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Background: Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision., Methods: We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach., Discussion: This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments., Systematic Review Registration: PROSPERO CRD42023402365., (© 2024. The Author(s).)

Cumulative trauma is usually devastating and can lead to severe psychological consequences, including posttraumatic stress disorder (PTSD). Exposure to various types of traumas, particularly during childhood, can be even more deleterious than the sheer number of events experienced. This epidemiological study is the first to investigate the impact of discrete childhood traumatic exposure on the risk of developing lifetime PTSD in a representative sample of the general population of the two biggest Brazilian cities. Participants were aged between 15 and 75 years old, living in São Paulo and Rio de Janeiro, Brazil, who had experienced traumatic events (N = 3,231). The PTSD diagnosis was assessed using the DSM-IV criteria through the version 2.1 of Composite International Diagnostic Interview. To operationalize childhood cumulative trauma, we considered the sum of 15 different childhood trauma categories that occurred before PTSD onset. The final multivariate logistic regression model indicated a strong relationship between the number of discrete types of childhood traumas and the likelihood of the lifetime PTSD development. The lifetime PTSD risk increased 28 % with each different type of childhood trauma when adjusted by confounds. Our study strengthens the evidence associating childhood cumulative trauma to increased lifetime PTSD risk., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Internet-delivered cognitive-behavioral therapy (I-CBT) is effective in treating post-traumatic stress disorder (PTSD) symptoms, offering enhanced accessibility and cost-effectiveness. However, it's important to note that these technologies may not be suitable for all age groups. Therefore, we conducted a systematic review and meta-analysis to determine if the effectiveness of I-CBT in treating PTSD varies based on the patients' mean age. We conducted a systematic review of the literature, focusing on randomized controlled trials (RCTs) in the ISI Web of Science, PubMed/MEDLINE, and PsycINFO databases. Following this, we performed a meta-analysis and evaluated the risk of bias using the Cochrane risk of bias quality assessment tool. In this study, we examined patient-related factors (civil or military status, age, and gender), clinical characteristics (baseline PTSD severity and type of trauma), and treatment characteristics (type of intervention, synchronous or asynchronous delivery, and the number of sessions) as independent variables. The dependent variable was the reduction in mean PTSD symptoms. Five RCTs out of 1,552 screened studies were included in this review, all of which showed some level of concern regarding potential bias. Our meta-analysis indicates that I-CBT is equally effective regardless of patients' mean age. Since all RCTs included only provide the mean age of the patients, further randomized controlled trials should address the effectiveness of I-CBT among different age groups.

Objective: This study aims to investigate handgrip strength and dynapenia prevalence among older adults stratified by Brazilian macroregions. Additionally, we aim to evaluate the overlap between dynapenia and Instrumental Activities of Daily Living (IADL) disability, depression, and executive dysfunction on a national basis and by each Brazilian macroregion., Methods: This cross-sectional analysis was based on data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil). A multistage cluster sample design was used, with a representative population-based study of non-institutionalized community-dwelling Brazilians aged ≥ 50 years from 70 municipalities across all five macroregions of the country. The outcome variable was dynapenia. Covariables were IADL disability, depression, and executive dysfunction. The Brazilian macroregions were used for stratification. In addition, the following additional variables were included: age group, gender, education level, macroregions (North, Northeast, Southeast, South, and Midwest), self-reported health, multimorbidity, and falls., Results: A total of 8,849 (94%) of the sample provided complete information for the handgrip strength assessment and were included in this analysis. Dynapenia prevalence was higher in North and Northeast regions (28.5% and 35.1%, respectively). We identified statistically significant differences between different macroregions for dynapenia, IADL disability, and verbal fluency, with worse values in the North and Northeast regions. In the North and Northeast macroregions, nearly half of the subjects that presented executive dysfunction and IADL disability also had dynapenia. There was a more significant overlap in the prevalence of all four conditions in the North and Northeast regions (4.8% and 5.5%, respectively), whereas the overlap was smaller in the South (2.3%). There was also a smaller overlap in the prevalence of dynapenia and depression in the South (5.8%) compared with other macroregions., Conclusions: Macroregions in Brazil exhibit marked differences in the prevalence of dynapenia and in its overlap with IADL disability, depression, and executive dysfunction.

The aim of this study was to estimate the prevalence of sexual dysfunction in depressive disorders in individuals not in pharmacological treatment. For this purpose, we performed a systematic review and meta-analysis using the PRISMA guidelines, and the review was registered in PROSPERO (registration number CRD42020179709). Studies that evaluated sexual function and dysfunction in major depressive disorder (MDD) and persistent depressive disorder (PDD) were identified through searches in PubMed/Medline, Web of Science, PsychINFO, Scopus, and Scielo. Twelve cross-sectional studies were eligible. In women with MDD, the pooled prevalence rates of sexual impairment were: 47.22% (95% CI: 34.86-59.58) for arousal; 65.30% (95% CI: 45.86-84.73) for desire; 36.98% (95% CI: 28.42-45.54) for lubrication; 34.17% (95% CI: 17.87-50.46) for orgasm; and 33.91% (95% CI: 17.48-50.34) for sexual satisfaction. In men, the sexual impairment prevalence rates were: 26.45% (95% CI: 12.26-40.63) for arousal; 40.32% (95% CI: 22.19-58.46) for desire; 32.07% (95% CI: 26.14-37.99) for erection; 35.27% (95% CI: 5.13-65.41) for orgasm; and 23.05% (95% CI: 13.60-32.51) for sexual satisfaction. Overall sexual dysfunction was found in 82.75% of women (95% CI: 74.71-90.78) and 63.26% of men (95% CI: 52.83-73.69). Our results show that various sexual functions are impaired in MDD, making imperative the systematic evaluation of these alterations by clinicians. Future studies should be conducted, especially in PDD, to elucidate the role of these disorders in sexual function., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To assess sexual desire in patients with treatment-resistant depression (TRD)., Methods: Baseline data were analyzed from an ongoing cohort study at an outpatient clinic specializing in TRD treatment in Brazil. The cohort comprised consecutive patients with the diagnosis of TRD who sought treatment at this center between November 2015 and January 2021. The Hamilton Depression Rating Scale (HDRS) genital symptoms item (item 14) was used as a proxy to assess sexual desire., Results: Sixty-five participants with TRD were included. There was sexual desire impairment in 67.7% of patients. Men (87.5%) were more affected than women (61.2%), and this difference was statistically significant ( P  = .05). Depression severity was associated with greater complaints of this aspect of sexual function ( P  < .01)., Conclusions: Participants with TRD had a high prevalence of sexual desire impairment, which was associated with greater depressive symptom severity and male sex. The findings suggest that health care professionals should systematically assess sexual desire in patients with TRD in daily clinical practice. Further longitudinal studies are needed in larger samples using specific instruments for assessing sexual dysfunction and comparing TRD and non-TRD populations., (© Copyright 2022 Physicians Postgraduate Press, Inc.)

Background: Posttraumatic stress disorder (PTSD) is a prevalent and disabling multisystem disorder, with significant physical and psychiatric morbidity and poor quality of life (QOL). Although peritraumatic reactions - tonic immobility and dissociation - are established predictors of PTSD severity and development, there is a dearth of investigation assessing the impact of peritraumatic reactions on QOL of PTSD patients. Quality of life has become increasingly important in health care and research as a reliable outcome measure. It comprises psychological, physical, social and environmental domains, providing important information about the impact of diseases on patient's life. This study aims to investigate the impact of peritraumatic tonic immobility and peritraumatic dissociation on QOL of PTSD civilian outpatients., Subjects and Methods: It is a cross-sectional study of 50 victims of urban violence with current PTSD, recruited in a specialized outpatient clinic. Instruments used were: Structured Clinical Interview IV, Peritraumatic Dissociative Experiences Questionnaire, Tonic Immobility Scale and WHOQOL-BREF (psychological, physical, social and environmental domains). Linear regression models were fitted to evaluate the impact of peritraumatic reactions - tonic immobility and dissociation - on WHOQOL-BREF scores. We controlled for sex as potential confounding., Results: The severity of peritraumatic tonic immobility negatively impacted on psychological and environment domains of quality of life. For each additional point on the Tonic Immobility Scale, there was a decreased of 0.8 points on the scores of these domains of WHOQOL-BREF. Neither the peritraumatic reactions showed effects on physical nor social domains. Possible limitations of this study include cross-sectional design, relatively small sample size of tertiary center outpatients and recall bias., Conclusions: Peritraumatic tonic immobility is related to poor quality of life, adding new insights about the relationship between this immobility reaction and PTSD.

Objectives: To compare musculoskeletal changes on a physical examination (PE), ultrasound (US) and magnetic resonance imaging (MRI) of the hands and wrists of patients with Chikungunya fever (CF)., Methods: The sample consisted of 30 patients in the chronic phase of CF. The sites analyzed were the interphalangeal (IP), metacarpophalangeal (MCP) and wrist/mediocarpal (WMC) joints and periarticular soft tissue. The interval between the PE and imaging tests was 7 days, and the interval between US and MRI was 2 days. The kappa coefficient was calculated to estimate the agreement between the PE and US and MRI findings and between the US and MRI findings., Results: Significant agreement was observed between PE and US in the diagnosis of synovitis. The only statistically significant agreement between US and MRI was the finding of flexor tenosynovitis; the agreement was moderate., Conclusions: US has great potential for use in diagnosing synovitis suspected based on a PE. The limited agreement observed between US and MRI, in turn, may suggest a complementary role of these methods., (© 2021 American Institute of Ultrasound in Medicine.)

Background: Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD)., Methods: We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I ² statistic and tested using the χ². This study was registered at PROSPERO (number 127170)., Results: The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies ( I 2  = 41.8, p  = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79)., Conclusion: The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.

The objective of this review is to provide an updated synthesis of studies in individuals with eating disorders that examined the following components of binge eating episodes (BEEs): caloric intake, episode duration, and also the association of BEE size with psychopathology. A systematic review and meta-analysis were performed following the PRISMA guidelines. Searches were conducted on PubMed, PsycINFO, Scopus, SciELO, ScienceDirect and ProQuest databases. Meta-analysis was performed using random effects models and meta-regression. Forty-three studies were included. There was a paucity of information regarding BEE in individuals with anorexia nervosa. The pooled caloric intake of participants with bulimia nervosa (BN) during BEE in laboratory studies was significantly greater in comparison to the caloric intake during BEE in clinical studies [(3070 (95%CI 2596, 3544) vs. 1789 (95%CI 1498, 2081)], respectively. In participants with binge eating disorder (BED), the pooled means were 2088 (95%CI 1819, 2358) kcal in laboratory studies and 1903 (95%CI 1622, 2184) kcal in clinical studies, with no statistically significant difference between groups. Overall, BEE had a mean duration of 37.3 min in participants with BN and 41.7 min in those with BED. We found a positive correlation between the average caloric intake and level of depression (β = 55.5; p = 0.019). BEE in individuals with BN or BED were characterized by the consumption of extremely large quantities of calories. This was mainly found in laboratory studies of individuals with BN. BEE had a mean duration of less than 1 h in individuals with BN or BED. BEE size was positively associated with depression severity. Future research should explore the relevance of binge size as a core component of binge eating in clinical samples, in males, and in pediatric populations., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: To estimate the prevalence of intermittent explosive disorder (IED) in comorbidity with other psychiatric disorders and to describe the temporal sequencing of disorders in the São Paulo Metropolitan Area, Brazil., Methods: Data from the São Paulo Megacity Mental Health Survey, a population-based study of 5037 adult individuals, were analyzed. The World Health Organization Composite International Diagnostic Interview (CID 3.0) was used to assess lifetime DSM-IV disorders, including IED, with a response rate of 81.3%., Results: The majority (76.8%) of respondents with IED meet the criteria for at least one other psychiatric disorder, with a prevalence almost twice as high as that observed in individuals without IED. The prevalence of any anxiety, mood, impulse control or substance use disorders in respondents with IED was more than two times higher compared to those without IED, with prevalence ratios ranging from 2.1 (95% CI 1.74-2.48) to 2.9 (95% CI 2.12-4.06). The diagnosis of IED occurred earlier than most of the other mental disorders, except for those with usual onset in early childhood, as Specific and Social Phobias and Attention Deficit Disorder., Conclusion: Considering that IED is a highly comorbid disorder and has an earlier onset than most other mental comorbidities in the Brazilian general population, these results may be useful in guiding governmental mental health actions.

Objectives: Tinnitus is the perception of sound in ears or head without corresponding external stimulus. Despite the great amount of literature concerning tinnitus treatment, there are still no evidence-based established treatments for curing or for effectively reducing tinnitus intensity. Sham-controlled studies revealed beneficial effects using repetitive transcranial magnetic stimulation (rTMS). Still, results show moderate, temporary improvement and high individual variability. Subcallosal area (ventral and dorsomedial prefrontal and anterior cingulate cortices) has been implicated in tinnitus pathophysiology. Our objective is to evaluate the use of bilateral, high frequency, dorsomedial prefrontal cortex (DMPFC) rTMS in treatment of chronic subjective tinnitus., Design: Randomized placebo-controlled, single-blinded clinical trial. Twenty sessions of bilateral, 10 Hz rTMS at 120% of resting motor threshold of extensor hallucis longus were applied over the DMPFC. Fourteen patients underwent sham rTMS and 15 were submitted to active stimulation. Tinnitus Handicap Inventory (THI), visual analog scale, and tinnitus loudness matching were obtained at baseline and on follow-up visits. The impact of intervention on outcome measures was evaluated using mixed-effects restricted maximum likelihood regression model for longitudinal data., Results: A difference of 11.53 points in the THI score was found, favoring the intervention group (p = 0.05). The difference for tinnitus loudness matching was of 4.46 dB also favoring the intervention group (p = 0.09)., Conclusions: Tinnitus treatment with high frequency, bilateral, DMPFC rTMS was effective in reducing tinnitus severity measured by THI and matched tinnitus loudness when compared to sham stimulation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Obesity hypertension is an ongoing pandemic. The first-line medications to treat this condition are still subject to debate. We compared diuretics, calcium-channel blockers (CCB), beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) as an initial antihypertensive therapy for prevention of cardiovascular morbimortality of hypertensive individuals who are overweight or obese., Methods: We conducted a search of the literature for randomized clinical trials in which at least 50% of the participants were overweight or obese. The primary outcomes were all-cause mortality, cardiovascular mortality, acute myocardial infarction (MI), heart failure (HF), stroke, or end-stage renal disease., Results: Our search yielded 16 randomized studies. Comparisons of two classes of drugs with at least two studies indicated that (1) CCB and ACEI increased the risk of HF [relative risk (RR) = 2.26; 95% confidence interval (CI) 1.16-4.40] and stroke [hazard ratio (HR) = 1.13; 1.00-1.26]), respectively, compared to diuretics; and (2) CCB showed a reduction in stroke (HR = 0.77; 0.66-0.89) and total mortality (HR = 0.94; 0.87-1.01) compared to the BB atenolol. Comparisons of two classes of antihypertensive medications with only one study showed that the risk of MI was higher with ARB valsartan versus CCB (HR = 1.19; 95% CI 1.02-1.38, p = 0.02). In contrast, losartan lowered the risk of a composite cardiovascular outcome compared to atenolol (HR = 0.87; 95% CI 0.77-0.98, p = 0.02)., Conclusions: In hypertensive subjects with excess weight, diuretics are more effective for preventing HF and stroke than CCB and ACEI, respectively. CCB are a good first-line choice for prevention of cardiovascular disease, except HF.

Background: To evaluate the early age of onset (AOO) of alcohol consumption and its association with sociodemographic, nutritional and lifestyle characteristics., Methods: A national cross-sectional multi-centered study assessed 12-17-year old adolescents from 1247 public and private schools in 124 Brazilian municipalities with more than 100 000 habitants. Our variable of interest was the AOO of alcohol consumption. Covariates comprised sociodemographic status, lifestyle habits and nutritional parameters. We used adapted survival models to investigate the association between covariates and the AOO of alcohol consumption., Results: From a sample of 67 672 adolescents, 50% were females. The mean AOO of alcohol consumption was 12.9 years. Male adolescents had a lower mean age of alcohol experimentation when compared to females in Northeast and South regions. The difference between private and public school for AOO was observed only for the Northeast Region (12.6 versus 13.1, respectively). Adolescents who reported smoking or mental health problems or from the Southern Region presented earlier alcohol use. Physical activity and overweight were positively associated with earlier use of alcohol., Conclusions: There is no homogeneity in the AOO of alcohol consumption among adolescents, which should be considered when formulating public policies and government campaigns directed toward reducing alcohol consumption., (© The Author(s) 2019. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

There is an increasing interest in the study of the aggregation of risk factors for noncommunicable chronic diseases. However, there are no studies among adolescents stratified by alcohol use. This study investigated the aggregation of cardiovascular risk factors in adolescents considering the use or not of alcohol. A total of 73,624 Brazilian adolescents aged 12-17 years from public and private schools were evaluated in a national cross-sectional study (March-2013 to December-2014). The aggregation of cardiovascular risk factors was the main outcome. The regression model was adjusted for sex, age, region of Brazil, and school type. Most alcohol users were 16 to 17 years old, while nonusers were between 12 and 13 years. Alcohol users showed a higher prevalence of smoking (8.1% vs. 0.8%) and sleep inadequacy (59.9% vs. 51.4%) than nonusers did. On the other hand, a sufficient level of physical activity was more frequent among alcohol users (51.2% vs. 44.2%). The presence of only one cardiovascular risk factor was more frequent in nonusers (42.3%) than alcohol users (38.9%). Alcohol users tended to aggregate more for the category of 3-4 cardiovascular risk factors when compared with the non-alcohol-using population (10.9% vs. 7.9%). Aggregation of three cardiovascular risk factors was more likely to be observed among male adolescent alcohol users. Inadequate sleep and smoking habit tended to aggregate among alcohol users. This finding highlights the importance of public policies aiming to reduce alcohol consumption at early ages and, consequently, to decrease the risk of future morbimortality of noncommunicable chronic diseases., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: In recent decades there has been an increase in the use of antidepressants (AD) and a decrease in the use of benzodiazepines (BDZ). Prevalence, cumulative incidence, and factors associated with the incidence of AD and BDZ use in a Brazilian population were estimated in this article., Methods: Data were collected with a self-administered questionnaire in a cohort of employees from a university in Rio de Janeiro. The prevalence of the use of AD and BDZ was calculated for 1999 (4,030), 2001 (3,574), 2006-07 (3,058), and 2012 (2,933). The cumulative incidences of the use of AD and BDZ between 1999 and 2007 were estimated by the Poisson models with robust variance estimates., Results: In 1999, the prevalence of the use of AD and BDZ were 1.4% (95%CI: 1.1-1.8) and 4.7% (95%CI: 4.1-5.4), respectively; in 2012, they were 5.4% (95%CI: 5.5-6.2) and 6.8% (95%CI: 6.0-7.8). The incidence of use, between 1999 and 2007, was 4.9% (95%CI: 4.2-5.7) for AD and 8.3% (95%CI: 7.3-9.3) for BDZ. The incidences of AD and BDZ use were higher among women and participants with a positive General Health Questionnaire., Conclusion: In this population, the increase in the use of AD was not accompanied by a decrease in the use of BDZ, showing the prescriptions for psychotropic medication do not follow the currently recommended guidelines for treatment of common mental health disorders.

Background: This study investigated the patterns of comorbidity between PTSD and depression, other anxiety disorders, alcohol-related disorders using the DSM-IV and ICD-10 criteria. The temporal sequence of the comorbid diagnoses was also investigated., Methods: We used data from a large population-based survey carried out between 2007 and 2008 in the two largest cities in Brazil: São Paulo and Rio de Janeiro., Results: Diagnoses of depression, other anxiety disorders, and alcohol-related disorder were more prevalent in the people with PTSD than in those without PTSD. Using the DSM-IV criteria, approximately 67% of cases presenting PTSD were also diagnosed with another mental disorder. The diagnosis category of other anxiety disorders presented the highest proportion of comorbidity (53%). Depression was found in 34% person with PTSD whilst alcohol-related disorders were observed in 7%. Considering the temporal relationship, the onset of comorbid depression was uniformly distributed through the periods before, within the same year and after PTSD's onset. When other anxiety disorders were comorbid with PTSD, in almost 90% of the cases the other anxiety disorders preceded PTSD. For comorbidity between of alcohol-related disorders and PTSD, in 50% of the cases alcohol-related disorders preceded the diagnosis of PTSD., Limitations: The cross-sectional design imposes limitations on establishing a temporal relationship between the onset of psychiatric disorders due to memory bias., Conclusions: Our findings indicate that among individuals presenting comorbid PTSD and other anxiety disorders, this diagnosis tend to precede PTSD. Comorbid cases are more frequent and more severe, and this should be taken into account in therapeutic research and clinical practice., Competing Interests: Declaration of Competing Interest Bressan reports, during the conduct of the study: grants, personal fees and non-financial support from Janssen, personal fees from Aché Laboratórios Farmacêuticos, grants and personal fees from Roche, outside the submitted work. The other authors declare that they have no competing interests., (Copyright © 2019. Published by Elsevier B.V.)

This study aimed to analyze the aggregation of alcohol consumption, smoking, excess weight, and short sleep in Brazilian adolescents. This was a cross-sectional multicenter study conducted with teens participating in the Study of Cardiovascular Risk Factors in Adolescents (ERICA in Portuguese). The sample consisted of adolescents that answered the complete questionnaires on sleep, tobacco, and alcoholic beverages, in addition to having their weight and height measured. Aggregation was analyzed by comparing the observed and expected prevalence of risk factors in all possible groupings, with the respective 95% confidence intervals. Analyses were performed in Stata 14 using the svy (survey) command for complex sample data. The sample included 73,624 adolescents, of whom 25.5% had excess weight and 24.2% consumed alcoholic beverages. Aggregation of the four risk factors was O/E = 5.6. Aggregation of three factors was more prevalent in those 15 to 17 years of age (P = 4.8). In the POR (prevalence odds ratio) analysis of the combination of two risk factors, those that smoked showed 11.80 higher odds of also consuming alcohol, compared to those that did not smoke, and vice versa, in private schools. In relation to age, adolescents 12 to 14 years of age that smoked showed 15.46 times higher odds of also drinking, and vice and versa. Adolescents in the sample presented the aggregate presence of four risk factors, and there was a significant relationship between tobacco and alcohol consumption.

Bariatric surgery has been recognized as the gold standard treatment for severe obesity. Although postbariatric surgery patients usually achieve and maintain substantial weight loss, a group of individuals may exhibit weight regain. Several factors are proposed to weight regain, including psychiatric comorbidity. The objective of the study is to conduct a systematic review and meta-analysis of studies investigating the relationship between psychiatric comorbidity and weight regain. A systematic review through PubMed, Web of Science, Cochrane Library, Scopus, and PsycINFO was performed, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a stepwise selection, 13 articles were included in the qualitative analysis and 5 were included for a meta-analysis. Women was majority in most of the studies (87.6%), and a bypass procedure was the bariatric intervention most evaluated (66.8%), followed by gastric banding (32.1%) and sleeve (1.1%). Higher rates of postbariatric surgery eating psychopathology were reported in patients with weight regain. However, the association between general psychopathology and weight regain was not consistent across the studies. In the meta-analysis, the odds of eating psychopathology in the weight regain group was higher compared with the nonweight regain group (OR = 2.2, 95% CI 1.54-3.15). Postbariatric surgery eating psychopathology seems to play an important role in weight regain., (© 2019 World Obesity Federation.)

The study's objectives: compare self-report measures of weight and height with direct measures; assess the impact of these discrepancies on body mass index (BMI) and prevalence of overweight and obesity; and apply correction models to the self-report measures and assess the degree of improvement in the corrected measures produced with the use of these models. A cross-sectional study was performed, assessing 4,151 adults (18 to 60 years) participating in the São Paulo Megacity Epidemiological Study. Linear regression models stratified by sex were proposed for correction of self-reported measures. Agreement was assessed with the intraclass correlation coefficient for the direct measures, self-report measures, and corrected measures, and kappa coefficient for BMI classification categories. Self-reported weight and the resulting BMI were underestimated, while height was overestimated, compared to direct measures. With all the correction models, the corrected measures were closer to the direct measures. Prevalence rates for excess weight, calculated by self-report measures, were underestimated by 24% in men and by 28% in women; with corrections, the underestimation decreased to 8% and 10%, respectively. The results showed moderate agreement for self-report measures and substantial agreement for corrected measures compared to direct measures. The use of correction equations for self-report data proved to be a useful method for producing more trustworthy estimates of prevalence of overweight and obesity in the general population, usually estimated from self-report measures of weight and height in population surveys.

This article sought to evaluate the effect of exposure, and exposure time, to breastfeeding on the occurrence of common mental disorders (CMD) among Brazilian adolescents enrolled in school. This study analyzed data from the Study of Cardiovascular Risk in Adolescents (ERICA), evaluating those whose questionnaire regarding breastfeeding had been filled out by parents or guardians. The presence of CMD was identified using the General Health Questionnaire, version 12 items (GHQ-12), and we considered two cutoff points (scores ≥ 3 and ≥ 5). We tested the associations in bivariate analyses and through multiple logistical regression models, adjusting for potential confounding variables. Of the 41,723 adolescents we evaluated, most were students of the female sex (54.6%), aged between 12 and 15 years (71%), attended public schools (83.1%), resided in the Southeastern region (51.9%) and belonged to the economic classes B (53.8%) and C (34.1%). Around half of the adolescents' mothers had not completed their secondary education (51.7%). The group of adolescents who were breastfed for more than six months (51.8%) had a lower CMD prevalence for both GHQ-12 cutoff points, when compared with the group who were not breastfed or who were breastfed for ≤ 1 month (IR = 0.82; 95%CI: 0.69-0.97 and IR = 0.74; 95%CI: 0.59-0.91 for 3 and 5 points, respectively). Prolonged breastfeeding seems to play a protective role on the occurrence of CMD in adolescence.

Objectives: To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training., Methods: We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records., Results: Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals., Conclusions: These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

Childhood abuse and PTSD are independently associated with severe psychiatric comorbidity. We hypothesized that among patients with adult-onset PTSD, a history of child abuse was associated with increased prevalence and severity of comorbid mental disorders. Participants were 109 adult treatment-seeking patients, 23.9% of whom had a history of childhood sexual, physical or emotional abuse. The socio-demographic characteristics and comorbidity profile of PTSD patients with and without history of child abuse were compared using the two-tailed t-test and the chi-square test. PTSD patients with a history of child abuse had significantly higher average PCL-C hyperarousal [21.8 (SD = 3.6) vs 19.8 (SD = 3.5)] and BDI [35.7 (SD = 9.2) vs 29.1 (SD = 13.9)] scores, a significantly increased average number of lifetime [4.85 (SD = 1.43) vs 3.93 (SD = 1.33)] and current [4.46 (SD = 1.24) vs 3.75 (SD = 1.32)] comorbid disorders, and a greater prevalence of lifetime (73.1% vs 44.6%) and current (79.2% vs 46.7%) panic disorder/agoraphobia and of psychotic symptoms (73.1% vs 30.1%). All effect sizes were in the medium to large range. Adult-onset PTSD patients with a history of child abuse may represent a subgroup with a more severe form of the disorder that is associated with a more serious clinical course, treatment resistance and poorer outcome., (Copyright © 2018. Published by Elsevier B.V.)

Background: There are few data on the epidemiology, clinical manifestations and management of RA in Brazil, even with the recognition of the high direct, indirect and societal costs of this disease. Herein, we report the formation of the REAL - Rheumatoid Arthritis in Real Life, the first nationally representative multicenter prospective observational study in Brazil., Methods: The REAL study was designed to include a total of 1300 evaluable patients from 13 tertiary care public health centers specialized in RA management and representative of 5 regions of Brazil. Each center was expected to enroll ~ 100 consecutively seen patients and follow them prospectively in a systematic protocol-driven fashion with scheduled visits at baseline, 6 and 12 months. Core clinical, laboratory and patient-reported outcomes measures were required to be collected at each visit., Results: A total of 1115 patients (89.4% female, mean age of 56.7 years and median disease duration of 12.7 years) were enrolled from 11 participating centers. Almost 80% of patients were of middle-low or low socioeconomic classes. The median educational time was 8 years, with 3.23% being below literacy level. The interval between symptoms and diagnosis varied from 1 to 457 months (median 12 months). Almost half of the patients were on glucocorticoids, 96.5% on DMARDs, with 35.7% on biologics. Median HAQ-DI was 0.875, ranging from 0 to 3. Median DAS28-ESR was 3.5, with 58.7% of patients presenting moderate or high disease activity., Conclusions: The first large cohort of Brazilian patients with RA in a real-life setting shows several striking differences from previously published cohorts from other countries. The long delay for diagnosis and start of DMARDs may partly explain the high frequency of erosive disease. An elevated percentage of patients on moderate or high disease activity was seen, despite of the high frequency of corticosteroid and biologics utilization. Data from this cohort may enable public health managers of developing countries better allocate the limited resources available for the care of RA patients.

Objectives: To demonstrate a study design that could be useful in low-resource and violent urban settings and to estimate the prevalence of child violence exposure (at home, community, and school) and child mental health problems in a low-income medium-size city., Methods: The Itaboraí Youth Study is a Norway-Brazil collaborative longitudinal study conducted in Itaboraí city (n = 1409, 6-15 year olds). A 3-stage probabilistic sampling plan (random selection of census units, eligible households, and target child) generated sampling weights that were used to obtain estimates of population prevalence rates., Results: Study strengths include previous pilot study and focus groups (testing procedures and comprehension of questionnaire items), longitudinal design (2 assessment periods with a mean interval of 12.9 months), high response rate (>80%), use of standardized instruments, different informants (mother and adolescent), face-to-face interviews to avoid errors due to the high frequency of low-educated respondents, and information gathered on a variety of potential predictors and protective factors. Children and adolescents presented relevant levels of violence exposure and clinical mental health problems., Conclusions: Prevalence estimates are probably valid to other Brazilian low-income medium-size cities due to similarities in terms of precarious living conditions. Described study methods could be useful in other poor and violent world regions., (Copyright © 2018 John Wiley & Sons, Ltd.)

Purpose: The purpose of the study is to identify early vulnerabilities for psychiatric disorders among Brazilian elementary school children, controlling for familial and community adversities., Methods: This is a cross-sectional study examining the association between child psychiatric disorders and potential early vulnerabilities (disability, low intellectual quotient, and negative dimensions of the temperament trait self-directedness (low resourcefulness, low purposefulness, low enlightened second nature), controlling for the potential confounders: familial and community adversities., Sample: Four probabilistic samples of second-to-sixth grade students from public schools in four towns from different Brazilian regions (N = 1620). The following instruments were applied: the K-SADS-PL (to assess child/adolescent psychiatric disorders); the Ten-Question Screen (to measure child disability); three structured questions used as proxy of self-directedness; and the reduced version of the WISC-III to measure IQ. To evaluate familial/community adversities: Self-Report Questionnaire-SRQ-20 (to assess maternal/primary caretaker anxiety/depression); questions derived from structured questionnaires (to measure child abuse, marital physical violence, neighborhood violence); Brazilian Association of Research Companies questionnaire (to evaluate poverty/socioeconomic status). Trained psychologists interviewed mothers/primary caretakers and evaluated children/adolescents individually., Results: A final logistic regression model showed that children/adolescents with low resourcefulness, low purposefulness, low enlightened second nature, lower IQ and disability were more likely to present any child psychiatric disorders., Conclusion: Early vulnerabilities such as low IQ, presence of disability, and dimensions of temperament were associated with psychiatric disorders among Brazilian elementary school children, after controlling for familial and ecological confounders. These early vulnerabilities should be considered in mental health prevention/intervention programs in low-middle-income countries like Brazil.

Objectives: To assess the prevalence of elder abuse and to investigate potential sociodemographic, health behavior, and medical correlates., Design: Cross-sectional data were collected in face-to-face assessments., Setting: São Paulo and Rio de Janeiro, Brazil., Participants: Individuals aged 60 to 75., Measurements: Information on elder abuse was obtained using the Brazil-adapted, nine-item Hwalek-Sengstock Elder Abuse Screening Test. Sampling design-adjusted descriptive statistics and logistic regression were used in analyses., Results: The overall prevalence of abuse was 14.4% (n = 46/259, 95% confidence interval (CI) = 9.82-20.61) in São Paulo and 13.3% (n = 27/197, 95% CI = 8.76-19.74) in Rio de Janeiro. Unadjusted analyses indicated that poor education, low physical activity, unemployment, heart disease, and psychiatric problems were associated with abuse, but in adjusted analyses, self-reported elder abuse was significantly associated only with psychiatric problems (São Paulo: OR = 4.48, 95% CI = 1.75-11.45; Rio de Janeiro: OR = 21.61, 95% CI = 6.39-73.14)., Conclusion: Elder abuse is prevalent in São Paulo and Rio de Janeiro, but whether concomitants of abuse are cause, effect, or both is unclear because this was a cross-sectional study. These findings highlight the importance of the problem, as well as the need to develop measures to increase awareness, facilitate prevention, and fight against abuse of elderly adults., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Background: Studies of the association between income inequality and mental health have shown mixed results, probably due to methodological heterogeneity. By dealing with such heterogeneity through a systematic review and meta-analysis, we examine the association between income inequality, mental health problems, use of mental health services, and resilience (defined as the ability to cope with adversity)., Methods: We searched the Global Health, PsychARTICLES, PsycINFO, Social Policy and Practice, Embase and MEDLINE databases up to July 6, 2016, for quantitative studies of the association of income inequality with prevalence or incidence of mental disorders or mental health problems, use of mental health services, and resilience. Eligible studies used standardised instruments at the individual level, and income inequality at the aggregated, contextual, and ecological level. We extracted study characteristics, sampling, exposure, outcomes, statistical modelling, and parameters from articles. Because several studies did not provide enough statistical information to be included in a meta-analysis, we did a narrative synthesis to summarise results with studies categorised as showing either a positive association, mixed results, or no association. The primary outcome in the random-effects meta-analysis was mental health-related morbidity, defined as the prevalence or incidence of any mental health problem. This study is registered with PROSPERO, number CRD42016036377., Findings: Our search identified 15 615 non-duplicate references, of which 113 were deemed potentially relevant and were assessed for eligibility, leading to the inclusion of 27 studies in the qualitative synthesis. Nine articles found a positive association between income inequality and the prevalence or incidence of mental health problems; ten articles found mixed results, with positive association in some subgroups and non-significant or negative association in other subgroups; and eight articles found no association between income inequality and mental health problems. Of the nine articles included in our meta-analysis, one reported a positive association between income inequality and mental health problems, six reported mixed results, and two reported no association. Pooled Cohen's d effect sizes for the association between income inequality and any mental disorder or mental health problems were 0·06 (95% CI 0·01-0·11) for any mental disorder, and 0·12 (0·05-0·20) for depressive disorders. Our meta-regression analysis showed that none of the factors considered (sample size, contextual level at which income inequality was assessed, quality assessment, type of instruments, and individual income as control variable) explained heterogeneity between studies (I 2 89·3%; p<0·0001). Only one study investigated the association between income inequality and resilience; it found greater income inequality was associated with higher prevalence of depression only among individuals with low income. The only study of the role of income inequality as a determinant of the use of mental health services reported no association., Interpretation: Income inequality negatively affects mental health but the effect sizes are small and there is marked heterogeneity among studies. If this association is causal and growing income inequality does lead to an increase in the prevalence of mental health problems, then its reduction could result in a significant improvement in population wellbeing., Funding: None., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Tonic immobility is an involuntary motor and vocal inhibition reaction, considered the last-ditch response of the defensive cascade model. It is elicited in context of inescapable threat and perception of entrapment. Our aim was to investigate the association between different traumatic events and peritraumatic tonic immobility (PTI) in a representative sample of the general population., Methods: This is a cross-sectional study of general population from Rio de Janeiro and São Paulo with 3231 victims of traumatic events aged 15-75 years who completed the Tonic Immobility Scale (TIS). We calculated the frequency of the different traumatic events and estimated the mean scores with 95% confidence intervals for each traumatic event, controlling for the potential confounders using multiple linear regression models. Finally, we calculated the proportion of individual scoring zero in TIS for the 16 traumatic events., Results: PTI scores in child sexual abuse and adult sexual violence were almost twice as high as in other types of traumatic events, even when controlled for gender and educational level. Torture and war also showed high PTI scores, but these were based on very small number of cases and need to be interpreted with caution. Furthermore, victims of sexual trauma had the lowest proportion of individuals with total absence of PTI symptoms., Limitations: This is a cross-sectional study and causal inferences must be drawn with caution., Conclusions: Peritraumatic tonic immobility is more strongly associated with sexual trauma, particularly in childhood, than to other types of trauma in the general population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

To assess the current practices in gout management among Brazilian rheumatology residents. We performed a cross-sectional online survey among all the rheumatology residents and those rheumatologists who had just completed their training (post-residency (PR)) regarding their approach to gout management. Results were compared with the 2012 American College of Rheumatology (ACR) gout guidelines and with the responses of a previous survey with a representative sample of practicing Brazilian rheumatologists (RHE). We received 224 responses (83%) from 271 subjects. Among all respondents, the first-choice treatment for gout flares was the combination of a nonsteroidal anti-inflammatory drug + colchicine for otherwise healthy patients. A target serum urate <6 mg/dL for patients without tophi was reported by >75%. Less than 70% reported starting allopurinol at low doses (≤100 mg/day) for patients with normal renal function and <50% reported maintaining urate-lowering therapy indefinitely for patients without tophi. Among residents and PR, the residency stage was the main predictor of concordance with the ACR guidelines, with PR achieving the greatest rates. Reported practices were commonly concordant with the 2012 ACR gout guidelines, especially among PR. However, some important aspects of gout management need improvement. These results will guide the development of a physician education program to improve the management of gout patients in Brazil.