Ligia Maria Giongo Fedeli

A Stepwise Approach to Stroke Surveillance in Brazil: the EMMA (Estudo de Mortalidade E Morbidade Do Acidente Vascular Cerebral) Study

Background: Stroke mortality rates in Brazil are the highest in the Americas. Deaths from cerebrovascular disease surpass coronary heart disease. Aim: To verify stroke mortality rates and morbidity in an area of São Paulo, Brazil, using the World Health Organization Stepwise Approach to Stroke Surveillance. Methods: We used the World Health Organization Stepwise Approach to Stroke Surveillance structure of stroke surveillance. The hospital-based data comprised fatal and nonfatal stroke (Step 1). We gathered stroke-related mortality data in the community using World Health Organization questionnaires (Step 2). The questionnaire determining stroke prevalence was activated door to door in a family-health-programme neighbourhood (Step 3). Results: A total of 682 patients 18 years and above, including 472 incident cases, presented with cerebrovascular disease and were enrolled in Step 1 during April–May 2009. Cerebral infarction (84.3%) and first-ever stroke (85.2%) were the most frequent. In Step 2, 256 deaths from stroke were identified during 2006–2007. Forty-four per cent of deaths were classified as unspecified stroke, 1/3 as ischaemic stroke, and 1/4 due to haemorrhagic subtype. In Step 3, 577 subjects over 35 years old were evaluated at home, and 244 cases of stroke survival were diagnosed via a questionnaire, validated by a board-certified neurologist. The population demographic characteristics were similar in the three steps, except in terms of age and gender. Conclusion: By including data from all settings, World Health Organization stroke surveillance can provide data to help plan future resources that meet the needs of the public-health system.

Early and One-Year Stroke Case Fatality in Sao Paulo, Brazil: Applying the World Health Organization’s Stroke STEPS

Case fatality rate is considered a main determinant of stroke mortality trends. We applied the World Health Organizations Stroke STEPS to identify case fatality rates in a community hospital in Brazil. We evaluated all patients with first-ever stroke seeking acute care at the hospitals emergency ward between April 2006 and December 2008 to verify early and late case fatality according to stroke subtype. We used years of formal education as a surrogate for socioeconomic status. Of 430 first-ever stroke events, 365 (84.9%) were ischemic and 65 (15.1%) were intracerebral hemorrhage. After 1 year, we adjudicated 108 deaths (86 ischemic; 22 hemorrhagic). Age-adjusted case fatality rates for ischemic stroke and intracerebral hemorrhage were 6.0% v 19.8% at 10 days, 10.6% v 22.1% at 28 days, 17.6% v 29.1% at 6 months, and 21.0% v 31.5% at 1 year. Illiteracy or no formal education was a predictor of death at 6 months (odds ratio [OR], 4.31; 95% confidence interval [CI] 1.34-13.91) and 1 year (OR, 4.21; 95% CI, 1.45-12.28) in patients with ischemic stroke, as well as at 6 months (OR, 3.19; 95% CI, 1.17-8.70) and 1 year (OR, 3.30; 95% CI, 1.30-8.45) for all stroke patients. Other variables, including previous cardiovascular risk factors and acute medical care, did not change this association to a statistically significant degree. In conclusion, case fatality, particularly up to 6 months, was higher in hemorrhagic stroke, and lack of formal education was associated with increased stroke mortality.

Design and baseline characteristics of a coronary heart disease prospective cohort: two-year experience from the strategy of registry of acute coronary syndrome study (ERICO study).

OBJECTIVES: To describe the ERICO study (Strategy of Registry of Acute Coronary Syndrome), a prospective cohort to investigate the epidemiology of acute coronary syndrome. METHODS: The ERICO study, which is being performed at a secondary general hospital in Sao Paulo, Brazil, is enrolling consecutive acute coronary syndrome patients who are 35 years old or older. The sociodemographic information, medical assessments, treatment data and blood samples are collected at admission. After 30 days, the medical history is updated, and additional blood and urinary samples are collected. In addition, a retinography, carotid intima-media thickness, heart rate variability and pulse-wave velocity are performed. Questionnaires about food frequency, physical activity, sleep apnea and depression are also applied. At six months and annually after an acute event, information is collected by telephone. RESULTS: From February 2009 to September 2011, 738 patients with a diagnosis of an acute coronary syndrome were enrolled. Of these, 208 (28.2%) had ST-elevation myocardial infarction (STEMI), 288 (39.0%) had non-ST-elevation myocardial infarction (NSTEMI) and 242 (32.8%) had unstable angina (UA). The mean age was 62.7 years, 58.5% were men and 77.4% had 8 years or less of education. The most common cardiovascular risk factors were hypertension (76%) and sedentarism (73.4%). Only 29.2% had a prior history of coronary heart disease. Compared with the ST-elevation myocardial infarction subgroup, the unstable angina and non-ST-elevation myocardial infarction patients had higher frequencies of hypertension, diabetes, prior coronary heart disease (p<0.001) and dyslipidemia (pu200a=u200a0.03). Smoking was more frequent in the ST-elevation myocardial infarction patients (pu200a=u200a0.006). CONCLUSIONS: Compared with other hospital registries, our findings revealed a higher burden of CV risk factors and less frequent prior CHD history.

Delineamento e implementacao do biobanco do ELSA-Brasil: estudo prospectivo na populacao brasileira

The Brazilian Longitudinal Study for Adult Health (ELSA-Brasil) is a multicenter prospective cohort of civil servants designed to assess the determinants of chronic diseases, especially cardiovascular diseases and type 2 diabetes. The present article describes the main design and implementation points of the ELSA-Brasil biobank project. Economic, political, logistical and technological aspects of this study are characterized. Additionally, it discusses the final biorepository protocol and the facilities implemented to achieve this objective. The design and implementation process of the ELSA-Brasil biobank took three years to be performed. Both the central and local biobanks were built according to the best biorepository techniques, using different technological solutions for the distinct needs expected in this study.

Intervention to reduce C-reactive protein determination requests for acute infections at an emergency department

Introduction C-reactive protein (CRP) levels rise during inflammatory processes and have been ordered for rheumatic disease follow-up since the 1950s. The number of tests ordered in the emergency setting has increased, but without evident improvement in medical care quality. Objective To determine the pattern of CRP determinations in the emergency department (ED) of a university hospital in Sao Paulo, Brazil, and to evaluate the effect of an intervention with staff and students about the best use of the test in the ED. Methods Data regarding CRP testing requests, related diagnoses and the number of monthly consultations in the hospital ED were analysed before and after the intervention. Because of an increase in CRP measurement requests from 2007 to 2009, the author started discussing the role of CRP determinations in the medical decision-making process in early 2010. Staff and faculty members openly discussed the pattern of requests in the hospital and related current medical literature. During 2010, the medical staff worked as multipliers to change the behaviour of new students and residents. The results of the first 4u2005months after the intervention were presented at another general meeting in July 2010. Results From 2007 to 2009, there were 11u2008786 CRP measurement requests with a clear exponential trend. After the intervention, during the calendar year 2010, there was a 48% reduction in adjusted annual CRP requests. Pneumonia, fever and urinary tract infections were the most common reasons for CRP requests. Discussion Inexpensive, well-directed, interactive educational interventions may affect professional behaviour and curb rates of laboratory tests.

Low education as a predictor of poor one‐year stroke survival in the EMMA Study (Study of Stroke Mortality and Morbidity in Adults), Brazil

Data linking low socioeconomic status and stroke survival in developing countries are scarce (1,2). We evaluated formal education and one-year survival in the Stroke Mortality and Morbidity Study [Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA) study] (3). We prospectively ascertained 430 (53% of men) consecutive first-ever stroke patients (ischaemic and haemorrhagic) in a community hospital in São Paulo, Brazil from April 2006 to December 2008. Data were collected using the STEPS Stroke Manual instructions (4). Kaplan–Meier method and Cox proportional hazards were used to perform survival analyses according to education (illiterate, 1–7 years, 8 years). The mean age in these strata were 75·1, 68·1, and 63·8 years old, respectively. Our stroke survival rate of 74·9% at one-year follow-up was similar to previous studies in both developed and developing countries. Illiterate stroke survivors had the poorest survival rate (60·7%), followed by patients with one to seven years of education (76·4%), and 8 years of education (81·1%) (Fig. 1). Particularly for ischaemic stroke, non-education was an independent predictor for fatal events [age-adjusted hazard ratio (HR) = 2·32; 95% confidence interval (CI), 1·26–4·27] that strengthened after adjusting for sociodemographics and cardiovascular factors (multivariate HR = 2·65; 95% CI, 1·37–5·13). Factors associated with a poor survival in a sub-group analysis were to be illiterate in persons <68 years [multivariate HR = 3·67; 95% confidence interval (CI), 1·10–12·45], female gender (multivariate HR = 3·42; 95% CI, 1·10–12·45), living alone (multivariate HR = 2·78; 95% CI, 1·16–6·66), and smoking habit (multivariate HR = 4·27; 95% CI, 1·28–14·19). This study has some strength as a good retention of participants and the use of education to evaluate socioeconomic status avoids the potential contamination of reverse causation. Our limitations include the small numbers of haemorrhagic strokes and lack of information on stroke severity at hospital admission. Concluding, stroke survival was directly related to years of education, especially for ischaemic stroke. Absence of education was a significant marker of fatal stroke in persons under age 68 years, who live alone, and who smoked.

Physical Activity and Lipid Profile in the ELSA- Brasil Study

Background Regular physical activity (PA) induces desirable changes in plasma levels of high- and low-density lipoproteins (HDL and LDL, respectively) and triglycerides (TG), important risk factors for cardiometabolic diseases. However, doubts whether intensity and duration have equivalent benefits remain. Objective To assess the association of PA intensity and duration with HDL, LDL and TG levels. Methods Cross-sectional study with 12,688 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline, who were not on lipid-lowering medication. After adjustment for important covariates, multiple linear regression was used to assess the association of PA intensity and duration with HDL, LDL and TG (natural logarithm) levels. Results Both moderate and vigorous PA and PA practice ≥ 150 min/week were significantly associated with higher HDL and lower TG levels. Vigorous PA was associated with lower LDL only on univariate analysis. After adjustments, moderate and vigorous PA increased mean HDL level by 0.89 mg/dL and 1.71 mg/dL, respectively, and reduced TG geometric mean by 0.98 mg/dL and 0.93 mg/dL, respectively. PA practice ≥ 150 min/week increased mean HDL level by 1.05 mg/dL, and decreased TG geometric mean by 0.98 mg/dL. Conclusion Our findings reinforce the benefits of both PA parameters studied on HDL and TG levels, with a slight advantage for vigorous PA as compared to the recommendation based only on PA duration.

Variability in baseline laboratory measurements of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Multi-center epidemiological studies must ascertain that their measurements are accurate and reliable. For laboratory measurements, reliability can be assessed through investigation of reproducibility of measurements in the same individual. In this paper, we present results from the quality control analysis of the baseline laboratory measurements from the ELSA-Brasil study. The study enrolled 15,105 civil servants at 6 research centers in 3 regions of Brazil between 2008–2010, with multiple biochemical analytes being measured at a central laboratory. Quality control was ascertained through standard laboratory evaluation of intra- and inter-assay variability and test-retest analysis in a subset of randomly chosen participants. An additional sample of urine or blood was collected from these participants, and these samples were handled in the same manner as the original ones, locally and at the central laboratory. Reliability was assessed with the intraclass correlation coefficient (ICC), estimated through a random effects model. Coefficients of variation (CV) and Bland-Altman plots were additionally used to assess measurement variability. Laboratory intra and inter-assay CVs varied from 0.86% to 7.77%. From test-retest analyses, the ICCs were high for the majority of the analytes. Notably lower ICCs were observed for serum sodium (ICC=0.50; 95%CI=0.31–0.65) and serum potassium (ICC=0.73; 95%CI=0.60–0.83), due to the small biological range of these analytes. The CVs ranged from 1 to 14%. The Bland-Altman plots confirmed these results. The quality control analyses showed that the collection, processing and measurement protocols utilized in the ELSA-Brasil produced reliable biochemical measurements.

Non-HDL-C goals based on the distribution of population percentiles in ELSA-Brasil: Is it time to change?

BACKGROUND AND AIMSnNon-high-density lipoprotein cholesterol (non-HDL-C) goals are defined as 30u202fmg/dL (0.78u202fmmol/L) higher than the respective low-density lipoprotein cholesterol (LDL-C) goals. This definition, however, do not consider the population distribution of non-HDL-C, which could represent a more appropriate individual goal when both markers are discordant. The aim of this study is to establish non-HDL-C goals at the same population percentiles of LDL-C.nnnMETHODSnNon-HDL-C values were assigned at the same percentiles correspondent to the LDL-C treatment goals for 14,837 participants from the Longitudinal Study of Adult Health (ELSA-Brasil) with triglycerides levelsu202f≤u202f400u202fmg/dL (4.52u202fmmol/L). We also assessed the frequency of reclassification, defined as the number of subjects with LDL-C levels in the recommended therapeutic category, but with non-HDL-C levels above or below the category.nnnRESULTSnThe non-HDL-C values, based on correspondent LDL-C population percentiles, were 92 (2.38), 122 (3.16), 156 (4.04), 191 (4.95), and 223u202fmg/dL (5.78u202fmmol/L). Among participants with LDL-C <70u202fmg/dL (1.81u202fmmol/L), 22.8% were reclassified in a higher category according to the guidelines-based non-HDL-C cut-off and 30.1% according to the population percentile-based cut-off; 25.6% and 64.1%, respectively, if triglycerides concurrently 150-199u202fmg/dL (1.69-2.25u202fmmol/L).nnnCONCLUSIONSnOur results demonstrated that non-HDL-C percentiles-based goals were up to 8u202fmg/dL (0.21u202fmmol/L) lower than the guidelines recommended goal and had a profound impact on the reclassification of participants, notably when LDL-C was <100u202fmg/dL (2.56u202fmmol/L), the treatment goal for high risk patients. Therefore, non-HDL-C goals should be changed for reduction of residual risk.