Epidemiological and Clinical Patterns of Newly Diagnosed Hepatocellular Carcinoma in Brazil: the Need for Liver Disease Screening Programs Based on Real-World Data.

PURPOSE: Describe sociodemographic and clinical characteristics of patients with hepatocellular carcinoma (HCC) and establish their history in the Brazilian public health system. METHODS: Retrospective observational study was conducted using the database from the Department of Informatics of the Unified Health System (DataSUS). Patients with at least one claim of HCC between July/2011 and June/2016 were included. A record linkage methodology was performed to obtain longitudinal data across different databases. Demographic and clinical data were evaluated, including the time elapsed between diagnosis of HCC risk-factors and the cancer development. Data was analyzed using descriptive statistics. RESULTS: A total of 28,822 HCC cases were identified between July/2011 and June/2016. Mean age was 59.7 years (SD = 14.7), and most patients were men (55.9%). The highest relative number of HCC cases was detected in the south of Brazil (> 20 cases/100,000 inhabitants). About 86.5% of the patients had diagnosis of HCC without previous liver diseases. Only 8% had diagnosis of chronic viral hepatitis and 3.5% cirrhosis. About 76% were diagnosed at an advanced stage, and only 11% of the patients had early stage HCC. Approximately 58% of patients with previous underlying liver diseases were diagnosed at early stages, compared with only 24% of patients without prior record of underlying diseases. CONCLUSION: The diagnosis of HCC in the Brazilian public health is usually made in patients with no previous diagnosis of liver disease and in advanced stages, when no curative treatment is available and survival rates are low. Public health policies are key for the screening and monitoring liver disease and, consequently, HCC.

Normal limits of the electrocardiogram derived from a large database of Brazilian primary care patients.

BACKGROUND: Knowledge of the normal limits of the electrocardiogram (ECG) is mandatory for establishing which patients have abnormal ECGs. No studies have assessed the reference standards for a Latin American population. Our aim was to establish the normal ranges of the ECG for pediatric and adult Brazilian primary care patients. METHODS: This retrospective observational study assessed all the consecutive 12-lead digital electrocardiograms of primary care patients at least 1 year old in Minas Gerais state, Brazil, recorded between 2010 and 2015. ECGs were excluded if there were technical problems, selected abnormalities were present or patients with selected self-declared comorbidities or on drug therapy. Only the first ECG from patients with multiple ECGs was accepted. The University of Glasgow ECG analysis program was used to automatically interpret the ECGs. For each variable, the 1st, 2nd, 50th, 98th and 99th percentiles were determined and results were compared to selected studies. RESULTS: A total of 1,493,905 ECGs were recorded. 1,007,891 were excluded and 486.014 were analyzed. This large study provided normal values for heart rate, P, QRS and T frontal axis, P and QRS overall duration, PR and QT overall intervals and QTc corrected by Hodges, Bazett, Fridericia and Framingham formulae. Overall, the results were similar to those from other studies performed in different populations but there were differences in extreme ages and specific measurements. CONCLUSIONS: This study has provided reference values for Latinos of both sexes older than 1 year. Our results are comparable to studies performed in different populations.

Electrocardiogram and Chagas disease: a large population database of primary care patients.

BACKGROUND: Chagas disease (ChD) used to be a disease restricted to Latin America, but has become a worldwide problem due to migration of infected individuals to developed countries. Electrocardiography has been considered an essential exam to evaluate ChD patients. OBJECTIVE: This study sought to identify prevalent electrocardiographic abnormalities in a large sample of ChD patients evaluated in the primary care setting. METHODS: This retrospective observational study assessed all consecutive digital 12-lead electrocardiograms (ECG) performed by the Telehealth Network of Minas Gerais, Brazil, from January 1 to December 31, 2011. In that time, the service attended primary care patients in 660 cities in the Minas Gerais province. ChD was self-reported, and the individuals who did not report having ChD were considered noninfected. The prevalence of electrocardiographic abnormalities was assessed. RESULTS: Self-reported ChD patients comprised 7,590 (2.9%) of 264,324 patients who underwent ECG during the study period. The mean age for ChD patients was 57.0 ± 13.7 years, and 64.1% of patients were women. The most common comorbidities were hypertension (61.3%), diabetes (9.1%), and dyslipidemia (6.9%), and 10.7% were smokers. The most frequent electrocardiographic abnormalities were nonspecific repolarization abnormalities (34.6%), right bundle branch block (RBBB) (22.7%), left anterior hemiblock (LAH) (22.5%), ventricular premature beats (5.4%), and atrial fibrillation (5.4%). Only 31.5% of the patients had no electrocardiographic abnormality versus 61.2% in noninfected individuals (p < 0.001). The prevalence of normal ECG decreased with aging and was significantly lower than for noninfected individuals in all age groups. Pacemaker rhythm (odds ratio [OR]: 13.3, 95% confidence intervals [CI]: 11.5 to 15.4), RBBB (OR: 10.7, 95% CI: 10.1 to 11.4), especially in association with LAH (OR: 12.1, 95% CI: 11.2 to 13.0), second atrioventricular block (OR: 4.1, 95% CI: 2.5 to 6.6), and third atrioventricular block (OR: 13.3, 95% CI: 11.5 to 15.4) were strongly related to ChD. CONCLUSIONS: In this large sample of primary care patients with ChD, there was a high prevalence of electrocardiographic abnormalities. Pacemaker rhythm, RBBB, especially in association with LAH, and second and third atrioventricular block were strongly related to ChD.

Atrial fibrillation: prevalence in a large database of primary care patients in Brazil.

AIMS: Although an increasing prevalence of atrial fibrillation (AF) has been reported worldwide, there are few studies from low- and middle-income countries. Our objective is to assess the prevalence of AF and the associated medical conditions in Brazilian primary care patients. METHODS AND RESULTS: This is an observational retrospective study. Patients ≥5 years of age from primary care centres of 658 municipalities in Minas Gerais, Brazil, who performed digital electrocardiograms (ECGs) by a public telehealth service in 2011 were assessed. Clinical data were self-reported, and ECGs were interpreted by a team of trained cardiologists using standardized criteria. To assess the relation between clinical characteristics and AF, odds ratios were estimated by logistic regression. A total of 262 685 primary care patients were included, mean (SD) age of 50.3 (19.3) years, 59.6% female. Hypertension was reported in 32.0%, family history of coronary heart disease in 15.0%, diabetes in 5.4%, hyperlipidaemia in 2.8%, Chagas disease in 2.9%, and 7.1% reported current smoking. The prevalence of AF was 1.8% overall: 2.4% in men (ranging from 0.001% from 5-19 years old to 14.6% in nonagenarians) and 1.3% in women (ranging from 0.001% from 5-19 years old to 8.7% in nonagenarians) (P < 0.001). The prevalence of AF increased with advancing age. The comorbidities associated with AF were Chagas disease, previous myocardial infarction, hypertension, and chronic obstructive pulmonary disease. Vitamin K antagonist use was reported by 1.5% of patients. CONCLUSION: The prevalence and age distribution of AF were similar to studies in high-income countries. The proportion of patients who reported the use of anticoagulants was alarmingly low. Our findings point out the necessity to formulate effective treatment strategies for AF in Brazilian primary care settings.

Suicide among physicians in the state of São Paulo, Brazil, across one decade.

OBJECTIVE: To describe mortality by suicide among physicians in the state of São Paulo, Brazil, between 2000 and 2009. METHODS: Secondary analysis of government mortality data. The variable of interest was "underlying cause of death", specifically deaths classified by the ICD-10 as intentional self-harm (X60 to X84). RESULTS: The analyses examined 2,297 declarations of death, among which suicide accounted for 50 cases, i.e., 1.7% of all causes of death. Women comprised 13.2% of the total sample and represented 24% of the death-by-suicide group, indicating an overrepresentation of women in the latter (p = 0.02). Deaths by suicide occurred on average 20 years earlier than deaths by other causes (46.8 ± 14.2 years and 68.1 ± 15.8 years, respectively; p = 0.001). There was a significant association between single and/or divorced status and suicide (p < 0.001). The average mortality rate during the study period was 4.2 deaths per 100,000 physicians registered with the Regional Board of Medicine of the State of São Paulo. CONCLUSION: Deaths by suicide occurred 20 years earlier than deaths by other causes. Medical institutions should develop strategies for the prevention and early detection of mental disorders and occupational stressors that elevate the risk of suicide among physicians.