Geraldo Marcelo da Cunha

Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms.

OBJECTIVE To examine factors associated with physical restraint in psychiatric emergency rooms. METHOD We extracted variables likely to predict use of physical restraints from a large randomised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro. We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints. RESULTS Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first 2 h of admission. In Rio, younger people (OR=1.03 for each year younger), exhibiting intense (OR=2.53) or extreme agitation (OR=7.71), thought to result from substance misuse (OR=1.75) or diagnoses other than psychosis (OR=1.88), arriving in the morning (OR=1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained. CONCLUSION Restraint practices in Rio are predictable and based on a limited clinical assessment. Predictive factors for physical restraint may vary worldwide, but should be monitored and studied to assist training, and to establish programs to evaluate and refine this controversial practice.

Conceitos básicos de epidemiologia e estatística para a leitura de ensaios clínicos controlados

The authors present the basic concepts in epidemiology and statistics needed for understanding properly the design and results of controlled clinical trials. Through a set of examples, the concepts of measures of association and effect, statistical significance tests, p-value, confidence interval and statistical power are presented and common their misinterpretations are discussed.

Spatial Distribution of Dengue in a Brazilian Urban Slum Setting: Role of Socioeconomic Gradient in Disease Risk

Background Few studies of dengue have shown group-level associations between demographic, socioeconomic, or geographic characteristics and the spatial distribution of dengue within small urban areas. This study aimed to examine whether specific characteristics of an urban slum community were associated with the risk of dengue disease. Methodology/Principal Findings From 01/2009 to 12/2010, we conducted enhanced, community-based surveillance in the only public emergency unit in a slum in Salvador, Brazil to identify acute febrile illness (AFI) patients with laboratory evidence of dengue infection. Patient households were geocoded within census tracts (CTs). Demographic, socioeconomic, and geographical data were obtained from the 2010 national census. Associations between CTs characteristics and the spatial risk of both dengue and non-dengue AFI were assessed by Poisson log-normal and conditional auto-regressive models (CAR). We identified 651 (22.0%) dengue cases among 2,962 AFI patients. Estimated risk of symptomatic dengue was 21.3 and 70.2 cases per 10,000 inhabitants in 2009 and 2010, respectively. All the four dengue serotypes were identified, but DENV2 predominated (DENV1: 8.1%; DENV2: 90.7%; DENV3: 0.4%; DENV4: 0.8%). Multivariable CAR regression analysis showed increased dengue risk in CTs with poorer inhabitants (RR: 1.02 for each percent increase in the frequency of families earning ≤1 times the minimum wage; 95% CI: 1.01-1.04), and decreased risk in CTs located farther from the health unit (RR: 0.87 for each 100 meter increase; 95% CI: 0.80-0.94). The same CTs characteristics were also associated with non-dengue AFI risk. Conclusions/Significance This study highlights the large burden of symptomatic dengue on individuals living in urban slums in Brazil. Lower neighborhood socioeconomic status was independently associated with increased risk of dengue, indicating that within slum communities with high levels of absolute poverty, factors associated with the social gradient influence dengue transmission. In addition, poor geographic access to health services may be a barrier to identifying both dengue and non-dengue AFI cases. Therefore, further spatial studies should account for this potential source of bias.

Prevalência e fatores associados à anemia em mulheres indígenas Suruí com idade entre 15 e 49 anos, Amazônia, Brasil

OBJECTIVES: to investigate the prevalence of and factors associated with the occurrence of anemia in indigenous Surui women aged between 15 and 49 years. METHODS: a cross-sectional study was carried out based on the 2005 census of Sete de Setembro indigenous territory in the Brazilian State of Rondonia. Hemoglobin measurement (Hb) was carried out using a portable β-hemoglobinometer. The cut-off points for anemia were Hb <12.0 g/dL in non-pregnant women and Hb <11.0 g/dL in pregnant women. Demographic and socio-economic data were gathered using a standardized questionnaire. The first stage of statistical analysis included the: chi-square; the chi-square linear tendency test; Students t; a test for linearity and analysis of variance. In the second stage, the final logistic model was adjusted. RESULTS: the overall prevalence of anemia in non-pregnant women was 67.3% and, in pregnant women, 81.8%. Multivariate analysis showed that women with one or two anemic children aged between 6 and 35 months were three times more likely to be anemic; women from the lowest socio-economic stratum were 3.5 times more likely to be anemic. The likelihood of a Surui woman of low socio-economic status being anemic was 26% higher than that of one from the highest socio-economic stratum. CONCLUSIONS: anemia is a serious health problem among Surui women and is influenced by household factors, such as having children with anemia and socio-economic circumstances. It is suggested that measures to treat and prevent anemia among the Surui take these factors into account.

Geographic weighted regression: applicability to epidemiological studies of leprosy

INTRODUCTION Geographic information systems (GIS) enable public health data to be analyzed in terms of geographical variability and the relationship between risk factors and diseases. This study discusses the application of the geographic weighted regression (GWR) model to health data to improve the understanding of spatially varying social and clinical factors that potentially impact leprosy prevalence. METHODS This ecological study used data from leprosy case records from 1998-2006, aggregated by neighborhood in the Duque de Caxias municipality in the State of Rio de Janeiro, Brazil. In the GWR model, the associations between the log of the leprosy detection rate and social and clinical factors were analyzed. RESULTS Maps of the estimated coefficients by neighborhood confirmed the heterogeneous spatial relationships between the leprosy detection rates and the predictors. The proportion of households with piped water was associated with higher detection rates, mainly in the northeast of the municipality. Indeterminate forms were strongly associated with higher detections rates in the south, where access to health services was more established. CONCLUSIONS GWR proved a useful tool for epidemiological analysis of leprosy in a local area, such as Duque de Caxias. Epidemiological analysis using the maps of the GWR model offered the advantage of visualizing the problem in sub-regions and identifying any spatial dependence in the local study area.

Lower Inter-Partum Interval and Unhealthy Life-Style Factors Are Inversely Associated with n-3 Essential Fatty Acids Changes during Pregnancy: A Prospective Cohort with Brazilian Women

Objective To analyze serum fatty acids concentrations during healthy pregnancy and evaluate whether socioeconomic, demographic, obstetric, nutritional, anthropometric and lifestyle factors are associated with their longitudinal changes. Study design A prospective cohort of 225 pregnant women was followed in the 5th–13th, 20th–26th and 30th–36th weeks of gestation. Serum samples were collected in each trimester of pregnancy and analyzed to determine the fatty acids composition using a high-throughput robotic direct methylation method coupled with fast gas-liquid chromatography. The independent variables comprised the subjects’ socioeconomic and demographic status, obstetric history, early pregnancy body mass index (BMI), dietary and lifestyle parameters. Analyses were performed using linear mixed-effects models. Results The overall absolute concentrations of fatty acids increased from the 1st to the 2nd trimester and slightly increased from the 2nd to the 3rd trimester. Early pregnancy BMI, inter-partum interval and weekly fish intake were the factors associated with changes in eicosapentaenoic + docosahexaenoic acids (EPA+DHA) and total n-3 polyunsaturated fatty acids (PUFAs). Early pregnancy BMI, age and monthly per-capita income were inversely associated with the changes in the n-6/n-3 ratio. Alcohol consumption was positively associated with the n-6/n-3 ratio. Conclusion Early pregnancy BMI was positively associated with EPA+DHA and total n-3 PUFAs, while presenting a reduced weekly fish intake and a lower inter-partum interval were associated with lower levels of n-3 PUFAs. A lower per-capita family income and a drinking habit were factors that were positively associated with a higher n-6/n-3 ratio.

Physical growth curves of indigenous Xavante children in Central Brazil: results from a longitudinal study (2009–2012)

Abstract Background: The nutritional profile of Indigenous children in Brazil is comparable to those observed in some of the least developed regions of the world. Aim: Weight and height growth curves were characterised based on longitudinal data from a local Indigenous population experiencing the double burden of child under-nutrition and adult obesity. Subjects and methods: Anthropometric data were collected in six waves from 2009–2011 for children <10 in two proximate Xavante villages in Central Brazil. Prevalence rates for stunting, wasting and thinness were calculated using WHO references. Weight and height data were adjusted for generalised additive mixed models to generate growth curves. Results: Prevalence rates of stunting and wasting were high, but cases of thinness and excess weight were negligible. Weight and height began close to WHO medians, but fell substantially before 12 months. Boys but not girls were able to catch-up in weight before age 10. From 3–10 years, height for both sexes remained between −2 and 0 z-scores. Conclusion: Impaired Xavante growth before 1 year followed by inconsistent recovery before 10 years reflects health and wellbeing disparities with regard to the Brazilian national population and a complex epidemiology of growth involving rapid nutritional change.

Obesidade e excesso de peso em adultos indígenas Xukuru do Ororubá, Pernambuco, Brasil: magnitude, fatores socioeconômicos e demográficos associados

Este estudo transversal visa a descrever a distribuicao de excesso de peso e obesidade e sua associacao com variaveis demograficas e socioeconomicas entre 794 adultos indigenas, de 19 a 59 anos, da etnia Xukuru do Ororuba, povo indigena cujas terras estao localizadas no Municipio de Pesqueira, agreste de Pernambuco, Brasil. A analise da associacao entre as variaveis de desfecho, excesso de peso (IMC > 24,99kg/m2) e obesidade (> 29,99kg/m2) e as variaveis explicativas foi realizada utilizando-se regressao logistica multinivel. Entre as mulheres, 52,2% estavam com excesso de peso e 21% obesas. Para os homens, as prevalencias foram de 44,1% e 7,5%, respectivamente. As variaveis sexo feminino e idade (> 30 anos) estiveram associadas a ocorrencia de ambos os agravos. Status socioeconomico e interacao sexo masculino e renda per capita elevada apresentaram associacao com obesidade. Assim como observado em outras populacoes indigenas, os achados sugerem que os Xukuru estao atravessando um acelerado processo de transicao nutricional.This cross-sectional study focused on the epidemiology of overweight and obesity and the association with demographic and socioeconomic variables in a sample of 794 Xukuru of Ororubá adults 19-59 years of age, from an indigenous reserve in Pesqueira County, Pernambuco State, Brazil. Descriptive analyses and multivariate logistic regression were carried out, using cut-off points of BMI > 24.99kg/m2 for overweight and > 29.99kg/m2 for obesity. Prevalence rates of overweight and obesity were higher in women (52.2% and 21%, respectively) than in men (44.1% and 7.5%, respectively). Female sex and age (> 30 years) were associated with both outcomes in the multivariate regression. For obesity, the following variable showed statistically significant associations: socioeconomic status and the interaction between male gender and per capita income. As in other indigenous populations in Brazil, the studys findings suggest that the Xukuru are experiencing a rapid nutritional transition.

Condições de saneamento e desigualdades de cor/raça no Brasil urbano: uma análise com foco na população indígena com base no Censo Demográfico de 2010

RESUMO: Objetivo: Os objetivos deste estudo foram analisar e descrever a presenca da infraestrutura de saneamento basico nas areas urbanas do Brasil, contrastando os perfis dos domicilios indigenas com os de nao indigenas. Metodos: Trata-se de um estudo transversal com base nos microdados do Censo 2010. As analises foram baseadas em estatisticas descritivas (prevalencias) e na construcao de modelos de regressao logistica multipla (ajustados por covariaveis socioeconomicas e demograficas). Estimaram-se as razoes de chance para a associacao entre as variaveis explicativas (covariaveis) e de desfecho (abastecimento de agua, esgotamento sanitario, coleta de lixo e saneamento adequado). O nivel de significância estatistica estabelecido foi de 5%. Resultados: Entre os servicos analisados, o esgotamento sanitario mostrou-se o mais precario. Em relacao a cor ou raca, os domicilios com responsaveis indigenas apresentaram as menores frequencias de presenca de infraestrutura sanitaria no Brasil Urbano. Os resultados das regressoes ajustadas mostraram que, em geral, os domicilios indigenas se encontram em desvantagem quando comparados aos de outras categorias de cor ou raca, especialmente quanto a presenca do servico de coleta de lixo. Essas desigualdades foram de maior magnitude nas regioes Sul e Centro-Oeste. Conclusao: As analises deste estudo nao somente confirmam o perfil de precarias condicoes de infraestrutura de saneamento basico dos domicilios indigenas em area urbana, como tambem evidenciam a persistencia de iniquidades associadas a cor ou raca no pais.Objective: The aims of this study were to analyze and describe the presence and infrastructure of basic sanitation in the urban areas of Brazil, contrasting indigenous with non-indigenous households. Methods: A cross-sectional study based on microdata from the 2010 Census was conducted. The analyses were based on descriptive statistics (prevalence) and the construction of multiple logistic regression models (adjusted by socioeconomic and demographic covariates). The odds ratios were estimated for the association between the explanatory variables (covariates) and the outcome variables (water supply, sewage, garbage collection, and adequate sanitation). The statistical significance level established was 5%. Results: Among the analyzed services, sewage proved to be the most precarious. Regarding race or color, indigenous households presented the lowest rate of sanitary infrastructure in Urban Brazil. The adjusted regression showed that, in general, indigenous households were at a disadvantage when compared to other categories of race or color, especially in terms of the presence of garbage collection services. These inequalities were much more pronounced in the South and Southeastern regions. Conclusion: The analyses of this study not only confirm the profile of poor conditions and infrastructure of the basic sanitation of indigenous households in urban areas, but also demonstrate the persistence of inequalities associated with race or color in the country.

Obesity and overweight in adult Xukuru of Ororubá Indians, Pernambuco State, Brazil: magnitude and associated socioeconomic and demographic factors

Este estudo transversal visa a descrever a distribuicao de excesso de peso e obesidade e sua associacao com variaveis demograficas e socioeconomicas entre 794 adultos indigenas, de 19 a 59 anos, da etnia Xukuru do Ororuba, povo indigena cujas terras estao localizadas no Municipio de Pesqueira, agreste de Pernambuco, Brasil. A analise da associacao entre as variaveis de desfecho, excesso de peso (IMC > 24,99kg/m2) e obesidade (> 29,99kg/m2) e as variaveis explicativas foi realizada utilizando-se regressao logistica multinivel. Entre as mulheres, 52,2% estavam com excesso de peso e 21% obesas. Para os homens, as prevalencias foram de 44,1% e 7,5%, respectivamente. As variaveis sexo feminino e idade (> 30 anos) estiveram associadas a ocorrencia de ambos os agravos. Status socioeconomico e interacao sexo masculino e renda per capita elevada apresentaram associacao com obesidade. Assim como observado em outras populacoes indigenas, os achados sugerem que os Xukuru estao atravessando um acelerado processo de transicao nutricional.This cross-sectional study focused on the epidemiology of overweight and obesity and the association with demographic and socioeconomic variables in a sample of 794 Xukuru of Ororubá adults 19-59 years of age, from an indigenous reserve in Pesqueira County, Pernambuco State, Brazil. Descriptive analyses and multivariate logistic regression were carried out, using cut-off points of BMI > 24.99kg/m2 for overweight and > 29.99kg/m2 for obesity. Prevalence rates of overweight and obesity were higher in women (52.2% and 21%, respectively) than in men (44.1% and 7.5%, respectively). Female sex and age (> 30 years) were associated with both outcomes in the multivariate regression. For obesity, the following variable showed statistically significant associations: socioeconomic status and the interaction between male gender and per capita income. As in other indigenous populations in Brazil, the studys findings suggest that the Xukuru are experiencing a rapid nutritional transition.