Association between psoriasis and thyroid function: results from the Brazilian Longitudinal Study of Adults Health (ELSA-Brasil)

ABSTRACT Objective: To determine the relationship between psoriasis, thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triodothyronine (FT3), thyroid peroxidase antibodies (TPOAb), and subclinical thyroid dysfunctions in middle-aged and older adults. Materials and methods: Cross-sectional analyses included a self-reported medical diagnosis of psoriasis and thyroid function from the 3rd visit (2017-2019) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). TSH, FT4, and FT3 levels were analyzed as continuous variables and quintiles, and TPOAb positivity and subclinical hypothyroidism as a yes/no variable. Logistic regression models were built as crude and adjusted by main confounders (age, sex, education level, race/ethnicity, and smoking). Results: From 9,649 participants (52.3% women; 59.2 ± 8.7 years old), the prevalence of psoriasis was 2.8% (n = 270). TSH, FT4, TPOAb positivity, and subclinical hypothyroidism were not associated with psoriasis in the main analyses. In the stratified analysis, our findings showed positive associations of the lowest (OR = 2.01; 95% CI 1.05-3.84; p = 0.036) and the highest (OR = 2.13; 95% CI 1.12-4.05; p = 0.022) quintiles of FT4 and a protective association of TPOAb positivity (OR = 0.43; 95% CI 0.19-0.98; p = 0.046) with prevalent psoriasis in women. In the logistic regression for FT3, participants in the 1st quintile showed a statistically significant association with psoriasis for the whole sample (OR = 1.66; 95% CI 1.11-2.46; p = 0.013) and for men (OR = 2.25; 95% CI 1.25-4.04; p = 0.007) in the sex-stratified analysis. Conclusions: The present study showed that the association of FT4 levels with psoriasis are different according to sex, with a possible U-shaped curve in women but not in men. Although there were some associations of FT3 with psoriasis, they may be a consequence of non-thyroidal illness syndrome. Further prospective data may clarify the association of thyroid function and psoriasis.

Estresse no trabalho e níveis de hemoglobina glicada: o papel da escolaridade. Dados da linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) / Job stress and glycated hemoglobin levels: the role of educational attainment. Baseline data from the Longitudinal Study of Adult Health (ELSA-Brasil)

Resumo Introdução: as condições estressantes do trabalho estão associadas ao aumento dos níveis glicêmicos, mas pouco se conhece sobre o papel da escolaridade neste contexto. Objetivos: analisar a associação entre o estresse psicossocial no trabalho e os níveis de hemoglobina glicada (HbA1c) e a influência da escolaridade como modificador de efeito. Métodos: estudo transversal com dados de 11.922 trabalhadores ativos da linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O estresse psicossocial no trabalho foi avaliado pelo modelo demanda-controle. Foram empregadas a regressão logística multinomial e interações multiplicativas. Resultados: em trabalhadoras do sexo feminino com baixa escolaridade, observou-se associação entre baixo uso de habilidades no trabalho (OR 1,56; IC95% 1,09-2,24) e HbA1c elevada. A baixa autonomia no trabalho foi relacionada à HbA1c limítrofe (OR 1,21; IC95% 1,01-1,45) e elevada (OR 1,73; IC95% 1,19-2,51). Entre trabalhadores do sexo masculino com baixa escolaridade, o trabalho de alto desgaste (OR 1,94; IC95% 1,18-3,21), o baixo uso de habilidades (OR 2,00; IC95% 1,41-2,83) e a baixa autonomia no trabalho (OR 1,58; IC95% 1,13-2,21) foram associados à HbA1c elevada. Conclusão: o estresse psicossocial no trabalho foi associado a níveis limítrofes e elevados de HbAlc para trabalhadores com baixa escolaridade de ambos os sexos. Assim, ações para modificar as relações de trabalho e prevenir doenças crônicas devem ser priorizadas.

Abstract Introduction: stressful work conditions are associated to increased glycemic levels, but little is known about the role of educational attainment in this association. Objectives: to analyze the association between psychosocial stress at work, levels of glycated hemoglobin (HbA1c), and the role of educational attainment as an effect modifier. Methods: a cross-sectional study with baseline data from 11,922 active workers who participated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Psychosocial stress at work was measured via the Demand-Control model. Multinomial logistic regression and multiplicative interactions were performed. Results: among female workers with low educational attainment, there was an association of low skill discretion and elevated HbA1c (OR 1.56; 95% CI 1.09-2.24). Low decision authority was associated to borderline (OR 1.21; 95% CI 1.01-1.45) and high (OR 1.73; 95% CI 1.19-2.51) HbA1c. Among male workers with low educational attainment, high strain (OR 1.94; 95% CI 1.18-3.21), low skill discretion (OR 2.0; 95% CI 1.41-2.83), and low decision authority (OR 1.58; 95% CI 1.13-2.21) were associated to high HbA1c. Conclusion: Stress at work was associated to high and borderline levels of HbAlc in workers from both genders with low educational attainment. Actions to modify work relations and to prevent chronic diseases should be prioritized for this group.

Hearing loss, tinnitus, and hypertension: analysis of the baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVES: To investigate the association among hypertension, tinnitus, and sensorineural hearing loss and evaluate the influence of other covariates on this association. METHODS: Baseline data (2008-2010) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were analyzed. Altogether, 900 participants were evaluated. The baseline assessment consisted of a 7-hour examination to obtain clinical and laboratory variables. Hearing was measured using pure-tone audiometry. RESULTS: Overall, 33.3% of the participants had hypertension. Participants with hypertension were more likely to be older, male, and diabetic compared to those without hypertension. The prevalence of tinnitus was higher among hypertensive participants and the odds ratio for tinnitus was higher in participants with hypertension than in those without hypertension. However, the difference was not significant after adjusting for age. Audiometric results at 250-8,000 Hz were worse in participants with hypertension than in those without hypertension in the crude analysis; however, the differences were not significant after adjustment for age, sex, diagnosis of diabetes, and exposure to noise. No significant difference was observed in hearing thresholds among participants having hypertension for <6 years, those having hypertension for ≥6 years, and individuals without hypertension. CONCLUSION: Hearing thresholds were worse in participants with hypertension. However, after adjusting for age, sex, diagnosis of diabetes, and exposure to noise, no significant differences were observed between participants with and without hypertension. A higher prevalence of tinnitus was observed in participants with hypertension compared to those without hypertension, but without significance after adjusting for age.

"Shadow" OSCE examiner. A cross-sectional study comparing the "shadow" examiner with the original OSCE examiner format

OBJECTIVES: Feedback is a powerful learning tool, but a lack of appropriate feedback is a very common complaint from learners to teachers. To improve opportunities for feedback on objective structured clinical examinations (OSCEs), a modified examiner role, termed the "shadow" examiner, was tested. This study aims to present and analyze comparisons between the "shadow" examiner and the original OSCE examiner format. METHODS: In 2011, experiments were carried out with modifications to the examiner's role to define the "shadow" examiner format. From February 2012 to May 2014, research was conducted with 415 6th-year medical students. Of these students, 316 were randomly assigned to assessments by both "shadow" and "fixed" examiners. Pearson correlation analysis with linear regression, Student's t-tests and Bland-Altman plots were the statistical methods used to compare the assessment modes. To strengthen the analysis, checklist items were classified by domain. RESULTS: High correlations between the "shadow" and "fixed" examiners' global scores were observed. The results of the analysis of specific domains demonstrated higher correlations for cognitive scores and lower correlations for affective scores. No statistically significant differences between the mean examiner global scores were found. The Bland-Altman analysis showed that the "shadow" examiners' affective scores were significantly higher than those of the "fixed" examiners, but the magnitude of this difference was small. CONCLUSION: The modified examiner role did not lead to any important bias in the students' scores compared with the original OSCE examiner format. This new strategy may provide important insights for formative assessments of clinical performance.

Avaliação da presença e extensão dos atributos de atenção primária em dois modelos coexistentes na rede básica de saúde do Município de São Paulo / Assessment of the presence and extent of primary care attributes in two coexisting models of the primary health care network of the city of São Paulo / Evaluación de la presencia y extensión de los atributos de atención primaria de salud en dos modelos coexistentes en la red básica de salud de la ciudad de São Paulo

Introdução: No Brasil, faltam avaliações que mensurem o desempenho direto da Atenção Primária à Saúde (APS). Serviços desenvolvidos para a atenção à demanda espontânea de baixa complexidade como as Assistências Médicas Ambulatoriais (AMA), de São Paulo, são oferecidos como alternativa à Estratégia de Saúde da Família (ESF), o serviço brasileiro oficial de APS, mas ainda não há estudos comparativos entre eles. Objetivo: Comparar a presença e extensão dos atributos de APS em dois representantes desses dois serviços da cidade de São Paulo: uma Unidade Básica de Saúde (UBS), parte integrante da ESF, e uma AMA. Métodos: Este artigo trata de um estudo transversal utilizando o Primary Care Assessment Tool, versão validada em português (PCATool Brasil). Resultados: Foram aplicados 616 questionários, 76,3% demonstrou-se afiliado à UBS e 12,3% à AMA. Os frequentadores da UBS se demonstraram mais pobres. A UBS apresentou escores essencial e geral maiores (5,64 e 5,58 contra 3,70 e 3,38, respectivamente) e teve médias superiores em todos os atributos, exceto "acessibilidade" (2,46 contra 3,68). Apenas a UBS apresentou atributos com escores superiores a 6,6: "Acesso de Primeiro Contato - Utilização" (7,22) e "Coordenação - Sistemas de Informação" (7,31). Entretanto, a má avaliação dos outros atributos do PCATool na UBS foi preponderante para considerá-la um serviço de baixa orientação à APS, assim como a AMA. Conclusão: Os usuários identificam muito pouco os atributos de APS nos dois serviços, em um nível aquém do considerado satisfatório, mesmo que os escores da UBS sejam mais elevados do que os da AMA em 8 dos 10 atributos. Apesar de ser reconhecido como um bom local para realizar o primeiro contato com o sistema, a falta de acessibilidade prejudica a UBS como serviço de APS. A AMA, apresentada como a solução para o problema, não demonstra desempenho que a justifique como alternativa.

Introduction: In Brazil, there is a lack of information about the direct performance of Primary Health Care. In the city of São Paulo, Outpatient Medical Care units (Assistências Médicas Ambulatoriais - AMAs), walk-in clinics developed to address acute diseases of low complexity, are offered as an alternative to the Family Health Strategy - FHS (Estratégia Saúde da Família), the official Brazilian PHC service, and there are no comparative studies of them. Objectives: To assess the presence and extent of PHC attributes in two units in the city of São Paulo: a Basic Health Unit (Unidade Básica de Saúde - BHU), part of the FHS, and an AMA. Methods: This article is a cross-sectional study using the Primary Care Assessment Tool validated version in Portuguese (PCATool Brazil). Results: Questionnaires were applied to 616 people, 76.3% of whom reported an affiliation with the BHU and 12.3% with the AMA. The BHU users were poorer. The BHU had higher essential and overall scores than the AMA (5.64 and 5.58 versus 3.70 and 3.38, respectively) and higher averages for all the attributes, except for "accessibility" (2.46 compared to 3.68. Only the BHU presented scores over 6.6: "Access to First Contact - Utilization" (7.22) and "Coordination - Systems of Information" (7.31). However, the poor evaluation of the other PCATool attributes in the BHU was preponderant to consider it as a low oriented PHC service, just as the AMA. Conclusion: The users identified a very low level of satisfactory development of PHC attributes in the two services evaluated, even though the BHU scores were higher than those of the AMA in 8 of the 10 attributes. Despite being recognized as a good place to get the first contact to the system, the lack of accessibility affects BHU as a PHC service. The AMA, presented as the solution to the problem, has no performance to justify itself as an alternative.

Introducción: En Brasil, carecen las evaluaciones que miden el desempeño directo de la Atención Primaria de Salud (APS). Servicios desarrollados para la atención a la demanda espontánea de baja complejidad como las "Assistências Médicas Ambulatoriais" (AMA) de São Paulo se ofrecen como una alternativa a la Estrategia de Salud Familiar (ESF), el servicio brasileño oficial de APS, pero todavía no hay estudios que comparaban ellos. Objetivos: Comparar la presencia y extensión de los atributos de la atención primaria entre dos representantes de esos dos servicios en São Paulo: una Unidad Básica de Salud (UBS), parte de la ESF, y un AMA. Métodos: Este artículo es un estudio transversal utilizando el Primary Care Assessment Tool validado versión en portugués (PCATool Brasil). Resultados: Se aplicaron 616 cuestionarios, 76,3% resultó estar afiliado a UBS y 12,3% a la AMA. Los clientes de la UBS se demostraron más pobres. UBS tuve puntuaciones superiores en los escores esenciales y generales (5,64 y 5,58 frente a 3,70 y 3,38) y tuvieron promedios más altos en todos los atributos excepto la "accesibilidad" (2,46 frente a 3,68). Sólo UBS presentó atributos con puntuaciones más altas que 6,6: "Acceso de Primer Contacto - Utilización" (7,22) y "Coordinación - Sistemas de Información" (7,31). Sin embargo, la mala evaluación de los otros atributos del PCATool en la UBS fue preponderante para considerarla como un servicio de baja orientación a la APS, así como la AMA. Conclusión: Los usuarios identificaron muy poco los atributos de APS en ambos los servicios a un nivel abajo de lo satisfactorio, aunque los resultados de UBS fueron superiores a la AMA en 8 de los 10 atributos. A pesar de ser reconocido como un buen lugar para lograr el primer contacto con el sistema, la falta de accesibilidad afecta la UBS como servicio de APS. La AMA, presentada como la solución al problema, no tiene el rendimiento para justificarla como una alternativa.

One-year Mortality after an Acute Coronary Event and its Clinical Predictors: The ERICO Study / Mortalidade em um Ano após Evento Coronário Agudo e seus Preditores Clínicos: O estudo ERICO

Information about post-acute coronary syndrome (ACS) survival have been mostly short-term findings or based on specialized, cardiology referral centers.

Diagnostic accuracy of a noninvasive hepatic ultrasound score for non-alcoholic fatty liver disease (NAFLD) in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) / Acurácia diagnóstica de um escore de ultrassonografia hepática não invasivo para doença hepática gordurosa não alcoólica (DHGNA) no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil)

CONTEXT AND OBJECTIVE: Noninvasive strategies for evaluating non-alcoholic fatty liver disease (NAFLD) have been investigated over the last few decades. Our aim was to evaluate the diagnostic accuracy of a new hepatic ultrasound score for NAFLD in the ELSA-Brasil study. DESIGN AND SETTINGS: Diagnostic accuracy study conducted in the ELSA center, in the hospital of a public university. METHODS: Among the 15,105 participants of the ELSA study who were evaluated for NAFLD, 195 individuals were included in this sub-study. Hepatic ultrasound was performed (deep beam attenuation, hepatorenal index and anteroposterior diameter of the right hepatic lobe) and compared with the hepatic steatosis findings from 64-channel high-resolution computed tomography (CT). We also evaluated two clinical indices relating to NAFLD: the fatty liver index (FLI) and the hepatic steatosis index (HSI). RESULTS: Among the 195 participants, the NAFLD frequency was 34.4%. High body mass index, high waist circumference, diabetes and hypertriglyceridemia were associated with high hepatic attenuation and large anteroposterior diameter of the right hepatic lobe, but not with the hepatorenal index. The hepatic ultrasound score, based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe, presented the best performance for NAFLD screening at the cutoff point ≥ 1 point; sensitivity: 85.1%; specificity: 73.4%; accuracy: 79.3%; and area under the curve (AUC 0.85; 95% confidence interval, CI: 0.78-0.91)]. FLI and HSI presented lower performance (AUC 0.76; 95% CI: 0.69-0.83) than CT. CONCLUSION: The hepatic ultrasound score based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe has good reproducibility and accuracy for NAFLD screening. .

CONTEXTO E OBJETIVO: Estratégias não invasivas para avaliar doença hepática gordurosa não alcoólica (DHGNA) têm sido investigadas nas últimas décadas. Nosso objetivo foi avaliar a acurácia diagnóstica de um novo escore de ultrassonografia hepática para DHGNA no estudo ELSA-Brasil. TIPO DE ESTUDO E LOCAL: Estudo de acurácia diagnóstica realizado no centro ELSA, no hospital de uma universidade pública. MÉTODOS: Dos 15.105 participantes do estudo ELSA avaliados para DHGNA, 195 indivíduos foram incluídos neste estudo. Foi realizada ultrassonografia hepática (atenuação do feixe de profundidade, índice hepatorrenal e diâmetro anteroposterior do lobo direito do fígado) que foi comparada aos achados de esteatose hepática da tomografia computadorizada (TC) de alta resolução de 64 canais. Avaliamos também dois índices clínicos relacionados à DHGNA: o índice de gordura hepática (FLI) e o índice de esteatose hepática (HSI). RESULTADOS: Entre os 195 participantes, a frequência de DHGNA foi de 34,4%. Altos índices de massa corpórea, circunferência de cintura, diabetes e hipertrigliceridemia foram associados a aumento da atenuação hepática e do diâmetro anteroposterior do lobo hepático direito, mas não ao índice hepato-renal. A pontuação da ultrassonografia hepática, que incluiu atenuação hepática e diâmetro anteroposterior do lobo direito do fígado, apresentou o melhor desempenho para o rastreio DHGNA sob o ponto de corte ≥ 1 ponto (sensibilidade: 85.1%; especificidade: 73.4%; acurácia: 79.3%), e área sob a curva (AUC, 0,85, IC 95%: 0,78-0,91). FLI e HSI apresentaram menor desempenho (AUC 0,76; IC 95%: 0,69-0,83) comparados à TC. CONCLUSÃO: O escore de ultrassonografia hepática, que incluiu atenuação hepática e o diâmetro anteroposterior do lobo direito do fígado, possui boa reprodutibilidade e acurácia para o rastreio de DHGNA. .