Spatio-temporal patterns of tuberculosis incidence in Ribeirão Preto, State of São Paulo, southeast Brazil, and their relationship with social vulnerability: a Bayesian analysis

INTRODUCTION

The purpose of this ecological study was to evaluate the urban spatial and temporal distribution of tuberculosis (TB) in Ribeirão Preto, State of São Paulo, southeast Brazil, between 2006 and 2009 and to evaluate its relationship with factors of social vulnerability such as income and education level.

METHODS

We evaluated data from TBWeb, an electronic notification system for TB cases. Measures of social vulnerability were obtained from the SEADE Foundation, and information about the number of inhabitants, education and income of the households were obtained from Brazilian Institute of Geography and Statistics. Statistical analyses were conducted by a Bayesian regression model assuming a Poisson distribution for the observed new cases of TB in each area. A conditional autoregressive structure was used for the spatial covariance structure.

RESULTS

The Bayesian model confirmed the spatial heterogeneity of TB distribution in Ribeirão Preto, identifying areas with elevated risk and the effects of social vulnerability on the disease. We demonstrated that the rate of TB was correlated with the measures of income, education and social vulnerability. However, we observed areas with low vulnerability and high education and income, but with high estimated TB rates.

CONCLUSIONS

The study identified areas with different risks for TB, given that the public health system deals with the characteristics of each region individually and prioritizes those that present a higher propensity to risk of TB. Complex relationships may exist between TB incidence and a wide range of environmental and intrinsic factors, which need to be studied in future research.

Gravidez na adolescência e características socioeconômicas dos municípios do Estado de São Paulo, Brasil: análise espacial

A gravidez na adolescência é um problema de saúde pública comum em todo o mundo. O objetivo deste estudo ecológico é estudar o padrão espacial da associação entre os percentuais de gravidez na adolescência e características socioeconômicas dos municípios do Estado de São Paulo, Brasil. Para isso, foi utilizado um modelo bayesiano com uma distribuição espacial que segue uma estrutura condicional autorregressiva (CAR), baseado em algoritmos Monte Carlo em cadeias de Markov (MCMC). Foram usados dados do Sistema de Informações sobre Nascidos Vivos (SINASC) e do Instituto Brasileiro de Geografia e Estatística (IBGE). Verificou-se que a ocorrência de gravidezes precoces apresentou-se maior nos municípios de menor produto interno bruto (PIB) per capita, com maior incidência de pobreza, de menor tamanho populacional, menor índice de desenvolvimento humano (IDH) e maior percentual de indivíduos com índice paulista de vulnerabilidade social (IPVS) igual a 5 ou 6, ou seja, mais vulneráveis. O estudo demonstra uma estreita associação entre gravidez na adolescência e indicadores econômicos e sociais.

The independent and combined effects of cannabis use and systemic inflammation during the early stages of psychosis: exploring the two-hit hypothesis

BACKGROUND

Cannabis consumption is a modifiable risk factor associated with psychosis, but not all cannabis users develop psychosis. Animal studies suggest that an antecedent active immune system interacts with subsequent cannabis exposure and moderates the cannabis-psychosis association, supporting the two-hit hypothesis. The clinical investigations are few, and it is unclear if the immune system is a biological candidate moderating the cannabis-psychosis association or whether cannabis increases inflammation, which in turn, augments psychosis likelihood.

METHODS

We explored the mediating and moderating role of blood inflammation using PROCESS macro. We used data from a cross-sectional study, including 153 first-episode psychosis patients and 256 community-based controls. Participants answered the Cannabis Experience Questionnaire (cannabis frequency, age of onset, and duration), and plasma cytokines were measured [interleukin (IL)-1β, IL-6, IL-4, IL-10, tumour necrosis factor-α (TNF-α), interferon-γ (IFN-γ), transforming growth factor-β (TGF-β); multiplex]. We computed an inflammatory composite score (ICS) to represent the systemic inflammatory state. Confounders included sex, age, ethnicity, educational level, body mass index, tobacco smoking, lifetime use of other drugs, and antipsychotic treatment.

RESULTS

Mediation: Cannabis consumption was not associated with increased inflammation, thus not supporting a mediating effect of inflammation. Moderation: Daily use and age of onset <17 interacted significantly with the ICS to increase the odds of psychosis beyond their individual effects and were only associated with psychosis among those scoring medium-high in the ICS.

CONCLUSIONS

Immune dysregulation might be part of the pathophysiology of psychosis, not explained by cannabis use or other confounders. We provide the first and initial evidence that immune dysregulation modifies the cannabis-psychosis association, in line with a two-hit hypothesis.

Excess mortality in a cohort of Brazilian patients with a median follow-up of 11 years after the first psychiatric hospital admission

PURPOSE

To estimate the mortality rates of a cohort of Brazilian patients after their first psychiatric admission and determine the possible risk factors associated with excess mortality.

METHODS

The study included a cohort of psychiatric patients hospitalised from Jan 1, 2002 to Dec 31, 2007 in the catchment area of Ribeirão Preto, São Paulo state, Brazil. Data were linked to deaths that occurred between Jan 1, 2002 and Dec 31, 2016 from the SEADE Foundation (state data analysis system of São Paulo). The mortality rate (MR), age-sex-standardised mortality ratio (SMR), life expectancy at birth, and years of life lost (YLL) were computed. The factors associated with mortality were analysed by survival analysis using a Cox proportional hazards regression model.

RESULTS

Of 4019 patients admitted (54.76% male), 803 died (69.74% male) during the follow-up (median = 11.25 years). Mortality rates were approximately three-fold higher than expected (SMR = 2.90, 95% CI 2.71-3.11). The highest mortality rate was noted in men with alcohol-related disorders (SMR = 5.50, 95% CI 4.87-6.19). Male sex (adjusted hazard ratio (aHR) = 1.62, 95% CI 1.37-1.92), higher age (aHR = 21.47, 95% CI 13.48-34.17), and unemployment (aHR = 1.22, 95% CI 1.05-1.43) significantly increased the mortality risk from all causes. The average YLL was 27.64 years with the highest YLL noted in nonalcohol substance-related disorders (39.22 years). The life expectancy at birth in this cohort was 47.27 years. Unnatural causes of death were associated with nonwhite skin colour and substance-related disorders.

CONCLUSION

An excess of mortality and a significant reduction in life expectancy of mentally disordered patients who were first admitted to psychiatric beds was noted, particularly patients admitted for substance-related disorders, which should represent a priority in mental health policies.

Preterm birth and postpartum depression within 6 months after childbirth in a Brazilian cohort

Preterm birth (PTB) and postpartum depression (PPD) are important public health issues, and although literature mainly supports the association between them, some reviews have highlighted methodological limitations in the studies in this field, restricting the interpretation of such finding. This study aimed at assessing the association between PTB and PPD, by comparing groups of preterm and full-term mothers in two Brazilian cities with contrasting sociodemographic indicators. This prospective convenience cohort study assessed 1421 women during pregnancy, at childbirth, and in the postpartum period. The Edinburgh Postnatal Depression Scale (EPDS) was administrated to assess PPD within 6 months after delivery and women were considered probably depressed if scores were EDPS ≥ 12. PTB was defined as the delivery before 37 completed weeks of pregnancy. A multivariate Poisson regression was used to estimate relative risk for PPD in mothers of preterm infants, and the final analysis models were adjusted for psychosocial variables, selected according to the directed acyclic graph (DAG) approach. Frequencies of PPD were not significantly different in mothers of preterm and full-term infants, in neither city. In the final adjusted model, PTB was not associated with PPD. The association between PTB and PPD was not confirmed in two large samples from two Brazilian cities with contrasting socioeconomic profile. However, maternal health during pregnancy plays an important role in predicting PPD. Prenatal care should promote maternal mental health as an effort towards decreasing unfavored outcomes for mothers, infants, and families.

Anatomic and neuropsychological findings in low-educated cognitively intact elderly from a Brazilian cohort

In elderly individuals, low educational level may represent a risk factor for the development of dementia and a proxy of cognitive reserve. Objective: This study examined the cognitive and neuroanatomic correlates of high versus low educational levels in cognitively healthy community-dwelling older adults in Brazil. Methods: Fifty-three older adults (mean age: 68±5.3 years) were divided into a “low education” group [LE; 1-4 years of education (N=33)] and “high education” group [HE; >11 years of education (N=20)]. Both groups completed a comprehensive neuropsychological battery and underwent in vivo structural MRI close to the time of testing. Results: Higher educational level increased the chance of having better scores on neuropsychological tests, including verbal and visual delayed recall of information, verbal learning, category fluency, global cognition, and vocabulary. Better scores on these tests were observed in the HE group relative to the LE group. Despite this, there were no group differences between MRI measures. Conclusion: Older adults with higher educational levels showed better scores on neuropsychological measures of cognition, highlighting the need for education-adjusted norms in developing countries. Given the absence of differences in structural anatomy between the groups, these findings appear to be best explained by theories of cognitive reserve.

Twenty-one days of low-intensity eccentric training improve morphological characteristics and function of soleus muscles of mdx mice

Duchene muscular dystrophy (DMD) is caused by the absence of the protein dystrophin, which leads to muscle weakness, progressive degeneration, and eventually death due to respiratory failure. Low-intensity eccentric training (LIET) has been used as a rehabilitation method in skeletal muscles after disuse. Recently, LIET has also been used for rehabilitating dystrophic muscles, but its effects are still unclear. The purpose of this study was to investigate the effects of 21 days of LIET in dystrophic soleus muscle. Thirty-six male mdx mice were randomized into six groups (n = 6/each): mdx sedentary group; mdx training group-3 days; mdx training group-21 days; wild-type sedentary group; wild-type training group-3 days and wild-type training group-21 days. After the training sessions, animals were euthanized, and fragments of soleus muscles were removed for immunofluorescence and histological analyses, and measurements of active force and Ca²⁺ sensitivity of the contractile apparatus. Muscles of the mdx training group-21 days showed an improvement in morphological characteristics and an increase of active force when compared to the sedentary mdx group. The results show that LIET can improve the functionality of dystrophic soleus muscle in mice.

Plasma amino acids profile in first-episode psychosis, unaffected siblings and community-based controls

Investigations of plasma amino acids in early psychosis and their unaffected siblings are rare. We measured plasma amino acids involved in the co-activation of dopaminergic, GABAergic, glutamatergic, and serotoninergic neurotransmitters in first-episode psychosis (FEP) patients (n = 166), unaffected siblings (n = 76), and community-based controls (n = 166) included in a cross-sectional study. Plasma levels of glutamic acid (GLU), glutamine, glycine, proline (PRO), tryptophan (TRP), tyrosine, serine and GABA were quantified by gas-chromatography-mass spectrometry. We used the generalized linear model adjusted by sex, age, and body mass index for group comparison and paired t-test for FEP-Sibling pairs. FEP had reduced GABA plasma levels compared to siblings and controls (p < 0.05 for both). Siblings had lower GLU, Glx and PRO (p < 0.05 for all) but increased TRP compared to patients and controls (p < 0.05 for both). FEP patients with longer duration of pharmacological treatment and medicated only with antipsychotics had increased GLU compared to FEP with shorter periods, or with those treated with a combination of medications (p < 0.05 for both). Finally, FEP patients treated only with antipsychotics presented higher Glx compared to those with mixed medications (p = 0.026). Our study suggests that FEP have low a GABA plasma profile. Unaffected siblings may be a possible risk group for metabolic abnormalities.

Spatial distribution of pregnancy in adolescence and associations with socioeconomic and social responsibility indicators: State of Minas Gerais, Southeast of Brazil

PURPOSE

To describe associations between pregnancy rates in adolescence and socioeconomic and social responsibility indicators in the municipalities of the State of Minas Gerais, Southeast of Brazil, in the year of 2010.

METHODS

Ecological study using data from the Brazilian Live Birth Information System (SINASC). The percentage of live births to adolescent mothers (LBAM) for each municipality was calculated based on the quotient between number of born alive infants of mothers aged 10-19 years old and total number of live births in the year of 2010. Fully Bayesian models were used to obtain the percentages of LBAM adjusted for spatial effects and to assess possible associations with socioeconomic and social responsibility indicators.

RESULTS

The crude percentage of LBAM for the total number of live births in the municipalities of Minas Gerais in 2010 ranged from 0 to 46.4%, with median percentage being 19.6% and the first and third quartiles being 15.6 and 23.1%, respectively. This study has demonstrated a close relationship between adolescent pregnancy and socioeconomic indicators. LBAM percentages were found to be higher in municipalities with low population density, low human development index and other low development indicators.

CONCLUSION

The strong relationship between LBAM percentages and socioeconomic indicators suggests that adolescent pregnancy is more a social than a biological problem. Therefore, programs and actions should go beyond sexual education and information on preventive health methods.

Conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão

Estudo descritivo exploratório que teve como objetivos identificar as características sociodemográficas das pessoas com lesão da medula espinhal (LME) e de seus cuidadores familiares e avaliar o conhecimento dos cuidadores sobre prevenção de úlcera por pressão (UPP). Participaram do estudo 47 pessoas com LME e 47 cuidadores que responderam a um teste de conhecimento sobre prevenção de UPP. Esse teste é composto por questões fechadas com opções de resposta: V = verdadeiro, F = falso e NS = não sei. Para análise estatística dos dados, foi utilizado o PROC TTEST do Software SAS® 9. Dos indivíduos com LME, 80,8% eram do sexo masculino, idade média de 41,6 anos e 57,5% tiveram lesão medular traumática. Quanto aos cuidadores, 89,3% eram do sexo feminino, com média de idade de 44 anos, 76,6% casados. A porcentagem média de acertos no teste de conhecimento foi de 67,8% (DP = 14,8), o mínimo foi 14,3% e o máximo foi 88,5%, o que demonstrou conhecimento insuficiente relacionado com a prevenção de UPP. A porcentagem de acertos no teste foi menor conforme o aumento da idade. A identificação dos déficits de conhecimento dos cuidadores sobre a temática permite ao enfermeiro realizar um planejamento de estratégias educativas para prevenção de UPP.

Spatio-temporal trends in the risk of adolescent pregnancy in Minas Gerais, Brazil, 2000-2015

PURPOSE

To investigate, through a spatio-temporal analysis, the association between the percentages of live births of adolescent mothers (LBAM) and the human development index (HDI), including the three components: income, education and longevity.

METHODS

The percentage of LBAM was obtained from the Brazilian Live Births Information System for the state of Minas Gerais, Brazil in the period 2000-2015 and the HDI data and its components were obtained from United Nations Development Program's (UNDP) Human Development Reports. A generalized additive model (GAM) was used to estimate the relative risk of LBAM in relation to the HDI and to identify spatial clusters of the geographical distribution of LBAM, the Moran global and local index was used.

RESULTS

There is an association between the HDI and its components with LBAM. The high values of relative risk are spatially concentrated in the northern part of the state of Minas Gerais. The graphs indicated a nonlinear relationship between LBAM over the years.

CONCLUSIONS

There is a strong spatial dependence of LBAM in Minas Gerais, which suggests that a geographical location plays a fundamental role in understanding it. The regional disparity confirmed in this study is inherent in the process of human development, it is important for planning actions aimed at the development of these regions in order to minimize existing disparities.

Neurocognition and brain functional connectivity in a non-clinical population-based sample with psychotic experiences

We characterized the neurocognitive profile of communed-based individuals and unaffected siblings of patients with psychosis from Brazil reporting psychotic experiences (PEs). We also analyzed associations between PEs and the intra and inter-functional connectivity (FC) in the Default Mode Network (DMN), the Fronto-Parietal Network (FPN) and the Salience Network (SN) measured by functional magnetic resonance imaging. The combined sample of communed-based individuals and unaffected siblings of patients with psychosis comprised 417 (neurocognition) and 85 (FC) volunteers who were divided as having low (<75th percentile) and high (≥75th percentile) PEs (positive, negative, and depressive dimensions) assessed by the Community Assessment of Psychic Experiences. The neurocognitive profile and the estimated current brief intellectual quotient (IQ) were assessed using the digit symbol (processing speed), arithmetic (working memory), block design (visual learning) and information (verbal learning) subtests of Wechsler Adult Intelligence Scale-third edition. Logistic regression models were performed for neurocognitive analysis. For neuroimaging, we used the CONN toolbox to assess FC between the specified regions, and ROI-to-ROI analysis. In the combined sample, high PEs (all dimensions) were related to lower processing speed performance. High negative PEs were related to poor visual learning performance and lower IQ, while high depressive PEs were associated with poor working memory performance. Those with high negative PEs presented FPN hypoconnectivity between the right and left lateral prefrontal cortex. There were no associations between PEs and the DMN and SN FC. Brazilian individuals with high PEs showed neurocognitive impairments like those living in wealthier countries. Hypoconnectivity in the FPN in a community sample with high PEs is coherent with the hypothesis of functional dysconnectivity in schizophrenia.

Catecholamine concentration as a predictor of mortality in emergency surgical patients

BACKGROUND

Trauma and emergency surgery are major causes of morbidity and mortality. The objective of this study was to determine whether serum levels of epinephrine and norepinephrine are associated with aging and mortality.

METHODS

This was a prospective observational cohort study conducted in a surgical critical care unit. We included 90 patients who were admitted for postoperative care, because of major trauma, or both. We collected demographic and clinical variables, as well as serum levels of epinephrine and norepinephrine.

RESULTS

For patients in the > 60-year age group, the use of vasoactive drugs was found to be associated with an undetectable epinephrine level (OR [95% CI] = 6.36 [1.12, 36.08]), p = 0.05). For the patients with undetectable epinephrine levels, the in-hospital mortality was higher among those with a norepinephrine level ≥ 2006.5 pg/mL (OR [95% CI] = 4.00 [1.27, 12.58]), p = 0.03).

CONCLUSIONS

There is an association between age and mortality. Undetectable serum epinephrine, which is more common in older patients, could contribute to poor outcomes. The use of epinephrine might improve the clinical prognosis in older surgical patients with shock.

Awareness for need of improvement in knowledgement about oral lesions for professionals in primary health care

Objetivo: O objetivo desse estudo foi avaliar a eficácia do diagnóstico e tratamento de lesões orais entre diferentes níveis de saúde. Material e Métodos: Todas as informações foram obtidas dos prontuários médicos de um Hospital Universitário e de fichas do Sistema Público de Regulação, considerando as características clínico-demográficas tal como, doenças orais diagnosticadas, sistema de referência e terapia empregada. A avaliação foi baseada na relação entre diagnóstico final, hipótese diagnóstica e prioridade para agendamento da consulta, também foi considerado o tempo decorrido entre o encaminhamento e o primeiro atendimento, data do diagnóstico final e início da terapia. Depois, a hipótese diagnóstica preenchida por profissionais de saúde do nível primário e terciário foram comparadas e a concordância entre ambos foi determinada. Resultados: Cerca de 51% dos encaminhamentos preenchidos pelos profissionais da atenção primária estavam incompletos, ou a hipótese diagnóstica estava descrita de forma inadequada. No nível terciário, o tempo médio entre o encaminhamento e a primeira consulta foi de 23 dias, a média entre o diagnóstico final e o início do tratamento foi de 22 dias. O tratamento cirúrgico foi o mais rápido (31 dias) quando comparado a radioterapia para lesões malignas (81 a 100 dias). Conclusão: É necessário melhorar o treinamento de profissionais de saúde da Atenção Básica no reconhecimento de lesões orais malignas. Claramente, o preenchimento adequado das hipóteses de diagnóstico, com o grau de prioridade correspondente acelera o diagnóstico e tratamento do paciente.