Problems with accessibility to health services by persons with disabilities in Sao Paulo, Brazil

Purpose. To describe the occurrence of self-reported problems of accessibility to health services used by persons with disabilities in terms of social and health services variables. Methods. We performed a cross-sectional household survey designed to assess problems with accessibility to health services faced by persons with disabilities. We interviewed 333 persons in Sao Paulo city, in 2007. Variables related to the presence of accessibility problems, disabilities, gender, age, family head income, ethnicity, use of health services and others were analysed using frequencies, percentages, chi(2)-test, ANOVA and Poisson regression models. Results. 15.92% of the interviewed persons reported problems with accessibility to health services. Persons having multiple (prevalence ratios; PR = 2.91) or mobility disability (PR = 6.46) had more problems with accessibility than persons with hearing disability. Persons younger than 78 years old had more problems with accessibility; those who needed help to go to the health service (PR = 3.01) also. Conclusions. Persons with multiple or mobility disability, younger than 78 years, and those who needed help of others to go to the health service were more likely to have problems with accessibility to health services. This information could be one of the first steps to the management and/or planning of appropriate health services for persons with disabilities.

Impact of socioeconomic and clinical factors on child oral health-related quality of life (COHRQoL)

Child oral health-related quality of life (COHRQoL) has been increasingly assessed; however, few studies appraised the influence of socioeconomic status on COHRQoL in developing countries. This study assessed the relationship of COHRQoL with socioeconomic backgrounds and clinical factors. This study followed a cross-sectional design, with a multistage random sample of 792 schoolchildren aged 12 years, representative of Santa Maria, a southern city in Brazil. Participants completed the Brazilian version of the Child Perceptions Questionnaire (CPQ(11-14)), their parents or guardians answered questions on socioeconomic status, and a dental examination provided information on the prevalence of caries, dental trauma and occlusion. The assessment of association used hierarchically adjusted Poisson regression models. Higher impacts on COHRQoL were observed for children presenting with untreated dental caries (RR 1.20; 95% CI 1.07-1.35) and maxillary overjet (RR 1.19; 95% CI 1.02-1.40). Socioeconomic factors also associated with COHRQoL; poorer scores were reported by children whose mothers have not completed primary education (RR 1.30; 95% CI 1.17-1.44) and those with lower household income (RR 1.13; 95% CI 1.02-1.26). Poor socioeconomic standings and poor dental status have a negative impact on COHRQoL; reducing health inequalities may demand dental programmes and policies targeting deprived population.

Sex and socioeconomic inequalities of lung cancer mortality in Barcelona, Spain and Sao Paulo, Brazil

The objective of this paper was to assess sex and socioeconomic inequalities in lung cancer mortality in two major cities of Europe and South America. Official information on mortality and population allowed the estimation of sex- and age-specific death rates for Barcelona, Spain and Sao Paulo, Brazil (1995-2003). Mortality trends and levels were independently assessed for each city and subsequently compared. Rate ratios assessed by Poisson regression analysis addressed hypotheses of association between the outcome and socioeconomic covariates (human development index, unemployment and schooling) at the inner-city area level. Barcelona had a higher mortality in men (76.9/100000 inhabitants) than Sao Paulo (38.2/100 000 inhabitants); although rates were decreasing for the former (-2%/year) and levelled-off for the [after. Mortality in women ranked similarly (9.1 for Barcelona, 11.5 for Sao Paulo); with an increasing trend for women aged 35-64 years (+ 7.7%/year in Barcelona and + 2.4%/year in Sao Paulo). The socioeconomic gradient of mortality in men was negative for Barcelona and positive for Sao Paulo; for women, the socioeconomic gradient was positive in both cities. Negative gradients indicate that deprived areas suffer a higher burden of disease; positive gradients suggest that prosmoking lifestyles may have been more prevalent in more affluent areas during the last decades. Sex and socioeconomic inequalities of lung cancer mortality reinforce the hypothesis that the epidemiologic profile of cancer can be improved by an expanded access to existing technology of healthcare and prevention. The continuous monitoring of inequalities in health may contribute to the concurrent promotion of well-being and social justice.

Self-rated oral health and associated factors in Brazilian elders

Objective: Self-rating provides a simple direct way of capturing perceptions of health. The objective of this study was to estimate the prevalence and associated factors of poor self-rated oral health among elders. Methods: National data from a cross-sectional population-based study with a multistage random sample of 4786 Brazilian older adults (aged 65-74) in 250 towns were analysed. Data collection included oral examinations (WHO 1997) and struct-ured interviews at elderly households. The outcome was measured by a single five-point-response-scale question dichotomized into `poor` (fair/poor/very poor) and `good` (good/very good) self-rated oral health. Data analyses used Poisson regression models stratified by sex. Results: The prevalence of poor self-rated oral health was 46.6% (95% CI: 45.2-48%) in the whole sample, 50.3% (48-52.5) in men and 44.2% (42.4-46) in women. Higher prevalence ratios (PR) were found in elders reporting unfavourable dental appearance (PR = 2.31; 95% CI: 2.02-2.65), poor chewing ability (PR = 1.64; CI: 1.48-1.8) and dental pain (PR = 1.44; CI: 1.04-1.23) in adjusted analysis. Poor self-perception was also associated with being men, black, unfavourable socioeconomic circumstances, unfavourable clinical oral health and with not using or needing a dental prosthesis. Conclusion: Assessment and understanding of self-rated oral health should take into account social factors, subjective and clinical oral symptoms.

Power series generalized nonlinear models

We introduce in this paper a new class of discrete generalized nonlinear models to extend the binomial, Poisson and negative binomial models to cope with count data. This class of models includes some important models such as log-nonlinear models, logit, probit and negative binomial nonlinear models, generalized Poisson and generalized negative binomial regression models, among other models, which enables the fitting of a wide range of models to count data. We derive an iterative process for fitting these models by maximum likelihood and discuss inference on the parameters. The usefulness of the new class of models is illustrated with an application to a real data set. (C) 2008 Elsevier B.V. All rights reserved.

Association between particulate matter from biomass burning and respiratory diseases in the southern region of the Brazilian Amazon

Objective. To investigate the short-term effects of exposure to particulate matter from biomass burning in the Amazon on the daily demand for outpatient care due to respiratory diseases in children and the elderly. Methods. Epidemiologic study with ecologic time series design. Daily consultation records were obtained from the 14 primary health care clinics in the municipality of Alta Floresta, state of Mato Grosso, in the southern region of the Brazilian Amazon, between January 2004 and December 2005. Information on the daily levels of fine particulate matter was made available by the Brazilian National Institute for Spatial Research. To control for confounding factors ( situations in which a non-causal association between exposure and disease is observed due to a third variable), variables related to time trends, seasonality, temperature, relative humidity, rainfall, and calendar effects ( such as occurrence of holidays and weekends) were included in the model. Poisson regression with generalized additive models was used. Results. A 10 mu g/m(3) increase in the level of exposure to particulate matter was associated with increases of 2.9% and 2.6% in outpatient consultations due to respiratory diseases in children on the 6th and 7th days following exposure. Significant associations were not observed for elderly individuals. Conclusions. The results suggest that the levels of particulate matter from biomass burning in the Amazon are associated with adverse effects on the respiratory health of children.

Factors associated with increased prevalence of human papillomavirus infection in a cohort of HIV-Infected Brazilian women

Objectives: Human papillomavirus (HPV) infection is a major risk factor for cervical disease. Using baseline data from the HIV-infected cohort of Evandro Chagas Clinical Research Institute at Fiocruz, Rio de Janeiro, Brazil, factors associated with an increased prevalence of HPV were assessed. Methods: Samples from 634 HIV-infected women were tested for the presence of HPV infection using hybrid capture 11 and polymerase chain reaction. Prevalence ratios (PR) were estimated using Poisson regression analysis with robust variance. Results: The overall prevalence of HPV infection was 48%, of which 94% were infected with a high-risk HPV. In multivariate analysis, factors independently associated with infection with high-risk HPV type were: younger age (<30 years of age; PR 1.5, 95% confidence interval (CI) 1.1-2.1), current or prior drug use (PR 1.3, 95% CI 1.0-1.6), self-reported history of HPV infection (PR 1.2, 95% CI 0.96-1.6), condom use in the last sexual intercourse (PR 1.3, 95% CI 1.1-1.7), and nadir CD4+ T-cell count <100 cells/mm(3) (PR 1.6, 95% CI 1.2-2.1). Conclusions: The estimated prevalence of high-risk HPV-infection among HIV-infected women from Rio de Janeiro, Brazil, was high. Close monitoring of HPV-related effects is warranted in all HIV-infected women, in particular those of younger age and advanced immunosuppression. (C) 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Landscape characteristics associated with species richness and occurrence of small native mammals inhabiting a coastal heathland: a spatial modelling approach

In the coastal region of south-western Victoria, Australia, populations of native small mammal species are restricted to patches of suitable habitat in a highly fragmented landscape. The size and spatial arrangement of these patches is likely to influence both the occupancy and richness of species at a location. Geographic Information System (GIS)-based habitat models of the species richness of native small mammals, and individual species  occurrences, were developed to produce maps displaying the spatial  configuration of suitable habitat. Models were generated using either generalised linear Poisson regression (for species richness) or logistic regression (for species occurrences) with species richness or  presence/absence as the dependent variable and landscape variables, extracted from both GIS data layers and multi-spectral digital imagery, as the predictor variables. A multi-model inference approach based on the Akaike Information Criterion was used and the resulting model was applied in a GIS framework to extrapolate predicted richness/likelihood of occurrence across the entire area of the study. A negative association between species  richness and elevation, habitat complexity and sun index indicated that richness within the study area decreases with increasing altitude, vertical vegetation structure and exposure to solar radiation. Landform  characteristics were important (to varying degrees) in determining habitat occupancy for all of the species examined, while the influence of habitat complexity was important for only one of the species. Performance of all but one of the models generated using presence/absence data was high, as indicated by the area under the curve of a receiver-operating characteristic plot. The effective conservation of the small mammal species in the area of concern is likely to depend on management actions that promote the protection of the critical habitats identified in the models.

Urban amphibian assemblages as metacommunities

1. Urban ecosystems are expanding throughout the world, and urban ecology is attracting increasing research interest. Some authors have questioned the value of existing ecological theories for understanding the processes and consequences of urbanization.
2. In order to assess the applicability of metacommunity theory to urban systems, I evaluated three assumptions that underlie the theory – the effect of patch area, the effect of patch isolation, and species–environment relations – using data on assemblages of pond-breeding amphibians in the Greater Melbourne area of Australia. I also assessed the relative impact of habitat fragmentation, habitat isolation, and changes to habitat quality on these assemblages.
3. Poisson regression modelling provided support for an important increase in species richness with patch area (pond size) and a decrease in species richness with increasing patch isolation, as measured by surrounding road cover. Holding all other variables constant, species richness was predicted to be 2·8–5·5 times higher at the largest pond than at the smallest, while the most isolated pond was predicted to have 12–19% of the species richness of the least isolated pond. Thus, the data were consistent with the first two assumptions of metacommunity theory evaluated.
4. The quality of habitat at a pond was also important, with a predicted 44–56% decrease in the number of species detected at ponds with a surrounding vertical wall compared with those with a gently sloping bank. This demonstrates that environmental differences between habitat patches were also influencing amphibian assemblages, providing support for the species-sorting and/or mass-effect perspectives of metacommunity theory.
5. Without management intervention, urbanization may lead to a reduction in the number of amphibian species persisting in urban ponds, particularly where increasing isolation of ponds by roads and associated infrastructure reduces the probability of re-colonization following local extinction.

Age-specific trends in cardiovascular mortality rates in Australia between 1980 and 2005

Aim: Recent analyses suggest the decline in coronary heart disease (CHD) mortality rates is slowing in younger age groups in countries such as the UK and US. We aimed to assess recent mortality rate trends in all circulatory disease and its subtypes in Australia.

Methods: Annual all circulatory, CHD, and cerebrovascular disease mortality rates between 1980 and 2005 for Australia were analysed. Data were stratified by sex and ten-year age group (age 35 to 85+). The annual rate of change and significant changes in trends were identified using joinpoint Poisson regression.

Results: Age standardised all circulatory disease mortality rates continue to decline in Australia, falling from 441 per 100,000 in 1980 to 145 per 100,000 in 2005 for males and from 264 per 100,000 to 96 per 100,000 for females. The rate of decline from both CHD and cerebrovascular disease appears to be stable or accelerating for individuals aged 55 years and over. However, the decline in young men and women aged 35-54 years is slowing for CHD and cerebrovascular disease mortality alike (except cerebrovascular disease mortality in males aged 35-44). For females aged 35-44 and 45-54 there has been no change in the cerebrovascular mortality rate since 1993 and 1999, respectively.

Conclusions: In Australia, whilst in older adults the decline in cardiovascular mortality rates is generally accelerating, in younger adults it appears to be slowing. It will be important to identify the causes of these trends.

Illness burden and medical comorbidity in the systematic treatment enhancement program for bipolar disorder

Objective:  Coexisting chronic medical conditions are common in bipolar disorder. Here, we report the prevalence and correlates of medical comorbidity in patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We were particularly interested in associations between variables reflecting illness chronicity and burden with comorbid medical conditions.

Method:  We used intake data from the open-label component of the STEP-BD. History of medical comorbidity was obtained from the affective disorders evaluation, and its presence was the outcome of interest. The sample size in analyses varied from 3399 to 3534. We used multiple Poisson regression to obtain prevalence ratios.

Results:  The prevalence of any medical comorbidity in the sample was 58.8%. In addition to demographic variable, several clinical characteristics were associated with the frequency of medical comorbidity. Having more than 10 previous mood episodes, childhood onset, smoking, lifetime comorbidity with anxiety, and substance use disorders were independently associated with having a medical comorbidity in the final multivariate model.

Conclusion:  The results presented here reveal strong associations between variables related to illness chronicity and medical burden in bipolar disorder. This lends further support to recent multidimensional models incorporating medical morbidity as a core feature of bipolar disorder.

Age-specific trends in cardiovascular mortality rates in the Netherlands between 1980 and 2009

Recent analyses suggest the decline in coronary heart disease mortality rates is slowing in younger age groups in countries such as the US and the UK. This work aimed to analyse recent trends in cardiovascular mortality rates in the Netherlands. Analysis was of annual all circulatory, ischaemic heart disease (IHD), and cerebrovascular disease mortality rates between 1980 and 2009 for the Netherlands. Data were stratified by sex and 10-year age group (age 35–85+). The annual rate of change and significant changes in the trend were identified using joinpoint Poisson regression. For almost all age and sex groups examined the rate of IHD and cerebrovascular disease mortality in the Netherlands has more than halved between 1980 and 2009. The decline in mortality from both IHD and cerebrovascular disease is continuing for all ages and sex groups, with anacceleration in the decline apparent from the late 1990s/early 2000s. The decline in age-specific all circulatory, coronary heart disease and cerebrovascular disease mortality rates continues for all age and sex groups in the Netherlands.

Socio-economic inequalities in mortality persist into old age in New Zealand : study of all 65 years plus, 2001-04

A number of studies have explored the relationship between socioeconomic status (SES) and mortality, although these have mostly been based on the working age population, despite the fact that the burden of mortality is highest in older people. Using Poisson regression on linked New Zealand census and mortality data (2001 to 2004, 1.3 million person years) with a comprehensive set of socioeconomic indicators (education, income, car access, housing tenure, neighourhood deprivation) we examined the association of socioeconomic characteristics and older adult mortality (65+ years) in New Zealand. We found that socioeconomic mortality gradients persist into old age. Substantial relative risks of mortality were observed for all socioeconomic factors, except housing tenure. Most relative risk associations decreased in strength with aging (e.g. most deprived compared to least deprived rate ratio for males reducing from 1.40 (95% CI 1.28 to 1.53) for 65-74 year olds to 1.13 (1.00 to 1.28) for 85+ year olds), except for income and education among women where the rate ratios changed little with increasing age. This suggests individual level measures of SES are more closely related to mortality in older women than older men. Comparing across genders, the only statistically significantly different association between men and women was for a weaker association for women for car access.

Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort

Objective: To describe risk factors for recurrence after exclusive surgical treatment of Mycobacterium ulcerans infection. Design, setting and participants: Prospective observational cohort study of all M. ulcerans cases managed with surgery alone at Barwon Health, a tertiary referral hospital, from 1 January 1998 to 31 December 2011. A random-effects Poisson regression model was used to assess rates and associations of treatment failure. Main outcome measures: Rates of treatment failure and rate ratios (RRs) for factors associated with treatment failure. Results: Of 192 patients with M. ulcerans infection, 50 (26%) had exclusive surgical treatment. Median age was 65.0 years (interquartile range [IQR], 45.5-77.7 years), and median duration of symptoms was 46 days (IQR, 26-90 days). There were 20 recurrences in 16 patients. For first lesions, the recurrence incidence rate was 41.8 (95% CI, 25.6-68.2) per 100 person-years, and median time to recurrence was 50 days (IQR, 30-171 days). Recurrence occurred ≤ 3 cm from the original lesion in 13 cases, and >3 cm in nine. On univariable analysis, age ≥60 years (RR 13.84; 95% CI, 2.21-86.68; P< 0.01), distal lesions (RR, 20.43; 95% CI, 1.97-212.22; P<0.01), positive histological margins (RR, 21.02; 95% CI, 5.51-80.26; P< 0.001), immunosuppression (RR, 17.97; 95% CI, 4.17-77.47; P <0.01) and duration of symptoms >75 days (RR, 10.13; 95% CI, 1.76-58.23; P =0.02) were associated with treatment failure. On multivariable analysis, positive margins (RR, 7.72; 95% CI, 2.71-22.01; P<0.001) and immunosuppression (RR, 6.45; 95% CI, 2.42-17.20; P =0.01) remained associated with treatment failure. Conclusions: Recurrence rates after exclusive surgical treatment of M. ulcerans disease in an Australian cohort are high, with increased rates associated with immunosuppression or positive histological margins.