Governmental surveillance system of healthcare-associated infection in Brazil


Objective: This study aimed to describe the structure of governmental surveillance systems for Healthcare Associated Infection (HAI) in the Brazilian Southeastern and Southern States. Method: A cross-sectional, descriptive and exploratory study, with data collection by means of two-phases: characterization of the healthcare structure and of the HAI surveillance system. Results: The governmental teams for prevention and control of HAI in each State ranged from one to six members, having at least one nurse. All States implemented their own surveillance system. The information systems were classified into chain (n=2), circle (n=4) or wheel (n=1). Conclusion: Were identified differences in the structure and information flow from governmental surveillance systems, possibly limiting a nationwide standardization. The present study points to the need for establishing minimum requirements in public policies, in order to guide the development of HAI surveillance systems.


Performance comparison of an active matrix flat panel imager, computed radiography system, and a screen-film system at four standard radiation qualities.

Four standard radiation qualities (from RQA 3 to RQA 9) were used to compare the imaging performance of a computed radiography (CR) system (general purpose and high resolution phosphor plates of a Kodak CR 9000 system), a selenium-based direct flat panel detector (Kodak Direct View DR 9000), and a conventional screen-film system (Kodak T-MAT L/RA film with a 3M Trimax Regular screen of speed 400) in conventional radiography. Reference exposure levels were chosen according to the manufacturer's recommendations to be representative of clinical practice (exposure index of 1700 for digital systems and a film optical density of 1.4). With the exception of the RQA 3 beam quality, the exposure levels needed to produce a mean digital signal of 1700 were higher than those needed to obtain a mean film optical density of 1.4. In spite of intense developments in the field of digital detectors, screen-film systems are still very efficient detectors for most of the beam qualities used in radiology. An important outcome of this study is the behavior of the detective quantum efficiency of the digital radiography (DR) system as a function of beam energy. The practice of users to increase beam energy when switching from a screen-film system to a CR system, in order to improve the compromise between patient dose and image quality, might not be appropriate when switching from screen-film to selenium-based DR systems.

Introducing systematic dispatcher-assisted cardiopulmonary resuscitation (telephone-CPR) in a non-Advanced Medical Priority Dispatch System (AMPDS): implementation process and costs.

OBJECTIVE: In order to improve the quality of our Emergency Medical Services (EMS), to raise bystander cardiopulmonary resuscitation rates and thereby meet what is becoming a universal standard in terms of quality of emergency services, we decided to implement systematic dispatcher-assisted or telephone-CPR (T-CPR) in our medical dispatch center, a non-Advanced Medical Priority Dispatch System. The aim of this article is to describe the implementation process, costs and results following the introduction of this new "quality" procedure. METHODS: This was a prospective study. Over an 8-week period, our EMS dispatchers were given new procedures to provide T-CPR. We then collected data on all non-traumatic cardiac arrests within our state (Vaud, Switzerland) for the following 12months. For each event, the dispatchers had to record in writing the reason they either ruled out cardiac arrest (CA) or did not propose T-CPR in the event they did suspect CA. All emergency call recordings were reviewed by the medical director of the EMS. The analysis of the recordings and the dispatchers' written explanations were then compared. RESULTS: During the 12-month study period, a total of 497 patients (both adults and children) were identified as having a non-traumatic cardiac arrest. Out of this total, 203 cases were excluded and 294 cases were eligible for T-CPR. Out of these eligible cases, dispatchers proposed T-CPR on 202 occasions (or 69% of eligible cases). They also erroneously proposed T-CPR on 17 occasions when a CA was wrongly identified (false positive). This represents 7.8% of all T-CPR. No costs were incurred to implement our study protocol and procedures. CONCLUSIONS: This study demonstrates it is possible, using a brief campaign of sensitization but without any specific training, to implement systematic dispatcher-assisted cardiopulmonary resuscitation in a non-Advanced Medical Priority Dispatch System such as our EMS that had no prior experience with systematic T-CPR. The results in terms of T-CPR delivery rate and false positive are similar to those found in previous studies. We found our results satisfying the given short time frame of this study. Our results demonstrate that it is possible to improve the quality of emergency services at moderate or even no additional costs and this should be of interest to all EMS that do not presently benefit from using T-CPR procedures. EMS that currently do not offer T-CPR should consider implementing this technique as soon as possible, and we expect our experience may provide answers to those planning to incorporate T-CPR in their daily practice.

Optimal regulation of a fully insured deposit banking system

We analyze risk sensitive incentive compatible deposit insurancein the presence of private information when the market value of depositinsurance can be determined using Merton's (1997) formula. We show that,under the assumption that transferring funds from taxpayers to financialinstitutions has a social cost, the optimal regulation combines differentlevels of capital requirements combined with decreasing premia on depositinsurance. On the other hand, it is never efficient to require the banksto hold riskless assets, so that narrow banking is not efficient. Finally,chartering banks is necessary in order to decrease the cost of asymmetricinformation.

Judges' cognition and market order

We argue that during the crystallization of common and civil law in the 19th century, the optimal degree of discretion in judicial rulemaking, albeit influenced by the comparative advantages of both legislative and judicial rulemaking, was mainly determined by the anti-market biases of the judiciary. The different degrees of judicial discretion adopted in both legal traditions were thus optimally adapted to different circumstances, mainly rooted in the unique, market-friendly, evolutionary transition enjoyed by English common law as opposed to the revolutionary environment of the civil law. On the Continent, constraining judicial discretion was essential for enforcing freedom of contract and establishing a market economy. The ongoing debasement of pro-market fundamentals in both branches of the Western legal system is explained from this perspective as a consequence of increased perceptions of exogenous risks and changes in the political system, which favored the adoption of sharing solutions and removed the cognitive advantage of parliaments and political leaders.

Reliability of the image evaluation system PGMI

Purpose: Many countries used the PGMI (P=perfect, G=good, M=moderate, I=inadequate) classification system for assessing the quality of mammograms. Limits inherent to the subjectivity of this classification have been shown. Prior to introducing this system in Switzerland, we wanted to better understand the origin of this subjectivity in order to minimize it. Our study aimed at identifying the main determinants of the variability of the PGMI system and which criteria are the most subjected to subjectivity. Methods and Materials: A focus group composed of 2 experienced radiographers and 2 radiologists specified each PGMI criterion. Ten raters (6 radiographers and 4 radiologists) evaluated twice a panel of 40 randomly selected mammograms (20 analogic and 20 digital) according to these specified PGMI criteria. The PGMI classification was assessed and the intra- and inter-rater reliability was tested for each professional group (radiographer vs radiologist), image technology (analogic vs digital) and PGMI criterion. Results: Some 3,200 images were assessed. The intra-rater reliability appears to be weak, particularly in respect to inter-rater variability. Subjectivity appears to be largely independent of the professional group and image technology. Aspects of the PGMI classification criteria most subjected to variability were identified. Conclusion: Post-test discussions enabled to specify more precisely some criteria. This should reduce subjectivity when applying the PGMI classification system. A concomitant, important effort in training radiographers is also necessary.

The role of matrix metalloproteinase mmp-9 in peripheral neural system regeneration

Multiple lines of evidence show that matrix metalloproteinases (MMPs) are involved in the peripheral neural system degenerative and regenerative processes. MMP-9 was suggested in particular to play a role in the peripheral nerve after injury or during Wallerian degeneration. Interestingly, our previous analysis of Lpin1 mutant mice (which present morphological signs of active demyelination and acute inflammatory cell migration, similar to processes present in the PNS undergoing Wallerian degeneration) revealed an accumulation of MMP-9 in the endoneurium of affected animals. We therefore generated a mouse line lacking both the Lpin1 and the MMP-9 genes in order to determine if MMP-9 plays a role in either inhibition or potentiation of the demyelinating phenotype present in Lpin1 knockout mice. The inactivation of MMP-9 alone did not lead to defects in PNS structure or function. Interestingly we observed that the double mutant animals showed reduced nerve conduction velocity, lower myelin protein mRNA expressions, and had more histological abnormalities as compared to the Lpin1 single mutants. In addition, based on immunohistochemical analysis and macrophage markers mRNA expression, we found a lower macrophage content in the sciatic nerve of the double mutant animals. Together our data indicate that MMP-9 plays a role in macrophage recruitment during postinjury PNS regeneration processes and suggest that slower macrophage infiltration delays regenerative processes in PNS.

Sample size and statistical power in the hierarchical analysis of variance: applications in morphometry of the nervous system.

Analysis of variance is commonly used in morphometry in order to ascertain differences in parameters between several populations. Failure to detect significant differences between populations (type II error) may be due to suboptimal sampling and lead to erroneous conclusions; the concept of statistical power allows one to avoid such failures by means of an adequate sampling. Several examples are given in the morphometry of the nervous system, showing the use of the power of a hierarchical analysis of variance test for the choice of appropriate sample and subsample sizes. In the first case chosen, neuronal densities in the human visual cortex, we find the number of observations to be of little effect. For dendritic spine densities in the visual cortex of mice and humans, the effect is somewhat larger. A substantial effect is shown in our last example, dendritic segmental lengths in monkey lateral geniculate nucleus. It is in the nature of the hierarchical model that sample size is always more important than subsample size. The relative weight to be attributed to subsample size thus depends on the relative magnitude of the between observations variance compared to the between individuals variance.

Open to closed system transition traced through the TDIC isotopic signature at the aquifer recharge stage, implications for groundwater 14C dating

14C dating models are limited when considering recent groundwater for which the carbon isotopic signature of the total dissolved inorganic carbon (TDIC) is mainly acquired in the unsaturated zone. Reducing the uncertainties of dating thus implies a better identification of the processes controlling the carbon isotopic composition of the TDIC during groundwater recharge. Geochemical interactions between gas, water and carbonates in the unsaturated zone were investigated for two aquifers (the carbonate-free Fontainebleau sands and carbonate-bearing Astian sands, France) in order to identify the respective roles of CO2 and carbonates on the carbon isotopic signatures of the TDIC; this analysis is usually approached using open or closed system terms. Under fully open system conditions, the seasonality of the 13C values in the soil CO2 can lead to important uncertainties regarding the so-called "initial 14C activity" used in 14C correction models. In a carbonate-bearing unsaturated zone such as in the Astian aquifer, we show that an approach based on fully open or closed system conditions is not appropriate. Although the chemical saturation between water and calcite occurs rapidly within the first metre of the unsaturated zone, the carbon isotopic contents (δ13C) of the CO2 and the TDIC evolve downward, impacted by the dissolution-precipitation of the carbonates. In this study, we propose a numerical approach to describe this evolution. The δ13C and the A 14C (radiocarbon activity) of the TDIC at the base of the carbonate-hearing unsaturated zone depends on (i) the δ13C and the A 14C of the TDIC in the soil determined by the soil CO2, (ii) the water's residence time in the unsaturated zone and (iii) the carbonate precipitation-dissolution fluxes. In this type of situation, the carbonate δ13C-A 14C evolutions indicate the presence of secondary calcite and permit the calculation of its accretion flux, equal to ~ 4.5 ± 0.5 x 10-9 mol grock-1 yr-1. More generally, for other sites under temperate climate and with similar properties to the Astian sands site, this approach allows for a reliable determination of the carbon isotopic composition at the base of the unsaturated zone as the indispensable "input function" data of the carbon cycle into the aquifer.

Status of Females in the Juvenile Justice System Iowa, 2009

Young women in the juvenile justice system present with characteristics and experiences that differentiate them from their male counterparts. As such, the juvenile justice system in Iowa must consider these factors if it is to effectively and efficiently impact recidivism, rehabilitation and public safety. Data reveal the following trends: All youth in the juvenile justice system experience a significantly higher rate of child maltreatment than do youth in the general population. Additionally, young women have a distinctly higher percentage of reported sexual abuse. Young women commit primarily non-violent offenses, with shoplifting and running away being the only two areas where they exceed young men in number. Young women are held in detention for a substantially higher percentage of misdemeanor versus felony offenses than young men. Young women of color, particularly African American females, are far more likely to come into contact with the juvenile justice system. Additionally, arrests of minority females have increased during the same time frame as arrests of Caucasian females have decreased. The general type of offense committed by young women is against public order (i.e. alcohol related violations, disorderly conduct) or property (i.e. shoplifting), though young women with subsequent charges of a violent nature are likely to have had violent offenses initially as well. Historically, young women have been a smaller segment of the juvenile justice population. They remain so today. Consequently, they are easy to overlook. But Iowa’s response to them is no less important. Perhaps, because they are fewer in number, our system can have a true and meaningful influence, with prevention of further penetration into both the juvenile and adult systems being the ultimate goal. The Iowa Task Force on Young Women recommends the following measures to facilitate movement toward that goal: 1. Facilities and programs striving to provide the most effective and efficient services to young women will opt for single gender environments with female responsive programming that includes components to address trauma. 2. All institutions and agencies that work with females involved in the juvenile justice system and which receive state funding should be required to provide annual female responsive training to their employees. Training should be research based, progressive, ongoing and result in an implementation plan. 3. As detention reform proceeds, gender and the disproportionate number of females in detention for misdemeanor offenses must be an integral part of policy and decision making discussions including any recommendations for solutions to be implemented. 4. As research, data and planning progresses related to disproportionate minority contact with the juvenile system, the needs of girls of color be given equal consideration. Specifically, assessment tools must be without race/ethnic bias and they must also be female responsive.

Infection of the central nervous system caused by varicella zoster virus reactivation: a retrospective case series study.

BACKGROUND: Recent data suggest that varicella zoster virus (VZV)-associated complications of the central nervous system (CNS) are more common and diverse than previously thought. The main purpose of this article is to describe the clinical characteristics and the outcome of patients suffering from meningitis and encephalitis caused by VZV reactivation. METHODS: A retrospective case study of adult patients (≥16 years old) diagnosed with a VZV reactivation in the CNS was performed. The cases were identified by a qualitative PCR DNA assay of the cerebrospinal fluid (CSF) at the Regional Hospital of Lugano between January 1, 2003 and July 31, 2010. RESULTS: Eleven out of 519 CSF samples (2.1%), submitted from patients with a clinical diagnosis of viral meningitis or encephalitis, were positive for VZV. A vesiculo-pustular skin eruption was observed in only five patients (45%). In six cases (55%), a systemic inflammatory syndrome was absent. The clinical outcome was favorable in eight patients (73%). Only one out of 11 patients (9%) died. The four patients with encephalitis had a less favorable prognosis: one patient recovered without residual neurological sequelae; two had a chronic neuropsychological handicap, speech difficulties, facial nerve palsy, and focal seizures; one patient died. We estimated an annual incidence rate of VZV infection of the CNS of 1.02/100 000 inhabitants for southern Switzerland. CONCLUSIONS: Screening of CSF for VZV by PCR is recommended for all patients with encephalitis and for those with viral meningitis of unclear origin in order to better target antiviral treatment.

Fertilizer 15N balance in a coffee cropping system: a case study in Brazil

Knowledge about the fate of fertilizer nitrogen in agricultural systems is essential for the improvement of management practices in order to maximize nitrogen (N) recovery by the crop and reduce N losses from the system to a minimum. This study involves fertilizer management practices using the 15N isotope label applied in a single rate to determine the fertilizer-N balance in a particular soil-coffee-atmosphere system and to deepen the understanding of N plant dynamics. Five replicates consisting of plots of about 120 plants each were randomly defined within a 0.2 ha coffee plantation planted in 2001, in Piracicaba, SP, Brazil. Nine plants of each plot were separated in sub-plots for the 15N balance studies and treated with N rates of 280 and 350 kg ha-1 during 2003/2004 and 2004/2005, respectively, both of them as ammonium sulfate enriched to a 15N abundance of 2.072 atom %. Plant shoots were considered as separate parts: the orthotropic central branch, productive branches, leaves of productive branches, vegetative branches, leaves of vegetative branches and fruit. Litter, consisting of dead leaves accumulated below the plant canopy, was measured by the difference between leaves at harvest and at the beginning of the following flowering. Roots and soil were sampled down to a depth of 1.0 at intervals of 0.2 m. Samples from the isotopic sub-plots were used to evaluate total N and 15N, and plants outside sub-plots were used to evaluate dry matter. Volatilization losses of NH3 were estimated using special collectors. Leaching of fertilizer-N was estimated from deep drainage water fluxes and 15N concentrations of the soil solution at 1 m soil depth. At the end of the 2-year evaluation, the recovery of 15N applied as ammonium sulfate was 19.1 % in aerial plant parts, 9.4 % in the roots, 23.8 % in the litter, 26.3 % in the fruit and 12.6 % remaining in the 0_1.0 m soil profile. Annual leaching and volatilization losses were very small (2.0 % and 0.9 %, respectively). After two years, only 6.2 % N were missing in the balance (100 %) which can be attributed to other non-estimated compartments and experimental errors. Results show that an enrichment of only 2 % atom 15N allows the study of the partition of fertilizer-N in a perennial crop such as coffee during a period of two years.

Diffusionless first-order phase transitions in systems with frozen configurational degrees of freedom

We consider systems that can be described in terms of two kinds of degree of freedom. The corresponding ordering modes may, under certain conditions, be coupled to each other. We may thus assume that the primary ordering mode gives rise to a diffusionless first-order phase transition. The change of its thermodynamic properties as a function of the secondary-ordering-mode state is then analyzed. Two specific examples are discussed. First, we study a three-state Potts model in a binary system. Using mean-field techniques, we obtain the phase diagram and different properties of the system as a function of the distribution of atoms on the different lattice sites. In the second case, the properties of a displacive structural phase transition of martensitic type in a binary alloy are studied as a function of atomic order. Because of the directional character of the martensitic-transition mechanism, we find only a very weak dependence of the entropy on atomic order. Experimental results are found to be in quite good agreement with theoretical predictions.

Critical behavior of a system with orientational and positional degrees of freedom: A Monte Carlo simulation study

The critical behavior of a system constituted by molecules with a preferred symmetry axis is studied by means of a Monte Carlo simulation of a simplified two-dimensional model. The system exhibits two phase transitions, associated with the vanishing of the positional order of the center of mass of the molecules and with the orientational order of the symmetry axis. The evolution of the order parameters and the specific heat is also studied. The transition associated with the positional degrees of freedom is found to change from a second-order to a first-order behavior when the two phase transitions are close enough, due to the coupling with the orientational degrees of freedom. This fact is qualitatively compared with similar results found in pure liquid crystals and liquid-crystal mixtures.

Influence of configurational atomic order on the relative stability of bcc and close-packed structures in Cu-based alloys

We present a study of the influence of atomic order on the relative stability of the bcc and the 18R martensitic structures in a Cu2.96Al0.92Be0.12 crystal. Calorimetric measurements have shown that disorder increases the stability of the 18R phase, contrary to what happens in Cu-Zn-Al alloys for which it is the bcc phase that is stabilized by disordering the system. This different behavior has been explained in terms of a model recently reported. We have also proved that the entropy change at the martensitic transition is independent of the state of atomic order of the crystal, as predicted theoretically. Our results suggest that differences in the vibrational spectrum of the crystal due to different states of atomic order must be equal in the bcc and in the close-packed phases.