YELLOW FEVER PREVENTION STRATEGIES AWARENESS AMONG HIV-INFECTED PATIENTS IN SÃO PAULO, BRAZIL

Introduction: Vaccination is the main preventive strategy against Yellow Fever (YF), which is a public health concern in Brazil. However, HIV-infected patients might have insufficient knowledge regarding YF, YF prevention, and vaccines in general. Methods: In this questionnaire-based study, data from 158 HIV-infected individuals were addressed in three distinct outpatient clinics in São Paulo. Information was collected on demographic and clinical characteristics, as well as patients' knowledge of vaccines, YF and YF preventive strategies. In addition, individual YF vaccine recommendations and vaccine status were investigated. Results: Although most participants adequately ascertain the vaccine as the main prevention strategy against YF, few participants were aware of the severity and lack of specific treatment for YF. Discrepancy in YF vaccine (patients who should have taken the vaccine, but did not) was observed in 18.8% of participants. Conclusion: YF is an important and preventable public health concern, and these results demonstrate that more information is necessary for the HIV-infected population.

The Impact of the Lisbon Football Derby on the Profile of Emergency Department Admissions

BACKGROUND: Variations in emergency department admissions have been reported to happen as a result of major sports events. The work presented assessed changes in volume and urgency level of visits to a major Emergency Department in Lisbon during and after the city's football derby. MATERIAL AND METHODS: Volume of attendances and patient urgency level, according to the Manchester Triage System, were retrospectively analyzed for the 2008-2011 period. Data regarding 24-hour periods starting 45 minutes before kick-off was collected, along with data from similar periods on the corresponding weekdays in the previous years, to be used as controls. Data samples were organized according to time frame (during and after the match), urgency level, and paired accordingly. RESULTS: A total of 14 relevant periods (7 match and 7 non-match) were analyzed, corresponding to a total of 5861 admissions. During the match time frame, a 20.6% reduction (p = 0.06) in the total number of attendances was found when compared to non-match days. MTS urgency level sub-analysis only showed a statistically significant reduction (26.5%; p = 0.05) in less urgent admissions (triage levels green-blue). Compared to controls, post-match time frames showed a global increase in admissions (5.6%; p = 0.45), significant only when considering less urgent ones (18.9%; p = 0.05). DISCUSSION: A decrease in the total number of emergency department attendances occurred during the matches, followed by a subsequent increase in the following hours. These variations only reached significance among visits triaged green-blue. CONCLUSION: During major sports events an overall decrease in emergency department admissions seems to take place, especially due to a drop in visits associated with less severe conditions.

Economic Evaluation of Ticagrelor for Secondary Prevention Following Acute Coronary Syndromes

INTRODUCTION AND OBJECTIVES: To estimate the cost-effectiveness and cost-utility of ticagrelor in the treatment of patients with acute coronary syndromes (unstable angina or myocardial infarction with or without ST-segment elevation), including patients treated medically and those undergoing percutaneous coronary intervention or coronary artery bypass grafting. METHODS: A short-term decision tree and a long-term Markov model were used to simulate the evolution of patients' life-cycles. Clinical effectiveness data were collected from the PLATO trial and resource use data were obtained from the Hospital de Santa Marta database, disease-related group legislation and the literature. RESULTS: Ticagrelor provides increases of 0.1276 life years and 0.1106 quality-adjusted life years (QALYs) per patient. From a societal perspective these clinical gains entail an increase in expenditure of €610. Thus the incremental cost per life year saved is €4780 and the incremental cost per QALY is €5517. CONCLUSIONS: The simulation results show that ticagrelor reduces events compared to clopidogrel. The costs of ticagrelor are partially offset by lower costs arising from events prevented. The use of ticagrelor in clinical practice is therefore cost-effective compared to generic clopidogrel.

Evaluating Dynamic Signage for Emergency Evacuation using an Immersive Video Environment

Dissertation submitted in partial fulfillment of the requirements for the Degree of Master of Science in Geospatial Technologies.

Adhesion Prevention in Laparoscopic Surgery

Adhesions have important consequences for patients, surgeons, and health services. Peritonealtissue injury can be prevented by using careful surgical techniques. A large number of antiadhesion products have been used experimentally and clinically to prevent postoperative adhesions. Methods: The current author reviewed the surgical literature published about epidemiology, pathogenesis, and various prevention strategies of adhesion formation. Results: Meticulous surgery is essential to reduce unnecessary morbidity and mortality rates from these untoward effects of surgery. Several preventive agents against postoperative peritoneal adhesions have been investigated. Bioresorbable membranes are site-specific antiadhesion products but may be more difficult to use laparoscopically. Liquids and gels have the advantage of more-widespread areas of action and increased ease of use, particularly during laparoscopic operations. Effective pharmacologic agents that can reduce release of proinflammatory cytokines or activate peritoneal fibrinolysis are under development. Their results are encouraging but most of them are contradictory. Conclusions: Many modalities are being studied to reduce this risk; despite initial promising results of different measures in postoperative adhesion prevention, none of them have become standard applications. With the current state of knowledge, preclinical or clinical studies are still necessary to evaluate the effectiveness of the several proposed prevention strategies for avoiding postoperative peritoneal adhesions.

Nursing Home-Acquired Pneumonia Presenting at the Emergency Department

Nursing home-acquired pneumonia (NHAP) is one of the most common infections arising amongst nursing home residents, and its incidence is expected to increase as population ages. The NHAP recommendation for empiric broad-spectrum antibiotic therapy, arising from the concept of healthcare-associated pneumonia, has been challenged by recent studies reporting low rates of multidrug-resistant (MDR) bacteria. This single center study analyzes the results of NHAP patients admitted through the Emergency Department (ED) at a tertiary center during the year 2010. There were 116 cases, male gender corresponded to 34.5 % of patients and median age was 84 years old (IQR 77-90). Comorbidities were present in 69.8 % of cases and 48.3 % of patients had used healthcare services during the previous 90 days. In-hospital mortality rate was 46.6 % and median length-of-stay was 9 days. Severity assessment at the Emergency Department provided CURB65 index score and respective mortality (%) results: zero: n = 0; one: n = 7 (0 %); two: n = 18 (38.9 %); three: n = 26 (38.5 %); four: n = 30 (53.3 %); and five; n = 22 (68.2 %); and sepsis n = 50 (34.0 %), severe sepsis n = 43 (48.8 %) and septic shock n = 22 (72.7 %). Significant risk factors for in-hospital mortality in multivariate analysis were polypnea (p = 0.001), age ≥ 75 years (p = 0.02), and severe sepsis or shock (p = 0.03) at the ED. Microbiological testing in 78.4 % of cases was positive in 15.4 % (n = 15): methicillin-resistant Staphylococcus aureus (26.7 %), Pseudomonas aeruginosa (20.0 %), S. pneumoniae (13.3 %), Escherichia coli (13.3 %), others (26.7 %); the rate of MDR bacteria was 53.3 %. This study reveals high rates of mortality and MDR bacteria among NHAP hospital admissions supporting the use of empirical broad-spectrum antibiotic therapy in these patients.

Acidentes em Crianças e Jovens, Que Contexto e Que Abordagem? Experiência de Nove Meses no Serviço de Urgência num Hospital de Nível II

Introdução: Os acidentes constituem uma importante causa de morbimortalidade infantil e de recurso ao serviço de urgência pediátrica. A nível nacional conhecem-se apenas alguns dados epidemiológicos. Métodos: Estudo observacional transversal com análise da coorte das crianças observadas no serviço de urgência pediátrica de um hospital nível II por motivo de acidente, durante um período de nove meses, com dados obtidos através de um inquérito e submetidos a análise estatística. Resultados: Das 22502 admissões de crianças até aos 14 anos registadas, 1746 (7,8%) foram por acidentes. A maioria era do sexo masculino e tinha mais de 5 anos. Os acidentes ocorreram maioritariamente no exterior da escola (29,1%) e interior de casa (25%), predominando a queda como tipo de acidente (55,5%) e a contusão como mecanismo de lesão (54,2%). A maioria das crianças (77,3%) foi submetida a exames complementares de diagnóstico destacando-se os radiológicos. Os diagnósticos mais frequentes foram os traumatismos superficiais (47,9%) e os ferimentos (24,8%). Em 6,6% (115) dos casos os acidentes foram considerados graves. Estas admissões por acidentes associaram-se a uma despesa imediata estimada de 124 mil euros. Discussão: A frequência elevada e o local de ocorrência dos acidentes coincidiram com a literatura. Apesar do predomínio das lesões minor superficiais (47,9%) verificou-se um número significativo de crianças com necessidade de cuidados hospitalares. Não foram registados óbitos. Os autores concluem que os acidentes em crianças foram um motivo frequente de ida ao serviço de urgência pediátrica com importante consumo de recursos. A sensibilização dos cuidadores é essencial na prevenção dos acidentes.

Fatores individuais de risco de infeção hospitalar : conhecer para prevenir

RESUMO - Medidas efetivas de prevenção e controlo de infeção, assim como a sua aplicação diária e consistente, devem fazer parte da cultura de segurança dos profissionais de saúde para promover a excelência da prestação de cuidados. Também a identificação dos fatores de riscos individuais de infeção é crucial e indispensável para a adoção de medidas para a gestão desses mesmos riscos. A avaliação do risco pretende determinar a probabilidade que um doente tem de adquirir ou disseminar uma infeção hospitalar (IH) (WIRRAL, 2008) nas unidades de saúde. A avaliação deve ser efetuada na admissão do doente e, de forma periódica durante o internamento, usando uma grelha de avaliação, integrada no processo global de cuidados do doente. Efetuada a avaliação de risco individual, que pressupõe a identificação dos fatores de risco do doente (fatores de risco intrínsecos e extrínsecos) pode ser implementado um plano de cuidados individualizado para os gerir. Pretendeu-se com este estudo identificar os fatores de risco de infeção hospitalar do doente que estão presentes na admissão e/ou que podem surgir durante o seu internamento, para que posteriormente seja possível determinar as medidas de prevenção (gestão do risco) a aplicar individualmente. Foi realizado um estudo de caso-controlo com os doentes internados no Hospital dos Lusíadas em 2011 com o objetivo de, por um lado, determinar os fatores de risco individuais que contribuem para a aquisição da IH e, por outro, caraterizar os fatores de risco para uma futura identificação de possíveis medidas de prevenção e controlo da aquisição e transmissão cruzada da infeção hospitalar. A população em estudo foi constituída pelos doentes que foram internados, entre 1 de Janeiro e 31 de Dezembro de 2011 sendo os casos os doentes em que foi identificada a presença de infeção hospitalar através do programa institucional de vigilância epidemiológica das infeções, tendo os controlos sido selecionados numa razão de 3:1 caso. Foi utilizado um suporte estruturado para a colheita de dados, com a listagem de fatores de risco identificados na revisão bibliográfica e de todos os fatores de risco apresentados pelos doentes em estudo. Os fatores de risco identificados que apresentaram um maior significado estatístico foram: a idade acima dos 50 anos, o género masculino, a administração de antimicrobianos nas três semanas anteriores ao internamento, a colocação de cateter venoso central, a algaliação e, no caso dos doentes cirúrgicos, a cirurgia de urgência e a classificação ASA 3. Após a identificação dos fatores de risco da população estudada neste hospital, é agora possível utilizar a informação obtida e delinear investigações adicionais, objetivando a construção de instrumentos para a identificação de doentes com risco aumentado de infeção.

Exploring motor neuron degeneration in ALS - prevention by glycoursodeoxycholic acid and signaling to microglia

Dissertação para obtenção do Grau de Mestre em Genética Molecular e Biomedicina

Analysis of molecular biology techniques for the diagnosis of human papillomavirus infection and cervical cancer prevention

The objective of the present study was to evaluate the usefulness of molecular methodologies to access human papillomavirus genome in the genital tract. Samples from 136 women aged 17 to 52 years old obtained from the Dr. Sérgio Franco Laboratories between 2000 and 2001, were analyzed by the hybrid capture assay and amplified by PCR with generic primers MY09/MY11 and specific primers for types 16, 18, 31, 33, 35, 58. Viral genome was detected in 71.3% of the samples by hybrid capture and 75% by amplification. When cytopathology was used as a reference method for screening lesions, hybrid capture (p=0) and amplification (p=0.002) presented positive association. The 3 methods showed absolute agreement when cytopathology confirmed papillomavirus infection and high grade intraepithelial lesion. Disagreements occurred for 10 cases: seven inflammatory cases positive by PCR and negative for hybrid capture and 3 low squamous intraepithelial lesions positive for hybrid capture but negative for amplification. In conclusion, hybrid capture was shown to be sensitive and specific enough for use in clinical routines. Moreover, the evaluation of viral load values obtained by this method were shown to be related to the severity of the lesion and merit further studies to analyze the possible association with risk of progression to malignancy.

Implementation of a pilot project for the treatment and prevention of substance abuse in children and adolescents : strengthening families for parents and youths 12-16

RESUMO: Antecendentes: Uma avaliação dos serviços de abuso de substâncias em Barbados identificou a necessidade de programas e serviços que são projetados especificamente para crianças e adolescentes. Objetivo: Realizar programa com base em evidências para reduzir a incidência de abuso de drogas entre crianças e adolescentes por meio do fortalecimento da unidade familiar através de parentalidade positiva, de maior funcionamento familiar e de resistência dos jovens. Método: Dois projetos-piloto foram realizadas com base no programa "Fortalecer as Famílias para Pais e Jovens de 12 a 16 anos (SFPY). O programa de nove semanas foi empregado como uma intervenção para criar laços familiares mais fortes, aumentar a resistência dos jovens e reduzir o abuso de drogas entre crianças e adolescentes de idades de 11 a 16 anos. A decisão foi tomada para incluir participantes de 11 anos desde que as crianças possam estar no primeiro ano da escola secundária nessa idade. IMPLEMENTATION OF SUBSTANCE ABUSE PILOT PROJECT FOR CHILDREN AND ADOLESCENTS 5 Resultados: Quinze famílias participaram em dois projetos-piloto e a avaliação final mostrou que os jovens após o programa, geralmente tornaram-se mais positivos sobre o seu lugar na unidade familiar e sentiram que sua participação no programa foi benéfica. Os pais, da mesma forma, relataram que eles conquistaram, com o programa uma relação mais positiva, uma melhor compreensão das necessidades, e consciência das mudanças de desenvolvimento de seus jovens. Desta forma, considera-se que o programa atingiu o resultado desejado de criar unidades familiares mais fortes. Conclusão: O Projeto Piloto “SFPY” foi bem sucedido em fazer pais e jovens mais conscientes de suas necessidades individuais e de responsabilidades dentro da unidade familiar. Como resultado, o relacionamentos das respectivas famílias melhorou. Estudos baseados em evidências têm demonstrado que um relação familiar mais forte diminui a incidência de uso e abuso de drogas na população adolescente, aumentando os fatores de proteção e diminuindo os fatores de risco. A implementação do programa, que foi desenvolvido e testado no ambiente norte-americano, demonstrou que era transferível para a sociedade de Barbados. No entanto, seu impacto total só pode ser determinado através de um estudo comparativo envolvendo um grupo de controle e / ou uma intervenção alternativa ao abuso de substâncias. Portanto, é recomendável que um estudo comparativo da intervenção SFPY deve envolver uma amostra representativa de adolescentes que estão em estágio de desenvolvimento anterior mais cedo. Evidências já demonstram que o programa é mais eficaz, com impacto mais longo sobre os jovens que participam em uma idade maisABSTRACT:Background: An evaluation of substance abuse services in Barbados has identified the need for programmes and services that are specifically designed for children and adolescents. Aim: To conduct an evidence-based programme to reduce the incidence of substance abuse among children and adolescents by strengthening the family unit through positive parenting, enhanced family functioning and youth resilience. Method: Two pilot projects were conducted based on the ‘Strengthening Families for Parents and Youths 12– 16’ (SFPY) programme. The nine-week programme was employed as an intervention to create stronger family connections, increase youth resiliency and reduce drug abuse among children and adolescents between the ages of 11 to 16. The decision was made to include participants from age 11 since children may be in the first year of secondary school at this age. IMPLEMENTATION OF SUBSTANCE ABUSE PILOT PROJECT FOR CHILDREN AND ADOLESCENTS 3 Results: Fifteen families participated in two pilot projects and an evaluation conducted at the conclusion showed that the youth were generally more positive about their perceived place in the family unit and felt that the being in the programme was generally beneficial. The parents similarly reported they had a more positive relationship with their youths and also had a better understanding of their needs, and an awareness of their developmental changes. This affirmed that the programme had achieved its desired outcome to create stronger family units. Conclusion: The SFPY Pilot Project was successful in making parents and youths more aware of their individual needs and responsibilities within the family unit. As a result relationships within their respective families were strengthened. Evidence-based studies have shown that enhanced family functioning decreases the incidence of substance use and abuse in the adolescent population by increasing protective factors and decreasing risk factors. The implementation of the programme, which was developed and tested in the North American environment, demonstrated that it was transferable to the Barbadian society. However, its full impact can only be determined through a comparative study involving a control group and/or an alternative substance abuse intervention. It is therefore recommended that a comparative study of the SFPY intervention should be delivered to a representative sample of adolescents who are at an earlier developmental stage. Evidence has shown that the programme is more effective, with longer impact on youths who participate at a younger age.

Etiological treatment of young women infected with Trypanosoma cruzi, and prevention of congenital transmission

The objective was to detect Trypanosoma cruzi infection in 32 children in Salta, Argentina, born to 16 chronically infected young women who were treated with benznidazole. Tests were performed to assess the efficacy of treatment after 14 years. At the end of the follow up, 87.5% of the women were non-reactive to EIA tests, 62.5% to IHA and 43.8% to IFA. 62.5% of the women were non-reactive according to two or three serological tests. No infected children were detected among the newborns of mothers treated before their pregnancy.

On an organizational level: How can the emergency department at Rouge Valley Centenary hospital improve their wait times?

The prolonged wait times may arguably put into question the Canadian Health Act of 1984. Statistics show throughput wait times are 5.5 hours and output wait times for admitted patients are 32.4 hours. After probing and analyzing best practices through a qualitative/quantitative Value Stream Mapping and a qualitative SWOT Analysis; Team Triage and an Overcapacity Protocol is suggested to improve non-admitted patients wait times by 1.89 hours and admitted patients wait times by 16 hours by eliminating wasteful steps in the patient process and upon overcapacity, effectively sharing already stabilized and admitted patients with all wards in the hospital.

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital

INTRODUCTION: Vancomycin-resistant enterococci (VRE) can colonize or cause infections in high-risk patients and contaminate the environment. Our objective was to describe theepidemiological investigation of an outbreak of VRE, the interventions made, and their impact on its control. METHODS: We conducted a retrospective, descriptive, non-comparative study by reviewing the charts of patients with a VRE-positive culture in the University Hospital of Campinas State University, comprising 380 beds, 40 of which were in intensive care units (ICUs), who were admitted from February 2008-January 2009. Interventions were divided into educational activity, reviewing the workflow processes, engineering measures, and administrative procedures. RESULTS: There were 150 patients, 139 (92.7%) colonized and 11 (7.3%) infected. Seventy-three percent were cared for in non-ICUs (p = 0.028). Infection was more frequent in patients with a central-line (p = 0.043), mechanical ventilation (p = 0.013), urinary catheter (p = 0.049), or surgical drain (p = 0.049). Vancomycin, metronidazole, ciprofloxacin, and third-generation cephalosporin were previously used by 47 (31.3%), 31 (20.7%), 24 (16%), and 24 (16%) patients, respectively. Death was more frequent in infected (73%) than in colonized (17%) patients (p < 0.001). After the interventions, the attack rate fell from 1.49 to 0.33 (p < 0.001). CONCLUSIONS: Classical risk factors for VRE colonization or infection, e.g., being cared for in an ICU and previous use of vancomycin, were not found in this study. The conjunction of an educational program, strict adhesion to contact precautions, and reinforcement of environmental cleaning were able to prevent the dissemination of VRE.