To examine the association of low-grade systemic inflammation with diabetes, as well as its heterogeneity across subgroups, we designed a case-cohort study representing the ϳ9-year experience of 10,275 Atherosclerosis Risk in Communities Study participants. Analytes were measured on stored plasma of 581 incident cases of diabetes and 572 noncases. Statistically significant hazard ratios of developing diabetes for those in the fourth (versus first) quartile of inflammation markers, adjusted for age, sex, ethnicity, study center, parental history of diabetes, and hypertension, ranged from 1.9 to 2.8 for sialic acid, orosomucoid, interleukin-6, and C-reactive protein. After additional adjustment for BMI, waist-to-hip ratio, and fasting glucose and insulin, only the interleukin-6 association remained statistically significant (HR ‫؍‬ 1.6, 1.01-2.7). Exclusion of GAD antibody-positive individuals changed associations minimally. An overall inflammation score based on these four markers plus white cell count and fibrinogen predicted diabetes in whites but not African Americans (interaction P ‫؍‬ 0.005) and in nonsmokers but not smokers (interaction P ‫؍‬ 0.13). The fully adjusted hazard ratio comparing white nonsmokers with score extremes was 3.7 (P for linear trend ‫؍‬ 0.008). In conclusion, a low-grade inflammation predicts incident type 2 diabetes. The association is absent in smokers and African-Americans. Diabetes 52:1799 -1805, 2003 T ype 2 diabetes is a leading cause of morbidity and mortality. Prevention of diabetes and its associated burden, primarily cardiovascular morbidity and mortality, have become major health issues worldwide (1). Obesity has also become a public health priority, given its growing worldwide epidemic and its vast health consequences. Thus, the pathogenesis of so-called "diabesity"-type 2 diabetes in the milieu of obesity-has recently received increased attention.Although insulin resistance and ␤-cell failure continue to be recognized as the central causal processes in the development of type 2 diabetes, other paradigms have evolved. Influenced by findings indicating an inflammatory basis for cardiovascular diseases and following the "common soil" hypothesis of coronary heart disease and type 2 diabetes, we investigated the association between inflammation markers and incident diabetes, reporting in 1999 that a low-grade inflammation precedes and predicts diabetes development in adults participating in the Atherosclerosis Risk in Communities (ARIC) Study (2). Several reports investigating various markers of inflammation in different population groups have confirmed this association (3-11). The marked variation in magnitude of these reported associations and the frequently modest correlations found between markers of inflammation highlight the difficulty of characterizing this low-grade systemic inflammatory state on the basis of a single analyte.Thus, the purpose of this study is to evaluate the association of incident type 2 diabetes with several markers of inflammation, examined individu...

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The aim of this study was to investigate the relationship between feeding practices in the first year of life and the occurrence of severe early childhood caries (S-ECC) at 4 years of age. A birth cohort study (n = 500) was conducted in children who were born within the public health system in São Leopoldo, Brazil. Feeding practices were assessed using standardized methods at 6 and 12 months of age. A total of 340 children were examined at 4 years of age. S-ECC was defined as recommended by an expert panel for research purposes: ≧1 cavitated, missing or filled smooth surfaces in primary maxillary anterior teeth or d₁₊ mfs ≧5. Poisson regression with robust variance was used in order to determine the early feeding practices which represent risk factors for the occurrence of S-ECC at 4 years of age. The multivariable model showed a higher adjusted risk of S-ECC for the following dietary practices at 12 months: breastfeeding ≧7 times daily (RR = 1.97; 95% CI = 1.45–2.68), high density of sugar (RR = 1.43; 95% CI = 1.08–1.89), bottle use for liquids other than milk (RR = 1.41; 95% CI = 1.08–1.86), as well as number of meals and snacks >8 (RR = 1.42; 95% CI = 1.02–1.97). Mother’s education ≤8 years was also associated with the outcome. The present study identified early feeding practices which represent risk factors for caries severity in subsequent years. These findings may contribute to developing general and oral health interventions, with special attention to families with low maternal education.

Aims/hypothesis The aim of this study was to investigate the association of leptin levels with incident diabetes in middle-aged adults, taking into account factors purportedly related to leptin resistance. Subjects and methods We conducted a case-cohort study (570 incident diabetes cases and 530 non-cases) representing the 9-year experience of 10,275 participants of the Atherosclerosis Risk in Communities Study. Plasma leptin was measured by direct sandwich ELISA. Results In proportional hazards models adjusting for age, study centre, ethnicity and sex, high leptin levels (defined by sex-specific cut-off points) predicted an increased risk of diabetes, with a hazard ratio (HR) comparing the upper with the lower quartile of 3.9 (95% CI 2.6-5.6). However, after further adjusting additionally for obesity indices, fasting insulin, inflammation score, hypertension, triglycerides and adiponectin, high leptin predicted a lower diabetes risk (HR=0.40, 95% CI 0.23-0.67). Additional inclusion of fasting glucose attenuated this protective association (HR=0.59, 95% CI 0.32-1.08, p<0.03 for linear trend across quartiles). In similar models, protective associations were generally seen across subgroups of sex, race, nutritional status and smoking, though not among those with lower inflammation scores or impaired fasting glucose (interaction p=0.03 for both). Conclusions/interpretation High leptin levels, probably reflecting leptin resistance, predict an increased risk of diabetes. Adjusting for factors purportedly related to leptin resistance unveils a protective association, independent of adiponectin and consistent with some of leptin's described protective effects against diabetes.

OBJECTIVES:To determine the characteristics, the frequency and the mortality rates of patients needing mechanical ventilation and to identify the risk factors associated with mortality in the intensive care unit (ICU) of a general university hospital in southern Brazil.METHOD:Prospective cohort study in patients admitted to the ICU who needed mechanical ventilation for at least 24 hours between March 2004 and April 2007.RESULTS:A total of 1,115 patients admitted to the ICU needed mechanical ventilation. The mortality rate was 51%. The mean age (± standard deviation) was 57±18 years, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22.6±8.3. The variables independently associated with mortality were (i) conditions present at the beginning of mechanical ventilation, age (hazard ratio: 1.01; p<0.001); the APACHE II score (hazard ratio: 1.01; p<0.005); acute lung injury/acute respiratory distress syndrome (hazard ratio: 1.38; p=0.009), sepsis (hazard ratio: 1.33; p=0.003), chronic obstructive pulmonary disease (hazard ratio: 0.58; p=0.042), and pneumonia (hazard ratio: 0.78; p=0.013) as causes of mechanical ventilation; and renal (hazard ratio: 1.29; p=0.011) and neurological (hazard ratio: 1.25; p=0.024) failure, and (ii) conditions occurring during the course of mechanical ventilation, acute lung injuri/acute respiratory distress syndrome (hazard ratio: 1.31; p<0.010); sepsis (hazard ratio: 1.53; p<0.001); and renal (hazard ratio: 1.75; p<0.001), cardiovascular (hazard ratio: 1.32; p≤0.009), and hepatic (hazard ratio: 1.67; p≤0.001) failure.CONCLUSIONS:This large cohort study provides a comprehensive profile of mechanical ventilation patients in South America. The mortality rate of patients who required mechanical ventilation was higher, which may have been related to the severity of illness of the patients admitted to our ICU. Risk factors for hospital mortality included conditions present at the start of mechanical ventilation conditions that occurred during mechanical support.

The ELSA-Brasil (Estudo Longitudinal de Saúde do Adulto -Brazilian Longitudinal Study for Adult Health) is a cohort study composed of 15,105 adults followed up in order to assess the development of chronic diseases, especially diabetes and cardiovascular disease. Its size, multicenter nature and the diversity of measurements required effective and effi cient mechanisms of quality assurance and control. The main quality assurance activities (those developed before data collection) were: careful selection of research instruments, centralized training and certifi cation, pretesting and pilot studies, and preparation of operation manuals for the procedures. Quality control activities (developed during data collection and processing) were performed more intensively at the beginning, when routines had not been established yet. The main quality control activities were: periodic observation of technicians, test-retest studies, data monitoring, network of supervisors, and cross visits. Data that estimate the reliability of the obtained information attest that the quality goals have been achieved. 2Quality assurance and control in ELSA-Brasil Schmidt MI et al Health research aims primarily to fi nd answers to diverse health issues, and the integrity of results is strongly determined by the quality of the information produced. 1,5,6 To guarantee the quality of the data in the Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil -Brazilian Longitudinal Study for Adult Health), Quality Assurance and Control (QAC) tools were developed, like the ones described by Szklo & Nieto, 7 for the planning, execution and analysis of epidemiological studies.ELSA-Brasil is a cohort study that aims to follow up 15,000 participants, in six research centers, based on interviews and tests of varied complexities. These characteristics -large size, longitudinal nature, multicenter organization, measurements of distinct complexities -structured the strategic defi nition of the QAC system to be adopted.Experience in planning and conducting large longitudinal studies, especially from the 1950s onwards, has enabled the development of QAC tools to be used in cohort studies 8 and in randomized clinical trials. 4 The QAC system of Elsa-Brasil was based on this international experience, and necessary adaptations were performed by the Steering Committee and its Advisory Committees, founded on principles outlined by the QAC Committee.The present study aimed to describe the QAC actions in the ELSA-Brasil, presenting them in the sequence in which they were developed and indicating how and when key QAC decisions were adopted in the construction of the cohort and in its follow-up. QUALITY ASSURANCEQuality assurance activities in the ELSA are defi ned by the set of actions developed before the beginning of data collection, in order to ensure the quality desired for the study's results. They are:• development of the research protocol;• selection of research instruments to fulfi ll the objectives of the study, based on literature data;• development of t...

Using a FPG cut-off to diagnose GDM and to determine the need for post-load OGTT measurements is a valid strategy to diagnose GDM by IADPSG criteria. This approach may improve feasibility of applying IADPSG diagnostic criteria by reducing costs and increasing convenience.