Hospital-acquired infections: a cost estimation for CLABSI in Portugal

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

The internationalization process of born global firms in high-tech and low-tech industries: Is there any difference?

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Corporate social responsible behaviour in the financial industry

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Saúde Mental em meio prisional : avaliação de necessidades de cuidados em reclusos com perturbação mental

RESUMO: A população prisional é constituída por indivíduos geralmente sujeitos a alguma forma de exclusão social e que apresentam problemas de saúde física e mental mais frequentes do que na população em geral. A prevalência mais elevada de perturbações mentais e de suicídio nos reclusos, em relação à população civil, é consensual e está demonstrada em numerosos estudos internacionais. O abuso/dependência de substâncias, a depressão, as psicoses e a perturbação anti-social de personalidade são as perturbações mais comuns na população prisional. As perturbações mentais são importantes factores de risco de suicídio, de vitimização, de reincidência e de reentrada no sistema prisional. Assim sendo, o grupo de reclusos com perturbação mental constitui um grupo de risco relevante. A avaliação de necessidades de cuidados foi iniciada no Reino Unido como um método para o planeamento, medição dos resultados e financiamento dos cuidados de saúde. Para esta avaliação foram desenvolvidos instrumentos que avaliam as necessidades em diversos domínios (clínicos e sociais) para aplicação aos utentes, cuidadores e profissionais. Até aos anos noventa, a avaliação de necessidades no contexto prisional incidia especialmente nas necessidades de segurança dos serviços, segundo a perspectiva dos profissionais. Contudo, a partir do relatório Reed (1992), sobre a situação dos reclusos com perturbação mental, verificou-se uma abordagem mais abrangente, que incluía a avaliação das necessidades de cuidados dos reclusos. Embora as necessidades dos reclusos com perturbação mental pareçam ser similares às dos doentes psiquiátricos em geral, existem diferenças em determinados domínios como a comorbilidade do eixo II, o abuso de substâncias e o risco de violência. Por este motivo, as necessidades de cuidados de saúde mental dos reclusos são elevadas e frequentemente não se encontram satisfeitas. De forma a incluir estas especificidades foi desenvolvida a versão forense do Camberwell Assessment of Need (CAN), designada por CAN - Forensic Version (CANFOR). Actualmente existe um consenso generalizado entre as instituições internacionais do dever de proporcionar aos reclusos cuidados de saúde, de prevenção e de tratamento, equivalentes aos cuidados disponíveis para a população civil - o princípio da equivalência de cuidados. A presente investigação pretendeu caracterizar e avaliar as necessidades de cuidados dos reclusos acompanhados nos serviços de psiquiatria prisionais na área da Grande Lisboa (internamento no Serviço de Psiquiatria do Hospital Prisional de S. João de Deus (HPSJD) e consultas nos Estabelecimentos Prisionais (EP) de Caxias e de Tires). De modo a estabelecer uma comparação com sujeitos civis foi seleccionada uma amostra de conveniência de pacientes acompanhados num departamento de psiquiatria da mesma região, segundo um emparelhamento por sexo, escalão etário, e por diagnóstico, num período de 3 meses. Realizou-se um estudo de tipo observacional, transversal e comparativo. Aplicaram-se os seguintes instrumentos de avaliação: questionário específico, Brief Psychiatric Rating Scale 4.0, Mini International Neuropsychiatric Interview 5.0.0, Global Assessment Functioning, CAN-R e CANFOR-R. No período do estudo (12 meses) foram assistidos 149 reclusos, dos quais, 35 (23,5%) não cumpriram os critérios de inclusão. A amostra final de reclusos (PRs) (n=114) foi constituída por 79 homens (69,3%) e 35 mulheres (30,7%), dos quais 77 eram condenados (67,5%) e 37 (32,5%) encontravam-se detidos preventivamente. A amostra final de participantes civis (PCs) foi constituída por 121 indivíduos, dos quais 76 eram homens (62,8%) e 45 eram mulheres (37,2%).A amostra final de participantes civis (PCs) foi constituída por 121 indivíduos, dos quais 76 eram homens (62,8%) e 45 eram mulheres (37,2%). Relativamente aos PRs, o diagnóstico mais frequente foi a Perturbação Anti-social da Personalidade (57,9%), seguida pela Depressão Major (56,1%). A maioria (53,5%) apresentava três ou mais categorias diagnósticas. Aproximadamente um terço dos PRs (30%) pontuou o nível elevado de risco de suicídio. A probabilidade deste risco aumentava, significativamente, nos portadores de Depressão Major, de um maior nível de psicopatologia e de uma condenação actual. Perto de metade dos PRs (47,4%) possuía duas ou mais condenações prévias e mais de metade estavam envolvidos em crimes contra pessoas (53,5%). A probabilidade de condenações múltiplas foi significativamente superior nos portadores de Perturbação Antisocial da Personalidade e nos reclusos com maior número de necessidades totais. Entre os PRs dos dois sexos, as principais diferenças significativas residiram na maior frequência de consumo de substâncias e no maior número de necessidades de cuidados nãosatisfeitas nos homens versus mulheres. A comparação entre os PRs, antes da detenção, e os PCs mostrou que os primeiros possuíam menor escolaridade, menos medicação psiquiátrica, mas mais emprego e mais consumos de substâncias ilícitas. A Perturbação Anti-social da Personalidade (OR=26,4; IC95%: 10,7-64,9), a Perturbação Pós-stress Traumático (OR=15,0; IC95%: 3,5-65,4), a Dependência/Abuso de Substâncias (OR=8,5; IC95%: 4,2-17,6) a Depressão Major (OR=2,6; IC95%: 1,5-4,4) e o Risco de Suicídio Elevado (OR=2,6; IC95%: 1,4-5,0) foram significativamente mais frequentes nos PRs versus PCs. Relativamente à avaliação de necessidades de cuidados, os PRs mostraram maior número de necessidades não-satisfeitas e maior necessidade de ajuda profissional, em relação aos PCs. Embora diversas necessidades não-satisfeitas possam resultar da condição de recluso, outras, em domínios da saúde física, da segurança do próprio e dos consumos tóxicos, poderão indicar que os PRs recebem um nível de cuidados inferior ao necessário, em comparação com os PCs. Os PRs apresentaram patologia mental, predominantemente não-psicótica e elevado risco de suicídio/auto-agressão, associado a depressão, necessidades de cuidados e uma pena de prisão. Possuíam, numa frequência elevada, características, consistentemente, associadas à reincidência criminal (personalidade anti-social, consumos tóxicos, condenações anteriores), pelo que se justifica um especial acompanhamento deste grupo, no período pré e pós-libertação. A comparação de necessidades de cuidados no contexto civil e prisional indica um maior nível de necessidades e um menor nível de cuidados recebidos pelos PRs, em relação aos PCs. O princípio da equivalência de cuidados poderá estar comprometido nos indivíduos reclusos com perturbação mental. A utilização do CANFOR foi fácil e poderá contribuir para um melhor planeamento, oferta e avaliação de resultados ao nível individual. Os PRs e PCs revelaram características clínicas e de necessidades muito diferentes entre si, pelo que, os reclusos com perturbação mental deverão ser assistidos em serviços de saúde mental preparados para abordar as suas especificidades.---------------ABSTRACT: The prison population is generally made up of individuals who are usually subject to some sort of social exclusion and who show physical and mental problems more frequently than the general population. Various international studies have found higher rates of mental disturbances and suicide within the prison population. The most common mental disturbances found are substance abuse or dependency, depression, psychosis, and anti-social personality disturbance. Such mental disturbances are important factors in suicide, victimization, delinquency recurrence, and the risk of reentry into prison. As a result, prison inmates with mental disturbances are a relevant at risk group. Assessment of needs of care first started in the United Kingdom as a method of care planning, results measuring and finance health care. The method involved the development of certain measuring instruments to be used by patients, caregivers and professionals in order to evaluate needs in various domains (clinical and social). Until the nineties, the assessment of needs of care in a prison context focused mainly on the service’s security needs. However, after the Reed (1992) report on mentally disturbed inmates, a much wider approach was considered, which included evaluation of the inmate’s needs of care. However similar mentally disturbed prison inmates’ needs may appear to those of other psychiatric patients, there are some differences in particular domains, namely, co-morbidity of Axis II, substance abuse and the risk of violence. For this reason, inmates’ mental health care needs are high and very often not met. In order to include these specificities, a forensic version of the Camberwell assessment of need (CAN,) designated CAN – Forensic version (CANFOR) was developed. There is now generalized consensus among international institutions of the duty under the equivalent health care principle to provide inmates with preventative health care and treatment, that are equivalent to the care available to the civil population. This investigation aims to characterize and assess the health care provision of prison inmates admitted to Lisbon’s Psychiatric Prison ward - the Psychiatric Ward of São João de Deus Hospital (HPSJD) - and inmates in the Caxias and Tires Prison Establishments (EP) undertaking outpatient treatment. In order to establish a comparison between prison and civilian patients, a convenience sample was selected from civilian patients being treated in a psychiatric ward in the same geographical area. This sample was paired by gender, age group and diagnosis during a three month period. The study was observational, transversal and comparative. The following measuring instruments were used: a purpose-built questionnaire, Brief Psychiatric Rating Scale 4.0, Mini International Neuropsychiatric Interview 5.0.0, Global Assessment Functioning Scale, CAN-R and CANFOR-R. During the research period (12 months), 149 inmates received care, of whom 35 (23.5%) did not comply with the prerequisite criteria of this study. The final sample of inmates (PRs) (n=114) comprised 79 men (69.3%) and 35 (30.7%) women, of whom 77 (67.5%) were convicted prisoners and 37 (32.5%) were in preventive custody. The final sample for Civilian Participants (PCs) was made up of 121 individuals, of whom 76 (62.8%) were men and 45 (37.2%) were women. The most common diagnosis among the PRs was Anti-Social Personality Disorder (57.9%), followed by Major Depression (56.1%). More than half of the subjects in the sample (53.5%) showed three or more diagnostic categories. Approximately one third (30%) of the PRs showed a high level of suicide risk. The probability of this risk was significantly higher among Major Depression patients, those showing a higher level of psychopathology and those with a current conviction. Almost half of the PRs (47.4%) had been given two or more prior convictions and more than half (53.5%) were involved in crimes against people. The probability of multiple convictions was significantly higher among inmates with Anti-Social Personality Disorder and in those with more total needs. With regard to gender, the main significant difference among the PRs was that men were found to have a higher frequency of substance use and a greater number of unsatisfied caring needs than women. Comparison between the PRs prior to detention and PCs revealed that the former held lower educational qualifications and received less psychiatric medication, but had higher levels of employment and showed greater consumption of illicit substances. In addition Anti-Social Personality Disorder (OR=26.4; IC 95%: 10.7-64.9), Post-Stress Traumatic Disturbance (OR=15.0; IC 95%: 3.5-65.4), Substance Dependency/Abuse (OR=8.5; IC 95%: 4.2-17.6), Major Depression (OR=2.6; IC 95%: 1.5-4.4), and High Suicide Risk (OR=2.6; IC 95%: 1.4-5.0) were significantly more frequent amongst PRs than PCs. The results for needs assessment revealed that the PRs showed higher levels of unmet needs and a greater need for professional help in comparison with the PCs. Although various unmet needs may result from the inmate’s condition, other needs - in particular those regarding physical health, personal security and toxic substance use - suggest that the care given to PRs may be inadequate in comparison with that given to PCs. This implies that the principle of equivalent health care for PRs with mental illnesses may not be upheld. Furthermore, the mental morbidity results of the PRs indicated that they suffer predominantly from non-psychotic and high suicide/self inflicted aggression risk associated with depression, caring needs and a prison sentence. They also often showed characteristics that are consistently associated with criminal recidivism (Anti-social Personality, use of toxic substances, prior convictions). This result justifies that there should be special follow-up for this group in the pre- and after release period. The use of CANFOR proved to be simple and the application delay was acceptable. No difficulties were encountered in the understanding of its categories by its users. As a result, itcould contribute towards better planning, supply and assessment of results at an individual level. Given that the PRs and PCs revealed different clinical and needs characteristics, it is recommended that inmates with mental disturbances should be assisted in mental health services that are adequately prepared to address their specificities.

Capillaria hepatica-induced hepatic fibrosis in rats: paradoxical effect of repeated infections

Multiple exposures to parasitic agents are considered an important factor in the genesis of the most severe forms of the diseases they cause. Capillaria hepatica-induced septal fibrosis of the liver in rats usually runs without signs of portal hypertension or hepatic failure. After determining the hepatic profile of 15 animals during the course of a single infection, we submitted 20 rats to multiple Capillaria hepatica infections to determine whether repeated exposures would augment fibrosis production, transforming septal hepatic fibrosis into a true cirrhosis. Ten single-infection rats served as controls. A total of 5 exposures, with 45-day intervals, were made. Histological changes were followed by means of surgical liver biopsies, collected prior to infection and to each re-infection. Functional changes were minimal and transient. Although a slight recrudescence of fibrosis was observed after the first two re-infections and when the single-infected control group was re-infected at the end of the experiment, subsequent re-infections failed to increase the amount of fibrosis. On the contrary, there occurred quantitative and qualitative evidence of collagen degradation and suppression of parasite development. These paradoxical results are in keeping with the hypothesis that a complex immunological modulation participates in the mechanism of hepatic fibrosis induced by Capillaria hepatica infection in rats.

Constraint reasoning with local search for continuous optimization

Optimization is a very important field for getting the best possible value for the optimization function. Continuous optimization is optimization over real intervals. There are many global and local search techniques. Global search techniques try to get the global optima of the optimization problem. However, local search techniques are used more since they try to find a local minimal solution within an area of the search space. In Continuous Constraint Satisfaction Problems (CCSP)s, constraints are viewed as relations between variables, and the computations are supported by interval analysis. The continuous constraint programming framework provides branch-and-prune algorithms for covering sets of solutions for the constraints with sets of interval boxes which are the Cartesian product of intervals. These algorithms begin with an initial crude cover of the feasible space (the Cartesian product of the initial variable domains) which is recursively refined by interleaving pruning and branching steps until a stopping criterion is satisfied. In this work, we try to find a convenient way to use the advantages in CCSP branchand- prune with local search of global optimization applied locally over each pruned branch of the CCSP. We apply local search techniques of continuous optimization over the pruned boxes outputted by the CCSP techniques. We mainly use steepest descent technique with different characteristics such as penalty calculation and step length. We implement two main different local search algorithms. We use “Procure”, which is a constraint reasoning and global optimization framework, to implement our techniques, then we produce and introduce our results over a set of benchmarks.

Contribuição para o estudo da anexina V na apoptose celular em concentrados de eritrócitos

A hemoterapia moderna baseia-se na utilização correcta dos diversos componentes sanguíneos, associados a um maior controle de qualidade do sangue, o que a torna mais segura e, actualmente, muitos doentes sao beneficiados pois, a transfusão de componentes sanguineos, em situaçoes várias, está na linha da frente na manutenção da vida e em casos extremos, o último recurso que salva vidas. A qualidade e a segurança nas transfusões de sangue são grandes preocupações da área médica, autoridades de saúde e doente1. O sangue obtido pelos Centros de Sangue provem de dadores voluntários, dotados de uma enorme sensibilidade social, que periodicamente assumem uma postura benevola e altruista e consequentemente mantêm os bancos de sangue providos de um produto imprescindivel no tratamento de diversas patologias. O produto final disponível – concentrado de eritrócitos (CE´s), plasma e concentrado plaquetário – tem de assumir um carácter seguro e viável de modo a que os riscos para o doente sejam diminutos2. O controlo de qualidade aplicado a todo o sangue doado realiza provas de conformidade nas unidades com especificações previamente definidas, sendo a hémolise um dos parâmetros importantes na avaliação da qualidade dos concentrados de eritrócitos, pois, pode ocasionar implicações clinicas para o receptor. Para além disso a avaliação da concentração de hemoglobina (Hg) no sangue doado mostra-se um controlo imprescindivel que salvaguarda a qualidade e segurança do componente a transfundir3;4.Até se obter um CE há todo um processo moroso e de responsabilidade vital. Todo o sangue obtido passa por várias etapas fundamentais até à obtenção do componente pretendido (analise, produção e armazenamento). Os CE’s obtidos quando armazenados, num ambiente de refrigeração, têm uma vida útil de 42 dias. Após este período, o sangue deve ser inutilizado por se verificar alterações bioquímicas, biomecânicas, e imunológicas nos CE’s e por consequência a sua instabilidade vital no que ao tratamento de patologias, para as quais este componente está indicado, diz respeito5. Foi realizado um estudo experimental com o objetivo de avaliar a contribuição da Anexina V na apoptose celular nos concentrados de eritrócitos, constatando a degradação dos mesmos ao longo de todo o período de armazenamento e validar o paradigma que a ciência preconiza: “Os CE’s após os 42 dias armazenados, em condições específicas (2 a 6º centígrados), são inviaveis para transfundir”6;7. A avaliação dos níveis de apoptose por citometria de fluxo é geralmente realizada por métodos que utilizam Anexina V como marcador vital, que se associa aos resíduos de fosfatidilserina, externalizados no início do processo apoptótico. A Anexina V é uma proteína humana endógena dependente do ião Ca+2, amplamente distribuída intracelularmente em altas concentrações na placenta e em concentrações mais baixas nos eritrócitos, plaquetas e monócitos. Apresenta como principal característica a capacidade de se ligar à fosfatidilserina, um fosfolipído presente na camada interna da bicamada lipídica, que durante a apoptose celular é translocada para a camada externa da membrana celular. A determinação da Anexina V é normalmente utilizada para verificar se as células são viáveis, apoptóticas ou necróticas por meio de diferenças na integridade da membrana plasmática. Assim, ao conjugar a Anexina V ao FITC (Isotiocianato de fluoresceína) é possível identificar e quantificar as células apoptóticas por citometria de fluxo7. Numa amostra de 15 CE’s, a qual foi induzida a hemólise, verificou-se, por citometria de fluxo, que a viabilidade deste componente se desvanesce ao longo do tempo, confirmando assim que o tratamento, manuseamento e armazenamento do sangue compromete a vitalidade terapeutica deste insubstituivel produto vital.

Hábitos e problemas do sono das crianças dos 2 a 10 anos

RESUMO: Enquadramento: O sono é cada vez mais reconhecido como um fator determinante na Saúde Infantil porque, quando desadequado, pode ter consequências na regulação emocional e do comportamento, nas funções cognitivas, no rendimento académico, na regulação do peso e no risco de lesões acidentais. Os hábitos e problemas do sono das crianças portuguesas não se encontram ainda bem caracterizados. Este conhecimento é importante para o desenvolvimento da investigação e para a promoção da saúde nesta área. Objetivos: Adaptar e validar o Children's Sleep Habits Questionnaire (CSHQ) para a cultura portuguesa; Caracterizar os hábitos de sono de uma amostra de crianças dos 2 aos 10 anos tendo em vista a obtenção de dados de referência; Estimar a prevalência dos problemas do sono na perspetiva dos pais; Avaliar se existem diferenças nos hábitos e problemas do sono entre as regiões de média-alta e baixa densidade populacional; Identificar potenciais consequências dos problemas do sono. Métodos: Foi realizado um estudo transversal, descritivo e correlacional. A versão portuguesa do questionário (CSHQ-PT) foi desenvolvida de acordo com as orientações previamente publicadas e validada numa amostra de 315 crianças dos 2 aos 10 anos. Para o estudo dos hábitos e problemas do sono, o CSHQ-PT foi distribuído aos pais de 2257 crianças recrutadas em 17 zonas de agrupamentos escolares (15 escolhidos de forma aleatória) das áreas da Grande Lisboa, Península de Setúbal e Alentejo, compreendendo zonas litorais e do interior, e de alta, média e baixa densidade populacional. Foram obtidos 1450 (64%) questionários válidos. Resultados: O CSHQ-PT mostrou propriedades psicométricas semelhantes às das versões de outros países e adequadas para a investigação. A avaliação dos hábitos de sono nos dias de semana mostrou que as crianças se deitam, em média, pelas 21h 44m (DP 38 min.). A necessidade da companhia dos pais para adormecer diminui com a idade, ocorrendo em 49% das crianças aos 2-3 anos e 10% aos 9-10 anos. O hábito de adormecer a ver televisão foi descrito em 15,8% das crianças. O tempo total de sono diário diminui com a idade, com uma diferença mais marcada dos 2 para os 3 anos e dos 3 para os 4 anos, quando a sesta se torna menos frequente. No fim de semana, 25% das crianças dormia pelo menos mais uma hora. As diferenças nos hábitos de sono entre regiões de média-alta e de baixa densidade populacional foram reduzidas, sem reflexo na duração média do sono. Considerando valores de referência de outros países, verificou-se que 10% das crianças estudadas tinha uma duração do sono dois desvios-padrão abaixo da média esperada para a idade. A prevalência dos problemas do sono na perspetiva dos pais foi de 10,4%, sem diferenças significativas entre classes etárias, subgrupos de nível educacional dos pais, nem entre zonas de média-alta e baixa densidade populacional. Estes problemas do sono mostraram-se associados, sobretudo, à duração do sono insuficiente, resistência em ir para a cama, dificuldade em adormecer sozinho, despertares noturnos frequentes e ocorrência de parassónias. A baixa prevalência de problemas do sono identificados pelos pais contrasta com cotações elevadas no CSHQ-PT que traduzem comportamentos-problema mais frequentes, que são bem aceites por alguns pais. O Índice de Perturbação do Sono foi mais elevado nas famílias com menor nível educacional. Em análise multivariada mostraram valor preditivo para a sonolência diurna: o tempo total de sono diário, a diferença da duração do sono noturno durante a semana e no fim de semana, a frequência de algumas parassónias e o hábito de adormecer a ver televisão. O rendimento escolar mostrou associação com os problemas do sono, que são mais frequentes nas crianças com dificuldades escolares e hiperatividade/problemas de atenção. A relação entre estas variáveis é complexa. Conclusões: Este estudo mostrou que os problemas comportamentais do sono e a privação de sono são frequentes na população estudada. Estes problemas têm consequências, uma vez que correspondem a uma frequência mais elevada de sintomas de sonolência diurna, por comparação com outros países. Perante este cenário, é muito importante reforçar a promoção de hábitos de sono saudáveis e continuar a estudar as consequências do sono desadequado nas crianças portuguesas. -----------ABSTRACT:Framework: Sleep is increasingly being recognized as important to Child Health, for inadequate sleep may impact behavioral and emotional regulation, cognitive functions, academic performance, weight regulation and the risk of accidental injuries. The sleep habits and sleep problems of Portuguese children are not well characterized. This knowledge is important to support further studies and health promotion actions. Objectives: Develop and validate a Portuguese version of the Children's Sleep Habits Questionnaire (CSHQ-PT); Characterize the sleep habits and problems in a sample of Portuguese children from the ages of 2 to 10 for future reference; Estimate the prevalence of parent-defined sleep problems; Assess whether there are differences in sleep habits and problems between regions of medium-high and low population densities; Identify potential consequences of sleep problems. Methods: We conducted a cross-sectional, descriptive and correlational study. The Portuguese version of the questionnaire (CSHQ-PT) was developed according to published guidelines and validated in a sample of 315 children from 2 to 10 years old (y.o.). In order to study sleep habits and problems we delivered the CSHQ-PT to 2257 children recruited from 17 school districts (15 were chosen randomly) in areas with low, medium and high population densities, including coastline and inland regions. 1450 (64%) valid questionnaires were obtained. Results: The CSHQ-PT demonstrated psychometric properties that were similar to the versions from other countries and adequate for research. The evaluation of sleep habits showed that on schooldays children go to bed, on average, at 21h 44m (SD 38 min.). The need of having the parent in the room at bedtime decreases with the age of the child, occurring in 49% of children with 2-3 y.o. and 10% of children between 9 and 10 y.o. The habit of going asleep while watching TV was reported in 15,8% of the children. Total sleep time diminishes with the age of the child, having a major decrease from 2 to 3 y.o. and from 3 to 4 y.o., along with less frequent naps. During the weekend, 25% of the children sleep at least one extra hour. Considering reference values from other series, we found that 10% of the children had a sleep duration two standard deviations below the mean for the age. The differences in sleep habits between regions of medium-high and low population densities are few, and there are no differences in average sleep durations. The prevalence of parent-defined sleep problems was 10.4%. There were no significant differences between age classes, parent education subgroups or between regions of medium-high and low population densities. These sleep problems were associated with insufficient sleep duration, bedtime resistance, difficulty in falling asleep alone, frequent night awakenings and the occurrence of parasomnias. The low prevalence of parent-defined sleep problems contrasts with high CSHQ scores meaning that problematic behaviors are more frequent, but acceptable to some parents. The Sleep Disturbance Score was higher in families with a lower educational level. In multivariate analysis, the following factors predicted the daytime somnolence score: total sleep time, the difference in night sleep duration between the weekend and school days, the frequency of some parasomnias and the habit of falling asleep while watching TV. School achievement showed a negative correlation with the sleep problems, which are more frequent in children with school difficulties and hyperactivity/attention problems. The relationship between these variables is complex. Conclusions: This study evidenced that behavioral sleep problems and sleep deprivation are common in our population. These sleep problems have consequences as they correspond to more symptoms of excessive daytime somnolence comparing to other countries. Therefore, we reinforce the importance of promoting healthy sleep habits and further study the consequences of inadequate sleep in Portuguese children.

Evaluation of motor neuron excitability by CMAP scanning with modulated current

It is important to have better evaluation and understanding of the motor neuron physiology, with the goal to early and objectively diagnose and treat patients with neurodegenerative pathologies. The Compound Muscle Action Potential (CMAP) scan is a non-invasive diagnosis technique for neurodegenerative pathologies, such as ALS, and enables a quick analysis of the muscle action potentials in response to motor nerve stimulation. This work aims to study the influence of different pulse modulated waveforms in peripheral nerve excitability by CMAP scan technique on healthy subjects. A total of 13 healthy subjects were submitted to the same test. The stimuli were applied in the medium nerve on the right wrist and electromyography signal collected on the Abductor Pollicis Brevis (APB) muscle surface on the right thumb. Stimulation was performed with an increasing intensities range from 4 to 30 mA, with varying steps, 3 stimuli per step. The procedure was repeated 4 times per subject, each repetition using a different single pulse stimulation waveform: monophasic square, monophasic triangular, monophasic quadratic and biphasic square. Results were retrieved from the averaging of the stimuli on each current intensity step. The square pulse needs less current intensity to generate the same response amplitude regarding the other waves and presents a more steep curve slope and this effect is gradually decreasing for the triangular and quadratic pulse,respectively, being the difference even more evident regarding the biphasic pulse. The control of the waveform stimulation pulse allows varying the stimulusresponse curve slope.

Intrahospital spread of carbapenem-resistant Pseudomonas aeruginosa in a University Hospital in Florianópolis, Santa Catarina, Brazil

INTRODUCTION: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) has been isolated with increasing frequency in Brazilian hospitals. Since June 2003, its detection in a teaching hospital in the city of Florianópolis, Brazil, has increased. This study aimed to investigate the minimal inhibitory concentration (MIC), presence of Metallo-β-lactamase (MβL) and a possible clonal relationship among the isolates. METHODS: The study included 29 CRPA and seven isolates with reduced susceptibility. The MIC was determined by agar-dilution. Detection of MβL was performed by Double Disk Sinergism (DDS) and Combined Disk (CD). The MβL gene was verified by PCR and nucleotide sequence analysis. Epidemiological typing was performed by pulsed-field gel electrophoresis. RESULTS: Among the 29 carbapenem-resistant isolates, polymyxin B presented 100% susceptibility and piperacillin/tazobactam 96.7%. Seventeen (62%) strains were verified as clonal (A clone) and among these, six isolates indicated phenotypically positive tests for MβL and harbored the blaSPM-1 gene. The first CRPA isolates were unrelated to clone A, harbored blaIMP-16 and were phenotypically positive only by CD. CONCLUSIONS: The spread of a high-level of resistance clone suggests cross transmission as an important dissemination mechanism and has contributed to the increased rate of resistance to carbapenems. This study emphasizes the need for continuous surveillance and improved strategies.

Trends in antimicrobial resistance among clinical isolates of enterococci in a Brazilian tertiary hospital: a 4-year study

INTRODUCTION: In the past two decades members of the genus Enterococcus have emerged as important nosocomial pathogens worldwide. This study prospectively analyzed the distribution of species and trends in antimicrobial resistance among clinical isolates of enterococci in a Brazilian tertiary hospital from 2006-2009. METHODS: Enterococcal species were identified by conventional biochemical tests. The antimicrobial susceptibility profile was performed by disk diffusion in accordance with the Clinical and Laboratory Standards Institute (CLSI). A screening test for vancomycin was also performed. Minimal inhibitory concentration (MIC) for vancomycin was determined using the broth dilution method. Molecular assays were used to confirm speciation and genotype of vancomycin-resistant enterococci (VRE). RESULTS: A total of 324 non-repetitive enterococcal isolates were recovered, of which 87% were E. faecalis and 10.8% E. faecium. The incidence of E. faecium per 1,000 admissions increased significantly (p < 0.001) from 0.3 in 2006 to 2.3 in 2009. The VRE rate also increased over time from 2.5% to 15.5% (p < 0.001). All VRE expressed high-level resistance to vancomycin (MIC >256µg/ mL) and harbored vanA genes. The majority (89.5%) of VRE belonged to E. faecium species, which were characteristically resistant to ampicillin and quinolones. Overall, ampicillin resistance rate increased significantly from 2.5% to 21.4% from 2006-2009. Resistance rates for gentamicin, chloramphenicol, tetracycline, and erythromycin significantly decreased over time, although they remained high. Quinolones resistance rates were high and did not change significantly over time. CONCLUSIONS: The data obtained show a significant increasing trend in the incidence of E. faecium resistant to ampicillin and vancomycin.

Quality of essential drugs in tropical countries: evaluation of antimalarial drugs in the Brazilian Health System

INTRODUCTION: The emergence of drug resistance is one of the main problems concerning malaria treatment. The use of counterfeit and/or substandard antimalarial drugs can contribute to the development of parasite resistance. Thus, the aim of this study was to evaluate the quality of antimalarial drugs distributed in Brazil. METHODS: Samples containing chloroquine phosphate, mefloquine hydrochloride, primaquine phosphate, and quinine sulfate tablets were delivered to the Rio de Janeiro central storeroom (CENADI), state storerooms (SS), and Basic Health Units (BHUs) in the north region of Brazil - a total of 10 sample sets. After 5 months of storage, the samples were collected, and in vitro quality control analyses according to official and published methods were performed. RESULTS: Inadequate drug storage conditions were found in two SS and in all BHUs evaluated. There were no quality deviations found in the chloroquine samples. The quinine samples exhibited weight variation above the allowed limits. The primaquine samples were found to have packaging deficiency. The release of mefloquine in samples from some regions showed a statistically significant difference when compared with the CENADI samples. CONCLUSIONS: It is important to periodically evaluate the quality and storage conditions of essential drugs. The quality deviations found with the primaquine and quinine samples are not related to storage conditions and must be addressed urgently. The decreased mefloquine release from tablets is related to formulation problems or influenced by inadequate storage conditions, prompting further investigation. Even with the mentioned problems, the samples would probably not contribute to resistant parasite selection.

Interpretation of the presence of IgM and IgG antibodies in a rapid test for dengue: analysis of dengue antibody prevalence in Fortaleza City in the 20th year of the epidemic

INTRODUCTION: The diagnosis of dengue and the differentiation between primary and secondary infections are important for monitoring the spread of the epidemic and identifying the risk of severe forms of the disease. The detection of immunoglobulin (Ig)M and IgG antibodies is the main technique for the laboratory diagnosis of dengue. The present study assessed the application of a rapid test for dengue concerning detection of new cases, reinfection recognition, and estimation of the epidemic attack rate. METHODS: This was a retrospective, cross-sectional, descriptive study on dengue using the Fortaleza Health Municipal Department database. The results from 1,530 tested samples, from 2005-2006, were compared with data from epidemiological studies of dengue outbreaks in 1996, 2003, and 2010. RESULTS: The rapid test confirmed 52% recent infections in the tested patients with clinical suspicion of dengue: 40% detected using IgM and 12% of new cases using IgG in the non-reactive IgM results. The positive IgM plus negative IgG (IgM+ plus IgG-) results showed that 38% of those patients had a recent primary dengue infection, while the positive IgG plus either positive or negative IgM (IgG+ plus IgM+/-) results indicated that 62% had dengue for at least a second time (recent secondary infections). This proportion of reinfections permitted us to estimate the attack rate as >62% of the population sample. CONCLUSIONS: The rapid test for dengue has enhanced our ability to detect new infections and to characterize them into primary and secondary infections, permitting the estimation of the minimal attack rate for a population during an outbreak.

Molecular epidemiology of hepatitis B virus among the indigenous population of the Curuçá and Itaquaí Rivers, Javari Valley, State of Amazonas, Brazil

INTRODUCTION: Hepatitis B virus (HBV) infection is one of the most serious public health problems in the world. In Brazil, HBV endemicity is heterogeneous, with the highest disease prevalence in the North region. METHODS: A total of 180 samples were analyzed and subjected to polymerase chain reaction (PCR) and semi-nested PCR of the HBV S-gene, with the aim of determining the prevalence of HBV-DNA (deoxyribonucleic acid) in indigenous groups inhabiting the areas near the Curuçá and Itaquaí Rivers in the Javari Valley, State of Amazonas, Brazil. RESULTS: The prevalence of the HBV-DNA S-gene was 51.1% (92/180). The analysis found 18 of 49 (36.7%) samples from the Marubo tribe, 68 of 125 (54.4%) from the Kanamary, and 6 of 6 (100%) from other ethnic groups to be PCR positive. There was no statistically significant difference in gender at 5% (p=0.889). Indigenous people with positive PCR for HBV-DNA had a lower median age (p<0.001) of 23 years. There was no statistical difference found in relation to sources of contamination or clinical aspects with the PCR results, except for fever (p<0.001). The high prevalence of HBV-DNA of 75% (15/20) in pregnant women (p=0.009) demonstrates an association with vertical transmission. CONCLUSIONS: The results confirm the high prevalence of HBV-DNA in the Javari Valley, making it important to devise strategies for control and more effective prevention in combating the spread of HBV.