Burnout among primary health care workers in Brazil: results of a multilevel analysis.

PURPOSE: Burnout among health care workers may hamper the quality of care and effectiveness of health systems. Hence, we examined the prevalence of burnout in primary care teams, including community health workers; and investigated associations between individuals' characteristics, team and primary care center factors, and burnout. METHODS: We carried out a cross-sectional study among primary care teams in the city of São Paulo, Brazil (n = 2940). We randomly selected 66 primary care centers. The Maslach burnout inventory was used to investigate burnout. We used multilevel modelling to examine the associations between individuals' characteristics, team and primary care center variables with burnout. RESULTS: We addressed 351 primary care teams, with 11.4% of participants presenting severe burnout. The variance in burnout among primary care workers was partially explained by individuals' characteristics, and by team and primary care center factors. Severe burnout was associated with the following: (1) individuals' characteristics: being black, being younger, a higher length of employment in primary care, and presenting a lack of feedback from supervisors; (2) team factors: working in deprived areas and not receiving the support of a multidisciplinary team; and (3) primary care center factors: inadequate infrastructure (less than one office available per team), and having a bad/very bad relationship with the community council. CONCLUSIONS: To reduce burnout among primary care teams, stakeholders should: (1) train managers/supervisors on leadership styles that prioritize performance feedback, support, and communication skills; (2) allocate catchment areas to teams according to each community's vulnerability; (3) provide a multidisciplinary team to support primary care workers; and (4) offer suitable facilities and infra-structure.

Critical evaluation of food intake and energy balance in young modern pentathlon athletes: a cross-sectional study.

BACKGROUND: Modern pentathlon comprises five sports: fencing, swimming, equestrian jumping, and a combined event of pistol shooting and running. Despite the expected high energy demand of this sport, there are few studies that provide support for the nutritional recommendations for pentathletes. The purpose of the present study was to evaluate young modern pentathlon athletes with respect to body composition, biochemical profile, and consumption of food and supplements. METHODS: Fifty-six young modern pentathletes aged 13.5 ± 2.4 years participated in the study: 22 adolescent girls and 34 adolescent boys, weight 55.8 ± 13.3 kg, height 1.6 ± 0.1 m, and body fat 21.1 ± 3.1 %. Food consumption was analyzed through a 24-h recall method and food-frequency questionnaire. Assessment of body composition was carried out by checking anthropometric measures (body mass, height, and skinfolds) and using protocols according to participants' age and sexual maturity. RESULTS: Male participants consumed less energy than the general recommendations for athletes from the American Dietetic Association (2749 ± 1024 kcal vs. 3113 ± 704 kcal, p < 0.01), whereas female participants consumed more energy than those recommendations (2558 ± 808 kcal vs. 2213 ± 4734 kcal, p < 0.01). Neither young men nor young women followed the carbohydrate intake recommendations for athletes (6.3 ± 2.5 g/kg/day and 6.6 ± 2.2 g/kg/day, respectively). Lipid and protein intakes corresponded to recommendations for both sexes; however, insufficient intakes of calcium, fruits, and vegetables were seen, as well as frequent consumption of baked goods and sugared soft drinks. CONCLUSIONS: Adolescent modern pentathlon athletes presented inadequate eating habits with respect to consumption of carbohydrates and energy. Many participants had insufficient intake of micronutrients, especially calcium. However, future research is needed that is aimed at elucidating the real nutritional demands for good physical performance in this sport and the impact of inadequate eating habits on performance, especially among young athletes who are in the growth-stage years and are exposed to intense physical exercise routines.

[Prevalence of common mental disorders and the relationship to the social context: multilevel analysis of the São Paulo Ageing & Health Study (SPAH)]. / Prevalência de transtornos mentais comuns e contexto social: análise multinível do São Paulo Ageing & Health Study (SPAH).

Social context can play a important role in the etiology and prevalence of mental disorders. The aim of the present study was to investigate risk factors for common mental disorders (CMD), considering different contextual levels: individual, household, and census tract. The study used a population-based sample of 2,366 respondents from the São Paulo Ageing & Health Study. Presence of CMD was identified by the SRQ-20. Sex, age, education, and occupation were individual characteristics associated with prevalence of CMD. Multilevel logistic regression models showed that part of the variance in prevalence of CMD was associated with the household level, showing associations between crowding, family income, and CMD, even after controlling for individual characteristics. These results suggest that characteristics of the environment where people live can influence their mental health status.

Prevalência de transtornos mentais comuns e contexto social: análise multinível do São Paulo Ageing & Health Study (SPAH) / Prevalence of common mental disorders and the relationship to the social context: multilevel analysis of the São Paulo Ageing & Health Study (SPAH) / Prevalencia de trastornos mentales comunes y contexto social: análisis multinivel del São Paulo Ageing & Health Study (SPAH)

O contexto social pode ter papel importante na etiologia dos transtornos mentais e na sua prevalência. O objetivo do presente estudo foi investigar fatores de risco que contribuem para a prevalência de transtornos mentais comuns (TMC), considerando distintos níveis contextuais: indivíduo, domicílio e setor censitário. Para isso, utilizou-se uma amostra de base populacional de 2.366 indivíduos participantes do São Paulo Ageing & Health Study. A presença de TMC foi identificada pelo instrumento SRQ-20. Sexo, idade, escolaridade e ocupação foram características individuais associadas à prevalência de TMC. Modelos de regressão logística multinível mostraram que parte da variância na prevalência de TMC foi associada ao nível do domicílio, com associações entre aglomeração, renda familiar e prevalência de TMC, mesmo após controle para características individuais. Esses resultados sugerem que características do ambiente onde as pessoas vivem contribuem para sua saúde mental.

Social context can play a important role in the etiology and prevalence of mental disorders. The aim of the present study was to investigate risk factors for common mental disorders (CMD), considering different contextual levels: individual, household, and census tract. The study used a population-based sample of 2,366 respondents from the São Paulo Ageing & Health Study. Presence of CMD was identified by the SRQ-20. Sex, age, education, and occupation were individual characteristics associated with prevalence of CMD. Multilevel logistic regression models showed that part of the variance in prevalence of CMD was associated with the household level, showing associations between crowding, family income, and CMD, even after controlling for individual characteristics. These results suggest that characteristics of the environment where people live can influence their mental health status.

El contexto social puede tener un importante papel en la etiología de los trastornos mentales y en su prevalencia. El objetivo del presente estudio fue investigar factores de riesgo que contribuyen a la prevalencia de trastornos mentales comunes (TMC), considerando distintos niveles contextuales: individuo, domicilio y área de censo. Para ello se utilizó una muestra de base poblacional con 2.366 individuos, participantes del São Paulo Ageing & Health Study. La presencia de TMC fue identificada por el instrumento SRQ-20. Sexo, edad, escolaridad y ocupación fueron las características individuales asociadas a la prevalencia de TMC. Los modelos de regresión logística multinivel mostraron que una parte de la variancia en la prevalencia de TMC se asoció al nivel de domicilio, con asociaciones entre aglomeración, renta de la familia y prevalencia de TMC, incluso después del control para características individuales. Estos resultados sugieren que las características del ambiente donde viven las personas contribuyen a su salud mental.

Co-ingestion of carbohydrate and pea protein does not enhance muscle recovery after strenuous exercise / A ingestão simultânea de carboidratos e proteína da ervilha não melhora a recuperação muscular após a realização de exercício extenuante

OBJECTIVE: To assess the influence of carbohydrate and added pea protein concentrate supplementation on muscle recovery after a military operation called Leader's Reaction Test. METHODS: Twenty-four soldiers from the Brazilian Army were divided into three equal groups (n=8). They received either carbohydrate (0.8.g/kg body weight/h), carbohydrate+carbohydrate (1.0.g/kg body weight/h), or carbohydrate+protein (0.8 g/kg body weight/h of carbohydrate + 0.2 g/kg body weight/h of protein), immediately, 60, and 120 minutes after the Leader’s Reaction Test. Prior, immediately after and 24 hours after the Leader’s Reaction Test, maximal isometric strength and body composition were assessed. Blood samples were also collected for later analysis of concentrations of lactate dehydrogenase and creatine kinase. RESULTS: Twenty-four hours after the Leader's Reaction Test, maximal creatine kinase levels were significantly lower than its levels immediately after (501.00 ± 422.09 versus 275.29 ± 242.08 U/L (carbohydrate); 616.88 ± 291.45 versus 334.57 ± 191.61 U/L (carbohydrate+carbohydrate); and 636.75 ± 340.67 versus 382.88 ± 234.42 U/L (carbohydrate+protein), p=0.004). The maximal isometric strength and lactate dehydrogenase levels were not significantly different during the time trials. CONCLUSION: The present findings suggest that carbohydrate+protein co-ingestion did not improve the recovery of muscle function nor did it attenuate post-exercise muscle damage markers over carbohydrate alone. .

OBJETIVO: Avaliar a influência da suplementação com carboidratos adicionada ao concentrado proteico de ervilha na recuperação muscular, após uma operação militar prática chamada Teste de Reação de Líderes. MÉTODOS: Vinte e quatro soldados do Exército Brasileiro foram divididos em três grupos iguais (n=8). Eles receberam a suplementação com carboidrato (0,8 g/kg de peso corporal/h) ou carboidrato mais carboidrato (1,0 g/kg de peso corporal/h) ou carboidrato mais proteína (0,8 g/kg de peso corporal/h de carboidrato + 0.2 g/kg de peso corporal/h de proteína), imediatamente, 60 e 120 minutos após o Teste de Reação de Líderes. Avaliaram-se a força isométrica máxima e a composição corporal antes do Teste de Reação de Líderes, imediatamente após e 24 horas após o teste. Amostras de sangue foram coletadas para análise posterior das concentrações de lactato desidrogenase e creatina quinase. RESULTADOS: Vinte e quatro horas após o Teste de Reação de Líderes, as concentrações de creatina quinase estavam significativamente reduzidas em comparação ao momento imediatamente posterior (501.00 ± 422,09 versus 275.29 ± 242.08 U/L (carboidrato); 616.88 ± 291,45 versus 334.57 ± 191,61 U/L (carboidrato+carboidrato) e 636.75 ± 340.67 versus 382.88 ± 234,42 U/L (carboidrato+proteína), p=0,004). A força isométrica máxima e os níveis de lactato desidrogenase não foram significativamente diferentes em nenhum momento. CONCLUSÃO: Os resultados sugerem que, em comparação à ingestão do carboidrato isoladamente, a coingestão de carboidrato e proteína não melhora a recuperação da função muscular nem atenua a liberação ...

Inhibition of Trypanosoma cruzi proline racemase affects host-parasite interactions and the outcome of in vitro infection

Proline racemase is an important enzyme of Trypanosoma cruzi and has been shown to be an effective mitogen for B cells, thus contributing to the parasite's immune evasion and persistence in the human host. Recombinant epimastigote parasites overexpressing TcPRAC genes coding for proline racemase present an augmented ability to differentiate into metacyclic infective forms and subsequently penetrate host-cells in vitro. Here we demonstrate that both anti T. cruzi proline racemase antibodies and the specific proline racemase inhibitor pyrrole-2-carboxylic acid significantly affect parasite infection of Vero cells in vitro. This inhibitor also hampers T. cruzi intracellular differentiation.

Inhibition of Trypanosoma cruzi proline racemase affects host-parasite interactions and the outcome of in vitro infection.

Proline racemase is an important enzyme of Trypanosoma cruzi and has been shown to be an effective mitogen for B cells, thus contributing to the parasite's immune evasion and persistence in the human host. Recombinant epimastigote parasites overexpressing TcPRAC genes coding for proline racemase present an augmented ability to differentiate into metacyclic infective forms and subsequently penetrate host-cells in vitro. Here we demonstrate that both anti T. cruzi proline racemase antibodies and the specific proline racemase inhibitor pyrrole-2-carboxylic acid significantly affect parasite infection of Vero cells in vitro. This inhibitor also hampers T. cruzi intracellular differentiation.

Métodos para estimar razão de prevalência em estudos de corte transversal / Métodos para estimar razón de prevalencia en estudios de cohorte transversal / Methods for estimating prevalence ratios in cross-sectional studies

OBJETIVO: Comparar empiricamente as regressões de Cox, log-binomial, Poisson e logística para estimar razões de prevalência em estudos de corte transversal. MÉTODOS: Foram utilizados dados de um estudo epidemiológico transversal (n=2.072), de base populacional, realizado com idosos na cidade de São Paulo (SP), entre maio de 2003 e abril de 2005. Diagnósticos de demência, possíveis casos de transtorno mental comum e autopercepção de saúde ruim foram escolhidos como desfechos com prevalência baixa, intermediária e alta, respectivamente. Foram utilizadas variáveis de confusão com duas ou mais categorias ou valores contínuos. Valores de referência para estimativas por ponto e por intervalo para as razões de prevalência (RP) foram obtidos pelo método de estratificação de Mantel-Haenszel. Estimativas ajustadas foram calculadas utilizando regressões de Cox e Poisson com variância robusta, e regressão log-binomial. Odds ratios (OR) brutos e ajustados foram obtidos pela regressão logística. RESULTADOS: As estimativas por ponto e por intervalo obtidas pelas regressões de Cox e Poisson foram semelhantes à obtida pela estratificação de Mantel-Haenszel, independentemente da prevalência do desfecho e das covariáveis do modelo. O modelo log-binomial apresentou dificuldade de convergência quando o desfecho tinha prevalência alta e havia covariável contínua no modelo. A regressão logística produziu estimativas por ponto e por intervalo maiores do que as obtidas pelos outros métodos, principalmente para os desfechos com maiores prevalências iniciais. Se interpretados como estimativas de RP, os OR superestimariam as associações para os desfechos com prevalência inicial baixa, intermediária e alta em 13 por cento, quase 100 por cento e quatro vezes mais, respectivamente. CONCLUSÕES: Em análise de dados de estudos de corte transversal, os modelos de Cox e Poisson com variância robusta são melhores alternativas que a regressão logística. O modelo de regressão log-binomial produz e...

Methods for estimating prevalence ratios in cross-sectional studies.

OBJECTIVE: To empirically compare the Cox, log-binomial, Poisson and logistic regressions to obtain estimates of prevalence ratios (PR) in cross-sectional studies. METHODS: Data from a population-based cross-sectional epidemiological study (n = 2072) on elderly people in Sao Paulo (Southeastern Brazil), conducted between May 2003 and April 2005, were used. Diagnoses of dementia, possible cases of common mental disorders and self-rated poor health were chosen as outcomes with low, intermediate and high prevalence, respectively. Confounding variables with two or more categories or continuous values were used. Reference values for point and interval estimates of prevalence ratio (PR) were obtained by means of the Mantel-Haenszel stratification method. Adjusted PR estimates were calculated using Cox and Poisson regressions with robust variance, and using log-binomial regression. Crude and adjusted odds ratios (ORs) were obtained using logistic regression. RESULTS: The point and interval estimates obtained using Cox and Poisson regressions were very similar to those obtained using Mantel-Haenszel stratification, independent of the outcome prevalence and the covariates in the model. The log-binomial model presented convergence difficulties when the outcome had high prevalence and there was a continuous covariate in the model. Logistic regression produced point and interval estimates that were higher than those obtained using the other methods, particularly when for outcomes with high initial prevalence. If interpreted as PR estimates, the ORs would overestimate the associations for outcomes with low, intermediate and high prevalence by 13%, almost by 100% and fourfold, respectively. CONCLUSIONS: In analyses of data from cross-sectional studies, the Cox and Poisson models with robust variance are better alternatives than logistic regression is. The log-binomial regression model produces unbiased PR estimates, but may present convergence difficulties when the outcome is very prevalent and the confounding variable is continuous.

High prevalence of dementia among older adults from poor socioeconomic backgrounds in São Paulo, Brazil.

BACKGROUND: The aim of this study was to determine the prevalence of dementia in a socioeconomically disadvantaged population of older adults living in the city of São Paulo, Brazil. METHODS: A cross-sectional one-phase population-based study was carried out among all residents aged > or = 65 in defined census sectors of an economically disadvantaged area of São Paulo. Identification of cases of dementia followed the protocol developed by the 10/66 Dementia Research Group. RESULTS: Of 2072 individuals in the study, 105 met the criteria for a diagnosis of dementia, yielding a prevalence of 5.1%. Prevalence increased with age for both men and women after age 75 years, but was stable from 65 to 74 years. Low education and income were associated with increased risk of dementia. CONCLUSIONS: The prevalence of dementia among older adults from low socioeconomic backgrounds is high. This may be partly due to adverse socioeconomic conditions and consequent failure to compress morbidity into the latter stages of life. The increasing survival of poorer older adults with dementia living in developing countries may lead to a rapid increase in the prevalence of dementia worldwide.

Reliability of the Brazilian version of the Camberwell Assessment of Needs (CAN) in first-episode psychosis cases in São Paulo, Brazil.

OBJECTIVE: To translate and adapt the Brazilian version of the Camberwell Assessment of Needs schedule for research, and to assess its inter-rater reliability in a sample of first-episode psychosis cases in São Paulo, Brazil. METHOD: A sub-sample of participants included in a study of first-episode psychosis in São Paulo was assessed utilizing the 22 domains of the Brazilian version of the Camberwell Assessment of Needs. The Camberwell Assessment of Needs was applied, tape-recorded and rated by research assistants. An independent rater gave scores to the same participants, based on the recorded interviews. The kappa coefficient and the intraclass correlation coefficient were used to assess inter-rater reliability. RESULTS: Fifty-two subjects were included. For seven domains the inter-rater reliability was almost perfect to total (range: 0.81 to 1.0). The domains with the lowest agreement were transport and benefits. The inter-rater reliability for the total number of needs was excellent (ICC = 0.95). CONCLUSIONS: The inter-rater reliability of the Camberwell Assessment of Needs was similar to what has been found in previous studies. The Camberwell Assessment of Needs showed to be easy to use and reliable with first-episode psychosis individuals. The use of standardized instruments to assess needs of care in Brazil will contribute to the assessment of the effectiveness of treatment and to the planning of individualized care for individuals with mental illnesses.

Reliability of the Brazilian version of the Camberwell Assessment of Needs (CAN) in first-episode psychosis cases in São Paulo, Brazil

OBJECTIVE: To translate and adapt the Brazilian version of the Camberwell Assessment of Needs schedule for research, and to assess its inter-rater reliability in a sample of first-episode psychosis cases in São Paulo, Brazil. METHOD: A sub-sample of participants included in a study of first-episode psychosis in São Paulo was assessed utilizing the 22 domains of the Brazilian version of the Camberwell Assessment of Needs. The Camberwell Assessment of Needs was applied, tape-recorded and rated by research assistants. An independent rater gave scores to the same participants, based on the recorded interviews. The kappa coefficient and the intraclass correlation coefficient were used to assess inter-rater reliability. RESULTS: Fifty-two subjects were included. For seven domains the inter-rater reliability was almost perfect to total (range: 0.81 to 1.0). The domains with the lowest agreement were transport and benefits. The inter-rater reliability for the total number of needs was excellent (ICC = 0.95). CONCLUSIONS: The inter-rater reliability of the Camberwell Assessment of Needs was similar to what has been found in previous studies. The Camberwell Assessment of Needs showed to be easy to use and reliable with first-episode psychosis individuals. The use of standardized instruments to assess needs of care in Brazil will contribute to the assessment of the effectiveness of treatment and to the planning of individualized care for individuals with mental illnesses.

OBJETIVO: Traduzir e adaptar a versão para pesquisa da escala Camberwell de Avaliação de Necessidades e avaliar sua confiabilidade entre avaliadores em uma amostra de casos incidentes de psicoses funcionais em São Paulo, Brasil. MÉTODO: Uma amostra de participantes incluídos em um estudo de casos incidentes de psicoses funcionais em São Paulo foi avaliada utilizando-se os 22 domínios da versão brasileira da escala Camberwell de Avaliação de Necessidades. A escala Camberwell de Avaliação de Necessidades foi aplicada, gravada e pontuada por assistentes de pesquisa. Um avaliador independente pontuou os mesmos participantes, baseando-se nas gravações das entrevistas. O coeficiente kappa e o coeficiente de correlação intraclasse foram utilizados para avaliar a confiabilidade entre avaliadores. RESULTADOS: Cinqüenta e dois indivíduos foram incluídos. Para sete domínios, a confiabilidade entre avaliadores foi de quase perfeita a total (k = 0,81 a 1,00). Os domínios com a menor concordância entre avaliadores foram transporte e benefícios. O coeficiente de correlação intraclasse para o total de necessidades foi excelente (ICC = 0,95). CONCLUSÕES: A confiabilidade entre avaliadores da escala Camberwell de Avaliação de Necessidades foi similar aos resultados de estudos anteriores. A escala Camberwell de Avaliação de Necessidades mostrou-se confiável e fácil de aplicar em indivíduos com psicoses incidentes. O uso de instrumentos padronizados para a avaliação de necessidades de cuidado no Brasil contribuirá para a avaliação da efetividade de tratamentos e para o planejamento de cuidados personalizados para indivíduos com transtornos mentais.

Cognitive deficits in first-episode psychosis: a population-based study in São Paulo, Brazil.

BACKGROUND: Studies conducted in high-income countries have reported significant cognitive deficits in first on set schizophrenia subjects relative to asymptotic controls, and it has been suggested that the severity of such deficits could be directly related to the duration of untreated psychosis (DUP). It is relevant to conduct similar studies in developing countries, given the supposedly better outcome for schizophrenia patients living in the latter environments. METHODS: We applied verbal fluency and digit span tests to an epidemiological-based series of patients with first-onset psychoses (n=179) recruited in the city of São Paulo, and compared the findings with those from non-psychotic control subjects randomly selected from the same geographical areas (n=383). RESULTS: Psychosis subjects showed lower scores on the three tests relative to controls, with greatest between-group differences for the backward digit span task (p<0.0001). There were no significant differences between subjects with affective and schizophreniform psychosis. Cognitive performance indices were negatively correlated with the severity of negative symptoms, but showed no relation to DUP. CONCLUSION: We found significant cognitive deficits in patients investigated early during the course of psychotic disorders in an environment that is distinct from those where the subjects investigated in previous studies have been drawn from. We found no support to the hypothesis of an association between greater cognitive deficits and a longer DUP.

Incidence of first-contact psychosis in São Paulo, Brazil.

BACKGROUND: Little is known about the incidence of first-episode psychosis in urban centres of low- or middle-income countries. AIMS: To estimate the incidence of psychosis in São Paulo, a large metropolis of Brazil. METHOD: Prospective survey of first-episode psychosis among residents aged 18-64 years resident in a defined area of São Paulo, over a 30-month period (July 20 2002-December 2004). Assessments were carried out with the SCID-I, and diagnoses given according to DSM-IV criteria. Population at risk was drawn from the 2000 Census data. RESULTS: There were 367 first-episode cases identified (51% women), and almost 40% fulfilled criteria for schizophrenia or schizophreniform disorder. The incidence rate for any psychosis was 15.8/100 000 person-years at risk (95% CI 14.3-17.6). Incidence of non-affective psychoses was higher among younger males. CONCLUSIONS: Incidence of psychosis in São Paulo was lower than expected for a large metropolis.

Nucleus behavior during the closed mitosis of Tritrichomonas foetus.

We present observations on the fine structure and the division process of the nucleus in the protist Tritrichomonas foetus, parasite of the urogenital tract of cattle. The nucleus was followed by immunofluorescence and electron microscopy during interphase and mitosis. Conventional karyotyping coupled to image processing and bright field Panotic staining were used to follow nucleus modifications, chromosome number and condensation pattern along the whole cell cycle. Confocal laser scanning microscopy (CLSM) using DNA fluorescent probes, followed by image processing in the SURF-Driver program, produced three-dimensional reconstruction data of the mitotic nucleus under each phase of the division process. Immunocytochemistry in thin-sections revealed the chromosome spatial arrangement after bromodeoxyuridine incorporation and immunogold labeling using anti-DNA monoclonal antibodies. Our results indicate that: (1) the nucleus assumes different size and shapes along mitosis: it appears oval in interphase, becoming lobed or concave in prophase, then undergoing torsion and constriction, displaying an 'S' shape (metaphase). Next, it becomes elongated and it is finally separated in two nuclei at the transition of anaphase to telophase; (2) T. foetus nucleus harbors five chromosomes; (3) chromosomes become condensed in a pre-mitotic phase; (4) the nucleolus persists during the mitosis.