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Background To understand the impact of the COVID-19 pandemic on mortality, this study investigates overall, sex- and age-specific excess all-cause mortality in 20 countries, during 2020. Methods Total, sex- and age-specific weekly all-cause mortality for 2015–2020 was collected from national vital statistics databases. Excess mortality for 2020 was calculated by comparing weekly 2020 observed mortality against expected mortality, estimated from historical data (2015–2019) accounting for seasonality, long- and short-term trends. Crude and age-standardized rates were analysed for total and sex-specific mortality. Results Austria, Brazil, Cyprus, England and Wales, France, Georgia, Israel, Italy, Northern Ireland, Peru, Scotland, Slovenia, Sweden, and the USA displayed substantial excess age-standardized mortality of varying duration during 2020, while Australia, Denmark, Estonia, Mauritius, Norway, and Ukraine did not. In sex-specific analyses, excess mortality was higher in males than females, except for Slovenia (higher in females) and Cyprus (similar in both sexes). Lastly, for most countries substantial excess mortality was only detectable (Austria, Cyprus, Israel, and Slovenia) or was higher (Brazil, England and Wales, France, Georgia, Italy, Northern Ireland, Sweden, Peru and the USA) in the oldest age group investigated. Peru demonstrated substantial excess mortality even in the Conclusions This study highlights that excess all-cause mortality during 2020 is context dependent, with specific countries, sex- and age-groups being most affected. As the pandemic continues, tracking excess mortality is important to accurately estimate the true toll of COVID-19, while at the same time investigating the effects of changing contexts, different variants, testing, quarantine, and vaccination strategies.

This work was supported by the University of Nicosia Medical School (internal funding)., Achilleos S, Quattrocchi A, Gabel J, Heraclides A, Kolokotroni O, Constantinou C, Pagola Ugarte M, Nicolaou N, Rodriguez-Llanes JM, Bennett CM, Bogatyreva E, Schernhammer E, Zimmermann C, Costa AJL, Lobato JCP, Fernandes NM, Semedo-Aguiar AP, Jaramillo Ramirez GI, Martin Garzon OD, Mortensen LH, Critchley JA, Goldsmith LP, Denissov G, Rüütel K, Le Meur N, Kandelaki L, Tsiklauri S, O'Donnell J, Oza A, Kaufman Z, Zucker I, Ambrosio G, Stracci F, Hagen TP, Erzen I, Klepac P, Arcos González P, Fernández Camporro Á, Burström B, Pidmurniak N, Verstiuk O, Huang Q, Mehta NK, Polemitis A, Charalambous A, Demetriou CA.

Objective To investigate the association between birth weight and excess weight among students aged 6–14 years, adjusted for life course confounding factors. Methods Cross-sectional study with 6–14-year-old schoolchildren in 2010; 795 school children from two public schools. In addition, a sub-sample was selected using a case-cohort study approach. Sociodemographic, breastfeeding, food introduction, previous weight gain, family history, current clinical and behavioral variables as well as maternal variables related to pregnancy, were collected. Multivariable weighted logistic regression was used to evaluate the association between birth weight and overweight. All prevalent cases of overweight (n = 160) were selected to compose the case group and a random sub-sample of all students participating in the study (n = 276 students, of whom 88 were cases) were the control group. Results An unadjusted 6% increase in the excess weight prevalence ratio (p-value = 0.004) was found for each 100 g increase in birth weight. With adjustment for age, sex and behavioral variables (models 1 and 2), the association of birth weight with excess weight was positive and statistically significant, but it was no longer significant in the final model (model 3) when clinical variables were considered. Conclusions Although some of the secondary associations were statistically significant, we could not identify a significant association between birthweight and excess weight in adolescents.

Resumo Objetivou-se investigar fatores associados à mortalidade por causas inespecíficas e mal definidas no estado do Amazonas (AM). Desenvolveu-se um estudo seccional incluindo 90.439 registros de óbitos não fetais, com residência e ocorrência no AM entre 2006 e 2012. Foram estimadas razões de chances de causas inespecíficas e mal definidas por meio de regressão logística multinomial hierárquica. A proporção de causas mal definidas e inespecíficas foi, respectivamente, 16,6% e 9,1%. A ocorrência de causas mal definidas diminuiu ao longo dos anos e a de causas inespecíficas somente no último biênio. As causas inespecíficas associaram-se com residência e ocorrência do óbito fora da capital, via pública, sexo feminino, dos 10 aos 49 anos, cor parda e quando atestadas por legistas. As causas mal definidas associaram-se com residência e ocorrência fora da capital, em domicílios, a partir de 40 anos, cor não branca, não ser solteiro, baixa escolaridade, assistência médica e falta de informação sobre o atestante. A mortalidade por causas mal definidas e inespecíficas no AM declinou entre 2006 e 2012, associando-se às dimensões espacial e temporal, fatores demográficos, socioeconômicos e à assistência médica na ocasião do óbito.

Introduction: Even though syphilis is an easily detectable and treatable disease, it is still considered a major public health problem, which may lead to Congenital Syphilis (CS). Objective: To analyze the final conclusion and the situations of vulnerability of cases of CS reported in Niterói in 2018 and 2019. Methods: A review of the reported cases of CS, except for abortions, diagnosed in 2018 and 2019, was carried out through SINAN forms and research questionnaires. Results: Of the 46 cases of CS in 2018 and the 107 cases in 2019, 8 (17.4%) and 4 (4%) did not undergo prenatal care, respectively; 2 (4.4%) and 4 (4%) were not screened for CS in the prenatal period; 3 (6.5%) and 13 (12%) were screened, but not treated; 11 (23.9%) and 17 (16%) did not receive an adequate treatment; 1 0 (21.7%) and 23 (21%) were reactive in the screening process, received adequate treatment, but were reinfected; 9 (19.6%) and 32 (30%) were reactive in the screening process, received adequate treatment, but had confirmed CS due to other criteria; 3 (6.5%) and 12 (11%) were non-reactive in prenatal care, but reactive in childbirth; and 0 (0%) and 2 (2%) were reactive, considered a serological scar, untreated, but confirmed by other criteria. The “low-income family” vulnerability aspect appears 21 times in 2018 and 50 times in 2019; “alcohol user”, 11 times in 2018; “frequent change of address”, 18 times in 2019. Conclusion: The social context of pregnant women living in Niterói in 2018 and 2019 may have determined the outcome of congenital syphilis.

Introdução: A sífilis congênita, embora seja um agravo possível de ser prevenido, ainda é considerada um grave problema de saúde pública. Objetivo: Analisar a conclusão e as vulnerabilidades dos casos de sífilis congênita residentes em Niterói (RJ) diagnosticados em 2018 e 2019. Métodos: Realizou-se análise dos casos de sífilis congênita residentes, exceto abortos, diagnosticados em 2018 e 2019, por fichas do Sistema de Informação de Agravos de Notificação e questionários de investigação. Resultados: Dos 46 casos de 2018 e 107 de 2019, respectivamente, 8 (17,4%) e 4 (4%) não fizeram pré-natal, 2 (4,4%) e 4 (4%) não fizeram triagem para sífilis congênita no pré-natal, 3 (6,52%) e 13 (12%) fizeram triagem porém não trataram, outros 11 (23,9%) e 17 (16%) não fizeram o tratamento adequado, 10 (21,7%) e 23 (21%) foram reagentes na triagem, tratamento adequado, porém reinfectaram, 9 (19,6%) e 32 (30%) foram reagentes na triagem, tratamento adequado, porém confirmaram sífilis congênita por outros critérios, 3 (6,52%) e 12 (11%) foram não reagentes no pré-natal porém foram reagentes no parto e 0 (0%) e 2 (2%) foram reagentes, considerados cicatriz sorológica, não tratada, e confirmaram por outros critérios. As principais vulnerabilidades identificadas foram família de baixa renda, 21 casos (45,7%) em 2018 e 50 casos (46,7%) em 2019, usuária de álcool e/ou outras drogas, 18 (39,1%) em 2018 e 34 (31,8%) em 2019. Conclusão: Investigar os casos de sífilis congênita com a atenção básica leva a identificar os casos que se referem a crianças expostas à sífilis materna e aos que de fato possuem critérios para sífilis congênita. A investigação dos casos de sífilis congênita é fundamental para qualificação da vigilância, aprimorando dados e apontando ações de educação permanente relacionadas à clínica e à avaliação das vulnerabilidades para pensar em estratégias intra e intersetoriais.

OBJECTIVESTo estimate TB mortality rates, describe multiple causes in death certificates in which TB was reported and identify predictors of TB reporting in death certificates in the State of Amazonas, Brazil, based on a multiple cause of death approach.METHODSDeath records of residents in AM within 2006-2014 were classified based on tuberculosis reporting in the death certificate as tuberculosis not reported (TBNoR), reported as the underlying cause of death (TBUC) and as an associate cause of death (TBAC). Age standardized annual mortality rates for TBUC, TBAC and with TB reported (TBUC plus TBAC) were estimated for the State of Amazonas, using the direct standardization method and WHO 2000-2025 standard population. Mortality odds ratios (OR) of reporting TBUC and TBAC were estimated using multinomial logistic regression.RESULTSAge standardized annual TBUC and TBAC mortality rates ranged, between 5.9-7.8/105 and 2.7-4.0/105, respectively. TBUC was associated with residence in the State capital (OR=0.66), female sex (OR=0.87), education level (OR=0.67 and 0.50 for 8 to 11 and 12 or more school years), non-white race/skin colour (OR=1.38) and occurrence of death in the State capital (OR=1.69). TBAC was related to time (OR=1.21 and 1.22 for years 2009-11 and 2012-14), age (OR=36.1 and 16.5 for ages 15-39 and 40-64 years) and when death occurred in the State capital (OR=5.8).CONCLUSIONTBUC was predominantly associated with indicators of unfavorable socioeconomic conditions and health care access constraints, whereas TBAC was mainly related to ages typical of high HIV disease incidence.Conflicts of interestNone.FundingFundação de Amparo à Pesquisa do Estado do Amazonas - FAPEAM

RESUMO: Introdução: Causas mal definidas de morte destacam-se entre idosos devido à alta frequência de comorbidades e consequente dificuldade de definir a causa básica. Objetivo: Analisar a validade e a confiabilidade da informação “diagnóstico principal” da internação hospitalar para recuperação da causa de morte natural de idosos que tiveram originalmente “causas mal definidas” como causa básica nas Declarações de Óbito, ocorridas no estado do Rio de Janeiro, em 2006. Métodos: As bases de dados obtidas dos Sistemas de Informações sobre Mortalidade e de Internação Hospitalar foram relacionadas probabilisticamente. Foram calculados percentuais de concordância, coeficiente Kappa, sensibilidade, especificidade e valor preditivo positivo do diagnóstico principal da internação de idosos que evoluíram para óbito por causas naturais. Óbitos por “causas mal definidas” tiveram uma nova causa definida a partir do diagnóstico principal. Resultados: A confiabilidade do diagnóstico principal foi boa, segundo a concordância percentual total (50,2%), e razoável, conforme o coeficiente Kappa (k = 0,4; p < 0,0001). Doenças do aparelho circulatório e neoplasias ocorreram com maior frequência entre os óbitos e as internações e apresentaram maior concordância e valores preditivos positivos por capítulo e agrupamento da Classificação Internacional de Doenças. A recuperação da causa básica ocorreu em 22,6% dos óbitos por causas mal definidas (n = 14). Conclusão: A metodologia desenvolvida e aplicada para recuperação da causa natural de óbito entre idosos neste estudo tem como vantagens a efetividade e a redução dos custos provenientes de uma investigação do óbito. Esta é recomendada nas situações de registros não relacionados e de baixo valor preditivo positivo. O monitoramento do perfil de mortalidade por causas é necessário para atualização periódica dos valores preditivos. ABSTRACT: Introduction: Ill-defined causes of death are common among the elderly owing to the high frequency of comorbidities and, consequently, to the difficulty in defining the underlying cause of death. Objective: To analyze the validity and reliability of the “primary diagnosis” in hospitalization to recover the information on the underlying cause of death in natural deaths among the elderly whose deaths were originally assigned to “ill-defined cause” in their Death Certificate. The hospitalizations occurred in the state of Rio de Janeiro, in 2006. Methods: The databases obtained in the Information Systems on Mortality and Hospitalization were probabilistically linked. The following data were calculated for hospitalizations of the elderly that evolved into deaths with a natural cause: concordance percentages, Kappa coefficient, sensitivity, specificity, and the positive predictive value of the primary diagnosis. Deaths related to “ill-defined causes” were assigned to a new cause, which was defined based on the primary diagnosis. Results: The reliability of the primary diagnosis was good, according to the total percentage of consistency (50.2%), and fair, according to the Kappa coefficient (k = 0.4; p < 0.0001). Diseases related to the circulatory system and neoplasia occurred with the highest frequency among the deaths and the hospitalizations and presented a higher consistency of positive predictive values per chapter and grouping of the International Classification of Diseases. The recovery of the information on the primary cause occurred in 22.6% of the deaths with ill-defined causes (n = 14). Conclusion: The methodology developed and applied for the recovery of the information on the natural cause of death among the elderly in this study had the advantage of effectiveness and the reduction of costs compared to an investigation of the death that is recommended in situations of non-linked and low positive predictive values. Monitoring the mortality profile by the cause of death is necessary to periodically update the predictive values.

Resumo Introdução Apesar do conhecimento sobre a etiologia multifatorial do crescimento intrauterino restrito, há escassez de estudos nacionais. Objetivo Estimar a adequação do peso ao nascer para idade gestacional e investigar fatores associados ao recém-nascido pequeno para idade gestacional (RN-PIG), com destaque para tabagismo e pré-natal. Método Estudo seccional em maternidades públicas no Rio de Janeiro e em Niterói, em 2011, com 1.771 nascidos vivos. Foram realizadas entrevistas com puérperas e consultas em prontuários. Estimaram-se prevalências e intervalos de confiança (IC95%) de recém-nascido pequeno para idade gestacional (RN-PIG), recém-nascido adequado para idade gestacional (RN-AIG) e recém-nascido grande para idade gestacional (RN-GIG), usando a curva INTERGROWTH-21st , segundo características maternas, da gestação e do recém-nascido. Utilizou-se regressão de Poisson, com o desfecho sendo nascer PIG. Resultados As prevalências foram de 9,3% para PIG e de 15,9% para GIG. Cor parda (RP = 1,4), baixa escolaridade (RP = 1,3), inadequação de pré-natal (RP = 1,3), tabagismo (redução/cessação: RP = 1,7; continuidade: RP = 2,4) e hipertensão arterial (RP = 1,3) foram associados ao PIG na análise univariada (p < 0,20), e apenas tabagismo manteve-se associado no modelo final (redução/cessação: RP = 1,7 e continuidade: RP = 2,3; p < 0,05). Conclusão A prevalência de PIG mostrou um efeito dose-resposta com o tabagismo. Estratégias populacionais antitabaco devem intensificar a prevenção direcionada às mulheres em idade fértil e, particularmente, às gestantes, com ações específicas para estímulo à cessação no pré-natal. Abstract Background There are few national studies despite the knowledge about the multifactorial etiology of restricted intrauterine growth. Objective To estimate the adequacy of birth weight for gestational age and investigate factors associated with the newborns small for the gestational age (NB-SGA). Method This is a cross-sectional study in public maternity hospitals in Rio de Janeiro and Niterói, RJ, in 2011 (1,771 live births). Data sources was through interviews with the mothers and medical records. The prevalence of NB-SGA, adequate (NB-AGA) and large (NB-LGA) for gestational age newborn were estimated (INTERGROWTH21st) according to maternal, gestational and newborn characteristics. Poisson regression was used (outcome SGA). Results The prevalence rates were: 9.3% SGA and 15.9% LGA. Brown skin color (prevalence rate - PR = 1.4), low scholarship (RP=1.3), prenatal inadequacy (RP = 1.3), smoking (reduction/cessation: RP = 1.7, continuity: RP = 2.4) and arterial hypertension (RP = 1.3) were associated with SGA in the univariate analysis (p

This study investigated the association between low birthweight and postnatal weight in full-term infants, taking social, economic, maternal and babies characteristics into account. A cross-sectional study was conducted with infants under six months old at 27 primary healthcare units in the Rio de Janeiro municipality, Brazil, in 2007. Only singleton full-term babies were included. The association between full-term low birthweight and postnatal weight was tested using the multiple regression model adjusted for the gender and age of the baby, as well as potential confounding factors. A total of 875 babies were evaluated, of whom 4.5% were small for gestational age. Small-for-gestational-age babies weighted, on average, 977.4 grams less than those born with adequate weight for gestational age, after adjustment by gender and age, as well as marital status and parity. Girls were 426.74 grams lighter than boys; children from mothers with live-in partners were 146.2 grams heavier than those of single mothers, and the babies of primiparae weighed 204.67 grams less than the children of multiparae. Low birthweight is an unfavorable factor for postnatal weight of full-term infants. These children, particularly daughters of primipara single mothers, must be followed more frequently in relation to their postnatal growth. Este estudo investigou a associação entre baixo peso ao nascer e peso pós-natal em crianças a termo, considerando-se características sociais, econômicas, maternas e infantis. Estudo transversal realizado em bebês com até seis meses de idade em 27 unidades de Atenção Primária à Saúde. Foram incluídos no estudo somente bebês a termo e não gemelares. A associação entre baixo peso ao nascer e peso pós-natal em crianças a termo foi testada utilizando modelo de regressão múltipla ajustada por sexo e idade do bebê e potenciais confundidores. Foram avaliadas 875 crianças, das quais 4,5% eram de baixo peso ao nascer. O peso pós-natal dos bebês a termo e com baixo peso foi em média 977,4 gramas menor do que entre aqueles que nasceram a termo com peso adequado, depois de ajustado por sexo e idade da criança, situação conjugal e paridade. Meninas pesavam 426,74 gramas a menos do que meninos, filhos de mães com parceiros pesavam 146,2 gramas a mais do que sem parceiros e os bebês de primíparas pesavam 204,67 gramas a menos do que os de multíparas. Nascer com baixo peso é uma situação desfavorável para o peso pós-natal de bebês a termo. Essas crianças, particularmente filhas de mães sem parceiros e primíparas, devem ser acompanhadas mais frequentemente em relação ao crescimento pós-natal.

Peso ao nascer é uma informação essencial nos estudos de programação fetal e, em geral, obtida retrospectivamente. No Sistema de Informações sobre Nascidos Vivos (SINASC), peso ao nascer é uma informação válida, mas nem sempre acessível. Objetivou-se estabelecer um algoritmo para seleção da fonte de dados de maior confiabilidade do peso ao nascer na ausência da informação do SINASC. No estudo seccional de estudantes de 6-14 anos, Niterói, Rio de Janeiro, Brasil, 2010, peso ao nascer foi coletado por meio de questionário de autopreenchimento, entrevista, prontuários do Programa Médico de Família (PMF), além do SINASC. Foram calculados coeficientes de correlação intraclasse (CCI) e diferenças das médias de peso ao nascer. CCIs variaram de 0,90 a 0,99. Todas as fontes apresentaram médias de peso ao nascer maiores do que SINASC, considerando-se aceitáveis diferenças até 100g. O peso ao nascer é registrado no nascimento (SINASC) ou próximo deste (PMF) e, na ausência dessas fontes, a lembrança do peso ao nascer de 6-14 anos após o nascimento é uma opção confiável. Para complementar a informação sobre peso ao nascer na ausência do SINASC, recomenda-se a seguinte ordenação: PMF, entrevista e questionário. Birth weight is essential information in fetal programming studies and is generally obtained retrospectively. In Brazil’s Information System on Live Births (SINASC), birth weight is valid information but is not always accessible. The study aimed to establish an algorithm for the selection of the most reliable data source for birth weight in the absence of information in the SINASC database. In a cross-sectional study of 6-14-year-old schoolchildren in Niterói, Rio de Janeiro State, Brazil, in 2010, birth weight was collected through a self-completed questionnaire, interview, medical records from the Family Physician Program, and the SINASC database. We calculated intra-class correlation coefficients (ICCs) and differences in mean birth weight. ICCs varied from 0.90 to 0.99. All the other sources showed higher mean birth weight than SINASC, allowing differences up to 100g. Birth weight is recorded at birth (SINASC) or close to it (Family Physician Program), and in the absence of these sources, birth weight as retrieved at 6-14 years of age is a reliable option. To complement information on birth weight in the absence of SINASC, we recommend the following order: Family Physician Program, interview, and questionnaire. El peso al nacer es una información esencial en los estudios de programación fetal y, en general, obtenida retrospectivamente. En el Sistema de Información sobre Nacidos Vivos (SINASC), peso al nacer es una información válida, pero no siempre accesible. Tuvo como objetivo establecer un algoritmo para la selección de la fuente de datos de mayor confiabilidad del peso al nacer, en ausencia de información del SINASC. En el estudio por secciones de estudiantes de 6-14 años, Niterói, Río de Janeiro, Brasil, 2010, el peso al nacer se recogió mediante un cuestionario para autocompletar, entrevista, historias clínicas del Programa Médico de Familia (PMF), además del SINASC. Se calcularon coeficientes de correlación intraclase (CCI) y diferencias de las medias de peso al nacer. Los CCIs variaron de 0,90 a 0,99. Todas las fuentes presentaron medias de peso al nacer mayores que el SINASC, considerándose aceptables diferencias hasta 100g. El peso al nacer es registrado en el nacimiento (SINASC) o cercano a este (PMF) y, en la ausencia de estas fuentes, el recuerdo del peso al nacer de 6-14 años tras el nacimiento es una opción fiable. Para complementar la información sobre peso al nacer, en ausencia del SINASC, se recomienda la siguiente ordenación: PMF, entrevista y cuestionario.

RESUMO: Objetivo: Descrever a metodologia de um estudo sobre associações entre crescimento intrauterino restrito (CIUR) e prevalência de sobrepeso, obesidade e hipertensão arterial em escolares. Métodos: O estudo, conduzido em dois estágios, foi desenvolvido em 2 escolas municipais de Niterói (RJ) de junho a dezembro de 2010, sendo elegíveis todos os escolares de 6 a 14 anos. O primeiro estágio consistiu em um inquérito nutricional e de potenciais fatores de risco. Foram aplicados questionários aos responsáveis e adolescentes. Concomitantemente, foram selecionados os participantes de um estudo caso-controle, com casos prevalentes definidos como todos os escolares que apresentaram excesso de peso (Z-score de índice de massa corporal -IMC/idade/sexo > +1,00). O grupo controle consistiu em uma amostra aleatória da população de estudo do inquérito, o que permitiu o cálculo de razões de prevalências. Foram realizados bioimpedância elétrica, exames de sangue, ultrassonografia da carótida e entrevistas. As variáveis proxy de CIUR foram definidas a partir de informações sobre peso ao nascer (PN) e idade gestacional (IG). Adicionalmente, foram coletadas informações sobre os dois primeiros anos de vida dos escolares a partir de seus prontuários médicos. Resultado s: Entre os 1.040 escolares elegíveis, participaram do estudo 795 escolares (76,4%). A taxa de retorno do questionário enviado para os responsáveis foi de 85,1%. Para o estudo caso-controle, 62,5% (n = 363) dos selecionados participaram, resultando em uma razão caso:controle de 1:1,8. Foram localizados 55,8% (n = 444) dos prontuários, dos quais em 65,7% (n = 292) foram coletadas informações dos primeiros anos de vida. Conclusão: O presente estudo permitirá a análise de múltiplos desfechos e exposições relacionados ao CIUR e alterações metabólicas.

The relationship between thyroid status, including subclinical hypothyroidism (SH) and serum leptin is controversial or uncertain. Therefore we evaluated serum leptin in SH and overt hypothyroidism (OH) and determined the effects of levothyroxine (LT(4)) replacement on serum leptin in these disorders.Serum leptin, thyrotropin (TSH), free thyroxine, insulin, glucose, and body composition parameters were compared in 55 SH, 20 OH, and 28 euthyroid (EU) pre- and postmenopausal women. In addition, the effect of LT(4) treatment on serum leptin in SH and OH was assessed.The mean +/- SD (median) serum leptin concentrations in the OH and SH groups were higher than in the EU group (35.1 +/- 27.2 [33.0] and 36.6 +/- 21.9 [30.6] ng/mL, respectively, vs. 23.2 +/- 19.3 [17.9] ng/mL, p = 0.011), but the difference was only significant in postmenopausal women. The body mass index (BMI), fat mass index (FMI), and the homeostasis model assessment-insulin resistance (HOMA-IR) index values were not different among these groups. In premenopausal women there was no correlation between leptin, BMI, or FMI and serum TSH levels (r(s) = 0.009, p = 0.474; r(s) = 0.043, p = 0.367; r(s) = 0.092, p = 0.232). In the postmenopausal women, the partial correlation coefficient between TSH and leptin was present, even when controlling for BMI (r(s) = 0.297, p = 0.042) and FMI (r(s) = 0.275, p = 0.050). LT(4) treatment was associated with a reduction of serum leptin concentrations in the OH group (p = 0.008). In SH group there were no differences between LT(4) replacement or no treatment, since a fall in serum leptin levels was detected in both SH subgroups, despite a more pronounced fall with LT(4) use. Treatment of the SH and OH groups with LT(4) did not influence HOMA-IR index or body composition.Serum leptin concentrations are elevated in postmenopausal women with SH or OH. A relationship between thyroid status and serum leptin is further supported by the fact that LT(4) treatment, to restore the EU status, reduced serum leptin levels in OH in the absence of significant effects on BMI. In women, hypothyroidism influences either leptin secretion or degradation and this effect is more pronounced in postmenopausal than in premenopausal women.

The study describes the characteristics of maternal deaths in the city of Rio de Janeiro, Brazil, during 2000-2003. After investigation by public-health services, 217 maternal deaths were identified among predominantly non-white (48.9%), single (57.1%) women aged 29.6 +/- 7.3 years on average. Direct obstetric causes corresponded to 77.4% of the maternal deaths, mainly due to hypertensive disorders. HIV-related diseases accounted for 4% of the maternal deaths. Almost three-fourths of the mothers who died were aged 20-39 years, although the highest risk of maternal death corresponded to the age-group of 40-49 years (248.9 per 100,000 livebirths). The socioeconomic and demographic profiles of maternal deaths in the city of Rio de Janeiro reflected a vulnerable social situation. Appropriate interventions aimed at reducing maternal mortality need to encompass all women of childbearing age, irrespective of the magnitude of the risk of maternal death.

The aim of this study was to evaluate the lipid profile of patients with different degrees of hypothyroidism and the effect of levothyroxine replacement in subclinical hypothyroidism (SH). Initially, a cross-sectional study was performed with 226 participants [SH = 133 participants, manifest hypothyroidism (MH) = 23 participants, and euthyroidism (EU) = 70 participants]. The mean levels of atherogenic lipid variables were greater in MH than in SH and were greater in SH than in EU, although the differences between SH and EU did not reach statistical significance. The SH subgroup with greater serum thyrotropin (TSH) levels and that with positive antithyroperoxidase antibodies (TPO-Ab) had greater levels of triglycerides and of the atherogenic index Apo B/Apo A. A positive correlation exists between serum TSH and total cholesterol (rs = 0.167; P = 0.006), triglycerides (rs = 0.219; P0.001), and ApoB levels (rs = 0.205; P0.001). Eleven patients who received levothyroxine (L-T4) treatment and 15 patients who received placebo were reevaluated 1 year after TSH adjusted intervention. A fall in atherogenic variables was observed in the L-T4-treated group, with significance for total cholesterol (-20.0 vs +16.1 mg/dL in the placebo group) and LDL-c (-21.7 vs +17.2 mg/dL). We concluded that SH leads to an intermediary lipid profile between euthyroid individuals and that found in manifest hypothyroidism and that a significant lipid profile improvement occurred 1 year after L-T4 replacement therapy.

Objetivo. Este estudo diz respeito à mensuração da incapacitação funcional, e seu uso no cálculo de indicadores de saúde e qualidade de vida. O seu objetivo foi estimar o grau de incapacitação associado a diferentes níveis funcionais, através de um modelo baseado na lógica fuzzy. Métodos. Desenvolveu-se um modelo lingüístico fuzzy, baseado na opinião de especialistas. As variáveis de entrada do modelo foram, respectivamente, a mobilidade, a atividade física e a atividade social. Ao todo, foram definidas 100 regras fuzzy relacionando as variáveis de entrada, a partir das quais determinou-se o grau de incapacidade funcional. As avaliações dos diferentes funcionais foram feitas sobre uma escala de avaliação fuzzy. Para cada nível funcional, o modelo gera uma estimativa do grau de incapacitação, d, no intervalo entre 0 e 10, valores estes representantes da morte e do melhor estado de saúde imaginável, respectivamente. Resultados. Ao todo, foram avaliados 100 diferentes níveis funcionais. A título de exemplificação, para o nível funcional caracterizado por um adulto que trabalha, mas apresenta restrições para desenvolver outras atividades sociais, necessita auxílio para usar transporte público ou dirigir, e anda com limitações, a estimativa de d foi igual a 5,8, segundo um dos especialistas. Isto significa que um ano nesta condição equivale a 0,58 anos de vida com saúde, sem qualquer tipo de limitação funcional. Conclusões. O modelo fuzzy foi considerado uma alternativa consistente para a mensuração do grau de incapacitação. Ele emula o raciocínio humano, e provê uma estrutura adequada para lidar com incertezas e imprecisões, características inerentes ao processo de mensuração da incapacitação funcional. Objective. This study is concerned with the measurement of disability, and its use in health and quality of life indicators. The aim was to estimate the degree of disability associated with varying functional levels, through a model based on fuzzy logic. Methods. A fuzzy linguistic model was developed, based on experts opinion. Three fuzzy input variables were considered according to: social activity, mobility and physical activity. A set with 100 fuzzy rules was derived and considered as consequent for each rule the functional disability. Functional levels were evaluated separately for each input variables on a fuzzy rating scale. The model provides a numerical estimate, d, of an individual\'s functional disability state, ranging from 0 to 10, which represent death and optimal function, respectively, obtained through defuzzification. Results. A total of 100 multidimensional functional levels were evaluated. As an example, for a functional level characterised by an individual who works but performs restrictively other social activities, needs help to use public transport and walks with physical limitations, d was estimated as 5,8, according to one of the experts. This means that one year in such a state is equivalent to 0.58 years of well life, in the absence of any kind of functional disability. Conclusions. The fuzzy model was considered a consistent alternative for the estimation of the degree of disability. It emulates human thinking, and provides an adequate framework to deal with uncertainty and imprecision, which are inherent in the measurement of functional disability.

Ill-defined causes of death are common among the elderly owing to the high frequency of comorbidities and, consequently, to the difficulty in defining the underlying cause of death.To analyze the validity and reliability of the "primary diagnosis" in hospitalization to recover the information on the underlying cause of death in natural deaths among the elderly whose deaths were originally assigned to "ill-defined cause" in their Death Certificate. The hospitalizations occurred in the state of Rio de Janeiro, in 2006.The databases obtained in the Information Systems on Mortality and Hospitalization were probabilistically linked. The following data were calculated for hospitalizations of the elderly that evolved into deaths with a natural cause: concordance percentages, Kappa coefficient, sensitivity, specificity, and the positive predictive value of the primary diagnosis. Deaths related to "ill-defined causes" were assigned to a new cause, which was defined based on the primary diagnosis.The reliability of the primary diagnosis was good, according to the total percentage of consistency (50.2%), and fair, according to the Kappa coefficient (k = 0.4; p0.0001). Diseases related to the circulatory system and neoplasia occurred with the highest frequency among the deaths and the hospitalizations and presented a higher consistency of positive predictive values per chapter and grouping of the International Classification of Diseases. The recovery of the information on the primary cause occurred in 22.6% of the deaths with ill-defined causes (n = 14).The methodology developed and applied for the recovery of the information on the natural cause of death among the elderly in this study had the advantage of effectiveness and the reduction of costs compared to an investigation of the death that is recommended in situations of non-linked and low positive predictive values. Monitoring the mortality profile by the cause of death is necessary to periodically update the predictive values.

Em 2011, o estado do Rio de Janeiro (ERJ) apresentou a mais alta taxa de incidência de tuberculose do país. Realizamos uma pesquisa qualitativa sobre a estrutura, a organização e os processos de trabalho no Programa de Controle da Tuberculose (PCT), por meio de uma análise temática de entrevistas com coordenadores do PCT em 13 municípios do ERJ. A descentralização do controle da tuberculose – por intermédio da incorporação de suas normas pela Estratégia de Saúde da Família (ESF) – exige a reorganização dos processos de trabalho do Programa. A substituição contínua de profissionais da ESF e a estrutura insuficiente do PCT prejudicam o controle da tuberculose. A superação do modelo baseado em um serviço de tratamento especializado requer a integração do PCT a todos os níveis do Sistema Único de Saúde, e atribuição de autonomia aos coordenadores, para tomarem decisões. In 2011, the state of Rio de Janeiro presented the highest tuberculosis incidence rate nationwide. We conducted a qualitative study on the structure, organization and working processes within the tuberculosis control program (TCP), by means of thematic analysis on interviews with the TCP coordinators of 13 municipalities in this state. Decentralization of the TCP, through incorporation of its guidelines by the family health strategy (FHS) teams, demands reorganization of the working processes within the TCP. Continuous substitution of FHS professionals and the insufficient structure of the TCP impair tuberculosis control. In order to go beyond a control model based on specialized tuberculosis treatment services, the TCP needs to be integrated with all levels of the Brazilian National Health System and autonomy needs to be given to the coordinators, regarding decision-making. En 2011, el Estado de Río de Janeiro (ERJ) presentó el más alto índice de incidencia de tuberculosis del país. Realizamos una encuesta cualitativa sobre la estructura, la organización y los procesos de trabajo en el Programa de control de la tuberculosis (PCT), por medio de un análisis temático de entrevistas con coordinadores del PCT en 13 municipios del ERJ. La descentralización del control de la tuberculosis – por intermedio de la incorporación de sus normas por parte de la Estrategia de Salud de la Familia (ESF) – exige la reorganización de los procesos de trabajo del programa. La sustitución continua de profesionales de la ESF y la estructura insuficiente del PCT perjudican el control de la tuberculosis. La superación del modelo basado en un servicio de tratamiento especializado requiere la integración del PCT en todos los niveles del Sistema Brasileño de Salud y la atribución de autonomía a los coordinadores para tomar decisiones.

Background The purpose of this study was to investigate the association between mean body mass index (BMI) and prevalence of obesity in adult populations living in Brazilian State capitals. Methods An ecological study was conducted, using data from the National Household Budget Survey conducted in July 2002 through June 2003, including a representative sample of 48.470 households. Pearson’s correlation and linear regression coefficients were estimated in order to define the relationships of mean BMI and sex-specific, age standardized obesity prevalence (BMI ≥ 30.0 kg/m2) in adults aged 20 to 59 years. Results Stronger correlations between BMI and prevalence of obesity were observed in women (r = 0.9; p

A avaliação das conseqüências dos problemas de saúde é um tema marcado pela diversidade conceitual e metodológica. Diferentes modelos conceituais são utilizados para o desenvolvimento de métodos para avaliação dos níveis de saúde de populações humanas. A avaliação das limitações e restrições da atividade física, devido a sua importância no âmbito das conseqüências das doenças crônicas, tem sido contemplada em inquéritos populacionais. Tais análises baseiam-se nas escalas de avaliação das atividades diárias da vida ou das atividades instrumentais diárias da vida. A PNAD, por meio do seu Suplemento Saúde realizado em 1998 e 2003, tem possibilitado a análise dos padrões de limitação das atividades habituais na população brasileira com idade superior a 13 anos. Neste estudo foram apresentados indicadores de diferentes graus de limitação, desenvolvidos com os dados da PNAD 2003. Os resultados preliminares mostram perfis diferenciados de limitação das atividades, segundo categorias das variáveis sexo e faixa etária. As mulheres e os indivíduos com mais idade apresentaram limitações com maior freqüência e em maior grau. A preocupação com o viés do informante se justifica pelo fato de metade das respostas ter sido fornecida por terceiros.The evaluation of the consequences of health problems is a subject characterized by conceptual and methodological diversity. Different conceptual models have been used for developing methods aimed at evaluating the health of populations. In the context of chronic diseases, the evaluation of physical activity restrictions and limitations based on scales of activities of daily living and instrumental activities of daily living is particularly important. Both the 1998 and 2003 National Household Survey Health Interviews have allowed for an analysis of activity limitation patterns of the Brazilian population aged 14 years and older. In the present study we present different indicators of varying degrees of limitation elaborated using data from the 2003 survey. Preliminary results showed varying patterns of activity limitation according to sex and age. In general, limitations were referred more frequently and to a higher degree among women and the elderly. The concern with information bias is justified by the fact that half of the questions were answered by proxy informants.

A partir dos dados do Suplemento Saúde da PNAD 1998, diversos estudos evidenciaram a presença de diferenças significativas nos padrões socioeconômicos, acesso, utilização de serviços de saúde e condições de saúde entre os segmentos populacionais cobertos e não cobertos por planos de saúde. Buscando contribuir para aprimorar o acervo dos conhecimentos sobre a estrutura e a dinâmica do mercado de planos e seguros de saúde no Brasil, admite-se e procura-se evidenciar a heterogeneidade dessas demandas. Para tanto, foi definida uma tipologia de planos de saúde, fundamentada nas origens institucionais das demandas e, subseqüentemente, pelas relações de dependência com titulares de planos e seguros de saúde, integrada por três categorias principais: os planos empresariais privados, os planos empresariais públicos e os planos individuais. As características etárias, socioeconômicas e de condições de saúde variam segundo os diferentes tipos de plano, sugerindo a presença de padrões distintos de demandas, especialmente entre os planos empresariais privados e os planos individuais.Several studies based on the 1998 PNAD Health Supplement data have shown significant differences in socioeconomic standards, access to and use of health services among population segments covered or not by health plans. Seeking to improve our knowledge on the structure and dynamics of the market of health plans and insurances in Brazil, we sought first to identify and then to highlight the different demands. To this effect, we conceived a typology of health plans on the basis of the institutional origin of the demands and on the relation between insurance and health plan holders and their dependents for three major categories: private employer plans, public employer plans and individual plans. Age, socioeconomic patterns and health conditions vary according to different health plan profiles, suggesting distinct patterns of demands, markedly between private employer and individual plans.

OBJETIVO: Analisar e correlacionar características clínicas, sintomas psiquiátricos e dados laboratoriais no hipotireoidismo subclínico (HS). MÉTODOS: Estudo transversal comparando achados de 103 pacientes com HS aos de 60 indivíduos eutireoidianos. A avaliação clínica e a psiquiátrica foram baseadas, respectivamente, na escala de Zulewski e nos questionários de Hamilton A, Hamilton D e Beck. Todos foram submetidos a dosagens de tireotropina (TSH), T4 livre e antitireoperoxidase (ATPO). Variáveis contínuas foram analisadas por meio do teste t de Student, quando de distribuição normal, e dos testes de Mann-Whitney e Kruskal Wallis, quando "não normais". Variáveis categóricas por meio dos testes Qui-quadrado, exato de Fisher e Kruskal Wallis. Análise multivariada foi utilizada para estudo de variáveis de confundimento. RESULTADOS: O nível médio de TSH, no HS, foi 7,76 ± 2,9 µUI/mL e 1,66 ± 0,6 µUI/mL nos eutireoideanos (p=0,001). O nível de T4L foi menor no HS, apresentando correlação linear negativa com TSH. Ocorreu maior freqüência de escore clínico anormal (48,3 vs 67%; p=0,020), de sintomas de depressão, pela escala de Beck no HS (20,5 vs 44,2%; p=0,011) e de sintomas de ansiedade (86 vs 63,4%; p=0,004) no HS. A presença de sintomas de depressão e ansiedade associou-se de forma positiva com pontuação no escore clínico e níveis de TSH. Não houve associação entre achados clínicos ou psiquiátricos e etiologia do HS, presença de ATPO, idade ou menopausa. CONCLUSÃO: O estudo aponta para associação entre HS, achados clínicos e sintomas psiquiátricos. Ensaios clínicos são necessários para avaliar uma possível melhora com levotiroxina.BACKGROUND: This investigation evaluated and correlated clinical, laboratorial aspects and psychiatric symptoms in sub clinical hypothyroidism (SH). METHODS: Cross sectional study involving 103 patients with SH and 60 subjects without thyroid disease. Clinical and psychiatric evaluation was respectively based on the Zulewski score and Hamilton A, Hamilton D and Beck questionnaires. Serum thyreotropin (TSH), (thyroxine) FT4 and (antithyroperoxidase) ATPO were measured in all participants. Analysis of continuums data was assessed by the Student t- test, for normally distributed data, and by the Mann- Whitney and Kruskal Wallis tests for non-parametric data. The chi2, Fisher's and Kruskal Wallis tests were used to study qualitative variables. Multivariate analyses were used to study confounding variables. RESULTS: Mean serum TSH level was 7.76 ± 2.9 µUI/mL in SH and 1.66 ± 0.6 µUI/mL in the group without thyroid disease (p=0.001). Mean serum T4L was slightly lower among patients with HS, and showed a negative linear correlation with TSH. Higher frequencies of abnormal clinical score (48.3 vs. 67.0%; p=0.02), depression self reported symptoms (20.5 vs. 44.2%; p=0.011) and anxiety symptoms (86.0 vs. 63.4%; p=0.004) occurred more frequently in SH. Frequency of psychiatric symptoms had a positive correlation with the clinical score and serum TSH. There was no association between the clinical and psychiatric findings and the etiology of SH, presence of ATPO, age or menopause. CONCLUSIONS: The study showed that SH was associated with clinical findings and with psychiatric symptoms. Clinical trials are required to evaluate possible improvement with levotiroxine.

In clinical or epidemiologic research, the measurement of variables always implies some degree of error. Because it is impossible to control the various sources of variation, the assessment of the reliability of a measurement is essential. Otherwise, concordance analysis must take into account the "clinical" interpretation of the measurement under study, because its practical usefulness is of central importance. In this article, we propose a new approach to assess the reliability of a quantitative measurement. We use a graphical approach familiar to statisticians and data analysts of the biomedical area, associating to it the useful feature of interpretation based on the proportion of concordant cases. We believe that the proposed graphical approach can serve as a complement, or as a alternative, to the Altman-Bland method for agreement analysis. It allows a simple interpretation of agreement that takes into account the "clinical" importance of the differences between observers or methods. In addition, it allows the analysis of reliability or agreement, by means of survival analysis techniques.

Este artigo apresenta uma investigação preliminar da presença da seleção adversa e do risco moral (moral hazard) na demanda ativa por planos de saúde no Brasil, a partir dos dados da PNAD/98. O presente estudo compara indivíduos cujas coberturas decorrem do vínculo de trabalho, com aqueles cujos planos resultam de uma demanda individual às empresas que os comercializam e os que não têm acesso a esquemas assistenciais alternativos ao SUS. A elaboração de uma tipologia de planos de saúde, combinada com variáveis relacionadas com as condições de saúde, utilização de serviços e gastos com saúde, sugere a existência de falhas de mercado. A percepção de uma condição de saúde mais desfavorável parece estar associada à busca de cobertura e o tipo de cobertura com o maior uso de serviços de saúde. Quando analisadas através de dois modelos de regressão logística com múltiplos controles, onde a variável de desfecho é indicadora de seleção adversa ou moral hazard, essas diferenças se atenuam, com exceção dos gastos com saúde. Os resultados não evidenciam uma inquestionável assimetria de informações, mas sinalizam a necessidade de aprofundar o conhecimento sobre as relações entre morbidade, utilização de serviços de saúde, gastos com saúde e tipo de cobertura. The authors investigate the extent to which adverse selection and moral hazard influence private health insurance demand in Brazil, based on the 1998 National Socioeconomic and Health Survey. Three population groups were compared, namely the one whose private health insurance was acquired by their employers, a second group whose insurance was individually acquired directly from insurance providers, and finally the one without any type of private health insurance and exclusively assisted by public health services. A taxonomy of health insurance plans was developed, and other covariates were also considered in the analysis, namely health states, health care services use, and health insurance coverage. The results suggest the occurrence of both types of market failures. Private health insurance coverage was found to be associated with unfavorable self-reported health states while the type of coverage appears to be associated with a more frequent use of health services. Multivariate logistic regression analyses, with multiple controls, showed that only health care expenditures remained associated with both adverse selection and moral hazard. Although a clear cut pattern of asymmetric information was not observed, results point out the need to further investigate the relations among morbidity, health care services use, health care expenditures and the varying types of health insurance plans.

Este artigo apresenta uma investigação preliminar da presença da seleção adversa e do risco moral (moral hazard) na demanda ativa por planos de saúde no Brasil, a partir dos dados da PNAD/98. O presente estudo compara indivíduos cujas coberturas decorrem do vínculo de trabalho, com aqueles cujos planos resultam de uma demanda individual às empresas que os comercializam e os que não têm acesso a esquemas assistenciais alternativos ao SUS. A elaboração de uma tipologia de planos de saúde, combinada com variáveis relacionadas com as condições de saúde, utilização de serviços e gastos com saúde, sugere a existência de falhas de mercado. A percepção de uma condição de saúde mais desfavorável parece estar associada à busca de cobertura e o tipo de cobertura com o maior uso de serviços de saúde. Quando analisadas através de dois modelos de regressão logística com múltiplos controles, onde a variável de desfecho é indicadora de seleção adversa ou moral hazard, essas diferenças se atenuam, com exceção dos gastos com saúde. Os resultados não evidenciam uma inquestionável assimetria de informações, mas sinalizam a necessidade de aprofundar o conhecimento sobre as relações entre morbidade, utilização de serviços de saúde, gastos com saúde e tipo de cobertura.The authors investigate the extent to which adverse selection and moral hazard influence private health insurance demand in Brazil, based on the 1998 National Socioeconomic and Health Survey. Three population groups were compared, namely the one whose private health insurance was acquired by their employers, a second group whose insurance was individually acquired directly from insurance providers, and finally the one without any type of private health insurance and exclusively assisted by public health services. A taxonomy of health insurance plans was developed, and other covariates were also considered in the analysis, namely health states, health care services use, and health insurance coverage. The results suggest the occurrence of both types of market failures. Private health insurance coverage was found to be associated with unfavorable self-reported health states while the type of coverage appears to be associated with a more frequent use of health services. Multivariate logistic regression analyses, with multiple controls, showed that only health care expenditures remained associated with both adverse selection and moral hazard. Although a clear cut pattern of asymmetric information was not observed, results point out the need to further investigate the relations among morbidity, health care services use, health care expenditures and the varying types of health insurance plans.

Background International ecological studies have shown a positive association between infant mortality as a proxy for low birth weight and cardiovascular disease mortality in adult life. Methods Mortality rates due to Cardiovascular Diseases (CVDMR) standardised by age in adults between 45 and 69 years of age and by place of birth (pob) and residence (res) were related to Infant Mortality Rates (IMR) in the Brazilian 1935 birth cohort. Results Two relationship patterns were noted between IMR and CVDMR: for the Southeast, South and Centre-West group of regions (r pob = 0.46; r res = 0.29) and for the North and Northeast group of regions (r pob = 0.21; r res = 0.33). For the latter pattern, two states were identified (Rio Grande do Norte and Paraiba) as atypical areas, whose exclusion strengthened the association (r pob = 0.73; r res = 0.91). Conclusions The direction of the associations changed after the analysis by group of Brazilian regions (indirect control of socio-economic levels, coverage and quality of the information). There is a positive, although weak association between IMR and CVDMR. Attempts to control or minimise the interference of migratory movements, cohort effects and socio-economic levels represented methodological progress in ecological analyses of foetal programming in Brazil.

To describe the methodological features of a study on the association between restricted intrauterine growth and prevalence of overweight, obesity and hypertension in school aged children.The study was conducted in two stages in two public schools in Niterói (RJ), from June through December 2010. All students aged 6 to 14 years were eligible to participate. The first stage consisted of an interview to collect information on demographic variables, diet and other variables. A sample was selected for the second stage, in order to conduct an equivalent of a case-cohort study. There was an interval of about 15 days between the two stages. Cases were overweight students, defined as a Z-score for BMI/age/sex+1.00 in the first stage. Controls were selected by using a random schedule in which the sample frame was the whole cohort. Bioelectrical impedance analysis, carotid ultrasound to measure intimal-medial thickness, blood measurements and interviews were obtained. Gestational age and weight at birth were used to define proxy variables of restricted intrauterine growth. Early health information was obtained from medical registers.The study participation was 76.4% (n = 795) out of 1,040 eligible to participate). 85.1% of parent's questionnaires were returned. 62.5% of the eligible children participated in the case-control study (case: control ratio = 1:1.8). Early life health information was obtained from 292 children.The present study has the potential to provide important information about multiple outcomes and exposures related to restricted intrauterine growth and metabolic abnormalities.

OBJECTIVE: To evaluate the prevalence of psychiatric disorders and symptoms in patients with subclinical hypothyroidism. METHOD: Ninety-four outpatients with at least two elevated serum thyrotrophin levels (> 4 µU/ml) and normal FT4, and 43 euthyroid outpatients, both groups from HUCFF-UFRJ, were evaluated. Psychiatric diagnosis was based on the Structured Clinical Interview Diagnostic for the DSM-IV axis I (SCID-I/DSM-IV), the psychopathological symptoms on Hamilton anxiety and depression scales, and the Beck Inventory. RESULTS: Our data showed an increased prevalence of psychiatric disorders in the subclinical hypothyroidism patients when compared to the euthyroid group (45.7% vs 25.6%; p = 0.025), mood disorders being the most frequent. The prevalence of depressive symptoms based on Beck's Scale among subclinical hypothyroidism patients was about 2.3 times higher than among euthyroid ones (45.6% vs 20.9%, p = 0.006). Anxiety symptoms were also more frequent among subclinical hypothyroidism patients (87.0% vs 60.5%, p < 0.001), mainly clinical anxiety (44.6% vs 23.3%; p = 0.001). CONCLUSION: Our results showed a significant association of subclinical hypothyroidism with psychiatric disorders and an increased frequency of subsyndromic depression and anxiety symptoms in subclinical hypothyroidism in relation to the euthyroid group. OBJETIVO: Avaliar a prevalência de sintomas e alterações psiquiátricas em pacientes com hipotireoidismo subclínico. MÉTODO: Foram estudados 94 pacientes ambulatoriais com pelo menos duas dosagens plasmáticas elevadas de tireotropina (> 4 µU/ml) e com T4 livre normal e, 43 eutireoidianos, ambos os grupos do HUCFF-UFRJ. Para diagnóstico psiquiátrico foi utilizada a entrevista clínica estruturada do eixo I (SCID-I/DSM-IV) e, para sintomas psicopatológicos, as escalas de ansiedade e depressão de Hamilton (HAM-A e HAM-D) e inventário de Beck. RESULTADOS: Encontramos uma prevalência aumentada de transtornos psiquiátricos no hipotireoidismo subclínico em comparação ao grupo eutireoidiano (45,7% vs 25,6%; p = 0,025), sendo o transtorno do humor o de maior freqüência. Sintomas de depressão no grupo com hipotireoidismo subclínico foram cerca de 2,3 vezes mais freqüentes que entre os eutireoidianos (45,6% vs 20,9%; p = 0,006) quando o instrumento utilizado foi a escala de Beck. Da mesma forma, sintomas de ansiedade também foram mais freqüentes no hipotireoidismo subclínico (87,0% vs 60,5%; p < 0,001), principalmente ansiedade clínica (44,6% vs 23,3%; p = 0,001). CONCLUSÃO: Os resultados indicaram uma associação do hipotireoidismo subclínico com os transtornos psiquiátricos, além de uma freqüência aumentada de sintomas de depressão e ansiedade subsindrômicos em relação ao grupo eutireoidiano.

INTRODUÇÃO: Diversas estratégias vêm sendo desenvolvidas para o enfretamento da mortalidade materna. Em 2008, o Ministério da Saúde tornou obrigatória a investigação de todos os óbitos de mulheres em idade fértil, medida de difícil cumprimento no Estado do Rio de Janeiro devido ao grande volume de óbitos ocorridos e dificuldades operacionais dos serviços de saúde. O objetivo deste trabalho foi desenvolver uma estratégia de seleção dos óbitos de mulheres em idade fértil a serem investigados prioritariamente pelos serviços de saúde. MÉTODO: Foram selecionados para investigação todos os óbitos de mulheres em idade fértil ocorridos entre maio e setembro de 2008 nos municípios de Belford Roxo e Niterói e classificados segundo prioridade de investigação, considerando-se as informações da causa básica e os campos 43 e 44 da declaração de óbito. RESULTADOS: Em Belford Roxo e Niterói respectivamente 46,7% e 47,1% das declarações de óbitos analisadas apresentaram incompletudes de preenchimento, e os percentuais de recuperação da informação dos campos 43 e 44 foram de 73,3% e 74,5% nestes municípios. Em 132 investigações realizadas foram identificados quatro óbitos ocorridos durante o ciclo gravídico-puerperal, todos classificados como prioritários para a investigação, e três deles foram recertificados como óbitos maternos. A metodologia de definição de prioridade de investigação desenvolvida mostrou-se adequada. INTRODUCTION: Different approaches have been developed in order to deal with maternal mortality. In 2008 the Brazilian Ministry of Health made mandatory the investigation of all deaths of women of reproductive age. So far, completeness of investigation has not been thoroughly accomplished in the State of Rio de Janeiro (RJ) due to the constrained capacity of public health services to investigate the large number of eligible deaths. Our aim was to develop a strategy to improve the selection of deaths of women of reproductive age for investigation under maternal death surveillance. METHODS: The study population comprised all deaths of women of reproductive age that occurred in the counties of Belford Roxo and Niterói, RJ, between May and September of 2008. Deaths were classified according to priority for investigation, based on data regarding its underlying cause and relation to either pregnancy, delivery or puerperium, as registered in deaths certificate's fields 43 and 44 (related to maternal deaths). RESULTS: Data related to fields 43 and 44 was missing in around 47% of death certificates; following investigation it was recovered for approximately 74% of such deaths. Of the 132 deaths investigated, four occurred either during pregnancy, delivery or puerperium and were classified as priority for investigation, among which three were classified as maternal deaths. The strategy developed to improve the selection of deaths of women of reproductive age for investigation under maternal death surveillance was considered appropriate.

OBJETIVO: Avaliar a qualidade do Sistema de Informações sobre Mortalidade (SIM) em uma coorte especial de pacientes hospitalizados pelo Sistema Único de Saúde (SIH-SUS) que sofreram amputação de membros inferiores (AMI) devido ao diabetes mellitus (DM) em 2000, e comparar a mortalidade por causas da coorte com a da base populacional do Estado do Rio de Janeiro (ERJ) de 2000 a 2003. MÉTODOS: Os dados foram gerados a partir do relacionamento entre as bases de dados do SIH-SUS (2000) e do SIM (2000-2003). Foram excluídos os registros de indivíduos com menos de 30 anos e para análise de menção de DM, óbitos por causa básica (CB) não natural. A mortalidade foi analisada segundo causas da coorte especial e da base populacional. Os marcadores de qualidade do SIM na coorte foram a proporção de causas mencionadas de morte por DM e a proporção de CB mal definidas (MD) e, na base populacional, apenas o último. RESULTADOS: 38,0% dos indivíduos da coorte (n = 977) morreram nos quatro anos subsequentes à AMI devido ao DM, sendo que 49,1% desses no primeiro ano. As doenças endócrinas, nutricionais e metabólicas (41,5%), do aparelho circulatório (28,5%) e as causas MD (8,1%) foram as primeiras CB de morte. O DM foi mencionado 41,0% como CB, 1,6% como causa consequencial e 10,0% como contribuinte entre os óbitos pelas demais CB naturais nas declarações de óbito. Na base populacional, a mortalidade proporcional por causas MD foi 11,8% . CONCLUSÃO: O elevado risco de morte, o perfil de causas de morte e a sub-declaração do DM no atestado de óbito dos diabéticos tiveram resultados semelhantes aos de outros estudos de base populacional. A qualidade da certificação das causas de morte preenchidas nas declarações de óbito da coorte especial foi considerada ruim. É necessário um grande investimento para melhorar a qualidade da certificação das causas de mortes com o correto preenchimento do atestado de óbito pelos médicos e da codificação das causas de morte e seleção da CB pelos técnicos dos serviços de saúde. A metodologia desenvolvida neste estudo visando qualificar o SIM (relacionamento de base de dados e causas múltiplas de morte) mostrou-se efetiva e eficiente. OBJECTIVE: The aim of this study was to demonstrate the quality of the National Mortality Information System (SIM) in a special cohort of inpatients submitted to lower limb amputation (LLA) as a result of diabetes mellitus (DM), and compare the mortality pattern by causes for the cohort and for the population base of the State of Rio de Janeiro, from 2000 to 2003. METHODS: Data were generated from the linkage of the National Hospital Admittance Authorization - SIH-SUS (2000) and SIM (2000-2003) databases. Individuals under 30 years were excluded from the study, and deaths due to violent causes were also excluded in order to analyze the mention of DM as cause of death. Analyses of causes of death were conducted both in the cohort and the population base. Quality markers of SIM in the cohort were the frequency of mention of diabetes mellitus in the death certificate and the proportion of deaths classified as non-specific causes of death, and non-specific causes of death in the population base. RESULTS: 38.0% in the special cohort (n = 977) died during the four years following LLA as a result of diabetes mellitus (DM), and 49.1% of these deaths occurred during the first year. Endocrine, nutritional metabolic (41.5%), and cardiovascular diseases (28.5%), and non-specific causes of death (8.1%) were the main underlying causes of death (UC). DM was mentioned as UC for 41.0%, as a sequential cause for 1.6%, and as contributive cause for 10.0%, among the other natural underlying causes of death besides DM on death certificates. Non-specific underlying causes of death accounted for 11.8% of death certificates in the population base. CONCLUSIONS: The high risk of death, the causes of death and the underreporting of DM on death certificates of adults with diabetes were similar to other population-based mortality studies. In the special cohort, the quality of the causes of death on certificates was considered bad. The improvement in the reliability of cause-of-death depends on the ability of physicians to register, and of healthcare facilities to codify correctly the causes of death on death certificates. The method (linkage of data and multiple causes of death) applied in this study to qualify death information was efficient and effective.

Purpose We aimed to examine the relationship of birthweight to cognitive performance in middle aged participants of the Atherosclerosis Risk in Communities Study (ARIC). Methods Cognitive function, assessed by means of three neuropsychological tests—the Delayed Word Recall Test (DWR), the Digit Symbol Subtest of the Wechsler Adult Intelligence Scale-Revised (DSS/WAIS-R), and the Word Fluency (WF) Test, was evaluated in relation to birthweight, as recalled through standardized interviews, by the use of data from the second and fourth follow-up visits of the Atherosclerosis Risk in Communities study cohort (1990−1992 and 1996−1998, respectively). Overall, 6785 participants satisfied the inclusion criteria and were included in the analysis. Results After adjusting for adult sociodemographic factors, childhood socioeconomic environment and parental risk factors, and adult anthropometric, health status-related. and behavioral variables, we observed linear trends for the relationship of birthweight to WF scores, although the trend was statistically significant only for those reporting exact birthweights ( p for trend = .004). For the other cognitive test results, results were either null or inconsistent with the a priori hypotheses. Conclusions Except for WF in those reporting exact birthweights, our study does not support the notion that birthweight influences cognitive function in adults.

ObjectiveTo investigate the correlation between the consumption of refined carbohydrates and fats and the prevalence of obesity in the state capitals of Brazil.DesignAn ecological evaluation of obesity and dietary risk factors was carried out in twenty-six state capitals of Brazil.SettingAnalysis was based on the age-standardized prevalence of obesity (BMI ≥ 30·0 kg/m2) among adults aged 20–59 years. Both intake and obesity prevalence were obtained from the last National Family Household Budget Survey (HBS). The survey was conducted from July 2002 to June 2003, based on a probabilistic national sample of 48 470 households. In each household, during seven consecutive days, all monetary and non-monetary expenses for food and beverages for family consumption were transformed into energy. The relative contribution of foods and food groups was expressed as the proportion (%) of total energy. Fruits and vegetables were also measured by the quantity bought in grams.ResultsPrevalence of obesity varied from 5·1 % to 13·6 % among women and from 5·2 % to 17·6 % among men. For women, there were statistically significant correlations between obesity and intake of sugar and soft drinks (rS = 0·60; P = 0·001), ready-to-eat meals (rS = 0·39; P = 0·05) and potatoes (rS = 0·40; P = 0·04). For men there were no such associations.ConclusionsIncreasing intake of refined carbohydrates, mainly soft drinks, may play a role in the prevalence of obesity among women in Brazil. Effecting changes in family purchase patterns may be a strategy to reduce obesity.

O objetivo deste estudo foi analisar o acesso a e a utilização de serviços odontológicos no Estado do Rio de Janeiro, Brasil, em 1998, a partir da Pesquisa Nacional por Amostra de Domicílios (PNAD 1998). A população de estudo foi composta por 7.756 indivíduos subdivididos em três estratos etários (15 a 19, 35 a 44 e 65 a 74 anos). A avaliação do acesso baseou-se na pergunta sobre a última vez que o entrevistado foi ao dentista. O fato de um indivíduo nunca ter ido ao dentista na vida foi considerado como indicativo de restrição de acesso, analisado segundo variáveis demográficas, sócio-econômicas e epidemiológicas. As proporções de indivíduos que nunca consultaram dentista foram 7,6%, 1,8% e 2,6% respectivamente, entre os jovens, adultos e idosos. Os resultados sugerem que indivíduos menos favorecidos em termos sócio-econômicos apresentavam maior limitação de acesso, ou seja, os menos escolarizados (jovens e adultos), com menor renda per capita (jovens e idosos) e com menor posse de eletrodomésticos (adultos). Entre os jovens e os adultos, a posse de plano de saúde mostrou-se inversamente associada à restrição de acesso. This study focused on access to and utilization of dental services in the State of Rio de Janeiro, Brazil, based on data from the 1998 National Household Sample Survey. The study population included 7,756 individuals, stratified by age (15 to 19, 35 to 44, and 65 to 74 years). Measurement of access to dental services was based on answers to the question regarding the last visit to a dentist. The answer "never visited a dentist" was interpreted as lack of access and was analyzed according to demographic, socioeconomic, and epidemiological variables. The proportions of individuals who had never visited a dentist were 7.6%, 1.8%, e 2.6%, respectively for young people, young adults, and the elderly. The results suggest that low socioeconomic status was associated with lack of access to dental services, characterized by low schooling (youth and young adults), low per capita income (youth and the elderly), and family wealth as measured by number of home appliances. Health insurance coverage was inversely associated with lack of access among youth and young adults.

INTRODUCTION: Neuropsychological changes are still controversial in patients with subclinical hypothyroidism (SH). The objective of this study is to assess these changes. METHOD: Cross-sectional study comparing the results of the neurocognitive evaluation of 65 SH patients and 31 individuals without thyroid disease. Subclinical hypothyroidism was defined as at least two elevated serum TSH levels (> 4 µUI/ml) with normal serum free T4 levels (0.9-1.8 ng/dl). The participants underwent the following neuropsychological assessment: Buschke’s Selective Reminding Procedure, Rey-Osterrieth Complex Figure Test, Warrington’s Recognition Memory Test for Words and Faces, and the Vocabulary subtest of the WAIS-R. RESULTS: The groups were similar in regard to mean age, sex and educational level. No neuropsychological change was found in patients with SH when compared with euthyroid individuals. CONCLUSION: No difference was observed in the performance of the neuropsychological tests between both groups in regard to the functions studied. INTRODUÇÃO: Até o presente momento, não se tem confirmação da presença de alterações neuropsicológicas em pacientes com hipotireoidismo subclínico (HS). O objetivo desta pesquisa foi avaliar essas alterações. MÉTODO: Estudo seccional comparando os achados neuropsicológicos de 65 pacientes com HS e 31 indivíduos eutireoidianos. HS foi confirmado por duas dosagens plasmáticas elevadas de TSH (> 4 µUI/ml) associadas com dosagem sérica de T4L na faixa da normalidade (0,9-1,8 ng/dl). Para avaliação neuropsicológica, foram utilizados o procedimento de Buschke, a figura de Rey-Osterrieth, o reconhecimento de palavras e faces de Warrington e o subteste Vocabulário do WAIS-R. RESULTADOS: Os grupos foram similares quanto a idade, sexo e nível de escolaridade. Não encontramos alterações neuropsicológicas nos pacientes com HS em comparação ao grupo eutireoidiano. CONCLUSÃO: Não foi encontrada nenhuma diferença nos resultados dos testes neuropsicológicos entre os dois grupos em relação às funções estudadas.

A avaliação das conseqüências dos problemas de saúde é um tema marcado pela diversidade conceitual e metodológica. Diferentes modelos conceituais são utilizados para o desenvolvimento de métodos para avaliação dos níveis de saúde de populações humanas. A avaliação das limitações e restrições da atividade física, devido a sua importância no âmbito das conseqüências das doenças crônicas, tem sido contemplada em inquéritos populacionais. Tais análises baseiam-se nas escalas de avaliação das atividades diárias da vida ou das atividades instrumentais diárias da vida. A PNAD, por meio do seu Suplemento Saúde realizado em 1998 e 2003, tem possibilitado a análise dos padrões de limitação das atividades habituais na população brasileira com idade superior a 13 anos. Neste estudo foram apresentados indicadores de diferentes graus de limitação, desenvolvidos com os dados da PNAD 2003. Os resultados preliminares mostram perfis diferenciados de limitação das atividades, segundo categorias das variáveis sexo e faixa etária. As mulheres e os indivíduos com mais idade apresentaram limitações com maior freqüência e em maior grau. A preocupação com o viés do informante se justifica pelo fato de metade das respostas ter sido fornecida por terceiros. The evaluation of the consequences of health problems is a subject characterized by conceptual and methodological diversity. Different conceptual models have been used for developing methods aimed at evaluating the health of populations. In the context of chronic diseases, the evaluation of physical activity restrictions and limitations based on scales of activities of daily living and instrumental activities of daily living is particularly important. Both the 1998 and 2003 National Household Survey Health Interviews have allowed for an analysis of activity limitation patterns of the Brazilian population aged 14 years and older. In the present study we present different indicators of varying degrees of limitation elaborated using data from the 2003 survey. Preliminary results showed varying patterns of activity limitation according to sex and age. In general, limitations were referred more frequently and to a higher degree among women and the elderly. The concern with information bias is justified by the fact that half of the questions were answered by proxy informants.

A partir dos dados do Suplemento Saúde da PNAD 1998, diversos estudos evidenciaram a presença de diferenças significativas nos padrões socioeconômicos, acesso, utilização de serviços de saúde e condições de saúde entre os segmentos populacionais cobertos e não cobertos por planos de saúde. Buscando contribuir para aprimorar o acervo dos conhecimentos sobre a estrutura e a dinâmica do mercado de planos e seguros de saúde no Brasil, admite-se e procura-se evidenciar a heterogeneidade dessas demandas. Para tanto, foi definida uma tipologia de planos de saúde, fundamentada nas origens institucionais das demandas e, subseqüentemente, pelas relações de dependência com titulares de planos e seguros de saúde, integrada por três categorias principais: os planos empresariais privados, os planos empresariais públicos e os planos individuais. As características etárias, socioeconômicas e de condições de saúde variam segundo os diferentes tipos de plano, sugerindo a presença de padrões distintos de demandas, especialmente entre os planos empresariais privados e os planos individuais. Several studies based on the 1998 PNAD Health Supplement data have shown significant differences in socioeconomic standards, access to and use of health services among population segments covered or not by health plans. Seeking to improve our knowledge on the structure and dynamics of the market of health plans and insurances in Brazil, we sought first to identify and then to highlight the different demands. To this effect, we conceived a typology of health plans on the basis of the institutional origin of the demands and on the relation between insurance and health plan holders and their dependents for three major categories: private employer plans, public employer plans and individual plans. Age, socioeconomic patterns and health conditions vary according to different health plan profiles, suggesting distinct patterns of demands, markedly between private employer and individual plans.

OBJETIVO: Analisar e correlacionar características clínicas, sintomas psiquiátricos e dados laboratoriais no hipotireoidismo subclínico (HS). MÉTODOS: Estudo transversal comparando achados de 103 pacientes com HS aos de 60 indivíduos eutireoidianos. A avaliação clínica e a psiquiátrica foram baseadas, respectivamente, na escala de Zulewski e nos questionários de Hamilton A, Hamilton D e Beck. Todos foram submetidos a dosagens de tireotropina (TSH), T4 livre e antitireoperoxidase (ATPO). Variáveis contínuas foram analisadas por meio do teste t de Student, quando de distribuição normal, e dos testes de Mann-Whitney e Kruskal Wallis, quando "não normais". Variáveis categóricas por meio dos testes Qui-quadrado, exato de Fisher e Kruskal Wallis. Análise multivariada foi utilizada para estudo de variáveis de confundimento. RESULTADOS: O nível médio de TSH, no HS, foi 7,76 ± 2,9 µUI/mL e 1,66 ± 0,6 µUI/mL nos eutireoideanos (p=0,001). O nível de T4L foi menor no HS, apresentando correlação linear negativa com TSH. Ocorreu maior freqüência de escore clínico anormal (48,3 vs 67%; p=0,020), de sintomas de depressão, pela escala de Beck no HS (20,5 vs 44,2%; p=0,011) e de sintomas de ansiedade (86 vs 63,4%; p=0,004) no HS. A presença de sintomas de depressão e ansiedade associou-se de forma positiva com pontuação no escore clínico e níveis de TSH. Não houve associação entre achados clínicos ou psiquiátricos e etiologia do HS, presença de ATPO, idade ou menopausa. CONCLUSÃO: O estudo aponta para associação entre HS, achados clínicos e sintomas psiquiátricos. Ensaios clínicos são necessários para avaliar uma possível melhora com levotiroxina. BACKGROUND: This investigation evaluated and correlated clinical, laboratorial aspects and psychiatric symptoms in sub clinical hypothyroidism (SH). METHODS: Cross sectional study involving 103 patients with SH and 60 subjects without thyroid disease. Clinical and psychiatric evaluation was respectively based on the Zulewski score and Hamilton A, Hamilton D and Beck questionnaires. Serum thyreotropin (TSH), (thyroxine) FT4 and (antithyroperoxidase) ATPO were measured in all participants. Analysis of continuums data was assessed by the Student t- test, for normally distributed data, and by the Mann- Whitney and Kruskal Wallis tests for non-parametric data. The chi2, Fisher's and Kruskal Wallis tests were used to study qualitative variables. Multivariate analyses were used to study confounding variables. RESULTS: Mean serum TSH level was 7.76 ± 2.9 µUI/mL in SH and 1.66 ± 0.6 µUI/mL in the group without thyroid disease (p=0.001). Mean serum T4L was slightly lower among patients with HS, and showed a negative linear correlation with TSH. Higher frequencies of abnormal clinical score (48.3 vs. 67.0%; p=0.02), depression self reported symptoms (20.5 vs. 44.2%; p=0.011) and anxiety symptoms (86.0 vs. 63.4%; p=0.004) occurred more frequently in SH. Frequency of psychiatric symptoms had a positive correlation with the clinical score and serum TSH. There was no association between the clinical and psychiatric findings and the etiology of SH, presence of ATPO, age or menopause. CONCLUSIONS: The study showed that SH was associated with clinical findings and with psychiatric symptoms. Clinical trials are required to evaluate possible improvement with levotiroxine.