O difícil acesso a serviços de média complexidade do SUS

O acesso aos serviços de média complexidade tem sido apontado, por gestores e pesquisadores, como um dos entraves para a efetivação da integralidade do SUS. Este artigo teve o objetivo de avaliar mecanismos utilizados pela gestão do SUS, no município de São Paulo, para garantir acesso à assistência de média complexidade, durante o período de 2005 a 2008. Optou-se pela estratégia de estudo de caso, utilizando as seguintes fontes de evidência: entrevistas com gestores; grupo focal com usuários e observação participante. Utilizouas técnica de análise temática, a partir do referencial teórico da integralidade da assistência, na dimensão da organização de serviços. Buscou-se descrever os caminhos percorridos pelos usuários para acessar os serviços da média complexidade, a partir da visão dos gestores e dos próprios usuários. A média complexidade foi identificada, pelos gestores, como o "gargalo" do SUS e um dos principais obstáculos para a construção da integralidade. Para enfrentar essa situação, o gestor municipal investiu na informatização dos serviços, como medida isolada e, ainda, sem considerar a necessidade dos usuários. Sendo assim, essa incorporação tecnológica teve pouco impacto na melhoria do acesso, o que se confirmou no relato dos usuários. Discute-se que para o enfrentamento de um problema tão complexo são necessárias ações articuladas, tanto no âmbito da política de saúde, quanto da organização dos serviços, bem como a (re)organização do processo de trabalho em todos os níveis do sistema de saúde

Saúde bucal no sistema único de saúde: 20 anos de lutas por uma política pública

Desde a criação do Sistema Único de Saúde (SUS) em 1988, a inserção da saúde bucal é marcada por conflitos e contradições, expressando os diferentes projetos em disputa na sociedade brasileira. No período pré-SUS predominavam programas odontológicos centralizados e verticais, tendo escolares e trabalhadores inscritos na previdência social como população-alvo. Com a criação do SUS, esse enfoque tornou-se incompatível com um sistema unificado e descentralizado de caráter universalista. Abriu-se, então, a possibilidade de conformação de uma agenda para gestão da saúde bucal enquanto política pública. Neste artigo são abordados alguns dos aspectos mais relevantes que marcaram os 20 anos de construção dessa política no plano nacional

Bioeticistas brasileiros e os princípios da universalidade e da integralidade no SUS

OBJETIVO: Compreender os sentidos que bioeticistas brasileiros atribuem aos princípios da universalidade e da integralidade no sistema público de saúde brasileiro. PROCEDIMENTOS METODOLÓGICOS: Estudo exploratório qualitativo, realizado com 20 professores universitários de bioética atuantes no campo das ciências da saúde, com funções de diretores e ex-diretores da Sociedade Brasileira de Bioética e de diretorias regionais, no período de julho de 2007 a julho de 2008. Foram realizadas entrevistas semi-estruturadas, com perguntas abertas, sendo realizada análise de conteúdo. ANÁLISE DE RESULTADOS: Quanto ao princípio da universalidade de acesso dos cidadãos brasileiros a um sistema público, as manifestações dos entrevistados se posicionaram majoritariamente em prol de sua manutenção. Todavia, quanto ao princípio da integralidade, as divergências foram manifestas, ensejando a maioria em restringi-lo. CONCLUSÕES: Os bioeticistas relatam pluralismo de valores morais e dificuldades em decidir moralmente sobre o que seria um sistema de saúde justo

A Paradigm Shift in Predoctoral Dental Curricula in Brazil: Evaluating the Process of Change

In 2002, the Brazilian Ministry of Education approved the official curricular guidelines for undergraduate courses in Brazil to be adopted by the nation's 188 dental schools. In 2005-06, the Brazilian Dental Education Association (BDEA) promoted workshops in forty-eight of the schools to verify the degree of transformation of the curriculum based on these guidelines. Among the areas analyzed were course philosophy (variables were v1: knowledge production based on the needs of the Brazilian Public Health System [BPHS]; v2: health determinants; and v3: postgraduate studies and permanent education); pedagogical skills (v4: curricular structure; v5: changes in pedagogic and didactic skills; and v6: course program orientation); and dental practice scenarios (v7: diversity of the scenarios for training/learning; v8: academic health care centers opened to the BPHS; and v9: participation of students in health care delivery for the population). The subjects consisted of faculty members (n=711), students (n=228), and employees (n=14). The results showed an incipient degree of curriculum transformation. The degree of innovation was statistically different depending on the type of university (public or private) for variables I, 2, 4, 5, 6, and 7. Private schools reported a higher level of innovation than public institutions. Resistance to transforming the dental curriculum according to the official guidelines may be linked to an ideological conception that supports the private practice model, continues to have faculty members direct all classroom activities, and prevents students from developing an understanding of professional practice as targeted towards the oral health needs of all segments of society.

Cost effectiveness of OptiMal (R) rapid diagnostic test for malaria in remote areas of the Amazon Region, Brazil

Background: In areas with limited structure in place for microscopy diagnosis, rapid diagnostic tests (RDT) have been demonstrated to be effective. Method: The cost-effectiveness of the Optimal (R) and thick smear microscopy was estimated and compared. Data were collected on remote areas of 12 municipalities in the Brazilian Amazon. Data sources included the National Malaria Control Programme of the Ministry of Health, the National Healthcare System reimbursement table, hospitalization records, primary data collected from the municipalities, and scientific literature. The perspective was that of the Brazilian public health system, the analytical horizon was from the start of fever until the diagnostic results provided to patient and the temporal reference was that of year 2006. The results were expressed in costs per adequately diagnosed cases in 2006 U. S. dollars. Sensitivity analysis was performed considering key model parameters. Results: In the case base scenario, considering 92% and 95% sensitivity for thick smear microscopy to Plasmodium falciparum and Plasmodium vivax, respectively, and 100% specificity for both species, thick smear microscopy is more costly and more effective, with an incremental cost estimated at US$ 549.9 per adequately diagnosed case. In sensitivity analysis, when sensitivity and specificity of microscopy for P. vivax were 0.90 and 0.98, respectively, and when its sensitivity for P. falciparum was 0.83, the RDT was more cost-effective than microscopy. Conclusion: Microscopy is more cost-effective than OptiMal (R) in these remote areas if high accuracy of microscopy is maintained in the field. Decision regarding use of rapid tests for diagnosis of malaria in these areas depends on current microscopy accuracy in the field.

The ethical component of professional competence in nursing: An analysis

The purpose of this article is to initiate a philosophical discussion about the ethical component of professional competence in nursing from the perspective of Brazilian nurses. Specifically, this article discusses professional competence in nursing practice in the Brazilian health context, based on two different conceptual frameworks. The first framework is derived from the idealistic and traditional approach while the second views professional competence through the lens of historical and dialectical materialism theory. The philosophical analyses show that the idealistic view of professional competence differs greatly from practice. Combining nursing professional competence with philosophical perspectives becomes a challenge when ideals are opposed by the reality and implications of everyday nursing practice.

The Pharmaceutical care of patients with type 2 diabetes mellitus

Objective To evaluate the efficiency of pharmaceutical care on the control of clinical parameters, such as fasting glycaemia and glycosylated haemoglobin in patients with Type 2 Diabetes mellitus. Setting This study was conducted at the Training and Community Health Centre of the College of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil. Methods A prospective and experimental study was conducted with 71 participants divided in two groups: (i) pharmaceutical care group (n=40), and (ii) the control group (n=31). The distribution of patients within these groups was made casually, and the patients were monitored for 12 months. Main outcome measure: Values for fasting glycaemia and glycosylated haemoglobin were collected. Results Mean values of fasting glycaemia in the pharmaceutical care group were significantly reduced whilst a small reduction was detected in the control group at the same time. A significant reduction in the levels of glycosylated haemoglobin was detected in patients in the pharmaceutical care group, and an average increase was observed in the control group. Furthermore, the follow-up of the intervention group by a pharmacist contributed to the resolution of 62.7% of 142 drug therapy problems identified. Conclusion In Brazil, the information provided by a pharmacist to patients with Type 2 Diabetes mellitus increases compliance to treatment, solving or reducing the Drug Therapy Problem and, consequently, improving glycaemic control.

Phagocytosis and Nitric Oxide Levels in Rheumatic Inflammatory States in Elderly Women

Background Very few studies have investigated, in the elderly, the effect of rheumatic inflammatory states on phagocyte function and free radical production. The objective of this article is to evaluate phagocytosis by neutrophils and the production of nitric oxide (.NO) by monocytes in elderly women recruited among patients of the Brazilian Public Health System. Methods: Forty patients aged more than 60 years with rheumatic inflammatory diseases were studied. Phagocytosis was measured by flow cytometry. .NO production was measured by the total nitrite assay and conventional inflammation markers were determined. Data were analyzed with the Mann Whitney nonparametric test and P<0.05 was considered significant. Results. C-reactive protein levels and white blood cell counts were significantly higher in inflammation than in the control group (P<0.05). The phagocytosis fluorescence intensity per neutrophil and the percentual of neutrophils expressing phagocytosis were significantly higher (P<0.05) in the test than in the control group. Furthermore, there was significant .NO overproduction by monocytes, (P<0.05). Conclusion: Phagocytosis and .NO production are affected by rheumatic states. This suggests that the increased .NO levels may play a part in the increased oxidative stress in rheumatic diseases in elderly women. J. Clin. Lab. Anal. 25:47-51, 2011. (C) 2011 Wiley-Liss, Inc.

Phagocytosis, Oxidative Burst, and Produced Reactive Species are Affected by Iron Deficiency Anemia and Anemia of Chronic Diseases in Elderly

Iron and oxidative stress have a regulatory interplay. During the oxidative burst, phagocytic cells produce free radicals such as hypochlorous acid (HOCl). Nevertheless, scarce studies evaluated the effect of either iron deficiency anemia (IDA) or anemia of chronic disease (ACD) on phagocyte function in the elderly. The aim of the present study was to determine the oxidative burst, phagocytosis, and nitric oxide ((aEuro cent)NO) and HOCl, reactive species produced by monocytes and neutrophils in elderly with ACD or IDA. Soluble transferrin receptor, serum ferritin, and soluble transferrin receptor/log ferritin (TfR-F) index determined the iron status. The study was constituted of 39 patients aged over 60 (28 women and 11 men) recruited from the Brazilian Public Health System. Oxidative burst fluorescence intensity per neutrophil in IDA group and HOCl generation in both ACD and IDA groups were found to be lower (p < 0.05). The percentages of neutrophils and monocytes expressing phagocytosis in ACD group were found to be higher (p < 0.05). There was an overproduction of (aEuro cent)NO from monocytes, whereas the fundamental generation of HOCl appeared to be lower. Phagocytosis, oxidative burst, and (aEuro cent)NO and HOCl production are involved in iron metabolism regulation in elderly patients with ACD and IDA.

COST-EFFECTIVENESS ANALYSIS OF CISPLATIN-BASED CHEMORADIATION TO TREAT PATIENTS WITH UNRESECTABLE, NONMETASTATIC HEAD AND NECK CANCER IN BRAZIL

Background. The purpose of this study was to analyze the cost-effectiveness of cisplatin-based chemoradiation compared to radiation therapy (RT) alone to treat patients with advanced head and neck cancer in Brazil. Methods. Data were collected retrospectively from the medical records of 33 patients treated with RT alone (strategy 1) and from 29 patients treated with cisplatin-based chemoradiation (strategy 2). The Brazilian National Health System (Sistema Unico de Saude [SUS]) reimbursement parameters perspective was considered, and the effectiveness was measured in years of disease-free life gained. One-way sensitivity analysis was performed to determine robustness of this study. Results. In strategy 1, there were 31% of the patients who lived without disease progression for more than 13 months after treatment, compared to 58% of patients in strategy 2. According to SUS parameters, the total cost per patient in strategy 1 was $1167.00 U.S. dollars and in strategy 2, it was $2058.00 U.S. dollars. Incremental cost-effectiveness ratio (ICER) was $3303.00 U.S. dollars per life-year gained. Conclusion. Cisplatin-based chemoradiation proved to be more cost-effective than RT alone. (C) 2010 Wiley Periodicals, Inc. Head Neck 33: 1199-1205, 2011

Health technology diffusion in developing countries: a case study of CT scanners in Brazil

Background The development of products and services for health care systems is one of the most important phenomena to have occurred in the field of health care over the last 50 years. It generates significant commercial, medical and social results. Although much has been done to understand how health technologies are adopted and regulated in developed countries, little attention has been paid to the situation in low- and middle-income countries (LMICs). Here we examine the institutional environment in which decisions are made regarding the adoption of expensive medical devices into the Brazilian health care system. Methods We used a case study strategy to address our research question. The empirical work relied on in-depth interviews (N = 16) with representatives of a wide range of actors and stakeholders that participate in the process of diffusion of CT (computerized tomography) scanners in Brazil, including manufacturers, health care organizations, medical specialty societies, health insurance companies, regulatory agencies and the Ministry of Health. Results The adoption of CT scanners is not determined by health policy makers or third-party payers of public and private sectors. Instead, decisions are primarily made by administrators of individual hospitals and clinics, strongly influenced by both physicians and sales representatives of the medical industry who act as change agents. Because this process is not properly regulated by public authorities, health care organizations are free to decide whether, when and how they will adopt a particular technology. Conclusions Our study identifies problems in how health care systems in LMICs adopt new, expensive medical technologies, and suggests that a set of innovative approaches and policy instruments are needed in order to balance the institutional and professional desire to practise a modern and expensive medicine in a context of health inequalities and basic health needs.

In situ apoptosis of adaptive immune cells and the cellular escape of rabies virus in CNS from patients with human rabies transmitted by Desmodus rotundus

The aim of the current study was to investigate the apoptosis of neurons, astrocytes and immune cells from human patients that were infected with rabies virus by vampire bats bite. Apoptotic neurons were identified by their morphology and immune cells were identified using double immunostaining. There were very few apoptotic neurons present in infected tissue samples, but there was an increase of apoptotic infiltrating CD4+ and TCD8+ adaptive immune cells in the rabies infected tissue. No apoptosis was present in NK, macrophage and astrocytes. The dissemination of the human rabies virus within an infected host may be mediated by viral escape of the virus from an infected cell and may involve an anti-apoptotic mechanism, which does not kill the neuron or pro-apoptosis of TCD4+ and TCD8+ lymphocytes and which allows for increased proliferation of the virus within the CNS by attenuation of the adaptive immune response. (C) 2011 Elsevier B.V. All rights reserved.

The universal newborn hearing screening in Brazil: From identification to intervention

Objective: The objective of the study is to investigate the results of the newborn hearing screening program carried out in a Public Hospital in Brazil, in the first 3 years regarding: (1) the prevalence of hearing impairment; (2) the influence of the universal hearing screening program on the age at which the diagnosis of hearing loss is defined; (3) the cost effectiveness of the program; (4) the outcomes, in terms of the age in which the hearing rehabilitation started. Methods: A descriptive study of the first 3 years after starting the universal newborn hearing screening in a Public Hospital of Bauru, Sao Paulo state, Brazil. The screening method consists of a two-stage screening approach with transient otoacoustic emissions (TOAE), conducted by an audiologist. If the outcome in the second-stage screening is REFER, the infant is submitted to diagnostic follow-up testing and intervention at the Audiology and Speech Pathology Clinic at the University of Sao Paulo, campus of Bauru. The evaluation of the costs of the universal newborn hearing screening program per each screened newborn (around 4000/year) was done based on a proposal by the National Center for Hearing Assessment and Management, of the Utah State University, United States of America. Results: 11,466 newborns were submitted to hearing screening, corresponding to 90.52% of the living newborns. The prevalence of sensorineural hearing loss was 0.96:1000. Of the 11 children with sensorineural hearing loss, eight children received hearing aids and five started the therapeutic process before the age of 1. Currently, four children between the ages of 11 months and 2 years old were submitted to cochlear implant surgery. The cost of hearing screening was US$7.00 and the annual cost of the universal newborn hearing screening program was US$26,940.47. Conclusion: The hospital-based universal newborn hearing screening carried out through the Brazilian National Health System is viable, with promising results. However, in a country such as Brazil, which presents large socio-economic differences, the same type of analyses should be performed in several regions, so as to take into account specific aspects, to implement the newborn hearing screening along with the Public System. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Taking advantage of contextualized interactions while users watch TV

While watching TV, viewers use the remote control to turn the TV set on and off, change channel and volume, to adjust the image and audio settings, etc. Worldwide, research institutes collect information about audience measurement, which can also be used to provide personalization and recommendation services, among others. The interactive digital TV offers viewers the opportunity to interact with interactive applications associated with the broadcast program. Interactive TV infrastructure supports the capture of the user-TV interaction at fine-grained levels. In this paper we propose the capture of all the user interaction with a TV remote control-including short term and instant interactions: we argue that the corresponding captured information can be used to create content pervasively and automatically, and that this content can be used by a wide variety of services, such as audience measurement, personalization and recommendation services. The capture of fine grained data about instant and interval-based interactions also allows the underlying infrastructure to offer services at the same scale, such as annotation services and adaptative applications. We present the main modules of an infrastructure for TV-based services, along with a detailed example of a document used to record the user-remote control interaction. Our approach is evaluated by means of a proof-of-concept prototype which uses the Brazilian Digital TV System, the Ginga-NCL middleware.

Sustentabilidade financeira e econômica do gasto público em saúde no nível municipal: reflexões a partir de dados de municípios mato-grossenses

O financiamento do SUS é regido pelo modelo de federalismo fiscal, pelas regras de partilha do Orçamento da Seguridade Social (OSS), por normas do Ministério da Saúde, e pela Emenda Constitucional nº. 29 (EC-29), que vincula à saúde recursos dos entes federados brasileiros. Discute-se aqui a sustentabilidade do gasto público com saúde no nível municipal. Foram estudados 21 municípios, utilizando-se dados dos balanços municipais. De 1996 a 2006 as receitas correntes gerais per capita subiram 280% acima da inflação acumulada e do Produto Interno Bruto (PIB) nacional, variando conforme o porte do município, o qual também definiu a composição dos orçamentos municipais. Já o orçamento que conforma a base da EC-29 elevou-se bem menos (178%), impondo limitações ao incremento da contrapartida municipal em saúde. Acredita-se que o observado nesses municípios se reproduza em milhares de municípios brasileiros e comprometa a capacidade de investimento municipal em saúde, principalmente a partir de 2008. A situação ainda pode se agravar tendo em vista a extinção da Contribuição Provisória sobre a Movimentação ou Transmissão de Valores e de Créditos e Direitos de Natureza Financeira (CPMF), a tramitação dos Projetos de Lei nº. 306/08 e nº. 233/08, e a recessão mundial, a partir da crise do sistema financeiro norte-americano.