Eduardo Freese

Vitamin D deficiency: a global perspective

Vitamin D is essential for the maintenance of good health. Its sources can be skin production and diet intake. Most humans depend on sunlight exposure (UVB 290-315 nm) to satisfy their requirements for vitamin D. Solar ultraviolet B photons are absorbed by the skin, leading to transformation of 7-dehydrocholesterol into vitamin D3 (cholecalciferol). Season, latitude, time of day, skin pigmentation, aging, sunscreen use, all influence the cutaneous production of vitamin D3. Vitamin D deficiency not only causes rickets among children but also precipitates and exacerbates osteoporosis among adults and causes the painful bone disease osteomalacia. Vitamin D deficiency has been associated with increased risk for other morbidities such as cardiovascular disease, type 1 and type 2 diabetes mellitus and cancer, especially of the colon and prostate. The prevalence of hypovitaminosis D is considerable even in low latitudes and should be taken into account in the evaluation of postmenopausal and male osteoporosis. Although severe vitamin D deficiency leading to rickets or osteomalacia is rare in Brazil, there is accumulating evidence of the frequent occurrence of subclinical vitamin D deficiency, especially in elderly people.

Vitamin D deficiency and its relationship with bone mineral density among postmenopausal women living in the tropics

OBJECTIVE To determine vitamin D (25OHD) status and its relationship with bone mineral density (BMD) in 93 postmenopausal women. SUBJECTS AND METHODS Patients were distributed in two groups: Group 1 - 51 to 65 years (n = 45) and Group 2 - 66 to 84 years (n = 48); 25OHD and PTH serum were analyzed and a DXA scan of the lumbar spine (LS) and femoral neck (FN) were taken. RESULTS Mean +/- SD of serum 25OHD levels were 80.6 +/- 43.3 nmol/L (Group 1) and 63.7 +/- 27.6 nmol/L (Group 2); 24% had 25OHD levels < 25 nmol/L and 43.7% < 50 nmol/L. The prevalence of vitamin D deficiency at the 62.5 nmol/L cutoff increased significantly with age. Patients with hypovitaminosis D had a lower BMD at the FN (0.738 +/- 0.102 vs. 0.793 +/- 0.115 g/cm, p = 0.03) and had been postmenopausal for longer (21.0 +/- 8.4 vs. 16.2 +/- 8.4 years, p = 0.01). CONCLUSION We found a high prevalence of hypovitaminosis D in postmenopausal women. Age, years elapsed since menopause and low BMD in the FN were associated with deficiency.

From mild to severe primary hyperparathyroidism: the Brazilian experience

Primary hyperparathyroidism often presents as an asymptomatic disorder. In our institution, routine serum calcium measurements have now been used as part of medical examination for 23 years. Out of 124 patients consecutively seen at our institution, 47% presented with no symptoms related to the disease, while 25% presented with severe skeletal involvement and osteitis fibrosa cystica, 25% with renal stone disease without overt bone involvement, and 2% with the typical neuropsychiatric syndrome. This same pattern is seen in the city of São Paulo. In severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. Bone mineral density is extremely low in these patients but usually show remarkable recovery following surgical cure. Serum PTH and bone markers are considerable higher in severely affected patients, who also have a high rate of vitamin D deficiency, and the parathyroid lesion is easier located compared with asymptomatic patients. From pathological specimens 87% had histological confirmation of a single adenoma, 6.4% multiple gland hyperplasia and 3.8% carcinoma.

RELATIONSHIP BETWEEN SERUM VITAMIN D STATUS AND CLINICAL MANIFESTATIONS OF PRIMARY HYPERPARATHYROIDISM

OBJECTIVE To compare vitamin D status represented by serum 25-hydroxyvitamin D (25-OHD) levels in a group of patients with primary hyperparathyroidism, stratified by clinical manifestations. METHODS We studied 22 patients (18 women and 4 men) with primary hyperparathyroidism--5 patients with severe osteitis fibrosa cystica, 10 symptomatic patients with active renal stone disease without overt bone disease, and 7 asymptomatic patients. Bone mineral density (BMD) measurements (T-scores) were done at the lumbar spine, femoral neck, and distal radius, and laboratory data for the three subgroups were analyzed. RESULTS Although considerably younger than the asymptomatic group, patients with osteitis fibrosa had significantly lower mean serum 25-OHD levels (16.7 +/- 1.1 ng/mL versus 29.9 +/- 2.9 ng/mL; P = 0.003). Moreover, patients with osteitis fibrosa had significantly lower BMD in comparison with patients who had renal stone disease as well as asymptomatic patients for all sites measured. Serum parathyroid hormone levels were significantly higher in patients with osteitis fibrosa than in asymptomatic patients (1,352.8 +/- 297.2 pg/mL versus 145.0 +/- 43.7 pg/mL; P<0.02) as well as in comparison with patients who had renal stone disease (P<0.02). Patients with osteitis fibrosa had urinary N-telopeptide levels that were significantly higher than those in asymptomatic patients (501.5 +/- 201.7 versus 51.3 +/- 6.4 nmol/mmol creatinine; P = 0.02) and those in patients with renal stone disease (P = 0.01). CONCLUSION The findings in this study demonstrate that vitamin D deficiency or insufficiency may contribute to disease severity in primary hyperparathyroidism.

Prevalence of central obesity in a large sample of adolescents from public schools in Recife, Brazil

OBJECTIVE To determine the prevalence and association of central obesity (CO) and hypertension and its associations with alcohol intake, smoking and physical activity in adolescents. SUBJECTS AND METHODS Cross sectional study in 1,824 students from 29 public schools in Recife. RESULTS 89.6% were normal weight, 6.7% overweight and 3.7% obese; 77.2% were normotensive, 5.9% prehypertensive and 16.9% hypertensive; CO was 10.2% when the 90th percentile was used as cutoff and 25.2% when the 75th percentile was used. There was a higher likelihood of central obesity among students aged 18 to 20 years, smoking and alcohol intake. The probability of hypertension increases if the subject is male, has a waist circumference (WC) ≥ 90, WC ≥ 75 and does not practice physical activity. CONCLUSIONS A high prevalence of CO and hypertension was found in adolescents. CO was more frequent in students aged 18 to 20 years, smokers and with alcohol intake and hypertension was associated with male, CO and no physical activity.

Análise da sustentabilidade de uma política de avaliação: o caso da atenção básica no Brasil

This study analyzes the sustainability of Brazils National Policy for the Evaluation of Primary Health Care, based on the identification and categorization of representative critical events in the institutionalization process. This was an evaluative study of two analytical units: Federal Management of Primary Health Care and State Health Secretariats, using multiple case studies with data collected through interviews and institutional documents, using the critical incidents technique. Events that were temporally classified as specific to implementation, sustainability, and mixed were categorized analytically as pertaining to memory, adaptation, values, and rules. Federal management and one of the State Health Secretariats showed medium-level sustainability, while the other State Secretariat showed strong sustainability. The results indicate that the events were concurrent and suggest a weighting process, since the adaptation of activities, adequacy, and stabilization of resources displayed a strong influence on the others. Innovations and the development of technical capability are considered the most important results for sustainability.

A vigilância epidemiológica no âmbito municipal: avaliação do grau de implantação das ações

This studys objective was to evaluate the degree of implementation of epidemiological surveillance activities by the Municipal Health Secretariat in Recife, Pernambuco State, Brazil. The design consisted of a case study with a normative approach. The logical model for epidemiological surveillance was outlined as the basis for selecting criteria that comprised a matrix submitted to specialists using the consensus technique or Delphi Method. This consensual matrix was used as the basis for the questionnaires used in the interviews. Three analytical levels were approached: the central level, 6 health districts, and 62 family health teams. According to the study, epidemiological surveillance has been partially implemented in the municipality, based on the degree of implementation at the three levels (already implemented at the central level and partially implemented in the health districts and family health teams). Despite the decentralization of epidemiological surveillance activities to the municipalities, different levels in the municipal system have different needs in dealing with the standards and norms, including the elaboration of internal guidelines to define responsibilities at the three levels.

Avaliação dos serviços de urgência e emergência da rede hospitalar de referência no Nordeste Brasileiro

This article evaluates the degree of implementation of ten urgent and emergency hospital services comprising the macro and micro-regional referral system in Pernambuco State, Northeast Brazil. The study analyzes criteria related to structure (physical and organizational, and material and human resources) and process (routine and referral/counter-referral activities), classifying the hospitals as satisfactory, acceptable, and deficient. The majority of the hospitals were classified as deficient, including all the micro-regional units and one macro-regional referral unit. Macro-regional units show better performance in the work process, while implementation of the structural dimension is better in the micro-regional hospitals. The results highlight the priority of upgrading these hospitals by strengthening decentralized human resources and technology policies, oriented towards the improvement of work processes in keeping with the States regional contexts.

Política de monitoramento e avaliação da atenção básica no Brasil de 2003 a 2006: contextualizando sua implantação e efeitos

OBJETIVOS: este artigo apresenta um estudo da Implantacao da Politica de Monitoramento e Avaliacao da Atencao Basica no Brasil. Estima o grau de implantacao dos dispositivos institucionais e da Intervencao, alem de avaliar a sua influencia nos efeitos produzidos a partir da interacao com o contexto politico-organizacional. METODOS: pesquisa avaliativa do tipo analise de implantacao. Estudo de caso com niveis de analise imbricados e triangulacao de metodos. Para estimar o grau de implantacao consideraram-se os dispositivos institucionais produzidos, representativos dos componentes do modelo logico da intervencao. Foram realizadas 20 entrevistas e analisados 29 documentos relacionados. RESULTADOS: a intervencao foi classificada como implantada em um grau Avancado, com 78% das acoes realizadas. O contexto politico-institucional foi caracterizado pela conjuncao de decisao politico-institucional, recursos financeiros, mecanismos tecnicos e estrategias organizacionais de qualificacao dos recursos humanos para avaliacao com vistas a construcao da capacidade institucional. Foi encontrado conjunto significante de efeitos nao-intencionais como decorrencia da pluralidade de dispositivos utilizados para a implantacao da intervencao. CONCLUSOES: A politica revela um franco esforco objetivando a integracao das acoes no âmbito institucional e a descentralizacao das acoes de avaliacao. Neste sentido, duas caracteristicas sao marcantes: o desenvolvimento de capacidade tecnica, por meio de processos avaliativos formativos, e o foco no fortalecimento das Secretarias Estaduais de Saude.

Contribuindo com a institucionalização da avaliação em saúde: uma proposta de auto-avaliação

In the context of measures to institutionalize the evaluation of primary health care in Brazil, the Ministry of Health proposed a formative and normative evaluation of the implementation of the project entitled Technical Capacity-Building of State Health Departments for Monitoring and Evaluation, as part of the National Policy for the Evaluation of Primary Care. One of the objectives was to develop a self-evaluation model using the rapid evaluation method (REM). This article presents the stages concluded to date in the self-evaluation model, together with the theoretical references. The final self-evaluation proposal was based on a theoretical evaluation model developed for formative evaluation and included the principal actions proposed for State health management, with all the tested indicators, thus increasing the internal validity and consistency. The final perspective is that this instrument, used with a participatory approach as provided in the proposal, helps assess the extent to which the projects objectives and actions are achieved, while identifying situations that can interfere in different contexts.