Contextual politics of service delivery reforms: Lessons from Delhi, Mexico city and Sao Paulo comparison

Little attention has been given to the contextual politics of service delivery reforms. By focusing on cases of reform in the healthcare sector and, to a lesser extent, in the main policies in the social service sector in India, Mexico and Brazil, this article explores two dimensions of analysis which have enormous relevance in understanding the reach and effectiveness of service delivery reforms: (1) the historical timing of reforms and sectorial baselines, and (2) the degree and institutional locus of local discretion in policy. Findings show that depending on both dimensions, there is an extraordinary variation as to the degree, interests involved and meaning of changes which, in theory, correspond to these countries` commitment to the service delivery reforms, However, consideration of the contextual politics is relevant not for the sake of diversity but for the similarities that this diversity reveals, pointing to underlying analytic dimensions that receive attention in this article.

Failure of Imiquimod 5% Cream to Prevent Recurrence of Surgically Excised Trunk Keloids

Keloids are characterized by benign proliferation of fibroblasts in the setting of an altered cytokine profile, with a high recurrence rate after surgical treatment. Imiquimod is a topically applied immune-response modifier. Recently, auxiliary therapy using imiquimod 5% cream to prevent keloid recurrence after excisional surgery was reported to have had good results. To evaluate the efficacy of topical imiquimod 5% cream applied after surgical excision and primary closure of trunk keloids in the prevention of recurrence. Nine patients with a keloid lesion on the trunk were treated with surgical excision and primary closure. Daily application of imiquimod 5% cream for 8 weeks was initiated the night of surgery. The patients were evaluated 2, 4, 8, 12, and 20 weeks after. Keloid recurrence occurred in eight patients, seven of them 12 weeks after surgery. We lost track of one patient. The results of this study suggest that imiquimod 5% cream is not effective in preventing recurrence of trunk keloids after surgical excision. Although this is a small case series, results strongly discourage other studies using imiquimod 5% cream in the prevention of surgically excised trunk keloids. The authors have indicated no significant interest with commercial supporters.

Nonhuman primate models and the failure of the Merck HIV-1 vaccine in humans

The adenovirus type 5 (Ad5)-based vaccine developed by Merck failed to either prevent HIV-1 infection or suppress viral load in subsequently infected subjects in the STEP human Phase 2b efficacy trial. Analogous vaccines had previously also failed in the simian immunodeficiency virus (SIV) challenge-rhesus macaque model. In contrast, vaccine protection studies that used challenge with a chimeric simian-human immunodeficiency virus (SHIV89.6P) in macaques did not predict the human trial results. Ad5 vector -based vaccines did not protect macaques from infection after SHIV89.6P challenge but did cause a substantial reduction in viral load and a preservation of CD4(+) T cell counts after infection, findings that were not reproduced in the human trials. Although the SIV challenge model is incompletely validated, we propose that its expanded use can help facilitate the prioritization of candidate HIV-1 vaccines, ensuring that resources are focused on the most promising candidates. Vaccine designers must now develop T cell vaccine strategies that reduce viral load after heterologous challenge.

Effect of different ferrule designs on the fracture resistance and failure pattern of endodontically treated teeth restored with fiber posts and all-ceramic crowns

OBJECTIVE: This study investigated the effect of different ferrule heights on endodontically treated premolars. MATERIAL AND METHODS: Fifty sound mandibular first premolars were endodontically treated and then restored with 7-mm fiber post (FRC Postec Plus #1 Ivoclar-Vivadent) luted with self-polymerized resin cement (Multilink, Ivoclar Vivadent) while the coronal section was restored with hybrid composite core build-up material (Tetric Ceram, Ivoclar-Vivadent), which received all-ceramic crown. Different ferrule heights were investigated: 1-mm circumferential ferrule without post and core (group 1 used as control), a circumferential 1-mm ferrule (group 2), non-uniform ferrule 2-mm buccally and 1-mm lingually (group 3), non-uniform ferrule 3-mm buccally and 2-mm lingually (group 4), and finally no ferrule preparation (group 5). The fracture load and failure pattern of the tested groups were investigated by applying axial load to the ceramic crowns (n=10). Data were analyzed statistically by one-way ANOVA and Tukey's post-hoc test was used for pair-wise comparisons (α=0.05). RESULTS: There were no significant differences among the failure load of all tested groups (P<0.780). The control group had the lowest fracture resistance (891.43±202.22 N) and the highest catastrophic failure rate (P<0.05). Compared to the control group, the use of fiber post reduced the percentage of catastrophic failure while increasing the ferrule height did not influence the fracture resistance of the restored specimens. CONCLUSIONS: Within the limitations of this study, increasing the ferrule length did not influence the fracture resistance of endodontically treated teeth restored with glass ceramic crowns. Insertion of a fiber post could reduce the percentage of catastrophic failure of these restorations under function.

Failure analysis of belt/roll tribological pair used for the production of eucalypt fiber panels

The premature failure of a large agglomeration machine used for the annual production of 360,000 m(3) of eucalypt fiber panels was investigated to identify the nucleation and growth mechanisms of cracking in PH stainless steel belts (126 m x 2.9 m x 3.0 mm). These belts are used to compress a cushion composed of eucalyptus fibers and glue, being the pressure transmitted from the pistons by the action of numerous case-hardening steel rolls. Examination of the belt working interfaces (belt/rolls and belt/eucalypt fibers) indicated that the main cracking was nucleated on the belt/roll interface and that there is a clear relationship between the crack nucleation and the presence of superficial irregularities, which were observed on the belt/roll working surface. Used rolls showed the presence of perimetric wear marks and 2 mu m silicon-rich encrusted particles (identified as silicon carbide). Lubricant residues contained the presence of helicoidal wires, which were originated by the release of the stainless steel cleaning brush bristles, and 15 mu m diameter metallic particles, which were generated by material detachment of the belt. The presence of foreign particles on the tribological interface contributed to an increase of the shear stresses at the surfaces and, consequently, the number of the contact fatigue crack nucleation sites in the belt/roll tribo-interface. The cracking was originated on the belt/roll interface of the stainless steel belt by a mixed rolling/slip contact fatigue mechanism, which promoted spalling and further nucleation and growth of conventional fatigue cracks. Finally, the system lubrication efficiency and the cleaning procedure should be optimised in order to increase the life expectancy of the belt. (c) 2006 Elsevier Ltd. All rights reserved.

Cracking of 2.25Cr-1.0Mo steel tube/stationary tube-sheet weldment of a heat-exchanger

The premature failure of a horizontal heat-exchanger, which occurred after service exposure at 580 degrees C for 50,000 h, revealed the occurrence of extensive through-thickness cracking in approximately 40% of the tube/stationary tube-sheet welds. Additionally, the internal surface of the welded joint featured intensive secondary intergranular cracking (up to 250 mu m deep), preferential formation of a 150 mu m thick layer of (Fe, Cr)(3)O-4 and internal intergranular oxidation (40 mu m deep). The welded region also showed intense carbon pick-up and, as consequence, severe precipitation of intergranular M7C3 and M23C6 carbides. The fracture surface was composed of two distinct regions: a ""planar"" region of 250 mu m, formed due to the stable crack growth along by the intergranular oxidation; and a slant region with radial marks, formed by the fast crack growth along the network of intergranular carbides. The association of intergranular oxidation pre-cracks with microstructural embrittlement promoted the premature failure, which took place by an overload mechanism, probably due to the jamming of the floating tube-sheet during the maintenance halt (cooling operation). (C) 2007 Elsevier Ltd. All rights reserved.

Mucosal leishmaniasis: description of case management approaches and analysis of risk factors for treatment failure in a cohort of 140 patients in Brazil

Background Mucosal leishmaniasis is caused mainly by Leishmania braziliensis and it occurs months or years after cutaneous lesions. This progressive disease destroys cartilages and osseous structures from face, pharynx and larynx. Objective and methods The aim of this study was to analyse the significance of clinical and epidemiological findings, diagnosis and treatment with the outcome and recurrence of mucosal leishmaniasis through binary logistic regression model from 140 patients with mucosal leishmaniasis from a Brazilian centre. Results The median age of patients was 57.5 and systemic arterial hypertension was the most prevalent secondary disease found in patients with mucosal leishmaniasis (43%). Diabetes, chronic nephropathy and viral hepatitis, allergy and coagulopathy were found in less than 10% of patients. Human immunodeficiency virus (HIV) infection was found in 7 of 140 patients (5%). Rhinorrhea (47%) and epistaxis (75%) were the most common symptoms. N-methyl-glucamine showed a cure rate of 91% and recurrence of 22%. Pentamidine showed a similar rate of cure (91%) and recurrence (25%). Fifteen patients received itraconazole with a cure rate of 73% and recurrence of 18%. Amphotericin B was the drug used in 30 patients with 82% of response with a recurrence rate of 7%. The binary logistic regression analysis demonstrated that systemic arterial hypertension and HIV infection were associated with failure of the treatment (P < 0.05). Conclusion The current first-line mucosal leishmaniasis therapy shows an adequate cure but later recurrence. HIV infection and systemic arterial hypertension should be investigated before start the treatment of mucosal leishmaniasis. Conflicts of interest The authors are not part of any associations or commercial relationships that might represent conflicts of interest in the writing of this study (e.g. pharmaceutical stock ownership, consultancy, advisory board membership, relevant patents, or research funding).

Failure modes of Y-TZP crowns at different cusp inclines

Objectives To compare the reliability of the disto-facial (DF) and mesio-lingual (ML) cusps of an anatomically correct zirconia (Y-TZP) crown system The research hypotheses tested were (1) fatigue reliability and failure mode are similar for the ML and DF cusps, (2) failure mode of one cusp does not affect the failure of the other Methods The average dimensions of a mandibular first molar crown were imported into CAD software, a tooth preparation was modelled by 1 5 mm marginal high reduction of proximal walls and occlusal surface by 2 0 mm The CAD-based tooth preparation was milled and used as a die to fabricate crowns (n = 14) with porcelain veneer on a 0 5 mm Y-TZP core. Crowns were cemented on composite reproductions of the tooth preparation The crowns were step-stress mouth motion fatigued with sliding (0 7 mm) a tungsten-carbide indenter of 6 25 mm diameter down on the inclines of either the DF or ML cusps Use level probability Weibull curve with use stress of 200 N and the reliability for completion of a mission of 50,000 cycles at 200 N load were calculated Results Reliability for a 200 N at 50,000 cycles mission was not different between tested cusps SEM imaging showed large cohesive failures within the veneer for the ML and smaller for the DF Fractures originated from the contact area regardless of the cusp loaded Conclusion No significant difference on fatigue reliability was observed between the DF compared to the ML cusp Fracture of one cusp did not affect the other (c) 2010 Elsevier Ltd All rights reserved

Trypanosoma cruzi benznidazole susceptibility in vitro does not predict the therapeutic outcome of human Chagas disease

Therapeutic failure of benznidazole (BZ) is widely documented in Chagas disease and has been primarily associated with variations in the drug susceptibility of Trypanosoma cruzi strains. In humans, therapeutic success has been assessed by the negativation of anti-T. cruzi antibodies, a process that may take up to 10 years. A protocol for early screening of the drug resistance of infective strains would be valuable for orienting physicians towards alternative therapies, with a combination of existing drugs or new anti-T. cruzi agents. We developed a procedure that couples the isolation of parasites by haemoculture with quantification of BZ susceptibility in the resultant epimastigote forms. BZ activity was standardized with reference strains, which showed IC50 to BZ between 7.6-32 µM. The assay was then applied to isolates from seven chronic patients prior to administration of BZ therapy. The IC50 of the strains varied from 15.6 ± 3-51.4 ± 1 µM. Comparison of BZ susceptibility of the pre-treatment isolates of patients considered cured by several criteria and of non-cured patients indicates that the assay does not predict therapeutic outcome. A two-fold increase in BZ resistance in the post-treatment isolates of two patients was verified. Based on the profile of nine microsatellite loci, sub-population selection in non-cured patients was ruled out.

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).

Beta-2 adrenergic receptor gene polymorphisms Gln27Glu, Arg16Gly in patients with heart failure

Background -: Beta-2 adrenergic receptor gene polymorphisms Gln27Glu, Arg16Gly and Thr164Ile were suggested to have an effect in heart failure. We evaluated these polymorphisms relative to clinical characteristics and prognosis of alarge cohort of patients with heart failure of different etiologies. Methods -: We studied 501 patients with heart failure of different etiologies. Mean age was 58 years (standard deviation 14.4 years), 298 (60%) were men. Polymorphisms were identified by polymerase chain reaction-restriction fragment length polymorphism. Results -: During the mean follow-up of 12.6 months (standard deviation 10.3 months), 188 (38%) patients died. Distribution of genotypes of polymorphism Arg16Gly was different relative to body mass index (chi(2) = 9.797; p = 0.04). Overall the probability of survival was not significantly predicted by genotypes of Gln27Glu, Arg16Gly, or Thr164Ile. Allele and haplotype analysis also did not disclose any significant difference regarding mortality. Exploratory analysis through classification trees pointed towards a potential association between the Gln27Glu polymorphism and mortality in older individuals. Conclusion -: In this study sample, we were not able to demonstrate an overall influence of polymorphisms Gln27Glu and Arg16Gly of beta-2 receptor gene on prognosis. Nevertheless, Gln27Glu polymorphism may have a potential predictive value in older individuals.

Performance analysis of an optical network employing waveband and traffic grooming

This paper analyses an optical network architecture composed by an arrangement of nodes equipped with multi-granular optical cross-connects (MG-OXCs) in addition to the usual optical cross-connects (OXCs). Then, selected network nodes can perform both waveband as well as traffic grooming operations and our goal is to assess the improvement on network performance brought by these additional capabilities. Specifically, the influence of the MG-OXC multi-granularity on the blocking probability is evaluated for 16 classes of service over a network based on the NSFNet topology. A mechanism of fairness in bandwidth capacity is also added to the connection admission control to manage the blocking probabilities of all kind of bandwidth requirements. Comprehensive computational simulation are carried out to compare eight distinct node architectures, showing that an adequate combination of waveband and single-wavelength ports of the MG-OXCs and OXCs allow a more efficient operation of a WDM optical network carrying multi-rate traffic.

Analysing the base of precast column in socket foundations with smooth interfaces

This paper analyzes the behavior of the base of a precast column in the socket foundation with smooth interfaces. This research is motivated by the lack of information and guidelines on the behavior of column bases in the embedded region. An experimental program with two full-scale specimens was carried-out. These two specimens had smooth interfaces at the internal faces of the socket, different embedded lengths and were subjected to loads with large eccentricities. The experimental results showed that the failure of the specimens occurred by the yielding of the longitudinal reinforcement out of the embedded region, while the transverse reinforcement was not very stressed. Some recommendations on the anchorage of the longitudinal reinforcement and a strut-and-tie model for the behavior of column bases in the embedded region are proposed.

Failure Mechanisms in Sand over a Deep Active Trapdoor

An experimental testing program was undertaken to investigate failure mechanisms induced by the active movement of a deep rectangular trapdoor underlying a granular soil. Reduced-scale models were tested under normal gravity as well as under an increased gravitational field using a centrifuge facility. Some models were used to evaluate the performance of both flexible and rigid pipes undergoing a localized loss of support. Failure mechanisms in the longitudinal direction of the models were characterized by a single, well-defined failure surface that developed within the limits of the trapdoor. However, failure mechanisms in the transverse direction of the models were characterized by multiple failure surfaces extending outside the limits of the trapdoor. Significant dilation of the soil located immediately above the trapdoor was identified in the failure of the models. The pattern of the failure mechanisms was found to be affected by the stress level and backfill density. Higher stress levels were found to lead to well-developed failure zones. The influence of backfill density was found to be more relevant in models involving flexible pipes. Pipes embedded within loose backfill were severely damaged after loss of support, while pipes embedded in dense backfill experienced negligible deformations. These results indicate that damage to pipelines caused by ground loss of support can be significantly minimized by controlling the compaction of the fill.

Sources of Variations When Comparing Concrete Carbonation Results

Carbonation is one of the main concerns for concrete service life in tropical countries. The mechanism and materials that produce it have been widely studied as well as natural and accelerated methods to report and analyze it. In spite of reported investigations, there is a need for information that could allow an adequate interpretation of the results of the standardization process. This lack of information can produce variations not only in the interpretation but also in the predictions of service life. The purpose of this paper is to analyze and discuss variables that could be sources of error, especially when performing accelerated tests. As a result, a methodologies to minimize variations when interpreting and comparing results is proposed, such as specimen geometry and preconditioning, spacing, relative humidity, and CO(2) concentration.