Improving pharmaceutical practice in diabetes care using point-of-care glycated haemoglobin testing in the community pharmacy.

OBJECTIVES: To evaluate the use of point-of-care testing to detect new cases of diabetes mellitus at a Brazilian public community pharmacy. METHODS: This cross-sectional study included individuals without a previous diagnosis of diabetes mellitus who met the criteria for screening according to the Brazilian Diabetes Society, which were identified during their presence at a Brazilian public community pharmacy. The measurements of HbA1c were performed using a Cobas b101 device (Roche Diagnostics) and were categorized according to the following classification established by the Brazilian Society of Diabetes: HbA1c <5.7%, normal; HbA1c between 5.7% and 6.4%, pre-diabetes; and HbA1c >6.4%, new diagnosis of T2DM. KEY FINDINGS: One hundred and eight users met the inclusion criteria. The patients' mean age was 54.4 (± 15.4) years old, ranging from 22 to 80 years old. Eighty (74.1%) participants presented with glycated haemoglobin levels over the standard threshold, of which 58 (72.5%) were in the pre-diabetes range (glycated haemoglobin levels between 5.7% and 6.4%), and 22 (27.5%) had glycated haemoglobin levels >6.4%, which corresponds to a new diagnosis of type 2 diabetes mellitus. CONCLUSIONS: The use of point-of-care glycated haemoglobin testing allowed community pharmacists at a Brazilian public community pharmacy to identify health system users with glycated haemoglobin alterations that corresponded to the pre-diabetes state or a new diagnosis of type 2 diabetes mellitus. This presented a good opportunity to refer these users to diabetes diagnosis and treatment services.

Hospitalizations in Brazil according to National Health Survey estimates, 2013 and 2019.

OBJECTIVE: To compare the profile and prevalence of hospitalizations in Brazil based on estimates from the National Health Survey (PNS), 2013 and 2019. METHODS: A cross-sectional study that used data from the 2013 PNS and the 2019 PNS. The outcome was having been hospitalized for 24 hours or more in the last 12 months. We calculated the proportion of the population in different categories of age group, presence or absence of chronic diseases, and perception of health status. We estimated the total number of hospitalizations and the proportion corresponding to each category of age group, chronic disease, and perceived health status. We calculated the prevalence of hospitalization according to geographic, socioeconomic, and health conditions. We compared the estimates of two editions of the PNS using Student's t-test for independent samples. We considered significant differences when the p-value was less than 0.01. And finally, we compared hospitalization estimates with administrative data to assess data consistency. RESULTS: We observed that the proportion of chronically ill people in the population increased from 15.04% to 31.48%. This group was responsible for 36.76% of the total number of hospitalizations in 2013 and 57.61% in 2019. The prevalence of hospitalizations increased significantly between the two surveys and the increases were higher in the Southeast region and among people who have private health insurance. A discrepancy was found between administrative data and survey estimates. Obstetric hospitalizations and health insurance hospitalizations were underestimated. CONCLUSION: There was an increase in overall hospitalization rates in the period between the PNS 2013 and PNS 2019, especially among people with better access to health services. The hospitalization profile also changed-in the 2013 PNS, hospitalizations of people without chronic diseases predominated. This was reversed in PNS 2019.

Factors associated with the quality of death certification in Brazilian municipalities: A data-driven non-linear model.

Studies evaluating the local quality of death certification in Brazil focused on completeness of death reporting or inappropriate coding of causes of death, with few investigating missing data. We aimed to use missing and unexpected values in core topics to assess the quality of death certification in Brazilian municipalities, to evaluate its correlation with the percentage of garbage codes, and to employ a data-driven approach with non-linear models to investigate the association of the socioeconomic and health infrastructure context with quality of death statistics among municipalities. This retrospective study used data from the Mortality Information System (2010-2017), and municipal data regarding healthcare infrastructure, socioeconomic characteristics, and death rates. Quality of death certification was assessed by missing or unexpected values in the following core topics: dates of occurrence, registration, and birth, place of occurrence, certifier, sex, and marital status. Models were fit to classify municipalities according to the quality of death certification (poor quality defined as death records with missing or unexpected values in core topics ≥ 80%). Municipalities with poor quality of death certification (43.9%) presented larger populations, lower death rates, lower socioeconomic index, healthcare infrastructure with fewer beds and physicians, and higher proportion of public healthcare facilities. The correlation coefficients between quality of death certification assessed by missing or unexpected values and the proportion of garbage codes were weak (0.11-0.49), but stronger for municipalities with lower socioeconomic scores. The model that best fitted the data was the random forest classifier (ROC AUC = 0.76; precision-recall AUC = 0.78). This innovative way of assessing the quality of death certification could help quality improvement initiatives to include the correctness of essential fields, in addition to garbage coding or completeness of records, especially in municipalities with lower socioeconomic status where garbage coding and the correctness of core topics appear to be related issues.

Hospitalizations in Brazil according to National Health Survey estimates, 2013 and 2019 / Hospitalizações no Brasil pelas estimativas da Pesquisa Nacional de Saúde, 2013 e 2019

ABSTRACT OBJECTIVE To compare the profile and prevalence of hospitalizations in Brazil based on estimates from the National Health Survey (PNS), 2013 and 2019. METHODS A cross-sectional study that used data from the 2013 PNS and the 2019 PNS. The outcome was having been hospitalized for 24 hours or more in the last 12 months. We calculated the proportion of the population in different categories of age group, presence or absence of chronic diseases, and perception of health status. We estimated the total number of hospitalizations and the proportion corresponding to each category of age group, chronic disease, and perceived health status. We calculated the prevalence of hospitalization according to geographic, socioeconomic, and health conditions. We compared the estimates of two editions of the PNS using Student's t-test for independent samples. We considered significant differences when the p-value was less than 0.01. And finally, we compared hospitalization estimates with administrative data to assess data consistency. RESULTS We observed that the proportion of chronically ill people in the population increased from 15.04% to 31.48%. This group was responsible for 36.76% of the total number of hospitalizations in 2013 and 57.61% in 2019. The prevalence of hospitalizations increased significantly between the two surveys and the increases were higher in the Southeast region and among people who have private health insurance. A discrepancy was found between administrative data and survey estimates. Obstetric hospitalizations and health insurance hospitalizations were underestimated. CONCLUSION There was an increase in overall hospitalization rates in the period between the PNS 2013 and PNS 2019, especially among people with better access to health services. The hospitalization profile also changed—in the 2013 PNS, hospitalizations of people without chronic diseases predominated. This was reversed in PNS 2019.

RESUMO OBJETIVO Comparar o perfil e a prevalência das hospitalizações no Brasil com base nas estimativas da Pesquisa Nacional de Saúde (PNS), 2013 e 2019. MÉTODOS Estudo transversal seriado que utilizou os dados das PNS 2013 e PNS 2019. O desfecho foi ter ficado internado por 24 horas ou mais nos últimos 12 meses. Calculamos a proporção da população nas diversas categorias de faixa etária, de presença ou ausência de doenças crônicas e de percepção do estado de saúde. Estimamos o número total de hospitalizações e a proporção correspondente a cada categoria de faixa etária, de doença crônica e de percepção do estado de saúde. Calculamos a prevalência de internação segundo fatores geográficos, socioeconômicos e condições de saúde. Comparamos as estimativas das duas edições da PNS utilizando o teste t de Student para amostras independentes. Consideramos as diferenças significativas quando o valor de p foi menor que 0,01. E finalmente comparamos as estimativas de hospitalização com os dados administrativos para avaliar a consistência dos dados. RESULTADOS Observamos que a proporção de doentes crônicos na população passou de 15,04% para 31,48%. Este grupo foi responsável por 36,76% do total de internações em 2013 e de 57,61% em 2019. A prevalência de hospitalizações aumentou significativamente entre os dois inquéritos e os incrementos foram maiores na região Sudeste e entre pessoas que possuem plano de saúde privado. Foi encontrada uma discrepância entre os dados administrativos e as estimativas dos inquéritos. As internações obstétricas e as internações por plano de saúde foram subestimadas. CONCLUSÃO Houve um aumento nas taxas globais de hospitalização no período compreendido entre as PNS 2013 e 2019, especialmente entre as pessoas com melhor acesso aos serviços de saúde. O perfil de hospitalização também mudou - na PNS 2013 predominaram internações de pessoas sem doenças crônicas. Isto se inverteu na PNS 2019.

Predição de choque séptico e hipovolêmico em pacientes de unidade de terapia intensiva com o uso de machine learning / Prediction of septic and hypovolemic shock in intensive care unit patients using machine learning

RESUMO Objetivo: Criar e validar um modelo de predição de choque séptico ou hipovolêmico a partir de variáveis de fácil obtenção coletadas na admissão de pacientes internados em uma unidade de terapia intensiva. Métodos: Estudo de modelagem preditiva com dados de coorte concorrente realizada em um hospital do interior do nordeste brasileiro. Foram incluídos pacientes com 18 anos ou mais sem uso de droga vasoativa no dia da admissão e que foram internados entre novembro de 2020 e julho de 2021. Foram testados os algoritmos de classificação do tipo Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost para a construção do modelo. O método de validação utilizado foi o k-fold cross validation. As métricas de avaliação utilizadas foram recall, precisão e área sob a curva Receiver Operating Characteristic. Resultados: Foram utilizados 720 pacientes para criação e validação do modelo. Os modelos apresentaram alta capacidade preditiva com área sob a curva Receiver Operating Characteristic de 0,979; 0,999; 0,980; 0,998 e 1,00 para os algoritmos de Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost, respectivamente. Conclusão: O modelo preditivo criado e validado apresentou elevada capacidade de predição do choque séptico e hipovolêmico desde o momento da admissão de pacientes na unidade de terapia intensiva.

ABSTRACT Objective: To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit. Methods: A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve. Results: A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively. Conclusion: The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.

Retrospective Analysis of the SARS-CoV-2 Infection Profile in COVID-19 Positive Patients in Vitoria da Conquista, Northeast Brazil.

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is responsible for causing Coronavirus Disease-2019 (COVID-19), a heterogeneous clinical condition that manifests varying symptom severity according to the demographic profile of the studied population. While many studies have focused on the spread of COVID-19 in large urban centers in Brazil, few have evaluated medium or small cities in the Northeast region. The aims of this study were: (i) to identify risk factors for mortality from SARS-CoV-2 infection, (ii) to evaluate the gene expression patterns of key immune response pathways using nasopharyngeal swabs of COVID-19 patients, and (iii) to identify the circulating SARS-CoV-2 variants in the residents of a medium-sized city in Northeast Brazil. A total of 783 patients infected with SARS-CoV-2 between May 2020 and August 2021 were included in this study. Clinical-epidemiological data from patients who died and those who survived were compared. Patients were also retrospectively divided into three groups based on disease severity: asymptomatic, mild, and moderate/severe. Samples were added to a qPCR array for analyses of 84 genes involved with immune response pathways and sequenced using the Oxford Nanopore MinION technology. Having pre-existing comorbidity; being male; having cardiovascular disease, diabetes, and/or chronic obstructive pulmonary disease; and PCR cycle threshold (Ct) values under 22 were identified as risk factors for mortality. Analysis of the expression profiles of inflammatory pathway genes showed that the greater the infection severity, the greater the activation of inflammatory pathways, triggering the cytokine storm and downregulating anti-inflammatory pathways. Viral genome analysis revealed the circulation of multiple lineages, such as B.1, B.1.1.28, Alpha, and Gamma, suggesting that multiple introduction events had occurred over time. This study's findings help identify the specific strains and increase our understanding of the true state of local health. In addition, our data demonstrate that epidemiological and genomic surveillance together can help formulate public health strategies to guide governmental actions.

Self-Care in Patients with Non-Optimal Diabetes Management in Brazilian Rural Areas: A Mixed-Methods Study.

Purpose: This study aims to assess self-care in patients with non-optimal diabetes management (HbA1c >7.0% for adults and >8.0 for those aged 60 or over) and the positive and negative experiences associated with it in the rural communities of a Brazilian municipality. Patient and Methods: This is a cross-sectional mixed-methods study. The data were collected from participants with high HbA1c through focus group discussions, subsequently performing thematic analysis, and through structured questionnaires (socioeconomic characteristics and the Summary of Diabetes Self-Care Activities (SDSCA)). Results: The mean HbA1c of the 156 study participants was 9.94% (95% confidence interval: 9.70-10.19%) and most participants (86.54%) had negative self-care behaviors, with an overall SDSCA mean score of 3.55. This mean was not positive for any of the socioeconomic characteristics. The self-care activities with the most satisfactory performance concerned non-smoking and the use of prescribed medications, and the poorest results were observed for the practice of specific physical activities. The qualitative data indicated that the study participants face many difficulties regarding self-care practices, especially those related to an adequate diet. Conclusion: The self-care assessment revealed unsatisfactory self-care behaviors as well as high HbA1c levels among the study participants and highlighted the various difficulties they encounter. This indicates the need for more attentive health teams to monitor patients, especially regarding actions focused on the non-pharmacological elements of self-care, such as lifestyle changes, which were found to be the dimensions with the most unsatisfactory results.

Physicians' and nurses' perspective on chronic disease care practices in Primary Health Care in Brazil: a qualitative study.

BACKGROUND: Primary health care-oriented systems provide better healthcare, especially for chronic diseases. This study analyzed the perspectives of physicians and nurses performing care for patients with chronic diseases in Primary Health Care in a Brazilian city. METHODS: A qualitative study was conducted in Vitória da Conquista, Bahia, Brazil, using semi-structured interviews with five physicians and 18 nurses. The interview included questions from an analytical matrix based on three dimensions of healthcare practices: organizational, technical care, and biopsychosocial, following a deductive approach. The interviews were fully transcribed and analyzed using a thematic categorical approach. RESULTS: The results indicated that the provision of chronic care occurs in a comprehensive way. Potentialities were identified in the diversification of access, offer of care actions and technologies, integration of teamwork, and bringing together social networks to foster autonomy and self-care. Weaknesses were mostly related to the high number of people in the teams, follow-up of several cases, high turnover of support teams, low integration of Primary Health Care with other levels, difficulties in intersectoral articulation and family participation in care. CONCLUSION: The multidimensional assessment of health care practices aimed at individuals with chronic noncommunicable diseases was useful to portray the strengths and weaknesses of the services. It also ratifies the need to consider the importance of and investment in primary health care by offering the necessary technical, political, logistical and financial support to the units, to ensure the sustainability of the actions by nurses, doctors and entire team.

Prediction of septic and hypovolemic shock in intensive care unit patients using machine learning. / Predição de choque séptico e hipovolêmico em pacientes de unidade de terapia intensiva com o uso de machine learning.

OBJECTIVE: To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit. METHODS: A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve. RESULTS: A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively. CONCLUSION: The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.

OBJETIVO: Criar e validar um modelo de predição de choque séptico ou hipovolêmico a partir de variáveis de fácil obtenção coletadas na admissão de pacientes internados em uma unidade de terapia intensiva. MÉTODOS: Estudo de modelagem preditiva com dados de coorte concorrente realizada em um hospital do interior do nordeste brasileiro. Foram incluídos pacientes com 18 anos ou mais sem uso de droga vasoativa no dia da admissão e que foram internados entre novembro de 2020 e julho de 2021. Foram testados os algoritmos de classificação do tipo Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost para a construção do modelo. O método de validação utilizado foi o k-fold cross validation. As métricas de avaliação utilizadas foram recall, precisão e área sob a curva Receiver Operating Characteristic. RESULTADOS: Foram utilizados 720 pacientes para criação e validação do modelo. Os modelos apresentaram alta capacidade preditiva com área sob a curva Receiver Operating Characteristic de 0,979; 0,999; 0,980; 0,998 e 1,00 para os algoritmos de Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost, respectivamente. CONCLUSÃO: O modelo preditivo criado e validado apresentou elevada capacidade de predição do choque séptico e hipovolêmico desde o momento da admissão de pacientes na unidade de terapia intensiva.

Industry workers with hypertension and diabetes mellitus, the prevalence of self-reported adherence, and disease control

Abstract To evaluate the prevalence of self-reported drug adherence and factors associated, as well as clinical health outcomes, for industry workers with hypertension (HTN) and diabetes mellitus (DM). This was a cross-sectional study of 137 Brazilian industry workers with HTN and/ or DM. Self-reported adherence was assessed, and the disease control was defined through blood pressure and capillary glycemia values. Data were descriptively analyzed and the factors associated with adherence were evaluated using the Poisson model with robust variance to calculate prevalence ratios. The prevalence of self-reported drug adherence was 79.6% and the prevalence of disease control was 53.8%. There was no statistically significant association between the two variables. In the controlled disease group, non-adherence was associated with being under 40 years of age, not having a partner, and having a risky alcohol consumption habit. In the uncontrolled disease group, adherence was highest for participants aged 40 years and older. The prevalence of self-reported drug adherence was high, but the prevalence of disease control was low and not associated with adherence, indicating that the self-reported adherence measure may be inaccurate. Our findings identify some factors that explain non-adherent behavior in the workforce.

Improving Access to the Glycated Hemoglobin Test in Rural Communities With Point-of-Care Devices: An Application Study.

Background: Living in a rural or remote area is frequently associated with impaired access to health services, which directly affects the possibility of early diagnosis and appropriate monitoring of diseases, mainly non-communicable ones, because of their asymptomatic onset and evolution. Point-of-care devices have emerged as useful technologies for improving access to several laboratory tests closely patients' beds or homes, which makes it possible to eliminate the distance barrier. Objective: To evaluate the application of point-of-care technology for glycated hemoglobin (HbA1c) estimation in the assessment of glycemic control and identification of new diagnoses of diabetes in primary care among rural communities in a Brazilian municipality. Materials and Methods: We included individuals aged 18 years or older among rural communities in a Brazilian municipality. From September 2019 to February 2020, participants were assessed for anthropometrics, blood pressure, and capillary glycemia during routine primary care team activities at health fairs and in patient groups. Participants previously diagnosed with diabetes but without recent HbA1c test results or those without a previous diagnosis but with random capillary glycemia higher than 140 mg/dL were considered positive and were tested for HbA1c by using a point-of-care device. Results: At the end of the study, 913 individuals were accessed. Of these, 600 (65.7%) had no previous diagnosis of diabetes, 58/600 (9.7%) refused capillary glycemia screening and 542/600 (90.7%) were tested. Among tested individuals, 73/542 (13.5%) cases without a previous diagnosis of diabetes, were positive for capillary glycemia. Among positives, 31/73 (42.5%) had HbA1c levels that were considered indicative of prediabetes and 16/73 (21.9%) were newly diagnosed with diabetes. Among the participants, 313/913 (34.3%) were previously diagnosed with diabetes. Recent HbA1c results were unavailable for 210/313 (67.1%). These individuals were tested using point-of-care devices. Among them, 143/210 (68.1%) had HbA1c levels higher than target levels (>7% and >8% for adults and elderly individuals, respectively. Conclusion: The application of point-of-care devices for HbA1c level measurement improved the access to this test for people living in rural or remote areas. Thus, it was possible to include this technology in the routine activities of primary health care teams, which increased the rates of new diagnoses and identification of patients with uncontrolled glycemia.

[Periodic occupational examination: an opportunity for diagnosis and monitoring of chronic noncommunicable diseases in men]. / Exame ocupacional periódico: oportunidade de diagnóstico e monitoramento de doença crônica não transmissível em homens.

The study aimed to estimate the prevalence of arterial hypertension as the principal marker of chronic noncommunicable diseases (NCDs) and to identify associated modifiable factors in male workers. Baseline data were used from a longitudinal study with a sample of 1,024 male workers 18 years or older in a municipality in Northeast Brazil. The marker for NCDs was arterial hypertension, defined as systolic pressure ≥ 140mmHg and/or diastolic pressure ≥ 90mmHg and/or prior diagnosis of arterial hypertension and/or use of antihypertensive medication. Poisson regression with robust variance was used, adopting hierarchical entry of variables. Population attributable fractions (PAFs) were calculated for the lifestyle variables to measure the impact of modifiable factors on workers' health. Prevalence of hypertension was 28.6% (95%CI: 25.9-31.5). Distal factors associated with hypertension were age > 40 years, black skin color, and family income ≥ 3 times the monthly minimum wage. Intermediate factors were alcohol abuse, smoking, high self-rated salt intake, and physical inactivity. Proximal factors were overweight and obesity. Calculation of PAFs showed that a reduction or elimination of unhealthy lifestyle habits and behaviors in this population group would reduce the prevalence of the target NCD, hypertension, by 56.1%. The identification of modifiable factors and the ways they can negatively impact male workers' health allows planning interventions in the workplace itself to reach the largest number of individuals, aimed at reducing the harmful effects of NCDs.

Objetivou-se estimar a prevalência de hipertensão arterial, como principal marcador de doença crônica não transmissível (DCNT), e identificar os fatores modificáveis associados, em trabalhadores homens. Foram utilizados dados da linha de base de um estudo longitudinal com uma amostra de 1.024 trabalhadores homens com 18 anos ou mais de um município do Nordeste do Brasil. O marcador de DCNT foi a hipertensão arterial, definida por pressão arterial sistólica ≥ 140mmHg e/ou pressão arterial diastólica ≥ 90mmHg e/ou diagnóstico prévio de hipertensão arterial e/ou uso de medicamentos anti-hipertensivos. Empregou-se a regressão de Poisson com variância robusta, adotando a entrada hierárquica de variáveis. Foram calculadas frações atribuíveis populacionais (FAP) para as variáveis de estilo de vida, a fim de dimensionar o impacto dos fatores modificáveis na saúde dos trabalhadores. A prevalência da hipertensão arterial nesta população foi de 28,6% (IC95%: 25,9-31,5), os fatores distais: idade > 40 anos, cor da pele preta e renda familiar ≥ 3 salários mínimos; fatores intermediários: consumo abusivo de álcool, consumo de tabaco, percepção de um consumo elevado de sal e inatividade física e o fator proximal: sobrepeso e obesidade associaram-se positivamente com a hipertensão arterial. O cálculo da FAP permitiu observar que se ocorresse a redução ou eliminação de hábitos e comportamentos relacionados ao estilo de vida deste público, reduziria em 56,1% a prevalência da DCNT estudada. A identificação de fatores modificáveis e como estes podem interferir negativamente na saúde de trabalhadores homens possibilita o planejamento de intervenções no próprio local de trabalho, a fim de alcançar o maior número de indivíduos, visando reduzir os efeitos deletérios das DCNT.

El objetivo fue estimar la prevalencia de hipertensão arterial, como principal marcador de enfermedad crónica no transmisible (ECNT), así como identificar factores modificables asociados, en hombres trabajadores. Se utilizaron datos de la línea de base, procedentes de un estudio longitudinal, con una muestra de 1.024 hombres trabajadores con 18 años o más de un municipio del Nordeste de Brasil. El marcador de ECNT fue la hipertensão arterial, definida por presión arterial sistólica ≥ 140mmHg y/o presión arterial diastólica ≥ 90mmHg y/o diagnóstico previo de hipertensão arterial y/o uso de medicamentos antihipertensivos. Se empleó la regresión de Poisson con varianza robusta, adoptando la entrada jerárquica de variables. Se calcularon fracciones atribuibles poblacionales (FAP) en las variables de estilo de vida, a fin de dimensionar el impacto de los factores modificables en la salud de los trabajadores. La prevalencia de la hipertensão arterial en esta población fue de 28,6% (IC95%: 25,9-31,5), los factores distales: edad > 40 años, color de piel negra y renta familiar ≥ 3 salarios mínimos; factores intermedios: consumo abusivo de alcohol, consumo de tabaco, percepción de un consumo elevado de sal e inactividad física y el factor proximal: sobrepeso y obesidad se asociaron positivamente con la hipertensão arterial. El cálculo de la FAP permitió observar que, si se produjese una reducción o eliminación de hábitos y comportamientos relacionados con el estilo de vida de este público, se reduciría en un 56,1% la prevalencia de la ECNT estudiada. La identificación de factores modificables y cómo pueden interferir negativamente en la salud de hombres trabajadores posibilita la planificación de intervenciones en el propio lugar de trabajo, con el fin de alcanzar al mayor número de individuos para reducir los efectos mortíferos de las ECNT.

Cost-Effectiveness Analysis of Evolocumab Therapy in Patients at High Risk of Cardiovascular Events in the Context of the Brazilian Unified Health System. / Análise de Custo-Efetividade da Terapia com Evolocumabe em Pacientes com Alto Risco de Eventos Cardiovasculares no Contexto do SUS ­ Brasil.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. OBJECTIVES: We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. METHODS: Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. RESULTS: Mean LV ejection fraction was not different between the groups. The E/e' ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, ß 2.79, p=0.027). CONCLUSIONS: LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

FUNDAMENTO: Em associação às estatinas, os inibidores da pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9) demonstraram ser eficazes na redução de eventos cardiovasculares em pacientes de alto risco. OBJETIVO: Analisar a custo-efetividade da implementação de evolocumabe para pacientes com alto risco de eventos cardiovasculares no contexto do Sistema Único de Saúde (SUS) no Brasil. MÉTODOS: Um modelo de Markov foi utilizado, baseando-se em uma amostra ambulatorial de pacientes com doença arterial coronariana. Os desfechos primários analisados foram infarto agudo do miocárdio, acidente vascular cerebral isquêmico (AVCi), revascularização do miocárdio e morte cardiovascular. O resultado foi expresso por meio da razão de custo-efetividade incremental (RCEI), considerando-se uma taxa de desconto de 5% ao ano, e uma análise de sensibilidade foi realizada, tendo em vista a imprecisão de valores. RESULTADOS: Selecionaram-se 61 pacientes com risco cardiovascular estimado em 35% em 10 anos, se em uso de atorvastatina 80mg/dia, e em 22,75%, se adicionado o evolocumabe. O custo global por paciente no período de 10 anos foi de R$ 46.522,44 no grupo em monoterapia com atorvastatina versus R$ 236.141,85 na terapia combinada, com uma efetividade global de 0,54 e 0,73, respectivamente. Isso resultou em uma RCEI R$ 1.011.188,07 (R$ 864.498,95 a R$ 1.296.748,43) por desfecho cardiovascular evitado. CONCLUSÕES: Apesar de não existirem padrões nacionais para custo-efetividade, os dados encontrados sugerem que a estratégia de associação do evolocumabe à terapia com estatina não é, no momento, custo-efetiva.

Análise de Custo-Efetividade da Terapia com Evolocumabe em Pacientes com Alto Risco de Eventos Cardiovasculares no Contexto do SUS - Brasil / Cost-Effectiveness Analysis of Evolocumab Therapy in Patients at High Risk of Cardiovascular Events in the Context of the Brazilian Unified Health System

Resumo Fundamento: Em associação às estatinas, os inibidores da pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9) demonstraram ser eficazes na redução de eventos cardiovasculares em pacientes de alto risco. Objetivo: Analisar a custo-efetividade da implementação de evolocumabe para pacientes com alto risco de eventos cardiovasculares no contexto do Sistema Único de Saúde (SUS) no Brasil. Métodos: Um modelo de Markov foi utilizado, baseando-se em uma amostra ambulatorial de pacientes com doença arterial coronariana. Os desfechos primários analisados foram infarto agudo do miocárdio, acidente vascular cerebral isquêmico (AVCi), revascularização do miocárdio e morte cardiovascular. O resultado foi expresso por meio da razão de custo-efetividade incremental (RCEI), considerando-se uma taxa de desconto de 5% ao ano, e uma análise de sensibilidade foi realizada, tendo em vista a imprecisão de valores. Resultados: Selecionaram-se 61 pacientes com risco cardiovascular estimado em 35% em 10 anos, se em uso de atorvastatina 80mg/dia, e em 22,75%, se adicionado o evolocumabe. O custo global por paciente no período de 10 anos foi de R$ 46.522,44 no grupo em monoterapia com atorvastatina versus R$ 236.141,85 na terapia combinada, com uma efetividade global de 0,54 e 0,73, respectivamente. Isso resultou em uma RCEI R$ 1.011.188,07 (R$ 864.498,95 a R$ 1.296.748,43) por desfecho cardiovascular evitado. Conclusões: Apesar de não existirem padrões nacionais para custo-efetividade, os dados encontrados sugerem que a estratégia de associação do evolocumabe à terapia com estatina não é, no momento, custo-efetiva.

Abstract Background: Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. Objectives: We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. Methods: Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. Results: Mean LV ejection fraction was not different between the groups. The E/e' ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, β 2.79, p=0.027). Conclusions: LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

Evaluation of blood pressure through home monitoring in brazilian primary care: a feasibility study.

Blood pressure measurements taken in a clinical setting are subject to errors, therefore there are advantages to monitoring blood pressure at home, especially in in patients diagnosed with hypertension. The study describes the feasibility of home monitoring to assess blood pressure in primary care and compares blood pressure measured at home and during a medical consultation. This cross-sectional study was carried out with patients whose used home blood pressure in the morning and evening, thrice for seven consecutive day sat home. Participants included patients older than 18 years with suspected whitecoat hypertension, taking antihypertensives, or those intolerant of ambulatory blood pressure monitoring, and excluded patients who did not follow the protocol, suffered from an irregular heart rate, and pregnant women. Of the 134 patients who participated in the study, 63.3% had altered blood pressure when measured at health facilities and 48% had higher blood pressure at home. The mean difference between the methods was 10.1 mmHg for systolic and 4.3 mmHg for diastolic. The prevalence of whitecoat hypertension was 19.4%. Blood pressure monitoring at home is a practicable strategy in the Brazilian healthcare system.

Comparison of cardiovascular risk calculators in patients with diabetes.

OBJECTIVE: Cardiovascular risk stratification is an important clinical practice to estimate the severity of cardiovascular disease in patients with type 2 diabetes. This study aimed to compare the stratification of global cardiovascular risk with the specific risk stratification for patients with type 2 diabetes, seen at specialized outpatient clinics, and to evaluate possible differences in diagnoses and treatments. METHODS: A total of 122 patients with type 2 diabetes treated at two specialized outpatient clinics, from 2017 to 2019, were studied. The cardiovascular risk stratification calculators, global risk score, Cardiovascular Risk Stratification Calculator, and United Kingdom Prospective Diabetes Study-Risk Engine, were used to calculate the risk of death from cardiovascular disease. The agreement between these calculators was analyzed using the kappa index. The indications for the use of statins and acetylsalicylic acid for the group studied were evaluated according to the Brazilian Diabetes Society Guideline. RESULTS: There was a low degree of agreement among the three risk calculators. The global risk score calculator showed insignificant agreement with the Cardiovascular Risk Stratification Calculator (kappa=0.0816; p=0.0671). There was no agreement between the global risk score calculator and United Kingdom Prospective Diabetes Study-Risk Engine (kappa=-0.099), or between the Cardiovascular Risk Stratification Calculator and United Kingdom Prospective Diabetes Study-Risk Engine (kappa=-0.0095). CONCLUSION: The substantial disagreements among the cardiovascular risk calculators may lead to different diagnoses and may consequently influence therapeutic strategies. The findings herein highlight the need for specific validated cardiovascular risk calculators for patients with DM2 that can reliably estimate risk in these individuals.

Evaluation of blood pressure through home monitoring in brazilian primary care: a feasibility study / Avaliação da pressão arterial através da monitorização residencial na atenção básica brasileira: um estudo de viabilidade

Abstract Blood pressure measurements taken in a clinical setting are subject to errors, therefore there are advantages to monitoring blood pressure at home, especially in in patients diagnosed with hypertension. The study describes the feasibility of home monitoring to assess blood pressure in primary care and compares blood pressure measured at home and during a medical consultation. This cross-sectional study was carried out with patients whose used home blood pressure in the morning and evening, thrice for seven consecutive day sat home. Participants included patients older than 18 years with suspected whitecoat hypertension, taking antihypertensives, or those intolerant of ambulatory blood pressure monitoring, and excluded patients who did not follow the protocol, suffered from an irregular heart rate, and pregnant women. Of the 134 patients who participated in the study, 63.3% had altered blood pressure when measured at health facilities and 48% had higher blood pressure at home. The mean difference between the methods was 10.1 mmHg for systolic and 4.3 mmHg for diastolic. The prevalence of whitecoat hypertension was 19.4%. Blood pressure monitoring at home is a practicable strategy in the Brazilian healthcare system.

Resumo A medição da pressão arterial no consultório está sujeita a erros; assim, a monitorização residencial da pressão arterial é utilizada para o monitoramento e diagnóstico da hipertensão. Descrever a viabilidade da monitorização residencial para avaliar a pressão arterial na atenção primária e comparar os valores da pressão arterial através da monitorização residencial e medida de consultório. Estudo transversal realizado com pacientes que utilizaram a monitorização residencial pela manhã e pela noite, em triplicata por sete dias consecutivos em domicílio. Foram incluídos pacientes maiores de 18 anos, com suspeita de hipertensão do avental branco, utilizando anti-hipertensivos ou intolerantes a monitorização ambulatorial. Foram excluídos pacientes que não seguiram o protocolo, aqueles que apresentavam ritmo cardíaco irregular ou mulheres grávidas. 134 pacientes participaram do estudo, 63,3% apresentaram pressão arterial alteradas em consultório e 48% pela monitorização residencial. A diferença média dos métodos foi de 10,1 mmHg para sistólica e 4,3 mmHg para diastólica. A prevalência de hipertensão do avental branco foi 19,4%. A monitorização residencial da pressão arterial no sistema de saúde brasileiro provou ser uma estratégia viável.

Gender Differences in the Quality of Life of Formal Workers.

BACKGROUND: This study aimed to assess the quality of life associated with gender inequalities in formal workers and to determine the effect of sociodemographic, clinical, and behavioral factors on the quality of life (QOL). METHODS: This cross-sectional study involved 1270 workers. Quality of life was measured using the EUROHIS-QOL 8-Item and assessed in terms of psychological, environmental, social, and physical domains, while demographic, socioeconomic, behavioral, and clinical variables served as explanatory variables. Analyses were performed using an ordinal logistic regression model whose significance level was 5%. RESULTS: Of the participants, 80.2% were men, and 19.8% were women; the mean age was 34 (standard deviation: ±10) and 32 (±9) years, respectively. In all prediction scenarios, men were more likely to have a higher quality of life, especially in the physical (odds ratio: 2.16; 95% confidence interval: 1.60-2.93) and psychological (odds ratio: 2.09; 95% confidence interval: 1.51-2.91) domains. CONCLUSIONS: Men and women had significantly different levels of quality of life, and sociodemographic, clinical, and behavioral variables partially clarified these differences, which were possibly established by a socio-historical process of construction of the work role determined by gender issues.

Community-Based Interventions to Improve the Control of Non-Communicable Diseases in Underserved Rural Areas in Brazil: A Before-and-After Study.

Background: Hypertension and diabetes mellitus are the second and third highest leading causes of disability-adjusted life-years (DALY), respectively, in Brazil. The clinical outcomes of chronic diseases are influenced by various factors. Therefore, there is a need for multifaceted interventions to achieve a decrease in the rate of DALY, with a better control of these diseases. Objective: To verify whether sustainable long-term interventions, such as health worker training and provision of health education to the patients, contribute to health improvements in patients with hypertension and diabetes from rural communities. Methods: Over a 6 month period, educational and medical interventions were provided to optimize the treatment of hypertension and diabetes. Furthermore, blood pressure and glycated hemoglobin (HbA1c) measurements were taken at baseline and after the interventions. Results: The monitored hypertensive patients (n = 276) had a reduction of 13.4 mmHg (p = 0.021) and 5.8 mmHg (p < 0.001) in mean systolic and diastolic blood pressure, respectively. Diabetic patients who were followed-up (n = 71) achieved a 0.55% (p = 0.185) reduction in HbA1c level. The desired blood pressure level (<140/90 mmHg) was achieved in 38.8% of patients with hypertension, whereas the desired level of HbA1c (<7.0% for adults and <8.0% for the elderly) was achieved in 16.9% of patients with diabetes; in addition, 38.0% had a reduction of HbA1c of at least 1%. Conclusion: The results showed that the interventions improved the blood pressure and HbA1c levels in patients with hypertension and diabetes from rural communities in a municipality in Northeast Brazil.

Práticas de cuidado para doenças não transmissíveis na Estratégia Saúde da Família / Prácticas de cuidado para enfermedades no transmisibles en la Estrategia Salud de la Familia / Care practices for non-communicable diseases in the Family Health Strategy

Objetivo: realizar uma reflexão crítica e analítica acerca das práticas de cuidado em saúde no Brasil voltadas para as doenças não transmissíveis no contexto da Estratégia Saúde da Família. Síntese do conteúdo: as reflexões sobre as práticas de cuidado revelaram importantes avanços materializados pela instituição de referências legais no âmbito políticonormativo e assistencial, refletindo em melhor controle das doenças crônicas por longo período. Contudo, o cenário de crise global impôs sérias restrições orçamentárias com implicações político-econômicas e técnico-assistenciais, constituindo, portanto, uma ameaça ao controle das doenças crônicas e um prejuízo para a qualidade de vida da população brasileira. Conclusões: maior sinergia de esforços entre distintos atores sociais será necessária para garantir a defesa da universalidade, a resolutividade, a equidade e a gratuidade das práticas de cuidado em saúde na Estratégia Saúde da Família com foco nas doenças crônicas.

Objetivo: realizar una reflexión crítica y analítica sobre las prácticas de atención en salud dirigidas a las enfermedades no transmisibles a partir del contexto de la Estrategia Salud de la Familia en Brasil. Síntesis de contenido: las reflexiones sobre las prácticas de cuidado revelaron importantes avances materializados por la institución de referencias legales en el ámbito político-normativo y asistencial, los cuales dan cuenta de un mejor control de las enfermedades crónicas durante un mayor período. No obstante, el escenario de crisis global impuso graves restricciones presupuestarias con implicaciones políticoeconómicas y de asistencia técnica, constituyendo una amenaza para el control de las enfermedades crónicas y un perjuicio para la calidad de vida de la población brasileña. Conclusiones: una mayor sinergia entre los diferentes actores sociales será necesaria para garantizar la defensa de la universalidad, resolución, equidad y las prácticas gratuitas de atención en salud promovidas por la Estrategia Salud de la Familia con enfoque en las enfermedades crónicas.

Objective: To provide a critical and analytical reflection on health care practices in Brazil aimed at non-communicable diseases in the context of the Family Health Strategy. Content synthesis: the reflections on the care practices revealed important advances materialized by the institution of legal references in the political-normative and assistance scope, reflecting in a better control of chronic diseases for a long period. However, the global crisis scenario imposed serious budgetary restrictions with political-economic and technical-assistance implications, thus constituting a threat to the control of chronic diseases and a detriment to the quality of life of the Brazilian population. Conclusions: Greater synergy between different social actors and their efforts will be necessary to guarantee the defense of universality, resolution, equity, and free health care practices in the Family Health Strategy with a focus on chronic diseases.