Evaluation of maternal and neonatal hospital care: quality index of completeness

OBJECTIVE Develop an index to evaluate the maternal and neonatal hospital care of the Brazilian Unified Health System.METHODS This descriptive cross-sectional study of national scope was based on the structure-process-outcome framework proposed by Donabedian and on comprehensive health care. Data from the Hospital Information System and the National Registry of Health Establishments were used. The maternal and neonatal network of Brazilian Unified Health System consisted of 3,400 hospitals that performed at least 12 deliveries in 2009 or whose number of deliveries represented 10.0% or more of the total admissions in 2009. Relevance and reliability were defined as criteria for the selection of variables. Simple and composite indicators and the index of completeness were constructed and evaluated, and the distribution of maternal and neonatal hospital care was assessed in different regions of the country.RESULTS A total of 40 variables were selected, from which 27 single indicators, five composite indicators, and the index of completeness of care were built. Composite indicators were constructed by grouping simple indicators and included the following variables: hospital size, level of complexity, delivery care practice, recommended hospital practice, and epidemiological practice. The index of completeness of care grouped the five variables and classified them in ascending order, thereby yielding five levels of completeness of maternal and neonatal hospital care: very low, low, intermediate, high, and very high. The hospital network was predominantly of small size and low complexity, with inadequate child delivery care and poor development of recommended and epidemiological practices. The index showed that more than 80.0% hospitals had a low index of completeness of care and that most qualified heath care services were concentrated in the more developed regions of the country.CONCLUSIONS The index of completeness proved to be of great value for monitoring the maternal and neonatal hospital care of Brazilian Unified Health System and indicated that the quality of health care was unsatisfactory. However, its application does not replace specific evaluations.

Advances and challenges in oral health after a decade of the “Smiling Brazil” Program

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil’s National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people’s participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.

Validity of selected clinical signs and symptoms in diagnosis of Schistosoma mansoni infection

Sensitivity, specificity and positive predictive values of selected clinical signs and symptoms in the diagnosis of Schistosoma mansoni infection were evaluated in 403 individuals (69% of inhabitants over 1 year of age) in an endemic area in Brazil (Divino). Highest sensitivity (13%) was found for blood in stools. Specificity over 90% was found for blood in stools, palpable liver with normal consistency and palpable hardened liver at middle clavicular (MCL) or middle sternal lines (MSL). Hardened liver at MSL (83%) or MCL (75%), and blood in stools (78%) presented higher positive predictive values for S. mansoni infection, while palpable liver with normal consistency at MCL (45%) or MSL (48%) presented smaller values. Enlarged liver without specification of its consistency has been traditionally used as an indicator of the infection in areas where malaria or Kalazar are not endemic. Our results demonstrate that the probability that a person with blood in stools or hardened palpable liver is infected is higher than among those with palpable liver with normal consistency.

Effect of skin colour and selected physical characteristics on Schistosoma mansoni dependent morbidity

The effect of the colour group on the morbidity due to Schistosoma mansoni was examined in two endemic areas situated in the State of Minas Gerais, Brazil. Of the 2773 eligible inhabitants, 1971 (71.1%) participated in the study: 545 (27.6%) were classified as white, 719 (36.5%) as intermediate and 707 (35.9%) as black. For each colour group, signs and symptoms of individuals who eliminated S.mansoni eggs (cases) were compared to those who did not present eggs in the faeces (controls). The odds ratios were adjusted by age, gender, previous treatment for schistosomiasis, endemic area and quality of the household. There was no evidence of a modifier effect of colour on diarrhea, bloody faeces or abdominal pain. A modifier effect of colour on hepatomegaly was evident among those heaviest infected (> 400 epg): the adjusted odds ratios for palpable liver at the middle clavicular and the middle sternal lines were smaller among blacks (5.4 and 6.5, respectively) and higher among whites (10.6 and 12.9) and intermediates (10.4 and 10.1, respectively). These results point out the existence of some degree of protection against hepatomegaly among blacks heaviest infected in the studied areas.

PRESENCE OF ANTI-TOXOCARA ANTIBODIES IN CHILDREN SELECTED AT HOSPITAL UNIVERSITÁRIO, CAMPO GRANDE, MS, BRAZIL

Visceral Larva Migrans syndrome (VLM) results from the presence or migration of helminth larvae in humans, who nonetheless only play the role of paratenic hosts in the helminths' life cycle. In humans, VLM can be caused by larvae of various nematode species, chiefly those of the ascarid Toxocara canis, which can then be found at a variety of body sites, such as the liver, lungs, heart, and brain. Clinical and pathological manifestations depend primarily on larvae number and location, infection duration, reinfection occurrence, and host's immunological condition. Signs and symptoms may range from asymptomatic infection to severe disease. In humans, infection is acquired through ingestion of T. canis eggs present in soil, containing larvae in the infective stage7, 8, 9. Indeed, eggs of Toxocara sp. have been found in sandboxes in several public places in the city of Campo Grande, Mato Grosso do Sul state2. This study was carried out to detect the presence of anti-Toxocara antibodies in children attending the Pediatrics division of Hospital Universitário of Universidade Federal de Mato Grosso do Sul at Campo Grande, Brazil. Over the years 1992-94, 454 serum samples, obtained from children of 5.25 ± 3.28 years of mean age and selected at that hospital on the basis of eosinophil count greater than or equal to 1000/mm3 of blood, were tested for the presence of antibodies by means of the ELISA technique employing Toxocara canis larvae excretory-secretory antigens5. A high prevalence rate for toxocariasis (35.55%) was found, which was observed to be associated with eosinophil levels lower than those usually reported in literature. Furthermore, a higher frequency of positive serology among boys was also observed (13 cases in contrast to only 3 among girls), a result also reported by other authors

ANTI M. leprae IgM ANTIBODY DETERMINATION BY ULTRAMICROIMMUNOENZYMATIC (UMELISA HANSEN) FOR THE DIAGNOSIS AND MONITORING LEPROSY

The relationship between the IgM antibody response, antigenic load as well as the clinical improvement after chemotherapy was studied in order to obtain useful data for the early diagnosis and monitoring leprosy. A level of 82% (94/115) agreement was obtained between IgM UMELISA HANSEN and slitskin smear examination. Discrepant results were observed in 16 patients who showed positive IgM response despite negative by the skin smear examination. In these patients, the IgM response was seen to be associated to the early signal for bacilli recurrence in the skin. In one of these patients the presence of bacilli was demonstrated in the skin, two months after IgM antibodies being detected by UMELISA HANSEN. Also in one of the treated patients positive by both diagnostic techniques, a remarkable decrease in the IgM antibody levels was seen, correlating with a significant clinical improvement. Moreover it was found a direct relationship between the IgM antibody response and bacterial antigenic load, regardless the time elapsed in the disease's evolution.

ANTIGENIC RELATEDNESS OF SELECTED FLAVIVIRUSES: STUDY WITH HOMOLOGOUS AND HETEROLOGOUS IMMUNE MOUSE ASCITIC FLUIDS

The antigenic relationship of 9 flaviviruses, Yellow fever (YF) , Wesselsbron (WSL) , Uganda S (UGS) , Potiskum (POT), West Nile (WN) , Banzi (BAN) , Zika (ZK) , Dengue type 1 (DEN-1) and Dengue type 2 (DEN-2), was assessed by cross-haemagglutination-inhibition (Cross-HI) and cross-complement fixation (Cross-CF) reactions between each of the viruses and their homologous immune mouse ascitic fluids. Titre ratios were calculated using the heterologous and homologous titres. Cross-CF reactions revealed wider antigenic variations among viruses than Cross-HI reactions. There was no significant antigenic variation between WSL, POT and YF viruses using either of those methods. However, definite differences in antigenicity were observed between them and UGS, BAN and ZK viruses. There were no significant differences between UGS, BAN and ZK or between DEN-1 and DEN-2. The serological relationship among flaviviruses is important in establishing diagnosis and epidemiology of these infections in Africa.

The perception, beliefs and practices toward genitourinary schistosomiasis by inhabitants of selected endemic areas (Edo/Delta States) in south-eastern Nigeria

Well-structured questionnaire on the perception, impression and response to genitourinary bilharziasis (Genitourinary schistosomiasis) was administered and explained in local languages: 'Igbo' 'Esan' 'Ezon' Itshekiri and Bini to 33815 inhabitants of selected endemic areas in south-eastern Nigeria from January, 1999 to December, 2001. Out of this number, 3815 (11.3%) were properly filled and returned. About 42.0% of the inhabitants admitted knowledge of the disease, while 14 (0.4%) knew about the aetiologic agent. About 181 (5.0%) who responded, admitted procuring treatment, while 100 (5.0%) declined to seek treatment of any sort. The relationships between water-bodies and human activities, and infection were well discussed. Amongst those who admitted knowledge of the disease but no knowledge of its etiologic agent, declined seeking treatment of any kind, but believe the disease is a natural phenomenon in ones developmental stage and therefore of no morbidity and mortality. Laboratory analysis of urine, faeces, semen and HVS was employed to assess questionnaire responses, and in some cases, physical examination was utilized to augment laboratory analysis in confirming urinal diagnosis. Haematuria was only directly related to egg count in the early part of life. Females were significantly haematuric and excreted more ova than males (p < 0.05). Headache (43.0%) and fever (31.0%) were major clinical signs while sexual pains (22.0%) were the least.

Study of antiretroviral mutants in HIV patients with treatment failures and the effect of risk factors in the virological failures

INTRODUCTION: Information about HIV phenotypes of resistant to available ART and the influence of different risk factors on virological failures (VF) in Costa Rican HIV positive patients prior or during HAART is unknown. MATERIALS AND METHODS: Eighty nine samples, 72 VF and 17 basal (before treatment) were analyzed by examining resistant mutants in reverse transcriptase (RT) and protease (PT) regions using Trugene or LIPA genotyping kits. Sixty eight control patients were selected and relevant information was collected in a questionnaire. RESULTS: Poor adherence, presence of resistant mutations and number of treatment's changes were the only significant factors found (p = 0.006, 0.04 and 0.01 respectively). From 66 sequenced samples, 78%, 50% and 50% showed resistance to NRTI (nucleoside reverse transcriptase inhibitors), NNRT (non-nucleoside reverse transcriptase inhibitors) and PI (protease inhibitors), respectively. The most frequent mutations were M41L, M184V, and T215FY in RT and L62PI, L10FIRV and M36I in PT. DISCUSSION: The most important factor related to treatment response in this study was adherence to treatment. Mutations in RT were related to the treatment failure while the ones found in PT were secondary mutations which have been previously described to influence the selection of primary resistance mutations in these regions. The study reveals the urgency to detect resistant mutations in VF to be considered by physicians for selection of treatment schedule, to analyze basal HIV patients for monitoring of the spread of resistant mutations and the importance to reinforce the adherence in the patients for overall treatment outcome.

Comparison of serology, antigenemia assay and the polymerase chain reaction for monitoring active cytomegalovirus infections in hematopoietic stem cell transplantation patients

Forty-six allogeneic hematopoietic stem cell transplantation (HSCT) patients were monitored for the presence of CMV antibodies, CMV-DNA and CMV antigens after transplantation. Immunoenzymatic serological tests were used to detect IgM and the increase in CMV IgG antibodies (increase IgG), a nested polymerase chain reaction (N-PCR) was used to detect CMV-DNA, and an antigenemia assay (AGM) was used to detect CMV antigens. The presence of CMV-IgM and/or CMV-increase IgG antibodies was detected in 12/46 (26.1%) patients, with a median time between HSCT and the detection of positive serology of 81.5 days. A positive AGM was detected in 24/46 (52.2%) patients, with a median time between HSCT and antigen detection of 62 days. Two or more consecutive positive N-PCR results were detected in 32/46 (69.5%) patients, with a median time between HSCT and the first positive PCR of 50.5 days. These results confirmed that AGM and mainly PCR are superior to serology for the early diagnosis of CMV infection. Six patients had CMV-IgM and/or CMV-increase IgG with a negative AGM (five cases) or N-PCR assay (one case). In five of these cases the serological markers were detected during the first 100 days after HSCT, the period of highest risk. These findings support the idea that serology may be useful for monitoring CMV infections in HSCT patients, especially when PCR is unavailable.

Characterization of a clone from an adult worm cDNA library selected with anti-Schistosoma mansoni human antibodies dissociated from immune complexes: a preliminary report

Considering the scarcity of defined antigens, actually useful and reliable for use in the field studies, we propose an alternative method for selection of cDNA clones with potential use in the diagnosis of schistosomiasis. Human antibodies specific to a protein fraction of 31/32 kDa (Sm31/32), dissociated from immune complexes, are used for screening of clones from an adult worm cDNA library. Partial sequencing of five clones, selected through this strategy, showed to be related to Schistosoma mansoni: two were identified as homologous to heat shock protein 70, one to glutathione S-transferase, one to homeodomain protein, and one to a previously described EST (expressed sequence tag) of S. mansoni. This last clone was the most consistently reactive during the screening process with the anti-Sm31/32 antibodies dissociated from the immune complexes. The complete sequence of this clone was obtained and the translation data yielded only one ORF (open reading frame) that code for a protein with 57 amino acids. Based on this amino acid sequence two peptides were chemically synthesized and evaluated separately against a pool of serum samples from schistosomiasis patients and non-schistosomiasis individuals. Both peptides showed strong reactivity only against the positive pool, suggesting that these peptides may be useful as antigens for the diagnosis of schistosomiasis mansoni.

Seroprevalence of selected viral, bacterial and parasitic infections among inpatients of a public psychiatric hospital of Mexico

We sought to determine the frequency of serological markers of selected infections in a population of psychiatric patients in Durango City, Mexico, and to determine whether there are any epidemiological characteristics of the subjects associated with the infections. One hundred and five inpatients of a public psychiatric hospital of Durango were examined for HBsAg, anti-HCV antibodies, anti-HIV antibodies, anti-Brucella antibodies, rapid plasma reagin and anti-Cysticercus antibodies by commercially available assays. Anti-Cysticercus antibodies were confirmed by Western blot and HBsAg by neutralization assay. Epidemiological data from each participant were also obtained. Seroprevalences of HBsAg, anti-HCV, anti-HIV, anti-Brucella, rapid plasma reagin and anti-Cysticercus antibodies found were 0.0%, 4.8%, 0.9%, 0.0%, 1.9%, and 0.9%, respectively. Overall, 9 (8.6%) inpatients showed seropositivity to any infection marker. We concluded that our psychiatric inpatients have serological evidence of a number of infections. HCV is an important pathogen among our psychiatric inpatients. Health care strategies for prevention and control of infections in Mexican psychiatric patients should be considered.

In vitro antimalarial activity and cytotoxicity of some selected cuban medicinal plants

Terrestrial plants have been demonstrated to be sources of antimalarial compounds. In Cuba, little is known about antimalarial potentials of plant species used as medicinals. For that reason, we evaluated the antimalarial activity of 14 plant species used in Cuba as antimalarial, antipyretic and/or antiparasitic. Hydroalcoholic extracts were prepared and tested in vitro for the antimalarial activity against Plasmodium falciparum Ghana strain and over human cell line MRC-5 to determine cytotoxicity. Parasite multiplication was determined microscopically by the direct count of Giemsa stained parasites. A colorimetric assay was used to quantify cytotoxicity. Nine extracts showed IC50 values lower than 100 µg/mL against P. falciparum, four extracts were classified as marginally active (SI < 4), one as partially active (Parthenium hysterophorus) exhibiting SI equal to 6.2 and two extracts as active (Bambusa vulgaris and Punica granatum), showing SI > 10. B. vulgaris showed the most potent and specific antiplasmodial action (IC50 = 4.7 µg/mL, SI = 28.9). Phytochemical characterization of active extracts confirmed the presence of triterpenoids in B. vulgaris and polar compounds with phenol free groups and fluorescent metabolites in both extracts as major phytocompounds, by thin layer chromatography. In conclusion, antimalarial use of B. vulgaris and P. hysterophorus was validated. B. vulgaris and P. granatum extracts were selected for follow-up because of their strong antimalarial activity.

Serological monitoring of a Toxoplasma infection after hematopoietic stem cell transplantation

We report a primary response to Toxoplasma gondii following a hematopoietic stem cell transplantation in a patient with multiple myeloma. The primary response to T. gondii was supported by IgM, IgG and IgA seroconversion. The patient was promptly treated and there were no complications related to toxoplasmosis in the subsequent months.