Métodos de avaliação do impacto económico dos eventos adversos em meio hospitalar

RESUMO - O sistema de saúde é constantemente sujeito a pressões sendo as mais relevantes a pressão para o aumento da qualidade e a necessidade de contenção de custos. Os Eventos Adversos (EAs) ocorridos em meio hospitalar constituem um sério problema de qualidade na prestação de cuidados de saúde, com consequências clinicas, sociais, económicas e de imagem, que afectam pacientes, profissionais, organizações e o próprio sistema de saúde. Os custos associados à ocorrência de EAs em meio hospitalar, incrementam significativamente os custos hospitalares, representando cerca de um em cada sete dólares gastos no atendimento dos doentes. Só na última década surgiram estudos com o objectivo principal de avaliar esse impacto em meio hospitalar, subsistindo ainda uma grande indefinição quanto às variáveis e métodos a utilizar. O objectivo principal deste trabalho de projecto foi conhecer e caracterizar as diferentes metodologias utilizadas para avaliação dos custos económicos, nomeadamente dos custos directos, relacionados com a ocorrência de eventos adversos em meio hospitalar. Tendo em atenção as dificuldades referidas, utilizou-se como metodologia a revisão narrativa da literatura, complementada com a realização de uma técnica de grupo nominal. Os resultados obtidos foram os seguintes: i) a metodologia utilizada na maioria dos estudos para determinar a frequência, natureza e consequências dos EAs ocorridos em meio hospitalar, utiliza matrizes de base observacional, analítica, com base em estudos de coorte retrospectivo recorrendo aos critérios definidos pelo Harvard Medical Practice Study; ii) a generalidade dos estudos realizados avaliam os custos directos dos EAs em meio hospitalar, iii) verificou-se a existência de uma grande diversidade de métodos para a determinação dos custos associados aos EAs. A generalidade dos estudos determina esse valor com base na contabilização do número de dias adicionais de internamento, resultantes do EA, valorizados com base em custos médios; iv) o grupo de peritos, propôs como metodologia para a determinação do custo associado a cada EA, a utilização de sistemas de custeio por doente; v) propõe-se o desenvolvimento de uma plataforma informática, que permita o cruzamento da informação disponível no registo clinico electrónico do doente com um sistema automático de identificação de EAs, a desenvolver, e com sistemas de custeio por doente, de modo a valorizar os custos por doente e por tipo de EA. A avaliação dos custos directos associados à ocorrência de EAs em contexto hospitalar, pelo impacto económico e social que tem nos doentes e organizações, será seguramente uma das áreas de estudo e investigação futuras, no sentido de melhorar a eficiência do sistema de saúde e a qualidade e segurança dos cuidados prestados aos doentes.

Maritime Security in the Gulf of Guinea: Issues and Solutions for the 21st Century

A producer of 5.4 M bbl/d, totalling almost half of the consumption of the entire European Union, the Gulf of Guinea is a fundamental lifeline and maritime link between Europe, the Americas and Africa. Geographically positioned as a staging post for transit originating in Latin America and coupled with its relatively porous borders, the region is also the perfect stepping stone for contraband heading to European shores. While blessed with an enviable wealth of marine and mineral resources, the region is also plagued by an ever-increasing spectre of maritime piracy; accounting for around 30% of incidents in African waters from 2003 to 2011. It is for these reasons that this research centres around the issues of maritime security in the Gulf of Guinea, with a particular focus on the first two decades of the 21st century. This research looks to examine the overall picture of the present state of play in the area, before going on to provide an analysis of potential regional developments in maritime security. This research begins with the analysis of concepts/phenomena that have played a notable role in the shaping of the field of maritime security, namely Globalisation and security issues in the post-Cold War era. The ensuing chapter then focuses in on the Gulf of Guinea and the issues dominating the field of maritime security in the region. The penultimate chapter presents a SWOT analysis, undertaken as part of this research with the aim of correlating opinions from a variety of sectors/professions regarding maritime security in the Gulf of Guinea. The final chapter builds upon the results obtained from the abovementioned SWOT analysis, presenting a series of potential proposals/strategies that can contribute to the field of maritime security in the region over the coming years. This research draws to a close with the presentation of conclusions taken from this particular investigation, as well as a final overview of the earlier presented proposals applicable to the field of maritime security during the second decade of the 21st century.

A Cidade do Trabalho: usos do património industrial (S. João da Madeira)

S. João da Madeira é uma localidade que desde cedo construiu os seus discursos em torno da identidade local sob o epíteto de Cidade do Trabalho. Mais recentemente, desde a última década do século XX, a cidade começou a olhar para a sua dimensão industrial do ponto de vista do seu cunho patrimonial, dentro do quadro emergente das políticas culturais e de identidade, no qual as identidades particulares – como à escala local – se querem afirmar no plano global. Partindo de uma primeira análise dos processos contemporâneos de patrimonialização do industrial no contexto de S. João da Madeira, concretizados pela via dos museus e do turismo, num trabalho de projeto que se apresenta como fase de investigação preliminar de um futuro trabalho de doutoramento, questiona-se como a antropologia poderá pensar o conceito de cultura popular fora dos contextos normalmente a estes atribuídos e como, consequentemente, poderá problematizar as fronteiras daquilo que poderá ser considerado ou não Património Cultural Imaterial (PCI), categoria com a qual a disciplina está historicamente comprometida.

An analysis of the spatiotemporal distribution of American cutaneous leishmaniasis in counties located along road and railway corridors in the State of Maranhao, Brazil

Introduction The incidence of American cutaneous leishmaniasis (ACL) is increasing in Latin America, especially in Brazil, where 256,587 cases were confirmed in the last decade. Methods This study used a Bayesian model to examine the spatial and temporal distribution of ACL cases between 2000 and 2009 in 61 counties of State of Maranhão located along the three main road and railway corridors. Results During the study period, 13,818 cases of ACL were recorded. There was a significant decrease in the incidence of ACL in the ten study years. The recorded incidence rate ranged from 7.36 to 241.45 per 100,000 inhabitants. The relative risk increased in 77% of the counties, decreased in 18% and was maintained in only five counties. Conclusions Although there was a decreased incidence of the disease, ACL was present in all of the examined municipalities, thus maintaining the risk of contracting this illness.

Listeriosis in the far South of Brazil: neglected infection?

Listeriosis is an under-diagnosed and under-reported infection; however, listeriosis is not a compulsorily notifiable disease in Brazil. We provide an overview of the rates of listeriosis in the United States of America (USA), Europe, Latin America, and Brazil during the past decade. We also report a case of miscarriage caused by listeriosis in which there was no suspicion of this infection. This overview and the case we report serve as reminders of the often-neglected threat of listeriosis and its potential to cause miscarriage while highlighting the necessity of recognizing listeriosis as a compulsorily notifiable disease in Brazil.

Low cost carriers: The case of Oporto Airport and its touristic impact in the region

Both Oporto and the North Region of Portugal definitions of tourism have evolved significantly during the past decade. In this journey it is relevant to highlight the contribution of the arrival of Low Cost Carriers (LCCs) at Francisco Sá Carneiro Airport, thus contributing to a rapid expansion of this region as a tourism destination. Hence, this work project aims to understand the touristic and economic impact motivated by the entry of LCCs in Oporto and in the North Region of Portugal and tries to understand if this event was in fact an asset in the development of the aforementioned tourism destinations.

“The impact of online ratings on video game sales”

Online third-party reviews have been grown over the last decade and they now play an important role as a tool for helping customers evaluate products and services that in many cases offer more than tangible features. This study intends to quantify the impact online ratings have over video game sales by conducting a linear regression analysis on 300 titles for the previous console generation (PlayStation® 3 and Xbox® 360) using a data from the video game industry to understand the existing influence on this particular market. The findings showed that these variables have a weak linear relationship thus suggesting that quality of a title explains little the commercial success of a video game and instead this should cover a wider range of factors. Afterwards, we compare results to previous ones and discuss the managerial implications for upcoming gaming generations.

Incidence of tuberculous meningitis in the State of Santa Catarina, Brazil

Introduction The aim of this study was to estimate the incidence of tuberculous meningitis in the State of Santa Catarina (SC), Brazil, during the period from 2001 to 2010. Methods Ecological, temporal, and descriptive methods were employed using data obtained from the Information System on Disease Notification (Sistema de Informação de Agravos de Notificação). Results One hundred sixteen reported cases of tuberculous meningitis occurred from 2001 to 2010, corresponding to 1.2% (0.2 cases/100,000 inhabitants) of all meningitis cases reported in SC. There was a predominance of new cases in males, corresponding to 56.9% of new cases (0.2 cases/100,000 inhabitants; males vs. females; p=0.374), in patients aged 20-39 years, corresponding to 52.6% of new cases (0.5 cases/100,000 inhabitants; 20-39 years versus others; p<0.001), and in urban areas, corresponding to 91.4% of new cases (0.2 cases/100,000 inhabitants; urban vs. rural; p=0.003). In 48.3% of cases, the outcome was death. Conclusions The incidence rate of tuberculous meningitis in SC has increased within the last decade, with the most affected population comprising young adult white males with an average education. Thus, tuberculous meningitis remains a serious disease, emphasizing the need for disease prevention with vaccination campaigns against tuberculosis, the development of faster and more accurate diagnostic methods, and the use of current epidemiological knowledge regarding the disease to facilitate the establishment of early treatment.

Triatominae (Hemiptera, Reduviidae) in the Pantanal region: association with Trypanosoma cruzi, different habitats and vertebrate hosts

ABSTRACTINTRODUCTION: The transmission cycle of Trypanosoma cruzi in the Brazilian Pantanal region has been studied during the last decade. Although considerable knowledge is available regarding the mammalian hosts infected by T. cruzi in this wetland, no studies have investigated its vectors in this region. This study aimed to investigate the presence of sylvatic triatomine species in different habitats of the Brazilian Pantanal region and to correlate their presence with the occurrences of vertebrate hosts and T. cruzi infection.METHODS: The fieldwork involved passive search by using light traps and Noireau traps and active search by visual inspection. The light traps were placed at five selected points along forested areas for seven nights during each of the nine excursions. At each point where a light trap was set, eight Noireau traps were placed in palm trees and bromeliads.RESULTS: In all, 88 triatomine bugs were collected: two and one individuals from light traps and Noireau traps, respectively; three from peridomestic areas; 23 in coati nests; and 59 in thornbird nests. In this study, active search in microhabitats showed higher efficiency than passive search, since 95% of the triatomine bugs were caught in nests. Further, triatomine bugs were only found to be infected by T. cruzi in coati nests.CONCLUSIONS: Coati nests might act as a point of convergence and dispersion for triatomine bugs and mammal hosts infected by T. cruzi, thereby playing an important role in the sylvatic cycle of T. cruziin the Pantanal region.

Blocking tumor exosome release using nanovectorization systems

Exosomes are small membrane vesicles secreted by most cell types, either normal or malignant and are found in most body fluids such as saliva, plasma and breast milk. In the past decade, the interest in these vesicles has been growing more and more since it was found that besides their beneficial functions such as the removal of cellular debris and unnecessary proteins during cell maturation process, they can also interact with other cells and transfer information between them, thus helping diseases like cancer to progress. The present work intended to use gold nanoparticles as vehicles for gene silencing in an attempt to reduce the tumor-derived exosome secretion, regulated by Rab27a protein, and also aimed to compare the exosome secretion between two breast cell lines, MCF7 and MDA. Changes in RAB27A gene expression were measured by Real-time Quantitative PCR and it was revealed a decreased in RAB27A gene expression, as expected. Exosomes were isolated and purified by two different methods, ultracentrifugation and the commercial kit ExoQuick™ Solution, and further characterized using Western Blot analysis. ExoQuick™ Solution was proven to be the most efficient method for exosome isolation and it was revealed that MDA cells secrete more exosomes. Furthermore, the isolated MCF7-derived exosomes were placed together with a normal bronchial/tracheal epithelial cell line (BTEC) for an additional assay, which aimed to observe the uptake of exosomes by other cells and the exosomes’ capability of promoting cell-cell communication. This observation was made based on alterations in the expression levels of c-Myc and miR-21 genes and the fact that they both have an increased expression in BTEC cells incubated with tumor-derived exosomes when compared to control cells (without incubation with the exosomes) lead us to the conclusion that the exosome uptake and exchange of information between the exosomes and the normal cells did occurred.

Progression of the load of waterborne and intestinal parasitic diseases in the State of Amazonas

In the State of Amazonas, Brazil, urban expansion together with precarious basic sanitation conditions and human settlement on river banks has contributed to the persistence of waterborne and intestinal parasitic diseases. Time series of the recorded cases of cholera, typhoid fever, hepatitis A and leptospirosis are described, using data from different levels of the surveillance systems. The sources for intestinal parasitosis prevalence data (non-compulsory reporting in Brazil) were Medical Literature Analysis and Retrieval System Online (MEDLINE), Literatura Latino-Americana (LILACS) and the annals of major scientific meetings. Relevant papers and abstracts in all languages were accessed by two independent reviewers. The references cited by each relevant paper were scrutinized to locate additional papers. Despite its initial dissemination across the entire State of Amazonas, cholera was controlled in 1998. The magnitude of typhoid fever has decreased; however, a pattern characterized by eventual outbreaks still remains. Leptospirosis is an increasing cause of concern in association with the annual floods. The overall prevalence of intestinal parasites is high regardless of the municipality and the characteristics of areas and populations. The incidence of hepatitis A has decreased over the past decade. A comparison of older and recent surveys shows that the prevalence of intestinal parasitic diseases has remained constant. The load of waterborne and intestinal parasitic diseases ranks high among the health problems present in the State of Amazonas. Interventions aiming at basic sanitation and vaccination for hepatitis A were formulated and implemented, but assessment of their effectiveness in the targeted populations is still needed.

HIV/AIDS epidemic in the State of Amazonas: characteristics and trends from 2001 to 2012

A scoping review was conducted to describe the epidemiological characteristics of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in the State of Amazonas, Brazil, from 2001 to 2012, and temporary patterns were estimated from surveillance data. The results suggest that in its third decade, the Amazon HIV/AIDS epidemic is far from being stabilized and displays rising AIDS incidence and mortality rates and late diagnoses. The data suggest that AIDS cases are hitting mostly young adults and have recently shifted toward men, both homosexual and heterosexual. AIDS cases among the indigenous people have remained stable and low. However, the epidemic has disseminated to the interior of the state, which adds difficulties to its control, given the geographical isolation, logistical barriers, and culturally and ethnically diverse population. Antiretroviral (ARV) therapy has been decentralized, but peripheral ARV services are still insufficient and too distant from people who need them. Recently, the expansion of point-of-care (POC) rapid HIV testing has been contributing to overcoming logistical barriers. Other new POC devices, such as the PIMA CD4 analyzer, will bring the laboratory to the patient. AIDS uniquely coexists with other tropical infections, sharing their epidemiological profiles. The increased demand for HIV/AIDS care services can only be satisfied through increased decentralization to peripheral health units, which can also naturally integrate care with other tropical infections and can promote a shift from vertical to integrated programming. Future challenges involve building surveillance data on HIV case notification and covering the spectrum of engagement in care, including adherence to treatment and follow-up loss.

Two decades of tuberculosis in a city in Northeastern Brazil: advances and challenges in time and space

Abstract: INTRODUCTION This study presents two decades of epidemiological data on tuberculosis (TB), in order to understanding the disease profile and its spatiotemporal dynamics. METHODS This descriptive study was performed in the City of Olinda/Pernambuco, Brazil, from 1991-2010, and it analyzed new patients with TB living in the city. We used the χ²-test with a p-value <0.05 to identify differences in trends. Incidence and cluster distribution were identified using spatial scan statistics. RESULTS In total, 6202 new cases were recorded during the two decades. The highest incidence occurred in 1995 (110 cases/100,000 inhabitants), and the lowest occurred in 2009 (65 cases/100,000 inhabitants) (β=-1.44; R²=0.43; p=0.0018). The highest mortality occurred in 1998 (16 deaths/100,000 inhabitants), and the lowest occurred in 2008 (5 deaths/100,000 inhabitants) (β=-0.19; R²=0.17; p=0.07). There was a male predominance (65%), and ages ranged from 20-49 years (65%). There was a substantial increase in the number of patients that were cured after treatment (60% to 67%; p<0.001) as well as those tested for HIV (1.9% to 58.5%; p<0.001). During the first decade, clusters with p-values <0.05 included 29% of the total notified cases, and in the second decade, that percentage was 12%. CONCLUSIONS We observed a decreasing trend in incidence, which was significant, and mortality rates, which was not significant. The increased number of laboratory tests performed reflects advances in surveillance, and a reduction in the proportion of cases in primary clusters suggests, among other things, that the disease is spreading across the region.

Age related changes in the elastic fiber system of the interfoveolar ligament

In order to evaluate age related changes of the elastic fiber system in the interfoveolar ligament, we studied the deep inguinal ring from 33 male cadavers aged from stillborn to 76 years. Selective and alternated staining methods for elastic fibers were performed to differentiate oxytalan, elaunin, and mature elastic fibers. We confirmed quantitative changes of the elastic fiber system with aging. There was a significant and progressive reduction of the oxytalan fibers (responsible for tissue resistance) and a significant increment in the mature elastic and elaunin fibers (responsible for tissue elasticity). Furthermore, there were structural changes in the thickness, shortness and curling of these mature elastic fibers. These changes induced loss of the elastic fiber function and loss of the interfoveolar ligament compliance. These factors predispose individuals to the development of indirect inguinal hernias that frequently emerge in adults and aged individuals, especially above the fifth decade.

Aplicação do CRM no contexto do bloco operatório

RESUMO - Introdução: Na última década, inúmera literatura sobre temas de saúde, principalmente abordando a Segurança do Doente, foca a necessidade e a importância do conceito de trabalho em equipa e da sua implementação na atividade dos profissionais de saúde. É também referido, como exemplo a seguir, por analogia e com a devida adaptação, o conceito e a metodologia do Crew Resource Management (CRM) da aviação civil, em que vários autores reviram a evidência da sua aplicação à medicina e concluíram que era uma ferramenta útil em formação não-técnica para a prática da cirurgia segura. Porquê esta analogia entre a saúde e a aviação civil? Porquê este despertar na saúde para o trabalho em equipa e, principalmente, baseando-se na metodologia do CRM da aviação civil? Qual a importância da formação não-técnica e como pode esta ser adaptada à atividade dos profissionais da saúde, nomeadamente no bloco operatório? São estas as principais questões que irão ser investigadas e analisadas ao longo deste estudo. Objetivos: Na aviação civil, a segurança é uma das prioridades desta indústria e um dos pilares da sua sustentabilidade. Sendo a indústria da aviação civil, como a saúde, uma atividade complexa importa em primeiro lugar compreender como a segurança deve ser abordada nas organizações complexas. Depois de compreendermos os quatro pilares da segurança (política, risco, garantia e promoção) aplicados na aviação civil, analisaremos a necessidade da formação não-técnica, explicando a importância da metodologia do CRM na aviação civil e a possibilidade da “importação” dos seus conceitos pela saúde. Metodologia: Para aferirmos a necessidade de formação não-técnica pelos profissionais da saúde foi desenvolvido um inquérito aos alunos finalistas dos Cursos de Enfermagem e dos Cursos de Medicina e outro inquérito a profissionais da saúde, Enfermeiros e Médicos (Anestesista e Cirurgião) com funções no Bloco Operatório, para responderem às seguintes inquietações:  Tiveram os profissionais de saúde formação formal na sua licenciatura ou pós-graduação em temas sobre comunicação, trabalho em equipa, gestão do erro, gestão do stress, liderança, atitudes e comportamentos para um trabalho em equipa eficiente e seguro?  Tiveram formação inicial no início da sua carreira e formação recorrente equivalente sobre estes temas ao longo da sua carreira?  Estão os profissionais de saúde preparados, com conhecimentos obtidos em formação formal, para trabalhar em equipa? Pretendeu-se igualmente, através de inquérito, saber se os alunos finalistas das licenciaturas acima identificadas consideram importante para a sua futura atividade como profissionais de saúde possuírem competências não-técnicas para o trabalho em equipa para evitarem os eventos adversos. No referido inquérito será também questionado quais as matérias a abordar nas licenciaturas (ou em outra etapa da formação), consideradas necessárias para se obterem competências de trabalho em equipa e qual a opinião sobre a frequência da formação recorrente sobre estes temas. Conclusão: O trabalho ficará concluído com uma proposta de conteúdos programáticos para a formação não-técnica dos profissionais de saúde, para a sua formação inicial e para a formação recorrente ao longo da carreira, baseada na metodologia do CRM da aviação civil. Objetivo final: Como objetivo final do estudo pretende-se contribuir, através da aplicação de formação não-técnicas aos profissionais de saúde, para a melhoria da Segurança do Doente nos cuidados em saúde.