Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Objective:

Disorders characterized by “distressing unexplained somatic symptoms” are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample.

Methodology:

As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed.

Results:

The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with “being a BSS” case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72).

Conclusion:

Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

Applying a health system perspective to the evolving Farmácia Popular medicines access programme in Brazil

The Farmácia Popular Program (FPP) launched a subsidy system in Brazil, but in coexistence with the ongoing regular governmental access to medicines (Unified Health System (SUS) dispensings) mechanisms, causing overlaps in terms of financing and target population. This characteristic is quite different from most countries with medicines cost-sharing schemes. This paper aims to analyse the FPP under a health systems perspective considering the different health system levels. We analysed the findings from the study ‘Impact of consecutive subsidies policies on access to and use of medicines in Brazil – ISAUM-Br’, designed with the objective of describing and evaluating the impact of the government medicines subsidy policies implemented between 2004 and 2011. Patient share of copayment increased with the implementation of the intervention, which decreased the reference price and decreased with SNP (Saúde Não Tem Preço; zero copayment for patients). There was an increased number of FPP dispensations over time, but SUS dispensings remained the most important source for medicines, especially for hypertension and diabetes. FPP allowed the establishment of a well-designed pharmaceutical information system in the country. Despite the improvement on control mechanism, fraud remained a problem. There were important effects on the pharmaceutical market and sales of generic medicines. FPP has proven to be a very important policy for promoting access to medicines for hypertension and diabetes in Brazil. Examining this policy with a health system perspective has allowed us to highlight many of its important consequences, including for the first time a broad and consistent information system on access to medicines in the country.

Psychometric evaluation of the SF-36 (v.2) questionnaire in a probability sample of Brazilian households: results of the survey Pesquisa Dimensões Sociais das Desigualdades (PDSD), Brazil, 2008

BACKGROUND

In Brazil, despite the growing use of SF-36 in different research environments, most of the psychometric evaluation of the translated questionnaire was from studies with samples of patients. The purpose of this paper is to examine if the Brazilian version of SF-36 satisfies scaling assumptions, reliability and validity required for valid interpretation of the SF-36 summated ratings scales in the general population.

METHODS

12,423 individuals and their spouses living in 8,048 households were selected from a stratified sample of all permanent households along the country to be interviewed using the Brazilian SF-36 (version 2). Psychometric tests were performed to evaluate the scaling assumptions based on IQOLA methodology.

RESULTS

Data quality was satisfactory with questionnaire completion rate of 100%. The ordering of the item means within scales clustered as hypothesized. All item-scale correlations exceeded the suggested criteria for reliability with success rate of 100% and low floor and ceiling effects. All scales reached the criteria for group comparison and factor analysis identified two principal components that jointly accounted for 67.5% of the total variance. Role emotional and vitality were strongly correlated with physical and mental components, respectively, while social functioning was moderately correlated with both components. Role physical and mental health scales were, respectively, the most valid measures of the physical and mental health component. In the comparisons between groups that differed by the presence or absence of depression, subjects who reported having the disease had lower mean scores in all scales and mental health scale discriminated best between the two groups. Among those healthy and with one, two or three and more chronic illness, the average scores were inverted related to the number of diseases. Body pain, general health and vitality were the most discriminating scales between healthy and diseased groups. Higher scores were associated with individuals of male sex, age below 40 years old and high schooling.

CONCLUSIONS

The Brazilian version of SF-36 performed well and the findings suggested that it is a reliable and valid measure of health related quality of life among the general population as well as a promising measure for research on health inequalities in Brazil.

Wheat bran- but not oat bran-enriched diets increase the mucosal height of the cecum and colon of newly weaned and aged rats

The effect of diets enriched with oat or wheat bran (prepared by the addition of 300 g of each fiber to 1000 g of the regular diet), given for 8 weeks, on the mucosal height of the colon and cecum was investigated. Newly weaned (21 days old) and aged (12 months old) male Wistar rats were used in this study. As compared to controls, diets enriched with wheat bran provoked a significant increase in the mucosal height, whereas oat bran did not cause any effect. In newly weaned rats (21 days old), wheat bran increased the mucosal height (microns) in the cecum by 20% (mean +/- SEM for 8 rats; 169.1 +/- 5.2 and 202.9 +/- 8.0 for control and wheat bran, respectively) and in the colon (218.8 +/- 7.2 and 264.5 +/- 18.8 for control and wheat bran, respectively). A similar effect was observed in aged rats (12 months old), with an increase of 15% in the mucosal height (microns) of the cecum (mean +/- SEM of 8 rats; 193.2 +/- 8.6 and 223.7 +/- 8.3 for control and wheat bran, respectively) and of 17% in the colon (300.4 +/- 9.2 and 352.2 +/- 15.9 for control and wheat bran, respectively).

Fatty acid composition of lymphocytes and macrophages from rats fed fiber-rich diets: a comparison between oat bran- and wheat bran-enriched diets

The effect of oat bran- (OBD) and wheat bran-enriched diets (WBD) on fatty acid composition of neutral lipids and phospholipids of rat lymphocytes and macrophages was investigated. In neutral lipids of lymphocytes, OBD reduced the proportion of palmitoleic acid (48%), whereas WBD reduced by 43% palmitoleic acid and raised oleic (18%), linoleic (52%), and arachidonic (2.5-fold) acids. In neutral lipids of macrophages, OBD increased palmitic (16%) and linoleic (29%) acids and slightly decreased oleic acid (15%). The effect of WBD, however, was more pronounced: It reduced myristic (60%), stearic (24%) and arachidonic (63%) acids, and it raised palmitic (30%) and linoleic (2.3-fold) acids. Neither OBD nor WBD modified the composition of fatty acids in phospholipids of lymphocytes. In contrast, both diets had a marked effect on composition of fatty acids in macrophage phospholipids. OBD raised the proportion of myristic (42%) and linoleic (2.4-fold) acids and decreased that of lauric (31%), palmitoleic (43%), and arachidonic (29%) acids. WBD increased palmitic (18%) and stearic (23%) acids and lowered palmitoleic (35%) and arachidonic (78%) acids. Of both cells, macrophages were more responsive to the effect of the fiber-rich diets on fatty acid composition of phospholipids. The high turnover of fatty acids in macrophage membranes may explain the differences between both cells. The modifications observed due to the effects of both diets were similar in few cases: an increase in palmitic and linoleic acids of total neutral lipids occurred and a decrease in palmitoleic and arachidonic acids of phospholipid. Therefore, the mechanism involved in the effect of both diets might be different.