Frailty in people 50 years or older living with HIV: A sex perspective.

OBJECTIVE: To estimate prefrailty and frailty prevalence and associated factors in people living with HIV (PLHIV) from a sex perspective. METHODS: Cross-sectional study on PLHIV at specialized public health centres in Brazil. Data were obtained from individuals aged ≥50 years using antiretroviral therapy (ART) and with an undetectable viral load through personal interviews, clinical evaluations and medical records. Frailty and prefrailty were characterized using the Fried Frailty Phenotype tool. Multinomial regression models were performed, and the associated factors were selected through the backward stepwise method. RESULTS: Among 670 patients, 373 men and 297 women were included. The prevalence of frailty and prefrailty was significantly higher for women (16.2% and 56.2%, respectively) than for men (11.5% and 46.4%, respectively). Low socioeconomic and educational level, multimorbidity, depression, subjective cognitive complaints, and low scores on the Mini-Mental State Exam (MMSE) were associated (P < 0.05) with frailty for both sexes. However, in the sex-specific analysis, while smoking (OR = 3.66, 95% CI: 1.58-8.48) and a history of low adherence to ART (OR = 3.10, 95% CI: 1.33-7.23) were associated with frailty in men, depression (OR = 3.39, 95% CI: 1.36- 8.44) and the absence of functional dentition (OR = 3.77, 95% CI: 1.36- 10.43) were associated with frailty in women. CONCLUSIONS: This study adds self-reported cognitive complaints as a potential predictor of frailty in both sexes and supports the known deleterious effect of multimorbidity on frailty in adults living with HIV. Furthermore, it suggests that other possible predictors, such as depression, oral health status and adherence to ART, may be sex-specific.

The association of continuous-use medications and sleep parameters in a sample of working adults.

PURPOSE: Although polypharmacy is linked to health outcomes in the elderly, the use of multiple medications is increasing in middle-aged adults. This study analyzed whether or not the increased number of continuous-use medications (C-UM) is associated with objective and subjective sleep parameters in a working population. METHODS: Cross-sectional study with schoolteachers from public schools in Londrina, Brazil. The participants were classified according to the self-reported number of C-UM. Sleep data were obtained with actigraphy and a concomitant sleep diary for 7 days. The analyses were adjusted for socio-demographic, lifestyle, and morbidity variables. RESULTS: A total of 17% of the participants were classified as using ≥3C-UM. In fully adjusted analyses, the use of ≥3C-UM was associated with lower actigraphic sleep duration (<6 h) (odds ratio [OR] = 2.51; 95% confidence interval [CI] = 1.01,6.21), higher actigraphic sleep onset latency (SOL) (OR = 2.65; 95%CI = 1.00,7.02), and with a higher number of awakenings during sleep measured by actigraphy (OR = 3.30; 95%CI = 1.32,8.28). The use of ≥3 C-UM was also associated with higher SOL (OR = 3.76; 95%CI = 1.36,10.5) and lower sleep efficiency (OR = 11.6; 95%CI = 2.92,46.1), as measured with the sleep diary. A 1-unit increment in the number of continuous-use medications was associated with higher self-reported SOL and lower subjective sleep efficiency. CONCLUSION: The continuous use of ≥3 medications is associated with worse objective and subjective parameters of sleep duration and quality in schoolteachers.

Association of lead, cadmium and mercury with paraoxonase 1 activity and malondialdehyde in a general population in Southern Brazil.

Metal exposure is associated with increased oxidative stress (OS), which is considered an underlying mechanism of metal-induced toxicity. Malondialdehyde (MDA) is a final product of lipid peroxidation, and it has been extensively used to evaluate metal-induced OS. Pro-oxidant effects produced by metals can be mitigated by paraoxonase 1 (PON1), an antioxidant enzyme known to prevent cardiovascular disease and atherosclerosis. Among other factors, the Q192R polymorphism and the exposure to heavy metals have been known to alter PON1 activity. Here, we evaluated the association of blood lead (Pb), cadmium (Cd) and mercury (Hg) levels with PON1 activity, and with MDA concentrations in a randomly selected sample of Brazilian adults aged 40 years or older, living in an urban area in Southern Brazil. A total of 889 subjects were evaluated for blood Pb and Cd levels, and 832 were tested for Hg. Geometric mean of blood Pb, Cd and Hg was 1.93µg/dL, 0.06µg/L and 1.40µg/L, respectively. PON1 activity was significantly different among various genotypes: QQ (PON1=121.4U/mL), QR (PON1=87.5U/mL), and RR (PON1=55.2U/mL), p<0.001. PON1 genotypes were associated only with Cd blood levels. Those with QR genotype had Cd concentrations higher (0.07µg/L) than those with the RR genotype (0.04µg/L) with p=0.034. However, PON1 activity was not significantly associated with metal concentrations. Cluster analysis showed that men who reported to be current smokers and drinkers with higher blood Pb and Cd levels, had significantly lower PON1 activity than non-smokers or -drinkers, and women with lower Pb and Cd levels. RR genotype carriers had lower PON1 activity than those with the QR genotype, and had higher levels of Pb and Cd compared with other genotype carriers. For blood Hg, no association with PON1 activity or genotype was noted. We found low levels of Pb, Cd and Hg in environmentally exposed Brazilian adults. Cd concentrations were increased in subjects with QR genotype. Those with RR genotype had lower PON1 activity and higher levels of Pb and Cd than other genotype carriers. The results of cluster analysis suggested that smoking status exerts a significant influence on PON1 activity. Other studies with environmentally exposed populations are required to further clarify whether low blood levels of metals influence OS biomarkers.

Identification and characteristics of patients with palliative care needs in Brazilian primary care.

BACKGROUND: The Brazilian healthcare system offers universal coverage but lacks information about how patients with PC needs are serviced by its primary care program, Estratégia Saúde da Família (ESF). METHODS: Cross-sectional study in community settings. Patients in ESF program were screened using a Palliative Care Screening Tool (PCST). Included patients were assessed with Karnofsky Performance Scale (KPS), Edmonton Symptom Assessment System (ESAS) and Palliative Care Outcome Scale (POS). RESULTS: Patients with PC needs are accessing the ESF program regardless of there being no specific PC support provided. From 238 patients identified, 73 (43 women, 30 men) were identified as having a need for PC, and the mean age was 77.18 (95 % Confidence Interval = ±2,78) years, with non-malignant neurologic conditions, such as dementia and cerebrovascular diseases, being the most common (53 % of all patients). Chronic conditions (2 or more years) were found in 70 % of these patients, with 71 % scoring 50 or less points in the KPS. Overall symptom intensity was low, with the exception of some cases with moderate and high score, and POS average score was 14.16 points (minimum = 4; maximum = 28). Most patients received medication and professional support through the primary care units, but limitations of services were identified, including lack of home visits and limited multi-professional approaches. CONCLUSION: Patients with PC needs were identified in ESF program. Basic health care support is provided but there is a lack of attention to some specific needs. PC policies and professional training should be implemented to improve this area.

Prevalence of Frailty Phenotypes in Older People Living with HIV: A Cross-Sectional Study from Brazil.

BACKGROUND: Frailty may affect people living with HIV (PLHIV) prematurely. Fried's frailty phenotype, composed of 5 criteria, is one of the most used instruments for its assessment. This study aimed to determine the prevalence of these criteria among PLHIV classified as prefrail and frail in Brazil. METHODS: A cross-sectional study analyzed the prevalence of the Frailty Phenotype in Brazil with 670 individuals aged ≥ 50 years and undetectable viral load. RESULTS: The prevalence of prefrail and frail individuals was 50.7% and 13.6%, respectively. A low level of physical activity was the most prevalent criterion (50.9%). Except for unintentional weight loss, all other criteria were more prevalent among individuals with lower education levels. All criteria were more prevalent among individuals of lower socioeconomic status than among those of moderate or high status (P < .05). CONCLUSIONS: A low level of physical activity was the component that most contributed to PLHIV being considered prefrail or frail.

Lipids and all-cause mortality among older adults: a 12-year follow-up study.

This is a 12-year follow-up cohort study with 800 people (60-85 years old). The association between lipid disorders and mortality was analysed by Cox proportional hazard adjusted model. All-cause mortality was considered the dependent variable, and lipid disorders as independent variables: total cholesterol (TC) >200 and <170 mg/dl, HDL-c <35 and 40, LDL-c >100 and 130, and triglycerides (TG) >50. An initial analysis of all subjects was performed and a second was carried out after having excluded individuals with a body mass index (BMI) <20 kg/m² or mortality in ≤ 2 years. The mortality showed a positive association with low TC and a negative association with high TC and high LDL-c. After the exclusion of underweight and premature mortality, there was a positive association only with TC <170 mg/dl (HR = 1.36, CI95%: 1.02-1.82). The data did not show a higher risk with high levels of TC, LDL-c, and TG. However, they showed higher mortality among older adults with low TC.

Palliative care: pathway in primary health care in Brazil. / Cuidados paliativos: percurso na atenção básica no Brasil.

In 2022, an important international report was published on the "value of death" not only in the field of health, but in relation to human societies in general. This report proposed to reimagine systems related to end of life in which death is understood not only as a physiological event but also as a relational and spiritual phenomenon with a value of its own and inseparable from life. It identifies the low priority given by most governments worldwide to the issue of alleviating suffering and supporting bereavement, evidenced by the low investment in palliative care. At the same time, we are witnessing in Brazil changes that threaten the feasibility of palliative care policies in primary health care. The denial of finitude within health systems is reflected in global indicators such as the quality of death index of The Economist magazine, in which Brazil ranks 42nd, the global atlas of palliative care of the World Hospice and Palliative Care Alliance, where Brazil is in level 3b, and the global trends in opioid consumption of International Narcotics Control Board of the World Health Organization, in which opioid consumption in Brazil is in the hundreds of doses per million inhabitants per day. Despite notable advances in the legislative and executive fields with regard to palliative care, the Brazilian Unified National Health System (SUS) and primary health care have suffered important structural setbacks that will impact the design of public policy for palliative care. The goal of this article is to undertake an initial analysis of the impacts of current policies within this context and their repercussions in the construction of a solid policy for palliative care.

Em 2022, foi publicado um importante relatório internacional acerca do "valor da morte" não apenas no campo da saúde, mas nas sociedades humanas de forma geral. Este relatório se propôs a reimaginar sistemas relacionados ao fim da vida nos quais a morte seja compreendida não apenas como um fenômeno fisiológico, mas também relacional e espiritual, com valor próprio e inseparável da vida. Identifica-se a baixa prioridade dada pela maior parte dos governos ao redor do mundo para a questão do alívio do sofrimento e dos cuidados com o luto, representada pelo baixo investimento em cuidados paliativos. Ao mesmo tempo, assistimos no Brasil a modificações ameaçadoras à exequibilidade de políticas de cuidados paliativos na atenção básica. A negação da finitude no âmbito dos sistemas de saúde se reflete em alguns indicadores mundiais, como o ranking de qualidade de morte da revista The Economist, em que o Brasil se encontra na 42ª posição, o mapeamento mundial de cuidados paliativos da Aliança Mundial de Cuidados Paliativos em Hospitais, no qual o Brasil se encontra no nível 3b, e o consumo mundial de opioides pelo Órgão Internacional de Controle de Entorpecentes, da Organização Mundial da Saúde, no qual o consumo dessas substâncias em nosso país está na casa das centenas de doses por milhão de habitantes por dia. Apesar de avanços notáveis nos campos legislativo e executivo no que se refere à temática dos cuidados paliativos, o Sistema Único de Saúde (SUS) e a atenção básica vêm sofrendo reveses importantes a nível estrutural que irão causar impacto na estruturação de uma política pública de cuidados paliativos. Este artigo procura fazer uma análise inicial dos impactos das políticas atuais dentro desse cenário e suas repercussões na construção de uma política de cuidados paliativos sólida.

En 2022 se publicó un importante informe internacional sobre el "valor de la muerte" no solo en el campo de la salud, sino en las sociedades humanas en general. Este informe se propuso reimaginar sistemas relacionados con el fin de la vida en los que la muerte se comprenda no solo como un fenómeno fisiológico, sino también relacional y espiritual, con un valor propio e inseparable de la vida. Se identifica la baja prioridad dada por la mayor parte de los gobiernos en todo el mundo para la cuestión del alivio del sufrimiento y de los cuidados con el duelo, representados por la baja inversión en cuidados paliativos. Al mismo tiempo, asistimos en Brasil a modificaciones amenazadoras a la viabilidad de políticas de cuidados paliativos en la atención básica. La negación de la finitud en el ámbito de los sistemas de salud se refleja en algunos indicadores mundiales como el ranking de calidad de la muerte de la revista The Economist en que Brasil está en la posición 42; el mapeo mundial de cuidados paliativos de la Alianza Mundial de Cuidados Paliativos y Hospicio donde Brasil se encuentra en el nivel 3b y el consumo mundial de opioides por la Junta Internacional de Fiscalización de Estupefacientes de la Organización Mundial de la Salud en el que nuestro consumo de opioides está en los cientos de dosis por millón de habitantes por día. A pesar de los notables avances en los ámbitos legislativo y ejecutivo en lo que se refiere a la temática de los cuidados paliativos, por otro lado, el Sistema Único de Salud brasileño (SUS) y la atención básica vienen sufriendo importantes retrocesos a nivel estructural que repercutirán en la estructuración de una política pública de cuidados paliativos. Este artículo pretende hacer un primer análisis de los impactos de las políticas actuales, dentro de este escenario, y sus repercusiones en la construcción de una política sólida de cuidados paliativos.

[The use of anticholinergic drugs and associated factors in middle-aged adults and the elderly]. / O uso de fármacos anticolinérgicos e fatores associados em adultos de meia-idade e idosos.

The objective of this article was to describe the use of anticholinergic drugs and possible factors associated with their use, in middle-aged adults and in the elderly. This is a cross-sectional study, based on data from a population-based study called VIGICARDIO. All respondents aged 44 or older interviewed in 2015 were included. Anticholinergic Drug Scale (ADS) was used to determine anticholinergic burden (ACB), categorized as significant (≥3) and non-significant (< 3). Poisson regression was conducted with crude and adjusted analysis to investigate the factors associated with ACB. There was a prevalence of 20.7% of significant ACB among respondents, higher among middle-aged adults (24.1%). After adjusted analysis, significant ACB (≥ 3) remained in the non-elderly age group with polypharmacy and sporadic use of two or more drugs. In the elderly, sporadic use of two or more medications and hospitalization in the last year continued to be associated with significant ACB. The results indicate a higher prevalence of ACB among middle-aged adults, polymedicated and in sporadic use of medications, which suggests that the investigation of the use of anticholinergicsin this age group requires greater attention.

O objetivo deste artigo foi descrever o uso de medicamentos anticolinérgicos e possíveis fatores associados ao seu uso em adultos de meia idade e idosos. Trata-se de um estudo transversal em que foram incluídos todos os respondentes de 44 anos ou mais entrevistados em 2015. Foi utilizada a Anticholinergic Drug Scale (ADS) para determinação da carga anticolinérgica (CAC), categorizada em elevada (≥ 3) e não-elevada (< 3). Conduziu-se regressão de Poisson com análise bruta e ajustada para investigar os fatores associados à CAC, com cálculo da razão de prevalência (RP) e intervalo de confiança 95% (IC95%). Constatou-se prevalência de 20,7% de CAC elevada entre os respondentes, maior entre adultos de meia idade (24,1%). Após análise ajustada, mantiveram-se associadas à CAC elevada na faixa etária não idosa a polifarmácia e uso esporádico de dois ou mais medicamentos. Nos idosos, continuaram associados à CAC elevada o uso esporádico de dois ou mais medicamentos e internação no último ano. Os resultados indicam maior prevalência de CAC entre adultos de meia-idade, polimedicados e em uso esporádico de medicamentos, o que sugere que a investigação do uso de anticolinérgicos nessa faixa etária demanda maior atenção.

Bidirectional associations between chronic low back pain and sleep quality: A cohort study with schoolteachers.

AIMS: Although both chronic low back pain (cLBP) and sleep problems are prevalent among active workers, the relation between these variables is not well established. This study aimed to examine the bidirectional association between cLBP and sleep in schoolteachers. METHODS: The Pittsburgh Sleep Quality Index (PSQI) and cLBP were self-reported by 530 schoolteachers in Londrina, Brazil, at baseline and after 2 years of follow-up. Generalized estimating equations were adjusted for sociodemographic, lifestyle and mental health variables. RESULTS: Poor sleep quality at baseline was associated with cLBP at follow-up after adjusting for sociodemographic and lifestyle variables (OR=1.61; 95% confidence interval [95% CI]=1.06, 2.47). Changes in the PSQI score over time were also associated with a higher likelihood of cLBP at follow-up (OR=1.13; 95% CI=1.07, 1.20 for each 1-point increase in the PSQI score), regardless of mental health condition. cLBP at baseline was associated with worse sleep quality at follow-up after adjusting for sociodemographic and lifestyle variables (OR=1.56; 95% CI=1.02, 2.37). The presence of cLBP also changed the PSQI score over time (ß coefficient=1.153; 95% CI=0.493, 1.814). CONCLUSIONS: Worse sleep quality was prospectively and bidirectionally associated with cLBP. Concretely, changes in PSQI values after 2 years of follow-up increased the likelihood of reporting cLBP, and baseline cLBP was associated with sleep quality worsening (i.e., higher score in the PSQI). Mental health conditions such as self-rated health, depression and anxiety play a relevant confounding role in the bidirectional associations between sleep and chronic low back pain.

[The relationship between the assessment of performance of primary health care and infant mortality in Brazil]. / Relação entre a avaliação de desempenho da atenção básica e a mortalidade infantil no Brasil.

The article assesses the relationship between the Infant Mortality Rate (IMR) and the percentage of health units that obtained good performance ratings in the appraisal by the National Program to Improve Access and Quality (PMAQ) of Primary Care in Brazilian states and the relation to the variables involved. Using a descriptive study, the results of the performance assessment of the participating units of the third cycle of PMAQ (2015-2017) and the relationship with the IMR (2015-2017) were analyzed. Descriptive, Pearson correlation, and cluster analysis were performed. The results revealed that there is a negative and moderate correlation (-0.534) between the IMR and the units with a good and statistically significant (p=0.005) performance rating. With cluster analysis, it was possible to confirm that Brazilian states from different regions reveal similarities in the variables of the study. Thus, there is a relationship between IMR and units with a good performance rating. The results also showed that the similarities between the states are not restricted to the region in which they are located. Therefore, the importance of investing in primary care training is paramount in terms of an effective impact on the health of the population.

O artigo verifica se há relação entre a Taxa de Mortalidade Infantil (TMI) e o percentual de unidades de saúde que obtiveram boa classificação de desempenho na avaliação do Programa Nacional de Melhoria do Acesso e da Qualidade da atenção básica (PMAQ) nos estados brasileiros, e a similaridade entre estes estados em relação a essas variáveis. Utilizando-se de um estudo descritivo, foram analisados os resultados da avaliação de desempenho das unidades participantes do 3º ciclo do PMAQ (2015-2017) e a relação com a TMI (2015-2017). Foram realizadas análises descritivas, de correlação de Pearson e análise de cluster. Os resultados demonstraram que há correlação negativa e moderada (-0,534) entre a TMI e as unidades com boa classificação de desempenho e estatisticamente significante (p=0,005). Com a análise de cluster, foi possível verificar que estados de diferentes regiões apresentam similaridade nas variáveis do estudo. Enfim, existe relação entre a TMI às unidades com boa classificação de desempenho, além disso, verificou-se que a similaridade entre os estados vai além da região a que pertencem. Portanto, fica evidente a importância do investimento na qualificação da AB para o impacto efetivo na saúde da população.

CRISPR-mediated multigene integration enables Shikimate pathway refactoring for enhanced 2-phenylethanol biosynthesis in Kluyveromyces marxianus.

BACKGROUND: 2-phenylethanol (2-PE) is a rose-scented flavor and fragrance compound that is used in food, beverages, and personal care products. Compatibility with gasoline also makes it a potential biofuel or fuel additive. A biochemical process converting glucose or other fermentable sugars to 2-PE can potentially provide a more sustainable and economical production route than current methods that use chemical synthesis and/or isolation from plant material. RESULTS: We work toward this goal by engineering the Shikimate and Ehrlich pathways in the stress-tolerant yeast Kluyveromyces marxianus. First, we develop a multigene integration tool that uses CRISPR-Cas9 induced breaks on the genome as a selection for the one-step integration of an insert that encodes one, two, or three gene expression cassettes. Integration of a 5-kbp insert containing three overexpression cassettes successfully occurs with an efficiency of 51 ± 9% at the ABZ1 locus and was used to create a library of K. marxianus CBS 6556 strains with refactored Shikimate pathway genes. The 33-factorial library includes all combinations of KmARO4, KmARO7, and KmPHA2, each driven by three different promoters that span a wide expression range. Analysis of the refactored pathway library reveals that high expression of the tyrosine-deregulated KmARO4K221L and native KmPHA2, with the medium expression of feedback insensitive KmARO7G141S, results in the highest increase in 2-PE biosynthesis, producing 684 ± 73 mg/L. Ehrlich pathway engineering by overexpression of KmARO10 and disruption of KmEAT1 further increases 2-PE production to 766 ± 6 mg/L. The best strain achieves 1943 ± 63 mg/L 2-PE after 120 h fed-batch operation in shake flask cultures. CONCLUSIONS: The CRISPR-mediated multigene integration system expands the genome-editing toolset for K. marxianus, a promising multi-stress tolerant host for the biosynthesis of 2-PE and other aromatic compounds derived from the Shikimate pathway.

Predictors of in-hospital COVID-19 mortality: A comprehensive systematic review and meta-analysis exploring differences by age, sex and health conditions.

OBJECTIVE: Risk factors for in-hospital mortality in confirmed COVID-19 patients have been summarized in numerous meta-analyses, but it is still unclear whether they vary according to the age, sex and health conditions of the studied populations. This study explored these variables as potential mortality predictors. METHODS: A systematic review was conducted by searching the MEDLINE, Scopus, and Web of Science databases of studies available through July 27, 2020. The pooled risk was estimated with the odds ratio (p-OR) or effect size (p-ES) obtained through random-effects meta-analyses. Subgroup analyses and meta-regression were applied to explore differences by age, sex and health conditions. The MOOSE guidelines were strictly followed. RESULTS: The meta-analysis included 60 studies, with a total of 51,225 patients (12,458 [24.3%] deaths) from hospitals in 13 countries. A higher in-hospital mortality risk was found for dyspnoea (p-OR = 2.5), smoking (p-OR = 1.6) and several comorbidities (p-OR range: 1.8 to 4.7) and laboratory parameters (p-ES range: 0.3 to -2.6). Age was the main source of heterogeneity, followed by sex and health condition. The following predictors were more markedly associated with mortality in studies with patients with a mean age ≤60 years: dyspnoea (p-OR = 4.3), smoking (p-OR = 2.8), kidney disease (p-OR = 3.8), hypertension (p-OR = 3.7), malignancy (p-OR = 3.7), diabetes (p-OR = 3.2), pulmonary disease (p-OR = 3.1), decreased platelet count (p-ES = -1.7), decreased haemoglobin concentration (p-ES = -0.6), increased creatinine (p-ES = 2.4), increased interleukin-6 (p-ES = 2.4) and increased cardiac troponin I (p-ES = 0.7). On the other hand, in addition to comorbidities, the most important mortality predictors in studies with older patients were albumin (p-ES = -3.1), total bilirubin (p-ES = 0.7), AST (p-ES = 1.8), ALT (p-ES = 0.4), urea nitrogen (p-ES), C-reactive protein (p-ES = 2.7), LDH (p-ES = 2.4) and ferritin (p-ES = 1.7). Obesity was associated with increased mortality only in studies with fewer chronic or critical patients (p-OR = 1.8). CONCLUSION: The prognostic effect of clinical conditions on COVID-19 mortality vary substantially according to the mean age of patients. PROSPERO REGISTRATION NUMBER: CRD42020176595.

Consultas tardías en los servicios de emergencias pediátricas durante la pandemia por COVID-19 en Uruguay, entre el 13 de marzo y el 29 de julio de 2020 / Delayed visits to Pediatric Emergency Departments during the COVID-19 pandemic in Uruguay between March 13 and July 29, 2020 / Consultas tardias nos Serviços de Emergência Pediátrica durante a pandemia de COVID-19 no Uruguai entre 13 de março e 29 de julho de 2020

En diciembre de 2019, en Wuhan, China, se detectaron los primeros casos de SARS-CoV-2. En Uruguay, desde el 16 de marzo de 2020 se suspendieron las actividades de enseñanza, deportivas y espectáculos públicos. Varios países reportaron una marcada disminución de las visitas a urgencias. Algunos niños presentaron enfermedades ocasionales o descompensaciones de enfermedades crónicas, consultando en forma tardía con el riesgo que ello implica. El objetivo de este trabajo es realizar una descripción de las consultas tardías durante la pandemia. Se realizó un estudio multicéntrico y descriptivo entre el 13 de marzo y el 29 de julio de 2020. Se definió consulta tardía como los ingresos por injurias agudas con más de 6 horas de evolución, fiebre mayor a 72 horas de evolución, dificultad respiratoria con más de 12 horas de evolución, síntomas agudos, como dolor abdominal, de más de 24 horas de evolución, síntomas de más de 12 horas de evolución en niños con enfermedades crónicas que determinaron descompensación e ingreso. Se incluyeron 27 centros. Se registraron un total de 34.260 consultas en urgencia, se incluyeron 189 niños para el estudio. El promedio de edad fue de 6 años; 17 pacientes requirieron ingreso a unidad de cuidados intensivos (UCI). Predominó la apendicitis entre los diagnósticos al alta. Esta investigación puso en evidencia la existencia de consultas tardías en nuestro país. Esto contribuye a ponderar el impacto negativo de la pandemia en la población pediátrica.

In December 2019, the first cases of SARS-CoV-2 were detected in Wuhan. In Uruguay, since March 16, teaching, sports and public entertainment activities were suspended. Several countries reported a marked decrease in emergency room visits. Some children presented occasional illnesses or decompensations from chronic illnesses, consulting late with the risk that this implies. The objective of the work is to make a description of late consultations during the pandemic. A multicenter and descriptive study was carried out between March 13 and July 29, 2020. "Late consultation" was defined as admissions for: Acute injuries with more than 6 hours of evolution, fever greater than 72 hours of evolution, difficulty respiratory disease with more than 12 hours of evolution, acute symptoms such as abdominal pain of more than 24 hours of evolution, symptoms of more than 12 hours of evolution in children with chronic diseases that determined decompensation and admission. 27 centers were included. A total of 34260 emergency consultations were registered, 189 children were included for the study. The average age was 6 years. 17 patients required admission to the ICU. Appendicitis predominated among the diagnoses at discharge. This research revealed the existence of late consultations in our country. This helps to weigh the negative impact of the pandemic on the pediatric population.

Em dezembro de 2019, em Wuhan, foram detectados os primeiros casos de SARS-CoV-2. No Uruguai, desde 16 de março, as atividades de ensino, esporte e entretenimento público foram suspensas. Vários países relataram uma diminuição acentuada nas visitas ao pronto-socorro. Algumas crianças apresentavam doenças ocasionais ou descompensações de doenças crônicas, consultando tardiamente os riscos que isso implica. O objetivo do trabalho é fazer uma descrição das consultas tardias durante a pandemia. Um estudo multicêntrico e descritivo foi realizado entre 13 de março e 29 de julho de 2020. Consulta tardia foi definida como internações por: Lesões agudas com mais de 6 horas de evolução, febre maior que 72 horas de evolução, dificuldade respiratória com mais de 12 horas de evolução, sintomas agudos como dor abdominal com mais de 24 horas de evolução, sintomas com mais de 12 horas de evolução em crianças com doenças crônicas que determinaram descompensação e internação. 26 centros foram incluídos. Um total de 34.260 consultas de emergência foram registradas, 189 crianças foram incluídas no estudo. A idade média era de 6 anos. 17 pacientes necessitaram de internação na UTI. Apendicite predominou entre os diagnósticos na alta. Esta pesquisa revelou a existência de consultas tardias em nosso país. Isso ajuda a pesar o impacto negativo da pandemia na população pediátrica.

[Characterization of chronic pain and analgesic approaches among community-dwelling elderly]. / Caracterização da dor crônica e métodos analgésicos utilizados por idosos da comunidade.

OBJECTIVE: To characterize chronic pain and analgesic approaches in community- dwelling elderly of the northern district of Londrina - Brazil. METHODS: Cross-sectional study with individuals 60 years old and more, resident in the local area of a Basic Health Unit (UBS) of Londrina, by home inquiry. Chronic pain was defined as pain lasting for six months or more. The elderly with pain, were questioned about characteristics of the pain as regards location, duration, frequency, intensity, improvement and worsening situations, as well as the impact of pain in the quality of life and also about analgesic approaches. RESULTS: One hundred and seventy two elderly were interviewed (101 women and 71 men). Presence of chronic pain was observed in 107 (62.%) of these 69.3% were female and 52.1% male (p = 0.004). The very old people, 80-year-old or more (p=0.01) and the depressive elderly (p=0.0008) presented higher frequency of chronic pain. Most prevalent pains were in the legs and back, with 31.2% each, and the majority of elderly referred to continuous, daily high intensity pain. Regarding analgesic approaches, the pharmacologic method was mentioned by 86 elderly (80.4%) and simple analgesic (32.6%) was the most used. CONCLUSION: Facts show that there is a high predominance of chronic pain in the population of elderly, mainly in women, in very old people and in depressive individuals.

Relationship between anticholinergic load and self-perceived health in a population aged 44 years or older / Relação entre carga anticolinérgica e autopercepção de saúde em população com mais de 44 anos

OBJECTIVE: To investigate the relationship between anticholinergic load (ACL) and self-perceived general health in adults in a medium-sized municipality in southern Brazil. METHODS: This cross-sectional study was based on 2015 data from a medium-sized municipality in southern Brazil. All respondents aged 44 years or older who reported using drugs in the 2 weeks before the interview were included (n = 662). The Anticholinergic Drug Scale was used to measure the ACL. Self-perceived health was categorized as positive self-perception (PSP) or negative self-perception (NSP). Crude and adjusted Poisson regression analyses were conducted to investigate the association between ACL and self-perceived health. RESULTS: NSP was found in 50.91% of 662 respondents. Significant ACL, older age, lower economic status, lower education, polypharmacy, and depression correlated with a higher frequency of NSP. Individuals with significant ACL had a prevalence of NSP of 1.27 (95% confidence interval: 1.02 ­ 1.58), and each additional ACL level represented a 6.10% higher chance of worse self-perceived health, regardless of confounding factors. CONCLUSIONS: An association was found between significant ACL and NSP, with an effect dependent on ACL level

OBJETIVO: Investigar a relação entre carga anticolinérgica (CAC) e autopercepção de saúde em adultos de um município de médio porte do sul do Brasil. METODOLOGIA: Trata-se de um estudo transversal com dados de 2015, realizado em um município de médio porte do sul do Brasil. Todos os entrevistados com 44 anos ou mais que relataram uso de drogas nas duas semanas anteriores à entrevista foram incluídos (n = 662). A Anticholinergic Drug Scale (ADS) foi utilizada para medir a CAC. A autopercepção da saúde foi categorizada em autopercepção positiva (APP) ou autopercepção negativa (APN). Análises de regressão de Poisson bruta e ajustada foram realizadas para investigar a associação entre CAC e autopercepção de saúde. RESULTADOS: Entre os 662 participantes, a CAC foi encontrada em 50,91% dos respondentes. CAC significativa, idade avançada, situação econômica mais baixa, menor escolaridade, polifarmácia e depressão foram correlacionados com maior frequência de APN. Indivíduos com CAC significativo apresentaram prevalência de APN de 1,27 (intervalo de confiança de 95%: 1,02 ­ 1,58), e cada nível adicional de CAC representou uma chance 6,10% maior de pior autopercepção de saúde, independentemente de fatores de confusão. CONCLUSÕES: Encontrou-se associação entre ACL significativo e APN, com efeito dependente do valor do CAC

[Salivary flow and psychoactive drug consumption in elderly people]. / Fluxo salivar e uso de drogas psicoativas em idosos.

OBJECTIVE: To analyze the association between low saliva flow rates and the use of psychoactive drugs among the elderly. METHODS: A cross-sectional study was carried out with 267 elderly people from 60 to 74 years of age who lived in a borough of the city of Londrina, Paraná State, Brazil. Individuals with high functional dependence or restricted to bed were excluded. Saliva flow rate was the dependent variable with values under the first tercile being considered as low flow rates (less than 0.44 ml/min). The continuous use of psychoactive drugs (antidepressant, antiepileptic, sedative, antipsychotic, hypnotic or sedative-hypnotic drugs) was the independent variable. Multivariate analysis was performed taking into account gender, age and smoking status. RESULTS: The majority of the elderly were women (80.5%), with a mean age of 66.5 years. Use of psychoactive drugs was observed among 31 elderly (11.6%). Mean saliva flow rate was 0.76 ml/min, lower among users of psychoactive drugs (0.67 ml/min). In the multivariate analysis, use of psychoactive drugs was associated with low saliva flow rates (<0.44 ml/min), independent of gender, age or smoking. CONCLUSION: Results show that there is an association between use of psychoactive drugs and low saliva flow rates in this group of independent and non-institutionalized elderly. These conclusions stress the need of a rational use of these drugs, particularly among the elderly.

Fracturas de olécranon. Nueva alternativa terapéutica / Olecranon fractures. A new therapeutic alternative

Introducción: Las fracturas de olécranon desplazadas mayoritariamente requieren de fijación quirúrgica. Las técnicas más usadas son las clavijas con alambre en 8 y las placas anatómicas, pero están asociadas a altas tasas de insatisfacción por irritación de las partes blandas. Una nueva opción quirúrgica es la fijación con suturas de alta resistencia y tornillo canulado. El objetivo de este estudio fue evaluar los rangos de movilidad, la consolidación ósea y las complicaciones utilizando esta técnica. Materiales y Métodos: Se presenta a 6 pacientes con fracturas tipo IIA y un promedio de edad de 43 años (rango 24-60) tratados con suturas de alta resistencia y tornillo canulado intramedular entre enero de 2020 y abril de 2021. Se evaluó el rango de movilidad posoperatorio, la consolidación ósea y las complicaciones. Todos fueron evaluados hasta el mes 6 posoperatorio. Resultados: A los 6 meses de la cirugía, el promedio de flexión fue de 143° (rango 90°-160°) y la extensión promedio, de 19° (0°-55°). Se logró la consolidación ósea en 5 pacientes y hubo un retraso de la consolidación con rigidez articular (complicación 16,6%). No hubo segundas intervenciones. Conclusión: La fijación con suturas de alta resistencia y tornillo canulado para las fracturas simples desplazadas de olécranon es una técnica simple, reproducible y económica, ya que no necesitaría de segundas intervenciones, como sí sucede con las fijaciones tradicionales. Nivel de Evidencia: IV

Objective: Displaced olecranon fractures mostly require surgical fixation. The most commonly used techniques are tension band wiring and plate fixation, but they are associated with high rates of discomfort due to soft tissue irritation. An alternative surgical option is fixation with high-strength sutures with intramedullary screws. The aim of this study is to evaluate the range of motion, bone healing and complications using this technique. Materials and Methods: Six patients with type IIA fractures with an average age of 43 years (range 24-60 years) treated with high strength suture and intramedullary screw between January 2020 - April 2021 were included. Post-operative range of motion, bone healing and complications were evaluated. All were evaluated up to 6 months postoperatively. Results: At the 6th postoperative month, the average flexion was 143° (range 90°-160°), average extension 19° (0°-55°), there was bone healing in 5 patients, and 1 nonunion with joint stiffness (complication 16.6%). There were no second surgeries. Conclusion: Simple displaced olecranon fractures treated with high-strength suture with intramedullary screws is a simple, reproducible and economical technique since it does not require a second surgery, as is the case with traditional fixation methods for this pathology. Level of Evidence: IV

Association between body composition and stair negotiation ability among individuals >55 years of age: a cross-sectional study.

BACKGROUND: Loss of muscle strength exerts a considerable impact on the quality of life and mortality of older adults. The present household survey study measured body composition and muscle strength with the aim of analyzing the roles of low lean mass, low muscle strength and obesity in stair negotiation ability and the effect of comorbidities on the relationship between body composition and functional capacity. METHODS: Body composition was assessed using bioelectrical impedance analysis and muscle strength was assessed with a hand grip dynamometer. The study population comprised individuals >55 years of age from a medium-sized Brazilian municipality. The sample included 451 participants. RESULTS: A total of 368 subjects were interviewed; their ages varied from 56 to 91 years. Among males, low muscle strength was associated with stair negotiation difficulty independent of muscle mass, age and obesity but muscle mass was not. However, when we analyzed comorbidities and body composition jointly, chronic lower limb pain and obesity were independently associated with stair negotiation difficulty but body composition and age were not. Among women, after comorbidities were included into the model, low muscle strength and obesity remained associated with stair negotiation difficulty as chronic lower limb pain and depression. The relationship between muscle function and comorbidities is discussed in this article.

Cuidados paliativos: percurso na atenção básica no Brasil / Cuidados paliativos: camino en la atención primaria en Brasil / Palliative care: pathway in primary health care in Brazil

Em 2022, foi publicado um importante relatório internacional acerca do "valor da morte" não apenas no campo da saúde, mas nas sociedades humanas de forma geral. Este relatório se propôs a reimaginar sistemas relacionados ao fim da vida nos quais a morte seja compreendida não apenas como um fenômeno fisiológico, mas também relacional e espiritual, com valor próprio e inseparável da vida. Identifica-se a baixa prioridade dada pela maior parte dos governos ao redor do mundo para a questão do alívio do sofrimento e dos cuidados com o luto, representada pelo baixo investimento em cuidados paliativos. Ao mesmo tempo, assistimos no Brasil a modificações ameaçadoras à exequibilidade de políticas de cuidados paliativos na atenção básica. A negação da finitude no âmbito dos sistemas de saúde se reflete em alguns indicadores mundiais, como o ranking de qualidade de morte da revista The Economist, em que o Brasil se encontra na 42ª posição, o mapeamento mundial de cuidados paliativos da Aliança Mundial de Cuidados Paliativos em Hospitais, no qual o Brasil se encontra no nível 3b, e o consumo mundial de opioides pelo Órgão Internacional de Controle de Entorpecentes, da Organização Mundial da Saúde, no qual o consumo dessas substâncias em nosso país está na casa das centenas de doses por milhão de habitantes por dia. Apesar de avanços notáveis nos campos legislativo e executivo no que se refere à temática dos cuidados paliativos, o Sistema Único de Saúde (SUS) e a atenção básica vêm sofrendo reveses importantes a nível estrutural que irão causar impacto na estruturação de uma política pública de cuidados paliativos. Este artigo procura fazer uma análise inicial dos impactos das políticas atuais dentro desse cenário e suas repercussões na construção de uma política de cuidados paliativos sólida.

En 2022 se publicó un importante informe internacional sobre el "valor de la muerte" no solo en el campo de la salud, sino en las sociedades humanas en general. Este informe se propuso reimaginar sistemas relacionados con el fin de la vida en los que la muerte se comprenda no solo como un fenómeno fisiológico, sino también relacional y espiritual, con un valor propio e inseparable de la vida. Se identifica la baja prioridad dada por la mayor parte de los gobiernos en todo el mundo para la cuestión del alivio del sufrimiento y de los cuidados con el duelo, representados por la baja inversión en cuidados paliativos. Al mismo tiempo, asistimos en Brasil a modificaciones amenazadoras a la viabilidad de políticas de cuidados paliativos en la atención básica. La negación de la finitud en el ámbito de los sistemas de salud se refleja en algunos indicadores mundiales como el ranking de calidad de la muerte de la revista The Economist en que Brasil está en la posición 42; el mapeo mundial de cuidados paliativos de la Alianza Mundial de Cuidados Paliativos y Hospicio donde Brasil se encuentra en el nivel 3b y el consumo mundial de opioides por la Junta Internacional de Fiscalización de Estupefacientes de la Organización Mundial de la Salud en el que nuestro consumo de opioides está en los cientos de dosis por millón de habitantes por día. A pesar de los notables avances en los ámbitos legislativo y ejecutivo en lo que se refiere a la temática de los cuidados paliativos, por otro lado, el Sistema Único de Salud brasileño (SUS) y la atención básica vienen sufriendo importantes retrocesos a nivel estructural que repercutirán en la estructuración de una política pública de cuidados paliativos. Este artículo pretende hacer un primer análisis de los impactos de las políticas actuales, dentro de este escenario, y sus repercusiones en la construcción de una política sólida de cuidados paliativos.

In 2022, an important international report was published on the "value of death" not only in the field of health, but in relation to human societies in general. This report proposed to reimagine systems related to end of life in which death is understood not only as a physiological event but also as a relational and spiritual phenomenon with a value of its own and inseparable from life. It identifies the low priority given by most governments worldwide to the issue of alleviating suffering and supporting bereavement, evidenced by the low investment in palliative care. At the same time, we are witnessing in Brazil changes that threaten the feasibility of palliative care policies in primary health care. The denial of finitude within health systems is reflected in global indicators such as the quality of death index of The Economist magazine, in which Brazil ranks 42nd, the global atlas of palliative care of the World Hospice and Palliative Care Alliance, where Brazil is in level 3b, and the global trends in opioid consumption of International Narcotics Control Board of the World Health Organization, in which opioid consumption in Brazil is in the hundreds of doses per million inhabitants per day. Despite notable advances in the legislative and executive fields with regard to palliative care, the Brazilian Unified National Health System (SUS) and primary health care have suffered important structural setbacks that will impact the design of public policy for palliative care. The goal of this article is to undertake an initial analysis of the impacts of current policies within this context and their repercussions in the construction of a solid policy for palliative care.

Frequency and factors associated with falls in adults aged 55 years or more.

OBJECTIVE: The objective of this study is to analyze the frequency and factors associated with falls in adults aged 55 years or more. METHODS: This is a study inserted into another population-based study with representative sample of persons aged 40 years or more of the urban area in a medium-sized municipality of the State of Paraná, Brazil, in 2011. That study obtained demographic and socioeconomic data and characteristics related to life habits, health conditions, and functional capacity (n = 1,180). In 2012, we selected all persons aged 55 years or more (n = 501). We have estimated grip strength and the occurrence of a fall since the last interview in 80.6% of the adults. The crude and adjusted odds ratios (OR) have been calculated by logistic regression according to a hierarchical model. RESULTS: The rate of fall was 24.3%. After adjustments, we could observe higher chances of falls among women (OR = 3.10; 95%CI 1.79-5.38), among persons aged 65 years or more (OR = 2.39; 95%CI 1.45-3.95), with poor sleep quality (OR = 1.78; 95%CI 1.08-2.93), and with low grip strength (OR = 2.31; 95%CI 1.34-3.97). CONCLUSIONS: Poor sleep quality and low muscle strength can be indicators of increased risk of falls and need assessments and interventions aimed at preventing them. OBJETIVO: Analisar a frequência e fatores associados à ocorrência de quedas em adultos de 55 anos ou mais. MÉTODOS: Estudo inserido em outro de base populacional com amostra representativa de pessoas com 40 anos ou mais da área urbana de município de médio porte do Paraná em 2011. Foram obtidos dados demográficos e socioeconômicos, características referentes aos hábitos de vida, às condições de saúde e à capacidade funcional (n = 1.180). Em 2012, selecionaram-se todas as pessoas com idade igual ou superior a 55 anos (n = 501). Foram estimadas a força de preensão palmar e a ocorrência de queda desde a última entrevista em 80,6% delas. Foram calculadas odds ratios (OR) brutas e ajustadas por regressão logística segundo modelo hierarquizado. RESULTADOS: A frequência de queda foi de 24,3%. Após ajustes, observaram-se chances maiores de queda entre mulheres (OR = 3,10; IC95% 1,79-5,38), entre pessoas com idade igual ou superior a 65 anos (OR = 2,39; IC95% 1,45-3,95), com qualidade do sono ruim (OR = 1,78; IC95% 1,08-2,93) e com baixa força de preensão palmar (OR = 2,31; IC95% 1,34-3,97). CONCLUSÕES: Qualidade ruim do sono e a baixa força muscular podem ser indicadores de maior risco de quedas e merecem avaliações e intervenções visando à prevenção desse agravo.