Tiótrefis G. Fernandes

A reappraisal of stroke mortality trends in Brazil (1979-2009)

Background Brazil has one of the highest cerebrovascular death rates in the Western Hemisphere. We investigated temporal trends according to gender and stroke subtypes. Methods We analyzed mortality rates between 1979 and 2009 for different stroke subtypes. Data were stratified by gender and age (35–74 years). The annual percent change and significant changes in the trends were identified with Poisson regression. Results After excluding deaths due to sequel from stroke for men, the annual percent changes (95% confidence intervals) were as follows: 1979–1984, 0·7 (−0·8 to 2·1); 1984–1994, −1·8 (−2·4 to −1·2); 1994–2007, −5·0 (−5·4 to −4·7); and 2007–2009, −0·8 (−7·0 to 5·8). For women, the annual percent changes were as follows: 1979–1994, −1·9 (−2·2 to −1·6); 1994–1997, −7·5 (−14·0 to −0·6); 1997–2007, −4·0 (−4·6 to −3·3); and 2007–2009, 1·6 (−5·5 to 9·2). For the 2006–2009 period, the average annual percent change (95% confidence interval) for all strokes was −3·1 (−3·3 to −2·9) for men and −2·9 (−3·1 to −2·8) for women. For the same period, the average annual percent change of death rates for stroke subtypes were, for men and women, respectively: intracerebral hemorrhage, −4·0 (−4·9 to −3·1) and −2·9 (−3·4 to −2·3); and ischemic stroke, −3·2 (−3·3 to −3·0) and −1·4 (−2·0 to −0·9). Conclusion Stroke mortality rates are declining in Brazil for all stroke subtypes.

Suicide rates and trends in São Paulo, Brazil, according to gender, age and demographic aspects: a joinpoint regression analysis

OBJETIVO: Avaliar as taxas de suicidio e as tendencias em Sao Paulo por genero, faixa etaria e metodos. METODOS: Dados de mortalidade foram coletados a partir de bases de dados da Prefeitura de Sao Paulo de 1996-2009. A populacao total foi estimada utilizando dados do Censo Nacional. Utilizamos o programa Joinpoint regression analysis para explorar tendencias temporais. Tambem avaliamos estado civil, etnia, local de nascimento e metodos de suicidio. RESULTADOS: No periodo, ocorreram 6.002 suicidios, uma taxa de 4,6 por 100.000 habitantes (7,5 em homens e 2,0 em mulheres), a relacao masculino-feminino foi cerca de 3,7. Tendencias de suicidio para os homens apresentaram uma queda significativa de 5,3% por ano entre 1996 e 2002, e um aumento significativo de 2,5% ao ano a partir de 2002. Mulheres nao apresentaram alteracoes significativas na tendencia. Para os homens, os idosos (> 65 anos) tiveram uma reducao significativa de 2,3% ao ano, enquanto os homens mais novos (25-44 anos) apresentaram um aumento significativo de 8,6% ao ano a partir de 2004. Mulheres nao apresentaram alteracoes significativas na tendencia por faixa etaria. Principais metodos de suicidio foram enforcamento e envenenamento, para homens e mulheres respectivamente. Outras analises mostraram um aumento do risco relativo ao suicidio para os solteiros e estrangeiros. CONCLUSOES: Foram identificadas tendencias epidemiologicas especificas do suicidio na cidade de Sao Paulo que merecem uma investigacao mais aprofundada. Grupos de alto risco - como os imigrantes - poderiam se beneficiar com estrategias focalizadas na prevencao do suicidio.

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.

Income and heart disease mortality trends in Sao Paulo, Brazil, 1996 to 2010

BACKGROUND Reductions in heart disease mortality rates are variable according to socioeconomic status. METHODS We performed a time trend analysis of all heart diseases (all circulatory diseases, except rheumatic, cerebrovascular, and aortic diseases) comparing three different household income levels (high, middle, and low) in the city of Sao Paulo from 1996 to 2010. RESULTS A total of 197,770 deaths were attributed to heart diseases; 62% of them were due to coronary diseases. The rate of death due to heart diseases declined for the city as a whole. The annual percent change (APC) and 95% confidence intervals for men living in the high, middle and low income areas were -4.1 (-4.5 to -3.8), -3.0 (-3.5 to -2.6), and -2.5 (-2.8 to -2.1), respectively. The decline in death rate was greatest among men in the wealthiest area. The trend rates of women living in the high-income area had one joinpoint; APC was -4.4 (-4.8 to -3.9) from 1996-2005 and -2.6 (-3.8 to -1.4) from 2005-2010. Middle and low income areas had an APC of -3.6 (-4.1 to -3.1) and -3.0 (-3.2 to -2.7) from 1996-2010, respectively. During the last 5years of observation, there was a gradient of the decline of the risk of death, faster for people living in the wealthiest area and slower for people living in the more deprived neighborhoods. CONCLUSION Reduction in deaths due to heart diseases is greatest for men and women living in the wealthiest neighborhoods.

Educational levels and the functional dependence of ischemic stroke survivors

We evaluated the functional dependence of stroke survivors from the Study of Stroke Mortality and Morbidity, using the Rankin Scale. Out of 355 ischemic stroke survivors (with a mean age of 67.9 years), 40% had some functional dependence at 28 days and 34.4% had some functional dependence at 6 months. Most predictors of physical dependence were identified at 28 days. These predictors were: low levels of education [illiterate vs. ≥ 8 years of education, multivariate odds ratio (OR) = 3.7; 95% confidence interval (95%CI): 1.60-8.54] and anatomical stroke location (total anterior circulation infarct, OR = 16.9; 95%CI: 2.93-97.49). Low levels of education and ischemic brain injury influenced functional dependence in these stroke survivors. Our findings reinforce the necessity of developing strategies for the rehabilitation of stroke patients, more especially in formulating specific strategies for care and treatment of stroke survivors with low socioeconomic status.

Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil

UNLABELLED Few studies have addressed early cerebrovascular lethality in Brazil. OBJECTIVE To evaluate 10 and 28-day stroke case-fatality rates in three hospitals in three Brazilian cities. METHODS We described the stroke registries in São Paulo, João Pessoa, and Natal. RESULTS Out of a total of 962 first-ever events (mean age, 68.1 years-old; 53% men), 83.6% (804 cases) were classified as ischemic and 16.4% (158) as hemorrhagic stroke. Overall, the case-fatality rates and 95% confidence intervals (95%CI) for hemorrhagic stroke events were higher than for ischemic events, both at 10 (12.3%; 95%CI 7.2-17.4 versus 7.0%; 95%CI 5.3-8.8) and at 28 days (19.8%; 95%CI 13.6-26.0 versus 11.1%; 95%CI 8.9-13.3). CONCLUSIONS We did not find any substantial differences in early case-fatality rates according to stroke subtypes, when comparing the three centers.

Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996-2011:

Background It is not clear the relationship between stroke mortality trends and socioeconomic inequalities in low- and middle-income countries. Aims We compared differences of trends in stroke mortality by socioeconomic status in the city of Sao Paulo, Brazil. Methods We analyzed the intra-urban distribution of stroke death rates from 1996 to 2011 for persons aged 35-74 years old according to income using joinpoint regression. Results We confirmed 77 848 stroke deaths in the period, 51-4% of them among persons aged 35-74 years old. For all areas, there was parallelism between genders, and the average annual percent changes combined was -5.2 (-5.7 to -4.6) from 1996 to 2005 and -30 (-4.3 to -1.7) from 2005 to 2011. The full period average annual percent changes of age-adjusted rates between persons living in the high- and low-income area were, respectively, -5.4 and -4.2 (P = 0.002) for men and -5.9 vs.-4.9 (P = 0.017) for women. Differences in the risk of stroke between the high- and low-income areas increased more than twofold in the period in both genders. Conclusions The risk of stroke death is decreasing in all regions, but the faster decline in mortality rates in the wealthiest area contributes to further greater inequalities.

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.

Stroke in the Rain Forest: Prevalence in a Ribeirinha Community and an Urban Population in the Brazilian Amazon

Background: Our objective was to determine the cerebrovascular prevalence in a town in the Brazilian Amazon basin and compare the ribeirinhos (riparians) to the urban population in the same municipality. Methods: From May to October 2011, 6,216 residents over 35 years of age in the town of Coari were interviewed using a screening questionnaire, the Stroke Symptom Questionnaire. Cerebrovascular prevalence rates (PRs) from the door-to-door surveillance were calculated according to the location of the home. Results: Respondent totals were 4,897 in the urban area and 1,028 in the rural area. The crude prevalence of stroke was 6.3% in rural and 3.7% in urban areas with differences maintained after sex and age adjustment. Among stroke cases, the ribeirinhos were those with less access to medical care in comparison to the urban area (32.1 vs. 52.5%, p = 0.01), and a positive association between rural area and no medical care for stroke remained (PR, 1.33; 95% confidence interval, 1.03-1.71), independently of age, sex, education and functional impairment. Conclusions: This study provides the first population-based cerebrovascular prevalence comparison between an urban and a rural population in the Amazon rain forest. The PRs were higher in the ribeirinha compared to the urban population in the same municipality.

A Atenção Básica no Brasil e o Programa Mais Médicos: uma análise de indicadores de produção

This study analyzes the number of medical appointments and referrals performed in primary health care in Brazil focusing on the Mais Medicos Program (More Doctors Program). It is a cross-sectional study on the work of physicians included, or not, to the Mais Medicos Program in 2014. Based on validation protocols, a unified database was created from two health information system databases – SIAB and ESUS. Absolute indicators were defined: the total of medical appointments per month; medical referrals and community health education activities. In addition, other indicators were considered, such as weekly rates and productivity of appointments, in line with the profile of Brazilian municipalities. The mean of all appointments was 285 per month corresponding to an average of 14.4 appointments/day. In the poorest municipalities, the figures for the Mais Medicos Program physicians were higher than national rates. The educational activities provided by primary care teams that included a Mais Medicos Program professional were higher in Brazilian capital cities. The Mais Medicos Program achieved one of its main goals, which was to increase health access for vulnerable populations and to contribute towards the consolidation of primary health care in Brazil.This study analyzes the number of medical appointments and referrals performed in primary health care in Brazil focusing on the Mais Médicos Program (More Doctors Program). It is a cross-sectional study on the work of physicians included, or not, to the Mais Médicos Program in 2014. Based on validation protocols, a unified database was created from two health information system databases - SIAB and ESUS. Absolute indicators were defined: the total of medical appointments per month; medical referrals and community health education activities. In addition, other indicators were considered, such as weekly rates and productivity of appointments, in line with the profile of Brazilian municipalities. The mean of all appointments was 285 per month corresponding to an average of 14.4 appointments/day. In the poorest municipalities, the figures for the Mais Médicos Program physicians were higher than national rates. The educational activities provided by primary care teams that included a Mais Médicos Program professional were higher in Brazilian capital cities. The Mais Médicos Program achieved one of its main goals, which was to increase health access for vulnerable populations and to contribute towards the consolidation of primary health care in Brazil.