Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Introduction: Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. Methods: This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. Results: A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. Conclusions: AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Association between the degree of physical impairment from leprosy and dependence in activities of daily living among the elderly in a health unit in the State of Minas Gerais

Introduction In addition to the common alterations and diseases inherent in the aging process, elderly persons with a history of leprosy are particularly vulnerable to dependence because of disease-related impairments. Objective determine whether physical impairment from leprosy is associated with dependence among the elderly. Methods An analytical cross-sectional study of elderly individuals with a history of leprosy and no signs of cognitive impairment was conducted using a database from a former leprosy colony-hospital. The patients were evaluated for dependence in the basic activities of daily living (BADL) and instrumental activities of daily living (IADL), respectively) and subjected to standard leprosy physical disability grading. Subsequently, descriptive and univariate analyses were conducted, the latter using Pearson's chi-squared test. Results A total of 186 elderly persons were included in the study. Of these individuals, 53.8% were women, 49.5% were older than 75 years of age, 93% had four or less years of formal education, 24.2% lived in an institution for the long-term care of the elderly (ILTC), and 18.3% had lower limb amputations. Among those evaluated, 79.8% had visible physical impairments from leprosy (grade 2), 83.3% were independent in BADL, and 10.2% were independent in IADL. There was a higher impairment grade among those patients who were IADL dependent (p=0.038). Conclusion s: The leprosy physical impairment grade is associated with dependence for IADL, creating the need for greater social support and systematic monitoring by a multidisciplinary team. The results highlight the importance of early diagnosis and treatment of leprosy to prevent physical impairment and dependence in later years.

Who uses NHS saúde 24 hotline? Has the user changed over time?

There has been an increase in the use of telephone-based services and internet throughout the years and, therefore, the Saúde 24 Hotline has become an important service in Portugal. This service aims to screen, counsel and refer the patient in order to avoid unnecessary visits to health institutions and also to indicate the most appropriate resource according to the illness. This work has two different questions: the first one examines the determinants of satisfaction that have more influence on the overall satisfaction of the Saúde 24 Hotline users. The second one aims to analyze if the confidence level of the users is increasing over time, measured by following the recommendation. The first study was conducted on a random sample collected from June to October 2014, which was taken from the User Satisfaction Survey. The second approach includes data from January 2008 to December 2014 from the Clinical Data Base of all users who have called the Hotline. Findings suggest that the majority of users are very satisfied with the service and the variables with more impact on the overall satisfaction are commitment and availability from the nurse, adequacy of call duration and quick identification of the problem. The survey indicates that 94% of respondents follow the recommendation and on average people have called the hotline 3 times in the previous year. The results from the Clinical Database show that people who were recommended to go to the emergency room are more likely to follow the advice than the people who were recommended to book routine appointments

Nosocomial infections in a neonatal intensive care unit during 16 years: 1997-2012

Introduction Surveillance of nosocomial infections (NIs) is an essential part of quality patient care; however, there are few reports of National Healthcare Safety Network (NHSN) surveillance in neonatal intensive care units (NICUs) and none in developing countries. The purpose of this study was to report the incidence of NIs, causative organisms, and antimicrobial susceptibility patterns in a large cohort of neonates admitted to the NICU during a 16-year period. Methods The patients were followed 5 times per week from birth to discharge or death, and epidemiological surveillance was conducted according to the NHSN. Results From January 1997 to December 2012, 4,615 neonates, representing 62,412 patient-days, were admitted to the NICU. The device-associated infection rates were as follows: 17.3 primary bloodstream infections per 1,000 central line-days and 3.2 pneumonia infections per 1,000 ventilator-days. A total of 1,182 microorganisms were isolated from sterile body site cultures in 902 neonates. Coagulase-negative staphylococci (CoNS) (34.3%) and Staphylococcus aureus (15.6%) were the most common etiologic agents isolated from cultures. The incidences of oxacillin-resistant CoNS and Staphylococcus aureus were 86.4% and 28.3%, respectively. Conclusions The most important NI remains bloodstream infection with staphylococci as the predominant pathogens, observed at much higher rates than those reported in the literature. Multiresistant microorganisms, especially oxacillin-resistant staphylococci and gram-negative bacilli resistant to cephalosporin were frequently found. Furthermore, by promoting strict hygiene measures and meticulous care of the infected infants, the process itself of evaluating the causative organisms was valuable.

Evaluation of the predictive indices for candidemia in an adult intensive care unit

INTRODUCTION: To evaluate predictive indices for candidemia in an adult intensive care unit (ICU) and to propose a new index. METHODS: A prospective cohort study was conducted between January 2011 and December 2012. This study was performed in an ICU in a tertiary care hospital at a public university and included 114 patients staying in the adult ICU for at least 48 hours. The association of patient variables with candidemia was analyzed. RESULTS: There were 18 (15.8%) proven cases of candidemia and 96 (84.2%) cases without candidemia. Univariate analysis revealed the following risk factors: parenteral nutrition, severe sepsis, surgical procedure, dialysis, pancreatitis, acute renal failure, and an APACHE II score higher than 20. For the Candida score index, the odds ratio was 8.50 (95% CI, 2.57 to 28.09); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.78, 0.71, 0.33, and 0.94, respectively. With respect to the clinical predictor index, the odds ratio was 9.45 (95%CI, 2.06 to 43.39); the sensitivity, specificity, positive predictive value, and negative predictive value were 0.89, 0.54, 0.27, and 0.96, respectively. The proposed candidemia index cutoff was 8.5; the sensitivity, specificity, positive predictive value, and negative predictive value were 0.77, 0.70, 0.33, and 0.94, respectively. CONCLUSIONS: The Candida score and clinical predictor index excluded candidemia satisfactorily. The effectiveness of the candidemia index was comparable to that of the Candida score.

A public transport bus assignment problem: parallel metaheuristics assessment

Combinatorial Optimization Problems occur in a wide variety of contexts and generally are NP-hard problems. At a corporate level solving this problems is of great importance since they contribute to the optimization of operational costs. In this thesis we propose to solve the Public Transport Bus Assignment problem considering an heterogeneous fleet and line exchanges, a variant of the Multi-Depot Vehicle Scheduling Problem in which additional constraints are enforced to model a real life scenario. The number of constraints involved and the large number of variables makes impracticable solving to optimality using complete search techniques. Therefore, we explore metaheuristics, that sacrifice optimality to produce solutions in feasible time. More concretely, we focus on the development of algorithms based on a sophisticated metaheuristic, Ant-Colony Optimization (ACO), which is based on a stochastic learning mechanism. For complex problems with a considerable number of constraints, sophisticated metaheuristics may fail to produce quality solutions in a reasonable amount of time. Thus, we developed parallel shared-memory (SM) synchronous ACO algorithms, however, synchronism originates the straggler problem. Therefore, we proposed three SM asynchronous algorithms that break the original algorithm semantics and differ on the degree of concurrency allowed while manipulating the learned information. Our results show that our sequential ACO algorithms produced better solutions than a Restarts metaheuristic, the ACO algorithms were able to learn and better solutions were achieved by increasing the amount of cooperation (number of search agents). Regarding parallel algorithms, our asynchronous ACO algorithms outperformed synchronous ones in terms of speedup and solution quality, achieving speedups of 17.6x. The cooperation scheme imposed by asynchronism also achieved a better learning rate than the original one.

Snakebites as a largely neglected problem in the Brazilian Amazon: highlights of the epidemiological trends in the State of Amazonas

Envenoming snakebites are thought to be a particularly important threat to public health worldwide, especially in rural areas of tropical and subtropical countries. The true magnitude of the public health threat posed by snakebites is unknown, making it difficult for public health officials to optimize prevention and treatment. The objective of this work was to conduct a systematic review of the literature to gather data on snakebite epidemiology in the Amazon region and describe a case series of snakebites from epidemiological surveillance in the State of Amazonas (1974-2012). Only 11 articles regarding snakebites were found. In the State of Amazonas, information regarding incidents involving snakes is scarce. Historical trends show an increasing number of cases after the second half of the 1980s. Snakebites predominated among adults (20-39 years old; 38%), in the male gender (78.9%) and in those living in rural areas (85.6%). The predominant snake envenomation type was bothropic. The incidence reported by the epidemiological surveillance in the State of Amazonas, reaching up to 200 cases/100,000 inhabitants in some areas, is among the highest annual snakebite incidence rates of any region in the world. The majority of the cases were reported in the rainy season with a case-fatality rate of 0.6%. Snakebite envenomation is a great disease burden in the State of Amazonas, representing a challenge for future investigations, including approaches to estimating incidence under-notification and case-fatality rates as well as the factors related to severity and disabilities.

Optimization of wastewater quality in the Sines refinery

In order to address and resolve the wastewater contamination problem of the Sines refinery with the main objective of optimizing the quality of this stream and reducing the costs charged to the refinery, a dynamic mass balance was developed nd implemented for ammonia and polar oil and grease (O&G) contamination in the wastewater circuit. The inadequate routing of sour gas from the sour water stripping unit and the kerosene caustic washing unit, were identified respectively as the major source of ammonia and polar substances present in the industrial wastewater effluent. For the O&G content, a predictive model was developed for the kerosene caustic washing unit, following the Projection to Latent Structures (PLS) approach. Comparison between analytical data for ammonia and polar O&G concentrations in refinery wastewater originating from the Dissolved Air Flotation (DAF) effluent and the model predictions of the dynamic mass balance calculations are in a very good agreement and highlights the dominant impact of the identified streams for the wastewater contamination levels. The ammonia contamination problem was solved by rerouting the sour gas through an existing clogged line with ammonia salts due to a non-insulated line section, while for the O&G a dynamic mass balance was implemented as an online tool, which allows for prevision of possible contamination situations and taking the required preventive actions, and can also serve as a basis for establishing relationships between the O&G contamination in the refinery wastewater with the properties of the refined crude oils and the process operating conditions. The PLS model developed could be of great asset in both optimizing the existing and designing new refinery wastewater treatment units or reuse schemes. In order to find a possible treatment solution for the spent caustic problem, an on-site pilot plant experiments for NaOH recovery from the refinery kerosene caustic washing unit effluent using an alkaline-resistant nanofiltration (NF) polymeric membrane were performed in order to evaluate its applicability for treating these highly alkaline and contaminated streams. For a constant operating pressure and temperature and adequate operating conditions, 99.9% of oil and grease rejection and 97.7% of chemical oxygen demand (COD) rejection were observed. No noticeable membrane fouling or flux decrease were registered until a volume concentration factor of 3. These results allow for NF permeate reuse instead of fresh caustic and for significant reduction of the wastewater contamination, which can result in savings of 1.5 M€ per year at the current prices for the largest Portuguese oil refinery. The capital investments needed for implementation of the required NF membrane system are less than 10% of those associated with the traditional wet air oxidation solution of the spent caustic problem. The operating costs are very similar, but can be less than half if reusing the NF concentrate in refinery pH control applications. The payback period was estimated to be 1.1 years. Overall, the pilot plant experimental results obtained and the process economic evaluation data indicate a very competitive solution through the proposed NF treatment process, which represents a highly promising alternative to conventional and existing spent caustic treatment units.

Analysis of a controversial decision process: the case of the pumped hydro storage power plant Atdorf in Germany

Based on the report for the unit “Métodos Interactivos de Participação e Decisão A” (Interactive methods of participation and decision A), coordinated by Prof. Lia Maldonado Teles de Vasconcelos and Prof. Nuno Miguel Ribeiro Videira Costa. This unit was provided for the PhD Program in Technology Assessment in 2015/2016.

Characterization of newborns with nonimmune hydrops fetalis admitted to a neonatal intensive care unit

PURPOSE: To determine the incidence and characteristics of nonimmune hydrops fetalis in the newborn population. METHOD: A retrospective study of the period between 1996 and 2000, including all newborns with a prenatal or early neonatal diagnosis of nonimmune hydrops fetalis, based on clinical history, physical examination, and laboratory evaluation. The following were analyzed: prenatal follow-up, delivery type, gender, birth weight, gestational age, presence of perinatal asphyxia, nutritional classification, etiopathic diagnosis, length of hospital stay, mortality, and age at death. RESULTS: A total of 47 newborns with hydrops fetalis (0.42% of live births), 18 (38.3%) with the immune form and 29 (61.7%) with the nonimmune form, were selected for study. The incidence of nonimmune hydrops fetalis was 1 per 414 neonates. Data was obtained from 21 newborns, with the following characteristics: 19 (90.5%) were suspected from prenatal diagnosis, 18 (85.7%) were born by cesarean delivery, 15 (71.4%) were female, and 10 (47.6%) were asphyxiated. The average weight was 2665.9 g, and the average gestational age was 35 3/7 weeks; 14 (66.6%) were preterm; 18 (85.0 %) appropriate delivery time; and 3 (14.3%) were large for gestational age. The etiopathic diagnosis was determined for 62%, which included cardiovascular (19.0%), infectious (9.5%), placental (4.8%), hematologic (4.7%), genitourinary (4.8%), and tumoral causes (4.8%), and there was a combination of causes in 9.5%. The etiology was classified as idiopathic in 38%. The length of hospital stay was 26.6 ± 23.6 days, and the mortality rate was 52.4%. CONCLUSIONS: The establishment of a suitable etiopathic diagnosis associated with prenatal detection of nonimmune hydrops fetalis can be an important step in reducing the neonatal mortality rate from this condition.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

The effect of deforestation on the water cycle in the amazon basin: an attempt reformulate the problem

If widespread deforestation in Amazon results in reduced evaporative water flux, then either a decrease in evaporation is compensated locally by reduced rainfall,or else changed moisture balance expresses itself downwind in the yet undisturbed forest. The question of where rain will occur is crucial. It is suggested that the appearance of clouds and the occurrence of rainout is governed primarily by the interplay of local meteorologic and physical geography parameters with the atmospheric stability structure except for a few well-defined periods when rain is dominated by large scale atmospheric instability. This means that the study of these phenomena (local heat balances,studies on cloud formation mechanism, vertical atmospheric stability, etc.) must be made on the scale of the cloud size, a few tens of kilometers at most.

Influence of employee volunteering on brand commitment

Purpose – The purpose of this paper is to explore the impact of corporate volunteering on employee bonding and to understand the barriers and motivation to participation in these events. In contrast to other studies the participants volunteer in their spare time without expecting any financial reward. Design/methodology/approach – Employees (n 3951) of a logistic company participated in the study based on an online questionnaire with 6 items and open questions. The employee sample was divided into 3 groups depending on the frequency of participation in volunteering events. Findings – Significant differences were found on bonding between the three groups. In addition, the relevance of control variables like gender, age and job level were obtained. Furthermore a moderation effect of motivation was found. The results were interpreted within the broader context that ties motivation theory, organizational identification and social exchange theory.

Perception of organizational politics and the effect of authenticity and affective commitment on deviance and task performance in contact centers

This study aimed to understand employees’ reactions to organizational politics in Contact Centers. Drawing from a sample of 187 supervisor-employee dyads, we studied the relationship between employees’ perceptions of organizational politics and supervisor-rated task performance and deviance, and mediation effects by authenticity at work and affective commitment. Results indicate that workers tend to react to workplace politics with deviant behavior and worse task performance. We found that the relationship between perceived politics and task performance was mediated by authenticity. The relationship between perceived politics and supervisor-rated deviance was mediated by affective commitment to the organization. Implications for management are discussed.