Effects of land cover and air pollution on the risk of preterm births / Efeitos da cobertura de solo e poluição do ar no risco de nascimentos prematuros

ABSTRACT OBJECTIVE To evaluate the association between gestational age and green areas, urban built areas, and the concentration of particulate matter 2.5 (PM2.5) in the city of São Paulo, analyzing the irregular distribution of these areas and pollution levels above the recommended level. METHODS The study population consisted of a cohort of live births from 2012, and data from the Live Birth Information System (Sinasc) of the city of São Paulo were used. Using satellite images and supervised classification, the distribution and quantity of green areas and built areas in the city of São Paulo was obtained, as well as the concentrations of PM2.5. Logistic regressions were used to obtain possible associations. RESULTS The results of the study show that a lower percentage of green areas is significantly associated with a higher chance of preterm births. A higher building density was positively associated with the odds ratio for preterm birth. We did not find any significant associations between air pollution (PM2.5) and preterm births. CONCLUSIONS The results of this study show that greener areas are less associated with preterm births when compared with less green areas.

RESUMO OBJETIVO Avaliar a associação entre a idade gestacional e as áreas verdes, áreas construídas urbanas e a concentração de material particulado 2,5 (MP2,5) em São Paulo, analisando a distribuição irregular dessas áreas e os níveis de poluição acima do recomendado. MÉTODOS A população utilizada no estudo foi a dos nascidos vivos no ano de 2012, com os dados do Sistema de Informações sobre Nascidos Vivo (Sinasc) na cidade de São Paulo. Por meio de imagens de satélites e realizando a classificação supervisionada, obtivemos a distribuição e quantidade de áreas verdes e de áreas construídas, na cidade de São Paulo, assim como as concentrações de MP2,5. Regressões logísticas foram utilizadas para obter possíveis associações. RESULTADOS Os resultados do estudo mostram que menor percentual de áreas verdes está associado significativamente com maior chance de prematuridade. Maior densidade de construção foi associada positivamente com a razão de chance de nascimento prematuro. Não encontramos resultados significativos entre a poluição do ar (MP2,5) e prematuridade. CONCLUSÕES Os resultados deste estudo demostraram que áreas mais verdes em relação às áreas menos verdes são menos associadas a nascimentos prematuros.

What else in times of COVID-19? The role of minimally invasive autopsy for the differential diagnosis of acute respiratory failure in a case of kala-azar

ABSTRACT Visceral leishmaniasis (VL) is a chronic vector-borne zoonotic disease caused by trypanosomatids, considered endemic in 98 countries, mainly associated with poverty. About 50,000-90,000 cases of VL occur annually worldwide, and Brazil has the second largest number of cases in the world. The clinical picture of VL is fever, hepatosplenomegaly, and pancytopenia, progressing to death in 90% of cases due to secondary infections and multi-organ failure, if left untreated. We describe the case of a 25-year-old female who lived in the metropolitan area of Sao Paulo, who had recently taken touristic trips to several rural areas in Southeastern Brazil and was diagnosed post-mortem. During the hospitalization in a hospital reference for the treatment of COVID-19, the patient developed acute respiratory failure, with chest radiographic changes, and died due to refractory shock. The ultrasound-guided minimally invasive autopsy diagnosed VL (macrophages containing amastigote forms of Leishmania in the spleen, liver and bone marrow), as well as pneumonia and bloodstream infection by gram-negative bacilli.

Linha do tempo do "tratamento precoce" para Covid-19 no Brasil: desinformação e comunicação do Ministério da Saúde / Timeline of Covid-19 "early treatment" in Brazil: disinformation and communications from the Ministry of Health / Línea del tiempo del "tratamiento precoz" para Covid-19 en Brasil: desinformación y comunicación del Ministerio de la Salud

Em fevereiro de 2020, a Organização Mundial da Saúde alertou sobre a gravidade da epidemia de Covid-19 e enfatizou que as iniciativas relacionadas ao seu combate têm sido acompanhadas por uma infodemia. O Ministério da Saúde do Brasil publicou diretrizes em relação ao manejo da doença com o "tratamento precoce". O objetivo deste artigo foi construir uma linha do tempo visual de janeiro de 2020 até abril de 2021 por meio de pesquisa bibliográfica, documental e análise de conteúdo. Sistematizaram-se as principais notícias veiculadas no website do Ministério da Saúde sobre o "tratamento precoce", as evidências científicas sobre os medicamentos relacionados a este e os dados das mortes e fatos relacionados à doença que aconteceram no Brasil. A linha do tempo evidencia a insistência da promoção do "tratamento precoce", no contexto da desinfodemia, pelo Ministério da Saúde na existência de evidências contrárias a essa intervenção.(AU)

In February 2020, the World Health Organisation warned about the gravity of the Covid-19 epidemic, emphasizing that initiatives to combat the problem had been accompanied by an "infodemic". Brazil's ministry of health published guidelines on the management of the disease using "early treatment". The aim of this study was to create a visual timeline from January 2020 to April 2021 based on the review of relevant literature and documents examined using document analysis. We synthesized the main items of news on early treatment published on the Ministry of Health website, scientific evidence on the medications used, and facts related to the disease in Brazil. The timeline evidenced the insistent promotion of early treatment by the Ministry of Health within the context of a "disinfodemic" despite the existence of evidence against this type of intervention.(AU)

En febrero de 2020, la Organización Mundial de la Salud alertó sobre la gravedad de la epidemia de Covid-19 y enfatizó que las iniciativas relacionadas con su combate habían sido acompañadas por una infodemia. El Ministerio de la Salud de Brasil publicó directrices con relación al manejo de la enfermedad con el "tratamiento precoz". El objetivo de este artículo fue construir una línea del tiempo visual desde enero de 2020 hasta abril de 2021 por medio de una investigación bibliográfica, documental y análisis de contenido. Se sistematizaron las principales noticias publicadas en la página web del Ministerio de la Salud sobre el "tratamiento precoz", las evidencias científicas sobre estos medicamentos y los datos de las muertes y hechos relacionados a la enfermedad en Brasil. La línea de tiempo dejará clara la insistencia de la promoción del "tratamiento precoz", en el contexto de la desinfodemia, por parte del Ministerio de la Salud con la existencia de evidencias contrarias a esta intervención.(AU)

Extended minimally invasive autopsy: Technical improvements for the investigation of cardiopulmonary events in COVID-19

OBJECTIVES: Ultrasound-guided minimally invasive autopsies (MIA-US) are an alternative to conventional autopsies and have been used in our institution to investigate the pathophysiology of COVID-19 since the beginning of the pandemic. Owing to the limitations of post-mortem biopsies for evaluating cardiopulmonary events involving large vessels, we continuously improved the technique during this period. Objectives: To demonstrate the usefulness of an extended MIA-US technique (EMIA-US) for the study of thoracic involvement in COVID-19. METHOD: US-guided percutaneous tissue sampling was combined with a small thoracic incision (≤5 cm), allowing for the sampling of larger tissue samples or even the entire organ (lungs and heart). RESULTS: EMIA-US was performed for eight patients who died of COVID-19 in 2021. We demonstrate cardiopulmonary events, mainly thromboembolism and myocardial infarction, that could be evaluated using EMIA-US. CONCLUSIONS: Minimally invasive image-guided post-mortem tissue sampling is a flexible and practical method to conduct post-mortem studies of human diseases, mainly in areas that do not have autopsy facilities or, alternatively, when autopsy is not possible owing to financial constraints, cultural and religious values, or for safety reasons, such as in the case of highly contagious infectious diseases. We present evidence that EMIA-US is feasible and can be used as an alternative to increase the accuracy of MIA-US in detecting cardiopulmonary events involving large vessels, which may not be assessed through post-mortem biopsies.

Salivary glands are a target for SARS-CoV-2: a source for salivacontamination

The ability of the new coronavirus SARS-CoV-2 to spread and contaminate is one of the determinants of the COVID-19 pandemic status. SARS-CoV-2 has been detected in saliva consistently, with similar sensitivity to that observed innasopharyngeal swabs. We conducted ultrasound-guided postmortem biopsies in COVID-19 fatal cases. Samples ofsalivary glands (SGs; parotid, submandibular, and minor) were obtained. We analyzed samples using RT-qPCR, immu-nohistochemistry, electron microscopy, and histopathological analysis to identify SARS-CoV-2 and elucidate qual-itative and quantitative viral proles in salivary glands. The study included 13 female and 11 male patients, with amean age of 53.12 years (range 8­83 years). RT-qPCR for SARS-CoV-2 was positive in 30 SG samples from18 patients (60% of total SG samples and 75% of all cases). Ultrastructural analyses showed spherical 70­100 nm viral particles, consistent in size and shape with the Coronaviridae family, in the ductal lining cell cytoplasm,acinar cells, and ductal lumen of SGs. There was also degeneration of organelles in infected cells and the presence of acluster of nucleocapsids, which suggests viral replication in SG cells. Qualitative histopathological analysis showedmorphologic alterations in the duct lining epithelium characterized by cytoplasmic and nuclear vacuolization, as wellas nuclear pleomorphism. Acinar cells showed degenerative changes of the zymogen granules and enlarged nuclei.Ductal epithelium and serous acinar cells showed intense expression of ACE2 and TMPRSS receptors. An anti-SARS-CoV-2 antibody was positive in 8 (53%) of the 15 tested cases in duct lining epithelial cells and acinar cellsof major SGs. Only two minor salivary glands were positive for SARS-CoV-2 by immunohistochemistry. Salivaryglands are a reservoir for SARS-CoV-2 and provide a pathophysiological background for studies that indicate theuse of saliva as a diagnostic method for COVID-19 and highlight this biological uid's role in spreading the disease.© 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

An autopsy study of the spectrum of severe COVID-19 in children: From SARS to different phenotypes of MIS-C

Background: COVID-19 in children is usually mild or asymptomatic, but severe and fatal paediatric cases have been described. The pathology of COVID-19 in children is not known; the proposed pathogenesis for severe cases includes immune-mediated mechanisms or the direct effect of SARS-CoV-2 on tissues. We describe the autopsy findings in five cases of paediatric COVID-19 and provide mechanistic insight into the mechanisms involved in the pathogenesis of the disease. Methods: Children and adolescents who died with COVID-19 between March 18 and August 15, 2020 were autopsied with a minimally invasive method. Tissue samples from all vital organs were analysed by histology, electron microscopy (EM), reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry (IHC). Findings: Five patients were included, one male and four female, aged 7 months to 15 years. Two patients had severe diseases before SARS-CoV-2 infection: adrenal carcinoma and Edwards syndrome. Three patients were previously healthy and had multisystem inflammatory syndrome in children (MIS-C) with distinct clinical presentations: myocarditis, colitis, and acute encephalopathy with status epilepticus. Autopsy findings varied amongst patients and included mild to severe COVID-19 pneumonia, pulmonary microthrombosis, cerebral oedema with reactive gliosis, myocarditis, intestinal inflammation, and haemophagocytosis. SARSCoV- 2 was detected in all patients in lungs, heart and kidneys by at least one method (RT-PCR, IHC or EM), and in endothelial cells from heart and brain in two patients with MIS-C (IHC). In addition, we show for the first time the presence of SARS-CoV-2 in the brain tissue of a child with MIS-C with acute encephalopathy, and in the intestinal tissue of a child with acute colitis. Interpretation: SARS-CoV-2 can infect several cell and tissue types in paediatric patients, and the target organ for the...(AU)

Development and evaluation of physical properties of a low-cost handheld device for airway clearance therapy / Desenvolvimento e avaliação das propriedades físicas de um dispositivo portátil de baixo custo para higiene brônquica / Desarrollo y evaluación de propiedades físicas de un dispositivo portátil de bajo costo para la higiene bronquial

ABSTRACT Several respiratory diseases are characterized by hypersecretion, requiring airway clearance therapy (ACT). Oral high-frequency oscillation (OHFO) devices are effective to enable daily ACT; however, they are still too expensive to become available for low-income patients. We sought to develop a low-cost device (OHFO-LC) and compare its physical properties with those OHFO commercially available (Shaker and Flutter). The OHFO-LC was developed from polyvinyl chloride material and one stainless steel sphere. Pressures and frequencies were measured at flows of 4, 6, 8, 10 and 15L/min. Pressures at the mouthpieces were measured by a transducer connected to a microcomputer. The oscillation frequencies were obtained from the graph of the pressure. The frequencies and pressures were compared among groups using one-way Anova and Tukey's post hoc tests, p≤0.05. There were no differences among the frequencies of the three devices in all tested flows. The OHFO-LC device showed a higher positive expiratory pressure compared with the Shaker at all tested flows (4 L/min: 4.7±1.2 vs. 1.0±0.2 cmH2O; 6 L/min: 8.6±1.5 vs. 3.5±0.5 cmH2O; 8 L/min: 10.8±1.6 vs. 5.4±0.2 cmH2O; 10 L/min: 13.5±1.2 vs. 7.7±0.4 cmH2O; 15 L/min: 14.3±1.1 vs. 7.8±0.2 cmH2O; OHFO-LC vs. Shaker; p≤0.05) and at 10 and 15 L/min compared with Flutter (10 L/min: 13.5±1.2 vs. 7.5±1.2 cmH2O; 15 L/min: 14.3±1.1 vs. 8.2±1.2 cmH2O; OHFO-LC vs. Flutter, p≤0.05). The cost of the OHFO-LC device was much lower than both the Shaker and the Flutter. Our results showed that the OHFO-LC had physical properties with similar frequencies but higher pressures than other OHFO devices that are commercially available. Future studies are necessary to evaluate its clinical efficacy.

RESUMO Diversas doenças respiratórias são caracterizadas por hipersecreção com necessidade de higiene brônquica (HB). Osciladores orais de alta frequência (OOAF) são dispositivos que promovem HB diária; entretanto, seu custo pode ser inviável para aquisição por pacientes com baixa renda. Os objetivos deste estudo foram: desenvolver um OOAF de baixo custo (OOAF-BC) e comparar suas propriedades físicas com as dos disponíveis comercialmente (Shaker e Flutter). O OOAF-BC foi desenvolvido com material de polivinil clorido e uma esfera de aço inoxidável. As pressões e frequências foram mensuradas nos fluxos de 4, 6, 8, 10 e 15 L/min. As pressões nos bocais foram medidas por um transdutor conectado ao computador. As frequências de oscilação foram derivadas do gráfico de pressão. A comparação dos dispositivos foi feita por Anova com post hoc de Tukey, p≤0.05. Não houve diferença entre as frequências dos três dispositivos em todos os fluxos testados. O OOAF-BC apresentou pressão mais alta comparado ao Shaker em todos os fluxos testados (4 L/min: 4,7±1,2 vs. 1,0±0,2 cmH2O; 6 L/min: 8,6±1,5 vs. 3,5±0,5 cmH2O; 8 L/min: 10,8±1,6 vs. 5,4±0.2 cmH2O; 10 L/min: 13,5±1,2 vs. 7,7±0.4 cmH2O; 15 L/min: 14,3±1,1 vs. 7,8±0,2 cmH2O; OOAF-BC vs. Shaker; p≤0.05) e nos fluxos de 10 e 15 L/min comparado ao Flutter (10 L/min: 13,5±1,2 vs. 7,5±1,2 cmH2O; 15 L/min: 14,3±1,1 vs. 8,2±1,2 cmH2O; OOAF-BC vs. Flutter, p≤0.05). O custo do OOAF-BC foi pelo menos seis vezes menor. O OOAF-BC apresentou frequências similares e pressões mais altas que os outros OOAF comercialmente disponíveis. Estudos futuros são necessários para avaliar sua eficácia clínica.

RESUMEN Varias enfermedades respiratorias se caracterizan por hipersecreción, que requiere higiene bronquial (HB). Los osciladores orales de alta frecuencia (OOAF) son dispositivos que promueven la HB diaria; sin embargo, su costo puede no ser factible para la adquisición por parte de pacientes con bajos ingresos. Los objetivos de este estudio fueron desarrollar un OOAF de bajo costo (OOAF-BC) y comparar sus propiedades físicas con las de los disponibles comercialmente (Shaker y Flutter). El OOAF-BC se desarrolló con material de polivinilo clorado y una bola de acero inoxidable. Las presiones y frecuencias se midieron en flujos de 4, 6, 8, 10 y 15 L/min. Las presiones de la boquilla se midieron mediante un transductor conectado a la computadora. Las frecuencias de oscilación se derivaron del gráfico de presión. Se compararon los dispositivos con la utilización de Anova con post hoc de Tukey, p≤0,05. No hubo diferencias entre las frecuencias de los tres dispositivos en todos los flujos probados. El OOAF-BC mostró una presión más alta en comparación con Shaker en todos los flujos probados (4 L/min: 4,7±1,2 vs. 1,0±0,2 cmH2O; 6 L/min: 8,6±1,5 vs. 3,5±0,5 cmH2O; 8 L/min: 10,8±1,6 vs. 5,4±0,2 cmH2O; 10 L/min: 13,5±1,2 vs. 7,7±0,4 cmH2O; 15 L/min: 14,3±1,1 vs. 7,8±0,2 cmH2O; OOAF-BC vs. Shaker; p≤0,05) y con flujos de 10 y 15 L/min en comparación con Flutter (10 L/min: 13,5±1,2 vs. 7,5±1,2 cmH2O; 15 L/min: 14,3±1,1 vs. 8,2±1,2 cmH2O; OOAF-BC vs. Flutter, p≤0,05). El costo de OOAF-BC fue al menos seis veces menor. El OOAF-BC mostró frecuencias similares y presiones más altas que otros OOAF disponibles comercialmente. Se necesitan estudios futuros para evaluar su eficacia clínica.

Gastos públicos com saúde: breve histórico, situação atual e perspectivas futuras / Public expenditure on health: brief history, current situation and future prospects

Apesar dos marcantes avanços de nosso sistema de saúde pública, hoje sintetizado em apenas três letras - SUS -, há ainda um grande caminho a percorrer para prover as condições de preservar a saúde da população do nosso Brasil. Neste texto abordamos de maneira despretensiosa conquistas e programas exitosos do SUS, mazelas do financiamento e má gestão, os desafios futuros e princípios que devem nortear as ações para alcançarmos um patamar mais eficiente de atenção à Saúde.(AU)

Despite the remarkable progress of the Brazilian public health system, nowadays better known by the acronym SUS (Sistema Único de Saúde), there is still a long way to go to ensure conditions to preserve the health of the Brazilian population. In this text, we unassumingly report the achievements and successful programs of SUS, the problems of financing and mismanagement, and the future challenges and principles that should guide actions to achieve more efficient health care in Brazil.(AU)

Longitudinal study of lung function in pregnant women: Influence of parity and smoking

OBJECTIVES: To evaluate pulmonary function in the first and third trimesters of pregnancy and analyze the influence of parity and smoking on spirometry parameters. METHODS: This longitudinal prospective study included a cohort of 120 pregnant women. The inclusion criteria were as follows: singleton pregnancy, gestational age less than 13.86 weeks, and no preexisting maternal diseases. The exclusion criteria were as follows: change of address, abortion, and inadequate spirometry testing. ClinicalTrials.gov: NCT02807038. RESULTS: A decrease in values of forced vital capacity and forced expiratory volume were noted in the first second from the first to third trimester. In the first and third trimesters, multiparous women demonstrated lower absolute forced vital capacity and forced expiratory volume values in the first second compared with nulliparous women (p<0.0001 and p=0.001, respectively). Multiparous women demonstrated reduced forced expiratory flow in 25% to 75% of the maneuver compared with nulliparous women in the first (p=0.005) and third (p=0.031) trimesters. The absolute values of forced expiratory flow in 25% to 75%, forced expiratory volume in the first second and predicted peak expiratory flow values in the third trimester were higher in smokers compared with nonsmokers (p=0.042, p=0.039, p=0.024, and p=0.021, respectively). CONCLUSION: There was a significant reduction in forced vital capacity and forced expiratory volume values in the first second during pregnancy. Parity and smoking significantly influence spirometric variables.

The effects of smoking and smoking cessation on nasal mucociliary clearance, mucus properties and inflammation

OBJECTIVE: The aim of the present study was to assess nasal mucociliary clearance, mucus properties and inflammation in smokers and subjects enrolled in a Smoking Cessation Program (referred to as quitters). METHOD: A total of 33 subjects with a median (IQR) smoking history of 34 (20-58) pack years were examined for nasal mucociliary clearance using a saccharine transit test, mucus properties using contact angle and sneeze clearability tests, and quantification of inflammatory and epithelial cells, IL-6 and IL-8 concentrations in nasal lavage fluid. Twenty quitters (mean age: 51 years, 9 male) were assessed at baseline, 1 month, 3 months and 12 months after smoking cessation, and 13 smokers (mean age: 52 years, 6 male) were assessed at baseline and after 12 months. Clinicaltrials.gov: NCT02136550. RESULTS: Smokers and quitters showed similar demographic characteristics and morbidities. At baseline, all subjects showed impaired nasal mucociliary clearance (mean 17.6 min), although 63% and 85% of the quitters demonstrated significant nasal mucociliary clearance improvement at 1 month and 12 months, respectively. At 12 months, quitters also showed mucus sneeze clearability improvement (∼26%), an increased number of macrophages (2-fold) and no changes in mucus contact angle or cytokine concentrations. CONCLUSION: This study showed that smoking cessation induced early improvements in nasal mucociliary clearance independent of mucus properties and inflammation. Changes in mucus properties were observed after only 12 months of smoking cessation.

Como as cidades podem favorecer ou dificultar a promoção da saúde de seus moradores? / How cities can promote or hinder the promotion of health of its residents?

Morar próximo a um parque pode reduzir o risco de infarto do miocárdio, enquanto a exposição à poluição do ar ambiente aumenta o risco. Evidências associam a exposição crônica ao ruído do tráfego ao ganho de peso. Em 2014, mais de mil pessoas morreram no trânsito de São Paulo. No entanto, recomendar que as pessoas fiquem em casa com as janelas fechadas é inviável. A adoção de hábitos saudáveis é favorecida ou dificultada pelo ambiente construído e pelo modo como a cidade está organizada. Além disso, alguns fatores de risco para doenças, como a exposição à poluição do ar, vão além de escolhas individuais e dependem, em grande parte, de ações governamentais. Neste artigo discutimos os aspectos que podem favorecer ou dificultar a promoção da saúde nas cidades, a partir dos tópicos propostos por Rydin et al. (2012)...

Living near a park can reduce the risk for myocardial infarction, while exposure to outdoor air pollution increases it. There is evidence associating chronic exposure to traffic noise and weight gain. In 2014, more than one thousand people died in the São Paulo’s traffic. However, recommending that people stay home with the windows closed is unfeasible. The adoption of healthy habits is aided or hindered by the man-made environment and by how the city is organized. Moreover, some risk factors for disease, such as exposure to air pollution, are beyond individual choices and call for governmental actions. In this paper, we discuss features that may aid or hinder the promotion of health in the city, based on a framework proposed by Rydin et al. (2012)...

Projeção da mortalidade e internações hospitalares na rede pública de saúde atribuíveis à poluição atmosférica no Estado de São Paulo entre 2012 e 2030 / Forecasting of mortality and hospital admissions from public healthcare attributable to air pollution in State of São Paulo between 2011 and 2030 / /Proyección de la mortalidad y las admisiones hospitalarias en la red pública de salud atribuibles a la contaminación atmosférica en el Estado de São Paulo entre 2011 y 2030

No Brasil, os padrões nacionais de qualidade do ar são da década de 1990, desatualizados em relação aos internacionais, o que dificulta um controle eficaz dos níveis de poluição e contribui para a continuidade de mortes e internações. A fim de quantificar o montante de desfechos desfavoráveis de saúde em decorrência da concentração de material particulado no Estado de São Paulo, esse trabalho tem como objetivo realizar projeções de mortes, internações e gastos com internações públicas atribuíveis à poluição atmosférica, para o período de 2012 a 2030. Para isso foram considerados distintos cenários de poluição por material particulado fino (MP2,5), tomando-se como referência o ano-base 2011. Os resultados mostram que, mantendo o mesmo nível de poluição observado em 2011, haverá um total de mais de 246 mil óbitos por todas as causas entre 2012 e 2030, cerca de 953 mil internações hospitalares públicas e um gasto público estimado em internações de mais de R$ 1,6 bilhão. A magnitude dos resultados aponta para a necessidade de implementação de medidas mais rigorosas para o controle da poluição do ar, formas alternativas de energia limpa de transporte, entre outras ações, como forma de reduzir os danos à saúde da população e os gastos governamentais...

Abstract National air quality standards in Brazil were established in the 1990s and are now outdated in relation to international patterns. This creates a challenge for effective control of air pollution levels and contributes to increasing mortality and hospital admissions rates. In order to quantify the impact of adverse health outcomes due to the concentration of particulate matter in São Paulo, this paper aims to project the number of deaths, hospitalizations and amounts spent on public hospital admissions from 2012 to 2030. It considers distinct scenarios of air pollution by fine particulate matter (PM2.5), using the year 2011 as baseline. The results show that if air pollution continues at the current levels, it will cause more than 246 thousand deaths from all causes between 2011 and 2030, as well as some 953 thousand hospital admissions and an estimated public health cost of R$ 1.6 billion due to hospitalizations. The magnitude of these results demonstrates the need to implement more rigorous measures to control air pollution and to encourage clean energy transportation, among other public actions, in order to reduce damage to the health of the population and to diminish government spending...

Resumen En Brasil, los estándares nacionales de calidad del aire datan de la década de 1990, es decir, están obsoletos en comparación con las normas internacionales, lo que dificulta un control eficaz de los niveles de contaminación y contribuye a la continuidad de las muertes y hospitalizaciones ocasionadas por esta razón. Con el fin de cuantificar el total de los resultados adversos para la salud debidas a la concentración de material particulado en el Estado de São Paulo, este trabajo tiene como objetivo realizar proyecciones de muertes, hospitalizaciones y gastos por internaciones en hospitales públicos atribuibles a la polución atmosférica en el período comprendido entre 2012 y 2030. Para ello se han considerado distintos escenarios de contaminación por material particulado fino (MP2,5), tomando como referencia el año base 2011. Los resultados muestran que, manteniendo el mismo nivel de contaminación observado en esa fecha, habrá un total de más de 246.000 muertes por todas las causas entre 2011 y 2030, alrededor de 953.000 ingresos hospitalarios en el sistema público de salud y un gasto público por internaciones estimado en más de R$ 1,6 billones. La magnitud de los resultados pone en evidencia la necesidad de implementar medidas más rigurosas para el control de la contaminación del aire, formas alternativas de transporte con energía limpia, entre otras acciones, con el fin de reducir los daños a la salud de la población y los gastos del gobierno...

Air pollution and children's health: sickle cell disease / Poluição do ar e a saúde das crianças: a doença falciforme / Contaminación atmosférica y salud de los niños: la enfermedad de células falciformes

The hallmarks of sickle cell disease are anemia and vasculopathy. The aim of this study was to assess the association between air pollution and children's emergency room visits of sickle cell patients. We adopted a case-crossover design. Daily counts of children's and adolescents' sickle cell disease emergency room visits from the pediatric emergency unit in São Paulo, Brazil, were evaluated from September 1999 to December 2004, matching by temperature, humidity and controlling for day of the week. Interquartile range increases of the four-day moving averages of PM10, NO2, SO2, CO, and O3 were associated with increases of 18.9% (95%CI: 11.2-26.5), 19% (95%CI: 8.3-29.6), 14.4% (95%CI: 6.5-22.4), 16,5% (95%CI: 8.9-24.0), and 9.8% (95%CI: 1.1-18.6) in total sickle cell emergency room visits, respectively. When the analyses were stratified by pain, PM10 was found to be 40.3% higher than in sickle cell patients without pain symptoms. Exposure to air pollution can affect the cardiovascular health of children and may promote a significant health burden in a sensitive group.

O objetivo deste estudo foi avaliar a associação entre a poluição do ar e atendimentos de emergência pediátrica de pacientes portadores de anemia falciforme. Adotamos um estudo de case-crossover. Visitas de crianças e adolescentes portadores de anemia falciforme ao pronto-socorro pediátrico, em São Paulo, Brasil, foram avaliadas a partir de setembro de 1999 até dezembro de 2004, controlando a temperatura, umidade e dia da semana. Variações interquartis das médias móveis de quatro dias de PM10, NO2, SO2, CO e O3 foram associadas com aumentos de 18,9% (IC95%: 11,2-26,5), 19% (IC95%: 8,3-29,6), 14,4% (IC95%: 6,5-22,4), 16,5% (IC95%: 8,9-24,0) e 9,8% (IC95%: 1,1-18,6) nos atendimentos totais, respectivamente. Quando as análises foram estratificadas por dor, verificou-se que PM10 apresentou correlação 40,3% maior do que a observada em pacientes falciformes sem sintomas de dor. A exposição à poluição do ar pode afetar a saúde cardiovascular de crianças e promover um fardo significativo para a saúde em um grupo suscetível, como o de pacientes com anemia falciforme.

El objetivo de este estudio fue evaluar la asociación entre la contaminación atmosférica y las visitas de emergencia de los pacientes pediátricos con anemia de células falciformes. Hemos adoptado un estudio de casos cruzados. Visitas de niños y adolescentes con anemia de células falciformes en urgencias pediátricas, en São Paulo, Brasil, se evaluaron entre 1999 y 2004 con un control de la temperatura, humedad y día de la semana. El rango intercuartil de los promedios móviles de 4 días de PM10, NO2, SO2, CO y O3 se asociaron con un aumento del 18,9% (IC95%: 11,2-26,5), 19,0% (IC95%: 8,3-29,6), 14,4% (IC95%: 6,5-22,4), 16,5% (IC95%: 8,9-24,0), y 9,8% (IC95%: 1,1-18,6) en el total de visitas, respectivamente. Cuando los análisis se estratificaron por el dolor, se encontró que el PM10 mostró una correlación un 40,3% mayor que la observada en pacientes sin síntomas de dolor. La exposición a la contaminación del aire puede afectar la salud cardiovascular de los niños y puede promover una importante carga para la salud en pacientes con anemia de células falciformes.

Nova contribuição ao estudo do remodelamento ventricular e dos anéis valvares na cardiomiopatia dilatada: avaliação anátomo-histopatológica / New contribution to the study of ventricular remodeling and valve rings in dilated cardiomyopathy: anatomical and histological evaluation

Introdução: A cardiomiopatia dilatada idiopática (CMDId) é causadora de grande impacto, porém aspectos de sua fisiopatologia são desconhecidos. Objetivo: Avaliar aspectos anatomo-histológicos de corações com CMDId comparando-os a corações normais, com medidas perimetrais dos anéis atrioventriculares direito (AVD) e esquerdo (AVE) e dos ventrículos direito (VD) e esquerdo (VE) e a porcentagem de fibras colágenas e elásticas dos anéis. Métodos: Foram avaliados 13 corações de cadáveres portadores de CMDId e 13 corações normais, que foram dissecados mantendo-se os anéis atrioventriculares e a massa ventricular, com laminação em segmentos correspondentes a 20%, 50% e 80% da distância entre o sulco atrioventricular e o ápice ventricular. Os cortes foram submetidos à digitalização fotográfica, sendo comparadas as medidas. Os anéis foram dissecados, medidos e enviados ao laboratório de anatomia patológica, sendo realizadas colorações por meio de hematoxilina-eosina, picrossírius e resorcina fuccina oxidada. Resultados: Com relação aos ventrículos, no grupo CMDId ocorre dilatação nos segmentos apical, equatorial e basal. A medida do AVD foi maior no grupo CMDId, não havendo diferença no AVE entre os grupos. Com relação ao percentual de fibras colágenas, há diminuição no grupo CMDId em relação ao grupo normal. Com relação às fibras elásticas, não houve diferença entre os grupos. Conclusão: Ocorre alteração da geometria ventricular com dilatação no grupo CMDId. Na CMDId observou-se aumento no perímetro do AVD. Não se observou aumento do perímetro do AVE. Houve diminuição percentual na área total de colágeno tanto no AVD quanto no AVE em corações com CMDId. .

Introduction: Idiopathic dilated cardiomyopathy causes great impact but many aspects of its pathophysiology remain unknown. Objective: To evaluate anatomical and histological aspects of hearts with idiopathic dilated cardiomyopathy and compare them to a control group, evaluating the behavior of the perimeters of the atrioventricular rings and ventricles and to compare the percentage of collagen and elastic fibers of the atrioventricular rings. Methods: Thirteen hearts with cardiomyopathy and 13 normal hearts were analysed. They were dissected keeping the ventricular mass and atrioventricular rings, with lamination of segments 20%, 50% and 80% of the distance between the atrioventricular groove and the ventricular apex. The sections were subjected to photo scanning, with measurement of perimeters. The atrioventricular rings were dissected and measured digitally to evaluate their perimeters, later being sent to the pathology laboratory, and stained by hematoxylin-eosin, picrosirius and oxidized resorcin fuccin. Results: Regarding to ventricles, dilation occurs in all segments in the pathological group, and the right atrioventricular ring measurement was higher in idiopathic dilated cardiomyopathy group, with no difference in the left side. With respect to collagen, both sides had lower percentage of fibers in the pathological group. With respect to the elastic fibers, there was no difference between the groups. Conclusion: There is a change in ventricular geometry in cardiomyopathy group. The left atrioventricular ring does not dilate, in spite of the fact that in both ventricles there is lowering of collagen. .

Isolated and synergistic effects of PM10 and average temperature on cardiovascular and respiratory mortality / Efeitos isolados e sinérgicos do MP10 e da temperatura média na mortalidade por doenças cardiovasculares e respiratórias

OBJECTIVE To analyze the effect of air pollution and temperature on mortality due to cardiovascular and respiratory diseases. METHODS We evaluated the isolated and synergistic effects of temperature and particulate matter with aerodynamic diameter < 10 µm (PM10) on the mortality of individuals > 40 years old due to cardiovascular disease and that of individuals > 60 years old due to respiratory diseases in Sao Paulo, SP, Southeastern Brazil, between 1998 and 2008. Three methodologies were used to evaluate the isolated association: time-series analysis using Poisson regression model, bidirectional case-crossover analysis matched by period, and case-crossover analysis matched by the confounding factor, i.e., average temperature or pollutant concentration. The graphical representation of the response surface, generated by the interaction term between these factors added to the Poisson regression model, was interpreted to evaluate the synergistic effect of the risk factors. RESULTS No differences were observed between the results of the case-crossover and time-series analyses. The percentage change in the relative risk of cardiovascular and respiratory mortality was 0.85% (0.45;1.25) and 1.60% (0.74;2.46), respectively, due to an increase of 10 μg/m3 in the PM10 concentration. The pattern of correlation of the temperature with cardiovascular mortality was U-shaped and that with respiratory mortality was J-shaped, indicating an increased relative risk at high temperatures. The values for the interaction term indicated a higher relative risk for cardiovascular and respiratory mortalities at low temperatures and high temperatures, respectively, when the pollution levels reached approximately 60 μg/m3. CONCLUSIONS The positive association standardized in the Poisson regression model for pollutant concentration is not confounded by temperature, and the effect of temperature is not confounded by the pollutant levels ...

OBJETIVO Analisar o efeito da poluição do ar e da temperatura na mortalidade por doenças cardiovasculares e respiratórias. MÉTODOS Foram analisados os efeitos da temperatura e do material particulado com diâmetro aerodinâmico < 10 micrômetros (MP10), isolado e sinérgico, na mortalidade de indivíduos > 40 anos por doenças cardiovasculares e na mortalidade de indivíduos > 60 anos por doenças respiratórias em São Paulo, SP, entre 1998 e 2008. Três tipos de metodologias foram aplicadas para avaliar a associação isolada: análise de séries temporais com regressão de Poisson, análise case-crossover com pareamento temporal bidirecional e análise case-crossover com pareamento pelo fator confundidor, i.e., temperatura média ou poluente. Foi interpretada a representação gráfica da superfície resposta, gerada por termo de interação entre tais fatores adicionado à regressão de Poisson, para avaliar o efeito sinérgico entre os fatores de risco. RESULTADOS Não foram observadas diferenças entre os resultados das análises case-crossover e de séries temporais. Estimou-se mudança percentual no risco relativo para mortalidade cardiovascular e respiratória de 0,85% (0,45;1,25) e 1,60% (0,74;2,46), respectivamente, devido ao aumento de 10 μg/m3 na concentração do MP10. O padrão de associação da temperatura para mortalidade cardiovascular foi de U-shape e para mortalidade respiratória foi de J-shape, representando maior risco relativo em temperaturas altas. As figuras do termo de interação indicaram maior risco relativo em baixas temperaturas para mortalidade cardiovascular e em altas temperaturas para mortalidade respiratória em níveis de poluição em torno de 60 μg/m3. CONCLUSÕES ...

pH in exhaled breath condensate and nasal lavage as a biomarker of air pollution-related inflammation in street traffic-controllers and office-workers

OBJECTIVE: To utilize low-cost and simple methods to assess airway and lung inflammation biomarkers related to air pollution. METHODS: A total of 87 male, non-smoking, healthy subjects working as street traffic-controllers or office-workers were examined to determine carbon monoxide in exhaled breath and to measure the pH in nasal lavage fluid and exhaled breath condensate. Air pollution exposure was measured by particulate matter concentration, and data were obtained from fixed monitoring stations (8-h work intervals per day, during the 5 consecutive days prior to the study). RESULTS: Exhaled carbon monoxide was two-fold greater in traffic-controllers than in office-workers. The mean pH values were 8.12 in exhaled breath condensate and 7.99 in nasal lavage fluid in office-workers; these values were lower in traffic-controllers (7.80 and 7.30, respectively). Both groups presented similar cytokines concentrations in both substrates, however, IL-1β and IL-8 were elevated in nasal lavage fluid compared with exhaled breath condensate. The particulate matter concentration was greater at the workplace of traffic-controllers compared with that of office-workers. CONCLUSION: The pH values of nasal lavage fluid and exhaled breath condensate are important, robust, easy to measure and reproducible biomarkers that can be used to monitor occupational exposure to air pollution. Additionally, traffic-controllers are at an increased risk of airway and lung inflammation during their occupational activities compared with office-workers. .