Maria Ines Reinert Azambuja

Markers of inflammation and prediction of diabetes mellitus in adults (Atherosclerosis Risk in Communities study): a cohort study

BACKGROUND Type 2 diabetes mellitus and atherosclerotic cardiovascular disease have common antecedents. Since markers of inflammation predict coronary heart disease and are raised in patients with type 2 diabetes, we investigated whether they predict whether people will develop type 2 diabetes. METHODS 12,330 men and women, aged 45-64 years, were followed up for a mean of 7 years. We analysed the association between different markers of acute inflammation and subsequent diagnosis of diabetes. In a subgroup of 610 individuals selected originally for an unrelated atherosclerosis case-control study, we also investigated diabetes associations with total sialic acid and orosomucoid, haptoglobin, and alpha1-antitrypsin. FINDINGS 1335 individuals had a new diagnosis of diabetes. Adjusted odds ratios for developing diabetes for quartile extremes were 1.9 (95% CI 1.6-2.3) for raised white-cell count, 1.3 (1.0-1.5) for low serum albumin, and 1.2 (1.0-1.5) for raised fibrinogen. In the subgroup analysis, individuals with concentrations of orosomucoid and sialic acid of more than the median had odds ratios of 7.9 (2.6-23.7) and 3.7 (1.4-9.8), respectively. Adjustment for body-mass index and waist-to-hip ratio lessened the associations; those for white-cell count (1.5 [1.3-1.8]), orosomucoid (7.1 [2.1-23.7]), and sialic acid (2.8 [1.0-8.1]) remained significant. INTERPRETATION Markers of inflammation are associated with the development of diabetes in middle-aged adults. Although autoimmunity may partly explain these associations, they probably reflect the pathogenesis of type 2 diabetes.

Mortalidade precoce por doenças cardiovasculares e desigualdades sociais em Porto Alegre : da evidência à ação

BACKGROUND: Two perspectives, the economic (disease causing impoverishment) and social (poverty causing illness), have internationally disputed the justification for public health policies. OBJECTIVE: To investigate the relationship between early mortality by cardiovascular disease (CVD) and socioeconomic (SE) conditions in the city of Porto Alegre (PA), and discuss bases and strategies for the prevention of CVD. METHODS: An ecological analysis of the association between mortality by CVD at 45-64 years of age and SE conditions of 73 districts/neighborhoods in PA. The relative risk (RR) and the fraction of risk (FRA) attributable to inequality among the districts grouped into 4 SE strata were estimated. RESULTS: Early mortality by CVD was 2.6 times higher in the districts classified in the worst compared to the best of the 4 SE strata. Among the extreme districts, the RR reached 3.3 for CVD and 3.9 for cerebrovascular disease. Compared to the mortality in the best stratum, 62% of the early deaths in the worst stratum and 45% of those in the city as a whole could be attributed to socioeconomic inequality. CONCLUSION: Almost half of the mortality by CVD before 65 years of age can be attributed to poverty. Disease, on the other hand, contributes towards poverty and reduces competitiveness of the country. It is necessary to reduce illness and recover the health of the poorest inhabitants with investments that result in national economic development and improvement of the social conditions of the population.

Similarities in mortality patterns from influenza in the first half of the 20th century and the rise and fall of ischemic heart disease in the United States: a new hypothesis concerning the coronary heart disease epidemic

The classic risk factors for developing coronary heart disease (CHD) explain less than 50% of the decrease in mortality observed since 1950. The transition currently under way, from the degenerative to the infectious-inflammatory paradigm, requires a new causal interpretation of temporal trends. The following is an ecological study based on data from the United States showing that in men and women an association between the age distribution of mortality due to influenza and pneumonia (I&P) associated with the influenza pandemic in 1918-1919 in the 10-49-year age bracket and the distribution of CHD mortality from 1920 to 1985 in survivors from the corresponding birth cohorts. It further shows a significant negative correlation (r = -0.68, p = 0.042) between excess mortality from I&P accumulated in epidemics from 1931 to 1940 (used as indicator for persistent circulation of H1N1 virus combined with vulnerability to infection) and the order of the beginning in the decline in CHD mortality in nine geographic divisions in the United States. In light of current biological knowledge, the data suggest that the 1918 influenza pandemic and the subsequent epidemics up to 1957 might have played a determinant role in the epidemic of CHD mortality registered in the 20th century.

Doenças crônicas não-transmissíveis no Brasil: repercussões do modelo de atenção à saúde sobre a seguridade social

A seguridade social envolve acoes do poder publico e da sociedade sobre direitos a previdencia social, a assistencia social e a propria saude. Este artigo traca um esboco de cada um desses elementos. Muitas doencas cronicas nao-transmissiveis tem fatores de risco comuns e demandam assistencia continuada de servicos. Comparando-se nossa populacao com a dos EUA, ve-se que e praticamente do mesmo tamanho ate a faixa dos 15 aos 24 anos. A americana e duas vezes maior dos 35 aos 44 anos e mais de quatro vezes maior acima dos 75 anos. Tais diferencas explicam porque o numero de mortes por DCNT e muito mais baixo no Brasil: nossa populacao e mais jovem e morre antes. Na medida em que o processo de envelhecimento avance, especialmente, via reducao da mortalidade precoce, aumentara a prevalencia das DCNT e sua repercussao na seguridade social. Assim como a atencao a saude, a previdencia social e a assistencia social sofrem pressoes politicas, economicas e culturais. Na tentativa de imaginar um cenario futuro possivel para a seguridade social no Brasil discute-se a necessidade de reformular o orcamento do Pais, visando ao equilibrio financeiro.

Connections : can the 20th century coronary heart disease epidemic reveal something about the 1918 influenza lethality?

This essay proposes that the ecologic association shown between the 20th century coronary heart disease epidemic and the 1918 influenza pandemic could shed light on the mechanism associated with the high lethality of the latter. It suggests that an autoimmune interference at the apoB-LDL interface could explain both hypercholesterolemia and inflammation (through interference with the cellular metabolism of arachidonic acid). Autoimmune inflammation, then, would explain the 1950s-60s acute coronary events (coronary thrombosis upon influenza re-infection) and the respiratory failure seen among young adults in 1918. This hypothesis also argues that the lethality of the 1918 pandemic may have not depended so much on the 1918 virus as on an immune vulnerability to it, possibly resulting from an earlier priming of cohorts born around 1890 by the 1890 influenza pandemic virus.

Coronary Heart Disease (CHD)\-\-One or Several Diseases? Changes in the Prevalence and Features of CHD

In retrospect, mortality from coronary heart disease (CHD) in the 20th century followed an epidemic pattern: mortality rates increased dramatically from 1920 until about 1960, remained roughly constant for almost a decade, and have been decreasing since the late 1960s. CHD has traditionally been conceived of as a single disease with multifactorial causality. We suggest instead that CHD cases may comprise at least two distinct populations: those associated with hypercholesterolemia, and those associated with insulin resistance. The epidemic of CHD was due primarily to changes in the incidence of the hypercholesterolemia subgroup. We propose that young adults who survived the 1918 influenza pandemic were rendered vulnerable to lipid-associated CHD and coronary thrombosis upon reinfection with influenza later in life. This vulnerability may be due to autoimmune disruption of low-density lipoprotein-receptor interactions. Historical events may affect the health of populations by affecting the susceptibility of populations to chronic diseases such as CHD. The life experiences of individuals are known to influence their susceptibility to infectious diseases; we suggest that life experiences may also influence individual susceptibility to chronic diseases.

Rise and fall in ischemic heart disease mortality: it may have happened before

The rise in ischemic heart disease (IHD) mortality occurring mostly during the first half of the 20th century is usually associated with economic development and its consequences for peoples lifestyles. On the basis of historical evidence, it is postulated that a previous IHD epidemic cycle may have occurred in England and Wales towards the turn of the nineteenth century. The implications of this on causal theories and current etiological research on atherosclerosis are discussed.

Inflammation as the cause of coronary heart disease

142 www.thelancet.com/infection Vol 10 March 2010 Reduced gametocyte carriage and decreased malaria transmissibility due to artemisinin-based combination therapies is a major argument for their use from a malaria-control perspective. The gametocytogenicity of quinine could be improved, especially in combination with primaquine that accelerates gametocyte clearance in malaria due to Plasmodium falciparum. Artemisinin-based combination therapy is the safest treat ment for malaria, but quinine remains a good asset in the treatment of malaria. The risks, benefi ts, and acceptance of dropping quinine should be addressed with health-care workers in Africa and should not be swept away in the euphoria of artemisinin-based combination therapy development. We advocate that manufacturers and stakeholders do not eliminate quinine but instead take advantage of this honeymoon with artemisininbased combination therapy to improve this well-known potent drug.

Influenza Recycling and Secular Trends in Mortality and Natality

Secular variations in longevity and in population aging are of huge interest to actuaries. It is shown here that temporal changes in mortality and natality accompany the recycling of influenza A viruses i.e., the re-exposure of human populations, from time to time, to influenza A viruses antigenically similar to viruses (H1, H2, H3) that circulated in the past. Mortality (and natality) change as birth cohorts (whole population and maternal) with specific types and levels of vulnerability to influenza A re-infections, acquired through early-life effects of infection with one (period-specific) influenza A sub-type, course through subsequent influenza A environments over time. Epidemiologic evidence of association between secular trends in mortality (and natality) and interactions between birth-cohort and period effects of influenza A circulation is presented both for the U.K. and the U.S. New interpretations to several epidemiologic and demographic observations follow from this finding.

Saúde urbana e indicadores intraurbanos do Programa das Nações Unidas para o Desenvolvimento (PNUD) - três relatos em Porto Alegre : resultados, limitações e potencialidades

INTRODUCAO: Os Objetivos de Desenvolvimento Sustentavel (ODS) sao uma iniciativa das Nacoes Unidas, subscrita pelo Brasil e outros 192 paises, com foco em investimentos em infraestrutura e desenvolvimento humano nas metropoles. Espera-se que informacoes georreferenciadas de saude e de desenvolvimento local favorecam governancas locais produtoras de mais equidade. Este artigo propoe-se a divulgar o Atlas de Desenvolvimento Humano Metropolitano (ADHM) do Programa das Nacoes Unidas para o Desenvolvimento (PNUD) lancado em 2014 e avaliar a utilidade dos dados referentes ao municipio de Porto Alegre (RS) para diferentes publicos. METODOS: O Atlas do PNUD foi apresentado em tres atividades desenvolvidas pelo Programa Saude Urbana, Ambiente e Desigualdades da Universidade Federal do Rio Grande do Sul para diferentes audiencias: 1) da comunidade – bairro Restinga, 2) da academia – disciplina integradora Praticas Integradasem Saude I, e 3) do servico de saude – Unidade Basica de Saude Santa Cecilia/HCPA. Para cada atividade descreveu-se a metodologia utilizada para produzir informacoes a partir dos dados disponibilizados pelo Atlas. RESULTADOS: Observou-se a necessidade de compatibilizar melhor as areas geograficas de referencia dos servicos e do Atlas para a implementacao das avaliacoes do impacto de investimentos intraurbanos em infraestrutura e desenvolvimento social na saude, e vice-versa. Foram discutidas as potencialidades e limitacoes identificadas. CONCLUSAO: A utilizacao de indicadores intraurbanos do ADHM do PNUD tem potencial para trazer informacoes de interesse para os servicos locais de saude e para a comunidade.