Bone mass, fracture risk, and associated factors in postmenopausal women living with HIV

OBJECTIVE

The aim of this study was to assess the prevalence of low bone mass (osteopenia/osteoporosis), the factors associated with low bone mass, and the risk of fractures in Brazilian postmenopausal women living with HIV (WLH) in the Amazon region.

METHODS

This is a cohort study with a cross-sectional assessment at baseline conducted between March 2021 to August 2022 with 100 postmenopausal WLH undergoing antiretroviral therapy (ART) between 45 and 60 years of age and 100 age-matched HIV-negative women. Data on bone mineral density in the lumbar spine (LS) and femoral neck (FN) were collected using dual x-ray absorptiometry and the 10-year risk of hip and major osteoporotic fractures was assessed using the Fracture Risk Assessment tool (FRAX).

RESULTS

The age of menopause onset occurred earlier in WLH ( P < 0.001). No differences in prevalence of osteoporosis and osteopenia in LS and FN were observed except for a lower T score in FN in WLH ( P = 0.039). The FRAX for major osteoporotic fracture and hip fracture were low in both groups, despite the mean of both FRAX scores was higher in WLH ( P < 0.001). Multivariate analysis showed that years since menopause onset, higher body mass index and higher FRAX major osteoporotic fracture were associated with the WLH group, while a higher frequency of physical activity was registered in the HIV-negative group. Multivariate analysis also showed that in WLH, a lower T score in FN was associated with years since menopause onset and body mass index and that the number of years since menopause onset was associated with a lower T score in the LS and a higher score in the FRAX hip fracture.

CONCLUSIONS

Our findings show a high prevalence of low bone mass (osteopenia/osteoporosis) in Brazilian postmenopausal women from the Amazon region. Women living with HIV have higher FRAX scores than HIV-negative women and a lower T score in the FN.

An overview on the current available treatment for COVID-19 and the impact of antibiotic administration during the pandemic

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has caused several problems in healthcare systems around the world, as to date, there is no effective and specific treatment against all forms of COVID-19. Currently, drugs with therapeutic potential are being tested, including antiviral, anti-inflammatory, anti-malarial, immunotherapy, and antibiotics. Although antibiotics have no direct effect on viral infections, they are often used against secondary bacterial infections, or even as empiric treatment to reduce viral load, infection, and replication of coronaviruses. However, there are many concerns about this therapeutic approach as it may accelerate and/or increase the long-term rates of antimicrobial resistance (AMR). We focused this overview on exploring candidate drugs for COVID-19 therapy, including antibiotics, considering the lack of specific treatment and that it is unclear whether the widespread use of antibiotics in the treatment of COVID-19 has implications for the emergence and transmission of multidrug-resistant bacteria.

The absence of birthweight paradox as a marker of disadvantages faced by low maternal education children

Background

This study tested the hypothesis that the birthweight paradox would not be observed when assessing the effect of maternal education on neonatal mortality in the presence of socioeconomic inequality in access to health care.

Methods

Non-concurrent cohort study. Passive follow-up of live-born infants using probabilistic record linkage of birth and death records for Rio de Janeiro (2004-2010; n = 1 445 367). Maternal age, birthweight and neonatal death were evaluated according to maternal educational level strata (<4, 4-11 and ≥12 years of study). We estimated the association between maternal educational level and neonatal mortality using logistical regression models adjusted for maternal age and birthweight (<2500 g and ≥2500 g).

Results

Neonatal mortality was 1.8 times higher in low educational level group compared with high educational level. We did not find birthweight-specific mortality curves crossing over in the stratum under 2500 g (birthweight paradox). The odds of a low birthweight child being born in facilities without neonatal intensive care units was about 70% higher in the group of low education when compared with mothers with high education.

Conclusions

The absence of crossing birthweight-specific mortality curves may be a reason for concern about the severity of the disadvantages faced by low maternal education women.

Delay from fracture to hospital admission: a new risk factor for hip fracture mortality?

The relationship between surgical timing and hip fracture mortality is unknown in the context of developing countries where large delays to surgery are common. We observed that delay from fracture to hospital admission is associated with decreased survival after a hip fracture.

INTRODUCTION

To examine the relationship between the time interval from fracture to surgery as well as its subcomponents (time from fracture to hospital admission and time from admission to surgery) and hip fracture survival.

METHODS

The medical records of all patients aged 60 years and older admitted to a public university hospital in the city of Rio de Janeiro with a primary diagnosis of hip fracture between 1995 and 2000 were reviewed. Survival to hospital discharge and at 1 year were examined.

RESULTS

Among 343 patients included in the study, there were 18 (5.3%) in-hospital deaths, and 297 (86.6%) patients remained alive 1 year after surgery. Very long delays from the time of fracture to hospital admission (mean 3 days) and from hospital admission to surgery (mean 13 days) were identified. Increased time from fracture to hospital admission was associated with reduced survival to hospital discharge (hazard ratio [HR] 1.09, 95% CI 1.03-1.15, p  =  0.005) and reduced survival at 1 year after surgery (HR 1.07, 95% CI 1.03-1.10, p < 0.001). The interval of time from hospital admission to surgery was not associated with reduced survival to hospital discharge (HR 1.03, 95% CI 0.96-1.10, p = 0.379) or at 1 year after surgery (HR 1.03, 95% CI 0.99-1.07, p= 0.185).

CONCLUSIONS

If the association estimated in our study is causal, our results provide evidence that some hip fracture-related deaths could be prevented by improved patient access to appropriate and timely hospital care in the context of a developing country.

Modifying effect of prenatal care on the association between young maternal age and adverse birth outcomes

OBJECTIVES

The objectives were to investigate the prevalence of adverse birth outcomes according to maternal age range in the city of Rio de Janeiro, Brazil, in 2002, and to evaluate the association between maternal age range and adverse birth outcomes using additive interaction to determine whether adequate prenatal care can attenuate the harmful effect of young age on pregnancy outcomes.

METHODS

A cross-sectional analysis was performed in women up to 24 years of age who gave birth to live children in 2002 in the city of Rio de Janeiro. To evaluate adverse outcomes, the exposure variable was maternal age range, and the outcome variables were very preterm birth, low birth weight, prematurity, and low 5-minute Apgar score. The presence of interaction was investigated with the composite variable maternal age plus prenatal care. The proportions and respective 95% confidence intervals were calculated for adequate schooling, delivery in a public maternity hospital, and adequate prenatal care, and the outcomes according to maternal age range. The chi-square test was used. The association between age range and birth outcomes was evaluated with logistic models adjusted for schooling and type of hospital for each prenatal stratum and outcome. Attributable proportion was calculated in order to measure additive interaction.

RESULTS

Of the 40,111 live births in the sample, 1.9% corresponded to children of mothers from 10-14 years of age, 38% from 15-19 years, and 59.9% from 20-24 years. An association between maternal age and adverse outcomes was observed only in adolescent mothers with inadequate prenatal care, and significant additive interaction was observed between prenatal care and maternal age for all the outcomes.

CONCLUSION

Adolescent mothers and their newborns are exposed to greater risk of adverse outcomes when prenatal care fails to comply with current guidelines.

Mortality within 1 year after hip fracture surgical repair in the elderly according to postoperative period: a probabilistic record linkage study in Brazil

OBJECTIVE

The purpose of this study was to assess, by applying probabilistic record linkage (PRL) methodology, the excess mortality and underlying causes of death in a cohort of elderly patients who underwent hip fracture surgical repair during 1995 in Rio de Janeiro, Brazil.

DISCUSSION

We searched the Brazilian Hospital Admission Information System (HAIS) for the city of Rio de Janeiro, identifying all cases of elderly patients who had hip fracture surgery between January 1 and December 31, 1995, and by means of the PRL methodology and RecLink software, crosslinked those data with the Brazilian Mortality Information System (MIS) for the same region for a follow-up period of 1 year. We calculated age- and gender-adjusted standardized mortality ratios (SMR) for three periods of time-1-30 days, 31-90 days, and 91-365 days after hospital admission-and analyzed the basic cause of death as reported in the death certificates and noted the death occurred at the index admission or after hospital discharge.

RESULTS

We found an overall 21.5% (95% CI 18.2-24.9) mortality rate in 1 year and a statistically significant SMR of 1,080 (95% CI 794-1450) and 512.8 (95% CI 366.4-698.3) for the first two periods, 1-30 days and 31-90 days after hospital admission, respectively. For the last period the SMR displayed a statistically nonsignificant trend of 137 (95% CI 99-183). Even in the first 15 days after the index hospital admission, most deaths (55.1%) occurred after hospital discharge, reinforcing the importance of linking hospital mortality databases with general population mortality information systems. The leading three basic causes of death, as reported in death certificates, were cardiovascular events, falls, and infections. This study represents an example of the application of PRL methodology to produce relevant data on hip fracture, a subject of rising epidemiological importance in developing countries.

Accessibility of selected hospitals and medical procedures by means of aerial and transit network-based measures

OBJECTIVE

This report investigates the use of linear and travelled route (transit network-based) distances in estimating the accessibility of hospitals to patients, for some selected hospital admission diagnostics.

METHODS

For patients admitted to 14 public hospitals in Rio de Janeiro City, during 1996, under the ICD-9 headings "Complications of Pregnancy, Childbirth and the Puerperium" and "Disorders of the Circulatory System", average distances between the patient's district of residence and hospital of admission were calculated (both as Euclidean and as network-based distances). Data were obtained from the country's public health data processing agency. Geographic co-ordinates were obtained for districts of residence from the postal codes of the patients' residences. Distances were estimated with the TransCAD Geographical Information System, based on a map of the city transit network. There were 8654 patients admitted under the "Complications of Pregnancy" heading and 3439 under "Disorders of Circulatory System".

RESULTS

Variations of up to a factor of 5.3, and up to 34 km, could be identified between linear and network estimates.

CONCLUSION

While recognizing that network estimates have advantages, the literature on accessibility frequently argues that aerial estimates are a good approximation for those. The present results show that this is not necessarily the case.

[Urban hospital markets: a methodological approach]

This study developed a method for the construction of hospital markets in a metropolitan area, focusing on users of the Unified Health System (SUS) with hip fractures and admitted to municipal hospitals in Rio de Janeiro in 1994-1995. The study used a spatial smoothing technique based on a Kernel (quartic) estimate for constructing areas of care for each hospital and subsequently for hospital markets. Areas of the city were presented where there was a market domain and a secondary domain for treating patients with hip fractures. Hospital market analysis can help health planners organize resources in the health care system.

[Inequality in health care use by the elderly in three districts in Rio de Janeiro]

This article analyzes social inequalities in health care services utilization by the elderly and tests the influence of place of residence. The study was based on a sample survey of residents 60 years of age and older from three different areas in the city of Rio de Janeiro. The multi-stage sampling method led to violations of the logistic regression assumptions which were considered in the data analysis stage. Need was the most important factor related to utilization. However, gender, type of service, income, and place of residence also showed positive impact on health care utilization. Moreover, the effect of the income was modified by place of residence. The area with the best living conditions (Copacabana) did not show inequalities in health care services utilization. The income gradient was more important in middle and lower-income areas, i.e., Méier and Santa Cruz, respectively.

GISEpi: a simple geographical information system to support public health surveillance and epidemiological investigations

One important question for the implementation of a surveillance system concern the type of instrument that can provide timely information on the course of diseases and other health events. This may facilitate prompt implementation of prevention and intervention efforts, such as strengthening control action in one specific area or initiation of epidemiological investigation. Since health related variables of interest are often spatially distributed they require special tools for representation and analysis. Owing to their inherent ability to manage spatial information, geographical information systems (GIS) provide an excellent framework for the design of surveillance systems. This paper presents a simple information system, based on the concepts of GIS, designed for representation and elementary analysis of epidemiological data. An example of its potential use to support malaria control activities in Brazil is discussed.

The correlation of CT findings and in-hospital mortality after cerebral infarction

OBJECTIVE

To evaluate whether findings on computed tomography (CT) are useful to predict early mortality after acute cerebral infarction.

METHODS

An admission CT was performed in 98 patients with disease-onset within 7 days; CT findings were analyzed using a checking list; their influence on hospital mortality was studied by logistic regression analysis.

RESULTS

There were 29 hospital deaths. Uncal herniation and midline shift > 4 mm were strongly correlated with fatal outcome. Also associated with increased mortality: infarction of a whole hemisphere or in the distribution of internal carotid artery; massive (> 90% expected area) infarction in the territory of the anterior or posterior cerebral arteries; massive or submassive (> 50% expected area) middle cerebral artery infarction; large lesion volume (death in 9/13 patients with lesions > 50cm3); any degree of mass effect. In 68 patients with single middle cerebral artery lesions, extension of the lesion to adjacent vascular territories was also associated with a worse outcome. The number of lesions and the presence of contrast enhancement, hemorrhagic changes or cerebral atrophy did not influence outcome.

CONCLUSIONS

CT findings indicating significant mass effect and large infarcts are associated with mortality after ischemic stroke. The best combination of clinical and CT variables to estimate death risk in individual patients remains to be determined.