ABSTRACT Objective: To determine the relationship between psoriasis, thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triodothyronine (FT3), thyroid peroxidase antibodies (TPOAb), and subclinical thyroid dysfunctions in middle-aged and older adults. Materials and methods: Cross-sectional analyses included a self-reported medical diagnosis of psoriasis and thyroid function from the 3rd visit (2017-2019) of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). TSH, FT4, and FT3 levels were analyzed as continuous variables and quintiles, and TPOAb positivity and subclinical hypothyroidism as a yes/no variable. Logistic regression models were built as crude and adjusted by main confounders (age, sex, education level, race/ethnicity, and smoking). Results: From 9,649 participants (52.3% women; 59.2 ± 8.7 years old), the prevalence of psoriasis was 2.8% (n = 270). TSH, FT4, TPOAb positivity, and subclinical hypothyroidism were not associated with psoriasis in the main analyses. In the stratified analysis, our findings showed positive associations of the lowest (OR = 2.01; 95% CI 1.05-3.84; p = 0.036) and the highest (OR = 2.13; 95% CI 1.12-4.05; p = 0.022) quintiles of FT4 and a protective association of TPOAb positivity (OR = 0.43; 95% CI 0.19-0.98; p = 0.046) with prevalent psoriasis in women. In the logistic regression for FT3, participants in the 1st quintile showed a statistically significant association with psoriasis for the whole sample (OR = 1.66; 95% CI 1.11-2.46; p = 0.013) and for men (OR = 2.25; 95% CI 1.25-4.04; p = 0.007) in the sex-stratified analysis. Conclusions: The present study showed that the association of FT4 levels with psoriasis are different according to sex, with a possible U-shaped curve in women but not in men. Although there were some associations of FT3 with psoriasis, they may be a consequence of non-thyroidal illness syndrome. Further prospective data may clarify the association of thyroid function and psoriasis. Objective thyroidstimulating stimulating TSH , (TSH) FT (FT4) (FT3) TPOAb, (TPOAb) middleaged middle aged adults methods Crosssectional Cross sectional selfreported self reported rd 20172019 2017 2019 (2017-2019 ELSABrasil. ELSABrasil ELSA Brasil . (ELSA-Brasil) yesno yes no variable age, age (age sex level raceethnicity race ethnicity race/ethnicity smoking. smoking smoking) Results 9649 9 649 9,64 52.3% 523 52 3 (52.3 592 59 2 59. 87 8 7 8. old, old old) 28 2.8 n 270. 270 270) analysis OR 2.01 201 01 95 1.053.84 105384 1.05 3.84 1 05 84 1.05-3.84 0.036 0036 0 036 2.13 213 13 1.124.05 112405 1.12 4.05 12 4 1.12-4.05 0.022 0022 022 0.43 043 43 0.190.98 019098 0.19 0.98 19 98 0.19-0.98 0.046 0046 046 st 1.66 166 66 1.112.46 111246 1.11 2.46 11 46 1.11-2.46 0.013 0013 013 2.25 225 25 1.254.04 125404 1.25 4.04 04 1.25-4.04 0.007 0007 007 sexstratified Conclusions Ushaped U shaped nonthyroidal non thyroidal syndrome (TSH (FT4 (FT3 (TPOAb 2017201 (2017-201 (ELSA-Brasil 964 64 9,6 52.3 5 (52. 2. 27 2.0 20 053 1.053.8 10538 105 1.0 384 3.8 1.05-3.8 0.03 003 03 2.1 21 124 1.124.0 11240 112 1.1 405 4.0 1.12-4.0 0.02 002 02 0.4 190 0.190.9 01909 019 0.1 098 0.9 0.19-0.9 0.04 004 1.6 16 6 1.112.4 11124 111 246 2.4 1.11-2.4 0.01 001 2.2 22 254 1.254.0 12540 125 1.2 404 1.25-4.0 0.00 000 00 (FT 201720 (2017-20 96 9, 52. (52 1.053. 1053 10 1. 38 3. 1.05-3. 0.0 1.124. 1124 40 4. 1.12-4. 0. 0.190. 0190 09 0.19-0. 1.112. 1112 24 1.11-2. 1.254. 1254 1.25-4. 20172 (2017-2 (5 1.053 1.05-3 1.124 1.12-4 0.190 0.19-0 1.112 1.11-2 1.254 1.25-4 (2017- ( 1.05- 1.12- 0.19- 1.11- 1.25- (2017 (201 (20 (2

Resumo Introdução: as condições estressantes do trabalho estão associadas ao aumento dos níveis glicêmicos, mas pouco se conhece sobre o papel da escolaridade neste contexto. Objetivos: analisar a associação entre o estresse psicossocial no trabalho e os níveis de hemoglobina glicada (HbA1c) e a influência da escolaridade como modificador de efeito. Métodos: estudo transversal com dados de 11.922 trabalhadores ativos da linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O estresse psicossocial no trabalho foi avaliado pelo modelo demanda-controle. Foram empregadas a regressão logística multinomial e interações multiplicativas. Resultados: em trabalhadoras do sexo feminino com baixa escolaridade, observou-se associação entre baixo uso de habilidades no trabalho (OR 1,56; IC95% 1,09-2,24) e HbA1c elevada. A baixa autonomia no trabalho foi relacionada à HbA1c limítrofe (OR 1,21; IC95% 1,01-1,45) e elevada (OR 1,73; IC95% 1,19-2,51). Entre trabalhadores do sexo masculino com baixa escolaridade, o trabalho de alto desgaste (OR 1,94; IC95% 1,18-3,21), o baixo uso de habilidades (OR 2,00; IC95% 1,41-2,83) e a baixa autonomia no trabalho (OR 1,58; IC95% 1,13-2,21) foram associados à HbA1c elevada. Conclusão: o estresse psicossocial no trabalho foi associado a níveis limítrofes e elevados de HbAlc para trabalhadores com baixa escolaridade de ambos os sexos. Assim, ações para modificar as relações de trabalho e prevenir doenças crônicas devem ser priorizadas.

Abstract Introduction: stressful work conditions are associated to increased glycemic levels, but little is known about the role of educational attainment in this association. Objectives: to analyze the association between psychosocial stress at work, levels of glycated hemoglobin (HbA1c), and the role of educational attainment as an effect modifier. Methods: a cross-sectional study with baseline data from 11,922 active workers who participated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Psychosocial stress at work was measured via the Demand-Control model. Multinomial logistic regression and multiplicative interactions were performed. Results: among female workers with low educational attainment, there was an association of low skill discretion and elevated HbA1c (OR 1.56; 95% CI 1.09-2.24). Low decision authority was associated to borderline (OR 1.21; 95% CI 1.01-1.45) and high (OR 1.73; 95% CI 1.19-2.51) HbA1c. Among male workers with low educational attainment, high strain (OR 1.94; 95% CI 1.18-3.21), low skill discretion (OR 2.0; 95% CI 1.41-2.83), and low decision authority (OR 1.58; 95% CI 1.13-2.21) were associated to high HbA1c. Conclusion: Stress at work was associated to high and borderline levels of HbAlc in workers from both genders with low educational attainment. Actions to modify work relations and to prevent chronic diseases should be prioritized for this group.

OBJECTIVES: To investigate the association among hypertension, tinnitus, and sensorineural hearing loss and evaluate the influence of other covariates on this association. METHODS: Baseline data (2008-2010) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were analyzed. Altogether, 900 participants were evaluated. The baseline assessment consisted of a 7-hour examination to obtain clinical and laboratory variables. Hearing was measured using pure-tone audiometry. RESULTS: Overall, 33.3% of the participants had hypertension. Participants with hypertension were more likely to be older, male, and diabetic compared to those without hypertension. The prevalence of tinnitus was higher among hypertensive participants and the odds ratio for tinnitus was higher in participants with hypertension than in those without hypertension. However, the difference was not significant after adjusting for age. Audiometric results at 250-8,000 Hz were worse in participants with hypertension than in those without hypertension in the crude analysis; however, the differences were not significant after adjustment for age, sex, diagnosis of diabetes, and exposure to noise. No significant difference was observed in hearing thresholds among participants having hypertension for <6 years, those having hypertension for ≥6 years, and individuals without hypertension. CONCLUSION: Hearing thresholds were worse in participants with hypertension. However, after adjusting for age, sex, diagnosis of diabetes, and exposure to noise, no significant differences were observed between participants with and without hypertension. A higher prevalence of tinnitus was observed in participants with hypertension compared to those without hypertension, but without significance after adjusting for age.

OBJECTIVES: Feedback is a powerful learning tool, but a lack of appropriate feedback is a very common complaint from learners to teachers. To improve opportunities for feedback on objective structured clinical examinations (OSCEs), a modified examiner role, termed the “shadow” examiner, was tested. This study aims to present and analyze comparisons between the “shadow” examiner and the original OSCE examiner format. METHODS: In 2011, experiments were carried out with modifications to the examiner’s role to define the “shadow” examiner format. From February 2012 to May 2014, research was conducted with 415 6th-year medical students. Of these students, 316 were randomly assigned to assessments by both “shadow” and “fixed” examiners. Pearson correlation analysis with linear regression, Student’s t-tests and Bland-Altman plots were the statistical methods used to compare the assessment modes. To strengthen the analysis, checklist items were classified by domain. RESULTS: High correlations between the “shadow” and “fixed” examiners’ global scores were observed. The results of the analysis of specific domains demonstrated higher correlations for cognitive scores and lower correlations for affective scores. No statistically significant differences between the mean examiner global scores were found. The Bland-Altman analysis showed that the “shadow” examiners’ affective scores were significantly higher than those of the “fixed” examiners, but the magnitude of this difference was small. CONCLUSION: The modified examiner role did not lead to any important bias in the students’ scores compared with the original OSCE examiner format. This new strategy may provide important insights for formative assessments of clinical performance.

Fundamento:Dados sobre sobrevida após uma síndrome coronariana aguda (SCA) são geralmente de curto prazo ou baseados em centros cardiológicos.Objetivo:Descrever a frequência de ocorrência de óbito em um ano no Estudo de Registro de Insuficiência Coronariana (ERICO), e seus preditores.Métodos:Foram analisados 964 participantes ERICO incluídos de fevereiro/2009 a dezembro/2012. O estado vital dos participantes foi obtido por telefone e fontes oficiais de óbito. A causa de morte foi determinada pelos certificados de óbito. Foi utilizado o teste log-rank para comparar probabilidades de sobrevivência. Construímos modelos de regressão de Cox, brutos e ajustados (para idade, sexo e subtipo de SCA), para estudar se o subtipo de SCA ou características de entrada no estudo foram preditores independentes de mortalidade.Resultados:Identificamos 110 óbitos (frequência de ocorrência de óbito, 12,0%). A idade (risco relativo [RR] em 10 anos = 2,04; intervalo de confiança de 95% [IC95%]=1,75-2,38), infarto do miocárdio sem elevação do segmento ST (RR = 3,82; IC95% = 2,21-6,60) ou infarto do miocárdio com elevação do segmento ST (RR = 2,59; IC95% = 1,38‑4,89) e diabetes (RR = 1,78; IC95% = 1,20-2,63) foram fatores de risco significativos para mortalidade geral em modelos ajustados. Encontramos resultados semelhantes para mortalidade cardiovascular. Diagnóstico prévio de doença arterial coronariana também foi um preditor independente de mortalidade geral (RR = 1,61; IC95% = 1,04-2,50), mas não de mortalidade cardiovascular.Conclusão:Encontramos uma frequência de ocorrência de óbito em um ano de 12,0% nesta amostra de pacientes pós-SCA de um hospital comunitário em São Paulo. Idade, subtipo de SCA e diabetes foram preditores independentes de pior sobrevida em um ano.

Background:Information about post-acute coronary syndrome (ACS) survival have been mostly short-term findings or based on specialized, cardiology referral centers.Objectives:To describe one-year case-fatality rates in the Strategy of Registry of Acute Coronary Syndrome (ERICO) cohort, and to study baseline characteristics as predictors.Methods:We analyzed data from 964 ERICO participants enrolled from February 2009 to December 2012. We assessed vital status by telephone contact and official death certificate searches. The cause of death was determined according to the official death certificates. We used log-rank tests to compare the probabilities of survival across subgroups. We built crude and adjusted (for age, sex and ACS subtype) Cox regression models to study if the ACS subtype or baseline characteristics were independent predictors of all-cause or cardiovascular mortality.Results:We identified 110 deaths in the cohort (case-fatality rate, 12.0%). Age [Hazard ratio (HR) = 2.04 per 10 year increase; 95% confidence interval (95%CI) = 1.75–2.38], non-ST elevation myocardial infarction (HR = 3.82 ; 95%CI = 2.21–6.60) or ST elevation myocardial infarction (HR = 2.59; 95%CI = 1.38–4.89) diagnoses, and diabetes (HR = 1.78; 95%CI = 1.20‑2.63) were significant risk factors for all-cause mortality in the adjusted models. We found similar results for cardiovascular mortality. A previous coronary artery disease diagnosis was also an independent predictor of all-cause mortality (HR = 1.61; 95%CI = 1.04–2.50), but not for cardiovascular mortality.Conclusion:We found an overall one-year mortality rate of 12.0% in a sample of post-ACS patients in a community, non-specialized hospital in São Paulo, Brazil. Age, ACS subtype, and diabetes were independent predictors of poor one‑year survival for overall and cardiovascular-related causes.

CONTEXTO E OBJETIVO: Estratégias não invasivas para avaliar doença hepática gordurosa não alcoólica (DHGNA) têm sido investigadas nas últimas décadas. Nosso objetivo foi avaliar a acurácia diagnóstica de um novo escore de ultrassonografia hepática para DHGNA no estudo ELSA-Brasil.TIPO DE ESTUDO E LOCAL: Estudo de acurácia diagnóstica realizado no centro ELSA, no hospital de uma universidade pública.MÉTODOS: Dos 15.105 participantes do estudo ELSA avaliados para DHGNA, 195 indivíduos foram incluídos neste estudo. Foi realizada ultrassonografia hepática (atenuação do feixe de profundidade, índice hepatorrenal e diâmetro anteroposterior do lobo direito do fígado) que foi comparada aos achados de esteatose hepática da tomografia computadorizada (TC) de alta resolução de 64 canais. Avaliamos também dois índices clínicos relacionados à DHGNA: o índice de gordura hepática (FLI) e o índice de esteatose hepática (HSI).RESULTADOS: Entre os 195 participantes, a frequência de DHGNA foi de 34,4%. Altos índices de massa corpórea, circunferência de cintura, diabetes e hipertrigliceridemia foram associados a aumento da atenuação hepática e do diâmetro anteroposterior do lobo hepático direito, mas não ao índice hepato-renal. A pontuação da ultrassonografia hepática, que incluiu atenuação hepática e diâmetro anteroposterior do lobo direito do fígado, apresentou o melhor desempenho para o rastreio DHGNA sob o ponto de corte ≥ 1 ponto (sensibilidade: 85.1%; especificidade: 73.4%; acurácia: 79.3%), e área sob a curva (AUC, 0,85, IC 95%: 0,78-0,91). FLI e HSI apresentaram menor desempenho (AUC 0,76; IC 95%: 0,69-0,83) comparados à TC.CONCLUSÃO: O escore de ultrassonografia hepática, que incluiu atenuação hepática e o diâmetro anteroposterior do lobo direito do fígado, possui boa reprodutibilidade e acurácia para o rastreio de DHGNA.

CONTEXT AND OBJECTIVE: Noninvasive strategies for evaluating non-alcoholic fatty liver disease (NAFLD) have been investigated over the last few decades. Our aim was to evaluate the diagnostic accuracy of a new hepatic ultrasound score for NAFLD in the ELSA-Brasil study.DESIGN AND SETTINGS: Diagnostic accuracy study conducted in the ELSA center, in the hospital of a public university.METHODS: Among the 15,105 participants of the ELSA study who were evaluated for NAFLD, 195 individuals were included in this sub-study. Hepatic ultrasound was performed (deep beam attenuation, hepatorenal index and anteroposterior diameter of the right hepatic lobe) and compared with the hepatic steatosis findings from 64-channel high-resolution computed tomography (CT). We also evaluated two clinical indices relating to NAFLD: the fatty liver index (FLI) and the hepatic steatosis index (HSI).RESULTS: Among the 195 participants, the NAFLD frequency was 34.4%. High body mass index, high waist circumference, diabetes and hypertriglyceridemia were associated with high hepatic attenuation and large anteroposterior diameter of the right hepatic lobe, but not with the hepatorenal index. The hepatic ultrasound score, based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe, presented the best performance for NAFLD screening at the cutoff point ≥ 1 point; sensitivity: 85.1%; specificity: 73.4%; accuracy: 79.3%; and area under the curve (AUC 0.85; 95% confidence interval, CI: 0.78-0.91)]. FLI and HSI presented lower performance (AUC 0.76; 95% CI: 0.69-0.83) than CT.CONCLUSION: The hepatic ultrasound score based on hepatic attenuation and the anteroposterior diameter of the right hepatic lobe has good reproducibility and accuracy for NAFLD screening.