Evaluation of pharmaceutical assistance in public primary care in Brasília, Brazil

OBJECTIVE: Pharmaceutical assistance is essential in health care and a right of citizens according to Brazilian law and drug policies. The study purpose was to evaluate aspects of pharmaceutical assistance in public primary health care. METHODS: A cross-sectional study using WHO drug indicators was carried out in Brasília in 2001. From a random sample of 15 out of 62 centers thirty exiting patients per center were interviewed. RESULTS: Only 18.7% of the patients fully understood the prescription, 56.3% could read it, 61.2% of the prescribed drugs were actually dispensed, and mean duration of pharmaceutical dispensing was 53.2 seconds. Each visit lasted on average 9.4 minutes. Of prescribed and non-dispensed drugs, 85.3% and 60.6% were on the local essential drug list (EDL) respectively. On average 83.2% of 40 essential drugs were in stock, and only two centers had a pharmacist in charge of the pharmacy. The mean number of drugs per prescription was 2.3, 85.3% of prescribed drugs were on the EDL, 73.2% were prescribed using the generic denomination, 26.4% included antibiotics and 7.5% were injectables. The most prescribed groups were: cardiovascular drugs (26.8%), anti-infective drugs (13.1%), analgesics (8.9%), anti-asthmatic drugs (5.8%), anti-diabetic drugs (5.3%), psychoactive drugs (3.7%), and combination drugs (2.7%). CONCLUSIONS: Essential drugs were only moderately available almost 30 years after the first Brazilian EDL was formulated. While physician use of essential drugs and generic names was fairly high, efficiency was impaired by the poor quality of pharmaceutical care, resulting in very low patient understanding and insufficient guarantee of supply, particularly for chronic diseases.

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.

Fungal contamination assessment in Portuguese elderly care centers

Individuals spend 80-90% of their day indoors and elderly subjects are likely to spend even a greater amount of time indoors. Thus, indoor air pollutants such as bioaerosols may exert a significant impact on this age group. The aim of this study was to characterize fungal contamination within Portuguese elderly care centers. Fungi were measured using conventional as well as molecular methods in bedrooms, living rooms, canteens, storage areas, and outdoors. Bioaerosols were evaluated before and after the microenvironments' occupancy in order to understand the role played by occupancy in fungal contamination. Fungal load results varied from 32 colony-forming units CFU m(-3) in bedrooms to 228 CFU m(-3) in storage areas. Penicillium sp. was the most frequently isolated (38.1%), followed by Aspergillus sp. (16.3%) and Chrysonilia sp. (4.2%). With respect to Aspergillus genus, three different fungal species in indoor air were detected, with A. candidus (62.5%) the most prevalent. On surfaces, 40 different fungal species were isolated and the most frequent was Penicillium sp. (22.2%), followed by Aspergillus sp. (17.3%). Real-time polymerase chain reaction did not detect the presence of A. fumigatus complex. Species from Penicillium and Aspergillus genera were the most abundant in air and surfaces. The species A. fumigatus was present in 12.5% of all indoor microenvironments assessed. The living room was the indoor microenvironment with lowest fungal concentration and the storage area was highest.

Avaliação e optimização operacional: estudo do terminal de contentores de Alcântara

Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia Mecânica - Ramo Manutenção e Produção

Surveillance of mother-to-child HIV transmission: socioeconomic and health care coverage indicators

OBJECTIVE: To identify clustering areas of infants exposed to HIV during pregnancy and their association with indicators of primary care coverage and socioeconomic condition. METHODS: Ecological study where the unit of analysis was primary care coverage areas in the city of Porto Alegre, Southern Brazil, in 2003. Geographical Information System and spatial analysis tools were used to describe indicators of primary care coverage areas and socioeconomic condition, and estimate the prevalence of liveborn infants exposed to HIV during pregnancy and delivery. Data was obtained from Brazilian national databases. The association between different indicators was assessed using Spearman's nonparametric test. RESULTS: There was found an association between HIV infection and high birth rates (r=0.22, p<0.01) and lack of prenatal care (r=0.15, p<0.05). The highest HIV infection rates were seen in areas with poor socioeconomic conditions and difficult access to health services (r=0.28, p<0.01). The association found between higher rate of prenatal care among HIV-infected women and adequate immunization coverage (r=0.35, p<0.01) indicates that early detection of HIV infection is effective in those areas with better primary care services. CONCLUSIONS: Urban poverty is a strong determinant of mother-to-child HIV transmission but this trend can be fought with health surveillance at the primary care level.

Determination of airborne nanoparticles in elderly care centres

According to numerous studies, airborne nanoparticles have a potential to produce serious adverse human health effects when deposited into the respiratory tract. The most important parts of the lung are the alveolar regions with their enormous surface areas and potential to transfer nanoparticles into the blood stream. These effects may be potentiated in case of the elderly, since this population is more susceptible to air pollutants in general and more to nanoparticles than larger particles. The main goal of this investigation was to determine the exposure of institutionalized elders to nanoparticles using Nanoparticle Surface Area Monitor (NSAM) equipment to calculate the deposited surface area (DSA) of nanoparticles into elderly lungs. In total, 193 institutionalized individuals over 65 yr of age were examined in four elderly care centers (ECC). The occupancy daily pattern was achieved by applying a questionnaire, and it was concluded that these subjects spent most of their time indoors, including the bedroom and living room, the indoor microenvironments with higher prevalence of elderly occupancy. The deposited surface area ranged from 10 to 46 μm2/cm3. The living rooms presented significantly higher levels compared with bedrooms. Comparing PM10 concentrations with nanoparticles deposited surface area in elderly lungs, it is conceivable that living rooms presented the highest concentration of PM10 and were similar to the highest average DSA. The temporal distribution of DSA was also assessed. While data showed a quantitative fluctuation in values in bedrooms, high peaks were detected in living rooms.

Household members and health care workers as supervisors of tuberculosis treatment

OBJECTIVE: To compare tuberculosis cure rates among patients supervised by household members or health care workers. METHODS: Prospective cohort study of 171 patients treated by the program in Vitoria, Southeastern Brazil, from 2004 to 2007. Each patient was followed-up for six months until the end of the treatment. Of the patients studied, a household member supervised 59 patients and healthcare workers supervised 112 patients. Patients' sociodemographic and clinic data were analyzed. Differences between groups were assessed using chi-square test or Student's t-test. Significance level was set at 5%. RESULTS: Most patients had smear positive, culture confirmed pulmonary tuberculosis. Two patients were HIV-positive. There were more illiterate patients in the healthcare-supervised group, in comparison to those supervised by their families (p=0.01). All patients supervised by a household member were cured compared to 90% of the patients supervised by health care workers (p = 0.024). CONCLUSIONS: Successful tuberculosis treatment was more frequent when supervised by household members.

Direct medical costs associated with schizophrenia relapses in health care services in the city of São Paulo

OBJECTIVE: To assess direct medical costs associated with schizophrenia relapses in mental health services. METHODS: The study was conducted in three health facilities in the city of São Paulo: a public state hospital; a Brazilian National Health System (SUS)-contracted hospital; and a community mental health center. Medical records of 90 patients with schizophrenia who received care in 2006 were reviewed. Information on inpatient expenditures was collected and used for cost estimates. RESULTS: Mean direct medical cost of schizophrenia relapses per patient was US$ 4,083.50 (R$ 8,167.58) in the public state hospital; US$ 2,302.76 (R$ 4,605.46) in the community mental health center; and US$ 1,198.50 (R$ 2,397.74) in the SUS-affiliated hospital. The main component was daily inpatient room rates (87% - 98%). Medication costs varied depending on the use of typical or atypical antipsychotic drugs. Atypical antipsychotic drugs were more often used in the community mental health center. CONCLUSIONS: Costs associated with schizophrenia relapses support investments in antipsychotic drugs and strategies to reduce disease relapse and the need for mental health inpatient services. Treating patients in a community mental health center was associated with medium costs and added the benefit of not depriving these patients from family life.

DOTS in primary care units in the city of Rio de Janeiro, Southeastern Brazil

OBJECTIVE: To describe the implantation and the effects of directly-observed treatment short course (DOTS) in primary health care units. METHODS: Interviews were held with the staff of nine municipal health care units (MHU) that provided DOTS in Rio de Janeiro City, Southeastern Brazil, in 2004-2005. A dataset with records of all tuberculosis treatments beginning in 2004 in all municipal health care units was collected. Bivariate analyses and a multinomial model were applied to identify associations between treatment outcomes and demographic and treatment process variables, including being in DOTS or self-administered therapy (SAT). RESULTS: From 4,598 tuberculosis cases treated in public health units administrated by the municipality, 1,118 (24.3%) were with DOTS and 3,480 (75.7%) with SAT. The odds of DOTS were higher among patients with age under 50 years, tuberculosis relapse and prior history of default or treatment failure. The odds of death were 52.0% higher among patients on DOTS as compared to SAT. DOTS modality including community health workers (CHWs) showed the highest treatment success rate. A reduction of 21.0% was observed in the odds of default (vs. cure) among patients on DOTS as compared to patients on SAT, and a reduction of 64.0% among patients on DOTS with CHWs as compared to those without CHWs. CONCLUSIONS: Patients with a "low compliance profile" were more likely to be included in DOTS. This strategy improves the quality of care provided to tuberculosis patients, although the proposed goals were not achieved.

Effects of home environment and center-based child care quality on children’s

This study examined the joint effects of home environment and center-based child care quality on children’s language, communication, and early literacy development, while also considering prior developmental level. Participants were 95 children (46 boys), assessed as toddlers (mean age = 26.33 months;Time 1) and preschoolers (mean age = 68.71 months; Time 2) and their families. At both times, children attended center-based child care classrooms in the metropolitan area of Porto, Portugal. Results from hierarchical linear models indicated that home environment and preschool quality, but not center-based toddler child care quality, were associated with children’s language and literacy outcomes at Time 2. Moreover, the quality of preschool classrooms moderated the association between home environment quality and children’s language and early literacy skills – but not communication skills – at Time 2, suggesting the positive cumulative effects of home environment and preschool quality. Findings further support the existence of a detrimental effect of low preschool quality on children’s language and early literacy outcomes: positive associations among home environment quality and children’s developmental outcomes were found to reduce substantially when children attended low-quality preschool classrooms.

Care cost for pregnant and parturient women with diabetes and mild hyperglycemia

OBJECTIVE: To compare inpatient and outpatient care costs for pregnant/parturient women with diabetes and mild hyperglycemia. METHODS: A prospective observational quantitative study was conducted in the Perinatal Diabetes Center in the city of Botucatu, Southeastern Brazil, between 2007 and 2008. Direct and indirect costs and disease-specific costs (medications and tests) were estimated. Thirty diet-treated pregnant women with diabetes were followed up on an outpatient basis, and 20 who required insulin therapy were hospitalized. RESULTS: The cost of diabetes disease (prenatal and delivery care) was US$ 3,311.84 for inpatients and US$ 1,366.04 for outpatients. CONCLUSIONS: Direct and indirect costs as well as total prenatal care cost were higher for diabetic inpatients while delivery care costs and delivery-postpartum hospitalization were similar. Prenatal and delivery-postpartum care costs were higher for these patients compared to those paid by Brazilian National Health System.

A checklist for patient safety rounds at the care pathway level

Objective - To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals. Design - We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors. Setting and Participants - A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated. Main outcome measures - Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR). Results - Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level. Conclusion - The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

Caracterização de estruturas portuárias: caso de estudo: ampliação do Terminal XXI, Sines

Relatório de Estágio para obtenção do grau de Mestre em Engenharia Civil

Ensaio de síntese crítica acerca do Cretácico terminal e do Paleogénico de Portugal

A synthetic essay about portuguese Late Cretaceous (Upper Campanian-Maastrichtian) and Paleogene is presented. This does include most of the so far known data, a critical approach to the problems of such formations, and to previous works on them. Our viewpoints (party original) are exposed in a shorter text in French where most of the discussion was suppressed (see reference in Resumo).

Le Crétacé terminal de Beira Litoral, Portugal: remarques stratigraphiques et écologiques,étude complémentaire de Rosasia soutoi (Chelonii, Bothremydidae)

The synthetic study of the uppermost Cretaceous of the Beira Litoral (fauna, flora) confirms its upper Campanian-Maastrichtian age. It shows the presence of a tropical to subtropical climate in an area constituted by a low coastal plain only occasionally linked to the sea, saturated with fresh water and possessing accordingly, a predominantely freshwater fauna (Viso, Aveiro); this plain changed towards the interior into a drier more forested zone with a more abundant terrestrial fauna which includes mammals (Taveiro). A thorough study of the chelonian Rosasia, abundant on the coastal plain, was made possible thanks to the discovery of a skull: it demonstrates that the genus belongs to the family Bothremydidae, revalided here. The composition of this family is presented, its phylogenetic and paleobiogeographic relation with the other pleurodires are analyzed, and its diagnosis established. The family is constituted of three groups; Rosasia belongs to one of these, the Bothremys group.