Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial.

BACKGROUND: An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown. METHODS: The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units. DISCUSSION: This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

Gender, race and socioeconomic influence on diagnosis and treatment of thyroid disorders in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Thyroid diseases are common, and use of levothyroxine is increasing worldwide. We investigated the influence of gender, race and socioeconomic status on the diagnosis and treatment of thyroid disorders using data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multicenter cohort study of civil servants (35-74 years of age) from six Brazilian cities. Diagnosis of thyroid dysfunction was by thyrotropin (TSH), and free thyroxine (FT4) if TSH was altered, and the use of specific medications. Multivariate logistic regression models were constructed using overt hyperthyroidism/hypothyroidism and levothyroxine use as dependent variables and sociodemographic characteristics as independent variables. The frequencies of overt hyper- and hypothyroidism were 0.7 and 7.4%, respectively. Using whites as the reference ethnicity, brown, and black race were protective for overt hypothyroidism (OR=0.76, 95%CI=0.64-0.89, and OR=0.53, 95%CI=0.43-0.67, respectively, and black race was associated with overt hyperthyroidism (OR=1.82, 95%CI=1.06-3.11). Frequency of hypothyroidism treatment was higher in women, browns, highly educated participants and those with high net family incomes. After multivariate adjustment, levothyroxine use was associated with female gender (OR=6.06, 95%CI=3.19-11.49) and high net family income (OR=3.23, 95%CI=1.02-10.23). Frequency of hyperthyroidism treatment was higher in older than in younger individuals. Sociodemographic factors strongly influenced the diagnosis and treatment of thyroid disorders, including the use of levothyroxine.

Impact of an integrated adolescent reproductive health program in Brazil.

An impact evaluation of an integrated school- and health-clinic-based adolescent reproductive health initiative was undertaken by the State Secretariats of Health and Education in Bahia, Brazil during 1997-99. The project was initiated in response to continued high pregnancy rates among adolescents and growing numbers of new HIV infections among young adults. It sought to promote responsible sexual and health-seeking behaviors among public secondary-school students, including the use of public health clinics. The study design included a matched control group used to measure project impact. The findings indicate that the project was successful in increasing the flow of sexual and reproductive health information to secondary-school students and that it had an impact on adolescents' intentions to use public health clinics in the future. No effects on sexual or contraceptive-use behaviors or on use of public clinics were observed, however. Client exit-interview data from a subset of project clinics indicate that adolescents who use clinic-based services are overwhelmingly female and considerably older on average and much more likely ever to have been pregnant than are adolescents in the target population for the project.

Hypertension in a female nursing staff--Pattern of occurrence, diagnosis, and treatment.

OBJECTIVE: To report the pattern of occurrence, diagnosis, and treatment of hypertension in a female nursing staff of an emergency hospital. METHODS: We carried out a cross-sectional study that included interviews and blood pressure measurements of 494 nursing professionals at an emergency hospital in the city of Salvador, in the state of Bahia, Brazil. We considered hypertensive all individual with blood pressure > or = 140/90 mmHg or normal pressure if on regular treatment. RESULTS: We found a prevalence of hypertension of 36.4%. Only 18.3% of the individuals ignored their hypertensive condition, and 64.2% admitted not being having regular treatment. Of those individuals who were having treatment, 69.4% had elevated blood pressure on examination. The major reasons for not being on treatment was the occasional elevation of blood pressure (22.2%) and medical counseling (20.0%). CONCLUSION: The results point to the need to introduce hypertension control measures in this occupational group, because of the magnitude of the disease and the potential impact on diffusion of knowledge and measures to control hypertension.

[Reliability of arterial blood pressure measurement in an arterial hypertension study]. / Confiabilidade da medida de pressão arterial sangüínea em um estudo de hipertensão arterial.

PURPOSE: To evaluate the relaibility of the blood pressure measurements in an arterial hypertension study. METHODS: It was evaluated 502 nurse workers of a public hospital. After careful training and selection of the observers for the quality control at the fieldwork, it was analyzed the correlation between the 1st and 2nd measurements, final digit preference and mean systolic (SBP) and diastolic pressure (DBP). 5% of the sample had their measures compared with those checked by an expert. RESULTS: There was a great confiability intra-observer (96.2% in the SBP and 93.4% in the DBP). The final digit distribution was almost identical. At the 5% sample, there was a strong correlation between them (96.0% in the SBP and 93.9% in the DBP). CONCLUSION: This methodology is feasible in national studies and confers validity to the results.

Confiabilidade da medida de pressão arterial sanguínea em um estudo de hipertensão arterial / Reliability of arterial blood pressure measurements in an arterial hypertension study

Purpose - To evaluate the reliability of the blood pressure measurements in an arterial hypertension study. Methods - It was evaluated 502 nurse workers of a public hospital. After careful training and selection of the observers, for the quality control at the field work, it was analyzed the correlation between the 1st and 2st measuments, final digit preference and mean systolic (SBP) and diastolic pressure(DBP). 5% of the sample had their measures compared with those checked by an expert. Results - There was a great confiability intraobserver (96.2% in the SBP and 93.4% in the DBP). The final digit distribution was almost identical. At the 5% sample, there was a strong correlation between them (96. 0% in the SBP and 93.9% in the DBP). Conclusion - This methodology is feasible in national studies and confers validity to the results

Objetivo - Avaliar a confiabilidade das medidas de pressão arterial sanguínea em um estudo sobre hipertensão arterial (HA). Métodos - Foram examinadas 502 trabalhadoras de enfermagem em hospital de Salvador. Após cuidadoso processo de treinamento e seleção para controle de qualidade do trabalho de campo, os valores aferidos foram analisados, quanto à correlação entre as medidas e à distribuição dos dígitos terminais e das médias de pressão arterial sistólica (PAS) e diastólica (PAD). Comparou-se amostra de 5% das medidas com as efetuadas, de modo cego, na mesma ocasião, por supervisora médica. Resultados - Observou-se grande confiabilidade intra-observadora (96,2% na PAS e 93,4% na PAD). A distribuição entre os dígitos terminais foi praticamente eqüitativa. Na amostra, houve grande correlação entre as medidas (96,0% na PAS e 93,9% na PAD). Conclusão - As estratégias adotadas para a uniformização das medidas foram satisfatórias, garantindo a confiabilidade dos resultados e factíveis em estudos nacionais

[Women, health, and labor in Brazil: challenges for new action]. / Mulher, saúde e trabalho no Brasil: desafios para um novo agir.

Despite the remarkable rise in women's participation in the labor market in Brazil, its consequences on health are still virtually unknown. This study aims to identify theoretical and methodological problems in the relationship between labor and women's health from a gender perspective. Characteristics of women's occupational placement are described and analyzed as resulting from their role in social reproduction. The study examines the development of several conciliatory strategies between paid work and housework which are discussed as potential determinants of health problems and support the need for a critical reappraisal of theoretical and methodological strategies to reach a better understanding of the complexity and specificities of women's living and working conditions. The author also stresses the role of women's recent participation in the trade union movements in defense of health, body rights, and women's issues in the workplace, as well as the need for a new framework embodied in the women's social movement. The study thus points to the challenge to produce knowledge on this subject in order to unveil the uniqueness of the national scenario marked by unemployment, informal jobs, low salaries, weak trade unions and other civil organizations, and traditional domestic and marriage relationships.

[Gender and health in Brazil: considerations based on the National Household Sampling Survey]. / Gênero e saúde no Brasil: considerações a partir da Pesquisa Nacional por Amostra de Domicílios.

As in the principal industrial countries, Brazilian women have lived longer than men. However, paradoxically, women present higher morbidity indicators than men. Knowledge of the Brazilian pattern regarding this matter could be a useful contribution to an understanding of their determinants in our specific reality, as well as enabling us to foresee future trends that would make it possible to plan adjustment in the health system. A morbidity study based on data from the National Household Sample Survey (PNAD/IBGE), was undertaken in ten Brazilian states in 1986 with this in view. Coefficients of the prevalence of perceived morbidity, demand for and utilization of health services according to sex, standardized by age and using the direct method, were built up. As a measurement of the differentials, sex ratios were calculated. The excess of perceived morbidity in women was constant in all the regions. The sex differential in the utilization of health services showed regional variations, suggesting a relationship with the health services supply. Sex differentials were not observed in childhood; the highest values were found during the woman's reproductive period, decreasing sharply after 60 years of age. The pattern is very similar in all regions. In the present study, the findings could be partially explained by the methodology adopted, but they are similar to the findings reported in other countries. The intense transformations in the reproductive pattern and in the social status of Brazilian women probably have a considerable impact on the health status and on the recourse to health services, not as yet evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Brazilian women have lived longer than men; however, the morbidity of women is higher than that of men. Knowledge of this Brazilian pattern could contribute to an understanding of morbidity determinants as well as help anticipate future trends to plan adjustment in the health system. A morbidity study based on data from the National Household Sample Survey (PNAD/IBGE) was undertaken in 10 Brazilian states in 1986 with this objective. Coefficients of the prevalence of perceived morbidity, as well as demand for and utilization of health services according to sex, were constructed and standardized by age using the direct method. As a measurement of the differentials, sex ratios were calculated. The highest rates of morbidity in both sexes were encountered in the state of Minas Gerais, in the Federal District, and in the state of Sao Paulo. The excess of perceived morbidity in women was constant in all the regions at 20-30%. The women utilized health services more than men, and major differences were found in the states of the north and northeast regions. The sex differential in the utilization of health services showed regional variations, suggesting a relationship with the health services supply. Sex differentials were not observed in childhood, and, up to age 14, the differences were nonexistent; the highest values were found in the 20-29 age segment during the woman's reproductive period, decreasing sharply after 60 years of age. The pattern was very similar in all regions. The findings could be partially explained by the methodology adopted, but they are similar to findings reported in other countries. The intense transformation in the reproductive pattern and social status of Brazilian women probably exerts considerable impact on health status and recourse to health services. More specific studies, which may contribute to the reorganization of a fair and universal health system, are recommended.

[Female mortality in Brazil: the weaker sex or stronger sex?]. / Mortalidade feminina no Brasil: sexo frágil ou sexo forte?

Population ageing in Brazil has been more rapid and more intense among women. This phenomenon is well described in developed countries where mortality rates are higher for men than women. In this regard, the analysis of mortality patterns by cause contributes to elucidate the determinant factors of the present situation in Brazil and provides indications of some future trends in female mortality. This is especially important due to the fact that in Brazil the social role of women has experienced great changes. This study presents data on mortality from ten capital cities in 1985, showing age-standardized overall and cause-specific mortality rates for five of the main groups of causes by sex. Ratios and differences effect estimators were used. The results revealed that regional patterns are associated with the urban and industrial processes with greater differences by sex in more developed regions. External causes and cardiovascular diseases are the main factors responsible for higher mortality among men with special emphasis on violent deaths. It is inferred that the present trend will be maintained, though it is possible that mortality differences by sex could decrease in the near future. The authors discuss that longer survival among women in Brazil does not reveal better life conditions.