Cost of schizophrenia: direct costs and use of resources in the State of São Paulo

OBJECTIVE: To estimate the direct costs of schizophrenia for the public sector. METHODS: A study was carried out in the state of São Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. RESULTS: Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US$191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. CONCLUSIONS: Most schizophrenia patients in the state of São Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.

Integrated Management of Childhood Illness: efficiency of primary health in Northeast Brazil

OBJECTIVE: The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. METHODS: Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. RESULTS: Facilities providing strategy-based care had significantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72% of children were correctly managed compared with 56% in comparison facilities (p=0.001). The cost per child managed correctly was US$13.20 versus US$21.05 in the strategy and comparison municipalities, respectively, after standardization for population size. CONCLUSIONS: The strategy improves the efficiency of primary facilities in Northeastern Brazil. It leads to better health outcomes at no extra cost.

Care cost for pregnant and parturient women with diabetes and mild hyperglycemia

OBJECTIVE: To compare inpatient and outpatient care costs for pregnant/parturient women with diabetes and mild hyperglycemia. METHODS: A prospective observational quantitative study was conducted in the Perinatal Diabetes Center in the city of Botucatu, Southeastern Brazil, between 2007 and 2008. Direct and indirect costs and disease-specific costs (medications and tests) were estimated. Thirty diet-treated pregnant women with diabetes were followed up on an outpatient basis, and 20 who required insulin therapy were hospitalized. RESULTS: The cost of diabetes disease (prenatal and delivery care) was US$ 3,311.84 for inpatients and US$ 1,366.04 for outpatients. CONCLUSIONS: Direct and indirect costs as well as total prenatal care cost were higher for diabetic inpatients while delivery care costs and delivery-postpartum hospitalization were similar. Prenatal and delivery-postpartum care costs were higher for these patients compared to those paid by Brazilian National Health System.

Hydatid cysts in muscles: clinical manifestations, diagnosis, and management of this atypical presentation

ABSTRACTINTRODUCTION: Hydatid cysts are rarely detected in muscle tissue (0.7-0.9%), even in endemic countries. The aim of this study was to present information regarding the clinical manifestations, diagnosis, and management of muscle echinococcosis.METHODS: Twenty-two patients with hydatid cysts in the muscle were followed from January 2006 through December 2014.RESULTS: Twenty-four sites of muscle involvement were observed in the 22 patients. Fifteen (68%) of our patients were women, while seven (32%) were men. The mean age was 28.1 ± 15.4 (6-61) years. The most frequent locations were the thigh (27.2%) and the paravertebral region (13.6%). Most patients reported a painless slow-growing mass with normal overlying skin. Most (90.2%) cases were treated by surgical excision and fine-needle aspiration.CONCLUSIONS: Primary muscle hydatid cyst should be considered in the differential diagnosis in cystic masses of the muscular system without pain and localized enlargement of soft tissue, especially in endemic areas. Hydatid cyst should be investigated using serological tests and imaging modalities. If possible, total surgical excision of hydatid cyst in the muscle should be performed.

Cost of drugs manufactured by the University Hospital - role of the Central Pharmacy

The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clinicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

Changes in Medical Management after Coronary CT Angiography

AbstractIntroduction:Coronary computed tomography angiography (CCTA) allows for non-invasive coronary artery disease (CAD) phenotyping. There are still some uncertainties regarding the impact this knowledge has on the clinical care of patients.Objective:To determine whether CAD phenotyping by CCTA influences clinical decision making by the prescription of cardiovascular drugs and their impact on non-LDL cholesterol (NLDLC) levels.Methods:We analysed consecutive patients from 2008 to 2011 submitted to CCTA without previous diagnosis of CAD that had two serial measures of NLDLC, one up to 3 months before CCTA and the second from 3 to 6 months after.Results:A total of 97 patients were included, of which 69% were men, mean age 64 ± 12 years. CCTA revealed that 18 (18%) patients had no CAD, 38 (39%) had non-obstructive (< 50%) lesions and 41 (42%) had at least one obstructive ≥ 50% lesion. NLDLC was similar at baseline between the grups (138 ± 52 mg/dL vs. 135 ± 42 mg/dL vs. 131 ± 44 mg/dL, respectively, p = 0.32). We found significative reduction in NLDLC among patients with obstrctive lesions (-18%, p = 0.001). We also found a positive relationship between clinical treatment intensification with aspirin and cholesterol reducing drugs and the severity of CAD.Conclusion:Our data suggest that CCTA results were used for cardiovascular clinical treatment titration, with especial intensification seen in patients with obstructive ≥50% CAD.

Association between Spirituality and Adherence to Management in Outpatients with Heart Failure

Abstract Background: Spirituality may influence how patients cope with their illness. Objectives: We assessed whether spirituality may influence adherence to management of outpatients with heart failure. Methods: Cross sectional study enrolling consecutive ambulatory heart failure patients in whom adherence to multidisciplinary treatment was evaluated. Patients were assessed for quality of life, depression, religiosity and spirituality utilizing validated questionnaires. Correlations between adherence and psychosocial variables of interest were obtained. Logistic regression models explored independent predictors of adherence. Results: One hundred and thirty patients (age 60 ± 13 years; 67% male) were interviewed. Adequate adherence score was observed in 38.5% of the patients. Neither depression nor religiosity was correlated to adherence, when assessed separately. Interestingly, spirituality, when assessed by both total score sum (r = 0.26; p = 0.003) and by all specific domains, was positively correlated to adherence. Finally, the combination of spirituality, religiosity and personal beliefs was an independent predictor of adherence when adjusted for demographics, clinical characteristics and psychosocial instruments. Conclusion: Spirituality, religiosity and personal beliefs were the only variables consistently associated with compliance to medication in a cohort of outpatients with heart failure. Our data suggest that adequately addressing these aspects on patient’s care may lead to an improvement in adherence patterns in the complex heart failure management.

Biology and management of the masked chafer Cyclocephala distincta Burmeister (Melolonthidae, Dynastinae, Cyclocephalini)

Adults of Cyclocephala distincta are flower visitors of Neotropical palms (Arecaceae) and commonly found in the Atlantic Forest of Pernambuco, Brazil. Males and females were collected in the wild and subjected to captive rearing and breeding. The egg hatching rate, the life cycle, longevity of immatures and adults, and oviposition parameters in captivity were analyzed. The average duration of the life cycle of C. distinctawas 108.2 days (n = 45). The egg stage lasted on average 10.9 days, and the egg-hatching rate was 73.9%. The immature stage lasted on average 93.4 days. The larvae stage exhibited negative phototaxis, and the size of their head capsules increased at a constant rate of 1.6 between instars, following Dyar's rule. The average duration of the first instar was 24.8 days (n = 88), whereas the second and third instars lasted for 17.2 (n = 76) and 40.4 (n = 74) days respectively, and survival rates were 21.6%, 86.4% and 97.4%. The pre-pupal stage was recorded, and pupal chambers were built before pupation. The average number of eggs laid per female was 15.5, the total reproductive period lasted for 3.3 days, and the total fertility was 81.2%. Adults that emerged in captivity exhibited an average longevity of 18.9 days. Adult C. distincta exhibited thanatosis behavior upon manipulation, a strategy observed for the first time in Cyclocephala.

Variability of apparently homogeneous soilscapes in São Paulo state, Brazil: II. quality of soil maps

The quality of semi-detailed (scale 1:100.000) soil maps and the utility of a taxonomically based legend were assessed by studying 33 apparently homogeneous fields with strongly weathered soils in two regions in São Paulo State: Araras and Assis. An independent data set of 395 auger sites was used to determine purity of soil mapping units and analysis of variance within and between mapping units and soil classification units. Twenty three soil profiles were studied in detail. The studied soil maps have a high purity for some legend criteria, such as B horizon type (> 90%) and soil texture class (> 80%). The purity for the "trophic character" (eutrophic, dystrophic, allic) was only 55% in Assis. It was 88% in Araras, where many soil units had been mapped as associations. In both regions, the base status of clay-textured soils was generally better than suggested by the maps. Analysis of variance showed that mapping was successful for "durable" soil characteristics such as clay content (> 80% of variance explained) and cation exchange capacity (≥ 50% of variance explained) of 0-20 and 60-80 cm layers. For soil characteristics that are easily modified by management, such as base saturation of the 0-20 cm layer, the maps had explained very little (< 15%) of the total variance in the study areas. Intermediate results were obtained for base saturation of the 60-80 cm layer (56% in Assis; 42% in Araras). Variance explained by taxonomic groupings that formed the basis for the legend of the soil maps was similar to, often even smaller than, variance explained by mapping units. The conclusion is that map boundaries have been very carefully located, but descriptions of mapping units could be improved. In future mappings, this could possibly be done at low cost by (a) bulk sampling to remove short range variation and enhance visualization of spatial patterns at distances > 100 m; (b) taking advantage of correlations between easily measured soil characteristics and chemical soil properties and, (c) unbending the link between legend criteria and a taxonomic system. The maps are well suited to obtain an impression of land suitability for high-input farming. Additional field work and data on former land use/management are necessary for the evaluation of chemical properties of surface horizons.

Effects of different management systems on porosity of oxisols in Paraná, Brazil

Soils play a fundamental role in the production of human foods. The Oxisols in the state of Paraná are among the richest and most productive soils in Brazil, but degradation and low porosity are frequently documented, due to intensive farming involving various management strategies and the application of high-tech solutions. This study aims to investigate changes in the porosity of two Red Oxisols (Latossolos Vermelhos), denoted LVef (eutroferric) and LVdf (dystroferric) under conventional and no-tillage soil management, with a succession of annual crops of soybean, maize and wheat over a continuous period of more than 20 years. After describing the soil profiles under native forest, no-tillage management and conventional tillage using the crop profile method, deformed and non-deformed soil samples were collected from the volumes most compacted by human intervention and the physical, chemical and mineralogical properties analyzed. The various porosity classes (total pore volume, inter-aggregate porosity between channels and biological cavities) and intra-aggregate porosity (determined in 10 cm³ saturated clods subjected to a pressure of -10 kPa to obtain a pore volume with a radius (r eq), > 15 μm and < 15 μm). The results showed that the effects of no-tillage farming on porosity are more pronounced in both soil types. Porosity of the LVdf was higher than pf the LVef soil, whatever the management type. In the LVdf soil, only pores with a radius of > 15 μm were affected by farming whereas in the LVef soil, pores with a radius of < 15 μm were affected as well.

Labile and stable fractions of soil organic matter under management systems and native cerrado

Soil organic matter can be analyzed on the basis of the different fractions. Changes in the levels of organic matter, caused by land use, can be better understood by alterations in the different compartments. The aim of this study was to evaluate the effect of different management systems on the labile and stable organic matter of a dystrophic Red Latosol (Oxisol). The following properties were determined: total organic C and total N (TOC and TN), particulate organic C and particulate N (POC and PN), organic C and N mineral-associated (MOC and NM) and particulate organic C associated with aggregate classes (POCA). Eight treatments were used: seven with soil management systems and one with native Cerrado as a reference. The experiment was designed to study the dynamics of systems of tillage and crop rotation, alternating in time and space. The experimental design was a randomized block design with three replications. The soil samples were collected from five depths: 0-5, 5-10, 10-20, 20-30 and 30-40 cm. Changes in organic C by land use occurred mainly in the fraction of particulate organic matter (> 53 mm). Proper management of grazing promoted increased levels of particulate organic matter by association with larger aggregates (2-8 mm), demonstrating the importance of the formation of this aggregate class for C protection in pasture.

Soil aggregation under different management systems

Considering that the soil aggregation reflects the interaction of chemical, physical and biological soil factors, the aim of this study was evaluate alterations in aggregation, in an Oxisol under no-tillage (NT) and conventional tillage (CT), since over 20 years, using as reference a native forest soil in natural state. After analysis of the soil profile (cultural profile) in areas under forest management, samples were collected from the layers 0-5, 5-10, 10-20 and 20-40 cm, with six repetitions. These samples were analyzed for the aggregate stability index (ASI), mean weighted diameter (MWD), mean geometric diameter (MGD) in the classes > 8, 8-4, 4-2, 2-1, 1-0.5, 0.5-0.25, and < 0.25 mm, and for physical properties (soil texture, water dispersible clay (WDC), flocculation index (FI) and bulk density (Bd)) and chemical properties (total organic carbon - COT, total nitrogen - N, exchangeable calcium - Ca2+, and pH). The results indicated that more intense soil preparation (M < NT < PC) resulted in a decrease in soil stability, confirmed by all stability indicators analyzed: MWD, MGD, ASI, aggregate class distribution, WDC and FI, indicating the validity of these indicators in aggregation analyses of the studied soil.

Soil physical properties and grape yield influenced by cover crops and management systems

The use of cover crops in vineyards is a conservation practice with the purpose of reducing soil erosion and improving the soil physical quality. The objective of this study was to evaluate cover crop species and management systems on soil physical properties and grape yield. The experiment was carried out in Bento Gonçalves, RS, Southern Brazil, on a Haplic Cambisol, in a vineyard established in 1989, using White and Rose Niagara grape (Vitis labrusca L.) in a horizontal, overhead trellis system. The treatments were established in 2002, consisting of three cover crops: spontaneous species (SS), black oat (Avena strigosa Schreb) (BO), and a mixture of white clover (Trifolium repens L.), red clover (Trifolium pratense L.) and annual rye-grass (Lolium multiflorum L.) (MC). Two management systems were applied: desiccation with herbicide (D) and mechanical mowing (M). Soil under a native forest (NF) area was collected as a reference. The experimental design consisted of completely randomized blocks, with three replications. The soil physical properties in the vine rows were not influenced by cover crops and were similar to the native forest, with good quality of the soil structure. In the inter-rows, however, there was a reduction in biopores, macroporosity, total porosity and an increase in soil density, related to the compaction of the surface soil layer. The M system increased soil aggregate stability compared to the D system. The treatments affected grapevine yield only in years with excess or irregular rainfall.

Effect of management systems and cover crops on organic matter dynamics of soil under vegetables

Vegetable production in conservation tillage has increased in Brazil, with positive effects on the soil quality. Since management systems alter the quantity and quality of organic matter, this study evaluated the influence of different management systems and cover crops on the organic matter dynamics of a dystrophic Red Latosol under vegetables. The treatments consisted of the combination of three soil tillage systems: no-tillage (NT), reduced tillage (RT) and conventional tillage (CT) and of two cover crops: maize monoculture and maize-mucuna intercrop. Vegetables were grown in the winter and the cover crops in the summer for straw production. The experiment was arranged in a randomized block design with four replications. Soil samples were collected between the crop rows in three layers (0.0-0.05, 0.05-0.10, and 0.10-0.30 m) twice: in October, before planting cover crops for straw, and in July, during vegetable cultivation. The total organic carbon (TOC), microbial biomass carbon (MBC), oxidizable fractions, and the carbon fractions fulvic acid (C FA), humic acid (C HA) and humin (C HUM) were determined. The main changes in these properties occurred in the upper layers (0.0-0.05 and 0.05-0.10 m) where, in general, TOC levels were highest in NT with maize straw. The MBC levels were lowest in CT systems, indicating sensitivity to soil disturbance. Under mucuna, the levels of C HA were lower in RT than NT systems, while the C FA levels were lower in RT than CT. For vegetable production, the C HUM values were lowest in the 0.05-0.10 m layer under CT. With regard to the oxidizable fractions, the tillage systems differed only in the most labile C fractions, with higher levels in NT than CT in the 0.0-0.05 m layer in both summer and winter, with no differences between these systems in the other layers. The cabbage yield was not influenced by the soil management system, but benefited from the mulch production of the preceding maize-mucuna intercrop as cover plant.

The effects of land use and soil management on the physical properties of an Oxisol in Southeast Brazil

Soils of the tropics are prone to a decrease in quality after conversion from native forest (FO) to a conventional tillage system (CT). However, the adoption of no-tillage (NT) and complex crop rotations may improve soil structural quality. Thus, the aim of this study was to evaluate the physical properties of an Oxisol under FO, CT, and three summer crop sequences in NT: continuous corn (NTcc), continuous soybean (NTcs), and a soybean/corn rotation (NTscr). Both NT and CT decreased soil organic carbon (SOC) content, SOC stock, water stable aggregates (WSA), geometric mean diameter (GMD), soil total porosity (TP), macroporosity (MA), and the least limiting water range (LLWR). However they increased soil bulk density (BD) and tensile strength (TS) of the aggregates when compared to soil under FO. Soil under NT had higher WSA, GMD, BD, TS and microporosty, but lower TP and MA than soil under CT. Soil under FO did not attain critical values for the LLWR, but the lower limit of the LLWR in soils under CT and NT was resistance to penetration (RP) for all values of BD, while the upper limit of field capacity was air-filled porosity for BD values greater than 1.46 (CT), 1.40 (NTscr), 1.42 (NTcc), and 1.41 (NTcs) kg dm-3. Soil under NTcc and NTcs decreased RP even with the increase in BD because of the formation of biopores. Furthermore, higher critical BD was verified under NTcc (1.62 kg dm-3) and NTcs (1.57 kg dm-3) compared to NTscr and CT (1.53 kg dm-3).