Brazilian Public Health System Research Articles

Chronic Pancreatitis in a Large Developing Country: Temporal Trends of Over 64,000 Hospitalizations from 2009 to 2019.

Chronic pancreatitis (CP) is a progressive inflammatory disorder associated with marked morbidity and mortality and frequently requires hospitalization. This study aimed to investigate the time trends and geographical distribution of hospital admissions, the lethality rate of CP across Brazil, and the potential relationship with social indicators and associated risk factors. Data were retrospectively obtained from the Brazilian Public Health System Registry between January 2009 and December 2019. The prevalence and lethality rates of CP per 100,000 inhabitants in each municipality were estimated from hospitalizations to in-hospital deaths and classified by age, sex, and demographic features. During the study period, 64,609 admissions were retrieved, and most of the patients were males (63.54%). Hospitalization decreased by nearly half (-54.68%) in both sexes. CP rates in males were higher in all age groups. The greatest reduction in admissions (-64%) was also noted in patients ≥ 70y. CP In-hospital lethality remained stable (5-6%) and similar for males and females. Patients ≥ 70y showed the highest lethality. The greatest increase in CP lethality rates (+ 10%) was observed in municipalities integrated into metropolises, which was mainly driven by small-sized municipalities (+ 124%). CP hospitalizations decrease in both urban and rural areas, particularly in the North, Northeast, and Central-West regions, and in those above 70years of age, but are not correlated with lethality rates in the South. This suggests ongoing changes in the environmental and socioeconomic factors in Brazil.

Perceptions of physicians on the use of screening tools for mental disorders in primary health care in Brazil.

This study aimed to analyse perceptions, knowledge and ways of incorporating screening tools for mental disorders (MDs) into the daily practice of physicians working in primary health care (PHC) in the Brazilian public health system. This is a descriptive qualitative study with a sample of 24 physicians. The data collected in the semi-structured interviews were subjected to reflective thematic analysis. The use of screening tools was low, not only due to lack of knowledge, but also due to reasoned criticism of this strategy developed by physicians trained in PHC. Physicians also presented a scenario of chaos, work overload and the fragility of the psychosocial care network as barriers to effective care of patients with MDs and to the incorporation of innovations in this care. Interventions aimed at improving the quality of mental health care should include training on the topic, (re)organizing work processes, strengthening the health care network and producing robust scientific evidence on interventions aimed at qualifying professionals in mental health in PHC.

Homeopathy as a Means to Improve Quality of Life.

Quality of life is a fundamental aspect of good health and differs from person to person, highlighting the importance of individualisation, which is one of the principles of homeopathic doctrine. Homeopathy aligns with the principles of the Brazilian public health system, reflecting the latter's ethos of universality, accessibility, care coordination, and comprehensiveness, offering a whole-person approach to health care. Homeopathy's individualised approach and expanded view of the health-disease process, with emphasis on healthy lifestyle guidance, contributes to the promotion of individual good health and quality of life. These attributes of homeopathy make it a valuable therapeutic option, with relevance to the health service of Brazil as well as to that of other countries across the world.

#2019 Comparing survival outcomes between hemodialysis and hemodiafiltration using real-world data from Brazil

Abstract Background and Aims The CONVINCE trial and others studies, demonstrates that high-dose hemodiafiltration offers a survival advantage and benefits in reducing cardiovascular complications for patients in high-flux hemodiafiltration group compared to hemodialysis. Method We compared the outcomes of hemodialysis and hemodiafiltration using real-world data. We conducted an analysis on a cohort of patients who underwent hemodiafiltration therapy (HDF) at a single center, NefroStar Clinics from 28/06/2021 to 30/05/2023. The results obtained were then compared with data from patients receiving hemodialysis (HD) therapy within the Brazilian Public Health System (SUS). Baseline data, type of access for dialysis and adequacy tests obtained through the average of monthly tests were collected. The HDF data were obtained through automatic extraction of electronic medical records and the HD data were obtained by Datasus. The primary outcome was mortality from any cause. Results 85 patients undergoing hemodiafiltration were compared with 149,372 patients receiving hemodialysis through the Brazilian Public Health System (SUS). Using a 2:1 propensity score, we compared the 170 best-match HD patients along with 85 HDF patients. The percentage of vascular access and male sex were similar in both groups. The mean age of HDF and HD patients was 54 [41-67] and 58 [46-68] years, p=0.054, respectively. The adequacy tests show higher hemoglobin values and mores PTH values in the HDF group. In the Cox analysis, HDF therapy showed a reduced risk of mortality with an HR of 0.29 [0.11 – 0.77]. The propensity score analysis showed a HR of 0.32 [95% CI: 0.11 – 0.91]. This analysis was adjusted for age, type of access, KT/v, hemoglobin, and phosphorus. The Kaplan-Meier analysis showed respective survival rates for HDF and HD at the end of one year, 92.1% and 79.9%, p<0.001. Conclusion These results suggest high flux hemodiafiltration had survival advantages over hemodialysis in real word scenario.

Enhancing diagnostic accuracy of multiple myeloma through ML-driven analysis of hematological slides: new dataset and identification model to support hematologists

Multiple Myeloma (MM) is a hematological malignancy characterized by the clonal proliferation of plasma cells within the bone marrow. Diagnosing MM presents considerable challenges, involving the identification of plasma cells in cytology examinations on hematological slides. At present, this is still a time-consuming manual task and has high labor costs. These challenges have adverse implications, which rely heavily on medical professionals’ expertise and experience. To tackle these challenges, we present an investigation using Artificial Intelligence, specifically a Machine Learning analysis of hematological slides with a Deep Neural Network (DNN), to support specialists during the process of diagnosing MM. In this sense, the contribution of this study is twofold: in addition to the trained model to diagnose MM, we also make available to the community a fully-curated hematological slide dataset with thousands of images of plasma cells. Taken together, the setup we established here is a framework that researchers and hospitals with limited resources can promptly use. Our contributions provide practical results that have been directly applied in the public health system in Brazil. Given the open-source nature of the project, we anticipate it will be used and extended to diagnose other malignancies.

Cost-effectiveness of restorative treatments for permanent molars with severe molar incisor hypomineralization: perspectives for the Brazilian public health system.

To undertake a cost-effectiveness analysis of restorative treatments for a first permanent molar with severe molar incisor hypomineralization from the perspective of the Brazilian public system. Two models were constructed: a one-year decision tree and a ten-year Markov model, each based on a hypothetical cohort of one thousand individuals through Monte Carlo simulation. Eight restorative strategies were evaluated: high viscosity glass ionomer cement (HVGIC);encapsulated GIC; etch and rinse adhesive + composite; self-etch adhesive + composite;preformed stainless steel crown; HVGIC + etch and rinse adhesive + composite; HVGIC + self-etch adhesive + composite, and encapsulated GIC + etch and rinse adhesive + composite. Effectiveness data were sourced from the literature. Micro-costing was applied using 2022 USD market averages with a 5% variation. Incremental cost-effectiveness ratio (ICER), net monetary benefit (%NMB), and the budgetary impact were obtained. Cost-effective treatments included HVGIC (%NMB = 0%/0%), encapsulated GIC (%NMB = 19.4%/ 19.7%), and encapsulated GIC + etch and rinse adhesive + composite (%NMB = 23.4%/ 24.5%) at 1year and 10years, respectively. The benefit gain of encapsulated GIC + etch and rinse adhesive + composite in relation to encapsulated GIC was small when compared to the cost increase at 1year (gain of 3.28% and increase of USD 24.26) and 10years (gain of 4% and increase of USD 15.54). Within the horizon and perspective analyzed, the most cost-effective treatment was encapsulated GIC restoration. This study can provide information for decision-making.

Abstract PO4-16-06: From Real-World Data to Improved Outcomes: Examining the Impact of Trastuzumab Disparities on Pathological Complete Response and Long-Term Survival in HER-2 Positive Breast Cancer Patients within the Brazilian Public Health System

Abstract Introduction: Equitable access to healthcare is a fundamental principle of public health, aiming to ensure that all individuals have the opportunity to receive effective treatments. However, disparities in access to healthcare still persist in many countries, including Brazil. These disparities can have significant impacts on the health and well-being of patients, particularly in the case of breast cancer treatment. Neoadjuvant chemotherapy (NAC) has been increasingly used for the treatment of breast cancer, encompassing conditions ranging from locally advanced tumors to early-stage triple-negative and HER-2 positive tumors. Objectives: The aim of this study is to evaluate the impact of disparities in the use of trastuzumab (Herceptin) within the Brazilian public health system on pathological complete response (pCR), overall survival (OS), and disease-free survival (DFS). We aim to investigate whether variations in access to trastuzumab treatment influence the achievement of pCR and impact long-term survival outcomes in breast cancer patients. Methods: This retrospective, multicenter cohort study included female patients over 18 years of age with a diagnosis of non-metastatic breast cancer undergoing NAC. pCR was defined as the absence of residual invasive or in situ tumor in the breast and axilla. As an exploratory real-world data study, no confirmatory hypothesis was established, thus no corrections for multiple comparisons were necessary. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method, calculated at five years. The study was approved by the Research Ethics Committee with registration number CAAE 64633422.4.0000.5463. Results: Between 2011 and 2020, a total of 1,891 patients were included in the study, of whom 454 (22.9%) were HER-2 positive. The pCR rate was 25.7%. Trastuzumab was accessed by 291 (64.1%) patients (p < 0.001). Among those who received trastuzumab, pCR was observed in 105 (36.1%) patients, compared to 12 (7.6%) in those who did not have access to trastuzumab (p < 0.001). OS in HER-2 positive patients was 90.1% with pCR and 64.5% without pCR (log-rank p < 0.001), while DFS was 89.2% with pCR and 68.2% without pCR (log-rank p = 0.003). Evaluating OS and DFS in patients who received trastuzumab versus those who did not, OS with trastuzumab and pCR was 94.3% and without pCR was 89.5% (log-rank p < 0.001); OS without trastuzumab and pCR was 83.3% and without pCR was 58.2% (log-rank p < 0.001). DFS in patients who received trastuzumab and achieved pCR was 94.5% and without pCR was 90.5% (log-rank p = 0.05), whereas without trastuzumab and pCR was 79.9% and without pCR was 62.1% (log-rank p = 0.001). Conclusion: These findings underscore the significant impact of disparities in trastuzumab utilization within the Brazilian public health system on pCR rates and long-term survival outcomes in HER-2 positive breast cancer patients. Access to trastuzumab was associated with higher pCR rates and improved overall and disease-free survival rates. Ensuring equitable access to targeted therapies is crucial for improving treatment response and long-term outcomes in breast cancer patients. Table 1 Clinicopathological characteristics of patients Legend: AJCC, American Joint Committee on Cancer; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; HR hormonal receptor. Table 2 - NAC schemas and correlation with pCR. AC-T, doxorubicin + cyclophosphamide – taxane; AC-TH, doxorubicin + cyclophosphamide – taxane+herceptin. Citation Format: Marcelo Antonini, Andre Mattar, Gabriel Pannain, Fernanda Grace Bauk Richter, Andressa Amorim, Marina Diogenes, Odair Ferraro, Luiz Gebrim, Reginaldo Coelho Lopes, Juliana Real. From Real-World Data to Improved Outcomes: Examining the Impact of Trastuzumab Disparities on Pathological Complete Response and Long-Term Survival in HER-2 Positive Breast Cancer Patients within the Brazilian Public Health System [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-16-06.

Abstract PO1-09-09: The journey of HR positive, HER2 negative metastatic breast cancer’s patients: heterogeneities and barriers in Brazilian public health system- a national survey

Abstract Background: Breast cancer is the most common neoplasm in Brazilian women, with high percent of patients diagnosed in advanced stages. Metastatic breast cancer (mBC) is a challenge in the country, where 75% of the population is covered by public health system (Sistema Único de Saúde, SUS). We conducted an on-line survey to describe the journey of human epidermal growth factor receptor 2-negative (HER2-), hormone receptor positive (RH+) mBC patients across public scenario in Brazil. Methods: An on-line survey comprised of 39 to 48 (depending on the kind of some questions, which could open another question in case of affirmative answer) objective questions were sent by e-mail to180 oncologists working in public and private health care system. Questions were focused on assessing wait time for first treatment after admission in the hospital in both systems, availability of oncological drugs within SUS according to essential medicines list by World Health Organization, and presence of palliative and multidisciplinary teams in both systems. Continuous variables were measured by median and mean. The level of statistical significance adopted was 5% with Teste p two-sided. Analyses were performed using SAS statistical software (version 25.0). Results: We had 150 respondents working in SUS and private health system, which fulfilled the inclusion criteria to participate in this survey. The other 30 respondents were excluded from the study because they worked exclusively in SUS or exclusively in the private system, and their answers were not analyzed. Median wait time for surgery was 60 days in the SUS (N=150) and 30 days in the private health system (N=150) e (p < 0,0001). Regardless of chemotherapy provided, median waiting time was 30 and 15 days in the SUS (N=150) and the private health system (N=150), respectively (p < 0,0001). Most oncologists in the SUS (N=125, 83.3%) pointed to endocrine therapy as their first-choice treatment in mBC. Concerning endocrine therapy in the SUS, Gonadotropin-Releasing Hormone Agonist (GnRHa) was available, and it was prescribed by 54 (36.0%) and Fulvestrant for 72 (48.0%) of respondents. Considering chemotherapy, weekly paclitaxel alone or combined with platin were available and they were prescribed by 124 (82.6%) and 109 (72.6%) of oncologists respectively. Vinorelbine was available and it was prescribed according to oncologists’ report by 109 (72.6%) and Pegylated liposomal doxorubicin (PLD) by 38 (25.3%) of oncologists. Oncologists answered agree or strongly agree that they had a multidisciplinary care team in SUS 77,3% (N =116) versus 87,3% (N=131) in the private system (p=0.022). Concerning palliative care 66,09% (N= 99) in the SUS versus 82,0% (N=123) in the private system answered that they agreed or strongly agreed that this service was available (p=0.001). Conclusions: The Brazilian government has continuously improved delivery of services and medicines via the public system (SUS), but there are still significant differences within this system and versus the private sector. Unavailability of endocrine therapy agents as GnRHa and Fulvestrant, and some chemotherapy agents as PLD and Vinorelbine for high percentage of patients, raises the existence of disparities within SUS. Also, longer waiting times for treatment in the SUS, lower availability of support teams such multidisciplinary and palliative care, they point out disparities between SUS and private health systems. The lack of a National Cancer Control Program and low health investment by Brazilian government might explain the difference in cancer patients’ access. Citation Format: Heloísa Resende, Igor Soares, Angélica Renó, Ana Cunha, Vinícius Aguiar, Letícia Tureta, Viviane Pereira. The journey of HR positive, HER2 negative metastatic breast cancer’s patients: heterogeneities and barriers in Brazilian public health system- a national survey [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-09.

Abstract PO2-20-05: Onco-Genome Brazil: Mapping Breast and Prostate Cancer in the Brazilian Public Health System

Abstract Background: Breast and prostate cancers are the most common malignancies diagnosed in women and men respectively, and present with great clinical heterogeneity, even in tumors with the same phenotypic characteristics. Somatic and germline molecular alterations in DNA may have prognostic and predictive impact, influencing response to therapies and overall survival. In addition, the evaluation of germline mutations can help identify individuals and families at higher risk for developing cancer. Aims: Our aim is to characterize the somatic and germline genomic landscape of women with locally advanced HER2-positive breast cancer and men with metastatic prostate cancer from Brazil. Secondarily, we aim to identify genetic variants associated with tumor prognosis and treatment response, identify patients carrying pathogenic alterations in cancer-predisposing genes, and characterize the genetic ancestry of the population included in the study. Trial design: This observational multicenter cohort study (NCT05306600) will include 550 adult patients from the five macro-regions of Brazil, divided into two arms: 1) breast cancer and 2) prostate cancer. Clinical and pathological data will be collected, as well as DNA samples from peripheral blood and tumor tissue. Whole-exome sequencing (WES) will be performed to identify variants that may be drivers and/or actionable in a specific patient or tumor. These variants will be interpreted and classified according to their population frequencies, in silico predictors, functional studies, and literature data, following international guidelines proposed by expert societies. This trial is supported by the Ministry of Health in Brazil and includes patients of the Public Health System. Eligibility criteria: In arm 1, the inclusion criteria are patients with a histological diagnosis of breast carcinoma with overexpression of HER-2, clinical stage II or III, and undergoing neoadjuvant treatment with chemotherapy plus trastuzumab. In arm 2, the criteria are patient with histological diagnosis of prostate adenocarcinoma, currently in clinical stage IV. Patients without availability of biological material collection are excluded from the study, as well as patients in whom there was no central confirmation of required histology. Statistical methods: Univariate and multivariate analyses will be conducted to evaluate the possible effect of specific genes or mutations on the investigated outcomes, including tumor prognosis and treatment response. Discussion: Currently, 265 participants have already been included in the study, 150 in arm 1 and 115 in arm 2. This trial will contribute to the construction of a robust database that should provide a better understanding of the genomic profile of patients with breast and prostate cancer in Brazil. For more information about the trial, please contact Daniela Rosa (daniela.rosa@hmv.org.br). Citation Format: Jaqueline Schuch, Cláudia Bordignon, Mahira Rosa, Angélica de Baumont, Marina Bessel, Gabriel Macedo, Daniela Rosa. Onco-Genome Brazil: Mapping Breast and Prostate Cancer in the Brazilian Public Health System [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-20-05.

Abstract PO1-09-12: Cancer health disparities among patients with early-stage estrogen receptor-positive (ER+) breast cancer treated in public or private practices in Brazil

Abstract Background Cancer registries in Brazil are deficient and data about patients’ profiles and cancer treatment patterns are scarce in the country. Moreover, while 30% of population has access to private insurance, almost 70% of population uses publicly health services. The objective of this work was to describe the sociodemographic and clinicopathological characteristics of women with early-stage ER+ breast cancer on adjuvant ET in different regions of Brazil, and to describe treatment patterns for this disease according public and private institutions. Methodology: We performed a real-world data analysis in different institution regions of Brazil. Women with a history of early-stage ER+ invasive carcinoma of the breast on adjuvant endocrine therapy for at least 6 months were invited to participate of this study in 12 centers in four different regions in Brazil. Demographic and clinicopathologic information was retrieved from medical records. In order to compare healthcare insurance type, we considered patients who were treated under the Brazilian public health system as publicly insured, and women who had private insurance or paid for their treatment as privately insured. High education level was defined by completed high school. Data collection was done with RedCap software. Qualitative variables were compared between groups using the Chi-square or exact Chi-square test and for quantitative variables the non-parametric Mann-Whitney test was used. P < 0.05 was considered significant. Analyzes were performed in SAS 9.4; Results: From June 2021 to May 2023, a total of 461 women with ER+, early BC, were included in this analysis. A total of 233 (50.6%) came from private institutions, the mean age was 56.02 years (range 22-93), 47.69% were non-white, 61.3% were post-menopause, 61.7% lived with a partner, and 76.2% were highly educated and 66.81% had comorbidities. Tumor staging at diagnosis was classified as III, II and I respectively in 21.26%, 43.17% and 35.57% of all cases. Regarding treatment received, 62.4% of patients underwent lumpectomy, 32.2% had axillary dissection, 67.6% received (neo)adjuvant chemotherapy, 45.2% were on aromatase inhibitors and 14.19% were on ovarian function suppression plus ET . Median duration of ET use was 2.78 years (range 6 months- 9.61 years). Publicly health insurance was associated significantly associated with younger age at diagnosis (< 60 yo), premenopausal status, to live alone, lower educational level, more advanced tumors, prior mastectomy, prior axillary dissection, prior neo-adjuvant chemotherapy, prior radiotherapy, lower use of aromatase inhibitors, ovarian function suppression plus ET, and CDK4/6 inhibitors, while higher use of concomitant medications. Conclusion: The study shows significant health disparities among women with early-stage ER+ breast cancer treated in private versus public institutions in Brazil. Importantly, despite having more advanced tumors, women in public institution had less access to ovarian suppression, CDK4/6 inhibitors and were treated with more aggressive surgical procedures. A deep discussion involving government, lawmakers, health care providers and patients should be conducted to try to decrease the described disparities. Patient’s characteristic and patterns of treatment among patients with estrogen receptor-positive breast cancer on adjuvant therapy according to health insurance in Brazil ALND: axillary lymph node dissection; CDK4/6i: CDK4/6 inhibitors; ET: endocrine therapy; OS: ovary suppression. Citation Format: Romualdo Barroso-Sousa, Daniele Assad-Suzuki, Danielle Santos, Fernanda Moura, Sulene Oliveira, Anna Luiza Galvão, Bruno Souza, Amanda Castro, Monalisa Andrade, Andrea Shimada, Yuri Beckedorff, Maria Cristina Magalhães, Cristiano Souza, Carlos Paiva, Heloísa Resende, Daniela Pereira, Angelica Rodrigues, Daniela Rosa. Cancer health disparities among patients with early-stage estrogen receptor-positive (ER+) breast cancer treated in public or private practices in Brazil [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-12.

Parkinson's disease and its financial impact on the Brazilian public health system

Parkinson's disease and its financial impact on the Brazilian public health system

Germline mutations in BRCA1 and BRCA2 among Brazilian women with ovarian cancer treated in the Public Health System

BackgroundGermline mutations in BRCA1 and BRCA2 genes are among the main causes of hereditary ovarian cancer. Identifying these mutations may reduce cancer risk, facilitate early detection, and enable personalized treatment. However, genetic testing is limited in the Brazilian Public Health System, and data regarding germline mutations in many regions are scarce. Therefore, the study aimed to investigate the prevalence of germline mutations in BRCA1 and BRCA2 in women with ovarian cancer treated in the Public Health System in Pernambuco, Brazil.MethodsA cross-sectional study was conducted in the Hereditary Cancer Program from two reference oncological centers in Pernambuco. Women (n = 45) with high-grade serous ovarian cancer underwent genetic counseling and DNA sequencing for BRCA1 and BRCA2 genes.ResultsThe prevalence of deleterious mutations in the BRCA1 and BRCA2 genes was 33%. Of the 15 germline mutations found, 13 were in BRCA1 and 2 in BRCA2; two mutations of unknown clinical significance were also found in BRCA2. Mutations c.5266dupC and c.2215 A > T were the most frequent; each was mutation observed in three patients. Additionally, the mutations c.7645dupT and c.921dupT were reported for the first time.ConclusionOne in three women showed a pathogenic mutation, demonstrating a significant prevalence of germline mutations in this sample. Additionally, the small sample revealed an interesting number of mutations, indicating the need to explore more regions of the country.

Brazilian Psychiatric Association Consensus on the physical structure and ideal team for psychiatric emergencies services.

An integral part of Brazil's public health system, the psychiatric emergency service (PES) has been instrumental in improving qualified support for crisis situations of mental disorders, equitable, universally accessible, and humanized. The purpose of this article is to present a systematic review and consensus about the physical area and facilities, and ideal team qualified for psychiatric emergencies services on both Brazilian settings. The authors conducted a literature search using electronic databases such as MEDLINE (PubMed), Scielo, the Cochrane Database, and documents from the WHO, the Brazilian Ministry of Health, and others deemed relevant by experts. A total of 6839 manuscripts were found, but only 46 were selected. The analysis of article content summarizes consensus statements using the Delphi method and a series of interactive versions to provide a final report. Changes to PES are evaluated considering various experiences and models. The authors highlighted that The Emergency Care Network (ECN) must be coordinated with qualified management, effective implementation of integration of all health equipment's and units. PES must have adequate infrastructure; qualified staff, including a psychiatrist; sufficient consultation and observational spaces; tools and resources for differential diagnosis; training for all staff members; and communication with the health care network to facilitate referrals following patient discharge are all necessary. These standardized models need to be available to public health managers so that they can guide the installation of new services and adjust the existing ones, always looking for improvement. The authors propose requirements for PES as a model to be passed over.

Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system

BackgroundCerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost...

Mapping breast and prostate cancer in the Brazilian public health system: study protocol of the Onco-Genomas Brasil.

Breast and prostate cancers are the most common malignancies diagnosed in women and men respectively, and present with great clinical heterogeneity, even in tumors with the same histology and same site of origin. Somatic and germline molecular alterations in DNA may have prognostic and predictive impact, influencing response to therapies and overall survival. Our aim is to characterize the somatic and germline genomic landscape of women with locally advanced HER2-positive breast cancer and men with metastatic prostate cancer in Brazil. Secondarily, we aim to identify genetic variants associated with tumor prognosis and treatment response, identify patients carrying pathogenic alterations in cancer-predisposing genes, and characterize the genetic ancestry of the population included in the study. This observational multicenter cohort study will include 550 adult patients from the five macro-regions of Brazil, divided into two arms: 1) breast cancer and 2) prostate cancer. Clinical and pathological data will be collected, as well as DNA samples from peripheral blood and tumor samples. In arm 1, the inclusion criteria are a histological diagnosis of breast carcinoma with overexpression of HER-2, clinical stage II or III, and current neoadjuvant treatment with chemotherapy plus trastuzumab. In arm 2, the criterion is a histological diagnosis of prostate adenocarcinoma, clinical stage IV. Whole-exome sequencing (WES) will be performed to identify variants that may be drivers and/or actionable in a specific patient or tumor. These variants will be interpreted and classified according to their population frequencies, in silico predictors, functional studies, and literature data, following international guidelines proposed by expert societies. This trial will contribute to the construction of a robust database that should provide a better understanding of the genomic profile of patients with breast and prostate cancer in Brazil. Considering the miscegenation of the Brazilian population, knowledge generated from these data will have implications for future studies of this specific population. [clinicaltrial.gov], identifier [NCT05306600].

Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium and risk factors among pregnant women in Brazil: Results from the national molecular diagnosis implementation project.

Sexually transmitted infections (STIs) are a public health problem. The aim of the present study was to assess the prevalence and risk factors associated with at least one STI (Chlamydia trachomatis [CT], Neisseria gonorrhoeae [NG], Trichomonas vaginalis [TV], and Mycoplasma genitalium [MG]) in Brazil. A cross-sectional study was conducted using secondary data from the pilot implementation of the National Service for molecular diagnosis of CT, NG, TV, and MG in pregnancy. We obtained Ministry of Health surveillance data from the implementation project. Data encompassing pregnant women aged 15-49 years from public antenatal clinics in Brazil in 2022 were included. A total of 2728 data of pregnant women were analyzed. The prevalence of at least one infection was 21.0% (573), with the highest prevalence in the Southeast region (23.3%) and the lowest in the Center-West region (15.4%). The prevalence of CT was 9.9% (270), NG 0.6% (16), TV 6.7% (184), and MG 7.8% (212). Factors associated with any infection were from 15 to 24 years (AOR = 1.93; 95% CI: 1.58-2.35); reported family income up to US$400 (AOR = 1.79; 95% CI: 1.03-3.34); declared not living maritally with their partners (AOR = 1.90, 95% CI: 1.52-2.37) and had more than one sexual partner in their lifetime (AOR = 2.09, 95% CI: 1.55-2.86). This study showed a high prevalence of at least one STI among pregnant women in Brazil, particularly among younger women. It also provides up-to-date national data on CT, NG, TV, and MG infections in this population. These findings underscore the importance of enhancing access to STI screening for young pregnant women within the Brazilian public health system.

Evaluation of hematological changes and immune response biomarkers as a prognostic factor in critical patients with COVID-19.

COVID-19 disease has been a challenge for health systems worldwide due to its high transmissibility, morbidity, and mortality. Severe COVID-19 is associated with an imbalance in the immune response, resulting in a cytokine storm and a hyperinflammation state. While hematological parameters correlate with prognosis in COVID patients, their predictive value has not been evaluated specifically among those severely ill. Therefore, we aim to evaluate the role of hematological and immune response biomarkers as a prognostic factor in critically ill patients with COVID-19 admitted to the intensive care unit. From May 2020 to July 2021, a retrospective cohort study was conducted in a reference hospital in Manaus, which belongs to the Brazilian public health system. This study was carried out as single-center research. Clinical and laboratory parameters were analyzed to evaluate the association with mortality. We also evaluated the role of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein-to-lymphocyte ratio (CLR). We gathered information from medical records, as well as from prescriptions and forms authorizing the use of antimicrobial medications. During the study period, 177 patients were included, with a mean age of 62.58 ± 14.39 years. The overall mortality rate was 61.6%. Age, mechanical ventilation (MV) requirement, leukocytosis, neutrophilia, high c-reactive protein level, NLR, and CLR showed a statistically significant association with mortality in the univariate analysis. In the multivariate logistic regression analysis, only MV (OR 35.687, 95% CI: 11.084-114.898, p< 0.001) and NLR (OR 1.026, 95% CI: 1.003-1.050, p = 0.028) remained statistically associated with the outcome of death (AUC = 0.8096). While the need for mechanical ventilation is a parameter observed throughout the hospital stay, the initial NLR can be a primary risk stratification tool to establish priorities and timely clinical intervention in patients with severe COVID-19 admitted to the ICU.

Access to Dermatological Services in the Brazilian Public Health System: a literature review

Introdução: Este estudo aborda os serviços dermatológicos do sistema público de saúde do Brasil, enfatizando os desafios de disponibilidade e acessibilidade. Examina os factores socioeconómicos, geográficos, culturais e psicológicos que influenciam o acesso, propondo estratégias para melhorar a situação. Oferecendo um panorama abrangente, o artigo busca ampliar a compreensão do estado atual e apresentar soluções para melhorar o acesso aos serviços dermatológicos no país. Objetivo: Este estudo investiga de forma abrangente os serviços dermatológicos do sistema público de saúde do Brasil, analisando disponibilidade, acessibilidade e determinantes que impactam o acesso. Tem como objetivo identificar estratégias para melhorar o acesso, considerando aspectos socioeconômicos, geográficos, culturais e psicológicos. O objetivo principal é contribuir para o aprofundamento do conhecimento do estado atual dos serviços dermatológicos no Brasil, oferecendo insights relevantes para políticas e práticas que promovam a equidade no acesso. Metodologia: Uma busca sistemática de fontes, incluindo artigos científicos e relatórios governamentais, foi realizada para investigar serviços dermatológicos no sistema público de saúde do Brasil. O período abrangido foi 2000-2023, priorizando a investigação científica. A seleção foi baseada em títulos e resumos, seguida de análise detalhada. Os resultados foram organizados em temas-chave, proporcionando uma visão abrangente. Cada estudo foi avaliado criticamente, destacando lacunas, desafios e possíveis estratégias para melhorar o acesso dermatológico no Brasil. Discussão e Resultados: O estudo destaca a oferta integral de serviços dermatológicos no sistema público de saúde do Brasil, abordando o diagnóstico, tratamento e prevenção de doenças de pele. O acesso a estes serviços enfrenta desafios, incluindo barreiras socioeconómicas, geográficas e culturais. As estratégias propostas para melhorar o acesso incluem teledermatologia, intervenções educativas e uma maior oferta de dermatologistas. A revisão enfatiza lacunas, desafios e a importância de abordagens equitativas para garantir acesso igualitário aos cuidados dermatológicos no Brasil. Conclusão: O estudo ressalta o papel crucial dos dermatologistas na saúde pública brasileira, revelando desafios no acesso aos serviços dermatológicos, principalmente para comunidades carentes. Discute-se a correlação entre cor/raça da pele e prevalência de doenças, expondo disparidades. O programa Redes Brasil é reconhecido como uma solução potencial, mas persiste o acesso limitado nas áreas rurais. A pesquisa destaca a necessidade de um serviço dermatológico robusto e diversidade de força de trabalho. A discussão fornece informações valiosas para melhorar o acesso aos cuidados dermatológicos no sistema público de saúde do Brasil.

Assessment of potential transthyretin amyloid cardiomyopathy cases in the Brazilian public health system using a machine learning model.

To identify and describe the profile of potential transthyretin cardiac amyloidosis (ATTR-CM) cases in the Brazilian public health system (SUS), using a predictive machine learning (ML) model. This was a retrospective descriptive database study that aimed to estimate the frequency of potential ATTR-CM cases in the Brazilian public health system using a supervised ML model, from January 2015 to December 2021. To build the model, a list of ICD-10 codes and procedures potentially related with ATTR-CM was created based on literature review and validated by experts. From 2015 to 2021, the ML model classified 262 hereditary ATTR-CM (hATTR-CM) and 1,581 wild-type ATTR-CM (wtATTR-CM) potential cases. Overall, the median age of hATTR-CM and wtATTR-CM patients was 66.8 and 59.9 years, respectively. The ICD-10 codes most presented as hATTR-CM and wtATTR-CM were related to heart failure and arrythmias. Regarding the therapeutic itinerary, 13% and 5% of hATTR-CM and wtATTR-CM received treatment with tafamidis meglumine, respectively, while 0% and 29% of hATTR-CM and wtATTR-CM were referred to heart transplant. Our findings may be useful to support the development of health guidelines and policies to improve diagnosis, treatment, and to cover unmet medical needs of patients with ATTR-CM in Brazil.

Analysis of Lower Limb Amputations in Brazil’s Public Health System over 13 Years

Understanding the causes of amputation is crucial for defining health policies that seek to avoid such an outcome, but only a few studies have investigated the epidemiology of patients submitted to amputations in developing countries. The objective of this study was to analyse all lower limb amputations performed in the public health system in Brazil over a 13 year period, evaluating trends in the number of cases, patient demographics, associated aetiologies, hospital length of stay, and in hospital mortality rate. This was a retrospective, population based analysis of all lower limb amputations performed in the Brazilian public health system between 1 January 2008 and 31 December 2020. Using a public database, all types of amputations were selected, defining the number of procedures, their main aetiologies, anatomical level of limb loss, demographic data, regional distribution, and other variables of interest. A total of 633 455 amputations were performed between 2008 and 2020, mostly (55.6%) minor amputations, predominantly in males (67%). There was an upward trend in the number of amputations, determined mainly by the increase in major amputations (50.4% increase in the period). Elderly individuals have the highest rates of amputation. Diabetes mellitus (DM) is becoming the main primary diagnosis associated with amputations over the years. The highest in hospital mortality rate occurred after major amputations and was associated with peripheral arterial disease (PAD). Amputation rates in Brazil show an upward trend. DM is becoming the most frequent associated primary diagnosis, although PAD is the diagnosis most associated with major amputations and in hospital death.