Increasing the percentage of vaginal birth in the private sector in Brazil through the redesign of care model

OBJETIVO: Implantar um novo modelo de cuidado ao parto e reduzir o percentual de cesarianas entre as gestantes da UNIMED Jaboticabal.MÉTODOS: Estudo descritivo desenvolvido em uma instituição do interior paulista, que teve início em 2012 e propôs o redesenho do modelo de cuidado ao parto com a revisão de todo o processo assistencial por meio da Ciência da Melhoria Contínua. Para medir os resultados das mudanças, foram selecionados nove indicadores e suas respectivas metas.RESULTADOS: O indicador de partos vaginais atingiu a meta de 40%, após sete meses do início da intervenção. Este indicador entre as gestantes do SUS atingiu 66%. A taxa de mortalidade perinatal decresceu 25% comparando-se 2012 a 2014 e a taxa de prematuridade foi de 3/100 nascidos vivos em 2014. O percentual de gestantes da UNIMED com 6 ou mais consultas de pré-natal atingiu 95%. Em relação aos custos hospitalares per capita referentes à assistência ao parto, notou-se um decréscimo de 27%, quando comparados os anos de 2012 e 2013. Tal queda não se sustentou e o custo hospitalar per capita, em 2014, retornou aos mesmos patamares de 2012. A remuneração dos obstetras registrou um acréscimo de 72%, se comparados os anos de 2012, 2013 e 2014. Houve queda de 61% dos custos com a unidade de terapia intensiva (UTI) neonatal, comparando os anos de 2012 e 2013. A taxa de admissão em UTI neonatal acompanhou a redução dos custos e foi de 55%, se comparados os anos de 2012 a 2014, entre as gestantes da UNIMED. Não houve o alcance da meta de 80% de participação das gestantes nos cursos de preparação para o nascimento. A porcentagem de gestantes satisfeitas e muito satisfeitas com a assistência ao parto atingiu 86%.CONCLUSÃO: Este projeto atingiu seus objetivos, reduzindo o percentual de cesarianas entre as gestantes da UNIMED Jaboticabal, e constituiu-se em um exemplo concreto da realização do triplo objetivo em saúde: melhorar a experiência dos envolvidos e os resultados de saúde de populações e indivíduos e realizar estas duas tarefas com menor custo, eliminando desperdícios assistenciais.

Idiosyncratic volatility around information release date

Several papers document idiosyncratic volatility is time-varying and many attempts have been made to reveal whether idiosyncratic risk is priced. This research studies behavior of idiosyncratic volatility around information release dates and also its relation with return after public announcement. The results indicate that when a company discloses specific information to the market, firm’s specific volatility level shifts and short-horizon event-induced volatility vary significantly however, the category to which the announcement belongs is not important in magnitude of change. This event-induced volatility is not small in size and should not be downplayed in event studies. Moreover, this study shows stocks with higher contemporaneous realized idiosyncratic volatility earn lower return after public announcement consistent with “divergence of opinion hypothesis”. While no significant relation is found between EGARCH estimated idiosyncratic volatility and return and also between one-month lagged idiosyncratic volatility and return presumably due to significant jump around public announcement both may provide some signals regarding future idiosyncratic volatility through their correlations with contemporaneous realized idiosyncratic volatility. Finally, the study show that positive relation between return and idiosyncratic volatility based on under-diversification is inadequate to explain all different scenarios and this negative relation after public announcement may provide a useful trading rule.

A surveillance of enteropathogens in piglets from birth to seven days of age in Brazil

The purpose of the study was to evaluate the real importance of anaerobic enteropathogens and rotavirus in contrast to more common agents as cause of diarrhea in piglets within the first week of life. Sixty 1- to 7-day-old piglets, 30 diarrheic and 30 non-diarrheic (control), from 15 different herds were selected, euthanized and necropsied. Samples of the jejunum, ileum, colon, cecum and feces were collected from the piglets and analyzed to determine the presence of the following enteropathogens: enterotoxigenic Escherichia coli (ETEC), Clostridium perfringens types A and C, Clostridium difficile, rotavirus and Isospora suis. Among diarrheic piglets, 23.3% were positive for C. difficile, 70% for C. perfringens type A cpb2+, 14.3% for rotavirus and 10% for ETEC. Among non-diarrheic control piglets, 10% were positive for C. difficile, 76.7% for C. perfringens type A cpb2+, 0% for rotavirus, 3.3% for ETEC and 3.3% for I. suis. C. perfringens type C was not detected in any of the animals. Histological lesions characteristic of C. difficile, E. coli and rotavirus were observed. However, no C. perfringens type A suggestive lesions were detected. There was a positive correlation between mesocolon edema and the presence of C. difficile toxins. Although C. perfringens type A cpb2+ was the most frequently detected enteropathogen, there was no association between its presence and diarrhea or macro or microscopic changes. C. difficile and Rotavirus were the most relevant pathogens involved with neonatal diarrhea in this study, and histopathology associated with microbiological test proved to be the key to reach a final diagnosis.

Montague ja Capulet, Julian hauta, Tyttöjen tanssi baletista Romeo ja Julia

Soitinnus: orkesteri.

EFFECTS OF PLANTING DATE AND SPATIAL ARRANGEMENT ON COMMON BEAN (Phaseolus vulgaris) YIELD UNDER WEED-FREE AND WEEDY CONDITIONS

ABSTRACTTo evaluate the effect of planting date and spatial pattern on common bean yield under weed-free and weed-infested conditions, an experiment was conducted in Kelachay, Northern Iran, in 2013. The experimental design was a randomized complete block in a factorial arrangement with three replicates. Factors were planting date (10 August and 20 August), spatial pattern (square and rectangular planting pattern, with a planting distance of 30 x 30 cm and 45 x 20 cm, respectively), and weed management regime (weed-free and weedy conditions, weeded and not weeded throughout the growing season, respectively). Results showed that the main effect of planting date was significant only for pod number per plant and seed number per pod. At the same time, pod number per plant, seed number per pod, pod length, and grain yield were influenced significantly by spatial pattern. Results of ANOVA have also indicated that all traits, except pod length, were influenced significantly by weed-management regimes. Moreover, effect of planting date and spatial pattern were nonsignificant for weed dry weight. Mean comparison has expressed a significant increment in seed yield for square planting arrangement (1,055 kg ha-1) over rectangular (971 kg ha-1). Weeding has also presented an overall 12% and 8% improvement in grain and pod yield over control (weedy check), respectively. Based on the results of this study, weed control, as well as square planting pattern, are recommended for obtaining the highest seed yield in common bean.

Daily birth numbers in Passo Fundo, South Brazil, 1997-1999: trends and periodicities

Between October 6, 1997 and April 30, 1999, 5011 births (mean: 8.76 per day) were registered in the city of Passo Fundo, South Brazil. The sequence of 572 daily birth numbers was not random (iteration test). Neyman distribution (m = ¥) showed the best fit. Clusters of days with higher birth numbers alternated with days with low numbers of births. Periodogram analysis revealed a significant periodicity of 6.98 days. The cosinor regression, testing 10 a priori supposed period lengths, found significant seasonality peaking in August-September and significantly highest birth numbers on Thursdays. Among the lunar and solar rotation cycles, the tropic lunar cycle and its 4th harmonic were most pronounced, in agreement with results concerning natality in Germany obtained by Svante Arrhenius in the 19th century. These findings confirm Derer-Halberg's concept of multiseptans. In addition to cycling, a significantly increasing linear trend with a daily increase of 0.0045 births was encountered. This documents a growth of the population in agreement with national statistical data.

Prenatal and perinatal risk factors for bipolar disorder

Bipolar disorder (BPD) is a severe mental disorder associated with considerable morbidity and mortality. Prenatal insults have been shown to be associated with later development of mental disorders and there is a growing interest in the potential role of prenatal and perinatal risk factors in the development of BPD. The aims of this thesis were to describe the overall study design of the Finnish Prenatal Study of Bipolar Disorders (FIPS-B) and demographic characteristics of the sample. Furthermore, it was aimed to examine the association of parental age, parental age difference, perinatal complications and maternal smoking during pregnancy with BPD. This thesis is based on FIPS-B, a nested case-control study using several nationwide registers. The cases included all people born in Finland between January 1st 1983 and December 31st 1998 and diagnosed with BPD according to the Finnish Hospital Discharge Register (FHDR) before December 31st 2008. Controls for this study were people who were without BPD, schizophrenia or diagnoses related to these disorders, identified from the Population Register Centre (PRC), and matched two-fold to the cases on sex, date of birth (+/- 30 days), and residence in Finland on the first day of diagnosis of the matched case. Conditional logistic regression models were used to examine the association between risk factors and BPD. This study included 1887 BPD cases and 3774 matched controls. The mean age at diagnosis was 19.3 years and females accounted for 68% of the cases. Mothers with the lowest educational level had the highest odds of having BPD in offspring. Being born in Eastern and Southern region of Finland increased the odds of having BPD later in life. A U-shaped distribution of odds ratio was observed between paternal age and BPD in the unadjusted analysis. Maternal age and parental age difference was not associated with BPD. Birth by planned caesarean section was associated with increased odd of BPD. Smoking during pregnancy was not associated with BPD in the adjusted analyses. Region of birth and maternal educational level were associated with BPD. Both young and old father’s age was associated with BPD. Most perinatal complications and maternal smoking during pregnancy were not associated with BPD. The findings of this thesis, considered together with previous literature, suggest that the pre- and perinatal risk factor profile varies among different psychiatric disorders.

Health in early adulthood: the contribution of the 1978/79 Ribeirão Preto birth cohort

The increase in non-communicable chronic diseases of adults is due to demographic changes and changes in the risk factors related to physical activity, smoking habits and nutrition. We describe the methodology for the evaluation of persons at 23/25 years of age of a cohort of individuals born in Ribeirão Preto in 1978/79. We present their socioeconomic characteristics and the profile of some risk factors for chronic diseases. A total of 2063 participants were evaluated by means of blood collection, standardized questionnaires, anthropometric and blood pressure measurements, and methacholine bronchoprovocation tests. The sexes were compared by the chi-square test, with alpha = 0.05. Obesity was similar among men and women (12.8 and 11.1%); overweight was almost double in men (30.3 vs 17.7%). Weight deficit was higher among women than among men (8.6 and 2.6%). Women were more sedentary and consumed less alcohol and tobacco. Dietary fat consumption was similar between sexes, with 63% consuming large amounts (30 to 39.9 g/day). Metabolic syndrome was twice more frequent among men than women (10.7 vs 4.8%), hypertension was six times more frequent (40.9 vs 6.4%); altered triglyceride (16.1 vs 9.8%) and LDL proportions (5.4 vs 2.7%) were also higher in men, while women had a higher percentage of low HDL (44.7 vs 39.5%). Asthma and bronchial hyper-responsiveness were 1.7 and 1.5 times more frequent, respectively, among women. The high prevalence of some risk factors for chronic diseases among young adults supports the need for investments in their prevention.

Inadequate utilization of prenatal care in two Brazilian birth cohorts

Data for two birth cohorts from two Brazilian municipalities, Ribeirão Preto in 1994 and São Luís in 1997/1998, were used to identify and compare factors associated with inadequate utilization of prenatal care and to identify factors capable of explaining the differences observed between the two cities. Prenatal care was defined as adequate or inadequate according to the recommendations of the Brazilian Ministry of Health. The chi-square test and Poisson regression were used to compare differences in the inadequacy of prenatal care utilization. The percentage of inadequacy was higher in São Luís (34.6%) than in Ribeirão Preto (16.9%). Practically the same variables were associated with inadequacy in both cities. Puerperae with lower educational level, without a companion or cohabiting, who delivered in public health units, younger than 20 years, multiparae and smokers, with low family income presented higher percentages of inadequate prenatal care utilization. However, the effects of some variables differed between the two cities. The risk for inadequate use of prenatal care was higher for women attended in the public health sector in São Luís and for cohabiting women in Ribeirão Preto. The effect of the remaining factors studied did not differ between cities. The category of admission accounted for 57.0% of the difference in the inadequate use of prenatal care between cities and marital status accounted for 45.3% of the difference. Even after adjustment for all variables, part of the difference in the inadequacy of prenatal care utilization remained unexplained.

Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA

We describe three birth cohort studies, respectively carried out in 1978/79 and 1994 in Ribeirão Preto, a city located in the most developed region of Brazil, and in 1997/98 in São Luís, a city located in a less developed region. The objective of the present report was to describe the methods used in these three studies, presenting their history, methodological design, objectives, developments, and difficulties faced along 28 years of research. The first Ribeirão Preto study, initially perinatal, later encompassed questions regarding the repercussions of intrauterine development on future growth and chronic adult diseases. The subjects were evaluated at birth (N = 6827), at school age (N = 2861), at the time of recruitment for military service (N = 2048), and at 23/25 years of age (N = 2063). The study of the second cohort, which started in 1994 (N = 2846), permitted comparison of aspects of perinatal health between the two groups in the same region, such as birth weight, mortality and health care use. In 1997/98, a new birth cohort study was started in São Luís (N = 2443), capital of the State of Maranhão. The 1994 Ribeirão Preto cohort and the São Luís cohort are in the second phase of joint follow-up. These studies permit comparative temporal analyses in the same place (Ribeirão Preto 1978/79 and 1994) and comparisons of two contrasting populations regarding cultural, economic and sociodemographic conditions (Ribeirão Preto and São Luís).

Are birth weight and maternal smoking during pregnancy associated with malnutrition and excess weight among school age children?

In the late 1980's child malnutrition was still prevalent in Brazil, and child obesity was beginning to rise in the richest regions of the country. To assess the extent of the nutritional transition during the period and the influence of birth weight and maternal smoking on the nutritional condition of schoolchildren, we estimated the prevalence of excess weight and malnutrition in a cohort of Brazilian schoolchildren from 1987 to 1989. We calculated the body mass index (BMI) of 8- to 10-year-old schoolchildren born in Ribeirão Preto in 1978/79. We considered children with a BMI <5th percentile (P5) to be malnourished, children with P5³BMIbirth factors (infant weight, sex, preterm delivery, number of pregnancies, maternal smoking during pregnancy, marital status, and schooling) and type of school using nominal logistic regression. A total of 2797 schoolchildren were evaluated. There was a significant prevalence of malnutrition (9.5%) and excess weight already tended to increase (15.7%), while 6.4% of the children were obese. Excess weight was more prevalent among children attending private schools (odds ratio, OR = 2.27) and firstborn children (OR = 1.69). Maternal smoking during pregnancy protected against malnutrition (OR = 0.56), while children with lower birth weight were at higher risk for malnutrition (OR = 4.23). We conclude that a nutritional transition was under way while malnutrition was still present, but excess weight and related factors were already emerging.

Examining life-course influences on chronic disease: the Ribeirão Preto and São Luís birth cohort studies (Brazil)

More than any other low- and middle-income country, Brazil has the longest research tradition of establishing, maintaining and exploiting birth cohort studies. This research pedigree is highlighted in the present issue of the Brazilian Journal of Medical and Biological Research, which contains a series of twelve papers from the Ribeirão Preto and São Luis birth cohort studies from the Southeast and Northeast of Brazil, respectively. The topics covered in this raft of reports vary and include predictors of perinatal health and maternal risk factors, early life determinants of cardiovascular risk factors in childhood and adolescence, use of health services, and a description of dietary characteristics of young adults, amongst other topics. There is also a guide to the background, objectives, sampling and protocols employed across these studies, which, together with similar pieces published in past issues of the Brazilian Journal, serve as a very useful starting point, particularly for potential collaborators. In the fervent hope that further follow-up of these cohorts will take place - we provide our own justification for cohort maintenance and extension in this issue - future data collection could include: genetic material, atherosclerosis, ascertained, for instance, by intima-media thickness, and IQ testing in children - scores from which are emerging as potentially important predictors of adult health outcomes up to six decades later.

Examining life-course influences on chronic disease: the importance of birth cohort studies from low- and middle- income countries. An overview

The objectives of this overview are to describe the past and potential contributions of birth cohorts to understanding chronic disease aetiology; advance a justification for the maintenance of birth cohorts from low- and middle-income countries (LMIC); provide an audit of birth cohorts from LMIC; and, finally, offer possible future directions for this sphere of research. While the contribution of birth cohorts from affluent societies to understanding disease aetiology has been considerable, we describe several reasons to anticipate why the results from such studies might not be directly applied to LMIC. More than any other developing country, Brazil has a tradition of establishing, maintaining and exploiting birth cohort studies. The clear need for a broader geographical representation may be precipitated by a greater collaboration worldwide in the sharing of ideas, fieldwork experience, and cross-country cohort data comparisons in order to carry out the best science in the most efficient manner. This requires the involvement of a central overseeing body - such as the World Health Organization - that has the respect of all countries and the capacity to develop strategic plans for `global' life-course epidemiology while addressing such issues as data-sharing. For rapid progress to be made, however, there must be minimal bureaucratic entanglements.