Teaching and learning production and operations management: the journey from identity crisis to a cross, disciplinary approach

Este artigo tem suas raízes em algumas questões relacionadas à "forma" e ao "conteúdo" do que nós, professores, ensinamos na área de Administração da Produção e Operações. Inicialmente, descrevo a evolução histórica desse campo no Brasil. Em seguida, discuto a crise de identidade que o campo está sofrendo. Com o objetivo de apresentar respostas para essa situação, apresento seis propostas para o desenvolvimento e consolidação do campo. Finalmente, descrevo uma iniciativa prática, envolvendo uma disciplina específica da área, ensinada para alunos de pós-graduação. Essa iniciativa enfatiza a "dimensão do conteúdo" (de uma abordagem técnico-operacional para uma abordagem estratégico-gerencial) como também a "dimensão da forma" (do foco no ensino para o foco no aprendizado). O sucesso dessa experiência em curso confirma a coerência da agenda proposta e induz futuros aperfeiçoamentos.

Non-venomous snake bite and snake bite without envenoming in a brazilian teaching hospital: analysis of 91 cases

A retrospective survey of 473 cases of snake bite admitted to a Brazilian teaching hospital from 1984 to 1990 revealed 91 cases of bite without envenoming and/or caused by non-venomous snakes. In 17 of these cases the snake was identified, and one patient was bitten by a snake-like reptile (Amphisbaena mertensii). In 43 cases diagnosis was made on clinical grounds (fang marks in the absence of signs of envenoming). The other 30 cases were of patients who complained of being bitten but who did not show any sign of envenoming or fang mark. Most cases occurred in men (66;73%), in the 10-19 years age group (26;29%), in the lower limbs (51/74;69%), between 6 A. M. and 2 P.M. (49;61%) and in the month of April (16; 18%). One patient bitten by Philodryas olfersii developed severe local pain, swelling and redness at the site of the bite, with normal clotting time. The patient bitten by Drymarcon corais was misdiagnosed as being bitten by a snake of the genus Bothrops, was given the specific antivenom, and developed anaphylaxis. One patient bitten by Sibynomorphus mikanii presented prolonged clotting time, and was also given antivenom as a case of Bothrops bite. Correct identification of venomous snakes by physicians is necessary to provide correct treatment to victims of snake bite, avoiding unnecessary distress to the patient, and overprescription of antivenom, which may eventually cause severe untoward effects.

Agreement between premortem and postmortem diagnoses in patients with acquired immunodeficiency syndrome observed at a brazilian teaching hospital

Acquired immunodeficiency syndrome (AIDS) is one of the main causes of death in adults worldwide. More commonly than in the general population, in patients with AIDS there is substantial disagreement between causes of death which are clinically suspected and those established by postmortem examination. The findings of 52 postmortem examinations were compared to the premortem (clinical) diagnoses, and there was 46% agreement between them. Fifty two percent of the patients had more than one postmortem diagnosis, and 48% had at least one AIDS-related disease not suspected clinically. Cytomegalovirus infection was the commonest (30.7%) autopsy finding, but not a single case had been suspected premortem. Bacterial infection, tuberculosis, and histoplasmosis were also common, sometimes not previously suspected, postmortem findings. This study shows that multiple infections occur simultaneously in AIDS patients, and that many among them are never suspected before the postmortem examination. These findings suggest that an aggressive investigation of infections and cancers should be done in patients with AIDS, particularly in those who do not respond to therapy of an already recognized condition

EXPERIENCE IN THE EVALUATION OF CHILDREN WITH HEPATOSPLENOMEGALY AT A TEACHING AMBULATORY, SÃO PAULO, BRAZIL

Objectives: Describe cases of children with hepatosplenomegaly (HS) attended at the General Pediatric Teaching Ambulatory (AGER) of Instituto da Criança, São Paulo, identifying the main causes, evolution, necessity for hospitalization and/or referral to specialists. Methodology: Retrospective analysis of the records of children presenting HS on admission at AGER from September 1, 1993 to August 31, 1996. Results: Of the 89 children included (age range, 1 to 148 months; median, 24 months), 64 (72%) were referred from other services for HS investigation. Most common presenting complaints were: fever - 39 (44%); pallor - 26 (29%); weight loss - 21 (24%) and jaundice - 14 (16%). Main alterations noticed on physical examination were: pallor - 47 (53%) and short stature - 17 (19%). Anemia was diagnosed in 70 children (79%); 35 children (39%) had infections; 7 (8%) metabolic disorders and 5 (6%) neoplastic disorders. The most frequent infections were of the urinary tract - 9 (10%) and hepatitis A - 6 (7%).Thirty six children (40%) were referred to specialists, 17 of which were already diagnosed. Conclusions: Most of the children with HS present deficiency anemia associated with infections which the general pediatrician is able to diagnose. Persistence of unexplained HS for more than 2 months, especially when there is substantial volume enlargement or alteration in the organs consistency, is an indication for referral to specialists.

Candida bloodstream infection: data from a teaching hospital in Mato Grosso do Sul, Brazil

The incidence of Candida bloodstream infection has increased over the past years. In the Center-West region of Brazil, data on candidemia are scarce. This paper reports a retrospective analysis of 96 cases of Candida bloodstream infection at a Brazilian tertiary-care teaching hospital in the state of Mato Grosso do Sul, from January 1998 to December 2006. Demographic, clinical and laboratory data were collected from medical records and from the hospital's laboratory database. Patients' ages ranged from three days to 92 years, with 53 (55.2%) adults and 43 (44.8%) children. Of the latter, 25 (58.1%) were newborns. The risk conditions most often found were: long period of hospitalization, utilization of venous central catheter, and previous use of antibiotics. Fifty-eight (60.4%) patients died during the hospitalization period and eight (13.7%) of them died 30 days after the diagnosis of candidemia. Candida albicans (45.8%) was the most prevalent species, followed by C. parapsilosis (34.4%), C. tropicalis (14.6%) and C. glabrata (5.2%). This is the first report of Candida bloodstream infection in the state of Mato Grosso do Sul and it highlights the importance of considering the possibility of invasive Candida infection in patients exposed to risk factors, particularly among neonates and the elderly.

Rapid HIV diagnostic test in undocumented pregnant women applied at an inner-city teaching hospital

A significant number of Brazilian gestational-age women are still not tested for HIV, representing a high risk of transmission to their newborns. The current study sought to identify the number of pregnant women with no previous testing or undocumented for HIV referred to the Gynecology and Obstetrics Department of a Regional Teaching Hospital and included diagnosis of HIV infection determined by a rapid test and perinatal transmission in pregnancy. Medical records of all pregnant women admitted to hospital from January 2001 to December 2005 were reviewed. Pregnant women without HIV results were submitted to a rapid HIV test. Those who tested positive were further tested by ELISA and confirmed by indirect immunofluorescence assay (IIA) or Western blot (WB). The viral load from babies born to HIV-infected mothers was assessed by bDNA. Of the 16,424 pregnant women analyzed (6.6%), 1,089 were undocumented for HIV. Eleven women were positive in rapid testing and 10 were confirmed by ELISA, IIA or WB, with 0.9% seropositivity. Mother/infant pairs received zidovudine monotherapy prophylaxis and infant viral load was lower than 50 copies/mL. A higher number of pregnant women previously tested for HIV during antenatal care was verified, compared to that obtained nationwide.

MOLECULAR CHARACTERIZATION AND SEQUENCE PHYLOGENETIC ANALYSIS OF SURFACE ANTIGEN 3 (SAG3) GENE OF LOCAL INDIAN ISOLATES (CHENNAI AND IZATNAGAR) OF Toxoplasma gondii

Context and objective:The molecular characterization of local isolates of Toxoplasma gondii is considered significant so as to assess the homologous variations between the different loci of various strains of parasites.Design and setting:The present communication deals with the molecular cloning and sequence analysis of the 1158 bp entire open reading frame (ORF) of surface antigen 3 (SAG3) of two Indian T. gondii isolates (Chennai and Izatnagar) being maintained as cryostock at the IVRI.Method:The surface antigen 3 (SAG3) of two local Indian isolates were cloned and sequenced before being compared with the available published sequences.Results:The sequence comparison analysis revealed 99.9% homology with the standard published RH strain sequence of T. gondii. The strains were also compared with other established published sequences and found to be most related to the P-Br strain and CEP strain (both 99.3%), and least with PRU strain (98.4%). However, the two Indian isolates had 100% homology between them.Conclusion:Finally, it was concluded that the Indian isolates were closer to the RH strain than to the P-Br strain (Brazilian strain), the CEP strain and the PRU strains (USA), with respect to nucleotide homology. The two Indian isolates used in the present study are known to vary between themselves, as far as homologies related to other genes are concerned, but they were found to be 100% homologous as far as SAG3 locus is concerned. This could be attributed to the fact that this SAG3 might be a conserved locus and thereby, further detailed studies are thereby warranted to exploit the use of this particular molecule in diagnostics and immunoprophylactics. The findings are important from the point of view of molecular phylogeny.

Pig bite in Brazil: a case series from a teaching hospital

A retrospective survey done from 1987 till 1990 revealed that 23 patients bitten by pigs sought medical help at a teaching hospital in Uberlândia, in southeastern Brazil. Most cases (21) were from Uberlândia. The cases were evenly distributed by month and by year; most of them (14/16; 87.5%) occurred between 7. OOa.m. and 7.00 p. m. The male to female ratio was 6.7:1. Age ranged from 6 to 73 (mean 38.95 ± SD 22.06, median 36). The bites were more common on the upper limbs, particularly on the forearms. In 11(47.8%) cases the injury was described as deep. In most cases where information was available the injury was related to capture, transport or immobilisation ofthe pigfor slaughter. The following medical procedures were performed: local cleansing in 19(82.6%) cases, rabies vaccine (12; 52.2%), antirabies serum (2; 8.7%), suturing (6; 26.1%) and tetanus vaccine (12; 52.2%). There was no case of infection at the bite site, neither of rabies or tetanus. By our data, the annual incidence of pig bite in Uberlândia can be estimated to be about 1.5/100.000.

Detection of enteroviral sequence in endomyocardial tissues from patients with cardiac diseases in Northern Brazil

In the present report we describe the results from a pilot study aimed at detecting enterovirus sequence in cardiac tissues, obtained through endomyocardial biopsies, from patients suffering from cardiac diseases in the Amazon region. Six samples that were collected from three patients were analysed by RT-PCR showing 3 positive and 3 negative results. These preliminary findings suggest the participation of enteroviruses in the etiology of cardiac diseases, mainly myocarditis, and warrant further and broader local studies on this subject.

Intrahospital spread of carbapenem-resistant Pseudomonas aeruginosa in a University Hospital in Florianópolis, Santa Catarina, Brazil

INTRODUCTION: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) has been isolated with increasing frequency in Brazilian hospitals. Since June 2003, its detection in a teaching hospital in the city of Florianópolis, Brazil, has increased. This study aimed to investigate the minimal inhibitory concentration (MIC), presence of Metallo-β-lactamase (MβL) and a possible clonal relationship among the isolates. METHODS: The study included 29 CRPA and seven isolates with reduced susceptibility. The MIC was determined by agar-dilution. Detection of MβL was performed by Double Disk Sinergism (DDS) and Combined Disk (CD). The MβL gene was verified by PCR and nucleotide sequence analysis. Epidemiological typing was performed by pulsed-field gel electrophoresis. RESULTS: Among the 29 carbapenem-resistant isolates, polymyxin B presented 100% susceptibility and piperacillin/tazobactam 96.7%. Seventeen (62%) strains were verified as clonal (A clone) and among these, six isolates indicated phenotypically positive tests for MβL and harbored the blaSPM-1 gene. The first CRPA isolates were unrelated to clone A, harbored blaIMP-16 and were phenotypically positive only by CD. CONCLUSIONS: The spread of a high-level of resistance clone suggests cross transmission as an important dissemination mechanism and has contributed to the increased rate of resistance to carbapenems. This study emphasizes the need for continuous surveillance and improved strategies.

Predictors of adherence to influenza vaccination for healthcare workers from a teaching hospital: a study in the prepandemic era

INTRODUCTION: Even before the 2009 pandemics, influenza in healthcare workers (HCW) was a known threat to patient safety, while Influenza vaccine coverage in the same group was generally low. Identification of predictors for HCW adherence to Influenza vaccination has challenged infection control committees. METHODS: Our group conducted a cross-sectional survey in December 2007, interviewing 125 HCWs from a teaching hospital to identify adherence predictors for Influenza vaccination. The outcomes of interest were: A - adherence to the 2007 vaccination campaign; B - adherence to at least three yearly campaigns in the past five years. Demographic and professional data were assessed through univariate and multivariate analysis. RESULTS: Of the HCWs interviewed, 43.2% were vaccinated against Influenza in 2007. However, only 34.3% of HCWs working in healthcare for more than five years had adhered to at least three of the last five vaccination campaigns. Multivariate analysis showed that working in a pediatric unit (OR = 7.35, 95%CI = 1.90-28.44, p = 0.004) and number of years in the job (OR = 1.32, 95%CI = 1.00-1.74, p = 0.049) were significant predictors of adherence to the 2007 campaign. Physicians returned the worst outcome performances in A (OR = 0.40, 95%CI = 0.16-0.97, p = 0.04) and B (OR = 0.17, 95%CI = 0.05-0.60, p = 0.006). CONCLUSIONS: Strategies to improve adherence to Influenza vaccination should focus on physicians and newly-recruited HCWs. New studies are required to assess the impact of the recent Influenza A pandemics on HCW-directed immunization policies.

Antimicrobial use and incidence of multidrug-resistant Pseudomonas aeruginosa in a teaching hospital: an ecological approach

INTRODUCTION: Multidrug-resistant Pseudomonas aeruginosa is a major threat in healthcare settings. The use of antimicrobials can influence the incidence of resistant strains by direct and indirect mechanisms. The latter can be addressed by ecological studies. METHODS: Our group attempted to analyze the relation between the use of antipseudomonal drugs and the incidence of MDR-PA among 18 units from a 400-bed teaching hospital. The study had a retrospective, ecological design, comprising data from 2004 and 2005. Data on the use of four antimicrobials (amikacin, ciprofloxacin, ceftazidime and imipenem) were tested for correlation with the incidence of MDR-PA (defined as isolates resistant to the four antimicrobials of interest) in clinical cultures. Univariate and multivariate linear regression analyses were performed. RESULTS: Significant correlations were determined between use and resistance for all antimicrobials in the univariate analysis: amikacin (standardized correlation coefficient = 0.73, p = 0.001); ciprofloxacin (0.71, p = 0.001); ceftazidime (0.61, p = 0.007) and imipenem (0.87, p < 0.001). In multivariate analysis, only imipenem (0.67, p = 0.01) was independently related to the incidence of multidrug-resistant strains. CONCLUSIONS: These findings share similarities with those reported in individual-based observational studies, with possible implications for infection control.

A first case of protease codon 35 amino acid insertion in a HIV-1 subtype B sequence detected in the Bauru region, state of São Paulo, Brazil: case report

Amino acid insertions in the protease have rarely been described in HIVinfected patients. One of these insertions has recently been described in codon 35, although its impact on resistance remains unknown. This study presents a case of an HIV variant with an insertion in codon 35 of the protease, described for the first time in Bauru, State of Sao Paulo, Brazil, circulating in a 38-year-old caucasian male with asymptomatic HIV infection since 1997. The variant isolated showed a codon 35 insertion of two amino acids in the protease: a threonine and an aspartic acid, resulting in the amino acid sequence E35E_TD.

Relationship between antibiotic consumption, oropharyngeal colonization, and ventilator-associated pneumonia by Staphylococcus aureus in an intensive care unit of a Brazilian teaching hospital

INTRODUCTION: his study evaluated the consumption of major classes of antibiotics, the colonization of the oropharynx of patients on mechanical ventilation, and the risk of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus in an intensive care unit for adults. METHODS: A case-control study was carried out using colonized patients (cases) by oxacillin-resistant S. aureus (ORSA) and (controls) oxacillin-sensitive S. aureus (OSSA) from May 2009 to August 2010. The occurrence of VAP by S. aureus was also evaluated in the same period. Antibiotic consumption was expressed as the number of defined daily doses (DDD)/1,000 patient-days for glycopeptides, carbapenems, and extended-spectrum cephalosporins. RESULTS: Three hundred forty-six (56.1%) patients underwent mechanical ventilation with a frequency of oropharyngeal colonization of 36.4%, corresponding to 63.5% for ORSA and 36.5% for OSSA. The risk of illness for this organism was significant (p<0.05), regardless of whether colonization/infection was by ORSA or OSSA. The consumption of antibiotics was high, mainly for broad-spectrum cephalosporins (551.26 DDDs/1,000 patient-days). The high density of use of glycopeptides (269.56 DDDs/1,000 patient-days) was related to colonization by ORSA (Pearson r=0.57/p=0.02). Additionally, age >60 years, previous antibiotic therapy, and previous use of carbapenems were statistically significant by multivariate analysis. CONCLUSIONS: There was a significant relationship between the colonization of the oropharyngeal mucosa and the risk of VAP by both phenotypes. The use of glycopeptides was related to colonization by ORSA.