Luciana Neves Nunes

The association of pattern of lifetime alcohol use and cause of death in the European Prospective Investigation into Cancer and Nutrition (EPIC) study

BACKGROUND There is limited evidence for an association between the pattern of lifetime alcohol use and cause-specific risk of death. METHODS Multivariable hazard ratios were estimated for different causes of death according to patterns of lifetime alcohol consumption using a competing risks approach: 111 953 men and 268 442 women from eight countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study were included. Self-reported alcohol consumption at ages 20, 30, 40 or 50 years and at enrollment were used for the analysis; 26 411 deaths were observed during an average of 12.6 years of follow-up. RESULTS The association between lifetime alcohol use and death from cardiovascular diseases was different from the association seen for alcohol-related cancers, digestive, respiratory, external and other causes. Heavy users (>5 drinks/day for men and >2.5 drinks/day for women), regardless of time of cessation, had a 2- to 5-times higher risk of dying due to alcohol-related cancers, compared with subjects with lifetime light use (≤1 and ≤0.5 drink/week for men and women, respectively). Compared with lifetime light users, men who used <5 drinks/day throughout their lifetime had a 24% lower cardiovascular disease mortality (95% confidence interval 2-41). The risk of death from coronary heart disease was also found to be 34-46% lower among women who were moderate to occasionally heavy alcohol users compared with light users. However, this relationship was only evident among men and women who had no chronic disease at enrollment. CONCLUSIONS Limiting alcohol use throughout life is associated with a lower risk of death, largely due to cardiovascular disease but also other causes. However, the potential health benefits of alcohol use are difficult to establish due to the possibility of selection bias and competing risks related to diseases occurring later in life.

Trends in hospitalizations for primary care sensitive conditions following the implementation of Family Health Teams in Belo Horizonte, Brazil

OBJECTIVES How to provide effective and efficient care to the burgeoning and aging populations of the major cities of low- and middle-income countries constitutes one of the principle public health issues of our times. We evaluated the Family Health Strategy, the Brazilian national health systems public approach to primary health care, in the major city of Belo Horizonte, describing trends and factors associated with hospitalizations for primary care sensitive conditions following the implementation of 506 family health teams, most of which were established in 2002. METHODS We conducted an ecological study covering 2003 to 2006, using mixed models to investigate time trends in public system hospitalizations as well as their association with social vulnerability and primary care team characteristics. RESULTS Sensitive conditions accounted for 115,340 (26.4%) hospitalizations. Over the 4-year period, hospitalizations for sensitive conditions declined by 17.9%, vs only 8.3% for non-sensitive ones (P<0.001). Hospitalization for sensitive conditions declined 22% for women in areas of high social vulnerability vs 9% for women in areas of low vulnerability (P<0.001); for men, 17% vs 10% (P=0.11). CONCLUSIONS Though the ecologic nature of our study limits the confidence with which conclusions can be affirmed, the Family Health Strategy appears to have contributed to a major reduction in hospitalizations due to primary care sensitive conditions in this large Brazilian metropolis, while at the same time promoting greater health equity.

Qualidade do processo da assistência pré-natal: unidades básicas de saúde e unidades de Estratégia Saúde da Família em município no Sul do Brasil

Prenatal care in traditional primary care units (UBS) and Family Health Strategy units (ESF) was evaluated by a cross-sectional study from July 2009 to February 2010 in Santa Maria, Rio Grande do Sul State, Brazil. Seven hundred and ninety-five postpartum women who had received prenatal care in either of the two types of units were interviewed. Four quality levels were used: level 1 (Kessner index modified by Takeda); level 2, which adds clinical obstetric procedures to level 1; level 3, which adds laboratory tests to level 1; and level 4, which includes all the above parameters. Prenatal care in the Family Health Strategy was superior to that of traditional primary care at all levels, with statistically significant differences in levels 1 and 2. Pregnant women received more guidance and prenatal care was superior in the Family Health Strategy. The study favored the Family Health Strategy, but improvement is still needed in the performance of procedures and laboratory tests in order to enhance prenatal care and strengthen primary care.

Lifetime alcohol use and overall and cause-specific mortality in the European Prospective Investigation into Cancer and nutrition (EPIC) study

Objectives To investigate the role of factors that modulate the association between alcohol and mortality, and to provide estimates of absolute risk of death. Design The European Prospective Investigation into Cancer and nutrition (EPIC). Setting 23 centres in 10 countries. Participants 380 395 men and women, free of cancer, diabetes, heart attack or stroke at enrolment, followed up for 12.6 years on average. Main outcome measures 20 453 fatal events, of which 2053 alcohol-related cancers (ARC, including cancers of upper aerodigestive tract, liver, colorectal and female breast), 4187 cardiovascular diseases/coronary heart disease (CVD/CHD), 856 violent deaths and injuries. Lifetime alcohol use was assessed at recruitment. Results HRs comparing extreme drinkers (≥30 g/day in women and ≥60 g/day in men) to moderate drinkers (0.1–4.9 g/day) were 1.27 (95% CI 1.13 to 1.43) in women and 1.53 (1.39 to 1.68) in men. Strong associations were observed for ARC mortality, in men particularly, and for violent deaths and injuries, in men only. No associations were observed for CVD/CHD mortality among drinkers, whereby HRs were higher in never compared to moderate drinkers. Overall mortality seemed to be more strongly related to beer than wine use, particularly in men. The 10-year risks of overall death for women aged 60 years, drinking more than 30 g/day was 5% and 7%, for never and current smokers, respectively. Corresponding figures in men consuming more than 60 g/day were 11% and 18%, in never and current smokers, respectively. In competing risks analyses, mortality due to CVD/CHD was more pronounced than ARC in men, while CVD/CHD and ARC mortality were of similar magnitude in women. Conclusions In this large European cohort, alcohol use was positively associated with overall mortality, ARC and violent death and injuries, but marginally to CVD/CHD. Absolute risks of death observed in EPIC suggest that alcohol is an important determinant of total mortality.

Câncer de mama: mortalidade crescente na Região Sul do Brasil entre 1980 e 2002

Breast cancer is the most prevalent form of cancer in the world. Breast cancer mortality rates are high in Brazil and show striking variations between geographic regions. A time-trend ecological study was performed in Southern Brazil from 1980 to 2002. Data were collected from the Mortality Information System (Ministry of Health) to assess age-standardized mortality rates. Linear regression for mortality time-trend analysis and multiple regression for mortality differences among three States were calculated. The highest mean mortality rate (14.45) was observed in Rio Grande do Sul, significantly greater (p < 0.001) than in Santa Catarina (8.93) and Paraná (9.95). An annual increase of 0.47 in the mortality rate was observed in the three States of Southern Brazil. According to these results, the South of Brazil and especially the State of Rio Grande do Sul showed a significant upward trend in breast cancer mortality. Continued efforts are needed to help explain these numbers and reverse the present situation.

Existe uma associação entre mortalidade por câncer e uso de agrotóxicos?: Uma contribuição ao debate

The chronic use of agrotoxics in rural regions of Rio Grande do Sul State (RS) has been tentatively associated to a possible increase in the incidence of cancer in rural areas. A time-trend ecological study was performed in the micro region of Ijui County (MI), in RS and Brazil, with data of the 1979 to 2003 period. Data was collected from the Mortality Information System, Brazilian Ministry of Health (DATASUS), to evaluate the cancer mortality rate, standardized by gender and age - corrected mortality ratios. Linear regression for mortality time-trend analysis and multiple regressions for mortality differences among three regions were calculated. The highest average mortality rate in men and also women were observed in RS and MI and they were significantly higher (p<0,001) than the one for Brazil. When the model was adjusted for three regions the upward trend on mortality remained the same. This data suggests that the relation between chronic use of agrotoxics and cancer cannot be denied and should be further investigated.

Comparison of simple and multiple imputation methods using a risk model for surgical mortality as example

INTRODUCTION It is common for studies in health to face problems with missing data. Through imputation, complete data sets are built artificially and can be analyzed by traditional statistical analysis. The objective of this paper is to compare three types of imputation based on real data. METHODS The data used came from a study on the development of risk models for surgical mortality. The sample size was 450 patients. The imputation methods applied were: two single imputations and one multiple imputation and the assumption was MAR (Missing at Random). RESULTS The variable with missing data was serum albumin with 27.1% of missing rate. The logistic models adjusted by simple imputation were similar, but differed from models obtained by multiple imputation in relation to the inclusion of variables. CONCLUSIONS The results indicate that it is important to take into account the relationship of albumin to other variables observed, because different models were obtained in single and multiple imputations. Single imputation underestimates the variability generating narrower confidence intervals. It is important to consider the use of imputation methods when there is missing data, especially multiple imputation that takes into account the variability between imputations for estimates of the model.

Post-weaning weight gain and pregnancy rate of beef heifers bred at 18 months of age: a meta-analysis approach

The objective of this study was to evaluate, using meta-analysis, the main factors related to post-weaning body weight and weight gain that affect pregnancy rate of heifers bred at 18 months of age. Data of 1398 beef heifers from six experiments were analyzed as a set. Information related to methodology and results of each experiment were codified in Microsoft Excel spreadsheets. The independent variables analyzed were: body weight at seven months of age (BW7M), daily weight gain from seven to 12 months (DWG7-12), body weight at 12 months of age (BW12M), daily weight gain from 12 to 15 months (DWG12-15), body weight at 15 months of age (BW15M), daily weight gain from 15 to 18 months (DWG15-18), daily weight gain from 7 to 18 months (DWG7-18) and body weight at 18 months of age (BW18M). The response variable was pregnancy rate (PR). Body weight at 18 months of age and DWG7-18 showed high correlation with PR and between each other. The other variables presented low correlation with PR. Body weight at first breeding and daily weight gain from seven to 18 months are the most important variables affecting the pregnancy rate of heifers bred at 18 months of age in the autumn. Weaning weight and weight gain during intermediate steps of the post-weaning period are not good predictors of pregnancy rate. Higher pregnancy rates can be obtained provided enough post-weaning weight gain and minimum body weight at first breeding are achieved, irrespective of when weight is gained.

Análise do modelo “Visão do Estudante” de avaliação de jogos sérios digitais

Este artigo apresenta uma analise do modelo de avaliacao de jogos serios digitais “Visao do Estudante”, que conta com a combinacao de dois instrumentos, sendo o primeiro a adaptacao de um questionario proposto por Savi (2011) e o segundo composto por itens de interacao com base em principios mencionados por Aarseth (2003). De forma a explorar o modelo, dados de sua aplicacao com uma amostra de 18 estudantes foram analisados, complementando-os com o uso de testes estatisticos. Como resultado, foram encontradas evidencias da relacao entre as percepcoes do estudante sobre aspectos motivacionais e sua opiniao sobre a experiencia de usuario, e observou-se diferencas significativas entre grupos em alguns aspectos avaliados, demonstrando a utilidade do modelo para analisar a aplicacao de um jogo educacional.

Odds Ratio or Prevalence Ratio? An Overview of Reported Statistical Methods and Appropriateness of Interpretations in Cross-sectional Studies with Dichotomous Outcomes in Veterinary Medicine

One of the most commonly observational study designs employed in veterinary is the cross-sectional study with binary outcomes. To measure an association with exposure, the use of prevalence ratios (PR) or odds ratios (OR) are possible. In human epidemiology, much has been discussed about the use of the OR exclusively for case–control studies and some authors reported that there is no good justification for fitting logistic regression when the prevalence of the disease is high, in which OR overestimate the PR. Nonetheless, interpretation of OR is difficult since confusing between risk and odds can lead to incorrect quantitative interpretation of data such as “the risk is X times greater,” commonly reported in studies that use OR. The aims of this study were (1) to review articles with cross-sectional designs to assess the statistical method used and the appropriateness of the interpretation of the estimated measure of association and (2) to illustrate the use of alternative statistical methods that estimate PR directly. An overview of statistical methods and its interpretation using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted and included a diverse set of peer-reviewed journals among the veterinary science field using PubMed as the search engine. From each article, the statistical method used and the appropriateness of the interpretation of the estimated measure of association were registered. Additionally, four alternative models for logistic regression that estimate directly PR were tested using our own dataset from a cross-sectional study on bovine viral diarrhea virus. The initial search strategy found 62 articles, in which 6 articles were excluded and therefore 56 studies were used for the overall analysis. The review showed that independent of the level of prevalence reported, 96% of articles employed logistic regression, thus estimating the OR. Results of the multivariate models indicated that logistic regression was the method that most overestimated the PR. The findings of this study indicate that although there are methods that directly estimate PR, many studies in veterinary science do not use these methods and misinterpret the OR estimated by the logistic regression.