Júlio Cesar Rodrigues Pereira

Air pollution and pediatric respiratory hospital admissions in São Paulo, Brazil

In order to investigate the relation between air pollution and child morbidity in Sao Paulo, a time-series study was carried out. Daily records of hospital admissions for children under 13 years old were obtained at the Health State Secretary, covering 112 hospitals in the period from October 1992 to October 1993. Daily levels of PM10, ozone, SO2, CO and NO2 were obtained from the environmental state agency (CETESB), while both CETESB and the Institute of Astronomy and Geophysics (IAG) of the University of Sao Paulo provided daily measures of temperature and relative humidity. Daily counts of child respiratory admissions (RESP) were considered as the dependent variable of pollutants in regression models, controlled for months of the year, days of the week, weather factors, and the daily number of non respiratory admissions (NORESP). PM10 and ozone were the pollutants that exhibited the most robust association with RESP. The mean levels of PM10observed during the period of study (70 μg m−3) were associated with an increase of 12% in RESP. The association between air pollution and RESP was significant within a time lag between 1 to 7 days and was dose-dependent. This result indicates that air pollution represents a significant pediatric health problem in Sao Paulo. Copyright

Complementarity of Subjective Global Assessment (SGA) and Nutritional Risk Screening 2002 (NRS 2002) for predicting poor clinical outcomes in hospitalized patients

BACKGROUND & AIMS We evaluated the ability of Nutritional Risk Screening 2002 (NRS 2002) and Subjective Global Assessment (SGA) to predict malnutrition related to poor clinical outcomes. METHODS We assessed 705 patients at a public university hospital within 48 h of admission. Logistic regression and number needed to screen (NNS) were calculated to test the complementarity between the tools and their ability to predict very long length of hospital stay (VLLOS), complications, and death. RESULTS Of the patients screened, 27.9% were at nutritional risk (NRS+) and 38.9% were malnourished (SGA B or C). Compared to those patients not at nutritional risk, NRS+, SGA B or C patients were at increased risk for complications (p=0.03, 0.02, and 0.003, respectively). NRS+ patients had an increased risk of death (p=0.03), and SGA B and C patients had an increased likelihood of VLLOS (p=0.008 and p<0.0001, respectively). Patients who were both NRS+ and SGA C had lower estimates of NNS than patients who were NRS+ or SGA C only, though their confidence intervals did overlap. CONCLUSIONS The concurrent application of SGA in NRS+ patients might enhance the ability to predict poor clinical outcomes in hospitalized patients in Brazil.

A cor da morte: causas de óbito segundo características de raça no Estado de São Paulo, 1999 a 2001

OBJECTIVE Assuming that ethnicity might be a basis for social differentiation and that such differences might represent vulnerability to sickness, this study attempts to verify whether race or ethnic origin have an effect on mortality patterns. METHODS The Sao Paulo State death register was examined from 1999 to 2001 in a contingence table of causes according to the 10th ICD and race or skin-color categories (White, Black, Mulatto and others). Chi-square test was used to check the association between skin-color and cause of death; residual analysis was used to elicit statistically significant excessive occurrences when each category of cause of death and skin color was combined; and correspondence analysis was used to examine overall relations among all categories considered. RESULTS A total of 647,321 valid death registers were analyzed, among which 77.7% were of Whites, 5.4% of Blacks, 14.3% of Mulattoes and 2.6% of others. A significant association between skin color or race and cause of death was found. It may be observed that, although Blacks and Mulattoes present a similar death profile, on the contrary of Whites and others, which could be aggregated into a single category, the former appear in distinct positions on the multidimensional map presented. Except for mal defined causes, which characterize only the deaths of Blacks, the other causes of death within this group are common to both Blacks and Mulattoes, varying however, in intensity and as to the order in which they appear death. CONCLUSIONS Analysis of mortality according to race or color revealed that death has a color. There is a White death, which has, among its causes, sicknesses, which, although variable, are nothing more than sicknesses. Theres a Black death, which is not caused by sicknesses but by external causes, complications in labor and delivery, mental disorders and ill-defined causes.

Estimativa de impacto da amamentação sobre a mortalidade infantil

OBJETIVO: A mortalidade infantil no Estado de Sao Paulo tem mostrado uma reducao progressiva nos ultimos anos. Atualmente, atinge niveis para alem dos quais uma maior reducao parece desafiadora. Causas neonatais precoces correspondem a 50% desses obitos. Entre os obitos nao neonatais precoces, destacam-se a pneumonia e a diarreia como as principais causas. O objetivo da pesquisa e estudar o impacto da amamentacao na reducao dos obitos. METODOS: Foram estudados 14 municipios da Grande Sao Paulo, onde coletaram-se informacoes relativas a amamentacao por entrevistas, em uma amostra por conglomerados em dias nacionais de vacinacao (Projeto Amamentacao e Municipios). Tambem foram consultadas informacoes sobre mortalidade infantil, recolhidas de fontes oficiais, dos anos de 1999 e 2000. Com base em parâmetros da literatura sobre o risco de obito por infeccao respiratoria e diarreia para criancas nao amamentadas, calculou-se a fracao de mortalidade evitavel por cada doenca. Os valores, aplicados ao numero de obitos registrados em cada municipio, permitiram o calculo do impacto da amamentacao sobre o Coeficiente de Mortalidade Infantil (CMI). RESULTADOS: A fracao de mortalidade evitavel por infeccao respiratoria variou, segundo o municipio e a faixa etaria, entre 33% e 72%. Para diarreia, a variacao ficou entre 35% e 86%. A estimativa media de impacto foi de 9,3% no CMI, com variacoes, segundo o municipio, entre 3,6% e 13%. CONCLUSOES: A amamentacao no primeiro ano de vida pode ser a estrategia mais exequivel de reducao da mortalidade pos-neonatal para alem dos niveis ja alcancados em municipios do Estado de Sao Paulo.

Risk factors associated with acute myocardial infarction in the São Paulo metropolitan region: a developed region in a developing country

OBJECTIVE To identify the risk factors associated with acute myocardial infarction (AMI) and their respective powers of association in the São Paulo metropolitan region. METHODS The cases comprised patients diagnosed with first AMI with an ST segment elevation. The controls were individuals with no known cardiovascular disease. The study comprised 271 cases and 282 controls from 12 hospitals. Risk factors were as follows: ethnic group; educational level; marital status; family income; family history of coronary artery disease; antecedents of arterial hypertension and of diabetes mellitus; hormonal replacement in women; smoking; physical activity; alcohol consumption; total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride, and glucose levels; body mass index; and waist-hip ratio (WHR). RESULTS The following risk factors showed and independent association with AMI: smoking [odds ratio (OR) = 5.86; 95% confidence interval (CI) 3.25-10.57; P < 0.00001); waist-hip ratio (first vs. third tertile) (OR = 4.27; 95% CI 2.28-8.00; P < 0.00001); antecedents of arterial hypertension (OR = 3.26; 95% CI 1.95-5.46; P < 0.00001); waist-hip ratio (first vs second tertile) (OR = 3.07; 95% CI 1.66-5.66; P = 0.0003); LDL-cholesterol level (OR = 2.75; 95% CI 1.45-5.19; P = 0.0018); antecedents of diabetes mellitus (OR = 2.51; 95% CI 1.45-5.19; P = 0.023); family history of coronary artery disease (OR = 2.33; 95% CI 1.44-3.75; P = 0.0005); and HDL-cholesterol level (OR = 0.53; 95% CI 0.32-0.87; P = 0.011). CONCLUSION Smoking, waist-hip ratio, antecedents of arterial hypertension and of diabetes mellitus, family history of coronary artery disease, and LDL-cholesterol and HDL-cholesterol levels showed to be independently associated with AMI within the São Paulo metropolitan region.

Sistema Nacional de Inovação em Saúde: relações entre áreas da ciência e setores econômicos

Health Science and Technology is currently the subject matter of government and university actions. Such actions should converge to the establishment of a National Health Innovation System, which still calls for acknowledgment from the economic sector counterpart. A study was carried out with the purpose of describing the relations between scientific fields and economic sectors as a means of learning more about this System. Records from the Brazilian Directory of Research Groups (version 4.1) were examined and selected when Health was a keyword either to field of knowledge or economic sector. Data were compiled into multiresponse variables and analyzed in contingency tables using residual, correspondence, and cluster analyses. It was found that the Brazilian National Health Innovation System constitutes a sectorial system where competitiveness is more socially than economically-oriented, making this System favorably in tandem with the National Unified Health System as well as responsive to public policies focused on social welfare.

Protein-energy malnutrition halts hemopoietic progenitor cells in the G0/G1 cell cycle stage, thereby altering cell production rates

Protein energy malnutrition (PEM) is a syndrome that often results in immunodeficiency coupled with pancytopenia. Hemopoietic tissue requires a high nutrient supply and the proliferation, differentiation and maturation of cells occur in a constant and balanced manner, sensitive to the demands of specific cell lineages and dependent on the stem cell population. In the present study, we evaluated the effect of PEM on some aspects of hemopoiesis, analyzing the cell cycle of bone marrow cells and the percentage of progenitor cells in the bone marrow. Two-month-old male Swiss mice (N = 7-9 per group) were submitted to PEM with a low-protein diet (4%) or were fed a control diet (20% protein) ad libitum. When the experimental group had lost about 20% of their original body weight after 14 days, we collected blood and bone marrow cells to determine the percentage of progenitor cells and the number of cells in each phase of the cell cycle. Animals of both groups were stimulated with 5-fluorouracil. Blood analysis, bone marrow cell composition and cell cycle evaluation was performed after 10 days. Malnourished animals presented anemia, reticulocytopenia and leukopenia. Their bone marrow was hypocellular and depleted of progenitor cells. Malnourished animals also presented more cells than normal in phases G0 and G1 of the cell cycle. Thus, we conclude that PEM leads to the depletion of progenitor hemopoietic populations and changes in cellular development. We suggest that these changes are some of the primary causes of pancytopenia in cases of PEM.

Serum cytokine profile in the subclinical form of visceral leishmaniasis

The factors determining the development or not of visceral leishmaniasis (VL) have not been completely identified, but a Leishmania-specific cellular immune response seems to play a fundamental role in the final control of infection. Few studies are available regarding the production of cytokines in the subclinical form of VL, with only the production of IFN-gamma and TNF-alpha known. The aim of the present study was to identify immunological markers for the oligosymptomatic or subclinical form of VL. A prospective cohort study was conducted on 784 children aged 0 to 5 years from an endemic area in the State of Maranhão, Brazil, between January 1998 and December 2001. During 30 consecutive months of follow-up, 33 children developed the oligosymptomatic form of the disease and 12 the acute form. During the clinical manifestations, serum cytokine levels were determined in 27 oligosymptomatic children and in nine patients with the acute form using a quantitative sandwich enzyme immunoassay. In the subclinical form of VL, variable levels of IL-2 were detected in 52.3% of the children, IL-12 in 85.2%, IFN-gamma in 48.1%, IL-10 in 88.9%, and TNF-alpha in 100.0%, with the last two cytokines showing significantly lower levels than in the acute form. IL-4 was not detected in oligosymptomatic individuals. Multiple discriminant analysis used to determine the profile or combination of cytokines predominating in the subclinical form revealed both a Leishmania resistance (Th1) and susceptibility (Th2) profile. The detection of both Th1 and Th2 cytokine profiles explains the self-limited evolution accompanied by the discrete alterations observed for the subclinical form of VL.

Tooth loss in Brazilian middle-aged adults: multilevel effects

Abstract Objective. To examine the link between tooth loss and multilevel factors in a national sample of middle-aged adults in Brazil. Material and methods. Analyses were based on the 2003 cross-sectional national epidemiological survey of the oral health of the Brazilian population, which covered 13 431 individuals (age 35–44 years). Multistage cluster sampling was used. The dependent variable was tooth loss and the independent variables were classified according to the individual or contextual level. A multilevel negative binomial regression model was adopted. Results. The average tooth loss was 14 (standard deviation 9.5) teeth. Half of the individuals had lost 12 teeth. The contextual variables showed independent effects on tooth loss. It was found that having 9 years or more of schooling was associated with protection against tooth loss (means ratio range 0.68–0.76). Not having visited the dentist and not having visited in the last ≥3 years accounted for increases of 33.5% and 21.3%, respectively, in the risk of tooth loss (P < 0.05). The increase in tooth extraction ratio showed a strong contextual effect on increased risk of tooth loss, besides changing the effect of protective variables. Conclusions. Tooth loss in middle-aged adults has important associations with social determinants of health. This study points to the importance of the social context as the main cause of oral health injuries suffered by most middle-aged Brazilian adults.

p63 Protein expression in high risk diffuse large B-cell lymphoma

Background: p63 gene is a p53 homologue that encodes proteins with transactivation, DNA-binding and tetramerisation domains. The isoforms TAp63 and TAp73 transactivate p53 target genes and induce apoptosis, whereas the isoforms ΔNp63 and ΔNp73 lack transactivation and might have dominant-negative effects in p53 family members. p63 is expressed in germinal centre lymphocytes and can be related to the development of the lymphoma, but the prognostic significance of its expression in the survival of patients with diffuse large B-cell lymphoma (DLBCL) remains unclear. Aims: To determine whether quantitative immunohistochemical (IHC) analysis of p63 protein expression correlates with CD10 antigen, Bcl-6 antigen and IRF4 antigen expression and to determine whether p63 is a surrogate predictor of overall survival in high–intermediate and high risk DLBCL populations. Methods: CD10, Bcl-6 and IRF4 expression were retrospectively evaluated by IHC in 73 samples of high–intermediate and high risk DLBCL and were used to divide the lymphomas into subgroups of germinal centre B-cell-like (GCB) and activate B-cell-like (ABC) DLBCL. Similarly, p63 expression was evaluated by IHC and the results were compared with subgroups of DLBCL origin and with the survival rates for these patients. Results: p63 was expressed in more than 50% of malignant cells in 11 patients and did not show correlation with subgroups of GCB-like DLBCL or ABC-like DLBCL, but p63(+) patients had better disease-free survival (DFS) than those who were negative (p = 0.01). Conclusions: p63(+) high–intermediate and high risk DLBCL patients have a better DFS than negative cases.