Health in Brazil 6 Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Impact of chronic disease on quality of life among the elderly in the state of Sao Paulo, Brazil: a population-based study

Objectives. To assess the impact of chronic disease and the number of diseases on the various aspects of health-related quality of life (HRQOL) among the elderly in Sao Paulo, Brazil. Methods. The SF-36 (R) Health Survey was used to assess the impact of the most prevalent chronic diseases on HRQOL. A cross-sectional and population-based study was carried out with two-stage stratified cluster sampling. Data were obtained from a multicenter health survey administered through household interviews in several municipalities in the state of Sao Paulo. The study evaluated seven diseases-arthritis, back-pain, depression/anxiety, diabetes, hypertension, osteoporosis, and stroke-and their effects on quality of life. Results. Among the 1958 elderly individuals (60 years of age or older), 13.6% reported not having any of the illnesses, whereas 45.7% presented three or more chronic conditions. The presence of any of the seven chronic illnesses studied had a significant effect on the scores Of nearly all the SF-36 (R) scales. HRQOL achieved lower scores when related to depression/anxiety, osteoporosis, and stroke. The higher the number of diseases, the greater the negative effect on the SF-36 (R) dimensions. The presence of three or more diseases significantly affected HRQOL in all areas. The bodily pain, general health, and vitality scales were the most affected by diseases. Conclusions. The study detected a high prevalence of chronic diseases among the elderly population and found that the degree of impact on HRQOL depends on the type of disease. The results highlight the importance of preventing and controlling chronic diseases in order to reduce the number of comorbidities and lessen their impact on HRQOL among the elderly.

ESTIMATING SENSORY SHELF LIFE OF CHOCOLATE AND CARROT CUPCAKES USING ACCEPTANCE TESTS

This study determined the sensory shelf life of a commercial brand of chocolate and carrot cupcakes, aiming at increasing the current 120 days of shelf life to 180. Appearance, texture, flavor and overall quality of cakes stored at six different storage times were evaluated by 102 consumers. The data were analyzed by analysis of variance and linear regression. For both flavors, the texture presented a greater loss in acceptance during the storage period, showing an acceptance mean close to indifference on the hedonic scale at 120 days. Nevertheless, appearance, flavor and overall quality stayed acceptable up to 150 days. The end of shelf life was estimated at about 161 days for chocolate cakes and 150 days for carrot cakes. This study showed that the current 120 days of shelf life can be extended to 150 days for carrot cake and to 160 days for chocolate cake. However, the 180 days of shelf life desired by the company were not achieved. PRACTICAL APPLICATIONS This research shows the adequacy of using sensory acceptance tests to determine the shelf life of two food products (chocolate and carrot cupcakes). This practical application is useful because the precise determination of the shelf life of a food product is of vital importance for its commercial success. The maximum storage time should always be evaluated in the development or reformulation of new products, changes in packing or storage conditions. Once the physical-chemical and microbiological stability of a product is guaranteed, sensorial changes that could affect consumer acceptance will determine the end of the shelf life of a food product. Thus, the use of sensitive and reliable methods to estimate the sensory shelf life of a product is very important. Findings show the importance of determining the shelf life of each product separately and to avoid using the shelf time estimated for a specific product on other, similar products.

Microbiological Shelf Life of Pasteurized Milk in Bottle and Pouch

Shelf life of pasteurized milk in Brazil ranges from 3 to 8 d, mainly due to poor cold chain conditions that prevail throughout the country and subject the product to repeated and/or severe temperature abuse. This study evaluated the influence of storage temperature on the microbiological stability of homogenized whole pasteurized milk (75 degrees C/15 s) packaged in high-density polyethylene (HDPE) bottle and low-density polyethylene (LDPE) pouch, both monolayer materials pigmented with titanium dioxide (TiO(2)). The storage temperatures investigated were 2, 4, 9, 14, and 16 degrees C. Microbiological evaluation was based on mesophilic and psychrotrophic counts with 7 log CFU/mL and 6 log CFU/mL, respectively, set as upper limits of acceptability for maintaining the quality of milk. The microbiological stability for pasteurized milk packaged in HDPE bottle and stored at 2, 4, 9, 14, and 16 degrees C was estimated at 43, 36, 8, 5, and 3 d, respectively. For milk samples packaged in LDPE pouch, shelf life was estimated at 37, 35, 7, 3, and 2 d, respectively. The determination of Q(10) and z values demonstrated that storage temperature has a greater influence on microbiological shelf life of pasteurized milk packaged in LDPE pouch compared to HDPE bottle. Based on the results of this study, HDPE bottle was better for storing pasteurized milk as compared to LDPE pouch.

Some Possible Dynamical Constraints for Life`s Origin

Oscillating biochemical reactions are common in cell dynamics and could be closely related to the emergence of the life phenomenon itself. In this work, we study the dynamical features of some classical chemical or biochemical oscillators where the effect of cell volume changes is explicitly considered. Such analysis enables us to find some general conditions about the cell membrane to preserve such oscillatory patterns, of possible relevance to hypothetical primitive cells in which these structures first appeared.

Life history, morphological variability and growth rates of the life phases of Gracilaria tenuistipitata (Rhodophyta: Gracilariales) in vitro

Gracilaria tenuistipitata, a species of commercial interest, is becoming a model organism for studies on red algal physiology and molecular biology as it can be grown easily in vitro under a broad range of conditions. Most of the experiments carried out around the world have been based on a tetrasporophytic clone isolated in our laboratory from a specimen collected in China. Here we describe the life history of this species, give anatomic details of the reproductive structures, illustrate the morphological variability of tetraspore progeny and compare the growth rate of gametophytic and sporophytic thalli. Tetrasporophytic branches showed higher growth rates than gametophytic branches.

Increased aerobic metabolism is essential for the beneficial effects of caloric restriction on yeast life span

Calorie restriction is a dietary regimen capable of extending life span in a variety of multicellular organisms. A yeast model of calorie restriction has been developed in which limiting the concentration of glucose in the growth media of Saccharomyces cerevisiae leads to enhanced replicative and chronological longevity. Since S. cerevisiae are Crabtree-positive cells that present repression of aerobic catabolism when grown in high glucose concentrations, we investigated if this phenomenon participates in life span regulation in yeast. S. cerevisiae only exhibited an increase in chronological life span when incubated in limited concentrations of glucose. Limitation of galactose, raffinose or glycerol plus ethanol as substrates did not enhance life span. Furthermore, in Kluyveromyces lactis, a Crabtree-negative yeast, glucose limitation did not promote an enhancement of respiratory capacity nor a decrease in reactive oxygen species formation, as is characteristic of conditions of caloric restriction in S. cerevisiae. In addition, K. lactis did not present an increase in longevity when incubated in lower glucose concentrations. Altogether, our results indicate that release from repression of aerobic catabolism is essential for the beneficial effects of glucose limitation in the yeast calorie restriction model. Potential parallels between these changes in yeast and hormonal regulation of respiratory rates in animals are discussed.

Oral health conditions among the elderly in Southeastern São Paulo State

OBJECTIVE: This study aimed to asses oral health conditions in a population aged 60 years and over living in Botucatu, Southeastern Brazil. A cross-sectional population-based study was carried out using a random sample (N=372) of the urban population aged 60 years and over from the city of Botucatu, in 2005. World Health Organization criteria and codes for oral health epidemiological surveys were used. Re-examination was carried out in 10% of individuals aiming to evaluate intra-examiner agreement. Statistical analysis was performed by one-way ANOVA or Kruskal-Wallis ANOVA, as applicable. Also, the t-test was used in the absence of homoscedasticity. Fisher's exact test was used for situations where the categories with less than five units were observed. Adjusted residuals and multiple-comparison analysis were conducted to identify associations between variable categories and subgroups. The intra-examiner agreement was 98% and Kappa statistics result was 0.95. Loss component represented 90.68% of DMF-T index, which was 29.85. The prevalence of edentulism was 63.17%. Upper and lower dentures were found in 80% and 58% respectively, with complete denture as the most commonly used. In those studied, 15% required upper and 38% lower dentures. There was more need for complete denture in both jaws. Approximately 20% had soft tissue alterations. For periodontal conditions, most sextants were excluded (81.81%). Periodontal pockets (4 - 5 mm) were seen in 11.29% of the examined individuals. The oral health status of the elderly population in Botucatu is poor, as well as in other Brazilian cities. The results of this study may help planning collective health actions, giving an accurate description of the oral problems among the elderly.

Acessibilidade em ambiente universitário: identificação de barreiras arquitetônicas no campus da USP de Bauru

A acessibilidade é um direito do cidadão assegurado por lei para que portadores de deficiência tenham a possibilidade de usufruir de recursos e ações no âmbito social. Barreiras arquitetônicas interferem na vida destes podendo deixá-los a parte da convivência e vida social. Os objetivos deste estudo foram: identificar, descrever e mapear barreiras físicas no Campus da Universidade de São Paulo de Bauru e apresentar as intervenções realizadas, durante o período de outubro de 2001 a dezembro de 2005. O estudo foi descritivo-quantitativo, no qual a coleta de dados centrou-se na análise das condições arquitetônicas das três unidades que compõe este campus, observada as normativas da Associação Brasileira de Normas técnicas e realizada intervenções. Foram identificados: 72 pontos de guias não rebaixadas, 21 pontos de acessos com diferenças de níveis sem rampas; 220m² de escadas/rampas sem corrimãos; 658m² de escadas/rampas com corrimãos em discordância com as normas vigentes; 03 rampas com inclinações superiores às determinadas nas normas técnicas; 10 banheiros parcialmente adaptados para deficientes; 02 vagas de estacionamento parcialmente adaptadas e 02 elevadores existentes. Foram executados, em 19 pontos, rebaixamentos de guias, somando 115 m², com linhas de piso tátil, pintados; 8 rampas; 14 pontos de escadas e rampas externas instaladas com corrimãos e guarda-corpos, 5 vagas exclusivas no estacionamento; instalado 2 centrais de atendimento telefônico para surdo e adquiridas 3 cadeira de rodas. As intervenções realizadas contribuíram para melhorar a acessibilidade de portadores de deficiência no campus favorecendo a utilização dos recursos existentes neste espaço público.

Survival and quality of life of patients with oral and oropharyngeal cancer at 1-year follow-up of tumor resection

OBJECTIVE: This study aimed to assess the survival and life quality evolution of patients subjected to surgical excision of oral and oropharyngeal squamous cell carcinoma. MATERIAL AND METHODS: Forty-seven patients treated at a Brazilian healthcare unit specialized in head and neck surgery between 2006 and 2007 were enrolled in the study. The gathering of data comprised reviewing hospital files and applying the University of Washington Quality of Life (UW-QOL) questionnaire previously and 1 year after the surgery. Comparative analysis used Poisson regression to assess factors associated with survival and a paired t-test to compare preoperative and 1-year postoperative QOL ratings. RESULTS: 1 year after surgery, 7 patients were not found (dropout of the cohort); 15 had died and 25 fulfilled the UW-QOL again. The risk of death was associated with having regional metastasis previously to surgery (relative risk=2.18; 95% confidence interval=1.09-5.17) and tumor size T3 or T4 (RR=2.30; 95%CI=1.05-5.04). Survivors presented significantly (p<0.05) poorer overall and domain-specific ratings of quality of life. Chewing presented the largest reduction: from 74.0 before surgery to 34.0 one year later. Anxiety was the only domain whose average rating increased (from 36.0 to 70.7). CONCLUSIONS: The prospective assessment of survival and quality of life may contribute to anticipate interventions aimed at reducing the incidence of functional limitations in patients with oral and oropharyngeal cancer.

Relationship between oral health and its impact on quality of life among adolescents

The aim of this study was to assess oral health status and its relationship with quality of life. A household population, cross-sectional study was carried out; participants were between 15 and 17 years of age (n = 247) and were examined by two calibrated dentists. Socio-economic status was classified according to ANEP-ABIPEME criteria. Clinical examinations to observe DMFT, CPI and Dean indices were performed as per WHO criteria. The Significant Caries Index (SiC) was used to evaluate polarization of the occurrence of caries among participants of the tercile with higher DMF-T. The OHIP instrument was used to measure quality of life. The Spearman and Mann-Whitney tests were used for assessing correlations (5% significance level). Examinations were carried out in 117 (47.37%) females and in 130 (52.63%) males. Of the examined participants, 45.75% were classified as belonging to socio-economic class C. Caries occurrence was observed in 218 subjects (88.26%); the mean DMFT was 5.40. The SiC index was 9.97. Almost half (47.77%) of the participants examined did not present sextants affected by periodontal disease. Of the participants examined, 80.16% presented absence of fluorosis. The mean OHIP was 3.95. The following correlations were observed: a positive and statistically significant correlation between the highest score in the OHIP and decayed teeth; a positive correlation with threshold significance between OHIP and DMFT; an inverse correlation between intact teeth and OHIP; and a positive and non statistically significant correlation between SiC and OHIP (correlation coefficient = 0.13, p = 0.245). Association between the mean OHIP and the terciles was not significant (p = 0.146); there were also no associations between periodontal condition and OHIP nor were there associations between the presence of fluorosis and mean OHIP.

Removal torque of zirconia abutment screws under dry and wet conditions

The aim of this study was to verify whether screw abutment lubrication can generate higher preload values compared to non-lubricated screws, a titanium abutment was screwed onto an implant analog and scanned with the Procera System to generate 20 zirconia abutments. MKIII Brånemark implants were clamped to a precision torque device, and the abutments were distributed in dry and wet groups with 10 specimens each. In the wet groups, the inner threads of the implants were filled with artificial saliva. All abutments were fastened with a Torqtite screw under 32 Ncm. Ten detorque measurements were performed per group pushing the reverse button of the Torque controller soon after screw tightening with values registered. The mean detorque values were calculated and compared by a Student's t test (?=0.05). The wet condition presented significantly higher mean detorque than the dry condition (31.5 ± 1.2 versus 27.5 ± 1.5 Ncm, respectively; p=0.0000024). In conclusion, there was always a loss in the initial torque values when the removal torque was measured under both conditions. The wet condition presented higher mean torque than the dry condition. Better preload values were established in the wet group, suggesting that the abutment screw must be lubricated in saliva to avoid further loosening.

Uso da manta térmica na prevenção da hipotermia intraoperatória

OBJETIVO: A hipotermia é prejudicial no período perioperatório. Não há consenso sobre o melhor método de aquecimento ativo e nem sobre o melhor período para fazê-lo. Este estudo teve como objetivo primário verificar a eficácia de diferentes períodos de utilização da manta térmica à temperatura de 38°C, como método de prevenção da hipotermia intraoperatória. Como objetivo secundário avaliou-se os efeitos adversos do uso da manta térmica na temperatura de 38°C. MÉTODOS: Foram comparados quatro grupos de 15 pacientes submetidos a operações ortopédicas. No grupo controle (Gcont) os pacientes não utilizaram manta térmica, nos grupos pré (Gpré), intra (Gintra) e total (Gtotal), os pacientes utilizaram manta térmica a 38ºC, respectivamente, durante 30 minutos antes da indução anestésica, após a indução anestésica até 120 minutos e antes e após a indução. Foram avaliados: temperatura central (timpânica), periférica (pele), da sala cirúrgica, variação das condições hemodinâmicas e efeitos adversos do aquecimento. RESULTADOS: O Gtotal foi o único grupo que não teve variação significativa da temperatura central. A temperatura central dos pacientes do grupo Gtotal foi significativamente maior (p <0,05) do que a dos outros grupos aos 60 e 120 min após a indução. Os pacientes dos grupos Gcont, Gpré e Gintra apresentaram hipotermia aos 60 min. CONCLUSÃO: O uso da manta térmica com fluxo de ar aquecido foi eficaz como método de prevenção da hipotermia intraoperatória quando foi empregada desde 30 min antes da indução anestésica até 120 min após o início da anestesia. Nas condições do estudo não ocorreram eventos adversos.

Physiological and biochemical characterization of the assai palm (Euterpe oleracea Mart.) during seed germination and seedling growth under aerobic and anaerobic conditions

Physiological and biochemical aspects of assai palm during seed germination and early seedling growth were investigated. Seeds collected from plants growing in flooded and upland forests were used to determine the influence of normoxic (aerobic) and anoxic (anaerobic) conditions in germination and the initial and average time of development in the roots and shoots. After 75 days, seedlings germinated under normoxia were transferred to trays and submitted to flooding. Seed reserves (lipids, proteins, soluble sugars and starch) were monitored for quiescent and germinated seeds maintained under normoxic and anoxic conditions, as well as after 5, 10 and 20 days of seedling growth. Alcohol dehydrogenase (ADH) activity was quantified in roots and leaves of seedlings without or with flooding (partial and total). Seeds were not able to germinate under anoxia. Different strategies of storage mobilization of lipids, proteins, soluble sugars and starch were observed in seeds of each environment. ADH activity was induced by anoxia, with the highest level observed in the leaves. This study showed that, under normoxic conditions, the best developmental performance of assai palm seeds, from flooded or upland forest areas, during germination was associated with primary metabolites mobilization and seedling flooding tolerance with increased ADH activity. We conclude that the assai palm is well adapted to the anoxic conditions provoked by flooding.

Intertidal life: field observations on the clingfish Gobiesox barbatulus in southeastern Brazil

The clingfish Gobiesox barbatulus shows nocturnal feeding activity, spending most part of the day stationary and adhered to the inferior part of stones. To feed, this species uses the sit-and-wait and particulate feeding tactics. It shows a carnivorous feeding habit mostly consuming small benthic crustaceans. It can move in two ways: (1) "stone-by-stone", sliding its ventral sucker disc across each stone and (2) "surf", when it takes advantage of the energy of the ebbing tide to quickly cross a distance up to four times its body length. Its reproductive season occurs between the end of spring and the beginning of summer, during which time it lays about 2,000 adhesive eggs of 1 mm each in a single layer under stones. It has more than one egg-laying session per reproductive season, therefore showing several different developmental stages. It performs fanning, mouthing and guarding of the eggs as forms of parental care. Data shown here also indicates that G. barbatulus has some shelter fidelity, being probably territorial.