Treatment of hemorrhagic shock with hypertonic saline solution modulates the inflammatory response to live bacteria in lungs

Shock and resuscitation render patients more susceptible to acute lung injury due to an exacerbated immune response to subsequent inflammatory stimuli. To study the role of innate immunity in this situation, we investigated acute lung injury in an experimental model of ischemia-reperfusion (I-R) followed by an early challenge with live bacteria. Conscious rats (N = 8 in each group) were submitted to controlled hemorrhage and resuscitated with isotonic saline (SS, 0.9% NaCl) or hypertonic saline (HS, 7.5% NaCl) solution, followed by intratracheal or intraperitoneal inoculation of Escherichia coli. After infection, toll-like receptor (TLR) 2 and 4 mRNA expression was monitored by RT-PCR in infected tissues. Plasma levels of tumor necrosis factor α and interleukins 6 and 10 were determined by ELISA. All animals showed similar hemodynamic variables, with mean arterial pressure decreasing to nearly 40 mmHg after bleeding. HS or SS used as resuscitation fluid yielded equal hemodynamic results. Intratracheal E. coli inoculation per se induced a marked neutrophil infiltration in septa and inside the alveoli, while intraperitoneal inoculation-associated neutrophils and edema were restricted to the interseptal space. Previous I-R enhanced lung neutrophil infiltration upon bacterial challenge when SS was used as reperfusion fluid, whereas neutrophil influx was unchanged in HS-treated animals. No difference in TLR expression or cytokine secretion was detected between groups receiving HS or SS. We conclude that HS is effective in reducing the early inflammatory response to infection after I-R, and that this phenomenon is achieved by modulation of factors other than expression of innate immunity components.

Comparison of baseline data between chronic kidney disease patients starting hemodialysis who live near and far from the dialysis center

Introduction: The treatment offered to chronic kidney disease (CKD) patients before starting hemodialysis (HD) impacts prognosis. Objective: We seek differences among incident HD patients according to the distance between home and the dialysis center. Methods: We included 179 CKD patients undergoing HD. Patients were stratified in two groups: "living near the dialysis center" (patients whose hometown was in cities up to 100 km from the dialysis center) or as "living far from the dialysis center" (patients whose hometown was more than 100 km from the dialysis center). Socioeconomic status, laboratory results, awareness of CKD before starting HD, consultation with nephrologist before the first HD session, and type of vascular access when starting HD were compared between the two groups. Comparisons of continuous and categorical variables were performed using Student's t-test and the Chi-square test, respectively. Results: Ninety (50.3%) patients were classified as "living near the dialysis center" and 89 (49.7%) as "living far from the dialysis center". Patients living near the dialysis center were more likely to know about their condition of CKD than those living far from the dialysis center, respectively 46.6% versus 28.0% (p = 0.015). Although without statistical significance, patients living near the dialysis center had more frequent previous consultation with nephrologists (55.5% versus 42.6%; p = 0.116) and first HD by fistula (30.0% versus 19.1%; p = 0.128) than those living far from the dialysis center. Conclusion: There are potential advantages of CKD awareness, referral to nephrologists and starting HD through fistula among patients living near the dialysis center.

Climate governance in an international system under conservative hegemony: the role of major powers

In the last five years, climate change has been established as a central civilizational driver of our time. As a result of this development, the most diversified social processes - as well as the fields of science which study them - have had their dynamics altered. In International Relations, this double challenge could be explained as follows: 1) in empirical terms, climate change imposes a deepening of cooperation levels on the international community, considering the global common character of the atmosphere; and 2) to International Relations as a discipline, climate change demands from the scientific community a conceptual review of the categories designed to approach the development of global climate governance. The goal of this article is to discuss in both conceptual and empirical terms the structure of global climate change governance, through an exploratory research, aiming at identifying the key elements that allow understanding its dynamics. To do so, we rely on the concept of climate powers. This discussion is grounded in the following framework: we now live in an international system under conservative hegemony that is unable to properly respond to the problems of interdependence, among which - and mainly -, the climate issue.

Prevalence of periodontal disease in dogs and owners' level of awareness - a prospective clinical trial

Periodontal disease (PD) is widely known among veterinarians for its high prevalence and serious consequences to the dogs. The objective of this study was to assess the occurrence of PD in dogs that live in the micro-region of Viçosa, treated at the Veterinary Hospital of the Federal University of Viçosa (HVT - Hospital Veterinário da Universidade Federal de Viçosa), as well as to assess how aware of this disease dog owners are. In order to do so, all dogs treated at the HVT from March 10th, 2009 to November 30th, 2009, on alternate days, had their oral cavities examined. Medical history data, such as age, type of food, main complaint and owner consent, halitosis, presence of dental calculus, inflammation and gingival recession and tooth loss, were collected. A prevalence of 88.67% was found for PD in dogs referred to the HVT, and 2.67% were referred due to this disease. Of all the owners who participated in the study, 43.83% knew about periodontal disease and of these 17.46% made use of some type of prevention or treatment. Therefore, periodontal disease is highly prevalent and the owners are not aware of the disease. Thus, a dog owner clarification program on periodontal disease is needed in the area where HVT-UFV operates.

O planejamento econômico no Brasil: considerações críticas

In the past thirty years, a series of plans have been developed by successive Brazilian governments in a continuing effort to maximize the nation's resources for economic and social growth. This planning history has been quantitatively rich but qualitatively poor. The disjunction has stimulated Professor Mello e Souza to address himself to the problem of national planning and to offer some criticisms of Brazilian planning experience. Though political instability has obviously been a factor promoting discontinuity, his criticisms are aimed at the attitudes and strategic concepts which have sought to link planning to national goals and administration. He criticizes the fascination with techniques and plans to the exclusion of proper diagnosis of the socio-political reality, developing instruments to coordinate and carry out objectives, and creating an administrative structure centralized enough to make national decisions and decentralized enough to perform on the basis of those decisions. Thus, fixed, quantified objectives abound while the problem of functioning mechanisms for the coordinated, rational use of resources has been left unattended. Although his interest and criticism are focused on the process and experience of national planning, he recognized variation in the level and results of Brazilian planning. National plans have failed due to faulty conception of the function of planning. Sectorial plans, save in the sector of the petroleum industry under government responsibility, ha e not succeeded in overcoming the problems of formulation and execution thereby repeating old technical errors. Planning for the private sector has a somewhat brighter history due to the use of Grupos Executivos which has enabled the planning process to transcend the formalism and tradition-bound attitudes of the regular bureaucracy. Regional planning offers two relatively successful experiences, Sudene and the strategy of the regionally oriented autarchy. Thus, planning history in Brazil is not entirely black but a certain shade of grey. The major part of the article, however, is devoted to a descriptive analysis of the national planning experience. The plans included in this analysis are: The Works and Equipment Plan (POE); The Health, Food, Transportation and Energy Plan (Salte); The Program of Goals; The Trienal Plan of Economic and Social Development; and the Plan of Governmental Economic Action (Paeg). Using these five plans for his historical experience the author sets out a series of errors of formulation and execution by which he analyzes that experience. With respect to formulation, he speaks of a lack of elaboration of programs and projects, of coordination among diverse goals, and of provision of qualified staff and techniques. He mentions the absence of the definition of resources necessary to the financing of the plan and the inadequate quantification of sectorial and national goals due to the lack of reliable statistical information. Finally, he notes the failure to coordinate the annual budget with the multi-year plans. He sees the problems of execution as beginning in the absence of coordination between the various sectors of the public administration, the failure to develop an operative system of decentralization, the absence of any system of financial and fiscal control over execution, the difficulties imposed by the system of public accounting, and the absence of an adequate program of allocation for the liberation of resources. He ends by pointing to the failure to develop and use an integrated system of political economic tools in a mode compatible with the objective of the plans. The body of the article analyzes national planning experience in Brazil using these lists of errors as rough model of criticism. Several conclusions emerge from this analysis with regard to planning in Brazil and in developing countries, in general. Plans have generally been of little avail in Brazil because of the lack of a continuous, bureaucratized (in the Weberian sense) planning organization set in an instrumentally suitable administrative structure and based on thorough diagnoses of socio-economic conditions and problems. Plans have become the justification for planning. Planning has come to be conceived as a rational method of orienting the process of decisions through the establishment of a precise and quantified relation between means and ends. But this conception has led to a planning history rimmed with frustration, and failure, because of its rigidity in the face of flexible and changing reality. Rather, he suggests a conception of planning which understands it "as a rational process of formulating decisions about the policy, economy, and society whose only demand is that of managing the instrumentarium in a harmonious and integrated form in order to reach explicit, but not quantified ends". He calls this "planning without plans": the establishment of broad-scale tendencies through diagnosis whose implementation is carried out through an adjustable, coherent instrumentarium of political-economic tools. Administration according to a plan of multiple, integrated goals is a sound procedure if the nation's administrative machinery contains the technical development needed to control the multiple variables linked to any situation of socio-economic change. Brazil does not possess this level of refinement and any strategy of planning relevant to its problems must recognize this. The reforms which have been attempted fail to make this recognition as is true of the conception of planning informing the Brazilian experience. Therefore, unworkable plans, ill-diagnosed with little or no supportive instrumentarium or flexibility have been Brazil's legacy. This legacy seems likely to continue until the conception of planning comes to live in the reality of Brazil.

The population of Brazil

In 1970 the population of Brazil with 94,508,554 inhabitants was extreme youth, since 42.67% was composed of children under 14 years old. In that year the proportion of female was 50.2%. The population density increased from 1.17 inhabitants /km² in 1872 to 11.18 in 1970, and in this last year the range was 1.03 in the North region and 43.90 in the South-East region. The urban population increased from 31.24% in 1940 to 55.98% in 1970 and for the first time the rural population was smaller than the urban population. In 1950 concerning with marital status 39% of the population 15 years old and over was single and 54% married. In 1970 this rate was respectively 35.4% and 56.6%. The population economically inactive increased from 49.17% in 1940 to 52.24% in 1970. The literacy ratio increased from 43% in 1940, to 48% in 1950 and 68.04% in 1970. The crude birth rate was 43/1000 live births in 1950 and fell to 37.7/1000 in 1970. The fertility rate decreased from 179.3/1000 women (15-49 years old} to 156.7/1000 in 1960/70. The crude death rate decreased from 20.60/1000 inhabitants in 1940/50 to 9.4/1000 in 1960/70. The infant mortality rate still remains high: 171/1000 live births in 1940/50 and 170/1000 in 1971. Concerning with the size of the cities, 8 in 1940 had 100,000 or more inhabitants and in 1970 this number increased to 94 cities. The population growth increased from 2.38% in 1940/50, to 2.99% in 1950/60 and 2.83% in 1960./70. Brazil is the first country in population size in Latin America and the eighth in the world. Concerning his area, Brazil is the fifth country in size.

Possible consequences of increasing life expectancy in Brazil: the perspective of a European historical demographer

Those over sixty years of age accounted for 6.6% of the total population of Brazil in 1985, in the Federal Republic of Germany this proportion was 20.3% in 1984. As early as 1950 it had been 14.5%. This proportion will not even be reached in Brazil in the year 2000 when persons aged sixty years and older are only projected to make up 8.8% of the total population. Similarly, in 1982/84 life expectancy at birth in the Federal Republic was 70.8 years for men and 77.5 for women; in Brazil the figures for 1980/85 were, by contrast, "only" 61.0 and 66.0. Against this background it is easy to understand why the discussion concerning an ageing society with its many related medical, economic, individual and social problems has been so slow in coming into its own in Brazil. As important as a more intensive consideration of these aspects may be in Brazil at present, they are, nevertheless, only one side of the story. For a European historical demographer with a long-term perspective of three of four hundred years, the other side of the story is just as important. The life expectancy which is almost ten years lower in Brazil is not a result of the fact that no one in Brazil lives to old age. In 1981 people sixty-five years and older accounted for 34.4% of all deaths! At the same time infants accounted for only 22.1% of total mortality. They are responsible, along with the "premature" deaths among youths and adults, for the low, "average" life expectancy figure. In Europe, by contrast, these "premature" deaths no longer play much of a role. In 1982/84 more than half of the women (52.8%) in the Federal Republic of Germany lived to see their eightieth birthdays and almost half of the men (47.3%) lived to see their seventy-fifth. Our biological existence is guaranteed to an extent today that would have been unthinkable a few generations ago. Then, the classic troika of "plague, hunger and war" threatened our forefathers all the time and everywhere. The radical transition from the formerly uncertain to a present-day certain lifetime, which is the result of the repression of "plague, hunger and war", led to unexpected consequences for our living together. Our forefathers were forced to live in closely knit Gemeinschaften in the interest of physical survival and to subordinate their egoistic goals to a common value, but now these pressures have, for the most part, fallen away. Correspondingly, this much more certain EGO has taken center stage. An ever greater number of us chooses to live life as single beings: the number of marriages is lower every year; the number of divorces is on the increase; in Berlin (West) more than half (sic! 52.3%) of all households are already composed on only one person. For the last dozen years the annual number of births in the Federal Republic has been insufficient to ensure population replacement. Not a population explosion but rather the opposite, a population implosion, is our problem. Human beings do not appear to be "social animals", as was axiomatically assumed for so long. They were only forced to behave as such for as long as "plague, hunger and war" forced them to do so. When these life endangering conditions no longer exist and life becomes certain even without their being integrated into a Gemeinschaft then humans suddenly show themselves more and more to be independent single beings. It is not the percentage of the population that is over sixty or sixty-five that is decisive in this context but rather how certain adults perceive their biological lives to be, since they are the ones who organize their lives, who build communities or who are ever more often willing only to enter into means-to-an-end personal unions without lasting or close ties and mutual responsibilities. There are many signs which seem to point to a development in this direction in Brazil as well. More and more adults in Brazil are caught up in the deep-seated transition from an uncertain to a certain lifetime. A third of them die after having reached their sixty-fifth birthday. It therefore seems to me to be high time that one began to give more consideration to the other side of the story in Brazil as well. And who is more suited intensively to consider the long-term perspectives than those engaged in the public health sector in whose competence, after all, such aspects, as "life certainty", "life expectancy" and "age at death" belong?

Mortality among patients with non-affective functional psychoses in a metropolitan area of South-Eastern Brazil

High mortality rates among those suffering from schizophrenia and related psychoses have been consistently described in developed societies. However, to date there is a lack of data on this matter in Brazil. In order to examine this issue, a prospective 2-year follow-up study was carried out in S. Paulo. The sample consisted of 120 consecutive admissions to psychiatric hospitals in a defined catchment area, aged 18 to 44 years old, with clinical diagnoses of non-affective functional psychoses according to the ICD-9. After 2 years, 116 (96.7%) subjects were traced. During the study period there were 7 deaths (6.0% of those traced), 5 (4.3%) due to suicide. All but one of the suicides occurred in the first year after discharge from hospital. Age and sex Standardised Mortality Ratios (relative to rates for the population of the city of Sao Paulo) were 8.4 for overall mortality (95% confidence interval: 4.0-15.9) and 317.9 for deaths due to suicide (95% confidence interval: 125.2-668.3). These results are in agreement with previous studies, and show that in Brazil non-affective functional psychoses are life-threatening illnesses, which need adequate care, particularly when patients go back to live in the community after hospital discharge.

Patterns of induced abortion in urban area of Southeastern region, Brazil

OBJECTIVE: To assess the behavior of induced abortion as a function of certain demographic variables, for the population of fertile women (15 to 49 years old) residing in the Vila Madalena subdistrict S. Paulo (Brazil). MATERIAL AND METHOD: Two population samples were selected. One sample, with 996 women, investigated the incidence of induced abortions during 1987, using the RRT. In the other, involving 1,004 women, the same information was detected through a conventional approach. In both samples, the induced abortion occurring during the reproductive life was recorded in direct fashion. Though this analysis refers only to information about past abortions, that is by 2,000 women -, it should be noted that it is exactly the RRT that lends credibility to the found or results given results. CONCLUSION: The analysis furnishes evidence showing that single women, young women between the ages of 15 and 19, women who have not had live births, women who have a number of children below the expected ideal, women who use contraceptive methods (especially inefficient ones) and women who do not have any restrictions as to abortion constitute the categories most inclined to resort to induced abortion. This grouping suggests the existence of interrelationships between categories, that is, each of these categories is probably composed primarily of the same women, those who are at the beginning of their reproductive lives.

Two-year follow-up study of elderly residents in S. Paulo, Brazil: methodology and preliminary results

INTRODUCTION: Previous cross-sectional studies have shown a high prevalence of chronic disease and disability among the elderly. Given Brazil’s rapid aging process and the obvious consequences of the growing number of old people with chronic diseases and associated disabilities for the provision of health services, a need was felt for a study that would overcome the limitations of cross-sectional data and shed some light on the main factors determining whether a person will live longer and free of disabling diseases, the so-called successful aging. The methodology of the first follow-up study of elderly residents in Brazil is presented. METHOD: The profile of the initial cohort is compared with previous cross-sectional data and an in-depth analysis of nonresponse is carried out in order to assess the validity of future longitudinal analysis. The EPIDOSO (‘Epidemiologia do Idoso’) Study conducted a two-year follow-up of 1,667 elderly people (65+), living in S. Paulo. The study consisted of two waves, each consisting of household, clinical, and biochemical surveys. RESULTS AND CONCLUSIONS: In general, the initial cohort showed a similar profile to previous cross-sectional samples in S. Paulo. There was a majority of women, mostly widows, living in multigenerational households, and a high prevalence of chronic illnesses, psychiatric disturbances, and physical disabilities. Despite all the difficulties inherent in follow-up studies, there was a fairly low rate of nonresponse to the household survey after two years, which did not actually affect the representation of the cohort at the final household assessment, making unbiased longitudinal analysis possible. Concerning the clinical and blood sampling surveys, the respondents tended to be younger and less disabled than the nonrespondents, limiting the use of the clinical and laboratory data to longitudinal analysis aimed at a healthier cohort. It is worth mentioning that gender, education, family support, and socioeconomic status were not important determinants of nonresponse, as is often the case.

Infant mortality rates according to socioeconomic status in a Brazilian city

OBJECTIVE: Data from municipal databases can be used to plan interventions aimed at reducing inequities in health care. The objective of the study was to determine the distribution of infant mortality according to an urban geoeconomic classification using routinely collected municipal data. METHODS: All live births (total of 42,381) and infant deaths (total of 731) that occurred between 1994 and 1998 in Ribeirão Preto, Brazil, were considered. Four different geoeconomic areas were defined according to the family head's income in each administrative urban zone. RESULTS: The trends for infant mortality rate and its different components, neonatal mortality rate and post-neonatal mortality rate, decreased in Ribeirão Preto from 1994 to 1998 (chi-square for trend, p<0.05). These rates were inversely correlated with the distribution of lower salaries in the geoeconomic areas (less than 5 minimum wages per family head), in particular the post-neonatal mortality rate (chi-square for trend, p<0.05). Finally, the poor area showed a steady increase in excess infant mortality. CONCLUSIONS: The results indicate that infant mortality rates are associated with social inequality and can be monitored using municipal databases. The findings also suggest an increase in the impact of social inequality on infant health in Ribeirão Preto, especially in the poor area. The monitoring of health inequalities using municipal databases may be an increasingly more useful tool given the continuous decentralization of health management at the municipal level in Brazil.

Narrowing inequalities in infant mortality in Southern Brazil

OBJECTIVE: To determine the trends of infant mortality from 1995 to 1999 according to a geographic area-based measure of maternal education in Porto Alegre, Brazil. METHODS: A registry-based study was carried out and a municipal database created in 1994 was used. All live births (n=119,170) and infant deaths (n=1,934) were considered. Five different geographic areas were defined according to quintiles of the percentage of low maternal educational level (<6 years of schooling): high, medium high, medium, medium low, and low. The chi-square test for trend was used to compare rates between years. Incidence rate ratio was calculated using Poisson regression to identify excess infant mortality in poorer areas compared to higher schooling areas. RESULTS: The infant mortality rate (IMR) decreased steadily from 18.38 deaths per 1,000 live births in 1995 to 12.21 in 1999 (chi-square for trend p<0.001). Both neonatal and post-neonatal mortality rates decreased although the drop seemed to be steeper for the post-neonatal component. The higher decline was seen in poorer areas. CONCLUSION: Inequalities in IMR seem to have decreased due to a steeper reduction in both neonatal and post-neonatal components of infant mortality in lower maternal schooling area.

Infant mortality and low birth weight in cities of Northeastern and Southeastern Brazil

OBJECTIVE: To compare estimates of low birth weight (LBW), preterm birth, small for gestational age (SGA), and infant mortality in two birth cohorts in Brazil. METHODS: The two cohorts were performed during the 1990s, in São Luís, located in a less developed area in Northeastern Brazil, and Ribeirão Preto, situated in a more developed region in Southeastern Brazil. Data from one-third of all live births in Ribeirão Preto in 1994 were collected (2,839 single deliveries). In São Luís, systematic sampling of deliveries stratified by maternity hospital was performed from 1997 to 1998 (2,439 single deliveries). The chi-squared (for categories and trends) and Student t tests were used in the statistical analyses. RESULTS: The LBW rate was lower in São Luís, thus presenting an epidemiological paradox. The preterm birth rates were similar, although expected to be higher in Ribeirão Preto because of the direct relationship between preterm birth and LBW. Dissociation between LBW and infant mortality was observed, since São Luís showed a lower LBW rate and higher infant mortality, while the opposite occurred in Ribeirão Preto. CONCLUSIONS: Higher prevalence of maternal smoking and better access to and quality of perinatal care, thereby leading to earlier medical interventions (cesarean section and induced preterm births) that resulted in more low weight live births than stillbirths in Ribeirão Preto, may explain these paradoxes. The ecological dissociation observed between LBW and infant mortality indicates that the LBW rate should no longer be systematically considered as an indicator of social development.

Infant mortality: comparison between two birth cohorts from Southeast and Northeast, Brazil

OBJECTIVE: To obtain population estimates and profile risk factors for infant mortality in two birth cohorts and compare them among cities of different regions in Brazil. METHODS: In Ribeirão Preto, southeast Brazil, infant mortality was determined in a third of hospital live births (2,846 singleton deliveries) in 1994. In São Luís, northeast Brazil, data were obtained using systematic sampling of births stratified by maternity unit (2,443 singleton deliveries) in 1997-1998. Mothers answered standardized questionnaires shortly after delivery and information on infant deaths was retrieved from hospitals, registries and the States Health Secretarys' Office. The relative risk (RR) was estimated by Poisson regression. RESULTS: In São Luís, the infant mortality rate was 26.6/1,000 live births, the neonatal mortality rate was 18.4/1,000 and the post-neonatal mortality rate was 8.2/1,000, all higher than those observed in Ribeirão Preto (16.9, 10.9 and 6.0 per 1,000, respectively). Adjusted analysis revealed that previous stillbirths (RR=3.67 vs 4.13) and maternal age <18 years (RR=2.62 vs 2.59) were risk factors for infant mortality in the two cities. Inadequate prenatal care (RR=2.00) and male sex (RR=1.79) were risk factors in São Luís only, and a dwelling with 5 or more residents was a protective factor (RR=0.53). In Ribeirão Preto, maternal smoking was associated with infant mortality (RR=2.64). CONCLUSIONS: In addition to socioeconomic inequalities, differences in access to and quality of medical care between cities had an impact on infant mortality rates.

Neonatal mortality in intensive care units of Central Brazil

OBJECTIVE: To identify potential prognostic factors for neonatal mortality among newborns referred to intensive care units. METHODS: A live-birth cohort study was carried out in Goiânia, Central Brazil, from November 1999 to October 2000. Linked birth and infant death certificates were used to ascertain the cohort of live born infants. An additional active surveillance system of neonatal-based mortality was implemented. Exposure variables were collected from birth and death certificates. The outcome was survivors (n=713) and deaths (n=162) in all intensive care units in the study period. Cox's proportional hazards model was applied and a Receiver Operating Characteristic curve was used to compare the performance of statistically significant variables in the multivariable model. Adjusted mortality rates by birth weight and 5-min Apgar score were calculated for each intensive care unit. RESULTS: Low birth weight and 5-min Apgar score remained independently associated to death. Birth weight equal to 2,500g had 0.71 accuracy (95% CI: 0.65-0.77) for predicting neonatal death (sensitivity =72.2%). A wide variation in the mortality rates was found among intensive care units (9.5-48.1%) and two of them remained with significant high mortality rates even after adjusting for birth weight and 5-min Apgar score. CONCLUSIONS: This study corroborates birth weight as a sensitive screening variable in surveillance programs for neonatal death and also to target intensive care units with high mortality rates for implementing preventive actions and interventions during the delivery period.