Economic burden of expected epidemiological changes in diseases related to tobacco, Mexico

OBJECTIVE: To determine health care costs and economic burden of epidemiological changes in diseases related to tobacco consumption. METHODS: A time-series analysis in Mexico (1994-2005) was carried out on seven health interventions: chronic obstructive pulmonary diseases, lung cancer with and without surgical intervention, asthma in smokers and non-smokers, full treatment course with nicotine gum, and full treatment course with nicotine patch. According with Box-Jenkins methodology, probabilistic models were developed to forecast the expected changes in the epidemiologic profile and the expected changes in health care services required for selected interventions. Health care costs were estimated following the instrumentation methods and validated with consensus technique. RESULTS: A comparison of the economic impact in 2006 vs. 2008 showed 20-90% increase in expected cases depending on the disease (p<0.05), and 25-93% increase in financial requirements (p<0.01). The study data suggest that changes in the demand for health services for patients with respiratory diseases related to tobacco consumption will continue showing an increasing trend. CONCLUSIONS: In economic terms, the growing number of cases expected during the study period indicates a process of internal competition and adds an element of intrinsic competition in the management of preventive and curative interventions. The study results support the assumption that if preventive programs remain unchanged, the increasing demands for curative health care may cause great financial and management challenges to the health care system of middle-income countries like Mexico.

Perspectives on access to in vitro fertilization in Portugal

OBJECTIVE: To analyze users' reasons for choosing in vitro fertilization treatment in public or private services and to identify their suggestions for improving fertility treatment. METHODS: A qualitative study using an interpretative approach was conducted. Fifteen semi-structured interviews were conducted with patients undergoing in vitro fertilization treatment (nine women, one man and five couples) at home or at their workplace in the districts of Viana do Castelo, Braga, Porto and Lisbon, Portugal, between July 2005 and February 2006. RESULTS: Users evaluated access to in vitro fertilization treatment in public and private services based mainly on their individual experiences and called for more access to less costly, faster and friendlier care with suitable facilities, appropriate time management and caring medical providers. These perceptions were also associated with views on the need for fighting stigmatization of infertility, protecting children's rights and guaranteeing sustainability of health care system. Interviewees sought to balance reduced waiting time and more attentive care with costs involved. The choice of services depended on the users' purchase power and place of residence and availability of attentive care. CONCLUSIONS: Current national policies on in vitro fertilization treatment meet user's demands of promoting access to, and quality, availability and affordability of in vitro fertilization treatment. However, their focus on legal regulation and technical-scientific aspects contrasts with the users' emphasis on reimbursement, insurance coverage and focus on emotional aspects of the treatment. The study showed these policies should ensure insurance coverage, participation of user representatives in the National Council for Assisted Reproductive Technology, promotion of infertility research and certification of fertility laboratories.

Access to medicines for acute illness in middle income countries in Central America

OBJECTIVE : To analyze the main predictors of access to medicines for persons who experienced acute health conditions. METHODS : This was a cross-sectional analytic study, based on data from household surveys. We examined the predictors of: (1) seeking care for acute illness in the formal health care system and (2) obtaining all medicines sought for the acute condition. RESULTS : The significant predictors of seeking health care for acute illnesses were urban geographic location, head of household with secondary school education or above, age under 15, severity of illness perceived by the respondent, and having health insurance. The most important predictor of obtaining full access to medicines was seeking care in the formal health care system. People who sought care in the formal system were three times more likely to receive all the medicines sought (OR 3.0, 95%CI 2.3;4.0). For those who sought care in the formal health system, the strongest predictors of full access to medicines were seeking care in the private sector, having secondary school education or above, and positive perceptions of quality of health care and medicines in public sector health facilities. For patients who did not seek care in the formal health system, full access to medicines was more likely in Honduras or Nicaragua than in Guatemala. Urban geographic location, higher economic status, and male gender were also significant predictors. CONCLUSIONS : A substantial part of the population in these three countries sought and obtained medicines outside of the formal health care system, which may compromise quality of care and pose a risk to patients. Determinants of full access to medicines inside and outside the formal health care system differ, and thus may require different strategies to improve access to medicines. 

Federalism and health policy: the intergovernmental committees in Brazil

OBJECTIVE To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states.METHODS The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low.RESULTS Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees’ ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast.CONCLUSIONS The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.

Is severe visceral leishmaniasis a systemic inflammatory response syndrome? A case control study

INTRODUCTION: The objective of the study is to identify the main risk factors for death by New World visceral leishmaniasis and establish a coherent pathogenic substrate of severe disease based on clinical findings. METHODS: Seventy-six deceased inpatients and 320 successfully treated inpatients with VL were studied in a case control study. RESULTS: Bacterial infection and bleeding were mutually exclusive events leading to death. Five risk factors were unique for death by bacterial infection (malnutrition, pulmonary rales, severe anemia, severe absolute neutropenia and higher neutrophil count), while another six were unique for death by bleeding (jaundice, severe relative neutropenia, severe thrombocytopenia, liver injury, kidney failure, higher bone marrow parasite load). Bacterial infection, bleeding, severe anemia, diarrhea, dyspnea, edema, jaundice and bone marrow parasite load were the main syndromes of visceral leishmaniasis among successfully treated patients. CONCLUSIONS: The data support the idea that bacterial infections are due to immune paralysis. Broad organ and system involvement is plausibly due to the high production of proinflammatory cytokines, whose actions fit well with visceral leishmaniasis. The syndromes and causative mediators are typical of a slowly developing systemic inflammatory response syndrome.

Epidemiologic aspects of toxoplasmosis and evaluation of its seroprevalence in pregnant women

INTRODUCTION: The aim of the present study was to analyze the exposure to risk factors for toxoplasmosis disease and the level of knowledge in pregnant women who were treated by the Public Health Care System (SUS) from October 2007 to September 2008 in Divinópolis City, Brazil. METHODS: We analyzed 2,136 prenatal exams of pregnant women that were treated from October 2007 to September 2008. RESULTS: Out of the 2,136 pregnant women evaluated, 200 answered a quantitative questionnaire; 49.5% were seropositive for immunoglobulin (Ig) G and 3.6% for IgM. Comparative analysis of congenital toxoplasmosis cases were evaluated in 11 regions and showed an irregular distribution (p < 0.01). This difference was also observed among the pregnant women observed in each location. The results from the questionnaire show that 93% of the pregnant women had no knowledge about toxoplasmosis, and 24% presented with positive serology, but no clinical manifestation. Analysis for pregnant IgG-positive women and the presence of pets showed a statistically significant correlation (p < 0.05), suggesting that the transmission of this disease might occur in the domestic environment. CONCLUSIONS: We suggest the implementation of a triage program for pregnant women and health education to encourage their use of SUS services.

Lymnaea columella in northern Brazil

The occurrence of a mollusc of the family Lymnaeidae is recorded for the first time in Brazil north of parallel 15ºS, as a result of the finding of Lymnaea columella in Manus and Benjamin Constant, state of Amazonas. A description is given of its shell, renal organ, genital system and radula, pointing to the morphological characteristics of diagnostic value to separate it from two other species previously studied by the author, Lymnaea viatrix and L. rupestris, which also occur in Brazil.

Lymnaea cousini Jousseaume, 1887, from Ecuador (Gastropoda: Lymnaeidae)

A description is given of the shell, renal organ, reproductive system and radula of topotypic specimens of Lymnaea cousini Jousseaume, 1887. A diagnosis between it and four other lymnaeids which also occur in South America and were previously studied by the author (L. columella, L. diaphana, L. viatrix and L. rupestris) is presented.

Daughter of time: the postmodern midwife (Part 2)

Any effort to make sense of the complexities of contemporary midwifery must deal not only with biomedical and governmental power structures but also with the definitions such structures impose upon midwives and the ramifications of these definitions within and across national and cultural borders. The international definition of a midwife requires graduations from a government-recognized educational program. Those who have not are not considered midwives but are labeled traditional birth attendants. Since there are myriad local names for midwives in myriad languages, the impact of this naming at local levels can be hard to assess. But on the global scale, the ramifications of the distinction between midwives who meet the international definition and those who do not have been profound. Those who do are incorporated into the health care system. Those who do not remain outside of it, and suffer multiple forms of discrimination as a result.

Desempenho de índices de gravidade para estimar risco de morte em Unidades de Terapia Intensiva

O Simplified Acute Physiology Score II (SAPS II) e o Logistic Organ Dysfunction System (LODS) são instrumentos utilizados para classificar pacientes internados em Unidades de Terapia Intensiva (UTI) conforme a gravidade e o risco de morte, sendo um dos parâmetros da qualidade da assistência de enfermagem. Este estudo teve por objetivo avaliar e comparar as performances do SAPS II e do LODS para predizer mortalidade de pacientes admitidos em UTI. Participaram do estudo 600 pacientes de quatro diferentes UTIs de São Paulo, Brasil. A curva Receiver Operator Characteristic (ROC) foi utilizada para comparar o desempenho discriminatório dos índices. Os resultados foram: as áreas sob a curva do LODS (0.69) e do SAPS II (0.71) apresentaram moderada capacidade discriminatória para predizer mortalidade. Não foi encontrada diferença estatisticamente significativa entre as áreas (p=0,26). Concluiu-se que houve equivalência entre SAPS II e LODS para estimar risco de morte de pacientes em UTI.

The mental health of graduate students at the Federal University of São Paulo: a preliminary report

We present data regarding the care provided to graduate level health professionals at the mental health center of the Federal University of São Paulo. From September 1996 to September 2003, 146 graduate students (99 in the Master's degree program and 47 in the Doctoral program) were attended. This population was predominantly female (68.5%), with a mean (± SD) age of 28.6 ± 4.42 years, not married (71.9%). Most of the subjects were professionals who had not graduated from the Federal University (78.1%). The students who sought help for psychological and/or psychiatric problems were classified into two categories: situational-adaptive crises and psychopathological crises. The main diagnoses were depression and anxiety disorders (44%) causing 4.5% of the subjects to be temporarily suspended from their graduate studies; 19.2% reported that they had used psychotropic drugs within the previous month, and 47.9% referred to sleep disturbances. Suicidal tendencies were mentioned by 18% of those interviewed. Students with emotional disturbances and academic dysfunctions should be recognized at an early stage, and it is fundamental for them to have access to mental health programs that provide formal, structured and confidential care. Thus, it is important that professors and advisors in graduate programs build a warm and affective learning environment. If we consider the expressive growth in Brazilian scientific production resulting from the implementation of an extensive national system of graduate education, it is important to focus efforts on enhancing and upgrading the mental health care system.

Myosin light chain kinase is necessary for post-shock mesenteric lymph drainage enhancement of vascular reactivity and calcium sensitivity in hemorrhagic-shocked rats

Vascular hyporeactivity is an important factor in irreversible shock, and post-shock mesenteric lymph (PSML) blockade improves vascular reactivity after hemorrhagic shock. This study explored the possible involvement of myosin light chain kinase (MLCK) in PSML-mediated vascular hyporeactivity and calcium desensitization. Rats were divided into sham (n=12), shock (n=18), and shock+drainage (n=18) groups. A hemorrhagic shock model (40±2 mmHg, 3 h) was established in the shock and shock+drainage groups. PSML drainage was performed from 1 to 3 h from start of hypotension in shock+drainage rats. Levels of phospho-MLCK (p-MLCK) were determined in superior mesenteric artery (SMA) tissue, and the vascular reactivity to norepinephrine (NE) and sensitivity to Ca2+ were observed in SMA rings in an isolated organ perfusion system. p-MLCK was significantly decreased in the shock group compared with the sham group, but increased in the shock+drainage group compared with the shock group. Substance P (1 nM), an agonist of MLCK, significantly elevated the decreased contractile response of SMA rings to both NE and Ca2+ at various concentrations. Maximum contractility (Emax) in the shock group increased with NE (from 0.179±0.038 to 0.440±0.177 g/mg, P<0.05) and Ca2+ (from 0.515±0.043 to 0.646±0.096 g/mg, P<0.05). ML-7 (0.1 nM), an inhibitor of MLCK, reduced the increased vascular response to NE and Ca2+ at various concentrations in the shock+drainage group (from 0.744±0.187 to 0.570±0.143 g/mg in Emax for NE and from 0.729±0.037 to 0.645±0.056 g/mg in Emax for Ca2+, P<0.05). We conclude that MLCK is an important contributor to PSML drainage, enhancing vascular reactivity and calcium sensitivity in rats with hemorrhagic shock.

Contractile profile of esophageal and gastric fundus strips in experimental doxorubicin-induced esophageal atresia

Esophageal atresia (EA) is characterized by esophageal and gastric motility changes secondary to developmental and postsurgical damage. This study evaluated the in vitro contractile profile of the distal esophagus and gastric fundus in an experimental model of EA induced by doxorubicin (DOXO). Wistar pregnant rats received DOXO 2.2 mg/kg on the 8th and 9th gestational days. On day 21.5, fetuses were collected, sacrificed, and divided into groups: control, DOXO without EA (DOXO-EA), and DOXO with EA (DOXO+EA). Strips from the distal esophagus and gastric fundus were mounted on a wire myograph and isolated organ-bath system, respectively, and subjected to increasing concentrations of carbamylcholine chloride (carbachol, CCh). The isolated esophagus was also stimulated with increasing concentrations of KCl. In esophagus, the concentration-effect curves were reduced in response to CCh in the DOXO+EA and DOXO-EA groups compared to the control group (P<0.05). The maximum effect values (Emax) for DOXO+EA and DOXO-EA were significantly lower than control (P<0.05), but the half-maximal effective concentration (EC50) values were not significantly different when the three groups were compared (P>0.05). In response to KCl, the distal esophagus samples in the three groups were not statistically different with regard to Emax or EC50 values (P>0.05). No significant difference was noted for EC50 or Emax values in fundic strips stimulated with CCh (P>0.05). In conclusion, exposure of dams to DOXO during gestation inhibited the contractile behavior of esophageal strips from offspring in response to CCh but not KCl, regardless of EA induction. The gastric fundus of DOXO-exposed offspring did not have altered contractile responsiveness to cholinergic stimulation.

Hospitalization of older adults due to ambulatory care sensitive conditions

OBJECTIVE To analyze the temporal evolution of the hospitalization of older adults due to ambulatory care sensitive conditions according to their structure, magnitude and causes. METHODS Cross-sectional study based on data from the Hospital Information System of the Brazilian Unified Health System and from the Primary Care Information System, referring to people aged 60 to 74 years living in the state of Rio de Janeiro, Souhteastern Brazil. The proportion and rate of hospitalizations due to ambulatory care sensitive conditions were calculated, both the global rate and, according to diagnoses, the most prevalent ones. The coverage of the Family Health Strategy and the number of medical consultations attended by older adults in primary care were estimated. To analyze the indicators’ impact on hospitalizations, a linear correlation test was used. RESULTS We found an intense reduction in hospitalizations due to ambulatory care sensitive conditions for all causes and age groups. Heart failure, cerebrovascular diseases and chronic obstructive pulmonary diseases concentrated 50.0% of the hospitalizations. Adults older than 69 years had a higher risk of hospitalization due to one of these causes. We observed a higher risk of hospitalization among men. A negative correlation was found between the hospitalizations and the indicators of access to primary care. CONCLUSIONS Primary healthcare in the state of Rio de Janeiro has been significantly impacting the hospital morbidity of the older population. Studies of hospitalizations due to ambulatory care sensitive conditions can aid the identification of the main causes that are sensitive to the intervention of the health services, in order to indicate which actions are more effective to reduce hospitalizations and to increase the population’s quality of life.

Hospitalizations for ambulatory care-sensitive conditions, Minas Gerais, Southeastern Brazil, 2000 and 2010

OBJECTIVE To analyze hospitalization rates and the proportion of deaths due to ambulatory care-sensitive hospitalizations and to characterize them according to coverage by the Family Health Strategy, a primary health care guidance program. METHODS An ecological study comprising 853 municipalities in the state of Minas Gerais, under the purview of 28 regional health care units, was conducted. We used data from the Hospital Information System of the Brazilian Unified Health System. Ambulatory care-sensitive hospitalizations in 2000 and 2010 were compared. Population data were obtained from the demographic censuses. RESULTS The number of ambulatory care-sensitive hospitalizations declined from 20.75/1,000 inhabitants [standard deviation (SD) = 10.42) in 2000 to 14.92/thousand inhabitants (SD = 10.04) in 2010 Heart failure was the most frequent cause in both years. Hospitalizations rates for hypertension, asthma, and diabetes mellitus, decreased, whereas those for angina pectoris, prenatal and birth disorders, kidney and urinary tract infections, and other acute infections increased. Hospitalization durations and the proportion of deaths due to ambulatory care-sensitive hospitalizations increased significantly. CONCLUSIONS Mean hospitalization rates for sensitive conditions were significantly lower in 2010 than in 2000, but no correlation was found with regard to the expansion of the population coverage of the Family Health Strategy. Hospitalization rates and proportion of deaths were different between the various health care regions in the years evaluated, indicating a need to prioritize the primary health care with high efficiency and quality.