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Eur J Epidemiol ; 34(9): 823-835, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31420761


When analyzing effect heterogeneity, the researcher commonly opts for stratification or a regression model with interactions. While these methods provide valuable insights, their usefulness can be somewhat limited, since they typically fail to take into account heterogeneity with respect to many dimensions simultaneously, or give rise to models with complex appearances. Based on the potential outcomes framework and through imputation of missing potential outcomes, our study proposes a method for analyzing heterogeneous effects by focusing on treatment effects rather than outcomes. The procedure is easy to implement and generates estimates that take into account heterogeneity with respect to all relevant dimensions at the same time. Results are easily interpreted and can additionally be represented by graphs, showing the overall magnitude and pattern of heterogeneity as well as how this relates to different factors. We illustrate the method both with simulations and by examining heterogeneous effects of obesity on HDL cholesterol in the Malmö Diet and Cancer cardiovascular cohort. Obesity was associated with reduced HDL in almost all individuals, but effects varied with smoking, risky alcohol consumption, higher education, and energy intake, with some indications of non-linear effects. Our approach can be applied by any epidemiologist who wants to assess the role and strength of heterogeneity with respect to a multitude of factors.

Epidemiologia/estatística & dados numéricos , Modelos Estatísticos , Projetos de Pesquisa/normas , Consumo de Bebidas Alcoólicas , HDL-Colesterol , Escolaridade , Ingestão de Energia , Humanos , Obesidade , Fumar
Public Health Rep ; 134(4): 379-385, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31161923


OBJECTIVES: To better understand the current status and challenges of the state public health department workforce, the Council of State and Territorial Epidemiologists (CSTE) assessed the number and functions of applied public health epidemiologists at state health departments in the United States. METHODS: In 2017, CSTE emailed unique online assessment links to state epidemiologists in the 50 states and the District of Columbia (N = 51). The response rate was 100%. CSTE analyzed quantitative data (27 questions) on funding, the number of current and needed epidemiologists, recruitment, retention, perceived capacity, and training. CSTE coded qualitative data in response to an open-ended question that asked about the most important problems state epidemiologists face. RESULTS: Most funding for epidemiologic activities came from the federal government (mean, 77%). State epidemiologists reported needing 1199 additional epidemiologists to achieve ideal capacity but noted challenges in recruiting qualified staff members. Respondents cited opportunities for promotion (n = 45, 88%), salary (n = 41, 80%), restrictions on merit raises (n = 36, 70%), and losses to the private or government sector (n = 33, 65%) as problems for retention. Of 4 Essential Public Health Services measured, most state epidemiologists reported substantial-to-full capacity to monitor health status (n = 43, 84%) and diagnose and investigate community health problems (n = 47, 92%); fewer respondents reported substantial-to-full capacity to conduct evaluations (n = 20, 39%) and research (n = 11, 22%). CONCLUSIONS: Reliance on federal funding negatively affects employee retention, core capacity, and readiness at state health departments. Creative solutions for providing stable funding, developing greater flexibility to respond to emerging threats, and enhancing capacity in evaluation and applied research are needed.

Fortalecimento Institucional/estatística & dados numéricos , Epidemiologistas/provisão & distribução , Epidemiologistas/estatística & dados numéricos , Epidemiologia/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Administração em Saúde Pública/estatística & dados numéricos , Recursos Humanos/estatística & dados numéricos , Adulto , District of Columbia , Humanos , Masculino , Pessoa de Meia-Idade , Governo Estadual , Estados Unidos
Public Health Rep ; 134(4): 386-394, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31211646


OBJECTIVES: The Council of State and Territorial Epidemiologists (CSTE) has periodically assessed the epidemiological capacity of states since 2001, but the data do not reflect the total US epidemiology capacity. CSTE partnered with the Big Cities Health Coalition (BCHC) in 2017 to assess epidemiology capacity in large urban health departments. We described the epidemiology workforce capacity of large urban health departments in the United States and determined gaps in capacity among BCHC health departments. METHODS: BCHC, in partnership with CSTE, modified the 2017 State Epidemiology Capacity Assessment for its 30 member departments. Topics in the assessment included epidemiology leadership, staffing, funding, capacity to perform 4 epidemiology-related Essential Public Health Services, salary ranges, hiring requirements, use of competencies, training needs, and job vacancies. RESULTS: The 27 (90%) BCHC-member health departments that completed the assessment employed 1091 full-time equivalent epidemiologists. All or nearly all health departments provided epidemiology services for programs in infectious disease (n = 27), maternal and child health (n = 27), preparedness (n = 27), chronic diseases (n = 25), vital statistics (n = 25), and environmental health (n = 23). On average, funding for epidemiology activities came from local (47%), state (24%), and federal (27%) sources. Health departments reported needing a 40% increase from the current number of epidemiologists to achieve ideal epidemiology capacity. Twenty-five health departments reported substantial-to-full capacity to monitor health problems, 21 to diagnose health problems, 11 to conduct evaluations, and 9 to perform applied research. CONCLUSIONS: Strategies to meet 21st century challenges and increase substantial-to-full epidemiological capacity include seeking funds from nongovernmental sources, partnering with schools and programs of public health, and identifying creative solutions to hiring and retaining epidemiologists.

Fortalecimento Institucional/estatística & dados numéricos , Epidemiologistas/provisão & distribução , Epidemiologistas/estatística & dados numéricos , Epidemiologia/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , Administração em Saúde Pública/estatística & dados numéricos , Serviços Urbanos de Saúde/estatística & dados numéricos , Adulto , District of Columbia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
Int J Circumpolar Health ; 78(1): 1611327, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31038401


This study aimed to evaluate disease and injury trends among wintering members of the Japanese Antarctic Research Expedition. Obtained information is indispensable to the advancement of medical system and research. Summation was performed based on medical records of reports prepared by each expedition over the period 1956-2016. The clinical department's classification methods of the names of injuries and diseases varied among expeditions, but the names were integrated following the same classification. Of 1734 members (29 women), 6837 disease or injury cases (4 cases/person) were recorded. The rates of cases were as follows: surgical-orthopaedic (45.3%), internal medical (21.7%), dental (11.6%), dermatological (8.4%), ophthalmological (5.8%), otorhinolaryngological (5.3%), psychiatric (1.6%), and urological (0.1%) cases. There was no major change in rates by type of medical case in each expedition. This analysis made it possible to prepare medical facilities, content of physical examinations to select members, training of physicians before departure, preventive hygiene at sites, and medical research themes.

Epidemiologia/estatística & dados numéricos , Expedições/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Regiões Antárticas/epidemiologia , Feminino , Nível de Saúde , Humanos , Japão/epidemiologia , Masculino , Saúde Mental , Estudos Retrospectivos , Estações do Ano
Rev. bras. cir. plást ; 34(1): 101-107, jan.-mar. 2019. tab
Artigo em Inglês, Português | LILACS | ID: biblio-994557


Introdução: Lesões decorrentes de trauma são agravos súbitos à saúde que podem levar a deficiências temporárias e interferir na qualidade de vida das vítimas. O serviço de Cirurgia Plástica Reparadora (CPR) do Hospital Metropolitano de Urgência e Emergência (HMUE) atua como a unidade de referência no tratamento de feridas dos pacientes vítimas de trauma no Estado do Pará. Métodos: Estudo observacional analítico, do tipo transversal prospectivo. A população foi composta por 78 pacientes atendidos no período de dezembro de 2015 até dezembro de 2016. Resultados: A população predominante foi de pacientes do sexo masculino, autônomos, entre 21 a 30 anos. Os acidentes automobilísticos foram os mais prevalentes. A área corporal mais afetada foi a dos membros inferiores e o tipo de cirurgia mais realizada foi enxerto. Tanto entre os pacientes submetidos à cirurgia de enxerto quanto os de retalho, predominou a viabilidade no intervalo de 90-100%. Não foi verificada associação significativa da faixa etária dos pacientes sob o grau de viabilidade. Houve relação entre o número de dias do acidente até a intervenção com o grau de viabilidade do enxerto. Conclusão: Os pacientes internados no hospital no mesmo dia do acidente têm seis vezes mais chance de apresentar viabilidade do enxerto acima de 80% e, portanto, desfecho favorável.

Introduction: Injuries due to trauma are health problems that can lead to temporary deficiencies and interfere with the quality of life of the victims. The Reconstructive Plastic Surgery (RPS) service of the Metropolitan Emergency and Emergency Hospital (HMUE) acts as the reference unit for the treatment of wounds of trauma victims in the State of Pará. Methods: An observational cross-sectional study. The population was composed of 78 patients attended in the period from December 2015 to December 2016. Results: The predominant population was male patients, between 21 and 30 years old. Automobile accidents were the most prevalent. The most affected body area was the lower limbs and the type of surgery performed was graft. Among the patients submitted to graft surgery as well as those of the graft, the viability predominated in the range of 90-100%. There was no significant association between the age of the group under the degree of viability. There was a relation between the number of days of the accident and the intervention with the degree of viability of the graft. Conclusion: Patients hospitalized on the same day of the accident are six times more likely to present graft viability than 80%.

Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Pacientes/estatística & dados numéricos , Cirurgia Plástica/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Ferimentos e Lesões/reabilitação , Epidemiologia/estatística & dados numéricos , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos
Food Chem Toxicol ; 124: 280-299, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30529261


According to the European Regulation (EC) No. 1223/2009, cosmetic products should be safe for human health when used under normal or foreseeable conditions of use. To perform a safety evaluation, consumption data of finished cosmetic product are necessary to assess the corresponding consumer's exposure. The aim of this review was to highlight consumption (percentage of users, frequency of use, amount used, number of products daily used, types of products co-used …) and exposure data to cosmetic products available in the literature. A systematic approach was used following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Literature search was performed in February 2018 using Pubmed and Scopus databases. The following information was collected for the 82 publications included in this review: type of study, characteristics of the population (number, age, sex, region of origin), period of data collection, types of products studied, method(s) of data collection, consumption and/or exposure parameters obtained. Because of the high number of quantitative results obtained in the different studies, these data are not presented here. Readers interested in one or more studies are invited to consult the results available in the original publication(s). This work could be very useful for safety assessors or other persons working in the risk assessment field.

Comportamento do Consumidor/estatística & dados numéricos , Cosméticos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Cosméticos/efeitos adversos , Bases de Dados Factuais/estatística & dados numéricos , Epidemiologia/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Gravidez , Medição de Risco , Adulto Jovem
Rev. salud pública (Córdoba) ; 23(2): 8-24, 2019. Tab, Ilus
Artigo em Espanhol | LILACS | ID: biblio-1006904


La planificación estratégica del sistema sanitario se basa en información epidemiológica. Estos datos se recaban principalmente de evaluaciones sobre las consultas que posee el sistema de salud y permiten estimar la población afectada. Las técnicas que se utilizan son principalmente la de organismos internacionales y estas no tienen consistencia ecológica ni están validadas en el país. Los objetivos de este estudio fueron analizar las propiedades psicométricas del Cuestionario Epidemiológico en Sintomatología Mental versión breve (CESIM) y brindar datos normativos para población adulta argentina. La investigación se enmarcó en un diseño instrumental. Participaron 1216 adultos de 18 a 90 años de edad, con una distribución proporcional en tres localidades argentinas: Gran Mendoza, La Plata y Avellaneda. A partir del estudio factorial del CESIM se obtuvo una estructura simple y clara del cuestionario compuesta por 37 ítems que se agruparon en 8 factores interpretables, los cuales explicaron el 46% de la varianza total del instrumento. El puntaje total del CESIM presentó una excelente consistencia interna. El estudio descriptivo de la sintomatología mental en las personas participantes indicó, en línea con investigaciones previas, que las mujeres y las personas con bajos niveles de instrucción presentaron mayores niveles de sintomatología mental. Los residentes de Mendoza presentaron los niveles más altos de sintomatología mental. Se concluye que el CESIM es un instrumento con adecuadas propiedades psicométricas y validez ecológica para evaluar la sintomatología mental en adultos argentinos

O planejamento estratégico do sistema de saúde é baseado em informações epidemiológicas. Esses dados são coletados principalmente a partir de avaliações sobre as consultas que o sistema de saúde possui e permitem estimar a população afetada. As técnicas utilizadas são principalmente aquelas de organizações internacionais e estas não possuem consistência ecológica nem são validadas no país. Os objetivos deste estudo foram analisar as propriedades psicométricas do Questionário Epidemiológico em Sintomatologia Mental versão curta (CESIM) e fornecer dados normativos para a população adulta argentina. A pesquisa foi enquadrada em um desenho instrumental. Participaram nela 1216 adultos com idades entre 18 e 90 anos de idade, com uma distribuição proporcional de três localidades argentinas: Gran Mendoza, La Plata e Avellaneda. Apartir do estudo fatorial de CESIM foi obtida uma estrutura simples e clara do questionário, composta de 37 itens que foram agrupados em 8 fatores interpretáveis que explicaram 46% da variância total do instrumento. A pontagem total do CESIM apresentou excelente consistência interna. O estudo descritivo da sintomatologia mental nos participantes indicou, em consonância com pesquisas anteriores, que mulheres e pessoas com baixa escolaridade apresentavam níveis mais elevados de sintomas mentais. Os moradores de Mendoza apresentaram os mais altos níveis de sintomas mentais. Conclui-se que o CESIM é um instrumento com adequadas propriedades psicométricas e validade ecológica para avaliar a sintomatologia mental em adultos argentinos.

The strategic planning of the health system is based on epidemiological information. Data are mainly obtained from evaluations on consultations the health system has, and allow an estimation of the affected population. Techniques used mainly belong to international organisms and do not have ecological consistency and are not validated in the country. The objectives of this study were to analyze the short version of the Epidemiological Questionnaire on Mental Symptomatology (CESIM, for its Spanish acronym) and provide regulatory data for the adult population. Research presented an instrumental design. There were 1216 adults from 18 to 90 years old, with a proportional distribution in three Argentinian locations: Gran Mendoza, La Plata and Avellaneda. From the factorial analysis of CESIM, a simple and clear structure of the questionnaire was obtained, made up of 37 items grouped in 8 interpretable factors which explained 46% of the instrument total variance. CESIM total score presented excellent internal consistency. The descriptive study of mental symptomatology in the participants showed, in accordance with previous research, that women and people with low educational level presented higher levels of mental symptomatology. Mendoza residents presented the highest levels of mental symptomatology. We conclude that CESIM is an effective instrument to assess mental symptomatology in Argentinian adults since it presents appropriate psychometric properties and ecological validity.

Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Saúde Mental , Argentina/epidemiologia , Saúde Mental/estatística & dados numéricos , Epidemiologia/estatística & dados numéricos , Inquéritos e Questionários , Adulto/psicologia
BMC Med Res Methodol ; 18(1): 90, 2018 08 31.
Artigo em Inglês | MEDLINE | ID: mdl-30170561


BACKGROUND: Multiple imputation by chained equations (MICE) requires specifying a suitable conditional imputation model for each incomplete variable and then iteratively imputes the missing values. In the presence of missing not at random (MNAR) outcomes, valid statistical inference often requires joint models for missing observations and their indicators of missingness. In this study, we derived an imputation model for missing binary data with MNAR mechanism from Heckman's model using a one-step maximum likelihood estimator. We applied this approach to improve a previously developed approach for MNAR continuous outcomes using Heckman's model and a two-step estimator. These models allow us to use a MICE process and can thus also handle missing at random (MAR) predictors in the same MICE process. METHODS: We simulated 1000 datasets of 500 cases. We generated the following missing data mechanisms on 30% of the outcomes: MAR mechanism, weak MNAR mechanism, and strong MNAR mechanism. We then resimulated the first three cases and added an additional 30% of MAR data on a predictor, resulting in 50% of complete cases. We evaluated and compared the performance of the developed approach to that of a complete case approach and classical Heckman's model estimates. RESULTS: With MNAR outcomes, only methods using Heckman's model were unbiased, and with a MAR predictor, the developed imputation approach outperformed all the other approaches. CONCLUSIONS: In the presence of MAR predictors, we proposed a simple approach to address MNAR binary or continuous outcomes under a Heckman assumption in a MICE procedure.

Algoritmos , Interpretação Estatística de Dados , Funções Verossimilhança , Modelos Teóricos , Confiabilidade dos Dados , Epidemiologia/normas , Epidemiologia/estatística & dados numéricos , Humanos , Método de Monte Carlo , /estatística & dados numéricos
J Pak Med Assoc ; 68(8): 1248-1253, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30108396


Use of GIS to visualize the pattern and distribution of health indices in Pakistan would help in better choreographing of health policy and resource allocation decisions. In this study, district-wise spatial distribution of under five-year old children who got sick or injured in the past two weeks, and health consultation pattern was studied using the Pakistan Social and Living Standards Survey 2014-2015. Sex, urban/rural residency status, and province-based differences in the district-wise distribution of under-five year old children who fell sick/injured in the past two weeks and their having received health consultation for it, were observed. For male children, southwestern districts of Sindh, southeastern districts of Balochistan, central districts of KPK, and one southeastern of Punjab reported the highest percent of children who were sick or injured in the past two weeks. For females the pattern was similar with few exceptions.

Epidemiologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Fatores Etários , Pré-Escolar , Feminino , Humanos , Masculino , Paquistão/epidemiologia , População Rural/estatística & dados numéricos , Fatores Sexuais , Análise Espacial , População Urbana/estatística & dados numéricos
PLoS Comput Biol ; 14(8): e1006211, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30110322


The spread of disease through human populations is complex. The characteristics of disease propagation evolve with time, as a result of a multitude of environmental and anthropic factors, this non-stationarity is a key factor in this huge complexity. In the absence of appropriate external data sources, to correctly describe the disease propagation, we explore a flexible approach, based on stochastic models for the disease dynamics, and on diffusion processes for the parameter dynamics. Using such a diffusion process has the advantage of not requiring a specific mathematical function for the parameter dynamics. Coupled with particle MCMC, this approach allows us to reconstruct the time evolution of some key parameters (average transmission rate for instance). Thus, by capturing the time-varying nature of the different mechanisms involved in disease propagation, the epidemic can be described. Firstly we demonstrate the efficiency of this methodology on a toy model, where the parameters and the observation process are known. Applied then to real datasets, our methodology is able, based solely on simple stochastic models, to reconstruct complex epidemics, such as flu or dengue, over long time periods. Hence we demonstrate that time-varying parameters can improve the accuracy of model performances, and we suggest that our methodology can be used as a first step towards a better understanding of a complex epidemic, in situation where data is limited and/or uncertain.

Métodos Epidemiológicos , Epidemiologia/estatística & dados numéricos , Humanos , Modelos Biológicos , Modelos Teóricos , Processos Estocásticos , Fatores de Tempo , Incerteza
Enferm. glob ; 17(51): 435-446, jul. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-173973


Objetivo: Conocer los problemas de salud que afectan a profesionales de enfermería en una unidad de emergencia hospitalaria pública y factores relacionados. Método: Estudio transversal con 86 profesionales de enfermería de una unidad de emergencia hospitalaria del interior del Estado de São Paulo, Brasil. Los datos recogidos a partir de cuestionarios fueron analizados utilizando la estadística descriptiva e inferencial. Resultados: 61,2% de los profesionales reportaron al menos una lesión o enfermedad con diagnóstico médico, y 59,6% de los profesionales tenían dos o más problemas de salud, siendo 2,8 la media de lesiones o enfermedades (IC95% 2,1–3,5). Los grupos 'lesiones por accidente' y 'enfermedades del sistema musculo-esquelético' fueron predominantes, sin embargo, las lesiones en la espalda, gastritis o irritación duodenal e hipertensión arterial fueron las enfermedades con mayor número de relatos. Los auxiliares o técnicos de enfermería presentaron, de media, mayor número de lesiones o enfermedades que los enfermeros, así como los profesionales con otro empleo, cansados y/o desanimados después del trabajo y que sufrieron violencia laboral. Diferencias estadísticamente significantes fueron observadas entre los grupos con o sin lesión o enfermedades en relación a las medianas de la edad del trabajador (p=0,0075) y edad de inicio en una actividad laboral (p=0,0188). Fue identificada relación con significancia estadística entre tener lesión o enfermedad y uso de medicamento (p=0,0304). Conclusión: Es importante que la institución propicie al trabajador condiciones de trabajo y organizacionales que posibiliten el mantenimiento de su salud, potencial y habilidades por el mayor tiempo posible

Objetivo: Conhecer os problemas de saúde que acometem profissionais de enfermagem em uma unidade de emergência hospitalar pública e fatores relacionados. Método: Estudo transversal com 86 profissionais de enfermagem de uma unidade de emergência hospitalar do interior do Estado de São Paulo, Brasil. Os dados coletados a partir de questionários foram analisados utilizando a estatística descritiva e inferencial. Resultados: 61,2% dos profissionais reportaram ao menos uma lesão ou doença com diagnóstico médico, e 59,6% dos profissionais possuíam dois ou mais problemas de sáude, sendo 2,8 a média de lesões ou doenças (IC 95% 2,1–3,5). Os grupos 'lesões por acidente' e 'doenças do sistema musculoesquelético' foram predominantes, no entanto, as lesões nas costas, gastrite ou irritação duodenal e hipertensão arterial foram as doenças com maior número de relatos. Os auxiliares ou técnicos de enfermagem apresentaram, em média, maior número de lesões ou doenças que os enfermeiros, assim como os profissionais com outro emprego, cansados e/ou desanimados após o trabalho e que sofreram violência ocupacional. Diferenças estatisticamente significantes foram observadas entre os grupos com ou sem lesão ou doença em relação às medianas da idade do trabalhador (p=0,0075) e idade de início em uma atividade laboral (p=0,0188). Foi identificada relação com significância estatística entre ter lesão ou doença e uso de medicamento (p=0,0304). Conclusão: É importante que a instituição propicie ao trabalhador condições de trabalho e organizacionais que possibilitem a manutenção da sua saúde, potencial e habil idades pelo maior tempo possível

Objective: To know the health problems that affect nursing professionals in the emergency unit of a public hospital and the related factors. Method: Cross-sectional study with 86 nursing professionals from a hospital emergency unit in the countryside of the State of São Paulo, Brazil. Data collected through questionnaires were analyzed using descriptive and inferential statistics. Results: 61.2% of the professionals reported at least one injury or illness with a medical diagnosis, and 59.6% of the professionals had two or more health problems, with a mean number of injuries or illnesses of 2.8 (CI95%2.1-3.5). The groups 'injury by accident' and 'musculoskeletal diseases' were predominant, however, injuries in the back, gastritis or duodenal irritation and hypertension were the illnesses with the highest number of reports. Nursing assistants or technicians presented, on average, more injuries or illnesses than nurses, as well as professionals with more than one employment those who felt tired and/or discouraged after work and who had suffered occupational violence. Statistically significant differences wereobserved between the groups with or without injury or illness in relation to medians of current age (p=0.0075) and age at the start of labor activity (p=0.0188) of workers. There was a statistically significant relationship between presenting an injury or illness and use of medication (p=0.0304). Conclusion: It is important that the institutions provide working and organizational conditions for workers, in order to enable them to maintain their health, potential and skills for as long as possible

Humanos , Nível de Saúde , Doença/classificação , Epidemiologia/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Enfermeiras e Enfermeiros/estatística & dados numéricos , Estudos Transversais , Inquéritos de Morbidade , Pesquisa sobre Serviços de Saúde/estatística & dados numéricos
PLoS Comput Biol ; 14(6): e1006115, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29944648


This paper presents a data analysis framework to uncover relationships between health conditions, age and sex for a large population of patients. We study a massive heterogeneous sample of 1.7 million patients in Brazil, containing 47 million of health records with detailed medical conditions for visits to medical facilities for a period of 17 months. The findings suggest that medical conditions can be grouped into clusters that share very distinctive densities in the ages of the patients. For each cluster, we further present the ICD-10 chapters within it. Finally, we relate the findings to comorbidity networks, uncovering the relation of the discovered clusters of age densities to comorbidity networks literature.

Fatores Etários , Análise por Conglomerados , Fatores Sexuais , Algoritmos , Brasil , Doença , Métodos Epidemiológicos , Epidemiologia/estatística & dados numéricos , Feminino , Humanos , Classificação Internacional de Doenças , Masculino
Biostatistics ; 19(4): 461-478, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29040386


Distributed lag models (DLMs) have been widely used in environmental epidemiology to quantify the lagged effects of air pollution on an outcome of interest such as mortality or cardiovascular events. Generally speaking, DLMs can be applied to time-series data where the current measure of an independent variable and its lagged measures collectively affect the current measure of a dependent variable. The corresponding distributed lag (DL) function represents the relationship between the lags and the coefficients of the lagged exposure variables. Common choices include polynomials and splines. On one hand, such a constrained DLM specifies the coefficients as a function of lags and reduces the number of parameters to be estimated; hence, higher efficiency can be achieved. On the other hand, under violation of the assumption about the DL function, effect estimates can be severely biased. In this article, we propose a general framework for shrinking coefficient estimates from an unconstrained DLM, that are unbiased but potentially inefficient, toward the coefficient estimates from a constrained DLM to achieve a bias-variance trade-off. The amount of shrinkage can be determined in various ways, and we explore several such methods: empirical Bayes-type shrinkage, a hierarchical Bayes approach, and generalized ridge regression. We also consider a two-stage shrinkage approach that enforces the effect estimates to approach zero as lags increase. We contrast the various methods via an extensive simulation study and show that the shrinkage methods have better average performance across different scenarios in terms of mean squared error (MSE).We illustrate the methods by using data from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS) to explore the association between PM$_{10}$, O$_3$, and SO$_2$ on three types of disease event counts in Chicago, IL, from 1987 to 2000.

Bioestatística/métodos , Inquéritos Epidemiológicos/estatística & dados numéricos , Modelos Estatísticos , Poluição do Ar/estatística & dados numéricos , Teorema de Bayes , Simulação por Computador , Exposição Ambiental/estatística & dados numéricos , Epidemiologia/estatística & dados numéricos , Humanos
Salvador; s.n; 2018. 79 p. ilus, tab.
Tese em Português | LILACS | ID: biblio-1005558


INTRODUÇÃO: Dengue é endêmico no Brasil desde 1981. O primeiro caso com transmissão autóctone de infecção por vírus Chikungunya (CHIKV) no Brasil foi confirmado em 2014, chamando a atenção das autoridades sanitárias, principalmente, devido a cronificação da artralgia. A partir de 2015 a circulação do vírus Zika (ZIKV) foi confirmada no país. OBJETIVO: Investigar aspectos epidemiológicos e clínicos de pacientes com infecções por ZIKV, DENV e CHIKV, e o processo de cronificação dos sintomas articulares dos pacientes confirmados por Chikungunya. MÉTODO: De setembro de 2014 a julho de 2016 foi realizado um estudo de vigilância para doença febril, em um centro de emergência em saúde de Salvador, para identificação de pacientes com idade ≥6 meses, que referiram febre nos últimos 7 dias ou que apresentaram temperatura ≥37,8ºC durante o atendimento. Entrevistamos os pacientes para coletar dados demográficos e clínicos, e revisamos os prontuários para obter a suspeita diagnóstica. Amostras de sangue de fase aguda e convalescente foram coletadas. Realizou-se testes moleculares e sorológicos para confirmar o diagnóstico de DENV, CHIKV, ZIKV ou Flavivírus não específico. Os participantes com confirmação laboratorial para CHIKV foram acompanhados via contato telefônico, em média, um ano e cinco meses após a fase aguda da doença, a fim de investigar a evolução do quadro clínico e fatores de risco associados a cronificação da artralgia. RESULTADOS: Dos 948 participantes inclusos, 247 (26,1%) tinham evidência laboratorial de uma infecção arboviral, dos quais 224 (23,6%) eram infecções simples (DENV: 32, 3,4%; CHIKV: 159, 16,7%; ZIKV: 13, 1,4% e Flavivírus: 20, 2,1%), e 23 (2,4%) foram co-infecções (DENV / CHIKV: 13, 1,4%; FLAV / CHIKV: 9, 0,9%; e DEN / ZIKV: 1, 0,1%). Rash e prurido foram mais frequente em pacientes com infecção por ZIKV, e artralgia foi mais comum em pacientes com infecção por CHIKV. Dos 265 pacientes confirmados com infecção por CHIKV, 153 (57,7%) foram acompanhados por contato telefônico, e destes, 65 (42,5%) referiram artralgia crônica, e 47 (30,7%) estavam sintomáticos no momento do contato telefônico. Sexo feminino e idade estão associados ao risco de cronificação da artralgia. CONCLUSÃO: Nossos achados revelam um desafio para um diagnóstico clínico preciso de infecções por DENV, CHIKV e ZIKV em uma área de co-circulação, além disso, coinfecções são eventos frequentes. Destacamos a alta frequência da dor articular persistente após uma infecção por CHIKV, e o impacto da artralgia crônica nas atividades diárias e laborais dos pacientes

INTRODUCTION: Dengue has been endemic in Brazil since 1981. The first case with autochthonous transmission of Chikungunya (CHIKV) virus infection in Brazil was confirmed in 2014, drawing attention of the health authorities, especially due to arthralgia chronification. Since 2015, the circulation of Zika virus (ZIKV) was confirmed in the country. AIM: To investigate the epidemiologic and clinical aspects of patients with ZIKV, DENV and CHIKV infection and the process of chronification of the joint symptoms of the patients confirmed for Chikungunya. METHOD: From September 2014 to July 2016, a surveillance study for febrile illness was carried out at a health emergency center in Salvador, to identify patients aged ≥6 months who reported fever in the last 7 days or who presented a temperature ≥ 37.8ºC during medical care. We interviewed the patients to collect demographic and clinical data. In addition, we reviewed the medical records to have the diagnostic suspicion. Acute and convalescent phase blood samples were collected. Molecular and serological tests were performed to confirm the diagnosis of DENV, CHIKV, ZIKV or non-specific Flavivirus. Participants with laboratory confirmation for CHIKV were assisted through telephone, on average, one year and five months after the acute stage of the disease to investigate the evolution of clinical picture and risk factors associated with arthralgia chronification. RESULTS: Of the 948 participants included, 247 (26.1%) had laboratory evidence of an arboviral infection, of which 224 (23.6%) were simple infections (DENV: 32, 3.4%, CHIKV: 159, 16.7%) and 23 (2.4%) were co-infections (DENV / CHIKV: 13, 1.4%, FLAV / CHIKV: 9, 0.9%, and DEN / ZIKV: 1, 0.1%). Rash and pruritus were more frequent in patients with ZIKV infection, and arthralgia was more common in patients with CHIKV infection. From the 265 patients confirmed with CHIKV infection, 153 (57.7%) were assisted by telephone and, among them, 65 (42.5%) reported chronic arthralgia and 47 (30.7%) remained symptomatic until the moment they were contacted. Female sex and age are associated with the risk of arthralgia chronification. CONCLUSION: Our findings reveal a challenge for an accurate clinical diagnosis of DENV, CHIKV and ZIKV infections in a cocirculation area, in addition, co-infections are frequent events. We highlight the high frequency of persistent joint pain after a CHIKV infection, and the impact of chronic arthralgia on patients' daily and work activities

Humanos , Epidemiologia/normas , Epidemiologia/estatística & dados numéricos , Dengue/diagnóstico , Dengue/imunologia , Dengue/prevenção & controle , Dengue/transmissão
Balkan Med J ; 34(4): 323-334, 2017 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-28443561


BACKGROUND: The causes of death have changed with regard to the epidemiological and demographic events in society. There is no evidence of prior research into the epidemiological transition in Turkey. This transition in Turkey should be observed starting with the Ottoman Empire period (19th to early 20th century). However, information about the Ottoman Empire is quite limited. AIMS: To discuss the epidemiological and demographic transitions in Turkey, using demographic, educational and urbanization data in our present study. STUDY DESIGN: A descriptive archive study. METHODS: Mortality statistics dating from 1931 and published by the Turkish Statistical Institute were analysed, and the causes of death were coded and classified according to ICD-10. Other data were obtained from the published reports and studies regarding the issue. RESULTS: In the 1930s, Turkey's life expectancy was low (aged 40 years), fertility and mortality rates were high (respectively 45% and 31%), and the main causes of death were infectious diseases. Nowadays, life expectancy is close to 80 years, the total fertility rate has dropped to 2.1 per woman, and the main causes of death are chronic diseases and cancer. The population rate in the urban areas has increased steadily from 24.2% in 1927 to 77.3% in 2012. level of education has also increased during this period. In 1935, less than 10% of women were literate, and in 2013 90% were literate. Qualitative and quantitative increase have been observed in the presentation and access of healthcare services compared to the early years of the Republic. CONCLUSION: Turkey has been undergoing a modernization period in the last 200 years, and it is believed that the epidemiological and demographic transitions result from this period. This process has led to urbanization and an increase in the level of education, as well as a decrease in premature deaths, lower fertility rates, and an increase in the elderly population and chronic diseases. It is therefore our conclusion that Turkey needs policies regarding the elderly population and the management of chronic diseases.

Causas de Morte/tendências , Epidemiologia/estatística & dados numéricos , Mortalidade/tendências , Dinâmica Populacional/estatística & dados numéricos , Coeficiente de Natalidade/tendências , Política de Saúde/tendências , Humanos , Expectativa de Vida/tendências , Império Otomano , Crescimento Demográfico , Turquia/epidemiologia
Stat Med ; 36(14): 2220-2236, 2017 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-28294368


An important statistical task in disease mapping problems is to identify divergent regions with unusually high or low risk of disease. Leave-one-out cross-validatory (LOOCV) model assessment is the gold standard for estimating predictive p-values that can flag such divergent regions. However, actual LOOCV is time-consuming because one needs to rerun a Markov chain Monte Carlo analysis for each posterior distribution in which an observation is held out as a test case. This paper introduces a new method, called integrated importance sampling (iIS), for estimating LOOCV predictive p-values with only Markov chain samples drawn from the posterior based on a full data set. The key step in iIS is that we integrate away the latent variables associated the test observation with respect to their conditional distribution without reference to the actual observation. By following the general theory for importance sampling, the formula used by iIS can be proved to be equivalent to the LOOCV predictive p-value. We compare iIS and other three existing methods in the literature with two disease mapping datasets. Our empirical results show that the predictive p-values estimated with iIS are almost identical to the predictive p-values estimated with actual LOOCV and outperform those given by the existing three methods, namely, the posterior predictive checking, the ordinary importance sampling, and the ghosting method by Marshall and Spiegelhalter (2003). Copyright © 2017 John Wiley & Sons, Ltd.

Epidemiologia/estatística & dados numéricos , Modelos Estatísticos , Teorema de Bayes , Bioestatística , Bases de Dados Factuais/estatística & dados numéricos , Doença , Métodos Epidemiológicos , Alemanha/epidemiologia , Humanos , Neoplasias Laríngeas/mortalidade , Neoplasias Labiais/epidemiologia , Cadeias de Markov , Método de Monte Carlo , Mortalidade , Distribuição de Poisson , Escócia/epidemiologia
Rio de Janeiro; s.n; fev. 2017. 101 f p. tab, graf, ilus.
Tese em Português | LILACS, BDENF - Enfermagem | ID: biblio-868459


Dados internacionais indicam que com o crescente envelhecimento da população mundial e o aumento das doenças não transmissíveis, dentre elas o câncer, a necessidade por cuidados paliativos aumentará drasticamente nos próximos 50 anos.Tal afirmativa traz repercussões importantes para a organização da assistência no cenário das práticas em saúde. Diante desse cenário, apontou-se como objeto para esse estudo: diretrizes para o gerenciamento do cuidado de enfermagem à pessoa com câncer avançado na atenção básica, objetivando: identificar saberes e práticas de enfermeiros acerca da oferta de cuidados paliativos à pessoa com câncer avançado na atenção básica; descrever os fatores intervenientes no gerenciamento do cuidado de enfermagem à pessoa com câncer avançado na visão dos enfermeiros e propor com os enfermeiros ações e estratégias que favoreçam a oferta de cuidados paliativos à pessoa com câncer avançado no âmbito da atenção básica. Estudo descritivo, de natureza qualitativa onde foi adotado como método, a Pesquisa Convergente Assistencial (PCA). Foram entrevistados 13 profissionais, sendo 11 enfermeiros, 01 psicóloga e 01 assistente social. O cenário do estudo foi o Município de Saquarema, localizado na Baixada Litorânea do Rio de Janeiro. A técnica de coleta de dados foi a entrevista individual (para caracterização do perfil dos participantes) e a criação de um grupo de discussão mediante a apresentação de um caso mobilizador. Houve consentimento dos participantes pelo Termo de consentimento Livre e Esclarecido (TCLE) e aprovação do estudo por Comitê de Ética em Pesquisa (CAEE n. 53185416.1.0000.5238.). Os dados foram distribuídos e agrupados em Unidades temáticas e núcleos de sentidos com a discussão dos resultados contemplando os três eixos principais do estudo: saberes e práticas sobre o cuidado paliativo; fatores intervenientes e diretrizes para ações do cuidado paliativo no contexto da Atenção Básica. Os resultados apontam a existência de fatores intervenientes para o gerenciamento do cuidado de enfermagem a pessoas com câncer avançado no Município, que impactam diretamente na oferta dos cuidados paliativos. Porém, destaca ações e estratégias elaboradas e propostas pelas participantes do estudo, como ferramentas capazes de promover mudanças no cenário da prática atual.Conclui-se que o primeiro passo foi dado para articular de forma integrada os saberes e práticas as ações do cuidado de enfermagem, delineando transformações na atenção oncológica do município.(AU)

Humanos , Dinâmica Populacional , Epidemiologia/estatística & dados numéricos , Neoplasias/epidemiologia , Neoplasias/enfermagem , Cuidados de Enfermagem , Organização e Administração/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos
Am Econ Rev ; 107(5): 516-21, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-29557569


It is estimated that about one quarter of the global disease burden in terms of healthy life years lost and about one quarter of all premature deaths can be attributed to modifiable environmental factors (Pruss-Ustun and Corvalan 2006). Three infectious diseases--diarrhea, respiratory infections, and malaria--account for the largest absolute burden in developing countries with children facing the greatest impacts. There is a growing body of evidence demonstrating the health burden of air and water pollution, as well as important productivity and income effects (see, for example, reviews of the literature in Pattanayak and Pfaff 2009 and Greenstone and Jack 2016). Studies that focus on the impacts of natural resource degradation are fewer. Notably, Garg (2016) provides the first causal estimates of the impact of sustained forest cover on reduced malarial incidence in Indonesia, demonstrating a large and previously understudied cost of forest cover loss. In this paper, we extend this new literature on the health impacts of environmental degradation by estimating the causal impact of forest loss on infectious disease incidence in young children using temporal and spatial variation in the last decade in Nigeria. Our estimation strategy involves geolinking a new high-resolution dataset of global forest change to child-level health data from the Nigeria Demographic and Health Surveys from 2008 and 2013. We find that forest loss significantly increases the incidence of malaria, though it does not affect the incidence of diarrhea and respiratory diseases. The impact of forest loss on malaria is large (one standard deviation of forest loss increases malaria incidence by around 4.5 percent in children under five) and the dynamic pattern of the impact suggests a temporary ecological disturbance consistent with findings in Garg (2016) and the tropical medicine literature.

Causalidade , Conservação dos Recursos Naturais , Diarreia/epidemiologia , Epidemiologia/estatística & dados numéricos , Malária/epidemiologia , Infecções Respiratórias/epidemiologia , Animais , Anopheles , Saúde da Criança , Pré-Escolar , Humanos , Nigéria