Antonio José Ledo Alves da Cunha

Prevalência dos fatores de risco para doença cardiovascular em funcionários do Centro de Pesquisas da Petrobras

OBJECTIVE: To determine the prevalence of risk factors for cardiovascular diseases in employees of the research center at Petrobras. METHODS: In a cross-sectional study, employees of the research center at Petrobras were assessed clinically and by laboratory testing from March 2000 and February 2001. Those who did not attend the periodical annual medical examination of 2000 were excluded from the study. The percentage of risk factor occurrence and the mean standard deviation of the biochemical variables, blood pressure, and body mass index were calculated. RESULTS: Of 1,911 employees, 970 were studied, 75.4% were men and 24.6% were women with a mean age of 42.2 years old. The risk factors were lack of exercise (67.3%), cholesterol > 200 mg/dL (56.6%), overweight (42%), obesity (17%), blood hypertension (18.2%), smoking (12.4%), and diabetes mellitus (2.5%). CONCLUSION: The high prevalence of risk factors for cardiovascular disease in young individuals draws attention to the need for the adoption of workplace programs to encourage healthy lifestyles and to prevent diseases.

Óbitos atribuídos à tuberculose no Estado do Rio de Janeiro

INTRODUCAO:Em 1998, o Rio de Janeiro era o estado de maior incidencia e mortalidade por tuberculose do Brasil. O Sistema de Informacao de Agravos de Notificacao em Tuberculose (SINAN-TB-RJ) nao era confiavel. OBJETIVO: Utilizar o estudo dos obitos por tuberculose como instrumento de avaliacao do programa de controle de tuberculose. METODO: Foram realizados estudos descritivos do SINAN-TB-RJ e do Sistema de Informacao de Mortalidade em tuberculose do Rio de Janeiro (SIM-TB-RJ) e os dois bancos de dados foram cruzados utilizando-se o programa Reclink. Foi tambem realizado um estudo baseado em prontuarios dos cinco hospitais onde ocorreu o maior numero de obitos por tuberculose. RESULTADOS: Em 1998 foram registrados no SINAN-TB-RJ 16.567 casos de tuberculose em maiores de 14 anos. A forma pulmonar estava presente em 13.989 (84,5%) casos, dos quais 8.223 (56,8%) tiveram baciloscopia positiva. A sorologia anti-HIV, recomendada para todos os pacientes com tuberculose, foi solicitada em apenas 4.141 (25%) casos. No SIM-TB-RJ foram registrados 1.146 obitos, dos quais 478 (41,7%) casos haviam sido notificados no SINAN-TB-RJ, entre 1995 e 1998. Dos 302 prontuarios estudados, em 154 (50,9%) o periodo de internacao foi inferior a 10 dias. O tempo entre o inicio dos sintomas e o diagnostico foi superior a 60 dias em 143 (47,3%) pacientes. Dos 125 pacientes em re-tratamento, para apenas 43 (34,4%) foi prescrito o esquema RHZE recomendado pelo Ministerio da Saude. CONCLUSAO: O estudo demonstra que a tuberculose e sub-notificada, o diagnostico e tardio, a utilizacao dos exames laboratoriais recomendados e baixa e as normas do Ministerio da Saude nao sao cumpridas.

Knowledge about STD/AIDS and sexual behavior among high school students in Rio de Janeiro, Brazil

The incidence of AIDS and other sexually transmitted diseases (STDs) is increasing among adolescents. In order to better understand high-risk sexual behavior among students, a cross-sectional study based on a self-answered anonymous questionnaire was conducted in 10 public and private high schools in Rio de Janeiro, Brazil. Data were obtained on sociodemographics, knowledge of STD/AIDS, and sexual behavior. Among 945 students aged 13-21, 59% were sexually initiated, and the median age at first sexual intercourse was 15 years (range: 7-19). Although 94% reported being aware of the need for condom use for protection, only 34% informed always using condoms during sex. Low family income was associated with unsatisfactory knowledge (OR = 9.40; 95% CI = 6.05-14.60) and inconsistent condom use (OR = 11.60; 95% CI = 5.54-24.30). However, unsatisfactory knowledge was not associated with inconsistent condom use. School-based educational programs should focus on sexual behavior more than on transmission of knowledge, as well as targeting low-income students.

Breastfeeding and pacifier use in Brazil

Objective: To determine the relationship between pacifier use and the duration of exclusive breast-feeding in the first six months of age, among poor children with unfavourable birth weight, from an underdeveloped region in Brazil.Method: Prospective cohort study with infants followed from birth to 6 months of age. Healthy children born with unfavourable birth weight (<3,000), being exclusively breastfed, were selected from 8 maternity hospitals in the city of Fortaleza (Brazil) between November 1996 and April 1997. Two main outcome measures were used: (i) time to stop exclusive breast-feeding at the 1st and (ii) at the 6th month of life. Main exposures were pacifier use at 1st and 6th month of age. Data were collected at maternity hospitals and during home interviews, using structured questionnaires, by trained data collectors unaware of the study aims, and analyzed using survival analysis and the Cox Proportional Hazard Model.Results: 500 children were enrolled and 13% were lost to follow up at the 1st month. Most of the families had a monthly income less than five times the minimum wage. One third of the mothers were adolescents, one fifth were working outside the home by the 6th month and most attended prenatal care visits. Approximately 60% of the children were using pacifiers by the 1st month. The average number of days for exclusive breast-feeding for pacifier use by the 6th month was 125.3 compared to 87.0 among non-users (p=0.0001). Children using pacifiers were 1,9 more likely to have stopped exclusive breastfeeding by the 6th month compared to non-users, even after controlling potential confounders.Conclusion: Pacifier use was associated with the early termination of breast-feeding in Brazil, among poor children with unfavourable birth weight, living in an underdeveloped area. As, a possible marker of early weaning, pacifier use can help health workers identify those mothers in need of extended counselling to reinforce breast-feeding practices.

Pesquisa Nascer no Brasil: perfil da mortalidade neonatal e avaliação da assistência à gestante e ao recém-nascido

Estudo de coorte sobre a mortalidade neonatal na pesquisa Nascer no Brasil, com entrevista e avaliacao de prontuarios de 23.940 puerperas entre fevereiro de 2011 e outubro de 2012. Utilizou-se modelagem hierarquizada para analise dos potenciais fatores de risco para o obito neonatal. A taxa de mortalidade foi 11,1 por mil; maior nas regioes Norte e Nordeste e nas classes sociais mais baixas. O baixo peso ao nascer, o risco gestacional e condicoes do recem-nascido foram os principais fatores associados ao obito neonatal. A inadequacao do pre-natal e da atencao ao parto indicaram qualidade nao satisfatoria da assistencia. A peregrinacao de gestantes para o parto e o nascimento de criancas com peso < 1.500g em hospital sem UTI neonatal demonstraram lacunas na organizacao da rede de saude. Obitos de recem-nascidos a termo por asfixia intraparto e por prematuridade tardia expressam a evitabilidade dos obitos. A qualificacao da atencao, em especial da assistencia hospitalar ao parto se configura como foco prioritario para maiores avancos nas politicas publicas de reducao das taxas e das desigualdades na mortalidade infantil no Brasil.This study examined neonatal deaths in the live-births cohort in the Birth in Brazil survey, which interviewed and examined medical records of 23,940 mothers from February 2011 to October 2012. Potential risk factors were analyzed using hierarchical modeling. Neonatal mortality rate was 11.1/1,000, the highest rates occurring in the North and Northeast regions and in lower social classes. Low birth weight, risks during pregnancy and conditions of the newborn were the main factors associated with neonatal death. Inadequate prenatal and childbirth care point to unsatisfactory quality of health care. Difficulty in gaining hospital admission for delivery, and children with birth weight<1,500g born at hospitals without a neonatal intensive care unit, indicate gaps in health system organization. Deaths from intra-partum asphyxia in term babies and late prematurity express preventable neonatal mortality. Better quality health care, especially hospital care during labor and birth, poses the main public policy challenge to progress in reducing mortality and inequalities in Brazil.

TUBERCULIN SKIN TEST CONVERSION AMONG MEDICAL STUDENTS AT A TEACHING HOSPITAL IN RIO DE JANEIRO, BRAZIL

OBJECTIVE To describe the cumulative incidence of and risk factors for tuberculosis (TB) infection among medical students. DESIGN In 1999, a cohort study of medical students with negative results (induration < 10 mm) on tuberculin skin test (TST) was performed. Students who had undergone two-step testing in 1998 were retested. SETTINGS University and teaching hospital and referral center for TB and acquired immunodeficiency syndrome, and the Health Sciences Building of the Medical School of the Federal University of Rio de Janeiro, Brazil. PARTICIPANTS A sample of 618 consecutive medical students with negative TST results who had been tested 12 months before were approached. Information about sociodemographic characteristics, bacille Calmette-Guérin vaccination history, and potential exposures to TB was obtained using a standardized questionnaire. Four hundred fourteen (67%) students completed the study. Students were at two different levels of their training programs (juniors = no contact with patients; seniors = intensive contact with patients). RESULTS Of 414 participants, 16 (3.9%; 95% confidence interval, 1.06% to 12.1%) had converted to a positive reaction after 1 year. In a multivariate logistic regression analysis, higher level of clinical training was confirmed to be an independent factor associated with TST conversion (odds ratio, 4.77; 95% confidence interval, 1.01 to 22.46; P= .048). CONCLUSION Senior medical students are at increased risk of Mycobacterium tuberculosis infection in this setting. Therefore, a program of routine tuberculin skin testing and specific TB infection control guidelines are needed for this population.

Predictive model for the diagnosis of tuberculous pleural effusion

This study developed a predictive model to identify pleural tuberculosis. A consecutive cases study of patients investigating the cause of pleural effusion, in an area of high prevalence of tuberculosis (Rio de Janeiro, Brazil). Clinical and laboratory variables were compared among patients with tuberculosis (TB) and without tuberculosis (NTB), individually and using logistic regression. The performance was described as diagnostic accuracy, compared to a gold standard in a masked way. We have studied 104 TB patients, 41 with malignant, 29 transudates, 28 parapneumonic, 13 with miscellaneous diseases. After identification of individual discrimination power aided by clinical, radiological and laboratory variables, the following ones were included in a multivariate analysis: ADA, total leukocytes, percentile of lymphocytes, protein, lactate dehydrogenase, duration of disease, age and gender. A logistic regression model to predict pleural tuberculosis including the five first variables showed the best performance. A receiver operating characteristic curve identified the best cutoff at 0.7, resulting in a sensitivity and specificity of more then 95%. The predictive model improved the specificity of ADA alone, keeping its sensitivity. This model seems helpful when a microbiological or histological diagnosis of pleural tuberculosis could not be established. External validation of these results is necessary before recommendation for routine application.

Evaluating mother-and-child health care in Brazil

OBJETIVO: Analisar e comparar os cuidados primarios prestados a populacao materno-infantil e contribuir para a avaliacao da assistencia integral a esse grupo. METODOS: Inquerito populacional realizado por entrevistas, no principal posto de vacinacao do Municipio de Teresopolis, RJ, no Dia Nacional de Vacinacao, que abrangeu questoes sobre utilizacao de servicos de saude e prestacao de cuidados primarios preventivos. RESULTADOS: Foram colhidas informacoes de 329 criancas e suas respectivas maes. Mais de 90% das criancas haviam comparecido a consulta pediatrica nos tres meses anteriores e quase todas possuiam o cartao da crianca, embora em 30% desses cartoes nao havia qualquer peso registrado no periodo. Observou-se associacao positiva entre consulta de puericultura e registro de peso no cartao da crianca (RP = 1,34; IC: 1,13-1,58; p = 0,0002). Cerca de 59% das maes compareceram a consulta de revisao de parto, mas 25% referiram nunca ter feito exame colpocitologico-oncotico e 36% nunca haviam realizado exame de mama. Observou-se associacao positiva entre a idade materna acima de 20 anos e a realizacao de algum exame colpocitologico-oncotico durante a vida reprodutiva (RP = 1,56; IC: 1,08-2,26; p = 0,03). Quase 70% das maes relataram uso de algum metodo anticoncepcional, principalmente pilula, condom e laqueadura tubaria. CONCLUSOES: Apesar de algumas limitacoes, os resultados sugerem a viabilidade da metodologia utilizada, permitindo a identificacao de deficiencias importantes na prestacao de cuidados primarios de saude para criancas e principalmente para maes.OBJECTIVE To describe and analyze primary health care provided to mother-and-child population in Teresópolis, state of Rio de Janeiro, Brazil. METHODS A population survey was performed at the main vaccination station on the local Vaccine National Day, to collect information about the use of health care services and preventive primary care. RESULTS Information was collected from 329 mothers and their children. More than 90% of children had at least one pediatric visit in the past three months. Almost all had their growth chart, but in 30% of them the childs weight was not registered. There was a positive association between having a routine visit and the registration of the childs weight in the card (RP = 1.34; IC: 1.13-1.58; p = 0.0002). Around 59% of the mothers had a medical visit after giving after birth; 25% said they had never had a Pap smear test before, and 36% never had a breast examination. There was a positive association between the mothers age being over 20 years and ever having a Pap smear test (RP = 1.56; IC: 1.08-2.26; p = 0.03). Almost 70% of the mothers referred the use of any contraception method, and the most common used were contraceptive pills, condoms and tubal ligation. CONCLUSIONS Despite some limitations, the results suggest a valid and useful methodology, which allows the identification of important needs in primary health care delivery to children and their mothers.OBJETIVO: Analisar e comparar os cuidados primarios prestados a populacao materno-infantil e contribuir para a avaliacao da assistencia integral a esse grupo. METODOS: Inquerito populacional realizado por entrevistas, no principal posto de vacinacao do Municipio de Teresopolis, RJ, no Dia Nacional de Vacinacao, que abrangeu questoes sobre utilizacao de servicos de saude e prestacao de cuidados primarios preventivos. RESULTADOS: Foram colhidas informacoes de 329 criancas e suas respectivas maes. Mais de 90% das criancas haviam comparecido a consulta pediatrica nos tres meses anteriores e quase todas possuiam o cartao da crianca, embora em 30% desses cartoes nao havia qualquer peso registrado no periodo. Observou-se associacao positiva entre consulta de puericultura e registro de peso no cartao da crianca (RP = 1,34; IC: 1,13-1,58; p = 0,0002). Cerca de 59% das maes compareceram a consulta de revisao de parto, mas 25% referiram nunca ter feito exame colpocitologico-oncotico e 36% nunca haviam realizado exame de mama. Observou-se associacao positiva entre a idade materna acima de 20 anos e a realizacao de algum exame colpocitologico-oncotico durante a vida reprodutiva (RP = 1,56; IC: 1,08-2,26; p = 0,03). Quase 70% das maes relataram uso de algum metodo anticoncepcional, principalmente pilula, condom e laqueadura tubaria. CONCLUSOES: Apesar de algumas limitacoes, os resultados sugerem a viabilidade da metodologia utilizada, permitindo a identificacao de deficiencias importantes na prestacao de cuidados primarios de saude para criancas e principalmente para maes.

Environmental and socio‐demographic factors associated to asthma in adolescents in Rio de Janeiro, Brazil

Although asthma is of frequent occurence, little is known about the factors associated with this disease in Brazil. We studied the association between asthma, environmental and socio‐demographic factors in adolescents in Nova lguacu, Rio de Janeiro State. Cross‐sectional study using the questionnaires about asthma and environmental factors from the International Study of Asthma and Allergies in Childhood (ISAAC). We performed bivariate analyses between asthma and the factors studied using prevalence ratio (PR), confidence intervals of 95% (95% Cl) and Chi‐squared test. Factors associated to asthma in a bivariate analysis were studied using logistic regression and odds ratio (OR). We included 3,033 students, aged 13–14 yrs, selected from 37 schools. The prevalence of asthma was 13.1%. Being female (OR = 1.40; 95%Cl:1.11–1.77), the presence of a mother who smokes (OR = 1.32; 95%Cl:1.04–1.66), a cat in the domicile (OR = 1.32; 95%Cl:1.04–1.69), being the firstborn (OR = 1.34; 95%Cl:1.07–1.68), frequent use of paracetamol (OR = 1.45; 95%Cl: 1.15–1.84), the presence of rhinitis (OR = 5.15; 95%:3.89–6.82) and eczema (OR = 2.35; 95%Cl:1.73–3.19) were independently associated to asthma. Environmental and socio‐demographic factors were associated to asthma in adolescents in Rio de Janeiro, irrespective of the presence of others allergic diseases. Interventions acting on these factors may decrease the occurence of asthma in this population.

Risco de infecção pelo Mycobacterium tuberculosis entre alunos da Faculdade de Medicina da Universidade Federal do Rio de Janeiro

INTRODUCTION: There have been few Latin American studies investigating the fact that the rate of tuberculosis (TB) infection among medical students is higher than the 1.3% rate seen in the population at large. OBJECTIVE: To describe the cumulative incidence and the relative risk for TB infection among medical students. METHOD: In 1998, a prospective cohort study was conducted involving medical students at the Universidade Federal do Rio de Janeiro Faculdade de Medicina who tested negative (induration <10 mm) on the tuberculin skin test (TST). Students were tested using the two-step TST method and were retested one year later. The students tested were at two different stages in their training: pre-clinical (no contact with patients) and final year (contact with patients). Information about demographic characteristics, BCG vaccination history, and instances of potential exposure to Mycobacterium tuberculosis were obtained using a standardized questionnaire. Of the 575 students initially enrolled, 72% (414) completed the study. RESULTS: The TSTs of 16 (3.9%) of the 414 students converted, representing a cumulative incidence of 3.9% (95% confidence interval = 1.06 to 12.1). Senior medical students were at an almost fourfold higher risk for M. tuberculosis infection than were those in pre-clinical training. CONCLUSION: The risk for TST conversion is very high in this population.