Browsing by Author "Staton, Catherine A"
Now showing 1 - 14 of 14
Results Per Page
Sort Options
Item Open Access A cross-sectional exploratory study of knowledge, attitudes, and practices of emergency health care providers in the assessment of child maltreatment in Maputo, Mozambique.(BMC emergency medicine, 2018-05-09) Pinto, Liliana; Lein, Adriana; Mahoque, Raquel; Wright, David W; Sasser, Scott M; Staton, Catherine ABACKGROUND:In Mozambique, and other low-income countries (LICs), there is little information on the burden of child maltreatment (CM). Emergency care services (ECS) play an important role in recognizing, treating, and intervening in situations of CM. We aim to identify knowledge, attitudes, and practices regarding CM among health care providers in ECS at Mavalane General Hospital in Maputo, Mozambique. METHODS:This exploratory cross-sectional study evaluates the knowledge, attitudes, and practices of health care providers to diagnose and treat cases of CM. A 25 min, pilot-tested verbal interview questionnaire was administered to 49 physicians and nurses working in ECS at Mavalane General Hospital. Interviews were completed between October-November 2010. Data were managed and analyzed in SPSS 14.0 and descriptive statistics were generated. RESULTS:Of 49 health care providers, 83.6% reporting receiving no, or very little CM education or training. Only 61.2% had knowledge of physical abuse as a main form of child maltreatment and 38.8% were able to identify corresponding symptoms of physical abuse. Sexual abuse as a main form of CM was mentioned by 26.5 and 2% cited its symptoms. While 87.7% of health care providers strongly agreed or agreed that they hold an important role in preventing CM, 51.1% also strongly disagreed or disagreed that they feel confident diagnosing and treating CM cases. In regards to follow-up, 14.3% strongly disagreed or disagreed that they know where to refer victims for further follow-up and an additional 14.3% did not know whether they agreed or disagreed. CONCLUSION:This study revealed knowledge gaps in emergency health care provider knowledge of the main forms of CM and their symptoms. The fact that a majority of health care providers in our sample did not receive information specific to CM in their medical education and training could explain this gap, as well as their unawareness of where to refer victims. Given that health care providers believe they play an important role in identifying and treating CM, future research should focus on raising physician awareness of CM and developing education and training materials grounded in cultural contexts to build response capacity in Mozambique and other LICs.Item Open Access A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda.(PloS one, 2017-01) Kuo, Benjamin J; Vaca, Silvia D; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Xu, Linda; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John; Kiryabwire, Joel; Nanjula, Lydia; Muhumuza, Christine; Rice, Henry E; Grant, Gerald A; Haglund, Michael MBackground
Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.Methods
We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.Results
563 TBI patients were enrolled from 1 June- 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3-5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.Conclusions
The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3-82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.Item Open Access An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.(PloS one, 2020-01) Zimmerman, Armand; Fox, Samara; Griffin, Randi; Nelp, Taylor; Thomaz, Erika Bárbara Abreu Fonseca; Mvungi, Mark; Mmbaga, Blandina T; Sakita, Francis; Gerardo, Charles J; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Staton, Catherine ABackground
Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting.Methods
We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes.Results
Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery.Conclusions
Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.Item Open Access Epidemiology of hypertension in Northern Tanzania: a community-based mixed-methods study.(BMJ Open, 2017-11-09) Galson, Sophie W; Staton, Catherine A; Karia, Francis; Kilonzo, Kajiru; Lunyera, Joseph; Patel, Uptal D; Hertz, Julian T; Stanifer, John WINTRODUCTION: Sub-Saharan Africa is particularly vulnerable to the growing global burden of hypertension, but epidemiological studies are limited and barriers to optimal management are poorly understood. Therefore, we undertook a community-based mixed-methods study in Tanzania to investigate the epidemiology of hypertension and barriers to care. METHODS: In Northern Tanzania, between December 2013 and June 2015, we conducted a mixed-methods study, including a cross-sectional household epidemiological survey and qualitative sessions of focus groups and in-depth interviews. For the survey, we assessed for hypertension, defined as a single blood pressure ≥160/100 mm Hg, a two-time average of ≥140/90 mm Hg or current use of antihypertensive medications. To investigate relationships with potential risk factors, we used adjusted generalised linear models. Uncontrolled hypertension was defined as a two-time average measurement of ≥160/100 mm Hg irrespective of treatment status. Hypertension awareness was defined as a self-reported disease history in a participant with confirmed hypertension. To explore barriers to care, we identified emerging themes using an inductive approach within the framework method. RESULTS: We enrolled 481 adults (median age 45 years) from 346 households, including 123 men (25.6%) and 358 women (74.4%). Overall, the prevalence of hypertension was 28.0% (95% CI 19.4% to 38.7%), which was independently associated with age >60 years (prevalence risk ratio (PRR) 4.68; 95% CI 2.25 to 9.74) and alcohol use (PRR 1.72; 95% CI 1.15 to 2.58). Traditional medicine use was inversely associated with hypertension (PRR 0.37; 95% CI 0.26 to 0.54). Nearly half (48.3%) of the participants were aware of their disease, but almost all (95.3%) had uncontrolled hypertension. In the qualitative sessions, we identified barriers to optimal care, including poor point-of-care communication, poor understanding of hypertension and structural barriers such as long wait times and undertrained providers. CONCLUSIONS: In Northern Tanzania, the burden of hypertensive disease is substantial, and optimal hypertension control is rare. Transdisciplinary strategies sensitive to local practices should be explored to facilitate early diagnosis and sustained care delivery.Item Open Access Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.(PloS one, 2023-01) Keating, Elizabeth M; Sakita, Francis; Vonderohe, Maddy; Nkini, Getrude; Amiri, Ismail; Loutzenheiser, Kelly; Young, Bryan; Rent, Sharla; Staton, Catherine A; Mmbaga, Blandina T; Watt, Melissa HBackground
Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge.Objective
The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania.Methods
This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis.Results
Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up.Conclusion
Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.Item Open Access Immune response profiling in patients with traumatic injuries associated with alcohol ingestion.(Clinical and translational science, 2021-09) Breslin, Adam W; Limkakeng, Alexander T; Silvius, Elizabeth; Staton, Catherine A; Almond, Chandra; Joshi, Mary-Beth; Adams, Bartley; Johnston, Bria; McGowan, Lauren; Kirk, Allan D; Elster, EricTraumatic injuries afflict more than 5 million people globally every year. Current and past animal research has demonstrated association among alcohol, trauma, and impaired immune function, whereas human registries have shown association between alcohol and morbidity as well as mortality. The purpose of this study is to elucidate the immune interactions with alcohol in traumatically injured patients. We prospectively enrolled 379 patients after trauma at three medical centers in the Surgical Critical Care Initiative. Plasma was analyzed using Luminex for up to 35 different cytokines. Collected samples were grouped by patients with detectable plasma alcohol levels versus those without. Univariate testing determined differences in analytes between groups. We built Bayesian belief networks with multiple minimum descriptive lengths to compare the two groups. All 379 patient samples were analyzed. Two hundred eighty-two (74.4%) patients were men, and 143 (37.7%) were White. Patients had a median intensive care unit length of stay (LOS) of 5.8 days and hospital LOS of 12 days. Using single variate analyses, eight different cytokines were differentially associated with alcohol. Cytokines IL-12 and IL-6 were important nodes in both models and IL-10 was a prominent node in the nonalcohol model. This study found select immune function differed between traumatically injured patients with measurable serum alcohol levels as compared with those without. Traumatically injured patients with positive blood alcohol content appear less able to inhibit inflammatory stress. Alcohol appears to suppress pro-inflammatory IL-12 and IL-6, whereas patients without alcohol have greater levels of anti-inflammatory IL-10 expressed at injury and may better regulate anti-inflammatory pathways. Future studies should determine the relationship with these markers with clinically oriented outcomes.Item Open Access Injury characteristics and their association with clinical complications among emergency care patients in Tanzania.(African journal of emergency medicine : Revue africaine de la medecine d'urgence, 2022-12) Zimmerman, Armand; Barcenas, Loren K; Pesambili, Msafiri; Sakita, Francis; Mallya, Simon; Vissoci, Joao Ricardo Nickenig; Park, Lawrence; Mmbaga, Blandina T; Bettger, Janet Prvu; Staton, Catherine ABackground
Over 5 million people annually die from injuries and millions more sustain non-fatal injuries requiring medical care. Ninety percent of injury deaths occur in low- and middle-income countries (LMICs). This study describes the characteristics, predictors and outcomes of adult acute injury patients presenting to a tertiary referral hospital in a low-income country in sub-Saharan Africa.Methods
This secondary analysis uses an adult acute injury registry from Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. We describe this patient sample in terms of socio-demographics, clinical indicators, injury patterns, treatments, and outcomes at hospital discharge. Outcomes include mortality, length of hospital stay, and functional independence. Associations between patient characteristics and patient outcomes are quantified using Cox proportional hazards models, negative binomial regression, and multivariable logistic regression.Results
Of all injury patients (n=1365), 39.0% were aged 30 to 49 years and 81.5% were men. Most patients had at least a primary school education (89.6%) and were employed (89.3%). A majority of injuries were road traffic (63.2%), fall (16.8%), or assault (14.0%) related. Self-reported comorbidities included hypertension (5.8%), HIV (3.1%), and diabetes (2.3%). Performed surgeries were classified as orthopedic (32.3%), general (4.1%), neurological (3.7%), or other (59.8%). Most patients reached the hospital at least four hours after injury occurred (53.9%). Mortality was 5.3%, median length of hospital stay was 6.1 days (IQR: 3.1, 15.0), self-care dependence was 54.2%, and locomotion dependence was 41.5%.Conclusions
Our study sample included primarily young men suffering road traffic crashes with delayed hospital presentations and prolonged hospital stays. Being older, male, and requiring non-orthopedic surgeries or having HIV portends a worse prognosis. Prevention and treatment focused interventions to reduce the burden of injury mortality and morbidity at KCMC are needed to lower injury rates and improve injury outcomes.Item Open Access Lifetime prevalence of intimate partner violence against women in an urban Brazilian city: A cross-sectional survey.(PloS one, 2019-01) Kwaramba, Tendai; Ye, Jinny J; Elahi, Cyrus; Lunyera, Joseph; Oliveira, Aline Chotte; Sanches Calvo, Paulo Rafael; de Andrade, Luciano; Vissoci, Joao Ricardo Nickenig; Staton, Catherine ABACKGROUND:Intimate partner violence is a global health burden that disproportionately affects women and their health outcomes. Women in Brazil are also affected by interpersonal violence. We aimed to estimate the lifetime prevalence of three forms of interpersonal violence against women (IPVAW) and to identify sociodemographic factors associated with IPVAW in one urban Brazilian city. METHODS:Using a cross-sectional design, we interviewed women aged ≥18 years in the urban Brazilian city, Maringá, who currently have or have had an intimate partner. The 13-item WHO Violence Against Women instrument was used to ask participants about their experiences with intimate partner violence, categorized into psychological, physical and sexual violence. We estimated associations between IPVAW and sociodemographic characteristics using generalized linear models. RESULTS AND CONCLUSIONS:Of the 419 women who were enrolled and met inclusion criteria, lifetime prevalence of IPVAW was 56%. Psychological violence was more prevalent (52%) than physical (21%) or sexual violence (13%). Twenty-eight women (6.4%) experienced all three forms of IPVAW. Women were more likely to experience violence if they were employed, did not live with their partner or had 4 or more children. Educational level, household income, age and race were not significantly associated factors. Our findings highlight a high prevalence of IPVAW in a community in southern Brazil.Item Open Access Machine Learning and Precision Medicine in Emergency Medicine: The Basics.(Cureus, 2021-09) Lee, Sangil; Lam, Samuel H; Hernandes Rocha, Thiago Augusto; Fleischman, Ross J; Staton, Catherine A; Taylor, Richard; Limkakeng, Alexander TAs machine learning (ML) and precision medicine become more readily available and used in practice, emergency physicians must understand the potential advantages and limitations of the technology. This narrative review focuses on the key components of machine learning, artificial intelligence, and precision medicine in emergency medicine (EM). Based on the content expertise, we identified articles from EM literature. The authors provided a narrative summary of each piece of literature. Next, the authors provided an introduction of the concepts of ML, artificial intelligence as an extension of ML, and precision medicine. This was followed by concrete examples of their applications in practice and research. Subsequently, we shared our thoughts on how to consume the existing research in these subjects and conduct high-quality research for academic emergency medicine. We foresee that the EM community will continue to adapt machine learning, artificial intelligence, and precision medicine in research and practice. We described several key components using our expertise.Item Open Access Population-level surgical rates and unmet need in India: a retrospective analysis of districts and states from 2011 to 2019.(International journal of surgery (London, England), 2024-03) Zadey, Siddhesh; Smith, Emily R; Staton, Catherine A; Fitzgerald, Tamara N; Vissoci, Joao Ricardo NickenigItem Open Access Prevention of childhood unintentional injuries in low- and middle-income countries: A systematic review.(PloS one, 2020-01) Tupetz, Anna; Friedman, Kaitlyn; Zhao, Duan; Liao, Huipeng; Isenburg, Megan Von; Keating, Elizabeth M; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Staton, Catherine AInjuries are a leading cause of death and disability among children. Numerous injury prevention strategies have been successful in high-income countries, but the majority of unintentional injuries happen to children living in low- and middle-income countries (LMICs). This project aims to delineate the childhood injury prevention initiatives in LMICs. For inclusion, peer-reviewed articles needed to address unintentional injury, include children <18, assess a prevention-related intervention, contain a control group, and be published after 1988. Two pairs of reviewers evaluated articles independently to determine study eligibility. 74 articles were included. 30 studies addressed road traffic injuries, 11 drowning, 8 burns, 3 falls, 8 poisonings, and 21 an unspecified injury type. The findings show positive effects on injury outcome measures following educational interventions, the need for longer follow-up periods after the intervention, the need for effectiveness trials for behavior change, and the need for an increase in injury prevention services in LMICs. This is the first systematic review to summarize the prevention initiatives for all types of childhood unintentional injuries in LMICs. Increased attention and funding are required to go beyond educational initiatives with self-reported measures and little follow-up time to robust interventions that will reduce the global burden of unintentional injuries among children.Item Open Access Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis.(PloS one, 2021-01) Ribeiro, Ana Graziela Araujo; Martins, Rafiza Félix Marão; Vissoci, João Ricardo Nickenig; da Silva, Núbia Cristina; Rocha, Thiago Augusto Hernandes; Queiroz, Rejane Christine de Sousa; Tonello, Aline Sampieri; Staton, Catherine A; Facchini, Luiz Augusto; Thomaz, Erika Bárbara Abreu FonsecaObjective
Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services.Methods
Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011-2012 and Cycle II: 2013-2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made.Results
The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was "Best completeness" in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with "Best completeness" increased by 89.1%, the one with "Worst completeness" increased by 20%, while those with "Average completeness" decreased by 66.3%.Conclusion
We identified positive changes in the indicators of potential access to oral health services, expanding the users' ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting.Item Open Access Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda.(Neurosurgery, 2019-01) Vaca, Silvia D; Kuo, Benjamin J; Nickenig Vissoci, Joao Ricardo; Staton, Catherine A; Xu, Linda W; Muhumuza, Michael; Ssenyonjo, Hussein; Mukasa, John; Kiryabwire, Joel; Rice, Henry E; Grant, Gerald A; Haglund, Michael MBACKGROUND:Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed. OBJECTIVE:To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda. METHODS:Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed. RESULTS:Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04). CONCLUSION:Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.Item Open Access The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access.(PloS one, 2019-01-10) Hertz, Julian T; Fu, Tommy; Vissoci, Joao Ricardo; Rocha, Thiago Augusto Hernandes; Carvalho, Elias; Flanagan, Brendan; de Andrade, Luciano; Limkakeng, Alex T; Staton, Catherine ABACKGROUND:Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality. METHODS AND RESULTS:Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables. CONCLUSIONS:The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.