Katia Vergetti Bloch

Risk factors for falls with severe fracture in elderly people living in a middle-income country: a case control study

BackgroundFracture after falling has been identified as an important problem in public health. Most studies of risk factors for fractures due to falls have been carried out in developed countries, although the size of the elderly population is increasing fast in middle income countries. The objective of this paper is to identify risk factors for fall related to severe fractures in those aged 60 or more in a middle-income country.MethodsA case-control study was carried out in Rio de Janeiro-Brazil based general hospitals between 2002–2003. Two hundred-fifty hospitalised cases of fracture were matched with 250 community controls by sex, age group and living area. Data were collected for socio-demographic variables, health status and drugs used before the fall. A conditional logistic regression model was fitted to identify variables associated with the risk of fall related severe fracture.ResultsLow body mass index, cognitive impairment, stroke and lack of urine control were associated with increased risk of severe fall related fractures. Benzodiazepines and muscle relaxants were also related to an increased risk of severe fractures while moderate use of alcohol was associated with reduced risk.ConclusionAlthough the association between benzodiazepines and fractures due to fall has been consistently demonstrated for old people, this has not been the case for muscle relaxant drugs. The decision to prescribe muscle relaxants for elderly people should take into account the risk of severe fracture associated with these drugs.

Clinical determinants of increased QT dispersion in patients with diabetes mellitus

AIMS To compare QT dispersion measurements in diabetic patients to control subjects and assess any associations between QT dispersion and diabetic clinical characteristics. METHODS A total of 512 diabetics and 50 age and gender matched controls were studied. QT interval was measured manually in 12-lead conventional electrocardiograms, and QT dispersion (QTd), heart rate-corrected QT dispersion (QTcd), number of leads-adjusted QT dispersion (adjuQTd) and adjacent QT dispersion (adjaQTd) were calculated. Demographic, clinical, laboratory and electrocardiographic data were recorded. RESULTS Diabetics showed increased QT dispersion compared to controls (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001), even those with recent diagnosis (less than 2 years) and without arterial hypertension, ECG abnormalities or chronic degenerative complications (QTd: P=0.01, QTcd: P<0.001, adjuQTd: P=0.04). Left ventricular hypertrophy (QTd: P<0.001, QTcd: P<0.001, adjuQTd: P<0.001, adjaQTd: P<0.001) and conduction disturbances (QTd: P=0.002, QTcd: P=0.003, adjuQTd: P=0.003) were the electrocardiographic findings associated with increased QT dispersion in bivariate analysis. Clinical variables were the presence of arterial hypertension (QTd: P=0.004, QTcd: P=0.01, adjuQTd: P<0.001), even without left ventricular hypertrophy (QTd: P=0.01, QTcd: P=0.03, adjuQTd: P=0.003), and the presence of diabetic cardiovascular complications (QTd: P=0.02, QTcd: P=0.01, adjuQTd: P=0.008, adjaQTd: P=0.03). No association between QT dispersion and the presence of diabetic microvascular complications, glycaemic control, age and gender, or cardiovascular drugs was observed. Multivariate regressive statistical analysis confirmed the associations noted in bivariate analysis. CONCLUSIONS Diabetic patients have increased QT dispersion compared to non-diabetics even those without arterial hypertension and cardiovascular complications and with recent diagnosis. The presence of arterial hypertension, diabetic cardiovascular complications and electrocardiographic abnormalities of left ventricular hypertrophy and conduction disturbances were associated to increased QT dispersion in diabetes mellitus.

Combined QT Interval and Voltage Criteria Improve Left Ventricular Hypertrophy Detection in Resistant Hypertension

QT interval parameters have been associated with left ventricular hypertrophy (LVH) in hypertensive patients. The aim of this study is to assess this relationship in resistant hypertension and, in particular, to evaluate whether any QT interval parameter could provide additive information for LVH beyond that obtained from the best electrocardiographic voltage criterion. In a cross-sectional study, 471 resistant hypertensives were submitted to standard 12-lead ECGs, 24-hour ambulatory blood pressure monitoring, and 2D echocardiographic examinations. QT interval durations and QRS voltages were measured, and maximum rate–corrected QT interval duration (QTcmax) and dispersion (QTd), and Sokolow’s and Cornell’s voltage product were calculated. Statistical analyses involved bivariate tests and multivariate logistic regression, with LVH as the dependent variable. A total of 383 patients (81%) had echocardiographic LVH. In bivariate comparisons, both QT interval parameters showed a predictive performance for LVH similar to Cornell’s product, the best ECG voltage criterion. In multivariate analysis, QT parameters and Cornell’s product were independently associated with LVH, after adjustment for other LVH determinants. QTc interval >440 ms1/2 and dispersion >60 ms were associated with a 2-fold (95% confidence interval [CI], 1.1 to 3.8) greater chance of having LVH, whereas Cornell’s product >240 mV·ms implied a 2.6-fold (95% CI, 1.2 to 6.1) increased chance of LVH. The combination of prolonged QT interval and increased Cornell’s product was associated with a 5.3- to 9.3-fold higher chance of having LVH. Hence, although in isolation, no QT interval parameter performs better for LVH detection than simpler Cornell’s product, it provides additive information and can be used in combination with voltage criteria to refine LVH risk stratification in resistant hypertension.

Importance of the Electrocardiographic Strain Pattern in Patients With Resistant Hypertension

The electrocardiographic strain pattern is a marker of left ventricular hypertrophy and adverse cardiovascular prognosis. The objective of this study was to assess the factors associated with the presence of ECG strain in patients with resistant hypertension and, specifically, to evaluate the relationships between strain and left ventricular mass (LVM) and structure. In a cross-sectional design, 440 resistant hypertensive subjects were evaluated. Clinical, laboratory, electrocardiographic, 24-hour ambulatory blood pressures, and echocardiographic variables were obtained. Statistical analysis involved bivariate tests, analysis of covariance, and multivariate logistic regression. An ECG strain pattern was present in 101 patients (23%). Patients with strain were more frequently men with lower body mass index, had more target-organ damage, higher 24-hour blood pressure, higher serum creatinine and 24-hour microalbuminuria, and more prolonged QT interval duration than those without strain. After controlling for all covariates, the presence of strain remained associated with increased LVM and wall thicknesses, both in all patients and also in those with echocardiographic left ventricular hypertrophy. Furthermore, the presence of ECG strain was associated with increased LVM (P<0.001), higher 24-hour systolic blood pressure (P<0.001), prolonged maximum QTc-interval duration (P<0.001), lower waist circumference (P=0.009), male gender (P=0.011), physical inactivity (P=0.020), higher serum creatinine (P=0.031) and fasting glycemia (P=0.027), and the presence of coronary heart disease (P=0.001) and peripheral arterial disease (P=0.045). Thus, in resistant hypertension patients, the presence of ECG strain is independently associated with increased left ventricular wall thicknesses and mass and also with other potentially adverse factors. These relationships offer insight into the known association between strain and unfavorable cardiovascular prognosis.

Demographic and clinical characteristics of hypertensive patients in the internal medicine outpatient clinic of a university hospital in Rio de Janeiro

CONTEXT Hypertension is one of the most important cardiovascular risk factors but its control is still a challenge for physicians all around the world. For blood pressure control to be improved, it is important to guarantee the quality of attendance provided for hypertensive patients, especially in teaching hospitals, where future physicians are being trained. OBJECTIVE To characterize the profile of hypertensive patients attending the internal medicine outpatient clinic of a university hospital in Rio de Janeiro,describing their cardiovascular risk and identifying flaws in the treatment provided for severely hypertensive patients, in order to implement an arterial hypertension management program. TYPE OF STUDY A descriptive cross-sectional population-based study. SETTING Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro. METHODS The study was carried out over a period of four months, involving all the hypertensive patients under treatment in the outpatient unit. The attending physician obtained information relating to demographic features, cardiovascular risk factors, target organ damage, blood pressure levels, therapeutic regimens and compliance with treatment. Means and the respective standard deviations and proportions were used to describe the distribution of patient data. RESULTS Of the total number of patients seen, 24.2% (1,699 patients) were hypertensive. Women accounted for 65.0% of the patients. The mean age was 63.9 years. Dyslipidemia (49.2%) and diabetes (29.8%) were the most frequently reported risk factors and heart disease was the most prevalent end-organ damage. Seventy percent of the patients were classified as high cardiovascular risk. In spite of the high intensity treatment provided for the most severe patients (19.4% on a regimen of 3 or more antihypertensive drugs), the rate of blood pressure control was low (27%). CONCLUSIONS The patients with arterial hypertension under treatment at the university hospital had a profile of high cardiovascular risk and poor blood pressure control. Greater effort for improving hypertension control is needed, since this is the only way to reduce the morbidity and mortality rates of cardiovascular diseases.

Sampling design for the Study of Cardiovascular Risks in Adolescents (ERICA)

O Estudo de Riscos Cardiovasculares em Adoles-centes (ERICA) objetiva estimar prevalencia de fatores de risco cardiovascular e da sindrome metabolica em adolescentes (12 a 17 anos) matriculados em escolas publicas e privadas dos 273 municipios com mais de 100 mil habitantes no Brasil. A populacao de pesquisa foi estratificada em 32 estratos geograficos (27 capitais e cinco conjuntos com os demais municipios de cada macrorregiao do pais) e uma amostra de 1.251 escolas foi selecionada com probabilidade proporcional ao tamanho. Em cada escola foram selecionadas tres combinacoes de turno (manha e da tarde) e ano (serie), e em cada uma destas combinacoes foi selecionada uma turma. Todos os alunos elegiveis das turmas selecionadas foram objeto de pesquisa. Os pesos amostrais do desenho foram calculados pelo produto dos inversos das probabilidades de inclusao em cada estagio da amostra e foram depois calibrados considerando as projecoes do numero de adolescentes matriculados em escolas localizadas nos estratos geograficos considerados por sexo e idade.The Study of Cardiovascular Risk in Adolescents (ERICA) aims to estimate the prevalence of cardiovascular risk factors and metabolic syndrome in adolescents (12-17 years) enrolled in public and private schools of the 273 municipalities with over 100,000 inhabitants in Brazil. The study population was stratified into 32 geographical strata (27 capitals and five sets with other municipalities in each macro-region of the country) and a sample of 1,251 schools was selected with probability proportional to size. In each school three combinations of shift (morning and afternoon) and grade were selected, and within each of these combinations, one class was selected. All eligible students in the selected classes were included in the study. The design sampling weights were calculated by the product of the reciprocals of the inclusion probabilities in each sampling stage, and were later calibrated considering the projections of the numbers of adolescents enrolled in schools located in the geographical strata by sex and age.

Meta-analysis of the prevalence of physical inactivity among Brazilian adolescents

A systematic review and meta-analysis were carried out to investigate the prevalence of physical inactivity among adolescents in Brazil. We identified articles that had been published up to August 2010 and the search was conducted using six electronic databases. We did not enforce any search limitations. Forest plot-type graphs were generated using the prevalence of physical inactivity stratified by region and sex. Meta-regression models were fitted to identify possible sources of heterogeneity in the prevalence estimates. Of the 1,496 articles initially identified, 37 were deemed appropriate for the systematic review. Prevalence rates ranged from 2% to 80% for male and from 14% to 91% for female subgroups. The lowest prevalence rates of physical inactivity were found to be for the Southern region, whereas the highest rates were observed in the North-Northeast. The methods employed to evaluate physical inactivity in Brazilian adolescents also differed among the studies. This variation demonstrates the need for standardised and validated methods of measuring physical activity in epidemiological investigation.

Characteristics and circumstances of falls leading to severe fractures in elderly people in Rio de Janeiro, Brazil

The circumstances associated with falls among elderly people have been well described in some developed countries, but little is known about such accidents in middle-income countries. The aim of this paper is to report the circumstances and characteristics associated with falls leading to severe fractures among elderly people living in Rio de Janeiro, Brazil. Cases were obtained from two case-control studies on risk factors for severe fractures due to falls among individuals 60 years or older. Fallers were stratified according to clinical and socio-demographic variables and circumstances of the accident. Women comprised three-fourths of the sample. The femur was the most frequently fractured bone, more common among individuals over 70 years of age. Most falls occurred at home, between 6:00 AM and 6:00 PM, but the rooms where they occurred differed according to gender and age. Most individuals did not attribute their falls to tripping or slipping. This samples data did not differ substantially from studies in developed countries.

Ensaios clínicos pragmáticos: uma opção na construção de evidências em saúde

The authors present and discuss the potential of pragmatic clinical trials as an alternative to both explanatory trials and observational studies to support the use of therapeutic interventions with good evidence. They argue that this strategy, when properly applied, can be a powerful tool to obtain unbiased measures of effectiveness, with simpler logistics and lower costs than in current clinical trials.

Socioeconomic aspects of spousal concordance for hypertension, obesity, and smoking in a community of Rio de Janeiro, Brazil

OBJECTIVE The present study aims to evaluate the environmental role in the distribution of hypertension, obesity, and smoking and spousal concordance for the presence/absence of these 3 cardiovascular risk factors. METHODS A cross-sectional study was conducted in a community in Rio de Janeiro, Brazil. The households were randomly selected. Odds ratios were estimated to measure spousal concordance, across socioeconomic levels. RESULTS Overall a significant aggregation of all 3 risk factors was present. The crude odds ratio for hypertension was 1.78 (95%CI=1.02-3.08); for obesity, it was 1.80 (95%CI=1.09-2.96); and for smoking, it was 3.40 (95% CI=2.07-5.61). The spousal concordance for hypertension decreased significantly (p<0.001) from the lower to the higher educational level. In the case of obesity and smoking, the opposite was observed, although p-values for the linear trend were 0.10 and 0.08, respectively. CONCLUSION In lower socioeconomic levels, couples are more concordant for hypertension and discordant for smoking. For hypertension and smoking, education seems to be a discriminant stronger than income, but for obesity the 2 socioeconomic indicators seem to represent different aspects of the environmental determinants of risk factor distribution.