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BackgroundThe Study of Cardiovascular Risk in Adolescents (Portuguese acronym, “ERICA”) is a multicenter, school-based country-wide cross-sectional study funded by the Brazilian Ministry of Health, which aims at estimating the prevalence of cardiovascular risk factors, including those included in the definition of the metabolic syndrome, in a random sample of adolescents aged 12 to 17 years in Brazilian cities with more than 100,000 inhabitants. Approximately 85,000 students were assessed in public and private schools. Brazil is a continental country with a heterogeneous population of 190 million living in its five main geographic regions (North, Northeast, Midwest, South and Southeast). ERICA is a pioneering study that will assess the prevalence rates of cardiovascular risk factors in Brazilian adolescents using a sample with national and regional representativeness. This paper describes the rationale, design and procedures of ERICA.Methods/DesignParticipants answered a self-administered questionnaire using an electronic device, in order to obtain information on demographic and lifestyle characteristics, including physical activity, smoking, alcohol intake, sleeping hours, common mental disorders and reproductive and oral health. Dietary intake was assessed using a 24-hour dietary recall. Anthropometric measures (weight, height and waist circumference) and blood pressure were also be measured. Blood was collected from a subsample of approximately 44,000 adolescents for measurements of fasting glucose, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, glycated hemoglobin and fasting insulin.DiscussionThe study findings will be instrumental to the development of public policies aiming at the prevention of obesity, atherosclerotic diseases and diabetes in an adolescent population.

OBJECTIVE To estimate the prevalence of arterial hypertension and obesity and the population attributable fraction of hypertension that is due to obesity in Brazilian adolescents.METHODS Data from participants in the Brazilian Study of Cardiovascular Risks in Adolescents (ERICA), which was the first national school-based, cross-section study performed in Brazil were evaluated. The sample was divided into 32 geographical strata and clusters from 32 schools and classes, with regional and national representation. Obesity was classified using the body mass index according to age and sex. Arterial hypertension was defined when the average systolic or diastolic blood pressure was greater than or equal to the 95th percentile of the reference curve. Prevalences and 95% confidence intervals (95%CI) of arterial hypertension and obesity, both on a national basis and in the macro-regions of Brazil, were estimated by sex and age group, as were the fractions of hypertension attributable to obesity in the population.RESULTS We evaluated 73,399 students, 55.4% female, with an average age of 14.7 years (SD = 1.6). The prevalence of hypertension was 9.6% (95%CI 9.0-10.3); with the lowest being in the North, 8.4% (95%CI 7.7-9.2) and Northeast regions, 8.4% (95%CI 7.6-9.2), and the highest being in the South, 12.5% (95%CI 11.0-14.2). The prevalence of obesity was 8.4% (95%CI 7.9-8.9), which was lower in the North region and higher in the South region. The prevalences of arterial hypertension and obesity were higher in males. Obese adolescents presented a higher prevalence of hypertension, 28.4% (95%CI 25.5-31.2), than overweight adolescents, 15.4% (95%CI 17.0-13.8), or eutrophic adolescents, 6.3% (95%CI 5.6-7.0). The fraction of hypertension attributable to obesity was 17.8%.CONCLUSIONS ERICA was the first nationally representative Brazilian study providing prevalence estimates of hypertension in adolescents. Regional and sex differences were observed. The study indicates that the control of obesity would lower the prevalence of hypertension among Brazilian adolescents by 1/5.

OBJECTIVE To determine the prevalence of metabolic syndrome and its components in Brazilian adolescents. METHODS We evaluated 37,504 adolescents who were participants in the Study of Cardiovascular Risks in Adolescents (ERICA), a cross-sectional, school-based, national study. The adolescents, aged from 12 to 17 years, lived in cities with populations greater than 100,000 inhabitants. The sample was stratified and clustered into schools and classes. The criteria set out by the International Diabetes Federation were used to define metabolic syndrome. Prevalences of metabolic syndrome were estimated according to sex, age group, school type and nutritional status. RESULTS Of the 37,504 adolescents who were evaluated: 50.2% were female; 54.3% were aged from 15 to 17 years, and 73.3% were from public schools. The prevalence of metabolic syndrome was 2.6% (95%CI 2.3-2.9), slightly higher in males and in those aged from 15 to 17 years in most macro-regions. The prevalence was the highest in residents from the South macro-region, in the younger female adolescents and in the older male adolescents. The prevalence was higher in public schools (2.8% [95%CI 2.4-3.2]), when compared with private schools (1.9% [95%CI 1.4-2.4]) and higher in obese adolescents when compared with nonobese ones. The most common combinations of components, referring to 3/4 of combinations, were: enlarged waist circumference (WC), low HDL-cholesterol (HDL-c) and high blood pressure; followed by enlarged WC, low HDL-c and high triglycerides; and enlarged WC, low HDL-c, high triglycerides and blood pressure. Low HDL was the second most frequent component, but the highest prevalence of metabolic syndrome (26.8%) was observed in the presence of high triglycerides. CONCLUSIONS ERICA is the first Brazilian nation-wide study to present the prevalence of metabolic syndrome and describe the role of its components. Despite the prevalence of Metabolic Syndrome being low, the high prevalences of some components and participation of others in the syndrome composition shows the importance of early diagnosis of this changes, even if not grouped within the metabolic syndrome.

BackgroundSecondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.ObjectivesTo conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.MethodsIncluded studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin–renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.ResultsOf 2246 screened articles, 25 studies were included (12 trials, 11 cohort studies, 1 cross-sectional study and 1 case–control study) with 132 140 individuals overall (smallest n=30, largest n=63 301). 3 studies included upper middle-income countries, 1 included a low middle-income country and 21 (84%) included high-income countries (9 in the USA). Studies concerned established CVD (n=4), cerebrovascular disease (n=7) and coronary heart disease (n=14). Three studies considered persistence and adherence. Quantity and quality of evidence was limited for adherence, persistence and across drug classes. Studies were concerned with governance and delivery (n=19, including 4 trials of fixed-dose combination therapy, FDC), intellectual resources (n=1), human resources (n=1) and health system financing (n=4). Full prescription coverage, reduced copayments, FDC and counselling were facilitators associated with higher adherence.ConclusionsHigh-quality evidence on health system barriers and facilitators to adherence to secondary prevention medications for CVD is lacking, especially for low-income settings. Full prescription coverage, reduced copayments, FDC and counselling may be effective in improving adherence and are priorities for further research.

OBJECTIVE To determine the distribution of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides in Brazilian adolescents, as well as the prevalence of altered levels of such parameters.METHODS Data from the Study of Cardiovascular Risks in Adolescents (ERICA) were used. This is a country-wide, school-based cross-sectional study that evaluated 12 to 17-year old adolescents living in cities with over 100,000 inhabitants. The average and distribution of plasma levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were evaluated. Dyslipidemia was determined by levels of total cholesterol ≥ 170 mg/dl, LDL cholesterol ≥ 130 mg/dl, HDL cholesterol < 45 mg/dL, or triglycerides ≥ 130 mg/dl. The data were analyzed by gender, age, and regions in Brazil.RESULTS We evaluated 38,069 adolescents – 59.9% of females, and 54.2% between 15 and 17 years. The average values found were: total cholesterol = 148.1 mg/dl (95%CI 147.1-149.1), HDL cholesterol = 47.3 mg/dl (95%CI 46.7-47.9), LDL cholesterol = 85.3 mg/dl (95%CI 84.5-86.1), and triglycerides = 77.8 mg/dl (95%CI 76.5-79.2). The female adolescents had higher average levels of total cholesterol, LDL cholesterol, and HDL cholesterol, without differences in the levels of triglycerides. We did not observe any significant differences between the average values among 12 to 14 and 15- to 17-year old adolescents. The most prevalent lipid alterations were low HDL cholesterol (46.8% [95%CI 44.8-48.9]), hypercholesterolemia (20.1% [95%CI 19.0-21.3]), and hypertriglyceridemia (7.8% [95%CI 7.1-8.6]). High LDL cholesterol was found in 3.5% (95%CI 3.2-4.0) of the adolescents. Prevalence of low HDL cholesterol was higher in Brazil’s North and Northeast regions.CONCLUSIONS A significant proportion of Brazilian adolescents has alterations in their plasma lipids. The high prevalence of low HDL cholesterol and hypertriglyceridemia, especially in Brazil’s North and Northeast regions, must be analyzed in future studies, to support the creation of strategies for efficient interventions.

Surgical correction of tracheal stenosis is still a complex and challenging procedure. Acellular human amniotic membranes (AHAM) represent a promising biomaterial source for tissue regeneration. The aim of this study was to evaluate whether AHAM grafts improve tissue regeneration of the trachea in a rabbit model of tracheostomy. Twenty rabbits were randomized into 2 groups. Animals in the control group underwent surgical tracheostomy only, and animals in the AHAM group underwent surgical tracheostomy and received an AHAM graft that covered the defect site. We examined tissues at the site of tracheostomy 60 days after surgery by histological analysis with haematoxylin and eosin, Movat's pentachrome stain and immunohistochemistry by analysis with antiaggrecan antibodies. The average perimeter and area of the defect 60 days after surgery were smaller in animals in the control group than in the AHAM group (p = .011 and p = .011, respectively). Histological analysis of AHAM group revealed neovascularization, islands of immature cartilage, pseudostratified ciliated epithelium. and connective tissue at the site of AHAM engraftment, whereas only pseudostratified ciliated epithelium and connective tissue were observed at the defect site in tissues of animals in the control group. Regeneration of islands of immature cartilage tissue with hyaline pattern and pseudostratified ciliated epithelium were confirmed by immunohistochemistry analysis. These results indicate that AHAM engraftment could facilitate neovascularization and regeneration of immature cartilage in a model of tracheal injury. Its use may lower the risk of post-operative complications including stenosis of trachea.

In the last two decades, statin therapy has proved to be the most potent isolated therapy for attenuation of cardiovascular risk. Its frequent use has been seen as one of the most important elements for the reduction of cardiovascular mortality in developed countries. However, the recurrent incidence of muscle symptoms in statin users raised the possibility of causal association, leading to a disease entity known as statin associated muscle symptoms (SAMS). Mechanistic studies and clinical trials, specifically designed for the study of SAMS have allowed a deeper understanding of the natural history and accurate incidence. This set of information becomes essential to avoid an unnecessary risk of severe forms of SAMS. At the same time, this concrete understanding of SAMS prevents overdiagnosis and an inadequate suspension of one of the most powerful prevention strategies of our times. In this context, the Luso-Latin American Consortium gathered all available information on the subject and presents them in detail in this document as the basis for the identification and management of SAMS.