The impact on disability of initial treatment with methotrexate in patients with rheumatoid arthritis: results from the MARI study.

The study aimed to assess in a population of subjects with rheumatoid arthritis (RA) treated with methotrexate (MTX) how the initial approach to the treatment influenced subsequent disability. We performed a cross-sectional analysis of data collected during the baseline visit of the MARI study, a multicenter observational study on patients with RA on treatment with MTX for at least 12 months. Subjects who fulfilled the Health Assessment Questionnaire (HAQ) were included in the evaluation. For every patient we retrospectively evaluated the disease duration, the duration of symptoms before the diagnosis, the time elapsed before first MTX treatment, the initial MTX dose, and the concomitant medications in the first six months of therapy. Disability was defined as a DI-HAQ score ≥1. The study population included 1015 subjects. Patients with a DI-HAQ score ≥1 had a longer duration of symptoms before diagnosis, a higher delay in treatment initiation, a lower initial dose of MTX and a more frequent co-treatment with symptomatic drugs. Disability was found less frequently in subjects treated with other concomitant disease modifying anti-rheumatic drugs (DMARDs) but not with biological agents. Logistic regression analysis identified as significant predictors of disability: older age, female sex, a longer time to complete diagnosis, a delay in starting MTX treatment higher than 6 months, and a concomitant treatment with symptomatic drugs, while a combination therapy with other DMARDs was associated with a lower risk of disability. A late diagnosis and a delay in starting a treatment with MTX are associated with poorer functional outcomes in patients with RA.

Long-term safety of anti-TNF adalimumab in HBc antibody-positive psoriatic arthritis patients: a retrospective case series of 8 patients.

Immunosuppressive drugs commonly used in the treatment of psoriatic arthritis make patients more susceptible to viral, bacterial, and fungal infections because of their mechanism of action. They not only increase the risk of new infections but also act altering the natural course of preexisting infections. While numerous data regarding the reactivation of tuberculosis infection are available in the literature, poor information about the risk of reactivation or exacerbation of hepatitis viruses B and C infections during treatment with biologics has been reported. Furthermore, reported series with biological therapy included short periods of followup, and therefore, they are not adequate to verify the risk of reactivation in the long-term treatment. Our study evaluated patients with a history of hepatitis B and psoriatic arthritis treated with adalimumab and monitored up to six years. During the observation period, treatment was effective and well tolerated in all patients, and liver function tests and viral load levels remained unchanged.

Ischemic heart disease. Hospitalization, length of stay and expenses in Brazil from 1993 to 1997.

OBJECTIVE: To identify characteristics of the hospitalizations due to ischemic heart disease (IHD) made by the Single Health System--"Sistema Unico de Saúde (SUS) in Brazil from 1993 to 1997. METHODS: The information used came from records of permissions for hospitalization due to IHD (diseases codified from 410 to 414 by the International Disease Classification--9th Revision) furnished by the data bank DATA-SUS. The material studied was classified according to age, sex and length of hospitalization of the patients, and expenses to the system for IHD. RESULTS: IHD represents 1.0% of total hospitalizations. Angina pectoris was the most frequent type, occurring in 53.3% of the cases, followed by acute myocardial infarct (26.6%). This later was more frequent in men and angina in women. The majority of patients with IHD stayed hospitalized from 5 to 8 days. In the years of 1997 the expenses due to hospital treatment for IHD reach to 0.01% of Brazil's Gross Internal Product. In the studied period (1993-1997), IHD was responsible by 1.0% of hospitalizations, however it was 3.3% of the expenses of SUS. CONCLUSION: IHD is an important cause of hospitalization by the SUS; it has a rather high cost, indicating the need for preventive measures aimed at reducing exposure to risk factors and to decrease the incidence of this group of diseases in the nation.

[Reflections on the measurement of maternal mortality]. / Reflexões sobre a mensuração da mortalidade materna.

The maternal mortality rate is a highly sensitive indicator for the health level of both women and the general population in a given geographical area. There is extensive variability among different countries, and rates are high in underdeveloped or developing areas, as in Brazil. Health authorities from various countries have launched programs aimed at reducing maternal deaths and have thus needed to estimate the actual rates to allow for a proper assessment and to control the programs' progress. However, there are many obstacles and difficulties in obtaining the real values of these measures, mainly because of incomplete data. The aim of this paper is to present some of the proposed methodologies for estimating maternal mortality rates and to call attention to the limits and biases of these methods. Based on the Brazilian case, the article also recommends an improvement in the quality and coverage of the Civil Registry, the official source of data on births and deaths.

Reliability of self-reported weight and height among state bank employees.

INTRODUCTION: Self-reported weight and height were compared with direct measurements in order to evaluate the agreement between the two sources. METHODS: Data were obtained from a cross-sectional study on health status from a probabilistic sample of 1,183 employees of a bank, in Rio de Janeiro State, Brazil. Direct measurements were made of 322 employees. Differences between the two sources were evaluated using mean differences, limits of agreement and intraclass correlation coefficient (ICC). RESULTS AND CONCLUSION: Men and women tended to underestimate their weight while differences between self-reported and measured height were insignificant. Body mass index (BMI) mean differences were smaller than those observed for weight. ICC was over 0.98 for weight and 0.95 for BMI, expressing close agreement. Combining a graphical method with ICC may be useful in pilot studies to detect populational groups capable of providing reliable information on weight and height, thus minimizing resources needed for field work.

[Use of the disease family classification in epidemiology and health related problems]. / O uso em epidemiologia da família de classificações de doenças e problemas relacionados à saúde.

This paper describes the evolution of disease frequency statistics and techniques used to present them. Beginning in the 17th century were the first specific references to causes of death and proceeding practically until the mid-20th century as mortality statistics by causes, the instrument for a methodical description of diseases was classification of causes of death. From the latter half of the 20th century on, in addition to mortality statistics by cause, morbidity statistics became routine, with the adoption of disease classification and no longer only classification by cause of death. More recently, classification has been adapted to medical specialties, resulting in what has been termed "disease family classification", including classification of the consequences of diseases, with statistics on disability. Disease classification, both for mortality and morbidity, fostered the development of various types of epidemiological studies (both descriptive and analytical) that expanded knowledge on health.

[Accidents and acts of violence in Brazil: II--Hospital morbidity from lesions and poisonings]. / Morbidade hospitalar por lesões e envenenamentos.

Today in Brazil the "Hospital Internment Authorizations" (AIH) represents about 80% of the total internments in the country and constitutes a data base of easy access available in CD-ROM. This high coverage allows one to draw a reasonable picture, close to reality, of the morbidity demanding hospitalization. Among the causes there is the diagnostic category lesions and poisonings noteworthy for severity and frequency. Hospital internments by this diagnostic category occurring in a month in 1994 have been focused on. Some epidemiological and hospital use characteristics, such as demographic aspects, specific diagnostic category, length of stay and mortality are described. It was observed that lesions and poisonings accounted for 5% to 6% of all hospital internments in the country, being predominantly among men under 65 of age. This diagnostic category was the first cause of hospital internments among men of from 15 to 29 years of age. Fractures were the most frequent specific diagnosis (about 37.5%), almost all of them involving members (legs or arms). The injuries were mainly located in hands, arms, head and neck and occurred predominantly among young men, leading to the believe that they were due to work or traffic accidents. Regarding burns, the fragment occurrence among children under 5 years of age is worthy of note. The authors lament the lack of information as to their causes such as would enable appropriate preventive actions to be taken.

[Indicators of maternal and infant health: implications of the 10th revision of the International Classification of Diseases]. / Indicadores da saúde materna e infantil: implicações da décima revisõ da Classificação Internacional de Doenças.

Since the end of the 1940s, when the World Health Organization assumed responsibility for the decennial revisions of the Classification of Causes of Death, the Classification came to include diseases and definitions of use in vital statistics, resulting in the Sixth International Classification of Diseases (ICD-6). The most recent revision of this work, the International Statistical Classification of Diseases and Related Health Problems (ICD-10), is more significantly different than any revision since ICD-6, especially in the area of maternal and child health. Among the changes introduced in ICD-10 are the inclusion of obstetrical tetanus in the chapter on infectious diseases, which will facilitate the recording of this cause of maternal death; the incorporation of new definitions, such as late maternal death; and the redefinition of the perinatal period, which ICD-10 defines as starting at 22 completed weeks of gestation and ending 7 completed days after birth. This article seeks to highlight these changes and to discuss their consequences for the presentation and interpretation of indicators used in the evaluation of maternal and child health.

[Evaluation of the use of the International Classification of Diseases for the codification of AIDS]. / Avaliação do uso da Classificação Internacional de Doenças para codificar a síndrome da imunodeficiência adquirida.

The International Classification of Diseases (ICD) provides codes for all conditions and permits international comparisons of morbidity and mortality. Because it has to be used all over the world its codes are not always perfectly appropriate. There are revisions from time to time to bring up-to-date the classification. This has happened with AIDS, included in the chapter of infectious diseases in the last revision, ICD-10. The use of ICD-10 AIDS codes is here appraised. All surveillance report forms of one specialized hospital in infectious diseases, notified in 1994, have been codified, but it was found that many diagnoses could not be codified in accordance with a single ICD-10 AIDS code.

[Mortality rate of children under 5 years of age proposed by UNICEF: critical analysis of its validity as a health indicator]. / Taxa de mortalidade de menores de 5 anos proposta pela UNICEF: análise crítica de sua validade como indicador de saúde.

The relationship between the Mortality Rate for children under age 5 as proposed by UNICEF and classical mortality indicators-infant mortality, mortality rates for children under age 1, for age 1 to 4, mortality for children under 5, and the probability of death from birth to 5 years of age, is evaluated. The theoretical equivalence between the rate and 5q0 is shown by means of a Lexis diagram. Practical evaluation is carried out using data from the 24 areas under analysis in the Inter-American Investigation of Mortality in Childhood. Kendall's Correlation shows high agreement between the rate and classical indicators, mainly for the Coefficient for children under 5 and for infant mortality.

Maternal mortality in Latin American urban areas: the case of São Paulo, Brazil.

This article describes maternal mortality trends in São Paulo, Brazil, from 1960 through 1990. In so doing, it compares mortality rates derived from death certificate data with rates suggested by three independent surveys conducted in the city of São Paulo in 1962-1963, 1974-1975, and 1986. In general, these data indicate that a substantial share of all maternal deaths in the city have been ascribed to other causes on death certificates, that prevailing maternal mortality levels are far higher than those found in the urban areas of most developed countries, and that in recent years levels of maternal mortality in the city have been rising. Various measures are suggested for improving the accuracy of available data and reducing the maternal mortality they describe.

[Analysis of information on health: 1893-1993, one hundred years since the International Classification of Diseases]. / Análise da informação em saúde: 1893-1993, cem anos da Classificação Internacional de Doenças.

The analysis of mortality by cause, as well as of morbidity, calls for an instrument that groups the diseases according to common characteristics, that is to say, a classification of diseases. The WHO International Classification of Diseases, in its Ninth Revision, is currently in use. This classification first appeared in 1893; its Tenth Revision is being proposed for 1993. This present paper describes the origins of this international classification, making special references to John Graunt, William Farr and Jacques Bertillon as well as describing the evolution that has occurred through its successive revisions. Initially it was a classification that included only causes of death. After the Sixth Revision included all the diseases and causes of medical consultations, thus allowing its use in morbidity. For the tenth and later revisions, a "family" of classifications is proposed, for a great variety of uses in health services, administration and epidemiology. Some critical observations on the current international classification of diseases are also presented.

Proportional cancer incidence according to selected sites--comparison between residents in the city of S. Paulo, Brazil: Japanese and Brazilian/Portuguese descent.

The percentual distributions of selected sites of cancer cases according to origin, sex and age are compared. Data were obtained from the Registry of Cancer of S. Paulo (School of Public Health of the University of S. Paulo, Brazil). The reference period for inhabitants of Japanese descent was 1969/78 and for those of Brazilian descent, the period was 1969/75. Standardized Proportionate Incidence Ratios (SPIR) with approximate 95% Confidence Intervals (CI) were evaluated using age specific Incidence Ratios of S. Paulo, 1973, as standards. The results agree with findings of previous works on mortality, but show different patterns according to origin. The well known fact that some sub-groups of a population may be different from the overall group is once again brought to the fore. Attention should be drawn to the differences detected for stomach, skin and prostate, in males, and for stomach, skin, cervix and uterus in females.

[Mortality of women in reproductive age in the municipality of São Paulo (Brazil), 1986. III--Death by different causes: cardiovascular diseases]. / Mortalidade de mulheres em idade fértil no Município de São Paulo (Brasil), 1986. III--Mortes por diferentes causas: doenças cardiovasculares.

Further to a research project into the accuracy of death given on the causes of death given on the death certificates of women of fertile age (10-49), resident in the City of S. Paulo, SP, Brazil, in 1986, the main causes of death for the population according to age, with remarks on the mortality from cardiovascular diseases (CVD), malignant neoplasms and external causes are presented. The CVD were responsible for 23.6% of all deaths in this age group, strokes occupying the position of greatest importance (51.1% of all CVD deaths) and coronary heart disease coming second (18.2% of all CVD deaths, the greater number of them being due to acute myocardial infarction). Comparing these results with those of a similar research project undertaken in the 60s, in the same place and using the same methodology, a decline of mortality from chronic rheumatic disease of the heart is to be noted, as also a rise in the mortality from stroke and coronary heart disease, but with a global reduction in age-adjusted rates for CVD overall. There was also a great number of references to arterial hypertension both combined with stroke (78.3% of all deaths due to this cause were of hypertensives) and with coronary heart disease (where this proportion was of 63.4%). The importance of the supposedly high prevalence of high blood pressure in the fertile female population and the indiscriminate use of oral contraceptives are discussed.