The variability and predictors of quality of AIDS care services in Brazil

Background: Since establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery. Methods: The survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality. Results: The questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities. Conclusion: The survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Impact of outdoor biomass air pollution on hypertension hospital admissions

Background This study aimed to evaluate the association between the total suspended particles (TSP) generated from burning sugar cane plantations and the incidence of hospital admissions from hypertension in the city of Araraquara. Methods The study was an ecological time-series study. Total daily records of hypertension (ICD 10th I10-15) were obtained from admitted patients of all ages in a hospital in Araraquara, Sao Paulo State, Brazil, from 23 March 2003 to 27 July 2004. The daily concentration of TSP (mu g/m(3)) was obtained using a Handi-Vol sampler placed in downtown Araraquara. The local airport provided daily measures of temperature and humidity. In generalised linear Poisson regression models, the daily number of hospital admissions for hypertension was considered to be the dependent variable and the daily TSP concentration the independent variable. Results TSP presented a lagged effect on hypertension admissions, which was first observed 1 day after a TSP increase and remained almost unchanged for the following 2 days. A 10 mu g/m(3) increase in the TSP 3 day moving average lagged in 1 day led to an increase in hypertension-related hospital admissions during the harvest period (12.5%, 95% CI 5.6% to 19.9%) that was almost 30% higher than during non-harvest periods (9.0%, 95% CI 4.0% to 14.3%). Conclusions Increases in TSP concentrations were associated with hypertension-related hospital admissions. Despite the benefits of reduced air pollution in urban cities achieved by using ethanol produced from sugar cane to power automobiles, areas where the sugar cane is produced and harvested were found to have increased public health risk.

A Novel Hepatitis C Virus Genotyping Method Based on Liquid Microarray

The strategy used to treat HCV infection depends on the genotype involved. An accurate and reliable genotyping method is therefore of paramount importance. We describe here, for the first time, the use of a liquid microarray for HCV genotyping. This liquid microarray is based on the 5'UTR - the most highly conserved region of HCV - and the variable region NS5B sequence. The simultaneous genotyping of two regions can be used to confirm findings and should detect inter-genotypic recombination. Plasma samples from 78 patients infected with viruses with genotypes and subtypes determined in the Versant (TM) HCV Genotype Assay LiPA (version I; Siemens Medical Solutions, Diagnostics Division, Fernwald, Germany) were tested with our new liquid microarray method. This method successfully determined the genotypes of 74 of the 78 samples previously genotyped in the Versant (TM) HCV Genotype Assay LiPA (74/78, 95%). The concordance between the two methods was 100% for genotype determination (74/74). At the subtype level, all 3a and 2b samples gave identical results with both methods (17/17 and 7/7, respectively). Two 2c samples were correctly identified by microarray, but could only be determined to the genotype level with the Versant (TM) HCV assay. Genotype ""1'' subtypes (1a and 1b) were correctly identified by the Versant (TM) HCV assay and the microarray in 68% and 40% of cases, respectively. No genotype discordance was found for any sample. HCV was successfully genotyped with both methods, and this is of prime importance for treatment planning. Liquid microarray assays may therefore be added to the list of methods suitable for HCV genotyping. It provides comparable results and may readily be adapted for the detection of other viruses frequently co-infecting HCV patients. Liquid array technology is thus a reliable and promising platform for HCV genotyping.

Hypothalamic-pituitary axis and peripheral tissue responses to TRH stimulation and Liothyronine suppression tests in normal subjects evaluated by current methods

Objective: To reevaluate the responses of thyrotropin-releasing hormone ( TRH) stimulation test in baseline condition as well as after the administration of graded supraphysiological doses of liothyronine ( L- T-3) in normal subjects. Design: To assess various parameters related to the hypothalamic-pituitary axis and peripheral tissue responses to L- T-3 in 22 normal individuals ( median age: 30.5 years). Subjects were submitted to an intravenous TRH test at baseline condition and also to the oral administration of sequential and graded doses of L- T-3 ( 50, 100, and 200 mu g/day), each given over 3 days, at an outpatient clinic. Blood samples were obtained for thyrotropin (TSH) and prolactin (PRL) at basal and then 15, 30, and 60 minutes after the TRH injection. Effects of L- T3 administration on cholesterol, creatine kinase, retinol, ferritin, and sex hormone-binding globulin ( SHBG) were also measured at basal and after the oral administration of L- T-3. Main outcome: TRH administration resulted in an increase of 4-to 14-fold rise in serum TSH ( 8.3 +/- 2.5-fold), and in a slight rise in serum PRL concentrations ( 3.8 +/- 1.5-fold). Administration of graded doses of triiodothyronine ( T-3) resulted in a dose-dependent suppression of TSH and PRL. Basal thyroxine- binding globulin (TBG) and cholesterol levels decreased, and ferritin and SHBG increased after L- T-3 administration, while creatine kinase and retinol did not change throughout the study. There was a positive correlation between basal TSH and TSH peak response to TRH at basal condition and after each sequential L- T-3 doses. On the other hand, TSH peak response to the TRH test did not predict cholesterol, TBG, ferritin, or SHBG values. Conclusion: Using the current methods on hormone and biochemical analysis, we standardized the response of many parameters to TRH stimulation test after sequential and graded T-3 suppression test in normal subjects. Our data suggest that the evaluation of the responses of the hypothalamus-pituitary axis to TRH test as well as the impact of L- T-3 on peripheral tissues were not modified by the current methods.

Predictive factors of non-deterioration of glucose tolerance following a 2-year behavioral intervention

Aim: To identify predictive factors associated with non-deterioration of glucose metabolism following a 2-year behavioral intervention in Japanese-Brazilians. Methods: 295 adults (59.7% women) without diabetes completed 2-year intervention program. Characteristics of those who maintained/improved glucose tolerance status (non-progressors) were compared with those who worsened (progressors) after the intervention. In logistic regression analysis, the condition of non-progressor was used as dependent variable. Results: Baseline characteristics of non-progressors (71.7%) and progressors were similar, except for the former being younger and having higher frequency of disturbed glucose tolerance and lower C-reactive protein (CRP). In logistic regression, non-deterioration of glucose metabolism was associated with disturbed glucose tolerance impaired fasting glucose or impaired glucose tolerance - (p < 0.001) and CRP levels <= 0.04 mg/dL (p = 0.01), adjusted for age and anthropometric variables. Changes in anthropometry and physical activity and achievement of weight and dietary goals after intervention were similar in subsets that worsened or not the glucose tolerance status. Conclusion: The whole sample presented a homogeneous behavior during the intervention. Lower CRP levels and diagnosis of glucose intolerance at baseline were predictors of non-deterioration of the glucose metabolism after a relatively simple intervention, independent of body adiposity.

Esophageal Ulcer in Brazilian Patients with HIV: Prevalence and Comparative Analysis Among Diagnostic Methods

Esophageal ulcer (EU) represents an important comorbidity in AIDS. We evaluated the prevalence of EU, the accuracy of the endoscopic and histologic methods used to investigate viral EU in HIV-positive Brazilian patients and the numerical relevance of tissue sampling. A total of 399 HIV-positive patients underwent upper gastrointestinal (UGI) endoscopy. HIV-positive patients with EU determined by UGI endoscopy followed by biopsies were analyzed by the hematoxylin-eosin (HE) and immunohistochemical (IH) methods. EU was detected in 41 patients (mean age, 39.2 years; 23 males), with a prevalence of 10.27%. The median CD4 count was 49 cells/mm(3) (range, 1-361 cells/mm(3)) and the viral load was 58,869 copies per milliliter (range, 50-77,3290 copies per milliliter). UGI endoscopy detected 29 of 41 EU suggestive of cytomegalovirus (CMV) infection and 7 of 41 indicating herpes simplex virus (HSV) infection. HE histology confirmed 4 of 29 ulcers induced by CMV, 2 of 7 induced by HSV, and 1 of 7 induced by HSV plus CMV. IH for CMV and HSV confirmed the HE findings and detected one additional CMV-induced case. UGI endoscopy showed 100% sensitivity and 15% specificity for the diagnosis of EU due to CMV or HSV compared to HE and IH. HE proved to be an adequate method for etiologic evaluation, with 87% sensitivity and 100% specificity compared to IH. The number of samples did not influence the etiologic evaluation. The data support the importance of IH as a complementary method for HE in the diagnosis of EU of viral etiology.

Nd:YAG Laser Improves Biocompatibility of Human Dental Root Surfaces

Objective: Our goal was to compare the in vivo biocompatibility of dental root surfaces submitted to four different treatments after tooth avulsion followed by implantation into rat subcutaneous tissue. Background Data: Dental root surface preparation prior to replanting teeth remains a challenge for endodontists. Root surface changes made by Nd:YAG irradiation could be an alternative preparation. Methods: Forty-eight freshly extracted human dental roots were randomly divided into four treatment groups prior to implantation into rat subcutaneous tissue: G1, dry root, left in the environment up to 3 h; G2, the same treatment as G1, followed by a soaking treatment in a 2.4% sodium fluoride solution (pH 5.5); G3, root soaked in physiologic saline after avulsion for 72 h; G4, the same treatment as G1, followed by Nd:YAG laser irradiation (2.0 W, 20 Hz, 100 mJ, and 124.34 J/cm(2)). The animals were sacrificed 1, 7, and 45 d later. Histological and scanning electron microscopy analyses were done. Results: All dental roots were involved and in intimate contact with connective tissue capsules of variable thicknesses. Differences were observed in the degree of inflammation and in connective tissue maturation. In G3 the inflammatory infiltrate was maintained for 45 d, whereas the Nd:YAG laser irradiation (G4) led to milder responses. The overall aspects of the root surfaces were similar, except by the irradiated roots, where fusion and resolidification of the root surface covering the dentinal tubules were observed. Conclusion: Nd:YAG laser irradiation improves the biocompatibility of dental root and thus could be an alternative treatment of dental root prior to replantation.

Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study

Background: Despite the importance of collecting individual data of socioeconomic status (SES) in epidemiological oral health surveys with children, this procedure relies on the parents as respondents. Therefore, type of school (public or private schools) could be used as an alternative indicator of SES, instead of collecting data individually. The aim of this study was to evaluate the use of the variable type of school as an indicator of socioeconomic status as a substitute of individual data in an epidemiological survey about dental caries in Brazilian preschool children. Methods: This study followed a cross-sectional design, with a random sample of 411 preschool children aged 1 to 5 years, representative of Catalao, Brazil. A calibrated examiner evaluated the prevalence of dental caries and parents or guardians provided information about several individual socioeconomic indicators by means of a semi-structured questionnaire. A multilevel approach was used to investigate the association among individual socioeconomic variables, as well as the type of school, and the outcome. Results: When all significant variables in the univariate analysis were used in the multiple model, only mother's schooling and household income (individual socioeconomic variables) presented significant associations with presence of dental caries, and the type of school was not significantly associated. However, when the type of school was used alone, children of public school presented significantly higher prevalence of dental caries than those enrolled in private schools. Conclusions: The type of school used as an alternative indicator for socioeconomic status is a feasible predictor for caries experience in epidemiological dental caries studies involving preschool children in Brazilian context.

Lineage divergence detected in the malaria vector Anopheles marajoara (Diptera: Culicidae) in Amazonian Brazil

Background: Cryptic species complexes are common among anophelines. Previous phylogenetic analysis based on the complete mtDNA COI gene sequences detected paraphyly in the Neotropical malaria vector Anopheles marajoara. The ""Folmer region"" detects a single taxon using a 3% divergence threshold. Methods: To test the paraphyletic hypothesis and examine the utility of the Folmer region, genealogical trees based on a concatenated (white + 3' COI sequences) dataset and pairwise differentiation of COI fragments were examined. The population structure and demographic history were based on partial COI sequences for 294 individuals from 14 localities in Amazonian Brazil. 109 individuals from 12 localities were sequenced for the nDNA white gene, and 57 individuals from 11 localities were sequenced for the ribosomal DNA (rDNA) internal transcribed spacer 2 (ITS2). Results: Distinct A. marajoara lineages were detected by combined genealogical analysis and were also supported among COI haplotypes using a median joining network and AMOVA, with time since divergence during the Pleistocene (< 100,000 ya). COI sequences at the 3' end were more variable, demonstrating significant pairwise differentiation (3.82%) compared to the more moderate 2.92% detected by the Folmer region. Lineage 1 was present in all localities, whereas lineage 2 was restricted mainly to the west. Mismatch distributions for both lineages were bimodal, likely due to multiple colonization events and spatial expansion (similar to 798 - 81,045 ya). There appears to be gene flow within, not between lineages, and a partial barrier was detected near Rio Jari in Amapa state, separating western and eastern populations. In contrast, both nDNA data sets (white gene sequences with or without the retention of the 4th intron, and ITS2 sequences and length) detected a single A. marajoara lineage. Conclusions: Strong support for combined data with significant differentiation detected in the COI and absent in the nDNA suggest that the divergence is recent, and detectable only by the faster evolving mtDNA. A within subgenus threshold of >2% may be more appropriate among sister taxa in cryptic anopheline complexes than the standard 3%. Differences in demographic history and climatic changes may have contributed to mtDNA lineage divergence in A. marajoara.

The qWR star HD 45166 - II. Fundamental stellar parameters and evidence of a latitude-dependent wind

Context. The enigmatic object HD 45166 is a qWR star in a binary system with an orbital period of 1.596 day, and presents a rich emission-line spectrum in addition to absorption lines from the companion star (B7 V). As the system inclination is very small (i = 0.77 degrees +/- 0.09 degrees), HD 45166 is an ideal laboratory for wind-structure studies. Aims. The goal of the present paper is to determine the fundamental stellar and wind parameters of the qWR star. Methods. A radiative transfer model for the wind and photosphere of the qWR star was calculated using the non-LTE code CMFGEN. The wind asymmetry was also analyzed using a recently-developed version of CMFGEN to compute the emerging spectrum in two-dimensional geometry. The temporal-variance spectrum (TVS) was calculated to study the line-profile variations. Results. Abundances and stellar and wind parameters of the qWR star were obtained. The qWR star has an effective temperature of T(eff) = 50 000 +/- 2000 K, a luminosity of log(L/L(circle dot)) = 3.75 +/- 0.08, and a corresponding photospheric radius of R(phot) = 1.00 R(circle dot). The star is helium-rich (N(H)/N(He) = 2.0), while the CNO abundances are anomalous when compared either to solar values, to planetary nebulae, or to WR stars. The mass-loss rate is. M = 2.2 x 10(-7) M(circle dot) yr(-1), and the wind terminal velocity is v(infinity) = 425 km s(-1). The comparison between the observed line profiles and models computed under different latitude-dependent wind densities strongly suggests the presence of an oblate wind density enhancement, with a density contrast of at least 8: 1 from equator to pole. If a high velocity polar wind is present (similar to 1200 km s(-1)), the minimum density contrast is reduced to 4:1. Conclusions. The wind parameters determined are unusual when compared to O-type stars or to typical WR stars. While for WR stars v(infinity)/v(esc) > 1.5, in the case of HD 45166 it is much smaller (v(infinity)/v(esc) = 0.32). In addition, the efficiency of momentum transfer is eta = 0.74, which is at least 4 times smaller than in a typical WR. We find evidence for the presence of a wind compression zone, since the equatorial wind density is significantly higher than the polar wind. The TVS supports the presence of such a latitude-dependent wind and a variable absorption/scattering gas near the equator.

Chemical evolution models for spiral disks: the Milky Way, M31, and M33

Context. The distribution of chemical abundances and their variation with time are important tools for understanding the chemical evolution of galaxies. In particular, the study of chemical evolution models can improve our understanding of the basic assumptions made when modelling our Galaxy and other spirals. Aims. We test a standard chemical evolution model for spiral disks in the Local Universe and study the influence of a threshold gas density and different efficiencies in the star formation rate (SFR) law on radial gradients of abundance, gas, and SFR. The model is then applied to specific galaxies. Methods. We adopt a one-infall chemical evolution model where the Galactic disk forms inside-out by means of infall of gas, and we test different thresholds and efficiencies in the SFR. The model is scaled to the disk properties of three Local Group galaxies (the Milky Way, M31 and M33) by varying its dependence on the star formation efficiency and the timescale for the infall of gas onto the disk. Results. Using this simple model, we are able to reproduce most of the observed constraints available in the literature for the studied galaxies. The radial oxygen abundance gradients and their time evolution are studied in detail. The present day abundance gradients are more sensitive to the threshold than to other parameters, while their temporal evolutions are more dependent on the chosen SFR efficiency. A variable efficiency along the galaxy radius can reproduce the present day gas distribution in the disk of spirals with prominent arms. The steepness in the distribution of stellar surface density differs from massive to lower mass disks, owing to the different star formation histories. Conclusions. The most massive disks seem to have evolved faster (i.e., with more efficient star formation) than the less massive ones, thus suggesting a downsizing in star formation for spirals. The threshold and the efficiency of star formation play a very important role in the chemical evolution of spiral disks. For instance, an efficiency varying with radius can be used to regulate the star formation. The oxygen abundance gradient can steepen or flatten in time depending on the choice of this parameter.

Chemical abundances of 11 bulge stars from high-resolution, near-IR spectra

Context. It is debated whether the Milky Way bulge has characteristics more similar to those of a classical bulge than those of a pseudobulge. Detailed abundance studies of bulge stars are important when investigating the origin, history, and classification of the bulge. These studies provide constraints on the star-formation history, initial mass function, and differences between stellar populations. Not many similar studies have been completed because of the large distance and high variable visual extinction along the line-of-sight towards the bulge. Therefore, near-IR investigations can provide superior results. Aims. To investigate the origin of the bulge and study its chemical abundances determined from near-IR spectra for bulge giants that have already been investigated with optical spectra. The optical spectra also provide the stellar parameters that are very important to the present study. In particular, the important CNO elements are determined more accurately in the near-IR. Oxygen and other alpha elements are important for investigating the star-formation history. The C and N abundances are important for determining the evolutionary stage of the giants and the origin of C in the bulge. Methods. High-resolution, near-infrared spectra in the H band were recorded using the CRIRES spectrometer mounted on the Very Large Telescope. The CNO abundances are determined from the numerous molecular lines in the wavelength range observed. Abundances of the alpha elements Si, S, and Ti are also determined from the near-IR spectra. Results. The abundance ratios [O/Fe], [Si/Fe], and [S/Fe] are enhanced to metallicities of at least [Fe/H] = -0.3, after which they decline. This suggests that the Milky Way bulge experienced a rapid and early burst of star formation similar to that of a classical bulge. However, a similarity between the bulge trend and the trend of the local thick disk seems to be present. This similarity suggests that the bulge could have had a pseudobulge origin. The C and N abundances suggest that our giants are first-ascent red-giants or clump stars, and that the measured oxygen abundances are those with which the stars were born. Our [C/Fe] trend does not show any increase with [Fe/H], which is expected if W-R stars contributed substantially to the C abundances. No ""cosmic scatter"" can be traced around our observed abundance trends: the measured scatter is expected, given the observational uncertainties.

BONA FIDE, STRONG-VARIABLE GALACTIC LUMINOUS BLUE VARIABLE STARS ARE FAST ROTATORS: DETECTION OF A HIGH ROTATIONAL VELOCITY IN HR CARINAE

We report optical observations of the luminous blue variable (LBV) HR Carinae which show that the star has reached a visual minimum phase in 2009. More importantly, we detected absorptions due to Si lambda lambda 4088-4116. To match their observed line profiles from 2009 May, a high rotational velocity of nu(rot) similar or equal to 150 +/- 20 km s(-1) is needed (assuming an inclination angle of 30 degrees), implying that HR Car rotates at similar or equal to 0.88 +/- 0.2 of its critical velocity for breakup (nu(crit)). Our results suggest that fast rotation is typical in all strong-variable, bona fide galactic LBVs, which present S-Dor-type variability. Strong-variable LBVs are located in a well-defined region of the HR diagram during visual minimum (the ""LBV minimum instability strip""). We suggest this region corresponds to where nu(crit) is reached. To the left of this strip, a forbidden zone with nu(rot)/nu(crit) > 1 is present, explaining why no LBVs are detected in this zone. Since dormant/ex LBVs like P Cygni and HD 168625 have low nu(rot), we propose that LBVs can be separated into two groups: fast-rotating, strong-variable stars showing S-Dor cycles (such as AG Car and HR Car) and slow-rotating stars with much less variability (such as P Cygni and HD 168625). We speculate that supernova (SN) progenitors which had S-Dor cycles before exploding (such as in SN 2001ig, SN 2003bg, and SN 2005gj) could have been fast rotators. We suggest that the potential difficulty of fast-rotating Galactic LBVs to lose angular momentum is additional evidence that such stars could explode during the LBV phase.

Low-amplitude variations detected by CoRoT in the B8IIIe star HD 175869

Context. The origin of the short-term variability in Be stars remains a matter of controversy. Pulsations and rotational modulation are the components of the favored hypothesis. Aims. We present our analysis of CoRoT data of the B8IIIe star HD 175869 observed during the first short run in the center direction (SRC1). Methods. We review both the instrumental effects visible in the CoRoT light curve and the analysis methods used by the CoRoT Be team. We applied these methods to the CoRoT light curve of the star HD 175869. A search for line-profile variations in the spectroscopic data was also performed. We also searched for a magnetic field, by applying the LSD technique to spectropolarimetric data. Results. The light curve exhibits low-amplitude variations of the order of 300 mu mag with a double wave shape. A frequency within the range determined for the rotational frequency and 6 of its harmonics are detected. The main frequency and its first harmonic exhibit amplitude variations of a few days. Other significant frequencies of low-amplitude from 25 to a few mu mag are also found. The analysis of line profiles from ground-based spectroscopic data does not detect any variation. In addition, no Zeeman signature was found. Conclusions. Inhomogeneities caused by stellar activity in or just above the photosphere are proposed to produce the photometric variability detected by CoRoT in the Be star HD 175869. The hypothesis that non-radial pulsations are the origin of these variations cannot be excluded.

Planetary transit candidates in Corot-IRa01 field

Context. CoRoT is a pioneering space mission devoted to the analysis of stellar variability and the photometric detection of extrasolar planets. Aims. We present the list of planetary transit candidates detected in the first field observed by CoRoT, IRa01, the initial run toward the Galactic anticenter, which lasted for 60 days. Methods. We analysed 3898 sources in the coloured bands and 5974 in the monochromatic band. Instrumental noise and stellar variability were taken into account using detrending tools before applying various transit search algorithms. Results. Fifty sources were classified as planetary transit candidates and the most reliable 40 detections were declared targets for follow-up ground-based observations. Two of these targets have so far been confirmed as planets, CoRoT-1b and CoRoT-4b, for which a complete characterization and specific studies were performed.