RESUMO

BACKGROUND: Up to 50% of women report sleep problems in midlife, and cardiovascular disease (CVD) is the leading cause of death in women. How chronic poor sleep exposure over decades of midlife is related to CVD risk in women is poorly understood. We tested whether trajectories of insomnia symptoms or sleep duration over midlife were related to subsequent CVD events among SWAN (Study of Women's Health Across the Nation) participants, whose sleep was assessed up to 16 times over 22 years. METHODS: At baseline, SWAN participants (n=2964) were 42 to 52 years of age, premenopausal or early perimenopausal, not using hormone therapy, and free of CVD. They completed up to 16 visits, including questionnaires assessing insomnia symptoms (trouble falling asleep, waking up several times a night, or waking earlier than planned ≥3 times/week classified as insomnia), typical daily sleep duration, vasomotor symptoms, and depressive symptoms; anthropometric measurements; phlebotomy; and CVD event ascertainment (ie, fatal or nonfatal myocardial infarction, stroke, heart failure, revascularization). Sleep trajectories (ie, insomnia, sleep duration) were determined by means of group-based trajectory modeling. Sleep trajectories were tested in relation to CVD in Cox proportional hazards models (multivariable models: site, age, race and ethnicity, education, CVD risk factors averaged over visits; additional covariates: vasomotor symptoms, snoring, depression). RESULTS: Four trajectories of insomnia symptoms emerged: low insomnia symptoms (n=1142 [39% of women]), moderate insomnia symptoms decreasing over time (n=564 [19%]), low insomnia symptoms increasing over time (n=590 [20%]), and high insomnia symptoms that persisted (n=668 [23%]). Women with persistently high insomnia symptoms had higher CVD risk (hazard ratio, 1.71 [95% CI, 1.19, 2.46], P=0.004, versus low insomnia; multivariable). Three trajectories of sleep duration emerged: persistently short (~5 hours: n=363 [14%]), moderate (~6 hours: n=1394 [55%]), and moderate to long (~8 hours: n=760 [30%]). Women with persistent short sleep had marginally higher CVD risk (hazard ratio, 1.51 [95% CI, 0.98, 2.33], P=0.06, versus moderate; multivariable). Women who had both persistent high insomnia and short sleep had significantly elevated CVD risk (hazard ratio, 1.75 [95% CI, 1.03, 2.98], P=0.04, versus low insomnia and moderate or moderate to long sleep duration; multivariable). Relations of insomnia to CVD persisted when adjusting for vasomotor symptoms, snoring, or depression. CONCLUSIONS: Insomnia symptoms, when persistent over midlife or occurring with short sleep, are associated with higher CVD risk among women.

Assuntos

Doenças Cardiovasculares , Distúrbios do Início e da Manutenção do Sono , Feminino , Humanos , Distúrbios do Início e da Manutenção do Sono/epidemiologia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/diagnóstico , Ronco , Sono , Saúde da Mulher

RESUMO

STUDY DESIGN: This study is a meta-analysis of prospective and retrospective studies identified in PubMed, Web of Science, and Embase with outcomes of patients who received intraoperative somatosensory-evoked potential (SSEP) monitoring during lumbar spine surgery. OBJECTIVE: The objective of this study is to determine the diagnostic accuracy of intraoperative lower extremity SSEP changes for predicting postoperative neurological deficit. As a secondary analysis, we evaluated three subtypes of intraoperative SSEP changes: reversible, irreversible, and total signal loss. SUMMARY OF BACKGROUND DATA: Lumbar decompression and fusion surgery can treat lumbar spinal stenosis and spondylolisthesis but carry a risk for nerve root injury. Published neurophysiological monitoring guidelines provide no conclusive evidence for the clinical utility of intraoperative SSEP monitoring during lumbar spine surgery. METHODS: A systematic review was conducted to identify studies with outcomes of patients who underwent lumbar spine surgeries with intraoperative SSEP monitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated and presented with forest plots and a summary receiver operating characteristic curve. RESULTS: The study cohort consisted of 5607 patients. All significant intraoperative SSEP changes had a sensitivity of 44% and specificity of 97% with a DOR of 22.13 (95% CI, 11.30-43.34). Reversible and irreversible SSEP changes had sensitivities of 28% and 33% and specificities of 97% and 97%, respectively. The DORs for reversible and irreversible SSEP changes were 13.93 (95% CI, 4.60-40.44) and 57.84 (95% CI, 15.95-209.84), respectively. Total loss of SSEPs had a sensitivity of 9% and specificity of 99% with a DOR of 23.91 (95% CI, 7.18-79.65). CONCLUSION: SSEP changes during lumbar spine surgery are highly specific but moderately sensitive for new postoperative neurological deficits. Patients who had postoperative neurological deficit were 22 times more likely to have exhibited intraoperative SSEP changes.Level of Evidence: 2.

Assuntos

Potenciais Somatossensoriais Evocados , Monitorização Neurofisiológica Intraoperatória , Humanos , Monitorização Intraoperatória , Procedimentos Neurocirúrgicos , Estudos Prospectivos , Estudos Retrospectivos

RESUMO

OBJECTIVE: To identify groups of women who share levels and patterns of change in follicle-stimulating hormone (FSH), self-reported sleep maintenance problems, and frequent vasomotor symptoms (VMS) up to 10 years before and after their final menstrual period and to evaluate their premenopausal characteristics. METHOD: Group-based multi-trajectory modeling grouped 1,407 women from the Study of Women's Health Across the Nation who had an observed natural menopause and did not use hormone therapy, based on repeated measures of FSH, sleep maintenance problems, and frequent VMS relative to final menstrual period. Multivariable analyses assessed race/ethnicity, body mass index, smoking, and depressive symptoms as predictors of group membership. RESULTS: Women formed five distinct groups: (1) low symptoms (low VMS/sleep problems)/high FSH rise (N = 552; 39.2%); (2) moderate VMS and sleep problems/low FSH rise (N = 169; 12.0%); (3) dominant sleep problems (lower VMS/high sleep problems)/high FSH rise (N = 203; 14.4%); (4) dominant VMS (high VMS/lower sleep problems)/high FSH rise (N = 297; 21.1%)); and (5) high symptoms (high VMS/high sleep problems)/intermediate FSH rise (N = 186; 13.2%)). Multivariate analyses showed that race/ethnicity, premenopausal body mass index and depressive symptoms, and increasing depressive symptoms during the early phase of the transition predicted group membership. CONCLUSIONS: Women can be classified based on shared levels and patterns of FSH, sleep maintenance problems, and frequent VMS across the menopause transition. Either VMS or sleep maintenance problems can be dominant in the face of high FSH. Experiencing one menopause-related symptom or hormone profile does not automatically imply that another is also being experienced.

Assuntos

Menopausa , Saúde da Mulher , Feminino , Hormônio Foliculoestimulante , Fogachos/epidemiologia , Humanos , Estudos Longitudinais , Sono

RESUMO

STUDY OBJECTIVES: Sleep disturbance is common among midlife women. Poor self-reported sleep characteristics have been linked to cerebrovascular disease and dementia risk. However, little work has considered the relation of objectively assessed sleep characteristics and white matter hyperintensities (WMHs), a marker of small vessel disease in the brain. Among 122 midlife women, we tested whether women with short or disrupted sleep would have greater WMH, adjusting for cardiovascular disease (CVD) risk factors, estradiol, and physiologically assessed sleep hot flashes. METHODS: We recruited 122 women (mean age = 58 years) without a history of stroke or dementia who underwent 72 h of actigraphy to quantify sleep, 24 h of physiologic monitoring to quantify hot flashes; magnetic resonance imaging to assess WMH; phlebotomy, questionnaires, and physical measures (blood pressure, height, and weight). Associations between actigraphy-assessed sleep (wake after sleep onset and total sleep time) and WMH were tested in linear regression models. Covariates included demographics, CVD risk factors (blood pressure, lipids, and diabetes), estradiol, mood, and sleep hot flashes. RESULTS: Greater actigraphy-assessed waking after sleep onset was associated with more WMH [B(SE) = .008 (.002), p = 0.002], adjusting for demographics, CVD risk factors, and sleep hot flashes. Findings persisted adjusting for estradiol and mood. Neither total sleep time nor subjective sleep quality was related to WMH. CONCLUSIONS: Greater actigraphy-assessed waking after sleep onset but not subjective sleep was related to greater brain WMH among midlife women. Poor sleep may be associated with brain small vessel disease at midlife, which can increase the risk for brain disorders.

Assuntos

Transtornos do Sono-Vigília , Substância Branca , Actigrafia , Feminino , Fogachos , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Sono , Substância Branca/diagnóstico por imagem

RESUMO

STUDY OBJECTIVES: For most women, the menopause is accompanied by hot flashes and sleep problems. Although hot flashes reportedly wake women from sleep, in the few studies that have used objective measures of both sleep and hot flashes, links between hot flashes and nocturnal awakening have been inconsistent. In a well-characterized cohort of midlife women, we examined the association between objectively assessed hot flashes and actigraphically defined wake from sleep. We hypothesized that wake episodes would be more likely during an objective hot flash relative to minutes without a hot flash. METHODS: Peri- and postmenopausal midlife women underwent simultaneous objective measurement of hot flashes (sternal skin conductance) and sleep (actigraphy) over 24 hours in the home. The likelihood of waking in the minutes during the hot flash relative to the minutes preceding the hot flash was compared using generalized estimating equations. RESULTS: We studied 168 women with at least one objective nocturnal hot flash and actigraphy data. Actigraphy-assessed wake episodes were concurrent with 78% of the objective hot flashes. We found an increased likelihood of wake in the minutes during the objective hot flash (0 to +5 min: OR [95% CI] = 5.31 (4.46 to 6.33); p < .0001) relative to the minutes preceding it (-10 to -1 min). The increased likelihood of wake occurred irrespective of whether the women reported the objective hot flash. CONCLUSION: Among these women who underwent objective measurement of sleep and hot flashes, nocturnal wakefulness was observed with the majority of hot flashes.

Assuntos

Fogachos/fisiopatologia , Distúrbios do Início e da Manutenção do Sono/fisiopatologia , Transtornos do Sono-Vigília/fisiopatologia , Actigrafia , Estudos de Coortes , Feminino , Humanos , Menopausa/fisiologia , Pessoa de Meia-Idade , Sono/fisiologia

RESUMO

STUDY OBJECTIVES: To describe racial/ethnic differences in sleep duration, continuity, and perceived sleep quality in postmenopausal women and to identify statistical mediators of differences in sleep characteristics. METHODS: Recruited from the observational Study of Women's Health Across the Nation (SWAN), 1,203 (548 white, 303 black, 147 Chinese, 132 Japanese, and 73 Hispanic; mean age 65 years, 97% postmenopausal) women participated in a week-long actigraphy and daily diary study in 2013-2015. Actigraphic measures of sleep duration and wake after sleep onset (WASO), and diary-rated sleep quality were averaged across the week. Candidate mediators included health-related variables; stress; and emotional well-being assessed up to 13 times across 18 years from baseline to sleep study. RESULTS: Whites slept longer than other groups; the significant mediators were concurrent financial hardship and increasing number of stressors for Hispanics or Japanese versus whites. Whites had less WASO than blacks and Hispanics; significant mediators were concurrent number of health problems, physical inactivity, waist circumference, vasomotor symptoms, number of life stressors, and financial hardship, and increasing number of health problems from baseline to sleep study. Whites reported better sleep quality than blacks, Chinese, and Japanese; significant mediators were concurrent physical inactivity, vasomotor symptoms, positive affect, and depressive symptoms. CONCLUSIONS: Sleep differences between blacks or Hispanics versus whites were mediated by health problems, number of stressors, and financial hardship, whereas sleep differences between Chinese or Japanese versus whites were mediated by emotional well-being. This is the first study using formal mediational approaches.

Assuntos

Etnicidade/psicologia , Grupos Raciais/etnologia , Grupos Raciais/psicologia , Sono/fisiologia , Saúde da Mulher/etnologia , Actigrafia/tendências , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Polissonografia/tendências , Pós-Menopausa/etnologia , Pós-Menopausa/fisiologia , Pós-Menopausa/psicologia , Estados Unidos/etnologia , Saúde da Mulher/tendências

RESUMO

OBJECTIVE: Hot flashes are experienced by most midlife women. Emerging data indicate that they may be associated with endothelial dysfunction. No studies have tested whether hot flashes are associated with endothelial function using physiologic measures of hot flashes. We tested whether physiologically assessed hot flashes were associated with poorer endothelial function. We also considered whether age modified associations. METHODS: Two hundred seventy-two nonsmoking women reporting either daily hot flashes or no hot flashes, aged 40 to 60 years, and free of clinical cardiovascular disease, underwent ambulatory physiologic hot flash and diary hot flash monitoring; a blood draw; and ultrasound measurement of brachial artery flow-mediated dilation to assess endothelial function. Associations between hot flashes and flow-mediated dilation were tested in linear regression models controlling for lumen diameter, demographics, cardiovascular disease risk factors, and estradiol. RESULTS: In multivariable models incorporating cardiovascular disease risk factors, significant interactions by age (P < 0.05) indicated that among the younger tertile of women in the sample (age 40-53 years), the presence of hot flashes (beta [standard error] = -2.07 [0.79], P = 0.01), and more frequent physiologic hot flashes (for each hot flash: beta [standard error] = -0.10 [0.05], P = 0.03, multivariable) were associated with lower flow-mediated dilation. Associations were not accounted for by estradiol. Associations were not observed among the older women (age 54-60 years) or for self-reported hot flash frequency, severity, or bother. Among the younger women, hot flashes explained more variance in flow-mediated dilation than standard cardiovascular disease risk factors or estradiol. CONCLUSIONS: Among younger midlife women, frequent hot flashes were associated with poorer endothelial function and may provide information about women's vascular status beyond cardiovascular disease risk factors and estradiol.

Assuntos

Artéria Braquial/diagnóstico por imagem , Endotélio Vascular/fisiopatologia , Fogachos/fisiopatologia , Perimenopausa/fisiologia , Pós-Menopausa/fisiologia , Adulto , Fatores Etários , Doenças Cardiovasculares/etiologia , Distribuição de Qui-Quadrado , Cromatografia Líquida , Estradiol/análise , Feminino , Fogachos/sangue , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Análise Multivariada , Fatores de Risco , Autorrelato , Estatísticas não Paramétricas , Espectrometria de Massas em Tandem , Ultrassonografia de Intervenção , Saúde da Mulher

RESUMO

OBJECTIVE: Trauma is a potent exposure that can have implications for health. However, little research has considered whether trauma exposure is related to endothelial function, a key process in the pathophysiology of cardiovascular disease (CVD). We tested whether exposure to traumatic experiences was related to poorer endothelial function among midlife women, independent of CVD risk factors, demographic factors, psychosocial factors, or a history of childhood abuse. METHODS: In all, 272 nonsmoking perimenopausal and postmenopausal women aged 40 to 60 years without clinical CVD completed the Brief Trauma Questionnaire, the Child Trauma Questionnaire, physical measures, a blood draw, and a brachial ultrasound for assessment of brachial artery flow-mediated dilation (FMD). Relations between trauma and FMD were tested in linear regression models controlling for baseline vessel diameter, demographics, depression/anxiety, CVD risk factors, health behaviors, and, additionally, a history of childhood abuse. RESULTS: Over 60% of the sample had at least one traumatic exposure, and 18% had three or more exposures. A greater number of traumatic exposures was associated with lower FMD, indicating poorer endothelial function in multivariable models (beta, ß [standard error, SE] -1.05 [0.40], P = 0.01). Relations between trauma exposure and FMD were particularly pronounced for three or more trauma exposures (b [SE] -1.90 [0.71], P = 0.008, relative to no exposures, multivariable). CONCLUSIONS: A greater number of traumatic exposures were associated with poorer endothelial function. Relations were not explained by demographics, CVD risk factors, mood/anxiety, or a by history of childhood abuse. Women with greater exposure to trauma over life maybe at elevated CVD risk.

Assuntos

Sobreviventes Adultos de Maus-Tratos Infantis/estatística & dados numéricos , Endotélio Vascular/fisiopatologia , Exposição à Violência/estatística & dados numéricos , Adulto , Velocidade do Fluxo Sanguíneo , Doenças Cardiovasculares/fisiopatologia , Feminino , Humanos , Pessoa de Meia-Idade , Fatores de Risco

RESUMO

BACKGROUND: Among women aged 50 to 59 years at baseline in the Women's Health Initiative (WHI) Estrogen-Alone (E-Alone) trial, randomization to conjugated equine estrogen-alone versus placebo was associated with lower risk of myocardial infarction and mortality, and, in an ancillary study, the WHI-CACS (WHI Coronary Artery Calcification Study) with lower CAC, measured by cardiac computed tomography ≈8.7 years after baseline randomization. We hypothesized that higher CAC would be related to post-trial coronary heart disease (CHD), cardiovascular disease (CVD), and total mortality, independent of baseline randomization or risk factors. METHODS AND RESULTS: WHI-CACS participants (n=1020) were followed ≈8 years from computed tomography scan in 2005 (mean age=64.4) through 2013 for incident CHD (myocardial infarction and fatal CHD, n=17), CVD (n=69), and total mortality (n=55). Incident CHD and CVD analyses excluded women with CVD before scan (n=89). Women with CAC=0 (n=54%) had very low age-adjusted rates/1000 person-years of CHD (0.91), CVD (5.56), and mortality (3.45). In comparison, rates were ≈2-fold higher for women with any CAC (>0). Associations were not modified by baseline randomization to conjugated equine estrogen-alone versus placebo. Adjusted for baseline randomization and risk factors, the hazard ratio (95% confidence interval) for CAC >100 (19%) was 4.06 (2.11, 7.80) for CVD and 2.70 (1.26, 5.79) for mortality. CONCLUSIONS: Among a subset of postmenopausal women aged 50 to 59 years at baseline in the WHI E-Alone Trial, CAC at mean age of 64 years was strongly related to incident CHD, CVD, and to total mortality over ≈8 years, independent of baseline randomization to conjugated equine estrogen-alone versus placebo or CVD risk factors. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000611.

Assuntos

Doença da Artéria Coronariana/epidemiologia , Terapia de Reposição de Estrogênios/métodos , Estrogênios Conjugados (USP)/administração & dosagem , Calcificação Vascular/epidemiologia , Saúde da Mulher , Distribuição de Qui-Quadrado , Angiografia por Tomografia Computadorizada , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Terapia de Reposição de Estrogênios/efeitos adversos , Terapia de Reposição de Estrogênios/mortalidade , Estrogênios Conjugados (USP)/efeitos adversos , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Análise Multivariada , Pós-Menopausa , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/mortalidade

RESUMO

BACKGROUND: Heart failure (HF) and dementia are major causes of disability and death among older individuals. Risk factors and biomarkers of HF may be determinants of dementia in the elderly. We evaluated the relationship between biomarkers of cardiovascular disease and HF and risk of dementia and death. Three hypotheses were tested: (1) higher levels of high-sensitivity cardiac troponin T, N-terminal of prohormone brain natriuretic peptide, and cystatin C predict risk of death, cardiovascular disease, HF, and dementia; (2) higher levels of cardiovascular disease biomarkers are associated with increased risk of HF and then secondary increased risk of dementia; and (3) risk of dementia is lower among participants with a combination of lower coronary artery calcium, atherosclerosis, and lower high-sensitivity cardiac troponin T (myocardial injury). METHODS AND RESULTS: The Cardiovascular Health Study Cognition Study was a continuation of the Cardiovascular Health Study limited to the Pittsburgh, PA, center from 1998-1999 to 2014. In 1992-1994, 924 participants underwent magnetic resonance imaging of the brain. There were 199 deaths and 116 developed dementia before 1998-1999. Of the 609 participants eligible for the Pittsburgh Cardiovascular Health Study Cognition Study, 87.5% (n=532) were included in the study. There were 120 incident HF cases and 72% had dementia. In 80 of 87, dementia preceded HF. A combination of low coronary artery calcium score and low high-sensitivity cardiac troponin T was significantly associated with reduced risk of dementia and HF. CONCLUSIONS: Most participants with HF had dementia but with onset before HF. Lower high-sensitivity cardiac troponin T and coronary artery calcium was associated with low risk of dementia based on a small number of events. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005133.

Assuntos

Envelhecimento , Aterosclerose/epidemiologia , Doença da Artéria Coronariana/epidemiologia , Demência/epidemiologia , Insuficiência Cardíaca/epidemiologia , Coração/fisiopatologia , Nefropatias/epidemiologia , Rim/fisiopatologia , Calcificação Vascular/epidemiologia , Fatores Etários , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Aterosclerose/diagnóstico , Aterosclerose/mortalidade , Aterosclerose/fisiopatologia , Biomarcadores/sangue , Causas de Morte , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Cistatina C/sangue , Demência/diagnóstico , Demência/mortalidade , Demência/fisiopatologia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Incidência , Nefropatias/diagnóstico , Nefropatias/mortalidade , Nefropatias/fisiopatologia , Imageamento por Ressonância Magnética , Masculino , Peptídeo Natriurético Encefálico/sangue , Testes Neuropsicológicos , Pennsylvania/epidemiologia , Fragmentos de Peptídeos/sangue , Prevalência , Fatores de Risco , Fatores de Tempo , Troponina T/sangue , Calcificação Vascular/diagnóstico , Calcificação Vascular/mortalidade , Calcificação Vascular/fisiopatologia

RESUMO

PURPOSE: Wrist-worn accelerometer devices measure sleep in free-living settings. Few studies, however, have investigated whether these devices can also measure waking movement behavior (e.g., total movement volume, physical activity). The purpose of this study was to investigate the ability of a wrist-worn Actiwatch 2 sleep monitor to rank total movement volume and physical activity levels compared with a waist-worn ActiGraph GT1M accelerometer and self-reported leisure time physical activity, respectively. In addition, we compared temporally matched activity measured via the ActiGraph GT1M and Actiwatch 2 over the study week. METHODS: A subset of women from the Healthy Women Study (n = 145; age, 73.3 ± 1.7 yr) wore an Actiwatch 2 on their nondominant wrist and an ActiGraph GT1M on their dominant hip for seven consecutive days. Participants recorded their leisure time physical activity in a 7-d diary and completed the past year version of the Modifiable Activity Questionnaire. Analyses were conducted for all wake periods and separately for active periods when both devices were worn. RESULTS: Spearman rank-order correlation coefficients for total movement volume between the Actiwatch 2 and ActiGraph GT1M were significant for wake periods (r = 0.47, P < 0.001) and, to a lesser extent, for active periods (r = 0.26, P < 0.01). However, the Actiwatch 2 did not rank participant's physical activity levels similarly to self-reported leisure time physical activity estimates (κ ≤ 0.05, P > 0.05). Multilevel model analyses comparing temporally matched activity measured via the ActiGraph GT1M and Actiwatch 2 suggest that the two devices yielded similar levels of activity during wake periods (B = 0.90; SE, 0.008; P < 0.001) and during active periods (B = 0.81; SE, 0.01; P < 0.001). CONCLUSIONS: A wrist-worn Actiwatch 2 may be useful for ranking total movement volume and for assessing the pattern of activity over a day in older women. However, our data do not support using a wrist-worn Actiwatch 2 device for measuring physical activity.

Assuntos

Actigrafia/instrumentação , Atividade Motora/fisiologia , Atividades Cotidianas , Idoso , Feminino , Humanos , Atividades de Lazer , Sono , Inquéritos e Questionários