission. Six months after hospital discharge, the incidence of major adverse cardiovascular events (cardiovascular death, new episode of ACS, and need for unplanned revascularization) was assessed. RESULTS: Mean age of patients was 64 +/- 11 years, and 58 (52%) were male. During the 6 months of follow-up, 33 patients (31.4%) experienced major adverse cardiovascular events. Median IL-18 serum levels were higher among patients who had events than among those who did not: 271.7 pg/ml (interquartile range: 172.9-389.6) and 139.7 pg/ml (interquartile range: 99.9-265.7), respectively (P < 0.01). In the Cox multivariate analysis, after adjustment for clinical risk factors and serum troponin, elevated levels of IL-18 were associated with higher incidence of events (hazard ratio: 2.5; 95% confidence interval: 1.14-5.52; P = 0.023). In this population, C-reactive protein was of borderline significance for events. CONCLUSION: Serum IL-18 levels in ACS patients were independent predictors of long-term cardiovascular events. These findings support the association between inflammation and prognosis of ACS patients, as well as the clinical impact of this biomarker.