Impact of long-stay beds on the performance of a tertiary hospital in emergencies

ABSTRACT OBJECTIVE To assess the impact of implementing long-stay beds for patients of low complexity and high dependency in small hospitals on the performance of an emergency referral tertiary hospital. METHODS For this longitudinal study, we identified hospitals in three municipalities of a regional department of health covered by tertiary care that supplied 10 long-stay beds each. Patients were transferred to hospitals in those municipalities based on a specific protocol. The outcome of transferred patients was obtained by daily monitoring. Confounding factors were adjusted by Cox logistic and semiparametric regression. RESULTS Between September 1, 2013 and September 30, 2014, 97 patients were transferred, 72.1% male, with a mean age of 60.5 years (SD = 1.9), for which 108 transfers were performed. Of these patients, 41.7% died, 33.3% were discharged, 15.7% returned to tertiary care, and only 9.3% tertiary remained hospitalized until the end of the analysis period. We estimated the Charlson comorbidity index – 0 (n = 28 [25.9%]), 1 (n = 31 [56.5%]) and ≥ 2 (n = 19 [17.5%]) – the only variable that increased the chance of death or return to the tertiary hospital (Odds Ratio = 2.4; 95%CI 1.3;4.4). The length of stay in long-stay beds was 4,253 patient days, which would represent 607 patients at the tertiary hospital, considering the average hospital stay of seven days. The tertiary hospital increased the number of patients treated in 50.0% for Intensive Care, 66.0% for Neurology and 9.3% in total. Patients stayed in long-stay beds mainly in the first 30 (50.0%) and 60 (75.0%) days. CONCLUSIONS Implementing long-stay beds increased the number of patients treated in tertiary care, both in general and in system bottleneck areas such as Neurology and Intensive Care. The Charlson index of comorbidity is associated with the chance of patient death or return to tertiary care, even when adjusted for possible confounding factors.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro

ABSTRACT OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health. METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011. RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours. CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

Sewage impact on the composition and distribution of Polychaeta associated to intertidal mussel beds of the Mar del Plata rocky shore, Argentina

The polychaete composition and distribution within mussel beds were studied in order to assess organic pollution due to domestic sewage in a rocky shore of Mar del Plata (Argentina) during 1997. Four stations and a control site were randomly sampled around the local effluent. Quantitative data on polychaetes, as well as sediment accumulated among mussels and its organic carbon content were measured. Polychaete distribution patterns are related to the organic matter gradient, being Capitella cf. capitata, Neanthes succinea (Frey & Leuckart, 1847) and Boccardia polybranchia (Haswell, 1885) the dominant indicator species close to the effluent. At medial distances, the cirratulids Caulleriella alata (Southern, 1914) and Cirratulus cirratus (Müller, 1776) are very important in abundance. The syllids Syllis prolixa Ehlers, 1901 and S. gracilis Grube, 1840 are distributed along the study area, but dominate at the medial stations and at the control site. The orbiniid Protoariciella uncinata Hartmann-Schröder, 1962 is subdominant at the control station.

Diel density variation of amphipods associated with Sargassum beds from two shores of Ubatuba, Southeastern, Brazil

Densities of mobile epifaunal assemblages associated with macrophytes are very variable during the day and the activity of visually-oriented predators is thought to have an important influence on this pattern. Here we compared densities of amphipods associated with a common brown alga, Sargassum stenophyllum (Phaeophyceae), at sites contrasting in water turbidity. We expected that diel variation of amphipods would occur in a shore with clear waters (Perequê), whereas no variation was expected in a shore with turbid waters (Lamberto). Amphipod density varied during the day at both shores, with no indication of a larger variation at Perequê. Most species showed two density peaks, one at night and the other in the afternoon. These peaks occurred close the times of high tide, suggesting that tidal rhythms could influence more amphipod densities than the activity of predators. Thus, more studies are necessary to understand factors that influence short-term variation of epifaunal assemblages.

Morfologia e partição de assimilados na batateira em função de época de amostragem e de doses de potássio

Com o objetivo de avaliar o efeito de época de amostragem e da adubação potássica sobre a morfologia e partição de assimilados na batateira (Solanum tuberosum L.), foram realizados dois experimentos no campo: o primeiro para avaliar o efeito de doses da adubação potássica e o segundo para avaliação do seu efeito residual. Foram aplicadas seis doses de K no campo (0, 60, 120, 240, 480 e 960 kg de K2O ha-1) na forma de sulfato de potássio, em delineamento de blocos casualizados, com quatro repetições. Tubérculos da cultivar Baraka, uniformemente brotados, foram plantados em espaçamento 0,8 x 0,3 m. Amostraram-se plantas aos 20 e 48 dias após emergência (DAE) para avaliação de área foliar, comprimento de caule, números e produções de matéria fresca e seca de folha, caule e tubérculo e teores de matéria seca de folha e caule. Apenas o comprimento de caule aumentou com as doses de K, resultando em menor sombreamento da batateira. No primeiro experimento, aos 20 DAE, a batateira apresentava, em média, 42 folhas, três hastes, 5.389 cm² de área foliar, 157,1 e 216,4 g de matéria fresca de caule e de folha, respectivamente, e 6,2 e 9,2% de teor de matéria seca de caule e de folha, respectivamente.

Avaliação do estado nutricional do nitrogênio em batateira por meio de polifenóis e clorofila na folha

O objetivo deste trabalho foi avaliar o efeito de doses de N sobre índices fisiológicos relacionados à nutrição nitrogenada e verificar a possibilidade de estimar indiretamente os teores foliares de N em batata. Foram avaliados os índices de flavonóis (IFLV), de clorofila (ICHL) e de balanço de N (IBN), e as estimativas dos teores foliares de N foram realizadas aos 21 e 42 dias após a emergência, por meio do medidor portátil Dualex. O experimento foi conduzido de novembro de 2010 a fevereiro de 2011, em delineamento de blocos ao acaso, e os tratamentos consistiram de cinco doses de N (0, 50, 100, 200 e 300 kg ha‑1 de N, na forma de ureia) aplicadas em pré‑plantio, com quatro repetições. Houve aumento no ICHL e no IBN e decréscimo no IFLV com o aumento das doses de N. Os índices determinados com o medidor Dualex correlacionaram-se com os teores de N e de clorofila extraível na quarta folha, bem como com o rendimento de tubérculos na safra. O Dualex pode ser utilizado para avaliar o estado nutricional de N em batateira e prognosticar a produtividade de tubérculos.

Previsão da requeima da batateira

Com o objetivo de adequar um sistema de previsão para uso criterioso do controle químico da requeima da batateira (Solanum tuberosum), foram instalados ensaios em condição de campo, seguindo-se o delineamento experimental em blocos ao acaso, com sete tratamentos e quatro repetições, com a cultivar Bintje. Os fungicidas dimetomorfe, cimoxanil, mancozeb e clorotalonil foram associados com diferentes esquemas de pulverização baseados no sistema de previsão modificado de Wallin (1962) e no sistema tradicional de controle da requeima. Os tratamentos consistiram de : 1) aplicação de dimetomorfe de acordo com VSD-12 + clorotalonil semanalmente; 2) aplicação de dimetomorfe de acordo com VSD-14 + clorotalonil semanalmente; 3) aplicação de dimetomorfe de acordo com VSD-16 + clorotalonil semanalmente; 4) aplicação dos fungicidas protetores mancozeb, clorotalonil e oxicloreto de cobre alternados a cada sete dias; 5) aplicação dos fungicidas mancozeb, dimetomorfe, clorotalonil e cimoxanil, alternados a cada sete dias; 6) aplicação de dimetomorfe + clorotalonil de acordo com VSD-12; e 7) testemunha (sem aplicação). O uso do sistema de previsão conforme os tratamentos 1, 2 e 3 apresentou eficiência comparável ao calendário semanal (tratamento 5) de pulverização no controle da requeima da batateira. Os tratamentos baseados no acúmulo de 12 e 14 VSD's apresentaram maior eficiência em prever a ocorrência de epidemias da requeima. Apenas o sistema de previsão 2, permitiu reduzir o número de pulverizações com fungicida sistêmico, sem que houvesse perda significativa na produção.

Efeito do silicato de potássio isoladamente ou em mistura com fungicida no controle da requeima da batateira

Este trabalho teve como objetivo avaliar o efeito da aplicação foliar de silicato de potássio, isoladamente ou em mistura com diferentes doses do fungicida, no controle da requeima, causada por Phytophthora infestans, da batateira. O experimento foi conduzido em condições de campo utilizando-se o delineamento em blocos casualizados com 8 tratamentos e 4 repetições. A cultivar de batata usada foi a Asterix. Foi utilizado o fungicida Cimoxanil + Mancozeb (60 + 700 g/Kg i.a.) e silicato de potássio na dose de 60 g/L (pH = 5,5). Os tratamentos (T) utilizados foram: T1 - Testemunha; T2 - Cimoxanil + Mancozeb (2,0 Kg/ha); T3 - Cimoxanil + Mancozeb (2,5 Kg/ha); T4 - Cimoxanil + Mancozeb (2,0 Kg/ha) + silicato de potássio; T5 - Cimoxanil + Mancozeb (2,5 Kg/ha) + silicato de potássio; T6 - Cimoxanil + Mancozeb (3,0 Kg/ha) + silicato de potássio; T7 - silicato de potássio e T8 - Cimoxanil + Mancozeb (3,0 Kg/ha). As pulverizações foram realizadas semanalmente. A severidade da requeima foi avaliada utilizando-se uma escala descritiva com notas de 0 a 100%. Os resultados da severidade foram utilizados para calcular a área abaixo da curva do progresso da requeima (AACPR). A AACPR foi de 72,5; 23,8; 18,3; 29,5; 19,7; 17,9; 68,3 e 16,3, respectivamente, nos tratamentos T1, T2, T3, T4, T5, T6, T7 e T8. Os tratamentos 3, 5, 6 e 8 foram os mais eficientes (menores AACPRs e maiores rendimentos) no controle da requeima. O silicato de potássio não foi eficiente e não apresentou nenhum efeito aditivo quando misturado ao fungicida no controle da requeima.

Gas-solid two-phase flow in the riser of circulating fluidized beds: mathematical modelling and numerical simulation

A mathematical model is developed for gas-solids flows in circulating fluidized beds. An Eulerian formulation is followed based on the two-fluids model approach where both the fluid and the particulate phases are treated as a continuum. The physical modelling is discussed, including the formulation of boundary conditions and the description of the numerical methodology. Results of numerical simulation are presented and discussed. The model is validated through comparison to experiment, and simulation is performed to investigate the effects on the flow hydrodynamics of the solids viscosity.

Acute lead-induced vasoconstriction in the vascular beds of isolated perfused rat tails is endothelium-dependent

Chronic lead exposure induces hypertension in humans and animals, affecting endothelial function. However, studies concerning acute cardiovascular effects are lacking. We investigated the effects of acute administration of a high concentration of lead acetate (100 µΜ) on the pressor response to phenylephrine (PHE) in the tail vascular bed of male Wistar rats. Animals were anesthetized with sodium pentobarbital and heparinized. The tail artery was dissected and cannulated for drug infusion and mean perfusion pressure measurements. Endothelium and vascular smooth muscle relaxation were tested with acetylcholine (5 µg/100 µL) and sodium nitroprusside (0.1 µg/100 µL), respectively, in arteries precontracted with 0.1 µM PHE. Concentration-response curves to PHE (0.001-300 µg/100 µL) were constructed before and after perfusion for 1 h with 100 µΜ lead acetate. In the presence of endothelium (E+), lead acetate increased maximal response (Emax) (control: 364.4 ± 36, Pb2+: 480.0 ± 27 mmHg; P < 0.05) and the sensitivity (pD2; control: 1.98 ± 0.07, 2.38 ± 0.14 log mM) to PHE. In the absence of endothelium (E-) lead had no effect but increased baseline perfusion pressure (E+: 79.5 ± 2.4, E-: 118 ± 2.2 mmHg; P < 0.05). To investigate the underlying mechanisms, this protocol was repeated after treatment with 100 µM L-NAME, 10 µM indomethacin and 1 µM tempol in the presence of lead. Lead actions on Emax and pD2 were abolished in the presence of indomethacin, and partially abolished with L-NAME and tempol. Results suggest that acute lead administration affects the endothelium, releasing cyclooxygenase-derived vasoconstrictors and involving reactive oxygen species.

Índices para avaliar o estado de nitrogênio da batata multiplicada por distintos materiais propagativos

Melhoria na eficiência de aplicação do N pode ser conseguida pela sincronização da demanda da planta com o suprimento de N durante o ciclo da batateira. O objetivo do trabalho foi determinar os valores ótimos de índices relacionados com o estado de nitrogênio ao longo do ciclo da batata cultivada em ambiente protegido, utilizando distintos materiais propagativos, tubérculo-semente, minitubérculo e broto, comuns na produção de tubérculo-semente básica. Os índices, determinados na quarta folha e na mais velha, foram intensidade da cor verde, avaliada pelo índice SPAD e pela tabela de cor, e características agronômicas: comprimento, largura, área e número de folíolos. Foram realizados três experimentos em vaso, em casa de vegetação na Universidade Federal de Viçosa. Em cada experimento, instalado no delineamento de blocos ao acaso, com quatro repetições, foram utilizadas seis doses de nitrogênio (0; 25; 50; 100; 200 e 400 mg dm-3). Os índices foram determinados a cada 10 dias iniciando-se aos 20 dias após a emergência. Com cada material de propagação, o índice SPAD medido tanto na QF quanto na FV respondeu de forma diferenciada ao incremento na dose de N e atingiu os valores ótimos de 41,3; 40,5; 37,0; 35,8; 36,0; 31,9 e 29,8 dos 20 aos 80 DAE, respectivamente, ao ser utilizado o tubérculo-semente básica. Com todos os materiais de propagação, a idade da planta influencia significativamente todas as variáveis, exceto o número de hastes ou o número de folhas, quando é utilizado broto ou minitubérculo, respectivamente. O valor ótimo dos índices relacionados com a intensidade da cor das folhas e das características agronômicas da planta foram estabelecidos e variam com o material de propagação e idade da planta de batata.

Influence of the N/K ratio on the production and quality of cucumber in hydroponic system

The objective of this work was to evaluate the quality of fruits and the nutritional status of cucumber CV. Aodai cultivated in nutrient solutions with different N:K ratios. The hydroponic cultivation was initially performed, during the vegetative growth, in nutrient solution with 1:2.0 mmol L-1 N:K, and, later, during fruit setting, in four different nutrient solutions with N:K (w/w) at the ratios 1:1.4, 1:1.7, 1:2.0 and 1:2.5. An additional treatment with a nutrient solution containing the ratio 1:2.2 (w/w) N:K during the vegetative growth and N:K 1:1.4 (w/w) during fruit setting, both with 10% ammonium (NH4+) was included. The treatments were arranged in a randomized design with six replicates. Irrigation was carried out with deionized water until seed germination, and then with nutrient solution until 30 days after germination, when plants were transplanted. Plants in the hydroponic growing beds were irrigated with the solutions for vegetative growth, and, after 21 days, the solutions were replaced by solutions for fruit setting. At 45 and 60 days after transplanting, the fresh weight, length, diameter, volume and firmness of the fruit were evaluated, and, at 45 days after transplanting, the macronutrient concentrations in the leaves were determined. The use of different N:K ratios during fruit setting influenced the cucumber production. The ratio of 1.0:1.7 N: K (w/w), with 10% of N in the form of ammonia, is recommended for the whole cycle.

The epidemiologic paradox of low birth weight in Brazil

OBJECTIVE: To examine whether the low birth weight (LBW) paradox exists in Brazil. METHODS: LBW and cesarean section rates between 1995 and 2007 were estimated based on data from SINASC (Brazilian Live Births Database). Infant mortality rates (IMRs) were obtained using an indirect method that correct for underreporting. Schooling information was obtained from census data. Trends in LBW rate were assessed using joinpoint regression models. The correlations between LBW rate and other indicators were graphically assessed by lowess regression and tested using Spearman's rank correlation. RESULTS: In Brazil, LBW rate trends were non-linear and non-significant: the rate dropped from 7.9% in 1995 to 7.7% in 2000, then increased to 8.2% in 2003 and remained nearly steady thereafter at 8.2% in 2007. However, trends varied among Brazilian regions: there were significant increases in the North from 1999 to 2003 (2.7% per year), and in the South (1.0% per year) and Central-West regions (0.6% per year) from 1995 to 2007. For the entire period studied, higher LBW and lower IMRs were seen in more developed compared to less developed regions. In Brazilian States, in 2005, the higher the IMR rate, the lower the LBW rate (p=0.009); the lower the low schooling rate, the lower the LBW rate (p=0.007); the higher the number of neonatal intensive care beds per 1,000 live births, the higher the LBW rate (p=0.036). CONCLUSIONS: The low birth weight paradox was seen in Brazil. LBW rate is increasing in some Brazilian regions. Regional differences in LBW rate seem to be more associated to availability of perinatal care services than underlying social conditions.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Hospitalization flow in the public and private systems in the state of Sao Paulo, Brazil

OBJECTIVE To describe the migration flows of demand for public and private hospital care among the health regions of the state of Sao Paulo, Brazil. METHODS Study based on a database of hospitalizations in the public and private systems of the state of Sao Paulo, Southeastern Brazil, in 2006. We analyzed data from 17 health regions of the state, considering people hospitalized in their own health region and those who migrated outwards (emigration) or came from other regions (immigration). The index of migration effectiveness of patients from both systems was estimated. The coverage (hospitalization coefficient) was analyzed in relation to the number of inpatient beds per population and the indexes of migration effectiveness. RESULTS The index of migration effectiveness applied to the hospital care demand flow allowed characterizing health regions with flow balance, with high emigration of public and private patients, and with high attraction of public and private patients. CONCLUSIONS There are differences in hospital care access and opportunities among health regions in the state of Sao Paulo, Brazil.