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Background: Climate change threatens sub-Saharan Africa's agricultural production, causing abiotic and biotic stressors. The study of plant responses to joint stressors is crucial for understanding molecular processes and identifying resilient crops for global food security. This study aimed to explore the shared and tailored responses of okra plants (cv. ''Meya'), at the biochemical and molecular levels, subjected to combined stresses of drought and Meloidogyne incognita infection., Design: The study involved 240 okra plants in a completely randomized design, with six treatments replicated 20 times. Okra plants were adequately irrigated at the end of every 10-days water deficit that lasted for 66 days (D). Also, the plants were infected with M. incognita for 66 days and irrigated at 2-days intervals (R). The stresses were done independently, in sequential combination (D before R and R before D) and concurrently (R and D). All biochemical and antioxidant enzyme assays were carried out following standard procedures., Results: Significant reductions in leaf relative water content were recorded in all stressed plants, especially in leaves of plants under individual drought stress (D) (41.6%) and plants stressed with root-knot nematode infection before drought stress (RBD) (41.4%). Malondialdehyde contents in leaf tissues from plants in D, nematode-only stress (RKN), drought stress before root-knot nematode infection (DBR), RBD, and concurrent drought-nematode stress (RAD) significantly increased by 320.2%, 152.9%, 186.5%, 283.7%, and 109.6%, respectively. Plants in D exhibited the highest superoxide dismutase activities in leaf (147.1% increase) and root (105.8% increase) tissues. Catalase (CAT) activities were significantly increased only in leaves of plants in D (90.8%) and RBD (88.9%), while only roots of plants in D exhibited a substantially higher CAT activity (139.3% increase) in comparison to controlled plants. Okra plants over-expressed NCED3 and under-expressed Me3 genes in leaf tissues. The NCED3 gene was overexpressed in roots from all treatments, while CYP707A3 was under-expressed only in roots of plants in RBD and RKN. CYP707A3 and NCED3 were grouped as closely related genes, while members of the Me3 genes were clustered into a separate group., Conclusion: The biochemical and molecular responses observed in okra plants (cv. ''Meya') subjected to combined stresses of drought and Meloidogyne incognita infection provide valuable insights into enhancing crop resilience under multifaceted stress conditions, particularly relevant for agricultural practices in sub-Saharan Africa facing increasing climatic challenges., (© 2024. The Author(s).)

Background: Head and Neck Cancer (HNC) is the eighth most prevalent global cancer. Timely recognition of symptoms is crucial for reducing mortality rates. The EVolution of a patiEnt-REported symptom-based risk stratification sySTem to redesign the suspected Head and Neck cancer referral pathway (EVEREST-HN) study aims to develop and evaluate a risk stratification tool using patient reported symptoms, which will be populated remotely in the community before the patient is seen by the clinician to hasten HNC diagnosis. EVEREST-HN will design a patient SYmptom iNput Clinical (SYNC) system to gather patient symptom data and calculate a risk score to aid clinicians in identifying high-risk cases. This identification potentially allows for high-risk patients to be seen sooner, thereby improving patient outcomes., Methods: Three workshop sessions were conducted involving a total of 17 unique participants, with several contributing to multiple sessions: nine in the co-design session, six in the validation session, and nine in the evaluation session. The co-design session employed online collaboration with patients' representatives. Thematic analysis was used to identify requirements and concerns informing the development of a low-fidelity prototype. The validation session assessed whether the prototype aligned with patient expectations. In the evaluation session, participants interacted with an online prototype and provided further feedback., Results: During the co-design workshop, participants emphasized the need for a concise and clear SYNC system questionnaire for reporting suspected HNC symptoms. Concerns were raised about questionnaire length, language clarity, and the inclusion of probing questions. Participants suggested concise questions using lay language, incorporating visual aids for topics like alcohol and tobacco use, and making the sexual activity question optional. Recommendations included diverse language options, hard copies for non-English speakers, and phone call options for those uncomfortable with screen-based technology. The validation workshop confirmed that the prototype reflected participants' ideas. Feedback highlighted the need for call-back features to help those not confident with technology and the need to present symptom questions first before social background questions. Feedback from the evaluation demonstrated a commitment to efficiency, and continuous improvement., Conclusion: This study aims to develop the SYNC system to enhance efficiency of suspected HNC referrals. The workshops highlighted the importance of end-user inclusiveness in the system development life cycle, with collaboration with stakeholders and repeated feedback, providing crucial insights for ensuring the SYNC system effectively addresses the needs and concerns of patients in the context of HNC diagnosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Evolution of a patient-reported symptom-based risk stratification system to redesign the suspected head and neck cancer (HNC) referral pathway (EVEREST-HN) will use a broad and open approach to the nomenclature and symptomatology. It aims to capture and utilise the patient reported symptoms in a modern way to identify patients' clinical problems more effectively and risk stratify the patient., Method: The review followed the PRISMA checklist for scoping reviews. A search strategy was carried out using Medline, Embase and Web of Science between January 1st 2012 and October 31st 2023. All titles, abstracts and full paper were screened for eligibility, papers were assessed for inclusion using predetermined criteria. Data was extracted pertaining to the aims, type of study, cancer type, numbers of patients included and symptoms, presenting complaints or signs and symptoms., Results: There were 9,331 publications identified in the searches, following title screening 350 abstracts were reviewed for inclusion and 120 were considered for eligibility for the review. 48 publications met the eligibility criteria and were included in the final review. Data from almost 11,000 HNC patients was included. Twenty-one of the publications were from the UK, most were retrospective examination of patient records. Data was extracted and charted according to the anatomical area of the head and neck where the symptoms are subjectively and objectively found, and presented according to lay terms for symptoms, clinical terms for symptoms and the language of objective clinical findings., Discussion: Symptoms of HNC are common presenting complaints, interpreting these along with clinical history, examination and risk factors will inform a clinician's decision to refer as suspected cancer. UK Head and Neck specialists believe a different way of triaging the referrals is needed to assess the clinical risk of an undiagnosed HNC. EVEREST-HN aims to achieve this using the patient history of their symptoms. This review has highlighted issues in terms of what is considered a symptom, a presenting complaint and a clinical finding or sign., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Bradley, Lee, Albutt, Hardman, Kellar, Odo, Randell, Rousseau, Tikka, Patterson and Paleri.)

Introduction: Between 2009/2010 and 2019/2020, England witnessed an increase in suspected head and neck cancer (sHNC) referrals from 140 to 404 patients per 100 000 population. 1 in 10 patients are not seen within the 2-week target, contributing to patient anxiety. We will develop a pathway for sHNC referrals, based on the Head and Neck Cancer Risk Calculator. The evolution of a patient-reported symptom-based risk stratification system to redesign the sHNC referral pathway (EVEREST-HN) Programme comprises six work packages (WPs). This protocol describes WP1 and WP2. WP1 will obtain an understanding of language to optimise the SYmptom iNput Clinical (SYNC) system patient-reported symptom questionnaire for sHNC referrals and outline requirements for the SYNC system. WP2 will codesign key elements of the SYNC system, including the SYNC Questionnaire, and accompanying behaviour change materials., Methods and Analysis: WP1 will be conducted at three acute National Health Service (NHS) trusts with variation in service delivery models and ensuring a broad mixture of social, economic and cultural backgrounds of participants. Up to 150 patients with sHNC (n=50 per site) and 15 clinicians (n=5 per site) will be recruited. WP1 will use qualitative methods including interviews, observation and recordings of consultations. Rapid qualitative analysis and inductive thematic analysis will be used to analyse the data. WP2 will recruit lay patient representatives to participate in online focus groups (n=8 per focus group), think-aloud technique and experience-based codesign and will be analysed using qualitative and quantitative approaches., Ethics and Dissemination: The committee for clinical research at The Royal Marsden, a research ethics committee and the Health Research Authority approved this protocol. All participants will give informed consent. Ethical issues of working with patients on an urgent cancer diagnostic pathway have been considered. Findings will be disseminated via journal publications, conference presentations and public engagement activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Urological surgeries are a significant part of surgical services. The need for these services varies regionally and globally. Knowledge of the local need is important for prioritisation of resources., Objectives: To describe the urological procedures done in our hospital for effective utilisation of the already scarce resource in this region., Patients and Methods: This was a retrospective one-year study of the urosurgical cases done in a Nigerian Teaching Hospital. The main theatre register was used to collate data. Data collected included age, sex, operation done and anaesthesia employed., Results: One hundred and twenty-two male and three female patients were included with a male-to-female ratio of 41:1. The mean age of the patients was 56.6 ± 19.89 years. Elective cases accounted for 102 (81.6%) of surgeries. Regional anaesthesia was the most common form of anaesthesia accounting for 105 (84%) followed by local anaesthesia in 16 (12.8%). Day cases accounted for 77 (61.6%) of procedures. More than 80% of the study population was 50 years and older. Overall, the three most common performed surgeries were digital-guided prostate biopsy 47 (37.6%), suprapubic cystostomy 16 (12.8%) and open prostatectomy 9 (7.2%). In male patients, the three most common procedures were prostate biopsy 47 (38.5%), suprapubic cystostomy 16 (13.1 %), open prostatectomy 9 (7.4%) whereas nephrectomy, pyeloplasty and stent removal each accounted for 33.3% each of procedures in female patients. Endourological procedures accounted for 5 (4%) of cases., Conclusion: Open surgeries accounted for the majority of these cases done with prostate-related procedures being the most common procedures. Few endourological procedures were performed., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of the west African college of surgeons.)

Background: Open prostatectomy (OP) is still a valid treatment option for benign prostatic hyperplasia (BPH), but it needs to be constantly reevaluated in the context of minimally invasive treatments (MITs)., Aim: Our purpose is to present contemporary data on patient presentation and surgical outcomes of OP with which other OP series and MITs can be compared., Methods: A retrospective study of all OP was carried out in our institution from January 2011 to December 2020. All patients had a thorough preoperative workup and optimization of comorbidities before surgery. Data were collected in a predesigned pro forma and analyzed., Results: The mean age of the 148 patients studied was 66.2 (±7.9) yrs. The mean duration of symptoms before surgery was 32.2 (±33.7) mos. The mean preoperative prostate volume was 118.0 (±67.1) cm 3 . There was a 54.4% comorbidity rate with diabetes mellitus (DM) topping the list (16.0%). An incidental prostate cancer rate of 6.1% was found. The overall complication rate was 45.3%. Perioperative hemorrhage requiring blood transfusion (BT) was the most common complication (26.1%). There was no significant difference in age, duration of surgery, and prostrate volume between subjects with and without BT (P > 0.05). Wound infection was significantly associated with diabetes (P = 0.043, OR = 3.507, 95% CI = 1.042-11.805). The reoperation rate was 1.4%, and mortality rate was 0.7%. The International Prostate Symptom Score (IPSS), quality-of-life (QOL) score, and post-void residual urine (PVR) volume were significantly improved (P < 0.001)., Conclusion: OP was found to be a safe and effective procedure for the relief of bladder outlet obstruction (BOO) secondary to BPH. However, it was associated with high morbidity and low reoperation rate., Competing Interests: None

The family is the simplest unit but possesses the strongest bond in society. These qualities - bond and proximity - that exist both within and across neighboring families, according to our research, can be instrumental in shaping a new kind of health promotion strategy that can transform health behaviors in communities. The Whole Family Approach (WFA) is a government-sanctioned approach to increase uptake of COVID-19 vaccines in Nigeria. The approach entails leveraging the high family-based demand for some primary health services, such as malaria, diabetes, hypertension, and reproductive services, to generate demand for COVID-19 and routine immunizations. However, since the announcement in 2021, there has been no available evidence to show the impact of the approach on COVID-19 vaccine uptake, though global literature generally favors family-centered health approaches. This study tests the effectiveness of the approach in increasing the utilization of target services in a Nigerian community and further provides a theoretical framework for the strategy. Two primary healthcare facilities were selected in two communities located in Abuja in a quasi-experimental design. After a small-sample landscape assessment of the communities and the facilities, family-targeting health promotion activities were facilitated in the intervention community (integrated health education by trained community health influencers) and facility (opportunistic health promotion through in-facility referrals) for one month. Anonymized service utilization data were acquired from both facilities over a period of four months to analyze their respective month-by-month service utilization trends. Time trend analysis was conducted and revealed that WFA significantly increased service utilization ( N  = 5870; p  < 0.001, α  = 0.01, 99% CI) across all the package services provided at the intervention facility. A supplementary Pearson's correlation analysis further presented a positive relationship ( r  = 0.432-0.996) among the services which favored the result. It can therefore be concluded that the "Whole Family Approach" of health promotion is efficacious in accelerating uptake of priority health services such as COVID-19 and routine immunizations. While there is more to be understood about this interesting approach, we recommend the improvement of communication and capacity gaps in Nigeria's primary healthcare system to ensure that promising strategies such as the WFA are adequately implemented at the community and facility levels., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Ade-Banjo, Offor, Nwankwo, Nwaononiwu, Adukwu, Egharevba, Owoyemi, Odo and Olatunji.)

Background: To demonstrate the outcome of our initial experience in the management of upper tract stones with ureteroscopy and Holmium: YAG laser lithotripsy., Methodology: The data of thirty-two patients who had ureteroscopy and laser lithotripsy for upper urinary tract stones at a private urology centre in Awka, Anambra State Nigeria from September 2020 to June 2022 (20months) were retrospectively studied. Their sociodemographic data, clinical symptoms, the location and size of the stones, preoperative and postoperative stent use, hospital stay, complications, and stone-clearance rates were analyzed., Results: A total of 32 procedures were performed on 32 patients. The mean age of the patients was 44.7 ± 12.2 years. The mean stone size was 15.4 ± 6.7mm with a range of 8.0-39mm, and Hounsfield unit ranging from 233-906. The stones were on the right tract, left tract, and bilateral in 46.9%, 43.7%, and 9.4% of the cases respectively. The patients had a mean length of hospital stay of 3.31 ± 1.45 days. The stone clearance rate was 90.3%. 53.1% of the patients had postoperative complications with 40.6% of these being post-operative fever which resolved with antibiotics. There was treatment failure in one patient due to the inability to scope the ureter on account of ureteral stricture., Conclusion: Ureteroscopy and laser lithotripsy are safe and effective options in the management of upper tract stones with the advantages of being performed via a natural orifice, being less painful, with reduced risk of severe bleeding, irreversible loss of renal parenchyma, as well as a short hospital stay., (Copyright © 2023 Nigerian Medical Association.)

In recent decades, cardiovascular disease (CVD) has become the leading cause of death in most countries of the world. Since many types of CVD are preventable by modifying lifestyle behaviors, the objective of this paper is to develop an effective personalized lifestyle recommendation algorithm for reducing the risk of common types of CVD. However, in practice, the underlying relationships between the risk factors (e.g., lifestyles, blood pressure, etc.) and disease onset is highly complex. It is also challenging to identify effective modification recommendations for different individuals due to individual's effort-benefits consideration and uncertainties in disease progression. Therefore, to address these challenges, this study developed a novel data-driven approach for personalized lifestyle behaviors recommendation based on machine learning and a personalized exponential utility function model. The contributions of this work can be summarized into three aspects: (1) a classification-based prediction model is implemented to predict the CVD risk based on the condition of risk factors; (2) the generative adversarial network (GAN) is incorporated to learn the underlying relationship between risk factors, as well as quantify the uncertainty of disease progression under lifestyle modifications; and (3) a novel personalized exponential utility function model is proposed to evaluate the modifications' utilities with respect to CVD risk reduction, individual's effort-benefits consideration, and disease progression uncertainty, as well as identify the optimal modification for each individual. The effectiveness of the proposed method is validated through an open-access CVD dataset. The results demonstrate that the personalized lifestyle modification recommended by the proposed methodology has the potential to effectively reduce the CVD risk. Thus, it is promising to be further applied to real-world cases for CVD prevention., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Physical inactivity (PIA) is the fourth leading risk factor in an estimated global death of 3.2 million annually. To reverse this negative impact of PIA, there is a need to increase physical activity (PA). This could be achieved through creation of awareness, promotion, and good practice of PA by healthcare workers., Objective: To evaluate physical activity among healthcare workers (HCW) in a major tertiary hospital, southeast Nigeria., Methods: The Global Physical Activity Questionnaire (GPAQ) was researcher-administered to investigate PA level among consenting HCW who met the inclusion criteria. Participants were recruited from their workstations in the hospital. The questionnaire recorded age, anthropometrics, demographics, and physical activity. Data were summarized with descriptive statistics of frequency and percentages. The spearman rank correlation test was used to assess for the relationship between PA and socio-demographic factors., Results: There were 209 participants with 93 (44.5%) males and 116 (55.5%) females. The mean age was 34.32±9.88 years. Amongst different professions, Nurses were 53(25.3%), Doctors, 31 (14.8%), and Dietitians, 21 (10%), Accountants, 19 (9.1%). The majority of the participants 100 (47.8%) had physical activity level that was high (extra sufficient), 31 (14.8%) had a moderate PA level while 78 (37.3%) had a low physical activity level. There was a significant negative relationship between PA and age, marital status, number of children, and other dependents respectively, whereas there was no significant relationship between PA and gender, income, and family type., Conclusion: HCWs have the minimum required PA in a week. About 63% met the minimum required PA in a week. Age, marital status, and having children or dependents reduce participation in PA. However, there is a need for conscious awareness and practice of PA among HCW in the hospital., Competing Interests: The Authors declare that no competing interest exists, (Copyright © 2023 by West African Journal of Medicine.)

Background: Hepatitis B and C viruses and HIV infections contribute a significant proportion to maternal and perinatal morbidity and mortality in low and middle-income countries. While the burden of hepatitis B and C viruses is higher in low and middle-income countries, Nigeria also has the second largest burden of HIV., Objectives: To determine the seroprevalence of hepatitis B and C viruses and HIV infections among antenatal women who sought care at a secondary health facility in Lagos., Methods: This was a retrospective review of patients managed in the antenatal clinic of 68 Nigerian Army Reference Hospital over one year. A study proforma was used to collect relevant data which were entered and analyzed using the IBM Statistical Package for Social Sciences (SPSS Statistics) Version 23., Results: A total of 347 women attended prenatal care during the study period, however, only 329 cases with complete data were included in the final statistical analysis. The prevalence of HIV in our study was 6.4%, while HBV and HCV accounted for 6.2% and 1.8% respectively. Hepatitis B, and hepatitis C viruses and HIV Infections occurred in 3 (0.9%) of our patients, 6 (1.8%) of the women had HIV-HBV co-infection while 1 (0.3%) was infected with HIV-HCV., Conclusion: Our study re-emphasizes the public health importance of HBV, HCV and HIV screening in our antenatal clinics. This knowledge is very important for the implementation of effective prevention and control measures that will further decrease the mother-to-child transmission of these viruses., Competing Interests: The Authors declare that no competing interest exists., (Copyright © 2022 by West African Journal of Medicine.)

Introduction: Prostate cancer (CaP) is the second most common cancer in men and the fifth most common cancer worldwide. The incidence in Nigeria is rising. Numerous challenges exist that prevent the successful management of these patients in this subregion., Aims and Objectives: This study aimed to report on the modes of presentation and difficulties encountered in managing patients with CaP in our environment with a view to finding solutions to these challenges., Materials and Methods: This was a retrospective study of all CaP patients who were managed in Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria over a 10-year period from 2012 to 2021. Data were collated using a pro forma. Numerical data were summarized as means, median, and standard deviation, whereas categorical data were summarized as frequencies. Statistical significance was pegged at P < 0.05., Results: Seventy-three patients were analysed. The mean age of the patients was 71.48 ± 8.15 years. The three most common presenting complaints were lower urinary tract symptoms (LUTSs) 23 (31.5%), acute urinary retention 9 (12.3%), and LUTS with low back pain 9 (12.3%). The median duration of symptoms was 6.5 months. No difference was noted among educational level, occupation, and stage of CaP, ( P =0.222 and P =0.548), respectively. The median total prostate-specific antigen was 85.0 ng/mL. Sixty-seven patients (91.8%) had an abdominopelvic ultrasound scan. Fifty patients (68.5%) had stage 4 disease. Thirty-eight (52.1%) had financial constraints. Forty-nine (67.1%) patients were lost to follow-up. Bilateral orchidectomy was offered to 28 (38.4%) patients., Conclusion: Financial constraint was a huge barrier in the management of CaP patients in this study. Late presentation was common in this study., Competing Interests: Nil., (Copyright: © 2022 Journal of the West African College of Surgeons.)

Critical, time-bounded, and high-stress tasks, like incident response, have often been solved by teams that are cohesive, adaptable, and prepared. Although a fair share of the literature has explored the effect of personality on various other types of teams and tasks, little is known about how it contributes to teamwork when teams of strangers have to cooperate ad-hoc , fast, and efficiently. This study explores the dynamics between 120 crowd participants paired into 60 virtual dyads and their collaboration outcome during the execution of a high-pressure, time-bound task. Results show that the personality trait of Openness to experience may impact team performance with teams with higher minimum levels of Openness more likely to defuse the bomb on time. An analysis of communication patterns suggests that winners made more use of action and response statements. The team role was linked to the individual's preference of certain communication patterns and related to their perception of the collaboration quality. Highly agreeable individuals seemed to cope better with losing, and individuals in teams heterogeneous in Conscientiousness seemed to feel better about collaboration quality. Our results also suggest there may be some impact of gender on performance. As this study was exploratory in nature, follow-on studies are needed to confirm these results. We discuss how these findings can help the development of AI systems to aid the formation and support of crowdsourced remote emergency teams., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Vinella, Odo, Lykourentzou and Masthoff.)

Background: Clostridioides difficile infection (CDI) is a leading cause of hospital-associated antibiotic-related diarrhea and deaths worldwide. Vancomycin is one of the few antibiotics recommended for both nonsevere and severe CDI cases. We sought to determine whether vancomycin nonsusceptible C. difficile strains are circulating in the patient population., Methods: Stool samples from patients with CDI were collected from 438 and 98 patients at a large university hospital in Houston, Texas, and Nairobi, Kenya, respectively. The stools were examined for the presence of vancomycin and metronidazole nonsusceptible C. difficile using broth dilution culture, Etest (BioMérieux, France), polymerase chain reaction (PCR), whole-genome sequencing, and in vivo testing in a CDI mouse model., Results: Of the Houston stool samples, 114/438 (26%) had vancomycin nonsusceptible C. difficile isolates and 128/438 (29%) were metronidazole nonsusceptible. Similarly, 66 out of 98 (67%) and 83/98 (85%) of the Nairobi patients harbored vancomycin and metronidazole nonsusceptible isolates, respectively. Vancomycin treatment of a CDI mouse model infected with a vancomycin nonsusceptible isolate failed to eradicate the infection. Whole-genome sequencing analyses did not identify vanA genes, suggesting a different mechanism of resistance., Conclusions: C. difficile strains exhibiting reduced susceptibility to vancomycin are currently circulating in patient populations. The spread of strains resistance to vancomycin, a first-line antibiotic for CDI, poses a serious therapeutic challenge. Routine susceptibility testing may be necessary., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Clonal replacement is a major driver for changes in bacterial disease epidemiology. Recently, it has been proposed that episodic emergence of novel, hypervirulent clones of group A Streptococcus (GAS) results from acquisition of a 36-kb DNA region leading to increased expression of the cytotoxins Nga (NADase) and SLO (streptolysin O). We previously described a gene fusion event involving the gene encoding the GAS M protein ( emm ) and an adjacent M-like protein ( enn ) in the emm4 GAS population, a GAS emm type that lacks the hyaluronic acid capsule. Using whole-genome sequencing of a temporally and geographically diverse set of 1,126 isolates, we discovered that the North American emm4 GAS population has undergone clonal replacement with emergent GAS strains completely replacing historical isolates by 2017. Emergent emm4 GAS strains contained a handful of small genetic variations, including the emm-enn gene fusion, and showed a marked in vitro growth defect compared to historical strains. In contrast to other previously described GAS clonal replacement events, emergent emm4 GAS strains were not defined by acquisition of exogenous DNA and had no significant increase in transcript levels of nga and slo toxin genes via RNA sequencing and quantitative real-time PCR analysis relative to historic strains. Despite the in vitro growth differences, emergent emm4 GAS strains were hypervirulent in mice and ex vivo growth in human blood compared to historical strains. Thus, these data detail the emergence and dissemination of a hypervirulent acapsular GAS clone defined by small, endogenous genetic variation, thereby defining a novel model for GAS strain replacement. IMPORTANCE Severe invasive infections caused by group A Streptococcus (GAS) result in substantial morbidity and mortality in children and adults worldwide. Previously, GAS clonal strain replacement has been attributed to acquisition of exogenous DNA leading to novel virulence gene acquisition or increased virulence gene expression. Our study of type emm4 GAS identified emergence of a hypervirulent GAS clade defined by variation in endogenous DNA content and lacking augmented toxin gene expression relative to replaced strains. These findings expand our understanding of the molecular mechanisms underlying bacterial clonal emergence.

Background: Urological emergencies constitute a significant part of emergency presentations in various referral centers. Data on the prevalence of these emergencies in West African sub-region are sparse., Objective: The study is aimed at determining the pattern of urological emergencies in our center and is geared towards bridging the gap in knowledge of the epidemiology of urological emergencies in this sub-region as a means of achieving efficient use of scarce resources., Subjects and Methods: It was a retrospective study of all urological emergency cases that presented over six years in a Federal University Teaching Hospital in Nigeria. Data were collected from emergency register and theatre logs. Data analysis was done using SPSS version 25., Results: A total of 267 patients presented with urological emergencies during the period of study with 258 (96.6%) men and 9 (3.4%) women. The mean age of the patients was 50.6 ± 20.8 years. Urinary retention was the most common urological emergency accounting for 159 (59.6%) cases followed by Fournier's gangrene 23 (8.6%) and testicular torsion 23 (8.6%). Bladder and ureteral injuries accounted for 5 (55.6%) of the urological emergency presentations in women while both injuries accounted for only 4 (1.6%) in men (P = 0.000). Urethral catheterization was the most commonly performed procedure 139 (52.1%), followed by percutaneous suprapubic cystostomy (SPC) 31 (11.6%)., Conclusion: Urological emergencies have varying presentations in both sexes. Urinary retention, and acute scrotum were the most common urological emergencies in our facility. This knowledge can be used in emergency preparedness planning which involves personnel training and resource allocation., Competing Interests: None

Background: Benign prostatic hyperplasia is one of the most common diseases in aging males. For men that need surgical treatment, transurethral resection of the prostate (TURP) is the gold standard. The aim of this article is to retrospectively review the complications of TURP over a 3-year period in Nnamdi Azikiwe University Teaching Hospital Nnewi and a Specialist Urology Center in Awka all in Anambra South-East Nigeria using Clavien-Dindo classification., Patients and Methods: The study was a retrospective review of consecutive TURPs done over a 3-year period. Patients' information and complications arising from the procedure were collected and graded using the Clavien-Dindo classification with a pro forma designed for the study and analyzed with the Statistical Package for the Social Sciences software version 20.0., Results: Ninety-seven patients had TURP during the period of this study. Twenty-nine complications were noted in 24 patients. The postoperative morbidity rate was 24.74%, and no mortality was recorded. Most of the complications were grade 2 (55%), followed by grade 1 and 3 (20.69%) each. Grade 4a complication accounted for only 3.45%. No grade 5 complication was recorded., Conclusion: TURP is safe, with minimal life-threatening morbidity even in a resource-poor economy where TURP is gradually gaining grounds., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Nigerian Journal of Surgery.)

Unlabelled: Clostridium difficile infection (CDI) is responsible for most of the definable cases of antibiotic- and hospital-associated diarrhea worldwide and is a frequent cause of morbidity and mortality in older patients. C. difficile, a multidrug-resistant anaerobic pathogen, causes disease by producing toxins A and B, which are controlled by an accessory gene regulator (Agr) quorum signaling system. Some C. difficile strains encode two Agr loci in their genomes, designated agr1 and agr2 The agr1 locus is present in all of the C. difficile strains sequenced to date, whereas the agr2 locus is present in a few strains. The functional roles of agr1 and agr2 in C. difficile toxin regulation and pathogenesis were unknown until now. Using allelic exchange, we deleted components of both agr loci and examined the mutants for toxin production and virulence. The results showed that the agr1 mutant cannot produce toxins A and B; toxin production can be restored by complementation with wild-type agr1 Furthermore, the agr1 mutant is able to colonize but unable to cause disease in a murine CDI model. These findings have profound implications for CDI treatment because we have uncovered a promising therapeutic target for the development of nonantibiotic drugs to treat this life-threatening emerging pathogen by targeting the toxins directly responsible for disease., Importance: Within the last decade, the number of cases of C. difficile infections has been increasing exponentially in the United States, resulting in about 4.8 billion U.S. dollars in health care costs annually. As a multidrug-resistant, spore-forming, anaerobic pathogen, C. difficile overpopulates the colon after the gut microbiota has been altered by antibiotic therapy. With increasing resistance to antibiotic treatment of C. difficile infections, patients are experiencing higher costs of health care and a lower quality of life as treatment options decrease. During infection, C. difficile produces toxins A and B, which directly cause disease. As a result, the toxins have become promising nonantibiotic treatment targets. Here, we have identified a pathway responsible for activating the production of the toxins. This important finding opens up a unique therapeutic target for the development of a novel nonantibiotic therapy for C. difficile infections., (Copyright © 2016 Darkoh et al.)

Background/objectives: In the last two decades, in Brazil, there has been a decreasing trend of consumption of in natura or minimally processed food, while intake of ultra-processed food has markedly increased. We estimated the contribution of dietary intake in trends from coronary heart disease mortality (CHDM), cardiovascular disease mortality (CVDM), and all-cause mortality (ACM) over 20years in Brazil., Methods: We used a representative sample of Brazilian households located in metropolitan areas to estimate dietary intake in 1987/88 and 2008/09. For both periods, we estimated fractions of CHDM, CVDM, and ACM attributable to healthy (fruits and vegetables) and unhealthy food items (sugar-sweetened beverages, processed and red meat). We also estimated the number of prevented or postponed deaths attributable to these food items., Results: The fraction of CHDM attributable to all food items increased from 28.6% in 1987/88 to 38.7% in 2008/09. CVDM attributable to food items increased from 13.7% in 1974 to 19.3% in 2008/09. ACM attributable to all food items increased from 20.1% in 1987/88 to 27.3% in 2008/09. Without the decrease in healthy food item consumption, and the increase in unhealthy food items, 3195 deaths from coronary heart disease, 5340 from cardiovascular disease, and 16,970 from all causes could have been prevented or postponed., Conclusions: The burden of cardiovascular diseases and mortality attributable to dietary intake has increased over the last 20years in Brazil. These findings suggest a need for a population prevention approach, focused on dietary intake to reduce the burden of disease., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Evidence of the influence of the school food environment on adolescent diet is still little explored in low- and middle-income countries. We aimed to evaluate the association between food environment in schools and the immediate vicinity and the regular consumption of unhealthy food among adolescents., Methods: We used cross-sectional data collected by the Brazilian National Survey of School Health (PeNSE) from a representative sample of adolescents attending 9th grade public and private schools in Brazil, in 2012. We estimated students' regular consumption (>5days/week) of unhealthy food (soft drinks, bagged salty snacks, deep fried salty snacks and sweets) and school availability, in the cafeteria or an alternative outlet, of the same food plus some healthy options (fruit and natural fruit juice). We performed multilevel logistic regression models., Results: Having a cafeteria inside school selling soft drinks (private schools OR=1.23; 95% CI=1.14-1.33; public schools OR=1.13; 95% CI=1.06-1.20) and deep fried salty snacks (private schools OR=1.41 95% CI=1.26-1.57; public schools OR=1.16 95% CI=1.08-1.24) was associated with a higher consumption of these unhealthy foods of among students. In private schools, cafeteria selling fruit and natural fruit juice was associated with lower student consumption of bagged salty snacks (OR=0.86; 95% CI 0.77-0.96) and soft drinks (OR=0.85; 95% CI=0.76-0.94). In addition, eating meals from the Brazilian School Food Program in public schools was associated with a lower consumption of unhealthy foods., Conclusions: Foods available in the school food environment are associated with the consumption of unhealthy food among adolescents in Brazil., (Copyright © 2016. Published by Elsevier Inc.)

This study aimed to estimate the prevalence of physical activity in different domains and the association with schooling, using a serial cross-sectional population-based design comparing data from two editions of a health survey in the city of São Paulo, Brazil. Participation included 1,667 adults in 2003 and 2,086 in 2008. Probabilistic sampling was performed by two-stage clusters. The long version of International Physical Activity Questionnaire (IPAQ) allowed evaluating multiple domains of physical activity. Poisson regression was used. Men were more active in their leisure time and at work and women in the home. Schooling was associated directly with leisure-time activity (2003 and 2008) and inversely with work-related physical activity (2003) for men and for women in housework. The studies showed that Brazilians with less schooling are becoming less active, so that intervention strategies should consider different educational levels. Interventions in the urban space and transportation can increase the opportunities for physical activity and broaden access by the population.

Objective: To analyze the association of physical activity facilities and extracurricular sports activities in schools with physical activity among adolescents., Methodology/principal Findings: We used data collected for the National Survey of School Health in 2012. The national representative sample comprised 109,104 Brazilian students from 2,842 schools. We calculated the prevalence of participation in physical education classes, leisure-time physical activity, and total physical activity level. We also evaluated the following physical activity facilities: sports courts, running/athletics tracks, schoolyard with teacher-directed physical activities, swimming pools, locker rooms; and the offer of extracurricular sports activities. Schools with at least one physical activity facility had increased odds of participation in physical education (OR 1.59; 95% CI 1.20 to 2.10). However, in order to increase leisure-time physical activity (OR1.14; 95% CI 1.03 to 1.26) and total physical activity level (OR 1.15; 95% CI 1.06 to 1.24) at least four and two facilities, respectively, were necessary. Extracurricular sports activities in schools were positively associated with leisure-time physical activity and physical activity level. The number of sports courts and swimming pool in a school were associated with participation in physical education classes. Availability of sports courts, running/athletics tracks, and swimming pool in schools were associated with leisure-time physical activity. Total physical activity was associated with schools with sports courts, schoolyard with teacher-directed physical activities, and swimming pool., Conclusions: School-level characteristics have important potential to increase the possibility of engagement in physical activity in and out of school, and therefore have a fundamental role in promoting these practices.

Objective: To analyse the dietary intake of Brazilian adolescents and investigate its association with sociodemographic factors as well as health-risk and health-protective behaviours., Design: Cross-sectional study., Setting: The study was based on data supplied by the National Survey of Schoolchildren's Health (2012) on sociodemographic factors, dietary intake and health-risk and health-protective behaviours of schoolchildren in Brazil. A nutritional scale was elaborated combining markers of healthy and unhealthy diets. Poisson regression analysis was applied to investigate the association between the sociodemographic factors and regular intake (≥5 times/week) of selected foods; linear regression analysis was applied to investigate the association of sociodemographic and behavioural factors with nutritional scale score., Subjects: A total of 109 104 adolescents attending the ninth year of education at 2842 schools in Brazil., Results: Fewer than 30 % of the adolescents consumed raw or cooked vegetables on a regular basis, whereas more than one-third reported regular intake of sweets, soft drinks and sweet biscuits. Adolescents from the southern area and the oldest ones were those most exposed to inadequate dietary intake. The nutritional scale average score was higher in the students attending public school and exhibited a positive correlation with protective behaviours, such as being physically active, having meals with parents and eating breakfast, and a negative correlation with risk behaviours such as eating while studying or watching television and having smoked, drunk alcohol or used other drugs in the previous 30 d., Conclusions: The results indicate an association between undesirable nutritional habits and other risk behaviours among Brazilian adolescents.

Background: In Brazil, one-fifth of the population reports not doing any physical activity. This study aimed to assess the impact of physical inactivity on major noncommunicable diseases (NCDs), all-cause mortality and life expectancy in Brazil, by region and sociodemographic profile., Methods: We estimated the population attributable fraction (PAF) for physical inactivity associated with coronary heart disease, type 2 diabetes, breast cancer, colon cancer, and all-cause mortality. To calculate the PAF, we used the physical inactivity prevalence from the 2008 Brazilian Household Survey and relative risk data in the literature., Results: In Brazil, physical inactivity is attributable to 3% to 5% of all major NCDs and 5.31% of all-cause mortality, ranging from 5.82% in the southeastern region to 2.83% in the southern region. Eliminating physical inactivity would increase the life expectancy by an average of 0.31 years. This reduction would affect mainly individuals with ≥ 15 years of schooling, male, Asian, elderly, residing in an urban area and earning ≥ 2 times the national minimum wage., Conclusions: In Brazil, physical inactivity has a major impact on NCDs and mortality, principally in the southeastern and central-west regions. Public policies and interventions promoting physical activity will significantly improve the health of the population.

OBJECTIVE To analyze lifestyle risk factors related to direct healthcare costs and the indirect costs due to sick leave among workers of an airline company in Brazil. METHODS In this longitudinal 12-month study of 2,201 employees of a Brazilian airline company, the costs of sick leave and healthcare were the primary outcomes of interest. Information on the independent variables, such as gender, age, educational level, type of work, stress, and lifestyle-related factors (body mass index, physical activity, and smoking), was collected using a questionnaire on enrolment in the study. Data on sick leave days were available from the company register, and data on healthcare costs were obtained from insurance records. Multivariate linear regression analysis was used to investigate the association between direct and indirect healthcare costs with sociodemographic, work, and lifestyle-related factors. RESULTS Over the 12-month study period, the average direct healthcare expenditure per worker was US$505.00 and the average indirect cost because of sick leave was US$249.00 per worker. Direct costs were more than twice the indirect costs and both were higher in women. Body mass index was a determinant of direct costs and smoking was a determinant of indirect costs. CONCLUSIONS Obesity and smoking among workers in a Brazilian airline company were associated with increased health costs. Therefore, promoting a healthy diet, physical activity, and anti-tobacco campaigns are important targets for health promotion in this study population.

Background: The polymorphisms of IL28B have been described as important in the pathogenesis of infections caused by some viruses. The aim of this research was to evaluate whether IL28B gene polymorphisms (SNP rs8099917 and SNP rs12979860) are associated with HAM/TSP., Methods: The study included 229 subjects, classified according to their neurological status in two groups: Group I (136 asymptomatic HTLV-1 carriers) and Group II (93 HAM/TSP patients). The proviral loads were quantified, and the rs8099917 and rs12979860 SNPs in the region of IL28B-gene were analyzed by StepOnePlus Real-time PCR System., Results: A multivariate model analysis, including gender, age, and HTLV-1 DNA proviral load, showed that IL28B polymorphisms were independently associated with HAM/TSP outcome in rs12979860 genotype CT (OR = 2.03; IC95% = 0.96-4.27) and in rs8099917 genotype GG (OR = 7.61; IC95%  = 1.82-31.72)., Conclusion: Subjects with SNP rs8099917 genotype GG and rs12979618 genotype CT may present a distinct immune response against HTLV-1 infection. So, it seems reasonable to suggest that a search for IL28B polymorphisms should be performed for all HTLV-1-infected subjects in order to monitor their risk for disease development; however, since this is the first description of such finding in the literature, we should first replicate this study with more HTLV-1-infected persons to strengthen the evidence already provided by our results.

Objective: To compare the results of physical activity (PA) classification according to five international guidelines (American College of Sports Medicine, Institute of Medicine, Advisory Committee on International Physical Activity Questionnaire, World Health Organization, and European Union)., Methods: Cross-sectional study with 52 779 adults of both sexes, living in state capitals and the Federal District, selected using probability sampling. Data about duration, intensity, and frequency of weekly PA were obtained from a yearly survey conducted by the Health Ministry of Brazil (Risk and Protection Factors for Chronic Diseases Telephone Surveillance System-VIGITEL)., Results: The percent of participants classified as inactive by the five recommendations was similar. Among those who reported having engaged in PA, 45% were classified in the same activity level by all five guidelines (24.8% as insufficiently active, 10.6% as active, and 9.1% as very active). For the additional 55% who reported having engaged in PA, different classifications were obtained, ranging from insufficiently active to very active depending on the guideline., Conclusions: Nuances in the criteria used for each guideline translated into differences in classification of PA. Even though the overall goals of all guidelines are the same, the lack of agreement regarding the minimum recommended amount of PA impacts the development of policies to promote PA.

Objective: 1) To synthesize the current observational evidence for the association between sedentary behavior and health outcomes using information from systematic reviews. 2) To assess the methodological quality of the systematic reviews found., Methodology/principal Findings: Medline; Excerpta Medica (Embase); PsycINFO; and Web of Science were searched for reviews published up to September 2013. Additional publications were provided by Sedentary Behaviour Research Network members. The methodological quality of the systematic reviews was evaluated using recommended standard criteria from AMSTAR. For each review, improper use of causal language in the description of their main results/conclusion was evaluated. Altogether, 1,044 review titles were identified, 144 were read in their entirety, and 27 were included. Based on the systematic reviews with the best methodological quality, we found in children and adolescents, strong evidence of a relationship between time spent in sedentary behavior and obesity. Moreover, moderate evidence was observed for blood pressure and total cholesterol, self-esteem, social behavior problems, physical fitness and academic achievement. In adults, we found strong evidence of a relationship between sedentary behavior and all-cause mortality, fatal and non-fatal cardiovascular disease, type 2 diabetes and metabolic syndrome. In addition, there is moderate evidence for incidence rates of ovarian, colon and endometrial cancers., Conclusions: This overview based on the best available systematics reviews, shows that sedentary behavior may be an important determinant of health, independently of physical activity. However, the relationship is complex because it depends on the type of sedentary behavior and the age group studied. The relationship between sedentary behavior and many health outcomes remains uncertain; thus, further studies are warranted.

Background: Physical activity in adolescents is associated with short- and long-term health benefits. Physical activity can occur in various domains and is influenced by a complex network of factors. The aims of this study are 1) to describe the physical activity of Brazilian adolescents in physical education classes, during leisure time, and during active commuting and 2) to investigate the socio-demographic and behavioral factors associated with physical activity., Methods: The representative sample included 109,104 Brazilian students in the final year of elementary school from 2,842 schools. The weekly frequency and duration of physical activity were assessed. A variety of socio-demographic and behavioral factors were studied. A multiple Poisson regression analysis was used to test for associations between physical activity and the socio-demographic and behavioral variables., Results: Most of the students (97.0%) engaged in physical activity in at least one of the domains studied, especially physical education at school (81.7%) and leisure time physical activity (67.5%). However, only 29% of the adolescents reached the recommended level of physical activity. Among the adolescents who reached the minimum recommended time for physical activity, the various domains contributed the following proportions to total physical activity: leisure time physical activity (PR 12.5; 95% CI 11.17-13.97), active commuting (PR 1.63; 95% CI 1.59-1.67), and physical education at school (PR 1.36; 95% CI 1.29-1.44). The weekly frequency of all activities was greater among boys than among girls. Moreover, nearly two-thirds (61.8%) of students spent more than two hours per day engaging in sedentary behaviors; the prevalence of sedentary behaviors was similar between boys and girls (59.0 and 64.5%, respectively).Total level of physical activity, leisure time physical activity, and active commuting were associated with higher nutritional scores., Conclusions: Physical activity is important in any health promotion program. Therefore, it is necessary to invest in policies and interagency initiatives that promote all domains and to ensure that the general population helps determine the scope and design of such policies.

Effective clinical utilization of non-steroidal anti-inflammatory drugs such as diclofenac sodium (DS) is significantly limited by their ulcerogenic potential and poor bioavailability after oral administration, thus necessitating the need for a better carrier to minimize these obvious limitations. The objective of this study was to evaluate Eudragit® RS100/RL100 microspheres formulated by the solvent-evaporation technique for improved delivery of diclofenac. Three batches of (DF1, DF2 and DF3) microspheres were prepared using different ratios of Eudragit RS-100 and RL-100 polymers based on the solvent-evaporation method. The microspheres were characterized based on morphological properties, particle size analysis and encapsulation efficiency (EE%). In vitro release of DS was investigated in both 0.1 N HCl (pH 1.2) and phosphate-buffered saline (pH 7.4), while anti-inflammatory studies were evaluated in the rat model. Maximum EE% of 86.61 ± 0.11, 88.14 ± 0.16 and 85.50 ± 0.21 was obtained for DF1, DF2 and DF3, respectively. Discrete, smooth and brownish microspheres of size range 437 ± 0.01-479 ± 0.21 µm were obtained. Release of DS from the formulation depends on the polymer ratio. All the batches exhibited good anti-inflammatory activities. Microsphere formulations based on Eudragit® polymers would likely offer a reliable and alternative means of delivering DS orally.

Objective: To describe an index to identify inequities in living conditions and health and its relationship with health planning., Methods: Variables and indicators that would reflect demographic, economic, environment and education processes as well as supply and production of health services were applied for nondimensional scaling and clustering of 5,507 Brazilian municipalities. Data sources were the 2000 Census and the Brazilian Ministry of Health information systems. Z-score test statistic and cluster analysis were performed allowing to defining 4 groups of municipalities by living conditions., Results: There was seen a polarization between the group with the best living conditions and health (Group 1) and the group with the worst living conditions (Group 4). Group 1 consisted of municipalities with larger populations while Group 4 comprised mainly the smallest municipalities. As for Brazilian macroregions, municipalities in Group 1 are clustered in the south and southeast and those in Group 4 are in the Northeast., Conclusions: The living conditions and health index comprises reality dimensions such as housing, environment and health which allows to identifying the most vulnerable municipalities and can provide input for setting priorities, and developing criteria for more equitable financing and resource allocation.

This study explored HIV risk behaviors among Hawaiian and Polynesian- identified transgender women living in Hawai'i. The term transgender encompasses the experience of individuals who violate rigid binomial Western gender roles (Bockting, Robinson, & Rosser, 1998; Lombardi, Wilchins, Priesing, & Malouf, 2001; Yep & Pietri, 1999, pp. 199-200). Although traditional Polynesian cultures tolerate more gender role variations than Western culture, postcolonial acculturation has resulted in notable stigma for transgender individuals in Hawaiì today (Kameèleihiwa, 1999; Kanuha, 2000). Mahu is a cross-Polynesian term originally describing transgender women or female-acting males (Link, 2004; Nanda, 2000; Odo & Hawelu, 2001; Souza, 1976). Mahuwahine is a newly coined term of empowerment among Hawaiì's transgender community signifying male-to-female (MTF) transgender identity in varying, personally chosen, forms and coincides with the Hawaiian cultural renaissance (Odo & Hawelu, 2001). Although most of the participants in this study identified as mahu or Mahuwahine there was a significant range in self-identifying terminology. Because of this range and intended audience this article will use the term transgender women in referring to individuals described in the findings.

The importance of the communications media in the construction of symbols has been widely acknowledged. Many of the articles on health published in the daily newspapers mention medical studies, sourced from scientific publications focusing on new risks. The disclosure of risk studies in the mass media is also a topic for editorials and articles in scientific journals, focusing the problem of distortions and the appearance of contradictory news items. The purpose of this paper is to explore the meaning and content of disclosing scientific risk studies in large-circulation daily newspapers, analyzing news items published in Brazil and the scientific publications used as their sources during 2000. The "risk" is presented in the scientific research projects as a "black box" in the meaning of Latour, with the news items downplaying scientific disputes and underscoring associations between behavioral habits and the occurrence of diseases, emphasizing individual aspects of the epidemiological approach, to the detriment of the group.

This paper presents case study findings in five municipalities in the São Paulo Metropolitan Region. Inequalities in access to health care services and their utilization were described through advanced tabulation data from the 1998 SEADE Life Conditions Survey. The variables analyzed were: owning or not owning private health care insurance, income and age brackets. The health care service attributes studied were: health care services coverage by a health insurance plan, health services demands and average waiting time to receive health care. Compared with other studies, using the 1998 IBGE PNAD, the results allowed us to confirm interregional imbalances which can only be detected in shorter special scale studies: the municipalities. Despite showing the high private health insurances coverage the São Paulo Metropolitan Region has a great inner heterogeneity. The inequalities in private health care insurance, access, waiting time, and type of insurance coverage were observed through income quintiles and age classes analyses. Findings suggest that an expansion of the State's regulation capacity is necessary in order to empower the Brazilian Health Care System principles of universality and equity to be qualified to offer Brazilians the right to access health care services.

This paper discusses the relationship between the public and private sectors in the Unified National Health System (SUS), based on research whose objective was to identify governance strategies and mechanisms for public/private relations in the health sector, considering the search for equity in Greater Metropolitan Sao Paulo, Brazil. Governance was used as an analytical category, with health system regulation as the issue. Municipal and State health secretaries, members of health councils, and SUS staff were interviewed, and the empirical material was classified as: (a) regulatory mechanisms and instruments; (b) power loci; and (c) actors' positions concerning the SUS and its relationship to the private sector. Mechanisms and instruments have been created and used in the municipalities for regulation of their own services. Regulatory measures for the complementary and supplementary healthcare sector are practically nonexistent. There are numerous institutional power loci, seen more as places for submitting demands than as forums for negotiation. Despite some progress, governance appears to be more of a formal issue. Discussion is needed on the relationship between the public and private sectors and its regulation by municipalities in order to improve the health system.

The concept of risk entails a broad discussion, ranging from a more general approach, seeking to contextualize it in the dynamic of societal change, to a more specific approach in the field of health, particularly in epidemiological studies on associations. The term "risk" has appeared with increasing frequency in medical journals in the last three decades, but the phenomenon is not exclusive to health and is permeated by the diversity of a notion that hides a conceptual gap. Given this diversity, the current paper begins with a literature review to systematize the discussion of risk. The result is organized in three sections: 1) an overview of the discussion on risk within the debate on societal change in the transition from modernity to a new phase of social organization; 2) a summary of various uses of the risk notion in health knowledge; and 3) the establishment of the epidemiological concept of risk and its link to clinical medicine.

Objective: To assess the lag structure between air pollution exposure and elderly cardiovascular diseases hospital admissions, by gender., Methods: Health data of people aged 64 years or older was stratified by gender in São Paulo city, Southeastern Brazil, from 1996 to 2001. Daily levels of air pollutants (CO, PM10, O3, NO2, and SO2) , minimum temperature, and relative humidity were also analyzed. It were fitted generalized additive Poisson regressions and used constrained distributed lag models adjusted for long time trend, weekdays, weather and holidays to assess the lagged effects of air pollutants on hospital admissions up to 20 days after exposure., Results: Interquartile range increases in PM10 (26.21 microg/m(3)) and SO2 (10.73 microg/m(3)) were associated with 3.17% (95% CI: 2.09-4.25) increase in congestive heart failure and 0.89% (95% CI: 0.18-1.61) increase in total cardiovascular diseases at lag 0, respectively. Effects were higher among female group for most of the analyzed outcomes. Effects of air pollutants for different outcomes and gender groups were predominately acute and some "harvesting" were found., Conclusions: The results show that cardiovascular diseases in São Paulo are strongly affected by air pollution.

An overview of health and social issues is presented here regarding Native Hawaiian transgenders. Perhaps due to relatively greater tolerance of gender diversity among Polynesian cultures, approximately 70% of all male-to-female transgenders in Hawai'i are Native Hawaiian. However, the overall climate is one of discrimination and harassment such that transgenders--who tend to be under-educated, under-employed, and medically underserved--may be the most severely impacted of all Native Hawaiians. Lei Anuenue, human immunodeficiency virus (HIV) prevention program for Native Hawaiians, has provided a variety of services for transgenders, including outreach, educational workshops, support groups, HIV testing, and case management. All services are provided by peer leaders who are employed by the program. Data for this article are based on case management, including client self-disclosures and reports of peer staff who knew details of clients' lives having shared with them both generic experiences and specific activities. Information from 100 transgender clients and their case managers indicated that the transgender health profile is far more serious than that of mainstream Native Hawaiians. For example, 74% smoke, 31% use illegal drugs (excluding marijuana), more than 50% have been involved in street or domestic violence, and few individuals over age 50 have been found during three years of outreach. To some extent, employment options limit transgenders to prostitution, drug dealing, and minimum-wage jobs. In addition, a lifestyle of multiple sex partners and lack of opportunities for stable relationships place transgenders at much greater risk for HIV, sexually transmitted diseases (STD), and other infectious and non-infectious diseases as compared to the mainstream Native Hawaiian community. Clients in this study were from O'ahu, primarily from downtown Honolulu, Chinatown, and Wai'anae. Future studies should compare the results of this sample to transgenders from the neighbor islands (especially in rural Hawaiian areas), as well as utilize a structured prospective longitudinal approach.