[Show abstract][Hide abstract] ABSTRACT: Obstructive sleep apnea (OSA) and hypertension are well-known cardiovascular risk factors. Their control could reduce the burden of heart disease across populations. Several drugs are used to control hypertension, but the only consistently effective treatment of OSA is continuous positive airway pressure. The identification of a drug capable of improving OSA and hypertension simultaneously would provide a novel approach in the treatment of both diseases.Methods/design: This is a randomized double-blind clinical trial, comparing the use of chlorthalidone with amiloride versus amlodipine as a first drug option in patients older than 40 years of age with stage I hypertension (140 to 159/90 to 99 mmHg) and moderate OSA (15 to 30 apneas/hour of sleep). The primary outcomes are the variation of the number of apneas per hour and blood pressure measured by ambulatory blood pressure monitoring. The secondary outcomes are adverse events, somnolence scale (Epworth), ventilatory parameters and C reactive protein levels. The follow-up will last 8 weeks. There will be 29 participants per group. The project has been approved by the ethics committee of our institution.
The role of fluid retention in OSA has been known for several decades. The use of diuretics are well established in treating hypertension but have never been appropriately tested for sleep apnea. As well as testing the efficacy of these drugs, this study will help to understand the mechanisms that link hypertension and sleep apnea and their treatment.Trial registration: ClinicalTrials.gov: NCT01896661.
[Show abstract][Hide abstract] ABSTRACT: A non-blinded randomized controlled trial evaluated efficacy of pharmaceutical care (PC) (Dáder method) on self-reported antiretroviral adherence and undetectable plasma viral load (UPVL), compared with usual care (UC) in HIV-positive patients in Brazil. Most were male (63 %), mean age 40.3 years (SD = 10). After 12 months, 79.8 % of those receiving PC versus 73.8 % in UC were adherent (RR 1.05, 95 % CI 0.95-1.15, P = 0.35), and 50.3 versus 49.8 % (PC vs. UC, respectively) had UPVL (RR 1.08, 95 % CI 0.97-1.20, P = 0.15). Factors associated with self-reported adherence were regular employment, UPVL, no depressive symptoms, and lower pill load in the treatment regimen. Older age, education, CD4 count <200 cells/mm(3), and shorter treatment duration were associated with UPVL. Of 94 reported drug-related problems, 43 % resolved. In subgroup analyses of patients who experienced therapeutic failure and who were non-adherent at the beginning of the trial (N = 50), no differences were found in UPVL (HR 1.35, 95 % CI 0.57-3.19). Only education level (>12 years) was independently predictive of viral suppression (HR 7.47, 95 % CI 1.69-32.91). In conclusion, PC was not associated with increased self-reported adherence to ART or UPVL in patients treated at a health care facility in southern Brazil. The study suggests, however, that PC could be effective for the subgroup of patients with poor adherence.
[Show abstract][Hide abstract] ABSTRACT: Pharmaceutical care (PC) has been shown to improve adherence to therapeutic interventions as well as improve clinical outcomes. We assessed the predictors of non-adherence to clinical follow-up (i.e., not attending three scheduled routine clinical visits over a 1 year period) among patients who participated in a clinical trial of PC intervention on adherence to HIV antiretroviral therapy uptake (the PC-HIV trial). A total of 332 patients participated: median age was 39 years, 63 % were male, 76 % had CD4 count ≥200 cells/mm³, and 52 % had undetectable viral load. About half, 52.7 %, were non-adherent to clinical follow-up. Identified risk factors for non-adherence were male gender, age <40 years, and being in the trial's "control" group (adjusted odds ratio [AOR] 1.67, 95 % CI 1.05-2.66; AOR 2.21, 95 % CI 1.42-3.47; AOR 1.67, 95 % CI 1.07-2.61, respectively). Younger, male patients may benefit from interventions such as PC, which facilitates engagement in care.
[Show abstract][Hide abstract] ABSTRACT: In a quasiexperimental study conducted to evaluate the impact of a Protective Environment implementation, febrile neutropenia (P = .009), overall mortality (P = .001), and 30-day adjusted mortality (P = .02) were reduced in cancer patients with chemotherapy-induced neutropenia. Our study highlights the potential success of a set of prevention measures mainly designed to reduce invasive environmental fungal infections in allogeneic hematopoietic stem cell transplant patients, in reducing fever and mortality among neutropenic cancer patients.
American journal of infection control 10/2012; · 3.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: : To investigate the association between hypertension and musculoskeletal complaints among men and women selected by a population-based sample.
: A cross-sectional study, with participants selected using a multistage sampling procedure and interviewed at home, was conducted to investigate the association between hypertension and musculoskeletal complaints. Hypertension was defined by the average of four measurements of blood pressure (BP) at least 140/90 mmHg or use of BP-lowering drugs. Musculoskeletal complaints in the 3 months before the interview were investigated by a structured questionnaire.
: Among 1858 participants, 58% were women, 64% were 18-49 years old, and 45% had up to 8 years of education. The prevalence of musculoskeletal complaint was 33% [95% confidence interval (CI) 30-36] and of hypertension was 34% (95% CI 32-37). Men and women with hypertension had higher prevalence of musculoskeletal complaint, which was no longer significant in women after adjustment for age, educational level, skin color, BMI, physical inactivity, diabetes mellitus, alcohol consumption, smoking and history of cardiovascular disease. Hypertensive men with uncontrolled hypertension using BP agents had higher prevalence of musculoskeletal complaint (adjusted risk ratio = 1.78; 95% CI 1.11-2.86).
: Chronic musculoskeletal complaints are more frequent in men with uncontrolled hypertension under drug treatment. The absence of association in women and in hypertensive men not taking BP drugs suggest that hypertension is not a risk or protection against musculoskeletal complaints.
Journal of Hypertension 08/2012; 30(11):2112-7. · 4.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Obstructive sleep apnea (OSA), a risk factor for coronary artery disease, remains under diagnosed. We investigated if OSA identified by the Berlin Questionnaire (BQ) is associated with the risk of coronary artery disease. Cases were patients referred for elective coronariography. The cases were classified with significant coronary lesions (stenosis ≥ 50% in an epicardial coronary) or without significant coronary lesions. Controls were selected from a population-based sample. Positive BQ results were identified in 135 (41.2%) of 328 cases, in contrast with 151 (34.4%) of 439 control subjects (p = 0.03). In a multinomial logistic analysis, the risk for OSA identified by the BQ was independently associated with coronary artery disease in cases with lesions of at least 50% (OR = 1.53; 95%CI: 1.02-2.30; p = 0.04). The risk from OSA identified by the BQ was higher in younger subjects (40-59 years) (OR = 1.76; 95%CI: 1.05-2.97; p = 0.03) and in women (OR = 3.56; 95%CI: 1.64-7.72; p = 0.001). In conclusion, OSA identified by the BQ greatly increases the risks of coronary artery disease in patients having significant coronary artery lesions indicated by anangiogram, particularly in younger individuals and in women.
Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 08/2012; 28(8):1530-8. · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The prevalence of depressive disorders in HIV-infected patients ranges from 12% to 66% and is undiagnosed in 50% to 60% of these patients. Depression in HIV-infected individuals may be associated with poor antiretroviral treatment (ART) outcomes, since it may direct influence compliance.
To assess the presence of symptoms and risk factors for depression in patients on ART.
Cross-sectional study. Certified interviewers administered questionnaires and the Beck Depression Inventory (BDI), and participants' self-reported compliance to ART. Clinical and laboratory variables were obtained from clinical records. Patients with BDI > 12 were defined as depressed. RESULTS Out of the 250 patients invited to participate, 246 (98%) consented. Mean age was 41 ± 9.9 years; most were male (63%). Income ranged from 0-14 Brazilian minimum wages. AIDS (CDC stage C) had been diagnosed in 97%, and 81% were in stable immune status. One hundred ninety-one (78%) reported compliance, and 161 (68%) had undetectable viral loads. The prevalence of depressive symptoms was 32% (95% CI 26-40). In multivariate analysis, depressive symptoms were significantly associated with income (prevalence ratio [PR] = 0.85; 95% CI 0.74-0.97; p = 0.02).
Depressive symptoms are frequent in patients on ART, and are associated with low income.
Revista Brasileira de Psiquiatria 06/2012; 34(2):162-7. · 1.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: In face of variable definitions and sampling criteria, the real prevalence of resistant hypertension in a clinical setting is unknown. OBJECTIVE: We investigated the prevalence of true resistant hypertension in an outpatient hypertension clinic. METHODS: True resistant hypertension was diagnosed when white coat phenomenon, lack of compliance and secondary hypertension were excluded in patients with blood pressure ≥ 140/90 mmHg in two consecutive visits, despite to be using three blood pressure-lowering agents, including a diuretic. RESULTS: In the total, 606 patients, with 35 to 65 years of age, mostly women, with BP of 156.8 ± 23.8 mmHg by 91.9 ± 15.6 mmHg and a BMI of 29.7 ± 5.9 Kg/m² were sequentially evaluated. One hundred and six patients using three BP drugs had uncontrolled blood pressure (17.5% of the whole sample) in the first visit. Eighty-six patients (81% of the patients with uncontrolled BP in the first evaluation) returned for the confirmatory evaluation. Twenty-five had controlled BP, 21 had evidence of low adherence to treatment, 13 had white coat phenomenon and 9 had secondary hypertension, leaving only 18 patients (20.9% of those uncontrolled in the confirmatory visit and 3% of the whole sample) with true resistant hypertension. Considering patients with secondary hypertension as cases of resistant hypertension, the prevalence of resistant hypertension increased to 4.5%. CONCLUSION: The frequency of patients with true resistant hypertension in non-elderly patients is low in a clinical setting, and is not substantially increased with the inclusion of patients with secondary hypertension. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0).
Arquivos brasileiros de cardiologia 05/2012; 99(1):630-635. · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate the proportion of different genotypes in countryside microregions in southern Brazil, and their association with risk factors.
Cross-sectional study including a convenience sample of patients who tested positive for HCV-RNA and were referred to a regional health center for genotyping, from December 2003 to January 2008. Data were obtained through the National Disease Surveillance Data System, from laboratory registers and from patient charts. Identification of genotypes was carried out using the Restriction Fragment Length Polymorphism "in house" technique. Independent associations with genotypes were evaluated in multinomial logistic regression and prevalence rates of genotypes were estimated with modified Poisson regression.
The sample consisted of 441 individuals, 41.1 ± 12.0 years old, 56.5% men. Genotype 1 was observed in 41.5% (95% CI 37.9-48.1) of patients, genotype 2 in 19.3% (95% CI 15.0-23.6), and genotype 3 in 39.2% (95% CI 35.6-43.0). HCV genotype was significantly associated with gender and age. Dental procedures were associated with higher proportion of genotype 2 independently of age, education, and patient treatment center.
The hepatitis C virus genotype 1 was the most frequent. Genotype 2 was associated with female gender, age, and dental procedure exposition.
The Scientific World Journal 01/2012; 2012:946954. · 1.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Risk factors for ischemic stroke are mostly known, but it is still unclear in most countries, what are their combined population-attributable risk percent (PAR%). In a case-control study the individual odds ratios (ORs) and the individual and combined PAR%, including risk factors not addressed in previous studies were estimated.
Cases and controls were selected from patients attending to an emergency department. Cases were patients aged with 45 years or more with the first episode of ischemic stroke, characterized by a focal neurological deficit or change in the mental status occurring during the previous 24 hours. Controls, matched to cases by age and gender, were selected from patients without neurological complaints.
133 cases and 272 controls were studied. Odds ratios for ischemic stroke were: atrial fibrillation (27.3; CI 95% 7.5-99.9), left ventricular hypertrophy (20.3; CI 95% 8.8-46.4), history of hypertension (11.2; CI 95% 5.4-23.3), physical inactivity (6.6; CI 95% 3.3-13.1), low levels of HDL-cholesterol (5.0; CI 95%2.8-8.9), heavy smoking (2.8; CI 95% 1.5-5.0), carotid bruit (2.5; CI 95% 1.3-4.6), diabetes (2.4; CI 95% 1.4-4.0) and alcohol abuse (2.1; CI 95% 1.1-4.0), The combination of these risk factors accounted for 98.9% (95% CI; 96.4%-99.7%) of the PAR% for all stroke.
Nine risk factors, easily identified, explain almost 100% of the population attributable risk for ischemic stroke.
PLoS ONE 01/2012; 7(4):e35680. · 3.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: High blood pressure and lipoprotein abnormalities were identified by many cohort studies as the major risk factors for cardiovascular disease. Laboratory experiments apparently confirmed their role in the causation of atherosclerosis, but a proof of concept requires the corroboration by clinical trials in human beings. The size of benefit in clinical trials regarding the control of high blood pressure was within the estimations of risk provided by cohort studies. For a reduction of 10 mmHg in systolic blood pressure or 5 mmHg in diastolic blood pressure, the relative risk reduction of coronary heart disease was 22% (95% confidence interval 27%-17%) in a meta-analysis of clinical trials, close to the estimation of reduction of 25% (95% confidence interval 23%-27%) provided by a meta-analysis of cohort studies. The corresponding values for stroke were 41% (95% confidence interval 33%-48%) in clinical trials compared to a cohort risk prediction of 36% (95% confidence interval 34%-38%). This efficacy was shared by all blood pressure-lowering drugs. The same figure has not paradoxically happened with drugs that act over abnormalities of cholesterol and lipoproteins. Only statins, which have other beneficial actions as well, have consistently lowered the incidence of cardiovascular diseases, an efficacy that was not reproduced by older and newer quite potent lipid drugs. The adverse effects of these drugs may nullify their beneficial effects over lipoproteins and abnormalities of lipoproteins may only be surrogate markers of the underlying real risks.
Vascular Health and Risk Management 01/2012; 8:437-42.
[Show abstract][Hide abstract] ABSTRACT: The consumption of the ultra-processed food items has emerged as a concern in public health.
To assess the effect of gender, age and day of the week on consumption of ultra-processed food items among adolescents and adults from southern Brazil.
A cross-sectional study investigated a population-based sample of 234 individuals, aged 11–90 years. Dietary data was obtained by 24-h recall. The food items were aggregated according to the level of processing as minimally (group 1), culinary or industry (group 2), and ultra-processed foods (group 3). The days of the week were categorised in weekend (Saturday and Sunday), beginning (Monday and Tuesday) and middle of the week (Thursday and Friday). The analysis was based on Generalised Estimated Equation (GEE).
Women consumed food items on average of 2.71 and men 3.22 times per day (p=0.007). The positive effect of age was observed for all processed foods. The number of food items of group 1 consumed for adolescents was 60% lower than for older individuals. On the other hand, adolescents consumed 40% more ultra-processed foods than older adults (p<0.001). Food items of group 3 were more consumed in the middle of the week (4.86 times per day; p=0.040) and by adolescents.
The results show that ultra-processed foods consumed on weekends and by adolescents were an important problem of public health.
World Congress of Epidemiology, Edinburgh; 01/2011
[Show abstract][Hide abstract] ABSTRACT: Introduction The consumption of the ultra-processed food has been associated with a growing prevalence of chronic diseases.
Objective To assess the effect of processed food consumption on systolic (SBP) and diastolic (DBP) blood pressure among hypertensive patients.
Methods This cross-sectional study enrolled 125 patients, aged 30–80 years, followed-up on the outpatient Hypertension Clinic from a reference Center (Hospital de Clínicas de Porto Alegre), in southern Brazil. Food intake was assessed by 24-h dietary recall administered four times one week apart. Food items were aggregated by the types of processing into unprocessed (group 1), culinary foods (group 2), and ultra-processed foods (group 3). The intake was calculated by the number of items per group consumed daily and categorised in quartiles. Generalised Estimated Equation (GEE) was adopted in the analysis.
Results The consumption amount of unprocessed and culinary food was not associated with blood pressure. Among ultra-processed foods, the comparison between patients in the first and the forth quartile showed a difference of 15.8±4.0 mm Hg in SBP (p<0.01) and 6.3±2.3 in DBP (p=0.02), controlled for age, gender and the consumption of both unprocessed and culinary food. No difference was observed for the 2nd and 3rd quartiles vs de 1st one.
Conclusion The ultra-processed foods consumption can affect SBP and DBP of hypertensive individuals.
World Congress of Epidemiology, Edimburgh; 01/2011
[Show abstract][Hide abstract] ABSTRACT: Dietary guidelines for hypertensive patients require methods able to identify food patterns and monitoring adherence, which could be based on a simplified Food Frequency Questionnaire (FFQ) for food groups.
To develop a FFQ for food groups in order to easily recommend the DASH (Dietary Approach to Stop Hypertension) diet for hypertensive patients.
A cross-sectional study was conducted among adults, aged 20 to 69 years, from a Hypertension clinic of a reference centre (Hospital de Clínicas de Porto Alegre), in southern Brazil. Data gathering using two sequential 24 h recalls (RA 24 h) were adopted to assess dietary intake. A list of food groups was generated, based on the DASH diet adapted to the southern Brazil population. A pilot study, including 30 individuals, was conducted to test the FFQ structure, consumption of food groups, two periods of recall, and pictures and wording for food items identification.
A sample of 127 hypertensive patients were interviewed at seven and 30 days, using a qualitative FFQ with 40 items aggregated into eight food groups, based on the DASH diet. The pictures of food items were useful to remind patients of the components of food groups. As a result, FFQ was quickly applied, in approximately 20 and 16 min for FFQ at 30 and for 7 days, respectively.
This first step allowed detecting that the FFQ for food groups was feasible at seven and 30 days, and no major issues were detected during the testing.
World Congress of Epidemiology, Edinburgh; 01/2011
[Show abstract][Hide abstract] ABSTRACT: This study assessed the validity of a food frequency questionnaire (FFQ-Porto Alegre), covering 135 food items, in comparison with the average of two consecutive 24-hour dietary recall questionnaires for adolescents, adults, and elderly who were randomly selected from a population-based survey. The Pearson correlation coefficients and cross-classification by quartiles of intake were used. The nutrients were log transformed and energy adjusted. The mean of adjusted de-attenuated correlation coefficient for adolescents was 0.44 and ranged from 0.18 (zinc) to 0.69 (folate) and for adult and elderly participants they were, respectively, 0.42, ranging from 0.16 (iron) to 0.73 (energy) and 0.52, ranging from 0.25 (vitamin E) to 0.84 (energy). The average classification percentage into the same or adjacent quartile for the two methods was 74.6% for adolescents, 74.9% for adults, and 81.2% for the elderly population. The FFQ showed fair relative validity for adolescents and adults, and may be used to study the dietary determinants of obesity and non-transmissible diseases in epidemiological surveys.
Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 11/2010; 26(11):2068-79. · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The benefit of liver transplantation relative to initial degree of underlying liver disease and time on the waiting list remains poorly defined. We sought to examine the survival benefit attributable to liver transplantation across a wide range of Model for End-Stage Liver Disease (MELD) scores.
The study population included patients with end-stage liver disease enlisted in Rio Grande do Sul, Brazil, between 2001 and 2005. Survival and hazard function for enlisted and transplanted patients were estimated using parametric and nonparametric methods. MELD score was utilized to account for underlying liver disease.
Of 1,130 eligible patients, 520 (46.0%) were transplanted, 266 (23.5%) died on the waiting list, 141 (12.5%) were excluded from the waiting list, and 203 (18.0%) remained enlisted and were awaiting transplantation at the time of last observation. At 1 year after transplantation, a MELD score of 15 represented a transition point in terms of overall survival benefit (MELD 10, 90% vs 83%; MELD 15, 81% vs 80%; MELD 20, 63% vs 78%; MELD 25, 42% vs 74%; MELD 30, 21% vs71%; enlisted vs transplant patients, respectively). MELD scores at which transplantation seemed to be beneficial relative to the amount of follow-up time was MELD 23, 17, 15, and 12 at 6 months, and 1, 2, and 5 years, respectively, from time of transplantation/enlistment.
Although patients with greater MELD scores enjoy a pronounced and early benefit from transplantation, patients with lesser MELD scores do gain from transplantation, although a greater period of time is needed to realize the survival benefit.
Surgery 12/2009; 147(3):392-404. · 3.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions.
This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm.
Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH.
The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU
European Journal of Clinical Pharmacology 09/2009; 65(12):1253-8. · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The use of portable respiratory monitoring (PM) has been proposed for the diagnosis of obstructive sleep apnea syndrome (OSAS), but most studies that validate PM accuracy have not followed the best standards for diagnostic test validation. The objective of the present study was to evaluate the accuracy of PM performed at home to diagnose OSAS and its outcomes after first validating PM in the laboratory setting by comparing it to polysomnography (PSG).
Patients with suspected OSAS were submitted, in random order, to PM at the sleep laboratory concurrently with PSG (lab-PM) or at home-PM. The diagnostic performance was assessed by sensitivity, specificity, positive and negative predictive values, positive likelihood ratio (+LR), negative likelihood ratio (-LR), intraclass correlation coefficients, kappa statistic, and Bland-Altman plot.
One hundred fifty-seven subjects (73% men, mean age +/- SD, 45 +/- 12 yr) with an apnea-hypopnea index (AHI) of 31 (SD +/- 29) events/h were studied. Excluding inadequate recordings, 149 valid comparisons with lab-PM and 121 with unattended home-PM were obtained. Compared to PSG for detecting AHI > 5, the lab-PM demonstrated sensitivity of 95.3%, specificity of 75%, +LR of 3.8, and -LR of 0.11; the home-PM exhibited sensitivity of 96%, specificity of 64%, +LR of 2.7, and -LR of 0.05. Kappa statistics indicated substantial correlation between PSG and PM results. Bland-Altman plot showed smaller dispersion for lab-PM than for home-PM. Pearson product moment correlation coefficients among the three AHIs and clinical outcomes were similar, denoting comparable diagnostic ability.
This study used all available comparison methods to demonstrate accuracy of PM in-home recordings similar to that of repeated PSGs. PM increases the possibility of correctly diagnosing and effectively treating OSAS in populations worldwide.