Proportional cancer mortality was calculated for Brazil and regions. The annual percentage change in rates for total cancer and specific types in each segment and in the selected unit of analysis was calculated by generalized linear regression with Gaussian binding.the proportion of cancer increased progressively for both sexes from 1978 to 2017. Important differences between the Capitals and the interior of the macro-regions were seen with disaggregated data. The greatest declines occurred for stomach cancer, except in the northern and interior regions of the Northeast, and for the cervix cancer, with a generalized fall, with the exception of the interior of the northern region. Lung cancer decreased among men in the Southeast and South regions and had a generalized increase among women. Breast and prostate cancers tended to decrease in the Southeast and South regions and among residents of the Capitals but showing an increase in the interior of the North and Northeast regions. Colorectal cancer had a general tendency to increase; with stability among men in the Capitals of the South region and among women of the Southeast and Midwest regions and, since 2007, a decrease among women in the South region.Cancer mortality showed great variation among residents of capitals and the interior of the country's major regions. Clear decrease in mortality was seen for the main types in the Southeast and South regions. The North and Northeast regions have patterns compatible with cancers associated with poverty, while the large increase of the cancers related to sedentary lifestyle stand out. Cancer is currently the second leading cause of illness and death in the world, with wide variation in incidence and mortality among countries due to socioeconomic status and exposure to risk factors related to social conditions and lifestyle.The analysis of current trends in cancer indicates that the ongoing economic and social transitions in several middle- and low-income countries are related to increased exposure to reproductive and hormonal risk factors and changes in food standardsIn Brazil, cancer mortality in the early 1980s still showed a typical pattern of middle- and low-income countries, with significant rates of cervical and stomach cancers. A transition, however, was already outlined, with an increase in the types associated with the best socioeconomic conditions Although cancer trends have been reported in Brazil and Federative units (FU) between 1990 and 2015Sistema de Informações sobre Mortalidade  was implemented in Brazil by the Ministry of Health (MH) in the late 1970s, with the death declaration as a source document. Since then, MH has been working to improve its completeness and coverageIn addition, it should be considered that the This study aims to describe the four-decade trend (1978-2017) of mortality of all cancers and the most frequent types among men and women living in the Capitals and other municipalities of the macro-regions of Brazil.This is a time series study that had as source the SIM data referring to the years between 1978The population denominators were those of the Brazilian Institute of Geography and Statistics (IBGE) censuses for the years 1980, 1991, 2000 and 2010In men, the main types were: lung , prostate  stomach , colorectal , and in women were: breast , lung , colorectal , and the cervix . Deaths that had ignored information for sex, age and municipality of residence were excluded. As for the year 1978, only proportional mortality from cancer was calculated, the ICD codes referring to the set of cancers (ICD-8: 140-209) and the chapter referring to the ill-defined causes (ICD-8: Ch. 16).The correction of the information on the underlying cause of death was done according to the methodology proposed by Mathers et al.With corrected data, the proportional mortality from cancer was calculated for Brazil. Since the 1978 data did not cover all regions, the proportional mortality series for macro-regions was started in 1979.Then, crude and age-standardized cancer mortality rates were calculated and for each sex by the direct method, taking as standard population the world population proposed by Segispline by parts, with break points in the years in which the trend changed its trajectory. The identification of the break points was visual and cubic splines with 10 degrees of freedom were used to highlight the points of inflection of the curve, allowing to define break points at specific moments of time and the respective trend in each interval, adjusting by a continuous line segment between the points. This approach was chosen because it concerns time series with trends that vary in time in a non-regular way, which makes inappropriate a linear model for global trend for the entire period.To estimate the trend, a linear regression model was used. For series with structural breaks, the time variable was introduced into the model by means of linear The models were evaluated via residues to verify if the usual assumptions were met, in particular the existence of residual autocorrelation through the functions of autocorrelation (FAC) and partial autocorrelation (FPAC). Models that showed significant autocorrelation in residues or with an absolute value greater than 0.5 were re-estimated using generalized least squares with a first-order autoregressive model AR(1) to model the autocorrelation and correct the variance of the coefficient estimators. We used the function “gls” with estimation for restricted maximum likelihood (REML) of the package “nlme”The coefficient of the term for each segment expresses the logarithm of the trend in that interval. Thus, the annual percentage change (APC) of mortality rates was calculated by the formula and respective p values.For the interpretation of trends, statistical non-significance  was used as a criterion to characterize an APC as stable. The statistically significant APC, when positive, indicated an increasing trend and, when negative, a decreasing trend. The analyses were performed in the R program, version 3.4.1.Proportional mortality from cancer increased from 1978 to 2017 in men, from 8.3% to 16.2%, and in women, from 9.1% to 18.3%. From 1979, it was possible to obtain data for the regions and it was observed that the lowest proportion was among men from the Northeast region in 1979 (5.4%) and the highest among women from the South region in 2017 (21.6%) .Mortality rates for the age-adjusted set of cancers showed different magnitude patterns between regions of the country for both sexes or between men and women separately  and the Disaggregating by place of residence, four trends were seen for both sexes in the Capitals  and only two in the interior (stability until 1990 and increase until 2017). Among men, it was in the Midwest region that the greatest fall was observed, which occurred in the Capitals , and the greatest increase, which occurred in the other municipalities . Among women, the greatest decline occurred in the southern region, both in the Capitals and in the interior, between 1980 and 1984 , while the greatest growth occurred among residents of the interior of the northern region .Among men, lung, prostate, colorectal and stomach cancers accounted for 44.9% of all cancer deaths in 1979 and 43.4% in 2017. Among women, breast, lung, colorectal and cervical cancers accounted for 39.0% of cancer deaths in 1979 and 44.4% in 2017. The cancers that showed the greatest decline in mortality were stomach and cervix. Markedly, stomach cancer in men declined in all regions throughout the period, with the exception of the northern region, where a tendency to increase was seen in the Capitals after 2010 and in the interior from 2001, and in the interior of the Northeast region between 1996 and 2017, as shown by the APC in the period.Among women, stomach cancer represented the seventh most frequent type of cancer in 2017 and, although the rates were much lower than those of men, the same decline occurred throughout the period, with the exception of the interior of the northern region, where there was an increase in the trend from 1980 to 1987, a fall from 1987 to 2001 and a resumption of growth from 2001 to 2017. Among residents of the interior of the Northeast region, there was a fall from 1980 to 1991 and an increase from 1991 to 2007, followed by stability thereafter (data not presented).Cervical cancer, which was the second most frequent among female deaths in 1980, rose to fourth place at the end of the period. Although rates in the Capitals were higher, they were descending in all regions. It is noteworthy that, in general, there was no difference in the magnitude and trend of rates of this type of cancer among residents of the Capitals or the interior of the Southeast and South regions. The APC analysis indicated a fall both in the Capitals and in the interior of all regions, except in the interior of the North region between 2002 and 2017 and in the interior of the Northeast region between 1994 and 2006. In the interior of the Northeast region, however, as of since 2006 rates became stable, which did not happen for residents outside the Capitals in the North region.Lung cancer had a different behavior according to sex and between the macro-regions and within them. Among men in the Capitals, rates began to fall from 1984 in the Southeast region, 1992 in the South Region, and 1995 in the Midwest region. Within the South-East and South regions, rates declined from 1994 and 1993, respectively. In the capitals of the North and Northeast regions, there was an unsustainable fall and a marked increase in the interior, especially from 2011 to 2017 in the North, and from 1994 to 2017 in the Northeast. In the Midwest region, the rates decreased in the Capitals between 1995 and 2017 and increased in the interior, but with intensity tending to decrease. Among women, there was a generalized tendency to increased mortality from lung cancer throughout the period, with the highest rates observed in the Southern region and the greatest increase in the temporal trend within the northern region throughout the series and within the Northeast region between 1993 and 2017.Breast cancer in the southern region showed an increase in the Capitals until 1990, and after that a fall until 2017, which did not occur in the interior. In the Capitals of the Southeast region, there was a decline from 1996, while in the interior the fall that occurred between 1996 and 2007 did not continue afterwards. In the North and Northeast regions there was a tendency to increase, especially high in the interior.Prostate cancer rates have always been higher in the Capitals than in the interior, especially in the North, Northeast and Midwest regions. The largest increases were observed in the interior of the northern regions between 2004 and 2017 and Northeast between 1993 and 2017. In the interior of the Midwest region, there was also a growing trend throughout the period. In the Capitals, between 1997 and 2017, rates declined in the Southeast, South and Midwest regions. Later, declining rates were observed in the interior of the Southeast region between 2004 and 2017, and the South region between 2007 and 2017.Colorectal cancer was ranked sixth among men and fourth among women throughout the country at the beginning of the period and began to occupy the fourth position among men and third among women at the end. The highest rates were observed in the Southeast and South regions, both for men and women. Among men, from 1999, it was possible to notice an increasing trend in the North region, and from 2000 in the Northeast region, both in capitals and in the interior. In the Midwest region, there was an increase in the Capitals between 1984 and 2017 and in the interior between 1992 and 2017. An increasing trend was also observed in the Southeast and South regions, with the exception of residents of the capitals of the southern region, which from 2002 to 2017 showed rate stability.Among women, there was also a tendency to increased mortality from colorectal cancer, both in the Capitals and in the interior of all regions, with the exception of the Capitals of the Southeast region, where rates remained stable between 1997 and 2017, and of the Midwest region, with stability between 2009 and 2017. Only in the capitals of the southern region there was a fall from 2007 to 2017.It is noteworthy that the largest increases in the last two decades have been seen in the interior of the North and Northeast regions, both in men and women. In the interior of the northern region, it occurred for men between 1999 and 2017  and in the Northeast region, between 2000 and 2017 . For women, the increase in the interior of the northern region occurred between 2000 and 2017  and in the interior of the Northeast region, between 1999 and 2017 .Cancer mortality in Brazil for both sexes at the end of the study period  was similar to that of high-income countries ,Data from other countries, mostly developed, point to the marked decrease in cancer mortality achieved in the last two decadesThe greatest fall detected in the study period occurred for stomach cancer in all regions, with the exception of the orthern region as a whole and the interior of the Northeast region. The decline, already reported in previous studiesCervical cancer declined in all regions, but not among women in the interior of the northern region, where rates in 2017 are three times more frequent than in the Southeast region. Some effect of screening based on Pap smear, introduced throughout the country from 1992The inverse correlation between the Human Development Index (HDI) and national estimates of cervical cancer is well reported in the literatureThe South region has the highest municipal Human Development Index (HDI) in the country (0.766), while the North and Northeast regions, despite having had more accelerated growth between 2000 and 2010, have the lowestThe experience of high-income countries, such as those in North America, part of Europe and Japan, is an example that investment in effective screening programs has made cervical cancer a rare diseaseDemographic changes in Brazil, with progressive population aging, increased life expectancy and reduced fertility, added to the increase in obesityThis same trend of decrease in the more developed regions of Brazil happens in relation to prostate cancer, for which there is a decline among residents in the capitals since 1997 and later among those of the interior. This trend may be related to the possibilities of specialized services offer for the treatment of early diagnosed casesThe increase in the incidence of prostate cancer in developed countries seems to be related to the increase in access to health services, as well as to the increase in the registration of cases,Lung cancer was declining among men from the Southeast and South regions and in residents of the Capitals of the Midwest region. This, however, was not observed among women, for whom, in a generalized way, the rates were ascending in the period studied. In this case, because it is a cancer with still high lethality, the decrease in mortality occurs as a function of the decrease in incidence. The increased mortality from lung cancer among women has already been identified in studies in previous periodsThe prevalence of smokers in Brazil decreased by 19% between 2008 and 2013, with a decline in all regions, in urban and rural areas, and in most states. There was a drop in all educational levels, but the highest prevalence was seen among blacks and mixed-raceColorectal cancer, the third and fourth most frequent among women and men, respectively, shows an evolutionary pattern that deserves attention. Although rates in the Southeast and South regions are higher among men, they are three times higher than in the North.The occurrence of colorectal cancer shows different patterns between countries. In several countries in Eastern Europe, Latin America and Asia, there was an upward trend in incidence and mortality. In Canada, European countries and Singapore, the incidence continues to increase, while there is a decline in mortality. In the group restricted to high HDI countries, there is a downward trend in both incidence and mortalityIt is noteworthy that, in the North and Northeast regions, the trends in mortality from colorectal cancer increased more significantly in the interior, but there was no difference in magnitude between sexes. This may be an indication that the increase in obesity and sedentary lifestyle, classic risk factors for this type of tumors,The main limitation of this study stems from the quality of information on deaths in the country. Due to the great discrepancy in terms of completeness of information on the underlying cause of death, especially in the North and Northeast regions in the first two decades of the study period,,garbage codes. In this set of codes, in addition to the deaths recorded in chapters 16 of ICD-9 and 18 of ICD-10, other ill-defined causes and incomplete diagnoses from other chapters are included. In this study, we chose not to include the other nonspecific codes outside chapters 16 of ICD-9 and 18 of ICD – 10 due to the absence of studies that validate the contribution of redistribution of deaths recorded in the other nonspecific codes among specific types of cancerSome previous studiesPrevious studies that showed the trend of cancer in Brazil, with methodology applying correction of death data, included shorter periods than presented here: 1980-2006,Another aspect to be considered is the coverage of the death record. Although it has improved significantly in the country over these four decades, under-registration still exists in certain areas, especially in the states of the North and Northeast regionsAs for the application of linear regression by parts to evaluate the trend in time, it should be considered that, if the time interval is too small, trajectory changes may not present statistical significance due to the reduced number of points. However, this did not occur because, in the case of a long study period, the APC that were calculated covered periods of at least four years. In addition, the results of this study considered only those intervals that reached statistical significance. It should also be noticed that the number of deaths in each unit of analysis was not small, considering that the data were disaggregated to the level of the Capitals and the interior of each large region, which decreased the possibility of instability in the estimation of rates and of high heterogeneity in their distribution, that is, lower variance.Another limitation of linear models for trend analysis is the possibility of residual autocorrelation. In this work, the models diagnosed with autocorrelation in residues were re-estimated via generalized least squares with a first-order autoregressive correlation structure-AR(1). No higher order correlation structures were identified. Therefore, when existing, autocorrelation was adequately treated in the model.It is worth emphasizing that, at the same time as the reduction of some cancers related to poverty is observed, there is a real increase in new cases of cancer associated with factors arising from reproductive and hormonal history and dietIt was seen that, in the Southeast and South regions, this intersection between mortality from breast cancer and cervical cancer occurred before the 1980s among women living in the Capitals. Already in these same regions, for residents in the interior, this transition occurred later. Intermediate situations occurred in the Northeast and Midwest regions, where the crossing point of mortality between these two types of cancer in the Capitals occurred in 1992 and 1993, respectively. In the interior, however, it occurred only in 2008 in the Northeast region and in 2007 in the Midwest region. The most extreme situation is seen in the northern region, where this transition has not yet occurred either in the Capitals or in the interior, indicating a picture found in poor countriesIn the same logic, among men, the crossing points of mortality curves for colorectal cancer, which is positively associated with HDISome results require a careful examination to understand the mechanisms involved both in relation to the accuracy of death information and in the quality of health care. The marked growth of prostate, colorectal and breast cancers within the North and Northeast regions deserves detailed investigation. One hypothesis would be an improvement in the diagnostic capacity, but with a high proportion of cases detected in late stagesFinally, the increase in rates for all cancers in recent years, particularly in the northern and northeastern regions, is worrying. This may mean a real increase in the incidence due to greater exposure to risk factors related to a sedentary lifestyle, but, in the case of mortality, the difficulties of access, especially to early detection and treatment of tumors of good prognosis such as breast and prostate, can lead to an increase in mortality.Brazil is a country in economic transition and, during these four decades, has undergone several demographic, social and political modificationsSince the creation of the Unified Health System, incorporated into the Federal Constitution in 1988, there has been a great expansion of public services, with a significant improvement in health equity, but not enough to reduce extreme inequalities throughout the countryThe results found reflect the existence of distinct patterns of magnitude and trend of specific types of cancer that are sometimes contrasting and may reflect processes of illness and death with particular dynamics between the large regions of the country and between residents of capitals and other municipalities. While for residents of the capitals of the more developed regions there is a tendency to decreased mortality, in the poorest regions the significant increases, especially in the interior, make clear a profile of extreme inequity in health. O câncer é atualmente a segunda causa de adoecimento e morte no mundo, havendo grande variação na incidência e na mortalidade entre países em função do nível socioeconômico e da exposição a fatores de risco relativos a condições sociais e ao estilo de vidaA análise das tendências atuais de câncer indica que as transições econômicas e sociais em curso, em vários países de média e baixa renda, estão relacionadas ao aumento da exposição a fatores de risco reprodutivos e hormonais e a mudanças nos padrões alimentaresNo Brasil, a mortalidade por câncer no início da década de 1980 ainda apresentava um padrão típico de países de média e baixa renda, com taxas expressivas de cânceres de colo do útero e estômago. Uma transição, entretanto, já se delineava, com aumento dos tipos associados às melhores condições socioeconômicas Embora tenham sido relatadas as tendências do câncer no Brasil e unidades federativas (UF) entre 1990 e 2015Além disso, deve ser considerado que o Sistema de Informação sobre Mortalidade (SIM) foi implementado no Brasil pelo Ministério da Saúde (MS) no final da década de 1970, tendo a declaração de óbito como documento-fonte. Desde então, o MS trabalha para aprimorar sua completitude e coberturaEste estudo tem como objetivo descrever a tendência de quatro décadas (1978–2017) da mortalidade do conjunto de cânceres e dos tipos mais frequentes entre homens e mulheres residentes nas capitais e demais municípios das macrorregiões do Brasil.Trata-se de estudo de séries temporais que teve como fonte os dados do SIM referentes aos anos entre 1978Os denominadores populacionais foram os dos censos do Instituto Brasileiro de Geografia e Estatística (IBGE) para os anos de 1980, 1991, 2000 e 2010Em homens os principais foram: pulmão , próstata , estômago , colorretal , e em mulheres foram: mama , pulmão , colorretal  e colo do útero . Foram excluídos os óbitos que tiveram informação ignorada para sexo, idade e município de residência. Como para o ano de 1978 foi calculada apenas a mortalidade proporcional por câncer, foram considerados os códigos CID referentes ao conjunto de cânceres (CID-8: 140-209) e o capítulo referente às causas maldefinidas (CID-8: cap. XVI).A correção da informação sobre a causa básica de óbito foi feita seguindo metodologia proposta por Mathers et al.Com dados corrigidos, calculou-se a mortalidade proporcional por câncer para o Brasil. Como os dados de 1978 não contemplavam todas as regiões, a série de mortalidade proporcional para as macrorregiões foi iniciada em 1979.Em seguida, foram calculadas as taxas de mortalidade por câncer brutas e padronizadas por idade  e para cada sexo pelo método direto, tomando-se como população padrão a população mundial proposta por Segispline linear por partes, com pontos de quebra nos anos em que a tendência mudou sua trajetória. A identificação dos pontos de quebra foi visual e foram usadas splines cúbicas com 10 graus de liberdade para realçar os pontos de inflexão da curva, permitindo definir pontos de quebra em instantes específicos do tempo e a respectiva tendência em cada intervalo, ajustando-se por um segmento de reta contínuo entre os pontos. Optou-se por essa abordagem por se tratar de séries temporais com tendências que variam no tempo de forma não regular, o que torna inadequado um modelo linear para tendência global para todo o período.Para estimar a tendência, foi utilizado modelo de regressão linear. Para séries com quebras estruturais, a variável tempo foi introduzida no modelo por meio de Os modelos foram avaliados via resíduos para verificar se os pressupostos usuais foram atendidos, em particular a existência de autocorrelação residual por meio das funções de autocorrelação (FAC) e autocorrelação parcial (FACP). Os modelos que apresentaram autocorrelação nos resíduos significativa ou com valor absoluto maior que 0,5 foram reestimados usando mínimos quadrados generalizados com um modelo autorregressivo de primeira ordem AR(1) para modelar a autocorrelação e corrigir a variância dos estimadores dos coeficientes. Foi utilizada a função “gls” com estimação por máxima verossimilhança restrita (REML) do pacote “nlme”annual percent change – APC) das taxas de mortalidade pela fórmula e respectivos valores de p.O coeficiente do termo referente a cada segmento expressa o logaritmo da tendência naquele intervalo. Assim, foram calculadas as variações percentuais anuais  foi utilizada como critério para caracterizar uma APC como estável. A APC estatisticamente significante, quando positiva, indicou tendência crescente e, quando negativa, decrescente. As análises foram realizadas no Programa R, versão 3.4.1.A mortalidade proporcional por câncer aumentou de 1978 a 2017 em homens, de 8,3% para 16,2%, e em mulheres, de 9,1% para 18,3%. A partir de 1979, foi possível obter dados para as regiões e observou-se que a menor proporção foi entre homens da região Nordeste em 1979  e a maior entre mulheres da região Sul em 2017  .As taxas de mortalidade para o conjunto de cânceres ajustadas por idade mostraram padrões de magnitude diferentes entre as regiões do país para ambos os sexos ou entre homens e mulheres em separado  e a tendDesagregando-se por local de residência, quatro tendências foram vistas para ambos os sexos nas capitais  e apenas duas no interior (estabilidade até 1990 e aumento até 2017). Entre os homens, foi na região Centro-Oeste que se observou a maior queda, a qual aconteceu nas capitais , e o maior aumento, que ocorreu nos demais municípios . Entre mulheres, o maior declínio ocorreu na região Sul, tanto nas capitais quanto no interior, entre 1980 e 1984 , enquanto o maior crescimento ocorreu entre as residentes do interior da região Norte .Entre homens, os cânceres de pulmão, próstata, colorretal e estômago corresponderam a 44,9% do total de óbitos por câncer em 1979 e 43,4% em 2017. Entre mulheres, os cânceres de mama, pulmão, colorretal e colo do útero totalizaram 39,0% dos óbitos por câncer em 1979 e 44,4% em 2017. Na Os cânceres que apresentaram o maior declínio na mortalidade foram o de estômago e do colo do útero. Marcadamente, o câncer de estômago em homens declinou em todas as regiões por todo o período, com exceção da regiões Norte, onde tendência a aumento foi vista nas capitais após 2010 e no interior a partir de 2001, e do interior da região Nordeste entre 1996 e 2017, como mostram as APC no período.Entre mulheres, o câncer de estomago representou o sétimo tipo de câncer mais frequente em 2017 e, embora, as taxas tenham sido bem inferiores do que as masculinas, o mesmo declínio se deu em todo o período, com exceção do interior da região Norte, onde houve aumento da tendência de 1980 a 1987, queda de 1987 a 2001 e retomada de crescimento de 2001 a 2017. Entre as residentes do interior da região Nordeste, houve queda de 1980 a 1991 e aumento de 1991 a 2007, seguido de estabilidade a partir daí (dados não apresentados).O câncer do colo do útero, que se colocava como o segundo mais frequente entre os óbitos femininos em 1980, passou para o quarto lugar no final do período. Embora as taxas nas capitais tenham sido mais altas, elas foram descendentes em todas as regiões. Ressalta-se que, em geral, não houve diferença na magnitude e tendência das taxas desse tipo de câncer entre residentes das capitais ou do interior das regiões Sudeste e Sul. A análise das APC indicou queda tanto nas capitais quanto no interior de todas as regiões, exceto no interior da região Norte entre 2002 e 2017 e no interior da região Nordeste entre 1994 e 2006. No interior da região Nordeste, contudo, a partir de 2006 as taxas se tornaram estáveis, o que não aconteceu para as residentes fora das capitais na região Norte.O câncer de pulmão teve um comportamento diferente segundo sexo e entre as macrorregiões e dentro delas. Entre os homens das capitais, as taxas começaram a cair a partir de 1984 na região Sudeste, 1992 na região Sul e 1995 na região Centro-Oeste. No interior das regiões Sudeste e Sul, as taxas declinaram a partir de 1994 e 1993, respectivamente. Nas capitais das regiões Norte e Nordeste, houve queda não sustentada e aumento marcante no interior, sobretudo de 2011 a 2017 no Norte e de 1994 a 2017 no Nordeste. Na região Centro-Oeste, houve queda nas capitais entre 1995 e 2017 e aumento das taxas no interior, mas com intensidade tendendo à diminuição. Já entre mulheres, houve tendência generalizada a aumento da mortalidade por câncer de pulmão em todo período, sendo as maiores taxas observadas na região Sul e o maior aumento na tendência temporal no interior da região Norte em toda a série e no interior da região Nordeste entre 1993 e 2017.O câncer de mama na região Sul mostrou aumento nas capitais até 1990, e a partir daí houve queda até 2017, o que não se verificou no interior. Já nas capitais da região Sudeste, houve declínio a partir de 1996, ao passo que no interior a queda ocorrida entre 1996 e 2007 não se manteve depois. Nas regiões Norte e Nordeste houve tendência a aumento, especialmente elevado no interior.As taxas do câncer de próstata foram sempre mais altas nas capitais que no interior, em especial nas regiões Norte, Nordeste e Centro-Oeste. Os maiores aumentos foram observados no interior das regiões Norte entre 2004 e 2017 e Nordeste entre 1993 e 2017. No interior da região Centro-Oeste, também foi verificada tendência crescente em todo o período. Já nas capitais, entre 1997 e 2017, as taxas declinaram nas regiões Sudeste, Sul e Centro-Oeste. Mais tardiamente, taxas em declínio foram verificadas no interior da região Sudeste entre 2004 e 2017 e da região Sul entre 2007 e 2017.O câncer colorretal se colocava na sexta posição entre homens e quarta entre as mulheres em todo o país no início do período e passou a ocupar a quarta posição entre homens e terceira entre as mulheres ao final. As maiores taxas foram observadas nas regiões Sudeste e Sul, tanto para homens quanto para mulheres. Entre os homens, a partir de 1999, foi possível notar tendência de aumento na região Norte, e a partir de 2000 na região Nordeste, tanto em capitais quanto interior. Já na região Centro-Oeste, observou-se aumento nas capitais entre 1984 e 2017 e no interior entre 1992 e 2017. Tendência a aumento também foi verificada nas regiões Sudeste e Sul, com exceção dos moradores das capitais da região Sul, que de 2002 a 2017 mostraram estabilidade das taxas.Entre as mulheres também houve tendência a aumento da mortalidade do câncer colorretal, tanto nas capitais quanto no interior de todas as regiões, com exceção das capitais da região Sudeste, onde as taxas mantiveram-se estáveis entre 1997 e 2017, e da região Centro-Oeste, com estabilidade entre 2009 e 2017. Apenas nas capitais da região Sul foi verificada queda de 2007 a 2017.Chama atenção que os maiores aumentos nas duas últimas décadas foram verificados no interior das regiões Norte e Nordeste, tanto em homens quanto em mulheres. No interior da região Norte, ele se deu para os homens entre 1999 e 2017  e na região Nordeste, entre 2000 e 2017 . Para as mulheres, o aumento no interior da região Norte aconteceu entre 2000 e 2017  e no interior da região Nordeste, entre 1999 e 2017 .A mortalidade por câncer no Brasil para ambos os sexos no final do período estudado  foi semelhante à de países de alta renda ,Dados de outros países, em sua maioria desenvolvidos, apontam para a queda marcante da mortalidade por câncer alcançada nas duas últimas décadasA maior queda detectada no período estudado ocorreu para o câncer de estômago em todas as regiões, com exceção da região Norte como um todo e do interior da região Nordeste. O declínio, já relatado em estudos anterioresO câncer de colo do útero declinou em todas as regiões, mas não entre mulheres do interior da região Norte, onde as taxas em 2017 chegam a ser três vezes mais frequentes do que na região Sudeste. Algum efeito do rastreamento com base no exame de Papanicolau, introduzido em todo o país a partir de 1992A correlação inversa entre o índice de desenvolvimento humano (IDH) e as estimativas nacionais de câncer do colo do útero é bem relatada na literaturaA região Sul é a que apresenta o maior índice de desenvolvimento humano municipal (IDHM) do país , ao passo que as regiões Norte e Nordeste, apesar de terem tido crescimento mais acelerado entre 2000 e 2010, têm os mais baixosA experiência de países de alta renda, como os da América do Norte, de parte da Europa e o Japão, são um exemplo de que o investimento em programas efetivos de rastreamento fizeram com que hoje o câncer do colo do útero seja considerado uma doença raraAs mudanças demográficas no Brasil, com progressivo envelhecimento populacional, aumento da expectativa de vida e redução da fecundidade, somadas ao aumento da obesidadeEssa mesma tendência de diminuição nas regiões mais desenvolvidas do Brasil acontece em relação ao câncer de próstata, para o qual se percebe queda entre os homens das capitais desde 1997 e mais tardiamente entre os residentes do interior. Tal tendência pode ter relação com as possibilidades de oferta de serviços especializados para o tratamento dos casos diagnosticados precocementeO aumento da incidência do câncer de próstata nos países desenvolvidos parece estar relacionado ao aumento de acesso aos serviços de saúde, assim como ao aumento do registro de casos,O câncer de pulmão foi declinante entre homens das regiões Sudeste e Sul e nos residentes das capitais da região Centro-Oeste. Isso, contudo, não se verificou entre as mulheres, para as quais, de forma generalizada, as taxas foram ascendentes no período estudado. Nesse caso, por se tratar de um câncer com letalidade ainda alta, a diminuição da mortalidade se dá em função da diminuição da incidência. O aumento da mortalidade por câncer de pulmão entre mulheres já havia sido identificado em estudos em períodos anterioresA prevalência de fumantes no Brasil diminuiu em 19% entre 2008 e 2013, com declínio em todas as regiões, na área urbana e na rural, e na maioria dos estados. Houve queda em todas as faixas de escolaridade, porém as mais altas prevalências foram vistas entre pretos e pardosO câncer colorretal, terceiro e quarto mais frequente entre mulheres e homens, respectivamente, mostra um padrão evolutivo que merece atenção. Embora as taxas nas regiões Sudeste e Sul sejam maiores entre homens, elas são três vezes superiores às da região Norte.A ocorrência de câncer colorretal mostra padrões diferenciados entre países. Em vários países do Leste Europeu, da América Latina e da Ásia, observou-se tendência ascendente na incidência e na mortalidade. Já no Canadá, em países da Europa e em Singapura, a incidência continua aumentando, enquanto há declínio na mortalidade. No grupo restrito a países de alto IDH, há tendência de queda tanto na incidência como na mortalidadeChama atenção o fato de que, nas regiões Norte e Nordeste, as tendências da mortalidade por câncer colorretal tiveram aumento mais expressivo no interior, porém não se observou diferença de magnitude entre os sexos. Isso pode ser um indicativo de que o aumento da obesidade e do sedentarismo, fatores de risco clássicos para este tipo de tumores,A principal limitação deste estudo decorre da qualidade das informações sobre os óbitos no país. Devido à grande discrepância em termos de completitude da informação sobre a causa básica do óbito, principalmente nas regiões Norte e Nordeste nas duas primeiras décadas do período estudado,,garbage. Nesse conjunto de códigos, são incluídos, além dos óbitos registrados nos capítulos XVI da CID-9 e XVIII da CID-10, outras causas maldefinidas e diagnósticos incompletos vindos de outros capítulos. Optou-se no presente estudo por não incluir os demais códigos inespecíficos fora dos capítulos XVI da CID-9 e XVIII da CID-10 pela ausência de estudos que validem a contribuição da redistribuição dos óbitos registrados nos demais códigos inespecíficos entre os tipos específicos de câncerAlguns estudos préviosEstudos anteriores que mostraram a tendência de câncer no Brasil, com metodologia aplicando correção dos dados de óbito, incluíram períodos menores do que aqui apresentados: 1980–2006,Um outro aspecto a ser considerado é a cobertura do registro de óbitos. Embora tenha melhorado sensivelmente no país ao longo dessas quatro décadas, o sub-registro ainda existe em determinadas áreas, especialmente nos estados das regiões Norte e NordesteQuanto à aplicação da regressão linear por partes para avaliar a tendência no tempo, deve ser considerado que, se o intervalo de tempo for muito pequeno, mudanças de trajetória podem não apresentar significância estatística em função do número reduzido de pontos. No entanto, isso não ocorreu pois, em se tratando de um longo período de estudo, as APC que foram calculadas cobriram períodos de no mínimo quatro anos. Além disso, os resultados deste estudo consideraram apenas os intervalos que alcançaram significância estatística. Deve ser considerado também que o número de óbitos em cada unidade de análise não foi pequeno, considerando que os dados foram desagregadas até o nível das capitais e do interior de cada grande região, o que diminuiu a possibilidade de instabilidade na estimativa das taxas e de haver alta heterogeneidade na distribuição delas, ou seja, menor variância.Outra limitação dos modelos lineares para a análise de tendência é a possibilidade de autocorrelação residual. Neste trabalho, os modelos com diagnóstico de autocorrelação nos resíduos foram reestimados via mínimos quadrados generalizados com uma estrutura de correlação autorregressiva de primeira ordem – AR(1). Não foram identificadas estruturas de correlação de ordem mais elevadas. Logo, quando existente, a autocorrelação foi adequadamente tratada no modelo.Vale enfatizar que, ao mesmo tempo que se assiste à redução de alguns cânceres relacionados à pobreza, é real o aumento de novos casos de câncer associados a fatores decorrentes da história reprodutiva, hormonal e da dietaFoi visto que, nas regiões Sudeste e Sul, esse ponto de cruzamento entre a mortalidade por câncer de mama e câncer do colo do útero ocorreu antes da década de 1980 entre as mulheres residentes nas capitais. Já nessas mesmas regiões, para as residentes no interior, essa transição se deu mais tarde. Situações intermediárias ocorreram nas regiões Nordeste e Centro-Oeste, onde o ponto de cruzamento da mortalidade entre estes dois tipos de câncer nas capitais aconteceu em 1992 e 1993, respectivamente. No interior, porém, ele se deu apenas em 2008 na região Nordeste e em 2007 na região Centro-Oeste. A situação mais extrema é vista na região Norte, onde essa transição ainda não ocorreu nem nas capitais, nem no interior, indicando um quadro encontrado em países pobresNa mesma lógica, entre os homens podem ser identificados os pontos de cruzamento das curvas de mortalidade por câncer colorretal, que se associa positivamente com IDHAlguns resultados encontrados demandam um exame cuidadoso para entender os mecanismos implicados tanto em relação à acurácia da informação de óbitos como na qualidade da assistência à saúde. O crescimento marcado dos cânceres de próstata, colorretal e de mama no interior das regiões Norte e Nordeste merece investigação detalhada. Uma hipótese seria estar ocorrendo uma melhora da capacidade diagnóstica, porém com proporção alta de casos detectados em estágios tardiosPor fim, é preocupante o crescimento das taxas para o conjunto dos cânceres em anos recentes, em especial no interior das regiões Norte e Nordeste. Isso pode significar um aumento real na incidência devido a uma maior exposição a fatores de risco relacionados a um estilo de vida sedentário, mas, em se tratando de mortalidade, as dificuldades de acesso, em especial à detecção precoce e ao tratamento de tumores de bom prognóstico como os de mama e de próstata, podem levar a um aumento da mortalidade.O Brasil é um país em transição econômica e, durante essas quatro décadas, passou por várias modificações demográficas, sociais e políticasA partir da criação do Sistema Único de Saúde, incorporado à Constituição Federal em 1988, houve uma grande expansão dos serviços públicos, com significante melhora na equidade em saúde, porém não suficiente para diminuir as extremas desigualdades em todo o paísOs resultados encontrados refletem a existência de padrões distintos de magnitude e tendência de tipos específicos de câncer que por vezes são contrastantes e podem refletir processos de adoecimento e morte com dinâmicas particulares entre as grandes regiões do país e entre residentes de capitais e demais municípios. Ao mesmo tempo que para moradores das capitais das regiões mais desenvolvidas há uma tendência à diminuição da mortalidade, nas regiões mais pobres os aumentos expressivos, sobretudo no interior, deixam claro um perfil de extrema iniquidade em saúde.


Fabry disease is a rare disease, defined as an X-linked lysosomal deposition disease that presents with multisystemic symptoms, including vascular impairment with thrombotic events. A 57-year-old female patient diagnosed with Fabry disease 11 years previously, presented with hyperhidrosis, hypoacusis, and angiokeratoma on the hands. Her previous pathological history included an episode of ischemic stroke before the age of 40 years and chronic acute thrombosis in the right lower limb, 1 year previously, which had been treated with stent angioplasty, with temporary improvement followed by recent relapse of the condition. Thrombotic events fit the typical symptoms of Fabry disease and are caused by deposition of globotriaosylceramide in the vascular endothelium, constituting a prothrombotic state and explaining the recurrence of symptoms and arterial thrombosis in the lower limb. She was a smoker, had systemic arterial hypertension, and was free from renal and cardiac complications. She had hyperhidrosis, hypoacusia, and angiokeratoma on the hands. She stated that she had had no other symptoms during the course of the disease. Her surgical history included three caesarean deliveries, varicose veins surgery, blepharoplasty, lipoaspiration, and mamoplasty. She was one of nine siblings, five of whom had been diagnosed with the disease , including the patient. Her mother, who had not been diagnosed, and both brothers suffered renal failure around the fourth decade of life. The patient had had an ischemic stroke episode at 40 years of age, without sequelae. Two years previously, she had complained of onset of pain at rest in the right lower limb, had undergone angiography of the limb and had been treated with percutaneous transluminal angioplasty with placement of a Supera Abbott® stent in the right superficial femoral artery (SFA), which was a technical success and resulted in resolution of the pain. The patient was put on double platelet antiaggregation with 100 mg acetylsalicylic acid (ASA) and 75mg clopidogrel and control color Doppler ultrasonography (CDUS) was conducted at 3-month intervals, showing that the stent was patent until, at 9 months of follow-up, the patient began to complain of intermittent claudication of the right lower limb after walking 50 meters. Angiotomography was conducted, showing the stent was patent, but revealing critical stenosis of the distal right popliteal artery . During Fabry disease is hereditary and is linked to the X chromosome, meaning that men have a severe form of the disease and transmit it to all of their daughters, but not to their sons. In the case described here, the patient was female and had a less severe form of FD caused by random inactivation of one of the X chromosomes (the Lyon hypothesis)Although there is little literature on vascular involvement in FD, clinical and experimental evidence suggest that the process of infiltrative changes to the artery wall that lead to ischemia may differ from those observed in classic atherosclerosis, and FD-specific atherosclerosis is more diffuse and has a different composition to plaques, in addition to primarily involving small penetrating arterial vessels. As already mentioned, build-up of Gb3 leads to endothelial dysfunction and acceleration of the atherosclerotic process, caused by elevated levels of myeloperoxidase and reactive oxygen species. It is worth pointing out that when thrombophilias are also present, in particular factor V Leiden, severity of signs and symptoms is increased and events occur earlier.Many drug-based treatments are being studied; but agalsidase enzyme appears to be the most promising approach, treating the deficiency that causes disease, and should be initiated at onset of the first vascular events, thus avoiding late treatment and increased risk of amputations and chronic kidney disease requiring dialysis. This medication is already registered for use in Brazil under the name fabrazyme (Genzyme® – Sanofi Company), but it is expensive.The patient in this case report had intermittent claudication with onset in adulthood that relapsed after surgery and drug treatment, which can be explained by deposition of glycosphingolipids such as Gb3 in the vascular endothelium and visceral and nervous system tissues, which is also related to another clinical finding in this patient - stroke. ,,,-,,-A doença de Fabry (DF) é uma doença de depósito lisossomal causada por mutações no gene GLA no cromossomo X Xq22.1)1,2. Surivaroxabana 20 mg/dia e AAS 100 mg/dia. Aos 12 meses de seguimento, após a segunda intervenção, a paciente apresentou dor aguda e parestesia em perna e pé direitos. Foi submetida a arteriografia de urgência, que mostrou oclusão proximal de AFS direita , incluindo a paciente. Sua mãe, sem diagnóstico, e os dois irmãos apresentaram insuficiência renal por volta da quarta década de vida. Teve um episódio de AVE isquêmico aos 40 anos de idade, sem sequelas. Há dois anos, apresentou quadro de dor ao repouso em membro inferior direito, sendo submetida a angiografia do membro seguida de angioplastia transluminal percutânea com implante de stent Supera Abbott® em artéria femoral superficial (AFS) direita, apresentando sucesso técnico e desaparecimento da dor. Foi feito controle com eco-Doppler colorido (EDC) de membros em intervalos de 3 meses, que mostrava perviedade do stent usando terapia de dupla antiagregação plaquetária com ácido acetilsalicílico (AAS) 100 mg e clopidogrel 75 mg, até que, após 9 meses de seguimento, a paciente começou a referir claudicação intermitente de membro inferior direito para 50 metros. Foi então realizada angiotomografia, que mostrou stent pérvio e estenose crítica de artéria poplítea direita distal . No segu direita , sendo e direita  e esteno direita  e 7. FoA DF tem caráter hereditário e é relacionada ao cromossomo X; sendo assim, os homens apresentam a doença de forma grave e transmitem-na a todas as filhas, mas não aos filhos. No caso em questão, trata-se de uma paciente do sexo feminino, em que a DF se apresenta de forma menos grave, devido à inativação aleatória de um dos cromossomos X (hipótese de Lyon)Embora o envolvimento vascular na DF tenha escassa literatura, evidências clínicas e experimentais sugerem que o processo de mudanças infiltrativas na parede arterial levando à isquemia pode diferir daquele observado na aterosclerose clássica, sendo as ateroscleroses específicas da DF mais difusas e com composição diferente das placas, além de envolverem principalmente os pequenos vasos arteriais penetrantes. Com já comentado, com o acúmulo de Gb3 ocorre disfunção endotelial e aceleração do processo aterosclerótico, causadas pelo aumento nos níveis de mieloperoxidase e de espécies reativas de oxigênio. Ressalta-se que a associação com trombofilias, principalmente com a presença do fator V de Leiden, leva a uma maior gravidade dos sinais e sintomas e à ocorrência de eventos mais precocesDiversos tratamentos farmacológicos estão em estudo; porém, o uso da enzima agalsidase se mostrou mais promissor para suprir a deficiência causadora da doença, devendo ser iniciado com os primeiros eventos vasculares, evitando início tardio e maiores riscos de amputações e de doença renal crônica dialítica. Trata-se de um medicamento já registrado para uso no território nacional com o nome de fabrazyme (Genzyme® – Sanofi Company), mas tem custo muito elevado


Scientific Reports 10.1038/s41598-020-70077-z, published online 06 August 2020Correction to: In the original version of this Article, J. Esteban Castelao and Sara Miranda Ponte were incorrectly affiliated with ‘Centro de Investigación en Tecnoloxías da Información (CITIUS), Universidade de Santiago de Compostela, Santiago de Compostela, Spain’. The correct affiliation is listed below.Oncology and Genetics Unit, Instituto de Investigación Sanitaria Galicia Sur, Vigo, SpainThis error has now been corrected in the PDF and HTML versions of the Article, and in the accompanying Supplementary Information.


A challenging but eventful year draws to a close: The global COVID-19 pandemic has also left its mark on the Journal of Comparative Politics (ZfVP)—especially during the first half of the year. We are therefore all the more pleased that our four multifaceted issues published in 2020 have received great interest. One area where this is visible is in the number of steadily increasing downloads. In September 2020 we recorded over 55,000 downloads, up from 51,000 downloads in October 2019—a laudable development! Equally gratifying is the submission rate. So far this year, 29 manuscripts have been submitted for the review process (as of early December 2020), which means that the number of submissions from last year has already been exceeded.Wenzelburger et al. on the subject of “Responsive policy-making in the German federal states? An attempt to systematize and develop a research program” (1/2020), as well as an essay by Klaus Ziemer on “Causes for the different development of democratic standards in the post-communist states of Europe” (4/2020).In addition to research articles that go through our standard double-blind peer-review, we also published other contributions this year. These include a number of insightful reviews and summary reports, a literature review by Conceptualizing and Measuring Meanings and Understandings of Democracy, which were published by the editors Norma Osterberg-Kaufmann, Toralf Stark and Christoph Mohamad-Klotzbach with a classifying contribution entitled “Challenges in Conceptualizing and Measuring Meanings and Understandings of Democracy”. This is the first Special Section to appear in our journal. We are very pleased that our focus formats are increasingly being used and are well received internationally. A thematic focus enables deeper examination of the research field, whereby the state of research can be presented in detail and developed further. In the coming year a Special Section will appear on Environmentalism and Populism—an uneasy relation. Climate Movements in Comparative Perspective, edited by Aron Buzogány, Hans-Joachim Lauth and Christoph Mohamad-Klotzbach. Two further Special Issues are currently in the planning stages: Christiane Hubo, Simon Fink and Annette Elisabeth Töller are preparing the Special Issue on Party differences in environmental policy. Thomas Krumm and Marta Regalia are also organizing a Special Issue on Majority versus proportionality? Trajectories of electoral reform in the Mediterranean since the 1990s.This issue (4/2020) contains five articles on the Special Section Dr. Norma Osterberg-Kaufmann (for the Democracy Research Working Group), PD Dr. Andreas Ufen  and Prof. Dr. Matthijs Bogaards . The jurors decided—from a wealth of nine submitted works—to award three dissertations.The award for dissertations in the field of comparative area research was granted for the third time this year in honor of our colleague and co-editor Gero Erdmann. This year’s jury for the Gero Erdmann Prize, which comprises the work units in which Gero Erdmann played a key role, consisted of Theresia Smolka on “Stress tests for the European Union. Change in the quality of democracy in the 27 member states between 2004 and 2012” received first place, worth €1000. Markus Langenfeld  and Franzisca Zanker (dissertation on “Legitimacy in Peacebuilding: Rethinking Civil Society Involvement in Peace Negotiations”) share second place (each €500). We congratulate the award recipients on this success!1The dissertation by Stephan Bröchler, who i.a. oversees the reviews section, followed the call to the Berlin School of Law and Administration (HWR) to take over the professorship for political and administrative sciences. We would like to announce another exceptional appointment from the editorial team: at the recommendation of Federal Environment Minister Svenja Schulze, Annette Elisabeth Töller was appointed by the Federal Cabinet as one of seven experts in the Advisory Council for Environmental Issues (SRU) for the term of office from July 1, 2020 to mid-2024.Good news also comes from the editorial team. Prof. Dr. Edeltraud Roller (University of Mainz), who repeatedly worked as a constructive reviewer for our journal and still did so this year. Such commitment to our profession is admirable and we are very grateful to her for her support. We convey our deepest condolences to her relatives, friends and colleagues.Yet there is also sad news. We have been deeply saddened to hear of the passing of our esteemed colleague open access in Springer Nature journals since January 1, 2020. The fees are covered by the DEAL agreement. The contract thus stands for more visibility, impact, efficiency, transparency and sustainability in the dissemination of the research results published in the ZfVP, which are now available free of charge for the benefit of the global scientific world.Another event is of great importance for the ZfVP as well as for German science in general. By signing Springer Nature and Projekt DEAL, the world’s most extensive open access transformation agreement, corresponding authors from a German university or research institution have been able to publish their articles https://www.editorialmanager.com/zfvp/default.aspx. If you are interested in submitting reviews, comments, literature and conference reports, or if you would like to plan a special issue with us, please do not hesitate to contact us. For questions and suggestions, we can be reached at any time at zfvp@uni-wuerzburg.de. Further information on the ZfVP can be found at: https://www.springer.com/journal/12286.Here we would like to highlight that the ZfVP is an excellent publication platform for comparative research and that we always welcome scientific contributions within this research context. You can send us your manuscript via the Editorial Manager: We would like to thank all authors, reviewers and employees of the Springer VS publishing house for their cooperation during this challenging year. In particular, we would like to thank you for the numerous and informative reviews and reports that were written despite COVID-19’s adverse effects on science and on university operations.Christine Le Jeune and Jansen Harris as well as Anja Löbert (https://www.textworks.eu/), who over the years have provided us with reliable and high-quality support on the proofreading and language correction of English manuscripts. We would also like to thank our student assistant Pia Röhrer for her support.In addition, we would like to thank We very much appreciate all of your commitment and look forward to further cooperation in the coming year.We wish you a good end to the year and the best of health!Ein herausforderndes, aber dennoch ereignisreiches Jahr neigt sich dem Ende zu: Die weltweite COVID-19-Pandemie ist auch an der Zeitschrift für Vergleichende Politikwissenschaft (ZfVP) – insbesondere in der ersten Jahreshälfte – nicht spurlos vorübergegangen. Umso mehr freuen wir uns, dass auch im Jahr 2020 vier facettenreiche Ausgaben erschienen sind, die auf großes Interesse stoßen. Dies zeigt sich unter anderem an den Downloadzahlen, die stetig ansteigen. Während wir im Oktober 2019 51.000 Downloads verzeichneten, sind es im September 2020 bereits über 55.500 – eine erfreuliche Entwicklung! Auch die Einreichungsquote ist erfreulich. In diesem Jahr wurden bislang 29 Manuskripte für den Begutachtungsprozess eingereicht (Stand Anfang Dezember 2020) und damit ist bereits jetzt die Anzahl der Einreichungen aus dem letzten Jahr übertroffen.Wenzelburger et al. zum Thema „Responsive Politikgestaltung in den deutschen Bundesländern? Versuch einer Systematisierung und Konzeption eines Forschungsprogramms“ (1/2020), sowie ein Essay von Klaus Ziemer zu „Ursachen der unterschiedlichen Entwicklung demokratischer Standards in den postkommunistischen Staaten Europas“ (4/2020).Neben den klassischen Aufsätzen, die Standardgemäß unser double-blind peer-review durchlaufen, veröffentlichten wir auch in diesem Jahr andere Beiträge. Dazu zählen eine ganze Reihe aufschlussreicher Rezensionen und Sammelberichte, ein Literaturbericht von Conceptualizing and Measuring Meanings and Understandings of Democracy, die von den Herausgebenden Norma Osterberg-Kaufmann, Toralf Stark und Christoph Mohamad-Klotzbach durch einen einordnenden Beitrag mit dem Titel „Challenges in Conceptualizing and Measuring Meanings and Understandings of Democracy“ eingeführt werden. Dies ist die erste Special Section, die in unserer Zeitschrift erscheint. Es freut uns sehr, dass unsere Schwerpunktformate vermehrt genutzt werden und diese international Anklang finden. Durch den Themenschwerpunkt wird eine tiefere Auseinandersetzung mit dem Forschungsfeld ermöglicht, und der Forschungsstand kann ausführlich dargestellt und weiterentwickelt werden. Im kommenden Jahr wird die Special Section zu Environmentalism and Populism – an uneasy relation. Climate Movements in Comparative Perspective, die von Aron Buzogány, Hans-Joachim Lauth und Christoph Mohamad-Klotzbach herausgegeben wird, erscheinen. Zudem sind zwei weitere Special Issues in Planung. Christiane Hubo, Simon Fink und Annette Elisabeth Töller bereiten das Sonderheft zu Parteiendifferenz in der Umweltpolitik vor. Unter der Leitung von Thomas Krumm und Marta Regalia wird zudem ein Special Issue zu Majority versus proportionality? Trajectories of electoral reform in the Mediterranean since the 1990s auf den Weg gebracht.In diesem Heft (4/2020) befinden sich fünf Beiträge zur Special Section Dr. Norma Osterberg-Kaufmann (für den Arbeitskreis Demokratieforschung), PD Dr. Andreas Ufen  und Prof. Dr. Matthijs Bogaards (für die Zeitschrift für Vergleichende Politikwissenschaft) zusammen. Die Juror*innen entschieden sich – aus der Fülle von neun eingereichten Arbeiten – drei Dissertationen zu prämieren.In ehrenvollem Andenken an unseren Kollegen und Mitherausgeber Gero Erdmann wurde in diesem Jahr zum dritten Mal der Förderpreis für Dissertationen aus dem Bereich der vergleichenden Area Forschung verliehen. Die diesjährige Jury des Gero Erdmann-Preises, die sich aus den Arbeitseinheiten bildet, an denen Gero Erdmann maßgeblich mitwirkte, setzte sich aus Theresia Smolka zu „Belastungsproben für die Europäische Union. Veränderung der Demokratiequalität in den 27 Mitgliedstaaten zwischen 2004 und 2012“ wurde auf den ersten Platz gesetzt, der mit 1000 € dotiert ist. Markus Langenfeld  und Franzisca Zanker (Dissertation zu „Legitimacy in Peacebuilding: Rethinking Civil Society Involvement in Peace Negotiations“) teilen sich den zweiten Platz (à 500 €). Wir gratulieren den Preisträger*innen zu diesem Erfolg!4Die Dissertation von Stephan Bröchler, der u. a. die Rubrik der Rezensionen betreut, ist dem Ruf an die Hochschule für Recht und Verwaltung Berlin (HWR) gefolgt und übernimmt dort die Professur für Politik- und Verwaltungswissenschaften. Eine weitere exzeptionelle Berufung aus dem Redaktionskreis möchten wir gerne vermelden: Annette Elisabeth Töller wurde, auf Vorschlag der Bundesumweltministerin Svenja Schulze, vom Bundeskabinett als eine von sieben Expert*innen in den Sachverständigenrat für Umweltfragen (SRU) – für die Amtsperiode 1. Juli 2020 bis Mitte 2024 – berufen.Auch im Rahmen der Redaktion gibt es erfreuliche Neuigkeiten. Prof. Dr. Edeltraud Roller (Universität Mainz) erfahren, die für unsere Zeitschrift immer wieder als konstruktive Gutachterin tätig war und dies auch noch in diesem Jahr war. Ein solcher Einsatz für unsere Profession ist bewundernswert und wir sind ihr für diese Unterstützung sehr dankbar. Unser Mitgefühl gilt den Angehörigen, Freunden und Kolleg*innen.Dennoch gibt es auch eine traurige Nachricht. Mit Betroffenheit haben wir vom Tod unserer geschätzten Kollegin Open Access in Springer-Nature-Zeitschriften zu veröffentlichen, wobei die Gebühren unter die deutsche DEAL-Vereinbarung fallen. Der Vertrag steht somit für mehr Sichtbarkeit, Wirkung, Effizienz, Transparenz und Nachhaltigkeit bei der Verbreitung der in der ZfVP veröffentlichten Forschungsergebnisse, die nun zum Nutzen der globalen Wissenschaftswelt kostenfrei zur Verfügung stehen.Ein anderes Ereignis hat eine gewichtige Bedeutung für die ZfVP sowie für die deutsche Wissenschaft im Allgemeinen. Durch die Unterzeichnung von Springer Nature und Projekt DEAL, des weltweit umfangreichsten Open Access-Transformationsvertrages, sind seit 1. Januar 2020 korrespondierende Autor*innen, die einer deutschen Universität oder Forschungseinrichtung angehören, berechtigt, ihre Artikel https://www.editorialmanager.com/zfvp/default.aspx. Falls Sie Interesse haben Rezensionen, Kommentare, Literatur- sowie Tagungsberichte einzureichen, oder ein Sonderheft mit uns planen wollen, dann nehmen Sie gerne Kontakt mit uns auf. Für Fragen und Anregungen sind wir jederzeit unter zfvp@uni-wuerzburg.de erreichbar. Weitere Informationen zur ZfVP finden Sie unter: https://www.springer.com/journal/12286.An dieser Stelle wollen wir darauf hinweisen, dass die ZfVP eine hervorragende Publikationsplattform für komparative Forschung darstellt und wir wissenschaftliche Beiträge aus diesem Forschungskontext stets begrüßen. Ihr Manuskript können Sie uns über den Editorial Manager zukommen lassen: Allen Autor*innen, Gutachter*innen und Mitarbeiter*innen des Verlags Springer VS gilt unser Dank für die Zusammenarbeit in diesem herausfordernden Jahr. Insbesondere möchten wir uns für die Anfertigung der zahlreichen sowie aufschlussreichen Rezensionen und Gutachten, die trotz der Corona bedingten Beeinträchtigungen des Wissenschafts- und Hochschulbetriebs verfasst wurden, herzlich bedanken.Christine Le Jeune und Jansen Harris sowie Anja Löbert (https://www.textworks.eu/), die uns bei der Sprachkorrektur der englischen Manuskripte im Laufe der Jahre zuverlässig und qualitativ hochwertig unterstützt haben. Unserer studentischen Hilfskraft Pia Röhrer danken wir ebenfalls für die Unterstützung.Zudem gilt unser großer Dank All ihr Engagement schätzen wir sehr und freuen uns auf die Kooperationen im nächsten Jahr.Wir wünschen Ihnen einen guten Jahresabschluss in bester Gesundheit!Pamela Abbott, Hartmut Aden, Michael Alvarez, Gal Ariely, Christiane Barnickel, Youngho Cho, Lasse Cronqvist, Judith Enders, Katalin Fabian, Eszter Farkas, Martin Florack, Jean-Paul Gagnon, Brigitte Geißel, Manuela Glaab, Tobias Haas, Mark Heckmann, Lea Heyne, Oliver Hidalgo, Ekrem Karococ, Pascal König, András Körösényi, Matthias Lemke, Natasha Lindstaedt, Robert Mattes, Marcus Maurer, Anja Mays, Katja Müller, Abel Reiberg, Michael Robbins, Pedro L. Rodríguez, Robert J. Rohrschneider, Edeltraud Roller, Hannes Schammann, Andreas Schedler, Harald Schoen, Wolf Jürgen Schünemann, Doh Chull Shin, Markus B. Siewert, Alexander Thumfart, Luca Tomini, Aiko Wagner, Michael Wahman, Alexander Weiß


To verify the association of obesity and infertility related to anovulatory issues.This case-control study was carried out with 52 women, aged 20 to 38 years, divided into two groups (infertile − cases − and fertile − control), seen at outpatient clinics, in the period from April to December, 2017.We found significant evidence that obesity negatively affects women’s fertility (p=0.017). The group of infertile women was 7.5-fold more likely to be obese than fertile women.Strategies that encourage weight control are indicated for women with chronic anovulation, due to hight metabolic activity of adipose tissue. It is an ever more frequent phenomenon in developed societies and affects about 48.5 million couples around the world. Infertility is defined as the absence of pregnancy after one year of regular sexual intercourse without the use of contraceptives, for women under 35 years, and as of the sixth month of attempting to conceive for women 35 or more years of age.  Among the primary factors involved in infertility of couples, those related to female issues are classified as being tuboperitoneal and ovulatory.  The latter are influenced by extremes of body weight, which contribute towards insulin resistance,  reflected in anovulation. Fertility can be negatively affected by various hypothalamic, pituitary, thyroid, adrenal, and ovarian disorders, as well as by the usage of drugs, advanced age, and obesity.  According to information from thePesquisa de Orçamentos Familiares[Family Budget Research], performed in Brazil between 2008 and 2009, among women aged 20 or more years, 48% were overweight (body mass index/BMI ≥25kg/m 2 ) and 17% were obese (BMI ≥30kg/m 2 ). This is a worldwide issue.  Until now, there have been few observational studies about the association between obesity and infertility in the Brazilian population.It is increasingly acknowledged that the obesity epidemic contributes towards fertility problems.  Obesity, and primarily abdominal obesity, participates in this etiology, and the awareness of its relation with infertility is extremely important, so that the nutritional status of subfertile women, that is, women with absence of conception who actively want to conceive, can be corrected. The lack of knowledge about infertility hinders the adoption of preventive measures in its treatment.  and, although not the only factors involved, one should carefully analyze the ovulatory issues with the intention of positive reversal for a fertility process.Ovulatory defects and inexplicable causes represent more than 50% of etiology of infertility  negatively affecting the complex hormone environment, generating disorders in the hypothalamus-pituitary-ovarian axis  and, consequently, acting in the deregulation of the menstrual cycle and in the reproductive capacity of the woman.Abdominal obesity, common in patients with polycystic ovary syndrome (PCOS), is involved in the secretion of various hormones and cytokines that contribute towards the start of a proinflammatory status and oxidative damage,  Obesity occurs in 30% to 75% of women with PCOS,  and increases the magnitude of hormone and metabolic dysfunction of these women. Polycystic ovary syndrome is a heterogeneous condition characterized by irregular ovulations or anovulation, hyperandrogenism, oligomenorrhea, and subfertility. To investigate the association of obesity and infertility related to anovulatory issues in women, and to identify associated factors.Instituto Nacional da Saúde da Mulher, Criança e do Adolescente Fernandes Figueira/Fundação Oswaldo Cruz(IFF/Fiocruz), in the city of Rio de Janeiro (State of Rio de Janeiro/RJ), between April and December 2017. Pairing of the sample was done by age.This is a case-control study conducted with women seen at outpatient clinics of theAs cases, women treated at the infertility outpatient clinic, with anovulatory problems defined by the physician in charge, were enrolled, and as controls, pregnant women seen at the prenatal outpatient clinic, who desired to participate in the study. In both groups, women under 20 years of age or over 38 years of age were excluded, in addition to those seen at the infertility outpatient clinic with tuboperitoneal problems or their partners’ sperm issues.The parameters used for the diagnosis of anovulatory issues included clinical history and determination of serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol and progesterone. which observed the marker of oxidative stress in follicular fluid in infertile women (lipid peroxidase/LPO). In Group 1, women without PCOS, with abdominal obesity  were enrolled, and for Group 2, women without PCOS and without abdominal obesity .The sample was calculated considering the results of the infertility study, The confidence interval adopted was 95% with a power of 80%, generating a sample size of 24 observations in each group, totaling up 48. The sample was incremented only in the controls by 16% (4 cases), due to the fact of more patients not having been seen with anovulation at the infertility outpatient clinic during the chosen period for collection, totaling 52 participants in the study, classified as Case (24) and Control (28) Groups.diabetes mellitus, hypertension, PCOS, other diseases, as well as the habit of smoking and using alcoholic beverages. The use of alcoholic beverages was classified as 1 - does not use / 2 - uses once in a while / 3 - uses daily / 4 - uses on weekends.Data collection was performed using the International Physical Activity Questionnaire (IPAQ) and a previously tested questionnaire, prepared for the investigation, divided into three parts: the first contained questions related to sociodemographic information, such as age, occupation, district, and city of residence. The second part contained information on the clinical history, such as2 ; 2 - adequate: 18.5 to 24.9kg/m 2 ; 3 - overweight: 25.0 to 29.9kg/m 2 ; 4 - obesity: ≥30.0kg/m 2 .In the third part, the anthropometric values of weight, height, abdominal circumference (AC), and hip circumference (HC) were described. The BMI was categorized as 1 - low weight: <18.5kg/m diabetes mellitus, hypertension, and PCOS were included in the study but were not analyzed between the two groups.The predictive variables analyzed in this study were BMI, physical activity, and alcohol and smoking habits. The remaining variables cited above, such as AC, HC,The BMI was calculated for each woman, by means of the weight/height squared ratio, and was classified as per the criteria of the World Health Organization (WHO), 2000 (https://www.who.int/nutrition/publications/obesity/WHO_TRS_894/en/).The anthropometric measurements of weight, height, AC, and HC of the cases were checked on the days patients were seen at the infertility outpatient clinic, and the anthropometric measurements of weight and height were obtained from pregestational reports of weight and height from the controls at the time of the interviews. For pregnant women who did not know their height, it was measured at the time of the interview.The AC of the cases was measured around the region of the greatest diameter, normally coinciding with the umbilical scar. The AC and HC variables were not evaluated for the Control Group, due to the anatomical modification related to pregnancy.diabetes mellitus, hypertension, and PCOS was only checked in the Case Group.The variables of use of alcohol, smoking, and physical activity were collected by self-reports and checked relative to the pregestational period in the Control Group, and relative to the current period for the Case Group. The condition of having We used the short version, which covers the types of physical activity that people do in their daily living, as part of a large study divided among different countries.The IPAQ was proposed by WHO in 1998 and was validated in Brazil by means of a pilot study in Brazilian young adults. The data was analyzed based on frequency , mean, and standard deviation .2 and Fisher’s exact tests were used, carried out with (SPSS) software, version 22.For comparison between the groups, the χ All the participants signed the Informed Consent Form (ICF). The research project was approved by the Committee of Ethics and Research in Human Beings (CEPIFF), under opinion number 2.374.634, CAAE: 63617616.6.0000.5269, submitted on February 15, 2017.The mean age of the infertile women observed was 31 years, and of fertile women, 27 years.The hypothesis test of the women seen at the infertility and prenatal outpatient clinics of IFF/Fiocruz by means of the variable BMI, presented with statistical evidence (p<0.05) that obesity interfered in fertility of women.Of all the variables with p<0.05 that were entered into the multivariate model, only BMI demonstrated significance; the Case Group was 7.5-fold more likely to be obese when compared to the fertile women .As to being a smoker, the comparison between the groups was close to statistical significance (p=0.115), although no infertile patient smoked, and only four women from the prenatal outpatient clinic smoked (14%). As to alcoholic beverages, in both groups, the majority of women did not consume them; no woman in the Case Group used alcohol daily, and only two fertile patients (7%) consumed alcoholic beverages every day.Active and irregularly active women were the majority in both groups studied.Abdominal obesity was noted in 21 infertile patients (87.5%), indicating an increased risk of metabolic complications in these patients .Of the infertile patients, only one reported being diabetic (4.2%), and two (8.3%) were hypertensive.,16 Knowledge about the association between obesity and infertility is important to deepen understanding of the factors that involve the worldwide obesity pandemic  and comprehend it in addition to chronic noncommunicable diseases.This study investigated the association between obesity and infertility, two prevalent issues in modern female life, according to other findings already described in literature.  The relation between weight loss and improvement of the reproductive function is well established, but the mechanisms that act in optimizing this function need to be better clarified. Most of the women with excessive weight, that is, overweight or obesity, were in the Case Group. Observing 1,880 women seen at infertility clinics in the United States and Canada, a study concluded that the relative risk of anovulatory infertility is 3.1 times greater in obese women.  and modifications in the metabolism of sex hormones  and insulin resistance. It is important to point out there are several factors that influence the anovulation process, and these often occur concomitantly: oxidative stress, which can affect the follicular fluid, diabetes mellitus, since there is an intermediate stage between the homeostasis of glucose and diabetes.  Half of the cases studied presented with obesity, and 95.8% of these patients did not suffer fromdiabetes mellitus, suggesting that they could be in this deficient glucose tolerance stage.Obese women may present with damaged or decreased tolerance to glucose without being carriers of,25 that observed an interference of these factors in the female reproductive capacity, since they cause modification in the hormone levels and decrease libido.As to the use of alcoholic beverages and smoking, these findings were different relative to those of other studies, diabetes mellitustype 2, and some kinds of cancer and dyslipidemia,  there are obese patients that present with only one or none of these comorbidities. This does not mean that there are cases of healthy obesity, since the inflammatory process is inherent to this disease, causing various damages to the health of patients.As to hypertension, 91.7% of cases studied reported not having this disease. Despite the fact that obesity is related to several comorbidities, such as hypertension,,11 reinforcing the hypothesis that obesity interferes in infertility.The result of physical activity, with few sedentary women (none in the Case Group and four – 14% − in Control Group), could be related to the manner in which the IPAQ classified the moderate activities, including domestic activities that moderately increase breathing rate or heart beats and were very often included by the participants of this study as the only physical activity reported. The potential of the present study was to demonstrate that population studies follow the same pattern found in studies carried out in other countries, Obesity influences infertility, that is, there is a positive correlation between obesity and infertility. Knowledge of such a relation is important in order to increase the chances of subfertile women of reversing the situation of infertility, and having a healthy pregnancy. Improving eating habits and engagement in physical exercises are important to promote changes in body composition and nutritional status of these women.The best management of women with chronic anovulation should be the development of strategies that stimulate weight control, before beginning a treatment cycle for assisted reproduction.We suggest hospitals providing treatment for infertility offer nutritional care and encourage the practice of physical exercise to the population seen. É um fenômeno cada vez mais comum nas sociedades desenvolvidas e afetando cerca de 48,5 milhões de casais em todo mundo.A infertilidade é definida como a ausência de gravidez após 1 ano de relações sexuais regulares sem uso de contraceptivos, para mulheres com menos de 35 anos, e a partir do sexto mês de tentativa de concepção, para as com 35 ou mais anos de idade.Dentre os principais fatores envolvidos na infertilidade conjugal, aqueles relacionados às questões femininas são classificados como os de tuboperitoneal e ovulatórios.Estes últimos são influenciados por extremos de peso corporal, que contribuem para a resistência insulínica,refletindo em anovulação.A fertilidade pode ser afetada negativamente por diferentes transtornos hipotalâmicos, pituitários, tireoideanos, adrenais e ovarianos, bem como pelo consumo de drogas, idade avançada e pela obesidade.Segundo informações da Pesquisa de Orçamentos Familiares realizada no Brasil entre 2008 e 2009, dentre as mulheres com 20 ou mais anos de idade, 48% estavam com peso excessivo  e 17% estavam obesas (IMC ≥30kg/m2). Esta é uma questão de escala mundial.Até o momento, há poucos estudos observacionais sobre a associação da obesidade e a infertilidade na população brasileira.É cada vez mais reconhecido que a epidemia de obesidade contribui para problemas de fertilidade.A obesidade, principalmente a abdominal, participa desta etiologia, e o conhecimento de sua relação com a infertilidade é de extrema importância, para que se possa atuar no estado nutricional das mulheres subférteis, ou seja, mulheres com falta de concepção e que ativamente desejam conceber.A falta de conhecimentos sobre a infertilidade dificulta a adoção de práticas preventivas em seu tratamento.e, embora não sejam os únicos fatores envolvidos, devem-se analisar as questões ovulatórias cuidadosamente, no intuito de reversão positiva para um processo de fertilidade.Os defeitos ovulatórios e as causas inexplicáveis representam mais de 50% da etiologia da infertilidaderefletindo negativamente no complexo ambiente hormonal, gerando distúrbios no eixo hipotálamo-hipofisário-ovarianoe, consequentemente, atuando na desregularização do ciclo menstrual e na capacidade reprodutiva da mulher.A obesidade abdominal, comum nas pacientes com síndrome do ovário policístico (SOP), está envolvida na secreção de vários hormônios e citocinas, que contribuem para o início de um estado pró-inflamatório e dano oxidativo,A obesidade ocorre em 30% a 75% das mulheres com SOP,e aumenta a magnitude da disfunção hormonal e metabólica dessas mulheres.A SOP constitui condição heterogênea caracterizada por ovulações irregulares ou anovulação, hiperandrogenismo, oligomenorreia e subfertilidade.Investigar em mulheres a associação entre obesidade e infertilidade, relacionada às questões anovulatórias, e identificar os fatores associados.Trata-se de estudo caso-controle desenvolvido com mulheres atendidas nos ambulatórios do Instituto Nacional da Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira/Fundação Oswaldo Cruz (IFF/ Fiocruz), no Rio de Janeiro (RJ), de abril a dezembro de 2017. O pareamento da amostra deu-se por idade.Como casos, foram incluídas mulheres atendidas no ambulatório de infertilidade com questões anovulatórias definidas pelo médico responsável e, como controles, gestantes atendidas no ambulatório do pré-natal, que desejaram participar do estudo. Em ambos os grupos, foram excluídas as mulheres até 20 anos ou com mais de 38 anos de idade, além daquelas atendidas no ambulatório de infertilidade com problemas tuboperitoneal ou questões de esperma do parceiro.Os parâmetros usados para diagnóstico das questões anovulatórias incluíram história clínica e avaliação das dosagens séricas dos hormônios folículo-estimulante (FSH), luteinizante (LH), estradiol e progesterona.que observou o marcador de estresse oxidativo no fluido folicular de mulheres inférteis (peroxidase lipídica/LPO). No grupo 1, foram incluídas mulheres sem SOP, com obesidade abdominal  e para o grupo 2, mulheres sem SOP e sem obesidade abdominal .A amostra foi calculada considerando os resultados de estudo sobre infertilidade,Consideraram-se nível de confiança de 95% e poder de 80%, gerando tamanho amostral de 24 observações em cada grupo, com total de 48. A amostra foi incrementada apenas nos controles em 16% (4 casos), pelo fato de não terem sido atendidas mais pacientes com anovulação no ambulatório de infertilidade no período estipulado para a coleta, totalizando 52 mulheres participantes do estudo, classificadas nos Grupo Caso (24) e Controle (28).diabetes mellitus, hipertensão arterial, SOP, outras doenças, hábito de fumar e de usar bebida alcóolica. O uso de bebida alcóolica foi classificado em: 1 - não usa / 2 - usa eventualmente / 3 - usa diariamente / 4 - usa final de semana.A coleta dos dados foi realizada utilizando-se o Questionário Internacional de Atividade Física (IPAQ) e questionário previamente testado, construído para a pesquisa, dividido em três partes: a primeira continha perguntas relacionadas a informações sociodemográficas, como idade, profissão, bairro e cidade onde reside. A segunda parte continha informações sobre a história clínica, como possuir2; 2 - adequado: de 18,5 a 24,9kg/m2; 3 - sobrepeso: de 25,0 a 29,9kg/m2; 4 - obesidade: ≥30,0kg/m2.Na terceira parte, foram descritos os valores antropométricos de peso, estatura, circunferência abdominal (CA) e circunferência do quadril (CQ). O IMC foi categorizado em: 1 - baixo peso: <18,5kg/mdiabetes mellitus, hipertensão arterial e SOP foram incluídas no estudo, mas não foram analisadas entre os dois grupos.As variáveis preditoras analisadas neste estudo foram IMC, atividade física, hábito de usar bebida alcóolica e de fumar. As demais variáveis citadas anteriormente: CA, CQ,O IMC foi calculado para cada mulher, por meio da relação do peso/estatura ao quadrado, sendo classificado a partir dos critérios de 2000 da Organização Mundial da Saúde (OMS) (https://www.who.int/nutrition/publications/obesity/WHO_TRS_894/en/).As medidas antropométricas de peso, estatura, CA e CQ dos casos foram aferidas nos dias de atendimento no ambulatório de infertilidade, e as medidas antropométricas de peso e estatura dos controles foram obtidas de relato do peso e da estatura pré-gestacional no momento das entrevistas. Para as gestantes que desconheciam sua estatura, esta foi aferida no momento da entrevista.A CA dos casos foi mensurada na região com o maior diâmetro, coincidindo normalmente com a cicatriz umbilical.As variáveis CA e CQ não foram avaliadas para o Grupo Controle, devido à alteração anatômica provocada pela gravidez.diabetes mellitus, hipertensão arterial e SOP foi verificada apenas no Grupo Caso.As variáveis uso de bebida alcóolica, fumo e atividade física foram coletadas por autorrelato e averiguadas em relação ao período pré-gestacional no Grupo Controle, e em relação ao período atual para o Grupo Caso. A condição de possuirUtilizou-se a versão curta, que aborda os tipos de atividades físicas que as pessoas realizam em seu dia a dia, sendo parte de um grande estudo desdobrado em diferentes países.O IPAQ foi proposto pela OMS em 1998 e validado no Brasil por meio de estudo piloto em adultos jovens brasileiros.Os dados foram analisados a partir de sua frequência (variáveis categóricas), da média e do desvio padrão (variáveis numéricas).2e exato de Fisher, efetuados no software (SPSS), versão 22.Para comparação entre os grupos, foram utilizados os testes do χTodas as participantes assinaram o Termo de Consentimento Livre e Esclarecido (TCLE). O projeto de pesquisa foi aprovado pelo Comitê de Ética e Pesquisa em Seres Humanos (CEPIFF), sob parecer 2.374.634, CAAE: 63617616.6.0000.5269, submetido em 15 de fevereiro de 2017.A média de idade das mulheres inférteis observada foi de 31 anos e das mulheres férteis de 27 anos.O teste de hipótese entre as amostras das mulheres atendidas no ambulatório de infertilidade e de pré-natal do IFF/Fiocruz, por meio da variável IMC, apresentou evidência estatística  de que a obesidade interferiu na fertilidade das mulheres. ADe todas as variáveis com p<0,05 que entraram no modelo multivariado, apenas o IMC demonstrou significância, sendo que o Grupo Caso teve 7,5 mais chances de serem obesas quando comparadas as mulheres férteis .Quanto a ser fumante, a comparação entre os grupos ficou próxima da significância estatística , embora nenhuma paciente infértil fumasse, e apenas quatro do ambulatório do pré-natal fumavam (14%). Em relação à bebida alcóolica, nos dois grupos, a maioria das mulheres não a consumia; nenhuma mulher do Grupo Caso fazia uso diariamente e apenas duas pacientes férteis (7%) consumia bebida alcóolica todos os dias.As mulheres ativas e irregularmente ativas foram a maioria nos dois grupos estudados.Observou-se obesidade abdominal em 21 pacientes inférteis , pelo resultado da aferição da CA >80cm, indicando risco aumentado de complicações metabólicas nestas pacientes .Das pacientes inférteis, apenas uma referiu ser diabética  e duas  hipertensas.,16Conhecer a associação entre obesidade e infertilidade é importante para se aprofundar em questões que envolvem a pandemia mundial da obesidadee entendê-la para além das doenças crônicas não transmissíveis.Este estudo investigou a associação entre obesidade e infertilidade, duas questões prevalentes na vida feminina moderna, à luz de outros achados já descritos na literatura.A relação entre perda de peso e melhora da função reprodutiva é bem estabelecida na literatura, mas os mecanismos que atuam na otimização desta função precisam ser melhor elucidados.As mulheres com excesso de peso, ou seja, sobrepeso ou obesidade estavam, em sua maioria, no Grupo Caso. Ao se observar 1.880 mulheres atendidas em clínicas de infertilidade nos Estados Unidos e Canadá, estudo concluiu que o risco relativo de infertilidade anovulatória é 3,1 vezes maior nas obesas.e as alterações no metabolismo dos hormônios sexuaise na resistência insulínica.É importante destacar que há vários fatores que influenciam no processo de anovulação, e estes ocorrem, muitas vezes, concomitantemente: o estresse oxidativo, que pode afetar o fluido folicular,diabetes mellitus, pois há um estágio intermediário entre a homeostase de glicose e o diabetes.Metade dos casos estudados apresentou obesidade e 95,8% do total destas pacientes não eram portadoras dediabetes mellitus, sugerindo que poderiam estar nesse estágio de tolerância à glicose prejudicada.Mulheres obesas podem apresentar tolerância à glicose prejudicada ou diminuída sem serem portadoras de,25que observaram interferência destes fatores na capacidade reprodutiva feminina, por causarem alterações na mudança dos níveis hormonais e diminuirem a libido.Quanto ao uso de bebida alcóolica e fumo, estes achados foram diferentes em relação aos de outros estudos,diabetes mellitustipo 2 e alguns tipos de câncer e dislipidemias,há pacientes obesas que apresentam apenas uma ou nenhuma destas comorbidades. Isto não significa que existam casos de obesidade saudável, pois o processo inflamatório é inerente a esta doença, causando diversos danos à saúde dos pacientes.Com relação à hipertensão arterial sistêmica, 91,7% dos casos estudados referiram não possuir essa doença. Apesar de a obesidade estar relacionada com diversas comorbidades, como a própria hipertensão arterial, o,11reforçando a hipótese de que a obesidade interfere na infertilidade.O resultado de atividade física, com poucas mulheres sedentárias (nenhuma no Grupo Caso e quatro – 14% − no Controle), pode ter relação com a forma como o IPAQ classifica as atividades moderadas, incluindo atividades domésticas que aumentam moderadamente a respiração ou os batimentos do coração e foram bastante incluídas pelas participantes desta pesquisa como a única atividade física relatada. O potencial do presente estudo foi demonstrar que a população estudada segue o mesmo padrão encontrado em pesquisas de outros países,A obesidade influencia na infertilidade, ou seja, há correlação positiva entre a obesidade e a infertilidade. Os conhecimentos sobre tal relação são importantes para aumentar as chances das mulheres subférteis de reverterem a situação de infertilidade e terem uma gravidez saudável. Melhorias no hábito alimentar e prática de exercício físico são importantes para promover mudanças na composição corporal e no estado nutricional destas mulheres.O melhor manejo de mulheres com anovulação crônica deve ser o desenvolvimento de estratégias que estimulem o controle do peso, antes de se começar um ciclo de tratamento de reprodução assistida.Sugere-se que os hospitais que fornecem tratamento para infertilidade ofereçam atendimento nutricional e incentivem a prática de exercício físico à população assistida.


The Women in Medicine Summit (WiMS) is a novel, student-led conference initiated at the University of Toronto to engage the medical community in a discussion about unique gender-distinctive challenges in medicine. We identified topics inadequately addressed in undergraduate curriculums, including techniques to address microaggressions and balance work-life commitments. Students from five Canadian medical schools attended WiMS in 2018. Attendees perceived significant improvement in readiness in identifying and resolving gender-associated issues following the conference. Our findings may be used to motivate curriculum development and adoption of similar initiatives to improve education on diversity.Le Sommet sur les femmes en médecine (WiMS) est une nouvelle conférence menée par des étudiants et lancée à l’Université de Toronto pour amener la communauté médicale à discuter des enjeux associés au genre en médecine. Nous avons relevé des sujets insuffisamment traités dans les programmes d’études de premier cycle, y compris des techniques pour examiner les micro-agressions et équilibrer les engagements professionnels et la vie privée. Des étudiants de cinq facultés de médecine canadiennes étaient présents au WiMS en 2018. Les participants ont perçu une importante amélioration dans leur capacité à discerner et à résoudre les enjeux associés au genre à la suite de la conférence. Nos résultats peuvent être utilisés pour inciter le développement de cursus et l’adoption d’initiatives similaires pour améliorer l’éducation sur la diversité.1 45-70% of American and Canadian medical school faculty reported curricular coverage of sex- and gender-based evidence as “minimal”.2,3 With recent increases in awareness, a parallel increase in efforts to fill this gap through curricular and non-curricular initiatives were seen.4,5While great strides have been made in achieving gender equity and diversity in medicine, female physicians remain disproportionately represented in leadership. In 2018, 2 of 17 (11.7%) Canadian Deans of Medicine and 6 of 26 (23%) CMA Board of Directors were women, despite 41% of Canadian physicians being women.In 2018, University of Toronto students launched the Women in Medicine Summit (WiMS) to contribute to these efforts. WiMS aimed to assess gender-associated challenges faced by medical trainees and to evaluate WiMS’ impact on attendees. Conferences organized by groups like the Federation of Medical Women of Canada and Canadian Women in Medicine encourage student attendance. However, WiMS 2018 was the first to be organized by and for Canadian medical students with topics unique to the undergraduate experience. The local research ethics board deemed this program evaluation exempt from ethics review.The full day summit featured two keynote speakers, three panels, and three workshops. 106 medical trainees from five Canadian medical schools attended the inaugural event on August 18, 2018. Topics addressed included leadership and power hierarchies, microaggressions, and the diversity of career paths. 55.8% of attendees who completed the post-program assessment 24/43,  reportedThe applicability of our results may be limited to the early experiences of medical school as 77% (33/43) of respondents were pre-clerks. We aim to improve attendance by clerks and allies in future annual iterations to elicit their important perspectives on workplace culture.Our results identify an extra-curricular opportunity to help address gender in undergraduate medicine. Feedback from WiMS 2018 suggests that it was an effective short-term intervention to help Canadian medical trainees feel more prepared to manage gender-associated challenges in clinical settings. WiMS has continued to garner positive response, with the most recent WiMS 2019 hosting 10 of 13 Canadian medical schools and American delegates. Based on this interest and our results, we believe that other medical schools may benefit from adopting a similar initiative to improve education on gender-associated medical challenges, and by utilizing topics identified by our attendees to inform curriculum development.