José Eduardo Cajado Moncau

Fatores de risco para doenças crônicas não-transmissíveis: inquérito domiciliar no Município de São Paulo, SP (Brasil). Metodologia e resultados preliminares

The non-communicable chronic diseases are important causes of death in Brazil, mainly in the great urban centres. There are various risk factors related to these diseases, whose remotion or attenuation would contribute to a fall in mortality. The methodology of the first comprehensive multicenter study into risk factors of non-communicable chronic diseases carried out in Latin America is explained. In Brazil, this study was carried out in the cities of S. Paulo, SP and Porto Alegre, RS. Preliminary results from the city of S. Paulo as to the prevalence of arterial hypertension (22.3%), tabagism (37.9%), obesity (18.0%), alcoholism (7.7%) and sedentarism (69.3%) are presented. These results are compared with existing data from Brazil and other countries, and the relationship between various risk factors and the mortality from cardiovascular diseases in S. Paulo and some developed countries is discussed.As doencas crionicas nao-transmissiveis sao causa importante de morte no Brasil, principalmente nos grandes centros urbanos. Existem inumeros fatores de risco relacionados a este tipo de doencas, cuja remocao, ou atenuacao, pode contribuir para o declinio da mortalidade. Descreve-se a metodologia do primeiro estudo muiticentrico abrangente realizado na America Latina sobre a questao dos fatores de risco de doencas cronicas nao-transmissiveis. No Brasil o estudo foi realizado nos municipios de Sao Paulo, SP e Porto Alegre, RS. Sao apresentados resultados preliminares para o Municipio de Sao Paulo quanto a prevalencia de hipertencao arterial (22,3%), tabagismo (37,9%), obesidade (18,0%), alcoolismo (7,7%) e sedentarismo (69,3%). Os resultados obtidos sao comparados com dados existentes para o Brasil e outros paises, e discute-se a relacao entre a magnitude dos diversos fatores de risco e a mortalidade por doencas cardiovasculares em Sao Paulo e alguns paises desenvolvidos.

Prevalência de hipertensão arterial sistêmica na cidade de Formiga, MG

OBJECTIVES: To estimate hypertension prevalence and identify associated socioeconomic, demographic, and anthropometric variables. METHODS: A cross-sectional study with probability sampling. Target population: people > 18 years of age living in the urban area of Formiga, Minas Gerais state, and registered with the Family Health Program (Programa Saude da Familia - PSF), which covers 94% of the population. Two hundred and eighty-five subjects (131 men and 154 women) were enrolled in the study. Criteria for the diagnosis of hypertension were the following: systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg, or current use of antihypertensive medication. A standard questionnaire was used to collect socioeconomic and demographic data, as well as information on alcohol consumption, smoking, and physical activity level. RESULTS: Overall prevalence of hypertension in the target population was estimated at 32.7% (95% CI): 28.2-37.2), 31.7% in men and 33.6% in women. Among subjects with prescribed antihypertensive drugs, 66% reported taking their medication regularly. Hypertension prevalence increased steadily with increasing age (OR = 1.07; 95% CI: 1.05-1.10) and was positively associated with waist circumference (OR = 3.05; 95% CI: 1.49-6.22) and negatively associated with the level of physical activity (OR = 0.45; 95% CI: 0.25-0.82). CONCLUSION: Hypertension prevalence was very high in the adult population registered with the PSF in Formiga, representing a major public health problem. Intervention programs that boost physical activity, promote compliance with drug treatment, and focus on hypertensive subjects unaware of their condition are needed.

AIDS by mother-to-child transmission: Survival analysis of cases followed from 1983 to 2002 in different regions of Brazil.

Antiretroviral therapy contributes to decreasing morbidity and mortality, and ultimately to increasing survival. In Brazil, there are regional differences in HIV epidemiology regarding pregnant women and children with HIV/AIDS. This study evaluates survival time after AIDS diagnosis in 914 children infected by mother-to-child transmission, reported between 1983 and 1998 and followed until 2002, in Brazils five regions. Time between birth and HIV diagnosis decreased over the years, mainly in the South and Southeast Regions. There was a significant improvement in survival; more than 75% of cases were still living four years after diagnosis in the 1997-1998 group. This Brazilian study demonstrates that even with regional inequalities in health care infrastructure it is possible for a developing country to establish an effective system of universal and free access to antiretroviral therapy that produces a significant increase in survival for children with AIDS.

Familial cancer aggregation and the risk of lung cancer

CONTEXT Around 90% of lung cancer worldwide is attributable to cigarette smoking, although less than 20% of cigarette smokers develop lung cancer. Other factors such as diet, chronic lung diseases, occupation and possibly environmental agents also contribute to this cancer. Genetic factors seem to play a role in lung cancer, but the precise characteristics influencing lung cancer susceptibility are not known, since genetic factors are easily obscured by the strong environmental determinants of lung cancer, particularly smoking. OBJECTIVE To estimate the effect that cancer occurrence among first-degree relatives has on the risk of lung cancer. DESIGN Hospital-based case-control study. SETTING The metropolitan region of São Paulo, Brazil. PARTICIPANTS 334 incident lung cancer cases and 578 controls matched by hospitals. MAIN MEASUREMENTS By means of a structured questionnaire, cases and controls were interviewed about cancer occurrence in first-degree relatives, tobacco smoking, exposure to passive smoking, occupation, migration and socioeconomic status. Non-conditional logistic regression was used to calculate the risk of familial cancer aggregation, the effect of cancer in first-degree relatives and smoking in conjunction, and for controlling confounders. RESULTS The adjusted odds ratio (OR) revealed a slight, but not statistically significant, excess risk of lung cancer for subjects with a history of lung cancer in relatives (OR 1.21; 95% confidence interval [CI] 0.50 - 2.92). The same was found among those with a history of other tobacco-related cancers in relatives (OR 1.36; 95% CI 0.87 - 2.14). A step gradient effect was observed regarding lung cancer risk, in accordance with increases in the number of pack-years of cigarette consumption. An interaction between familial cancer aggregation and tobacco smoking was detected. CONCLUSIONS A mildly elevated risk of lung cancer among persons with a positive history of lung and other tobacco-related cancers was observed. The finding of an interaction between the variables of familial cancer aggregation and smoking suggests that familial cancer aggregation could be considered as a marker of susceptibility, increasing the risk of lung cancer among smokers. These results improve our knowledge of lung carcinogenesis and can guide future cancer genetic studies.

Trabalho industrial e câncer de pulmão

In a hospital-based case-control study, 316 lung cancer cases and 536 controls were interviewed for their occupational, smoking, passive smoking, cancer in the family and residential histories as well as social economic status, by trained interviewers, using a standardized questionnaire. Cases and controls were matched by hospital, sex and age. The study was carried out between 1st July 1990 and 31st January 1991 in 14 hospitals in the Metropolitan Region of S. Paulo, the most highly industrialized and urbanized region in Brazil. Score criteria were developed for the ordering of the individuals of the study by occupational exposure to know carcinogens to the lung, in order to evaluate this exposure during the occupational life of each person. The criteria accumulated information on exposure to carcinogens as regards type, sector of work and time in each employment. The unconditional logistic regression analysis showed an odds ratio of 1.97 (95% IC: 1.52 to 2.55) for the highest exposure group. This result showed that workers linked to the production sectors of several industries have about twice the risk of developing lung cancer as workers involved in non-industrial activities.

Mortalidade por câncer em trabalhadores da indústria da borracha de São Paulo

OBJETIVO: Avaliar as mortes por câncer em trabalhadores da industria da borracha de acordo com o tamanho da empresa. METODOS: Coorte historica com 9.188 trabalhadores masculinos, matriculados em sindicato de trabalhadores da industria de borracha do Estado de Sao Paulo entre 1975 e 1985, sobreviventes em janeiro de 1990 e acompanhados ate o final de 2000. As mortes por câncer foram comparadas internamente a coorte, cujos membros foram subdivididos em estratos por porte e sub-ramo da empresa, setor de trabalho e qualificacao profissional. A abordagem por conjuntos de risco e regressao logistica condicional foi utilizada para o calculo dos riscos relativos, ajustados por idade, tempo desde o primeiro emprego e tempo de trabalho na industria da borracha. RESULTADOS: Quando comparados aos empregados de grandes empresas, trabalhadores de pequenas empresas mostraram excesso de mortes por todos tipos de câncer (RR=2,33; IC 95%: 0,90-6,03); tumores de estomago (RR=3,47; IC 95%: 2,57-4,67) e do trato aero-digestivo superior (RR=2,49; IC 95%: 1,78-3,48). Identificou-se excesso de mortes por câncer nos trabalhadores dos setores de manutencao (RR=2,23; IC 95%: 0,73-6,76); expedicao, armazenamento e transporte (RR=2,97; IC 95%: 0,77-11,38); e producao (RR=3,51; IC 95%: 1,07-11,57), comparados aos trabalhadores dos setores administrativos. CONCLUSOES: Os resultados mostram evidencias de aumento do risco de tumores de estomago e do trato aero-digestivo superior e, possivelmente, por câncer em geral em trabalhadores de empresas de pequeno porte da industria da borracha quando comparados aos trabalhadores das grandes empresas.

Chronic myeloid leukemia (CML): prognostic factors and survival analysis

The prognostic value of different factors upon diagnosis of CML was analysed in 45 Philadelphia (Ph1)-positive patients. The median survival was 48 months. Univariate analysis showed 5 poor prognostic factors (male sex, under 45 years-old, bone marrow blasts greater than or equal to 10 percent, blood basophils greater than or equal to 6 percent and blood eosinophils greater than or equal to 6 percent) which provided for the development of a clinical staging system: Stage I with none or one factor and a two-year survival rate of 100 percent; Stage II with two or three factors and two-year survival of 72.2 percent; and Stage III with four or five factors and two-year survival of 0 percent (p = 0.00016). Multivariate survival analysis showed that combination of blood basophilia and bone marrow blasts had the strongest predictive relationship to survival time. We conclude that a combination of pretreatment factors identifies different risk subcategories in CML patients and is helpful in assessing the overall prognosis and the treatment approach.

Myelodysplastic syndromes (MDS): prognostic factors and scoring systems

OBJECTIVE To evaluate the score systems of Cassano and Sanz and suggest a new one. DESIGN Case series. LOCATION Teaching hospitals: EPM UNIFESP and Faculdade de Medicina de Botucatu. PARTICIPANTS 59 patients diagnosed from 1979 to 1992. INTERVENTION Evaluation of clinical-laboratorial data. MEASUREMENT Statistical comparison, uni and multivariate analysis and actuarial survival curves. RESULTS Cassanos system divided the patients into high and low risk (p = 0.0966) while Sanzs gave high, intermediate and low risk (p = 0.0108). The univariate analysis showed hemoglobin, WBC count, E/M ratio, liver size and blast percentage in BM as statistically significant. The multivariate analysis showed blast percentage in BM (p = 0.004) and Hb (p = 0.050) as significant. Our system, considering the multivariate analysis data, divided the patients into high, intermediate and low risk (p = 0.0038). CONCLUSIONS Sanzs system was more functional than Cassanos, while ours showed predictive survival value and ease of use in clinical practice.

Comparación de cinco métodos para estimar la prevalencia de diabetes mellitus en estudios de base poblacional

To aid in the search for more practical and reliable methods for use in population-based studies of diabetes mellitus, this article compares five ways of estimating prevalence rates. The analysis was performed on secondary data from a cross-sectional study of a cluster sample of the adult population in nine state capitals in Brazil. The original study was carried out from 1986 to 1988. The 21,846 participants were classified as diabetic or not diabetic by five different methods: household questionnaires administered to the entire sample population (M1); individual questionnaires administered to the selected population (M2); measurement of fasting glucose levels in capillary blood, with levels > or = 120 mg/dL as the cutoff (M3); individual questionnaire and fasting capillary blood glucose > or = 120 mg/dL (M4); and individual questionnaire plus fasting capillary blood glucose > or = 120 mg/dL and capillary glucose 2 hours after oral glucose loading > or = 200 mg/dL (M5). Agreement between the methods was determined by comparison of the rates obtained and use of the kappa coefficient. The age-adjusted prevalence rates of diabetes varied according to the method used. Values obtained with M1 were lower than those indicated by M2; M3 values were higher than M2 values, except in the age group 60-69 years; and with M5 the rates were higher than with M4, except among persons 30-39 years old. With regard to the age-adjusted rates found by the various methods, M1 detected 84% of the M2 estimate, M2 detected 91% of the M3, M3 detected 70% of the M4, and M4 detected 86% of the M5. Previously diagnosed diabetes cases accounted for 64% and 55% of the totals estimated by M4 and M5, respectively. Kappa values were at least 0.70 for M1 compared against M2, M1 against M4, M2 against M4, and M3 against M4. Based on the results of this study, it was concluded that the questionnaires used in M1 and M2 constituted appropriate methods for detecting previously diagnosed cases of diabetes mellitus, and their use is recommended for the purposes of health services planning or evaluation. Fasting glucose measurement (M3) as the sole method did not show a significant advantage over the individual questionnaire (M2). Of the combined or multiple methods, fasting glucose together with the individual questionnaire (M4) was efficient in comparison to M5, which incorporated measurement of blood glucose 2 hours after oral glucose ingestion.

Significado prognóstico das metástases nos linfonodos regionais do adenocarcinoma colo-retal

Trezentos e vinte doentes com adenocarcinoma colo-retal submetidos a resseccao curativa foram estudados com o intuito de verificar, nas pecas ressecadas, o comprometimento ou nao dos linfonodos, o numero dos acometidos e a area ocupada peia neoplasicas. Chamou-se de linfonodos invadidos aqueles com raros focos de celulas neoplasicas presentes, que nao interferiam na estrutura do nodo e de destruidos aqueles que apresentavam sua estrutura em grande parte ou totalmente ocupada pelo tumor. Os linfonodos positivos foram agrupados em subgrupos contendo 1 a 4 e em mais de 4.120 (38,6%) doentes apresentaram linfonodos comprometidos, dos quais 24,2% eram invadidos e 75,8% destruidos. Portadores de linfonodos livres apresentaram sobrevivencia de cinco anos de 71,7%; a sobrevivencia de doentes com nodos invadidos - 58,6%- foi significantemente maior que a dos com nodos destruidos - 29,7%, mas nao diferiu estatisticamente da apresentada pelos portadores de linfonodos livres. Doentes com mais de 4 linfonodos comprometidos sobreviveram significantemente menos (20,0%) que aqueles com 1 a 4 linfonodos acometidos (43,5%). Entre os portadores de linfonodos invadidos a sobrevivencia de 5 anos foi a mesma para os com 1 a 4 ou mais de 4 linfonodos invadidos. Isto nao aconteceu com portadores de linfonodos destruidos, onde os com 1 a 4 sobreviveram em cerca de 37,7% e os com mais de 4, 13,3%. Faz-se necessario identificar adequadamente a area ocupada pela neoplasia no linfonodo, pois o comportamento biologico do tipo invadido diferiu substancialmente do destruido. O melhor prognostico dos portadores de linfonodos invadidos pode explicar a sobrevivencia aparentemente paradoxal observada em alguns doentes estadiados na classe C de DUKES.