Care during the continuation phase

As the patient`s treatment progresses, symptoms start to disappear and he or she becomes more familiar with the treatment. The standards in this section focus on the types of elements that need to be considered as the patient progresses from the intensive to the continuation phase of tuberculosis (TB) treatment, leading to less contact with the TB service and a resumption of `normal` activities. Social and psychological as well as physical factors need to be assessed to plan effective care and treatment for the continuation phase. Treatment for TB takes a minimum of 6 months, during which changes to the regimen and personal changes associated with making a recovery can create barriers to continuation of treatment. Lifestyle and other changes that may occur during 6 months of anybody`s life can complicate or be complicated by TB treatment. The patient may move to another location at any point during the course of treatment, in which case it may be necessary to transfer his or her care to another TB management unit. This process needs to be carefully managed to maintain contact with the patient and avoid any break in treatment; this is covered by the third standard in this chapter.

Care during the intensive phase: promotion of adherence

The standards in this chapter focus on maximising the patient`s ability to adhere to the treatment prescribed. Many people are extremely shocked when they are told they have TB, some refuse to accept it and others are relieved to find out what is wrong and that treatment is available. The reaction depends on many factors, including cultural beliefs and values, previous experience and knowledge of the disease. Even though TB is more common among vulnerable groups, it can affect anyone and it is important for patients to be able to discuss their concerns in relation to their own individual context. The cure for TB relies on the patient receiving a full, uninterrupted course of treatment, which can only be achieved if the patient and the health service work together. A system needs to be in place to trace patients who miss their appointments for treatment (late patients). The best success will be achieved through the use of flexible, innovative and individualised approaches. The treatment and care the patient has received will inevitably have an impact on his or her willingness to attend in the future. A well-defined system of late patient tracing is mandatory in all situations. However, when the rates are high (above 10%), any tracing system will be useless without also examining the service as a whole.

Starting treatment: caring for patients and their families

The standards presented in this section focus on providing physical, social and psychological care for the patient at the point he or she is diagnosed with tuberculosis (TB) and starts treatment. Detailed guidance is included with regard to organising directly observed treatment (DOT) safely and acceptably for both the patient and the management unit. The aim is to give the patient the best possible chance of successfully completing treatment according to a regimen recommended by the World Health Organization. If the health service where the patient is diagnosed cannot offer ongoing treatment and care due to a lack of facilities, overcrowding or inaccessibility, the patient needs to be referred to a designated TB management unit (BMU) elsewhere. The patient may also receive treatment from a facility outside a BMU. However care is organised, it is essential for all patients who are diagnosed with TB to be registered at an appropriate BMU so that their progress can be routinely monitored and programme performance can be assessed. To avoid the risk of losing contact with the patient at any stage of their care, good communication is essential between all parties involved, from the patient him/herself to the person supervising their DOT to the BMU.

City tuberculosis control coordinators` perspectives of patient adherence to DOT in Sao Paulo State, Brazil, 2005

SETTING: Thirty-six priority cities in Sao Paulo State, Brazil, with a high incidence of tuberculosis (TB) cases, deaths and treatment default. OBJECTIVE: To identify the perspectives of city TB control coordinators regarding the most important components of adherence strategies adopted by health care teams to ensure patient adherence in 36 priority cities in the State of Sao Paulo, Brazil. DESIGN: Qualitative research with semi-structured interviews conducted with the coordinators of the National TB Control Programme involved in the management of TB treatment services in the public sector. RESULTS: The main issues thought to influence adherence to directly observed treatment (DOT) by coordinators include incentives and benefits delivered to patients, patient-health care worker bonding and comprehensive care, the encouragement given by others to follow treatment (family, neighbours and health professionals), and help provided by health professionals for patients to recover their self-esteem. CONCLUSION: The main aspects mentioned by city TB control coordinators regarding patient adherence to treatment and to DOT in Sao Paulo are improvements in communications, relationships based on trust, a humane approach and including the patients in the decision-making process concerning their health.

Identifying an active case of tuberculosis

The best practice standards set out in chapter 2 of the Best Practice guide focus on the various aspects of identifying an active case of TB and aim to address some of the challenges associated with case detection. The importance of developing a good relationship with the patient from the start, when he or she is often most vulnerable, is emphasised. The first standard focuses on the assessment of someone who might have TB and the second gives detailed guidance about the collection of sputum for diagnosis. The standards are aimed at the health care worker, who assesses the patient when he or she presents at a health care facility and therefore needs to be familiar with the signs, symptoms and risk factors associated with TB. Having suspected TB, the health care worker then needs to ensure that the correct tests are ordered and procedures are followed so that the best quality samples possible are sent to the laboratory and all documentation is filled out clearly and correctly. The successful implementation of these standards can be measured by the accurate and prompt reporting of results, the registration of every case detected and the continued attendance of every patient who needs treatment.

Guidance for the implementation of best practice for the care of patients with tuberculosis

The first two chapters of Best practice for the care of patients with tuberculosis: a guide for low-income countries include an introduction and guidance regarding implementation of best practice. The background to how the guide was developed is significant, as it was developed in collaboration with nurses and other health workers working in the most challenging settings. It therefore provides realistic and practical guidance for best practice where patient loads are large and resources are stretched. Guidance regarding standard setting and clinical audit is an important part of enabling people to recognise the strengths that already exist in their practice and approach those areas that require change in a systematic and practical way. The guide itself consists of a series of standards covering different aspects of patient care, from the moment they seek health care with symptoms to their diagnosis to early stages of treatment, directly observed treatment, the continuation phase and transfer of treatment. There are also standards relating specifically to HIV testing and the care of patients co-infected with tuberculosis and HIV. The standards themselves will appear in full in the subsequent chapters of this series.

Friere`s Dialogic Concept Enables Family Health Program Teams to Incorporate Health Promotion

Objective The study analyzes the possibility of incorporating health promotion measures into the work processes of Family Health Program teams at a primary health care clinic in Brazil. Design and Sample We used the participatory research concept developed in 1968 by Freire. The study sample comprised the end-users of the health care system, together with 3 multidisciplinary teams. A total of 77 health care users and 55 health professionals participated in the study. Measures Culture circles composed of health care professionals, and users from different areas investigated generative topics, encoded/decoded topics, and engaged in critical probing for clarification. Topics affecting quality of life and health were heuristically evaluated. Results Although most topics were related to changing the focus of health care facilities, some were related to subsidizing community-based interventions, improving environmental strategies, individual skills, and public policies. Incorporating the novel health promotion measures and creating an expanded full-treatment clinic are important steps toward that goal. Conclusions Topics that can stimulate dialogue among the members of the culture circles include creating an environment of closer cultural contact, with repercussions for work processes, family health models, and general health models, as well as the inclusion of social aspects in the decision-making processes related to health issues that affect the living conditions of the population.

Promoting health in families of children with type 1 diabetes mellitus

This paper presents a study of families of children with type 1 diabetes mellitus, emphasizing the identification of social supports and networks to strengthen interventions aimed at health promotion. The approach selected was a qualitative research, using a case study design. Four families of children with diabetes type 1 were studied, totalling seven participants. Data were collected between April and June 2007, through in-depth interviews and the construction of a genogram and an ecomap. The results presented the families` characterization and testimonies grouped in the following categories: social support, social networks and family roles. To promote care in practice, there is a need to identify the characteristics of each family and resources available that provide better living conditions. We concluded that identifying supports and social networks allows for more personalized care delivery to each family with a view to health promotion.

Efficiency and feasibility of product disassembly: A case-based study

The productivity associated with commonly available disassembly methods today seldomly makes disassembly the preferred end-of-life solution for massive take back product streams. Systematic reuse of parts or components, or recycling of pure material fractions are often not achievable in an economically sustainable way. In this paper a case-based review of current disassembly practices is used to analyse the factors influencing disassembly feasibility. Data mining techniques were used to identify major factors influencing the profitability of disassembly operations. Case characteristics such as involvement of the product manufacturer in the end-of-life treatment and continuous ownership are some of the important dimensions. Economic models demonstrate that the efficiency of disassembly operations should be increased an order of magnitude to assure the competitiveness of ecologically preferred, disassembly oriented end-of-life scenarios for large waste of electric and electronic equipment (WEEE) streams. Technological means available to increase the productivity of the disassembly operations are summarized. Automated disassembly techniques can contribute to the robustness of the process, but do not allow to overcome the efficiency gap if not combined with appropriate product design measures. Innovative, reversible joints, collectively activated by external trigger signals, form a promising approach to low cost, mass disassembly in this context. A short overview of the state-of-the-art in the development of such self-disassembling joints is included. (c) 2008 CIRP.

GOOAL: A routine based on Genetic Algorithms to track harmonics in electric power systems

Voltage and current waveforms of a distribution or transmission power system are not pure sinusoids. There are distortions in these waveforms that can be represented as a combination of the fundamental frequency, harmonics and high frequency transients. This paper presents a novel approach to identifying harmonics in power system distorted waveforms. The proposed method is based on Genetic Algorithms, which is an optimization technique inspired by genetics and natural evolution. GOOAL, a specially designed intelligent algorithm for optimization problems, was successfully implemented and tested. Two kinds of representations concerning chromosomes are utilized: binary and real. The results show that the proposed method is more precise than the traditional Fourier Transform, especially considering the real representation of the chromosomes.

Integrating technology roadmapping and portfolio management at the front-end of new product development

Many authors point out that the front-end of new product development (NPD) is a critical success factor in the NPD process and that numerous companies face difficulties in carrying it out appropriately. Therefore, it is important to develop new theories and proposals that support the effective implementation of this earliest phase of NPD. This paper presents a new method to support the development of front-end activities based on integrating technology roadmapping (TRM) and project portfolio management (PPM). This new method, called the ITP Method, was implemented at a small Brazilian high-tech company in the nanotechnology industry to explore the integration proposal. The case study demonstrated that the ITP Method provides a systematic procedure for the fuzzy front-end and integrates innovation perspectives into a single roadmap, which allows for a better alignment of business efforts and communication of product innovation goals. Furthermore, the results indicated that the method may also improve quality, functional integration and strategy alignment. (C) 2010 Elsevier Inc. All rights reserved.

Natural and human forcing in recent geomorphic change; case studies in the Rio de la Plata basin

An analysis of geomorphic system`s response to change in human and natural drivers in some areas within the Rio de la Plata basin is presented The aim is to determine whether an acceleration of geomorphic processes has taken place in recent years and, if so, to what extent it is due to natural (climate) or human (land-use) drivers Study areas of different size, socio-economic and geomorphic conditions have been selected: the Rio de la Plata estuary and three sub-basins within its watershed Sediment cores were extracted and dated ((210)Pb) to determine sedimentation rates since the end of the 19th century. Rates were compared with time series on rainfall as well as human drivers such as population, GDP, livestock load, crop area, energy consumption or cement consumption, all of them related to human capacity to disturb land surface Data on river discharge were also gathered Results obtained indicate that sedimentation rates during the last century have remained essentially constant in a remote Andean basin, whereas they show important increases in the other two, particularly one located by the Sao Paulo metropolitan area Rates in the estuary are somewhere in between It appears that there is an intensification of denudation/sedimentation processes within the basin. Rainfall remained stable or varied very slightly during the period analysed and does not seem to explain increases of sedimentation rates observed. Human drivers, particularly those more directly related to capacity to disturb land surface (GDP, energy or cement consumption) show variations that suggest human forcing is a more likely explanation for the observed change in geomorphic processes It appears that a marked increase in denudation, of a ""technological"" nature, is taking place in this basin and leading to an acceleration of sediment supply This is coherent with similar increases observed in other regions (C) 2010 Elsevier B V All rights reserved

Motivations for the establishment of PNHRs and analysis of the incentives for their creation and management in Mato Grosso do Sul

The development of efficient programs of incentive to voluntary conservation in private lands require an extensive knowledge on the motivations of land owners for conservation and their degree of acceptance on the benefits offered. Thus, this paper intended to evaluate the motivations for the establishment of PNHRs, the difficulties faced by their recognition and the incentives received for their establishment and management in Mato Grosso do Sul, and also to discuss some possibilities of widening the benefits offered. To this end, people responsible for 34 PNHRs were interviewed between March/2008 and March/2009. The results show that conservation is among the main reasons for the creation of these areas, in spite of economical and personal factors also being mentioned. The slowness and the red tape during the process of recognition were also emphasized as problems; on the other hand, several PNHRs received or receive support for their creation or management. Finally, some considerations are made on the benefits offered to owners of PNHRs and their possibilities of widening throughout the state.

HEMOPLASMAS IN WILD CANIDS AND FEUDS IN BRAZIL

Hemotropic mycoplasmas, epicellular erythrocytic bacterial parasites lacking a cell wall, are the causative agents of infectious anemia in numerous mammalian species. The presence of hemotropic mycoplasmas in blood samples of neotropical and exotic wild canids and felids from Brazilian zoos were recorded using molecular techniques. Blood samples were collected from 146 Brazilian wild felids, 19 exotic felids, 3 European wolves (Canis lupus), and from 97 Brazilian wild canids from zoos in the Brazilian states of Sao Paulo and Mato Grosso and the Federal District. Using conventional polymerase chain reaction (PCR), this work found 22 (13%) wild felids positive to Candidatus Mycoplasma haemominutum [4 jaguars (Panthera onca); 3 pumas (Puma concolor); 10 ocelots (Leopardus pardalis); 2 jaguarondis (Puma yagouaroundi); and 3 little spotted cats (Leopardus tigrinus)]. Only one little spotted cat (Leopardus tigrinus) was positive to Mycoplasma haemofelis, and none was positive to Candidatus Mycoplasma turicensis. Two bush dogs (Speothos venaticus) were positive for a Mycoplasma sp. closely related to Candidatus Mycoplasma haematoparvum, and two European wolves were positive for a Mycoplasma sp. closely related to candidatus Mycoplasma haemominutum. This is the first study regarding the molecular detection of hemotropic mycoplasmas in wild canids.

Chemical composition of mixed construction and demolition recycled aggregates from the State of Sao Paulo

Construction and Demolition Waste (CDW) represents. about 50% of the total Brazilian municipal solid waste: thus, recycling represents huge benefits both in environmental and economic perspectives. Herein, the chemical characterization results of three samples from two different recycling plants from the State of Sao Paulo is prevented. The results demonstrated that the visual classification into grey and red is not related to the chemical composition but mostly to the grain size fraction. The chemical composition of the CDW varies according to the content of cement paste, natural aggregates (quartz sand or granite), red ceramic and clay. Furthermore, the production of recycled concrete aggregates requires two crushing stages to meet the technical standards. The sand fraction (below 4.8 mm) presents high grades of SiO(2), which indicates the liberation of cement paste to fines (< 0.15 mm). The fines have a great potential to be used in the cement industry.