Health in Brazil 4 Chronic non-communicable diseases in Brazil: burden and current challenges

Non-communicable diseases (NCDs) have become a major health priority in Brazil-72% of all deaths were attributable to NCDs in 2007. They are also the main source of disease burden, with neuropsychiatric disorders being the single largest contributor. Morbidity and mortality due to NCDs are greatest in the poor population. Although the crude NCD mortality increased 5% between 1996 and 2007, age-standardised mortality declined by 20%. Declines were primarily for cardiovascular and chronic respiratory diseases, in association with the successful implementation of health policies that lead to decreases in smoking and the expansion of access to primary health care. Of note, however, the prevalence of diabetes and hypertension is rising in parallel with that of excess weight; these increases are associated with unfavourable changes of diet and physical activity. Brazil has implemented major policies for the prevention of NCDs, and its age-adjusted NCD mortality is falling by 1.8% per year. However, the unfavourable trends for most major risk factors pose an enormous challenge and call for additional and timely action and policies, especially those of a legislative and regulatory nature and those providing cost-effective chronic care for individuals affected by NCDs.

A subunit vaccine based on biodegradable microspheres carrying rHsp65 protein and KLK protects BALB/c mice against tuberculosis infection

Of the hundreds of new tuberculosis ( TB) vaccine candidates some have therapeutic value in addition to their prophylactic properties. This is the case for the DNA vaccine encoding heat-shock protein 65 (DNAhsp65) from Mycobacterium leprae. However, there are concerns about the use of DNA vaccines in certain populations such as newborns and pregnant women. Thus, the optimization of vaccination strategies that circumvent this limitation is a priority. This study evaluated the efficacy of a single dose subunit vaccine based on recombinant Hsp65 protein against infection with M. tuberculosis H37Rv. The Hsp65 protein in this study was either associated or not with immunostimulants, and was encapsulated in biodegradable PLGA microspheres. Our results demonstrate that the protein was entrapped in microspheres of adequate diameter to be engulfed by phagocytes. Mice vaccinated with a single dose of Hsp65-microspheres or Hsp65 + CpG-microspheres developed both humoral and cellular-specific immune responses. However, they did not protect mice against challenge with M. tuberculosis. By contrast, Hsp65+KLK-microspheres induced specific immune responses that reduced bacilli loads and minimized lung parenchyma damage. These data suggest that a subunit vaccine based on recombinant protein Hsp65 is feasible.

Effects of the pendulum appliance, cervical headgear, and 2 premolar extractions followed by fixed appliances in patients with Class II malocclusion

Introduction: In this retrospective study, we compared the cephalometric effects, the dental-arch changes, and the efficiency of Class II treatment with the pendulum appliance, cervical headgear, or extraction of 2 maxillary premolars, all associated with fixed appliance therapy. Methods: The sample of 82 patients with Class II malocclusion was divided into 3 groups: group 1 patients (n = 22; treatment time, 3.8 years) were treated with the pendulum appliance and fixed orthodontic appliances. Group 2 patients (n = 30; treatment time, 3.2 years) were treated with cervical headgear followed by fixed appliances; group 3 patients (n = 30; treatment time, 2.1 years) were treated with 2 maxillary premolar extractions and fixed appliances. The average starting ages of the groups ranged from 13.2 to 13.8 years. Data were obtained from serial cephalometric measurements and dental casts. The dental casts were analyzed with the treatment priority index. The treatment efficiency index was also used. Results: The 3 treatment protocols produced similar cephalometric effects, especially skeletally. Comparisons among the 2 distalizing appliances (pendulum and cervical headgear) and extraction of 2 maxillary premolars for Class II treatment showed changes primarily in the maxillary dentoalveolar component and dental relationships. The facial profile was similar after treatment, except for slightly more retrusion of the upper lip in the extraction patients. The treatment priority index demonstrated that occlusal outcomes also were similar among the groups. The treatment efficiency index had higher values for the extraction group. Conclusions: The effects of treatment with the pendulum appliance or cervical headgear and extraction of 2 maxillary premolars associated with fixed appliances were similar from both occlusal and cephalometric standpoints. Class II treatment with extraction of maxillary teeth was more efficient because of the shorter treatment time. Differences in maxillary incisor retraction should be noted, but these differences might have been due to greater maxillary dentoalveolar protrusion in the extraction group before treatment. (Am J Orthod Dentofacial Orthop 2009;136:833-42)

Relationship between malocclusion severity and treatment success rate in Class II nonextraction therapy

Introduction: The purpose of this study was to evaluate the treatment success rate of Class II malocclusion without extractions, according to initial severity. Methods: Class II subjects (n = 276) were divided into 2 groups according to the severity of the malocclusion. Group 1 comprised 144 patients with bilateral half Class II malocclusion at the initial mean age of 12.27 years. Group 2 comprised 132 patients who initially had bilateral complete Class II malocclusion at the initial mean age of 12.32 years. The patients` initial and final study models were evaluated with Grainger`s treatment priority index. Chi-square tests were used to test for differences between the 2 groups for categorical variables. Variables regarding occlusal results were compared with independent t tests. Results: Group 1 had a significantly better final occlusal result, a shorter treatment time, and a higher treatment efficiency index. Conclusions: Based on these results, it was concluded that bilateral half Class II malocclusion has a better treatment success rate than bilateral complete Class II malocclusion when treatment is conducted without extractions. (Am J Orthod Dentofacial Orthop 2009; 135: 274.e1-274.e8)

Comparison of the effects produced by headgear and pendulum appliances followed by fixed orthodontic treatment

This study compared the effects produced by two different molar distalizers, namely cervical headgear (CHG) and the intraoral pendulum appliance, associated with fixed orthodontic appliances. The headgear group comprised 30 patients (19 females, 11 males), with an initial age of 13.07 years [standard deviation (SD) = 1.3], treated with CHG and fixed orthodontic appliances for a mean period of 3.28 years, and the pendulum group 22 patients (15 females, 7 males), with initial age of 13.75 years (SD = 1.86), treated with the pendulum appliance followed by fixed orthodontic appliances for a mean period of 4.12 years. Lateral cephalograms were taken at the start (T1) and on completion (T2) of orthodontic treatment. The pendulum and CHG groups were similar as to initial age, severity of the Class II malocclusion, gender distribution, initial cephalometric characteristics, and initial and final treatment priority index (TPI). Only treatment time was not similar between the groups, with a need for annualization for data for the pendulum group. The data were compared with independent t-tests. There was significantly greater restriction of maxillary forward growth and improvement of the skeletal maxillomandibular relationship in the CHG group (P < 0.05). The maxillary molars were more mesially tipped and extruded and the mandibular molars more uprighted in the CHG group compared with the pendulum group (P < 0.05). There was more labial tipping of the mandibular incisors and greater overbite reduction in the pendulum group. The pendulum appliance produced only dentoalveolar effects, different from the CHG appliance, which restricted maxillary forward displacement, thus improving the skeletal maxillomandibular relationship.

Influence of cephalometric characteristics on the occlusal success rate of Class II malocclusions treated with 2-and 4-premolar extraction protocols

Introduction: The objectives of this investigation were to compare the initial cephalometric characteristics of complete Class II Division 1 malocclusions treated with 2 or 4 premolar extractions and to verify their influence on the occlusal success rate of these treatment protocols. Methods: A sample of 98 records from patients with complete Class II Division 1 malocclusion was divided into 2 groups with the following characteristics: group 1 consisted of 55 patients treated with 2 maxillary first premolar extractions at an initial mean age of 13.07 years; group 2 included 43 patients treated with 4 premolar extractions, with an initial mean age of 12.92 years. Initial and final occlusal statuses were evaluated on dental casts with Grainger`s treatment priority index (TPI), and the initial cephalometric characteristics were obtained from the pretreatment cephalograms. The initial cephalometric characteristics and the initial and final occlusal statuses of the groups were compared with the t test. A multiple regression analysis was used to evaluate the influence of all variables in the final TPI. Results: The 2-premolar extraction protocol provided a statistically smaller TPI and consequently a better occlusal success rate than the 4-premolar extraction protocol. The 4-premolar extraction group had statistically smaller apical base lengths, more vertical facial growth patterns, and greater hard- and soft-tissue convexities at pretreatment than the 2-premolar extraction group. However, the multiple regression analysis showed that only the extraction protocol was significantly associated with the final occlusal status. Conclusions: The initial cephalometric characteristics of the groups did not influence the occlusal success rate of these 2 treatment protocols.

Towards a molecular epidemiology of alcohol dependence analysing the interplay of genetic and environmental risk factors

Background Progress in identifying genetic factors protective against alcohol dependence (AlcD) requires a paradigm shift in psychiatric epidemiology. Aims To integrate analysis of research into the genetics of alcoholism. Method Data from prospective questionnaire and interview surveys of the Australian twin panel, and from a subsample who underwent alcohol challenge, were analysed. Results In men, effects of alcohol dehydrogenase ADH2*1/*2 genotype or high alcohol sensitivity (risk-decreasing), and of history of childhood conduct disorder, or having monozygotic co-twin or twin sister with AlcD (risk-increasing) were significant and comparable in magnitude. Religious affiliation (Anglican versus other) was associated with the ADH2 genotype, but did not explain the associations with AlcD symptoms. No protective effect of the ADH2*1/*2 genotype was observed in women. Conclusions The early onset and strong familial aggregation of AlcD, and opportunity for within-family tests of genetic association to avoid confounding effects, make epidemiological family studies of adolescents and young adults and their families a priority.

Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: Findings from the WHO MONICA Project

Objectives. This report analyzes cigarette smoking over 10 years in populations in the World Health Organization (WHO) MONICA Project (to monitor trends and determinants of cardiovascular disease). Methods. Over 300 000 randomly selected subjects aged 25 to 64 years participated in surveys conducted in geographically defined populations. Results. For men, smoking prevalence decreased by more than 5% in 16 of the 36 study populations, remained static in most others, but increased in Beijing. Where prevalence decreased, this was largely due to higher proportions of never smokers in the younger age groups rather than to smokers quitting. Among women, smoking prevalence increased by more than 5% in 6 populations and decreased by more than 5% in 9 populations. For women, smoking tended to increase in populations with low prevalence and decrease in populations with higher prevalence; for men, the reverse pattern was observed. Conclusions. These data illustrate the evolution of the smoking epidemic in populations and provide the basis for targeted public health interventions to support the WHO priority for tobacco control.

Charles Handy: The exemplary guru

Among many managers Charles Handy might well be described as a ‘world class’ management thinker. He is certainly the first British management author to have achieved international guru status. The author of widely-commended management best-sellers and MBA set texts, known through broadcasting and management videos, he has presented himself more recently as a self-styled ‘social philosopher’. But just how philosophical is he? Does he offer genuinely new ideas? And what explains his vast appeal? Ashly Pinnington considers three works from Handy’s social philosopher period. He argues that they are conservative and focused on the interests of managers and business owners rather than employees or society as a whole. Like a mediaeval friar seeking converts, Handy uses mythic structures and exempla to invest his claims and propositions with plausibility and authority. Drawing on research into management gurus as a phenomenon, Ashly Pinnington concludes that when we read authors like Handy we should attend not merely to the ‘philosophy’ but also to the way narrative techniques are used in conveying ideological and moral messages.

The status of the Diplosentidae (Acanthocephala : Palaeacanthocephala) and a new family of acanthocephalans from Australian wrasses (Pisces : Labridae)

The status and composition of the Diplosentidae Tubangui et Masilungan, 1937 are reviewed. The type species of the type genus, Diplosentis amphacanthi Tubangui et Masilungan, 1937 from Siganus canaliculatus (Park, 1797) in the Philippines, is concluded to have been described inaccurately,in supposedly possessing, only two cement glands and lemnisci enclosed in a membranous sac. The species is almost certainly very close to species of Neorhadinorhynchus yamaguti, 1939 and Sclerocollum Schmidt of Paperna, 1978 which have also been reported from siganids from the tropical Indo-Pacific. Species of these genera have four cement glands and unexceptional lemnisci. As a result, Diplosentis Tubangui et Masilungan, 1937 is best considered to have affinities with the Cavisomidae Meyer, 1932. The Cavisomidae has priority over the Diplosentidae; thus the Diplosentidae becomes a synonym of the Cavisomidae. Neorhadinorhynchus and Sclerocollum are considered synonyms of Diplosentis. The affinities of the other species and genera formerly included in the Diplosentidae (other species of Diplosentis, Allorhadinorhynchus Yamaguti, 1959, Amapacanthus Salgado-Maldonado et Santos, 2000, Pararhadinorhynchus Johnston et Edmonds, 1947, Golvanorhynchus Noronha, do Fabio et Pinto, 1978 and Slendrorhynchus Amin et Soy, 1996) are discussed. It is concluded that all but Pararhadinorhynchus, two species of Diplosentis and Amapacanthus can be accommodated elsewhere satisfactorily. A new family, Transvenidae, is proposed for a small group of acanthocephalans that genuinely possess only two cement glands. Transvena annulospinosa gen. n., sp. n. is described from the labrids Anampses neoguinaicus Bleeker, 1878 (type host), A. geographicus Valenciennes, 1840, A. caeruleopunctatus Ruppell, 1829, Hemigymnus fasciatus (Bloch, 1792), and H. melapterus (Bloch, 1791) from the Great Barrier Reef, Queensland, Australia. Transvena gen. n. is distinguished from all other acanthocephalan genera by having a combination of a single ring of small spines on its trunk near or at the junction between the neck and trunk, two cement glands, a double-walled proboscis receptacle and hooks which decrease in length from the apex to the base of the proboscis. A second new genus within the Transvenidae, Trajectura, is proposed for T. perinsolens sp. n. from Anampses neoguinaicus, also from the Great Barrier Reef. Trajectura gen. n. is distinguished by the possession of only two cement glands and an anterior conical projection (function unknown) on the females. Diplosentis ikedai Machida, 1992 shares these characters and is recombined as Trajectura ikedai comb. n. Pararhadinorhynchus is transferred to the Transvenidae and Diplosentis manteri Gupta et Fatma, 1979 is recombined as Pararhadinorhynchus manteri comb. n.

From idola conceptiones to discourse analysis: A response to Bart Crum

Crum's notion of idola as a conceptual fallacy is interesting, somewhat helpful, yet potentially limiting in a critique of research in PE if one is to accept a postmodern or poststructuralist position. In line with a poststructuralist position, a strength in Crum's application of idola is the recognition that research in PE is constituted by the researcher and their social world which, in turn, constitutes the researcher. Limitations to Crum's idola thesis arise when the notion is used to suggest that as a result of the researcher's lack of conceptual clarity, the quest for knowledge or truth about PE pedagogy is undermined as this assumes that meanings can be unequivocal and precede a linear research process. In contrast, this response argues that a priority in research should be to examine how, and under what conditions, particular discourses come to shape PE practices in schools and universities. In a postmodern world, conceptual clarity should not be the goal but rather a coming to understand how PE knowledge and practice is being constructed across sites and contexts.

A methodology for discipline-specific curriculum development

A methodology and framework for discipline-specific curriculum development in a local context is described. These activities, as part of the Thailand-Australia Science and Engineering Assistance Project, were in response to a needs analysis for curriculum assistance to a number of publicly-funded Thai universities in the engineering priority area of Materials Processing and Manufacturing. The paper outlines a strategy for the delivery of a centralised curriculum development workshop for academic staff follow-up visits and local curriculum activities with participating universities, and the presentation of technical short courses as guidance for such activity in other settings and/or discipline areas. This paper is part of a process of documentation so that others can apply the developed methodology and framework for curriculum development. While the paper is a report on curriculum activities in a particular setting, it is written in a manner that allows application of the methodology to other settings. The reader is advised that each curriculum activity needs to adopt a methodology and strategy to fit the particular circumstances being considered To assist in applying this approach elsewhere, a description of the various steps in the curriculum process, and typical responses to some of the more global issues, have been presented. Full details are available in the various TASEAP reports prepared by the authors. Specific detail has been omitted where this detail does not provide any information for generalized consumption.

International childcare practices study: Infant sleeping environment

Background: The International Child Care Practices Study (ICCPS) has collected descriptive data from 21 centres in 17 countries. In this report, data are presented on the infant sleeping environment with the main focus being sudden infant death syndrome (SIDS) risk factors (bedsharing and infant using a pillow) and protective factors (infant sharing a room with adult) that are not yet well established in the literature. Methods: Using a standardised protocol, parents of infants were surveyed at birth by interview and at 3 months of age mainly by postal questionnaire. Centres were grouped according to geographic location. Also indicated was the level of SIDS awareness in the community, i.e. whether any campaigns or messages to “reduce the risks of SIDS” were available at the time of the survey. Results: Birth interview data were available for 5488 individual families and 4656 (85%) returned questionnaires at 3 months. Rates of bedsharing varied considerably (2–88%) and it appeared to be more common in the samples with a lower awareness of SIDS, but not necessarily a high SIDS rate. Countries with higher rates of bedsharing appeared to have a greater proportion of infants bedsharing for a longer duration (>5 h). Rates of room sharing varied (58–100%) with some of the lowest rates noted in centres with a higher awareness of SIDS. Rates of pillow use ranged from 4% to 95%. Conclusions: It is likely that methods of bedsharing differ cross-culturally, and although further details were sought on different bedsharing practices, it was not possible to build up a composite picture of “typical” bedsharing practices in these different communities. These data highlight interesting patterns in child care in these diverse populations. Although these results should not be used to imply that any particular child care practice either increases or decreases the risk of SIDS, these findings should help to inject caution into the process of developing SIDS prevention campaigns for non-Western cultures.

Quality of care of patients hospitalized with acute coronary syndromes

Background: Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions. Aim: To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators. Methods: Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main out-come measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received -specific interventions (i.e. patients with clear indi-cations and lacking contraindications). Results: Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely per-formance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital and post-hospital cardiac rehabilitation (47% and 7%, respectively). Conclusion: There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Pragmatic solidarism and the dilemmas of humanitarian intervention

The theory and practice of humanitarian intervention in the 1990s has produced a series of seemingly intractable dilemmas. Why do states act in some cases and not others? How are we to evaluate the legitimacy of particular acts? This article introduces a new perspective on these questions informed by a combination of pragmatism and solidarism. It argues that although the search for criteria that may be used to judge the legitimacy and efficacy of humanitarian intervention may be a futile one, it is possible to think about a politics of legitimate humanitarian intervention. Such a politics may be based on three key insights drawn from pragmatism: the dialogic construction of moral knowledge, the fallibility of knowledge, and the priority of democracy over philosophy. The article discusses how such a pragmatic solidarism may be used to interrogate the quest for legitimising criteria and to build a new politics of humanitarian intervention.