Tecnología apropiada en obstetricia: definición y evaluación desde las perspectivas de la población y del personal de salud

Se parte de la hipótesis de que para lograr satisfacer las necesidades de salud de la población, es preciso, entre otras cosas, que los servicios de salud utilicen tecnologías apropiadas. El problema que surge es el de definir lo que se considera "adecuado" y quiénes lo definen. Para ello se ha efectuado una investigación que permite detectar y analizar comparativamente la definición que, desde las perspectivas de la población y de los profesionales, se hace de la tecnología apropiada en obstetricia, como así también la tecnología utilizada en los distintos sectores de atención (público, de obras sociales y privado). Se presentan algunos datos referidos a dos aspectos de la atención: Utilización de técnicas y procedimientos biomédicos (pujar, jadear, episiotomía, anestesia, etc.) y consideración de las relaciones interpersonales en el proceso de atención (continuidad de la atención, rol del padre, favorecimiento del vínculo madre-hijo, etc.). Se observa que se utilizan modalidades de atención diferenciales según sectores de atención: son más tecnologizadas y medicalizadas en el sector privado. A la vez en éste se consideran más las relaciones interpersonales que favorecen la atención. Además, las opiniones de los profesionales, en cuanto a lo que cosideran adecuado, concuerdan más con las de las madres de dicho sector, siendo sus necesidades satisfechas en mayor medida que las de las demás. Resulta así que las necesidades de las mayorías - las que se atienden en servicios privados y de obras sociales - son cubiertas en menor medida, no qual se opone a un enfoque de riesgo que vuelca sus recursos en los grupos considerados vulnerables.

Relación del personal de salud con los pacientes en la Ciudad de México

OBJETIVO: Analizar la calidad de la relación del personal de salud con los pacientes hospitalizados. MÉTODOS: Estudio cualitativo realizado de febrero a julio del 2005, en la Ciudad de México. Se aplicaron 40 entrevistas a profundidad a pacientes internados en un hospital de tercer nivel. Las categorías de análisis para explorar la percepción del trato entre los informantes fueron las siguientes: actitudes y acciones del personal médico y de enfermería, comunicación efectiva, grado de conocimiento del paciente y/o familiares sobre el diagnóstico, tratamiento clínico, evolución del agravo. RESULTADOS: En general, se encontró un alto grado de satisfacción con la atención médica. No obstante, los pacientes hospitalizados percibieron como inadecuado el trato cotidiano (no clínico) del personal médico y de enfermería del hospital, relacionado con la falta de confianza para solicitar información acerca de su padecimiento. El uso excesivo de tecnicismos por parte del prestador de servicios reforzó esta percepción de trato inadecuado. CONCLUSIONES: La percepción del trato inadecuado por el personal de salud fuera del ámbito técnico, mostró que la efectividad clínica no significa una plena calidad de la atención y que es necesario incorporar las necesidades y expectativas de trato no clínico de los pacientes a la eficiencia técnica y científica.

Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix

OBJECTIVE: To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS: A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS: Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS: The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

Effectiveness of motivational interviewing at improving oral health: a systematic review

OBJECTIVE : To analyze the effectiveness of motivational interviewing (MI) at improving oral health behaviors (oral hygiene habits, sugar consumption, dental services utilization or use of fluoride) and dental clinical outcomes (dental plaque, dental caries and periodontal status). METHODS : A systematic search of PubMed, LILACS, SciELO, PsyINFO, Cochrane and Google Scholar bibliographic databases was conducted looking for intervention studies that investigated MI as the main approach to improving the oral health outcomes investigated. RESULTS : Of the 78 articles found, ten met the inclusion criteria, all based on randomized controlled trials. Most studies (n = 8) assessed multiple outcomes. Five interventions assessed the impact of MI on oral health behaviors and nine on clinical outcomes (three on dental caries, six on dental plaque, four on gingivitis and three on periodontal pockets). Better quality of evidence was provided by studies that investigated dental caries, which also had the largest population samples. The evidence of the effect of MI on improving oral health outcomes is conflicting. Four studies reported positive effects of MI on oral health outcomes whereas another four showed null effect. In two interventions, the actual difference between groups was not reported or able to be recalculated. CONCLUSIONS : We found inconclusive effectiveness for most oral health outcomes. We need more and better designed and reported interventions to fully assess the impact of MI on oral health and understand the appropriate dosage for the counseling interventions.

Cyclosporine versus tacrolimus: cost-effectiveness analysis for renal transplantation in Brazil

OBJECTIVE To analyze the cost-effectiveness of treatment regimens with cyclosporine or tacrolimus, five years after renal transplantation.METHODS This cost-effectiveness analysis was based on historical cohort data obtained between 2000 and 2004 and involved 2,022 patients treated with cyclosporine or tacrolimus, matched 1:1 for gender, age, and type and year of transplantation. Graft survival and the direct costs of medical care obtained from the National Health System (SUS) databases were used as outcome results.RESULTS Most of the patients were women, with a mean age of 36.6 years. The most frequent diagnosis of chronic renal failure was glomerulonephritis/nephritis (27.7%). In five years, the tacrolimus group had an average life expectancy gain of 3.96 years at an annual cost of R$78,360.57 compared with the cyclosporine group with a gain of 4.05 years and an annual cost of R$61,350.44.CONCLUSIONS After matching, the study indicated better survival of patients treated with regimens using tacrolimus. However, regimens containing cyclosporine were more cost-effective.

Intra-hospital organ and tissue donation coordination project: cost-effectiveness and social benefits

OBJECTIVE To evaluate the viability of a professional specialist in intra-hospital committees of organ and tissue donation for transplantation. METHODS Epidemiological, retrospective and cross-sectional study (2003-2011 and 2008-2012), which was performed using organ donation for transplants data in the state of Sao Paulo, Southeastern Brazil. Nine hospitals were evaluated (hospitals 1 to 9). Logistic regression was used to evaluate the differences in the number of brain death referrals and actual donors (dependent variables) after the professional specialist started work (independent variable) at the intra-hospital committee of organ and tissue donation for transplantation. To evaluate the hospital invoicing, the hourly wage of the doctor and registered nurse, according to the legislation of the Consolidation of Labor Laws, were calculated, as were the investment return and the time elapsed to do so. RESULTS Following the nursing specialist commencement on the committee, brain death referrals and the number of actual donors increased at hospital 2 (4.17 and 1.52, respectively). At hospital 7, the number of actual donors also increased from 0.005 to 1.54. In addition, after the nurse started working, hospital revenues increased by 190.0% (ranging 40.0% to 1.955%). The monthly cost for the nurse working 20 hours was US$397.97 while the doctor would cost US$3,526.67. The return on investment was 275% over the short term (0.36 years). CONCLUSIONS This paper showed that including a professional specialist in intra-hospital committees for organ and tissue donation for transplantation proved to be cost-effective. Further economic research in the area could contribute to the efficient public policy implementation of this organ and tissue harvesting model.

Treatment of relapsing chronic infections of the respiratory tract: a comparative study of the effectiveness of non specific immunotherapy with the immunoadjuvant p40 and of vaccinotherapy

The treatment of relapsing chronic infections (RCI) encounters many difficulties. In the present study, the use of the immuno adjuvant P40 either alone or in association with vaccinotherapy for the treatment of RCI turned out to be very effective, whereas vaccinotherapy alone was not. It is hypothesized that cell-mediated immunity may play a major role in controlling RCI, since the clinical improvement of the patients kept up with the positivation of previously negative skin tests carried out with either the specific infecting agent or with recall-anti gens.

Blood culture as a parameter of treatment effectiveness in experimental histoplasmosis of the hamster

The aim of this study was to determine the value of blood culture as a parameter of treatment effectiveness in experimental histoplasmosis. A total of thirty five hamsters, weighing approximately 120g, were inoculated intracardiacly with 0.1 ml of a suspension containing 4 x 10(7) cells/ml of the yeast phase of H. capsulatum. Treatments were started one week after the infection and lasted for 3 weeks. The azoles, (itraconazole, saperconazole and fluconazole) were administered once a day by gavage, at a dose of 8 mg/kg; Amphotericin B was given intraperitonealy every other day at a dose of 6mg/kg. Blood samples (1 ml) were obtained by heart punction from the 4th day after infection and were seeded in Sabouraud honey-agar and BHI-agar. The hamsters that survived were killed one week after treatment completion and the following criteria were considered for treatment evaluation: 1) rate of spontaneous death, at the end of the experience; 2) microscopic examination of Giemsa smears from liver and spleen and 3) determination of CFU in spleen cultures. Amphotericin B was the most effective drug, with negative blood cultures at day 20, negative spleen cultures in all cases and all the animals survived until the end of the study. Fluconazole was the less effective drug, blood cultures were positive during the whole experience, spleen cultures showed a similar average of CFU when compared with the control animals and 42.8% of these animals died. Saperconazole and itraconazole showed a similar activity, with survival of all hamsters and negative blood cultures at 23 and 26 days respectively. Blood culture seems to be valuable parameter for treatments' evaluation in experimental histoplasmosis of the hamster.

Heparin-antivenom association: differential neutralization effectiveness in Bothrops atrox and Bothrops erythromelas envenoming

Heparin, in some regions of Brazil has been used in the treatment of bothropic accidents, but the data found in the literature are inconclusive about its effectiveness. The venoms of Bothrops atrox and of B. erythromelas were characterized according to their biological activities. The capacity of heparin in neutralizing these activities was tested with doses of 3 and 6 IU in isolated form and associated to Antibothropic Serum (ABS). It was verified that heparin, in doses of 3 and 6 IU, was not effective in neutralizing the desfibrinating and edema-forming activities of B. atrox venom and the hemorrhagic and coagulant actions of both venoms. Heparin diminished the effectiveness of the ABS in the neutralization of the hemorrhagic and edema-forming activities of the B. atrox venom. However, heparin in the 6 IU dose was capable of neutralize the edema-forming of the B. erythromelas and increase the effectiveness of the ABS. Heparin also neutralized the phospholipasic A2 activity of B. atrox (14.3%) and B. erythromelas (28.0%) venoms. For B. erythromelas venom, the associated treatment, heparin and ABS, was more effective in the neutralization of its lethal activity.

Effectiveness of influenza vaccination in elderly outpatients in São Paulo city, Brazil

To investigate the effectiveness of the influenza vaccine in a population of elderly outpatients, we compared the occurrence and frequency of influenza like illness (ILI), respiratory illness and hospitalization in vaccinated and non-vaccinated subjects. All the outcomes were clinically defined. The two groups were similar with respect to demographics, health situation and habits. The influenza vaccine contributed to the protection of the elderly investigated, since the vaccinated subjects referred a significantly lower number of ILI than the non-vaccinated. There is a need for more studies about the effectiveness of the influenza vaccine in our country in elderly and other groups of our population.

Comparative study of the topical effectiveness of the andiroba oil (Carapa guianensis) and DEET 50% as repellent for Aedes sp

DEET (N,N-diethyl-3-methylbenzamide) is nowadays the most effective mosquito repellent available, however, its use can present some topical and systemic side effects. Some botanical compositions, as Andiroba (Carapa guianensis), have been proved repellent properties at low cost and toxicity. An experimental study was driven involving four volunteers submitting their forearms covered with Andiroba oil at 100%, DEET 50%, refined soy oil, Andiroba oil 15% and in the absence of products, directly to healthy females of Aedes sp. The times of first and third bites were checked. The results showed that the median of the first bite without any product was 17.5s and the third bite, 40.0s. In the soy oil, the bites happened in 60.0s and 101.5s, in the presence of Andiroba oil 100%, in 56.0s and 142.5s and in Andiroba oil 15%, in 63.0s and 97.5s. The volunteers using DEET 50% had not received bites after 3600s in most of the experiments (p < 0.001 Wilcoxon). Pure Andiroba oil compared to the soy oil, forearm without product and Andiroba oil 15%, showed discreet superiority (p < 0.001 Wilcoxon). Our conclusion is that this study demonstrated that the pure Andiroba oil presents discreet repellent effect against bite of Aedes sp., being significantly inferior to DEET 50%.

Effectiveness of house dust mite acaricide tri-n-butyl tin maleate on carpets, fabrics and mattress foam: a standardization of methodology

The aim of this study was to determine the effectiveness of the acaricide tri-n-butyl tin maleate, industrially applied to samples of carpets, mattress foam, and fabrics used for furniture upholstery, soft toys and shoe uppers. Approximately 100 adult house dust mites of the species Dermatophagoides pteronyssinus were inoculated into a Petri dish containing the sample (a piece of carpet, mattress foam, or fabric), treated with the acaricide, randomly collected. Mite-maintenance culture medium was added on top of each sample. After one, two, three, seven and 30 days of incubation at 25 ºC and 75% relative humidity, each dish was examined using a 40X stereoscopic microscope (40X). One hundred percent acaricide effectiveness was obtained in treated materials by the end of the 30th-day postinoculation period, under optimal conditions for mite maintenance.

Effectiveness of the Brazilian influenza vaccination policy, a systematic review

Since 1999, Brazil has undertaken annual influenza vaccine campaigns, free of charge, targeting the elderly population, health professionals, and immune-deficient patients. We conducted a systematic review of literature in order to evaluate the effectiveness of the initiative. We used the keywords influenza, vaccine, Brazil and effectiveness to search the main databases. Thirty-one studies matched our inclusion and exclusion criteria. Influenza vaccine coverage among the elderly is high, though not as high as suggested by the official figures. Estimates on effectiveness are scarce. The majority come from ecological studies that show a modest reduction in mortality and hospital admissions due to influenza-related causes. Such reduction is not evident in the North and Northeastern states of Brazil, a finding that is probably related to the different seasonal pattern of influenza in equatorial and tropical regions. Brazilian epidemiologists still owe society better-designed studies addressing the effectiveness of influenza vaccine campaigns.

ASSOCIATION BETWEEN SMOKING, CRACK COCAINE ABUSE AND THE DISCONTINUATION OF COMBINATION ANTIRETROVIRAL THERAPY IN RECIFE, PERNAMBUCO, BRAZIL

Despite the effectiveness of combination antiretroviral therapy in the treatment of people living with HIV/AIDS (PLWHA), nonadherence to medication has become a major threat to its effectiveness. This study aimed to estimate the prevalence of self-reported irregular use of antiretroviral therapy and the factors associated with such an irregularity in PLWHA. A cross-sectional study of PLWHA who attended two referral centers in the city of Recife, in Northeastern Brazil, between June 2007 and October 2009 was carried out. The study analyzed socioeconomic factors, social service support and personal habits associated with nonadherence to antiretroviral therapy, adjusted by multivariable logistic regression analysis. The prevalence of PLWHA who reported irregular use of combination antiretroviral therapy (cART) was 25.7%. In the final multivariate model, the irregular use of cART was associated with the following variables: being aged less than 40 years (OR = 1.66, 95%-CI: 1.29-2.13), current smokers (OR = 1.76, 95%-CI: 1.31-2.37) or former smokers (OR = 1.43, 95%-CI: 1.05-1.95), and crack cocaine users (OR = 2.79, 95%-CI: 1.24-6.32). Special measures should be directed towards each of the following groups: individuals aged less than 40 years, smokers, former smokers and crack cocaine users. Measures for giving up smoking and crack cocaine should be incorporated into HIV-control programs in order to promote greater adherence to antiretroviral drugs and thus improve the quality of life and prolong life expectancy.