{"paper_id":"5bb8b907-a0cd-4e10-a644-655ac6259c74","body_text":"Currently, the Brazilian prison system houses a total of 663,387 people of both sexes\ndeprived of their liberty, with those in the state of São Paulo accounting\nfor 30.17%. There are 200,178 inmates imprisoned in the state of São Paulo,\nof whom 8,897 are women, representing 4.44% of all prisoners in the state and 30.92%\nof all female inmates in the country as a whole ( 1 ) . The confinement experienced by female inmates and the\nresulting lack of contact with family members creates expectations that result in a\ncontinuous process of physical and emotional stress that can lead to physical and\nmental illness ( 2 , 3 ) . Therefore, early detection of health problems is\nparticularly important, because there are few strategies to control chronic diseases\nwithin the prison system ( 4 , 5 ) .\nThe population of female inmates in Brazil has certain characteristics. Most such\ninmates are young and typically have unprotected sex, as well as sex with multiple\npartners, thereby increasing their risk of sexually transmitted diseases, such as\ninfection with human papillomavirus, which is associated with cervical\ncancer ( 6 , 7 ) . Women in prison have little access to tests for\nearly detection, the most common being preventive cytology for cervical cancer by\nPap smear ( 8 ) .\nWomen who have been incarcerated are significantly less likely to receive adequate\nprenatal care, including ultrasound examination, than are women in the general\npopulation ( 9 ) . Female\ninmates rarely undergo imaging examinations to detect problems at an early stage,\nparticularly in areas at risk for cancer, such as the breasts, lungs, thyroid,\nabdomen, and pelvic region. Because ultrasound is a simple imaging modality that is\nfree of ionizing radiation, inexpensive, and accessible, it could be an appropriate\nmethod for screening female prisoners for disease.\nTo our knowledge, there have been no studies evaluating ultrasonographic findings in\nfemale inmates. The aim of this study was to characterize the ultrasonographic\nfindings of female inmates in a prison unit in the state of São Paulo,\ndescribing the most common conditions, as well as to analyze the association between\nultrasonographic findings and sociodemographic characteristics.\n\nThis was a retrospective cohort study that analyzed ultrasound examinations\nconducted between 2015 and 2020 of consecutive female inmates from a prison unit\nin the city of São Paulo. All ultrasound examinations were performed at\nthe Cruz de Malta Treatment Center, based on a partnership between the prison\nunit and this nonprofit health care facility. All ultrasound examinations, as\nwell as the collection of clinical and demographic data, were performed by an\nexaminer who had 24 years of experience in general ultrasound and was board\ncertified by the Brazilian College of Radiology. The study was approved by the\nResearch Ethics Committee of the University of São Paulo (Reference no.\n69572723.0.0000.5421).\nUltrasound examinations were performed with a portable ultrasound system (Logiq\nP5; GE HealthCare, Milwaukee, WI, USA) equipped with linear, convex, and\nendocavity transducers (11L, 5C, and E8C, respectively; GE HealthCare). The\nfollowing ultrasound examinations were performed: soft tissue, thyroid,\ncervical, breasts, transvaginal, pelvic gynecology, total abdomen, upper\nabdomen, kidneys, and urinary tract in B-mode, with color Doppler, or both. The\nscheduling of ultrasound examinations varied according to the clinical\nindications, and more than one ultrasound examination could be performed in the\nsame woman. Preparation for the ultrasound examinations varied according to the\ntype of examination. Women who declined to undergo the ultrasound examination,\npregnant women, and women with emergency conditions were excluded.\nThe following sociodemographic variables were assessed: age, nationality,\neducation level, marital status, body mass index (BMI), ethnicity, profession,\nreligion, sexual orientation, and the presence of tattoos. Female inmates remain\nin the semi-open prison system for up to three years.\nData were transferred to a Microsoft Excel spreadsheet, and statistical analyses\nwere performed with the IBM SPSS Statistics software package, version 24.0 (IBM\nCorp., Armonk, NY, USA) and R software version 3.6.3 (The R Project for\nStatistical Computing, Vienna, Austria). Statistical analysis was performed\nusing summary measurements such as mean, median, minimum/maximum values,\nstandard deviation, absolute values, relative frequencies (percentages),\nincluding the creation of pie charts, bar graphs, box plots, and one-dimensional\nscatter plots. The inferential analyses used to confirm or refute the evidence\nfound in the descriptive analysis were the Mann-Whitney U test, Pearson’s\nchi-square test, and Fisher’s exact test or its extension. A 5% alpha\nsignificance level was used for all inferential conclusions.\n\nThe initial sample comprised 489 women. However, 11 women were excluded: three\nbecause they declined to undergo the ultrasound examination; five because they were\npregnant; and three because they presented with emergency conditions. Therefore, the\nfinal sample comprised 478 women who underwent a total of 1,274 ultrasound\nexaminations. The majority of the women were Brazilian (93.1%), followed by Peruvian\n(0.8%), Bolivian (0.6%), and South African (0.6%), and 89.7% had some type of\ntattoo. As shown in  Table 1 , the mean age was\n40.0 years (range, 22-73 years). Just over half of these women were single (58.2%),\nwhite (50.2%), and self-identified as heterosexual (59.6%). Only 49 (10.3%) of the\nwomen had completed 9 years of schooling and 101 (21.1%) had completed 12 years of\nschooling. The most common religion among this group of women was evangelical\n(44.8%), followed by catholic (38.9%). The most common occupations were homemaker\n(in 18.4%), saleswoman (in 7.3%), domestic worker (in 6.9%), and hairdresser (in\n5.4%). The mean body weight was 66.4 kg (range, 41-135 kg), the mean height was 1.62\nm (range, 1.45-1.80 m), and the mean BMI was 25.22 kg/m 2  (range,\n16.53-49.59 kg/m 2 ).\nSociodemographic characteristics of the female inmates (N = 478).\nAll 478 women underwent multiple ultrasound examinations: upper and total abdomen (in\n70.1%); transvaginal (in 65.3%); gynecological pelvic (in 48.3%); breast (in 36.6%);\nDoppler flow study (in 14.0%); soft tissue (in 11.3%); thyroid (in 9.6%); and\nkidneys/urinary tract (in 7.1%). It is worth noting that some women underwent more\nthan one examination during the study period.\nThe ultrasound examinations revealed several important findings, the most common of\nwhich were uterine myoma, biliary lithiasis, renal lithiasis, simple ovarian cyst,\nadenomyosis, breast nodule, polycystic ovaries, abdominal wall hernia, and simple\nbreast cyst. It is important to note that of the 478 women, 97 (20.3%) had no\nfindings, 115 (24.1%) had findings other than those summarized in  Table 2 , and 266 (55.6%) had at least one of\nthe findings described in  Table 2 .\nUltrasonographic findings in female inmates (N = 478).\nTables 3  to  7  show the correlation between ultrasonographic findings (uterine myoma,\nsimple ovarian cyst, adenomyosis, breast nodule, and polycystic ovaries,\nrespectively) and the sociodemographic characteristics of the female inmates. An\nultrasonographic finding of uterine myoma was associated with older age\n( p  = 0.022), higher BMI ( p  = 0.022) and being\ntattooed ( p  = 0.040). A finding of a simple ovarian cyst was\nassociated with sexual orientation ( p  = 0.020), whereas adenomyosis\nwere associated with older age ( p  = 0.012). An ultrasonographic\nfinding of polycystic ovaries was associated with younger age ( p \n< 0.001). The other ultrasonographic findings showed no statistical correlation\nwith sociodemographic characteristics.\nDistribution of ultrasound findings of a uterine myoma according to the\nsociodemographic characteristics of female inmates.\nMann-Whitney U test;\nFisher’s exact test;\nPearson’s chi-square test.\nDistribution of ultrasound findings of a simple ovarian cyst according to the\nsociodemographic characteristics of female inmates.\nMann-Whitney U test;\nFisher’s exact test;\nPearson’s chi-square test.\nDistribution of ultrasound findings of adenomyosis according to the\nsociodemographic characteristics of female inmates.\nMann-Whitney U test;\nFisher’s exact test;\nPearson’s chi-square test.\nDistribution of ultrasound findings of a breast nodule according to the\nsociodemographic characteristics of female inmates.\nMann-Whitney U test;\nFisher’s exact test;\nPearson’s chi-square test.\nDistribution of ultrasound findings of polycystic ovaries according to the\nsociodemographic characteristics of female inmates.\nMann-Whitney U test;\nFisher’s exact test;\nPearson’s chi-square test.\nIn the women with uterine myomas ( Figure 1A ),\nultrasound examination allowed monitoring of the progression of menstrual symptoms,\nthe identification of benign nodules, and the identification of uterine masses that\nwere amenable to immediate surgical treatment. In six cases, submucosal myomas were\ndiagnosed, with symptoms including excessive vaginal bleeding and clinical\nmanifestations of anemia. In seven cases, the uterine volume was greater than 400\nmL, being considerably greater in three cases (781, 1,000, and 1,400 mL,\nrespectively). The women were all referred for surgery and passed the postoperative\nperiod, starting from postoperative day 3, in the prison, without any\ncomplications.\nFigure 1 Ultrasonographic findings in female inmates. A: Uterine myoma. B: Uterine\npolyp. C: Simple ovarian cyst. D: Breast nodule suggestive of\nmalignancy.\nUltrasonographic findings in female inmates. A: Uterine myoma. B: Uterine\npolyp. C: Simple ovarian cyst. D: Breast nodule suggestive of\nmalignancy.\nOf the 478 women evaluated, 35 (7.3%) had abnormal uterine bleeding and dysmenorrhea.\nIn one of those women, the ultrasound image was characteristic of an endometrial\ncyst, and in another it was characteristic of an endometrioma. Because the most\ncommon complaints were abnormal uterine bleeding and dysmenorrhea, consistent with\nthe suspicion of adenomyosis/endometriosis, and because ultrasound examination\nshowed textural changes in the myometrium, and given the urgency of the cases, we\nroutinely started treatment with contraceptives, preferably continuous, to relieve\nthe symptoms. In all of those cases, the symptoms resolved without surgery. In three\nwomen with abnormal bleeding, ultrasound showed endometrial thickening. Those three\nwomen underwent surgical hysteroscopy, which revealed the presence of polyps ( Figure 1B ); after removal of the polyps, they had\nno more bleeding.\nAmong the female prison inmate population, the majority of ovarian ultrasound\nfindings were simple cysts (in 7.7%), as depicted in  Figure 1C , which could be promptly resolved with simple guidance on\nexpectant management or, rarely, with the prescription of oral contraceptives.\nOf the seven cases in which there were suspicious breast nodules, two were determined\nto be breast cancer: one was in the early stages and the other had metastasized to\nthe cervical region. In the latter case ( Figure\n1D ), the patient underwent surgery, radiotherapy, and chemotherapy, and\nremained stable until discharge.\n\nThe focus of our study was to identify the most common endemic conditions among\nfemale inmates and to evaluate the impact of expediting ultrasound examinations for\nthose waiting for the normal scheduling in the public health care system. The\nmajority of our population consisted of Brazilian women, around 40 years of age, who\nwere homemakers, were White, were high school graduates, had at least one tattoo,\nwere evangelical Christians, were heterosexual, and were overweight. In a study\ninvolving 15 female prisons in eight Brazilian states, with a collective sample of\n1,327 women, the population was overwhelmingly Black or mixed, of low socioeconomic\nstatus, poorly educated, and composed mainly of domestic workers ( 10 ) .\nIn the present study, relevant ultrasonographic findings were present in 60% of the\nfemale inmates evaluated, 40% of whom were symptomatic, which highlights the\nimportance of valuing their complaints. In addition, ultrasound examination proved\nto be a valuable tool for diagnosing and monitoring health conditions, leading to\nmore qualified care within the prison system. For 20% of the female inmates,\nultrasound examination enabled the diagnosis of previously unknown conditions and\nprompt intervention in the more serious cases. In a study conducted in the American\nstate of New Jersey, involving 908 female inmates, the prison appeared to improve\naccess to behavioral health treatment among the women ( 11 ) . However, in the Australian state of Queensland,\nwomen prisoners were found to have poorer nutrition, exercise less, have higher\nrates of smoking, and be more likely to have asthma and diabetes, in comparison with\nwomen in the community ( 12 ) .\nIn our study, uterine disorders were the most prevalent, represented by uterine\nmyomas (in 13.6%) and adenomyosis (in 7.3%). Transvaginal ultrasound has good\nsensitivity, specificity, and positive and negative predictive values for the\ndiagnosis of adenomyosis in women scheduled for hysterectomy ( 13 ) . It has also been shown to be as\neffective as magnetic resonance imaging in detecting uterine myomas in premenopausal\nwomen who have undergone hysterectomy for benign reasons ( 14 ) . To our knowledge, there have been no previous\nassessing the rates of uterine disorders in female inmates.\nWith regard to breast disease, in any population, it is essential that precursor\nlesions and risk factors are always analyzed with a view toward early detection of\nbreast cancer, which is the leading cause of cancer death among women in lowto\nmiddle-income countries and the second leading cause of such in high-income\ncountries ( 15 ) . In our\nstudy, requests for the examination (by women with or without complaints) led to\nbreast ultrasound being performed in 36.6% of the sample. Those examinations\nidentified 31 nodules, seven of which were suspected to be malignant, and 24 cysts.\nAmong the risk factors for breast cancer observed in our population, smoking was the\nmost common. Other, less common, risk factors included obesity, a sedentary\nlifestyle, alcohol consumption, steroid use, a family history of breast cancer, and\nno history of breastfeeding ( 16 ) .\nIn a cross-sectional survey including 100 incarcerated women in a unit prison in the\nAmerican state of Rhode Island, 58% of the female inmates > 40 years of age\nreported having had a mammogram in the past two years ( 17 ) .\nIn our study sample, there were 14 cases of hepatic steatosis (mild in four and\nmoderate in 10), which accounted for 2.5% of all ultrasonographic findings. In the\ngeneral population of women, the reported prevalence of hepatic steatosis is 15-20%\nand there is evidence that metabolic dysfunction-associated steatotic liver disease\nis associated with insulin resistance, atherosclerosis, dyslipidemia, and arterial\nhypertension ( 18 ) . Despite\nthe high prevalence of alcoholism among female inmates, our study showed that\nmetabolic factors caused the most liver damage. The damage caused by alcohol depends\non the frequency, the type of drink and constitutional differences ( 19 , 20 ) .\nBiliary lithiasis was the second most prevalent ultrasonographic finding (in 13.4%).\nIn the prison system, a sedentary lifestyle together with a diet rich in lipids and\nprocessed foods probably explains this finding, although there are other risk\nfactors, such as age, female gender, elevated non-high-density lipoprotein\ncholesterol level, and a high BMI ( 21 , 22 ) . In a\ncross-sectional study of 1,013 female inmates in the state of São\nPaulo ( 23 ) , 47% were found\nto be overweight/obese and half were found to have high serum triglycerides. A high\nprevalence of daily consumption of ultra-processed foods was observed, with hot dog\nbuns/sweet bread with margarine consumed by 86.5%, sugar-sweetened beverages by\n68.4%, and cookies/candy by 77.1%.\nIn our study, renal lithiasis accounted for 11.5% of ultrasound findings. This\ncondition is associated with comorbidities such as arterial hypertension, diabetes\nmellitus, obesity, liver disease, metabolic disorders, and low water intake.\nHematuria and pain are the manifestations that lead people to seek emergency\ntreatment ( 24 , 25 ) . The female inmates were given\npreventive measures for renal lithiasis based on lifestyle changes such as drinking\n2.5-3.0 L of fluid per day, frequent urination, a diet rich in fiber and vegetables,\ncontrolled calcium intake (1.0-1.2 g/day), moderate sodium intake (4-5 g/day),\nmoderate protein intake (0.8-1.0 g/day), and losing weight. As recommended in the\nliterature ( 24 ) , the\nadditional measures we prescribed included citrate supplementation and the\nadministration of thiazide diuretics together with allopurinol (up to 300\nmg/day).\nIn the vast majority of cases, ultrasound examination was sufficient to diagnose or\nconfirm a pathology, contributing to prompt clinical or surgical treatment with good\noutcomes. Only in cases of suspected malignancy were women referred for other\nimaging modalities.\n\nThe most common ultrasonographic findings in female inmates in a prison unit in the\nstate of São Paulo, Brazil, were uterine myoma, biliary lithiasis, and renal\nlithiasis. This study opens up new perspectives for implementing policies that\nimprove quality of life, as well as greater access to primary care for women in\nprisons.","source_license":"CC-BY-4.0","license_restricted":false}