Obama's law : analysis of a breakthrough law on healthcare access and lessons for the Portuguese health system management

ABSTRACT - The Patient Protection and Affordable Care Act shook the foundations of the US health system, offering all Americans access to health care by changing the way the health insurance industry works. As President Obama signed the Act on 23 March 2010, he said that it stood for “the core principle that everybody should have some basic security when it comes to their health care”. Unlike the U.S., the Article 64 of the Portuguese Constitution provides, since 1976, the right to universal access to health care. However, facing a severe economic crisis, Portugal has, under the supervision of the Troika, a tight schedule to implement measures to improve the efficiency of the National Health Service. Both countries are therefore despite their different situation, in a conjuncture of reform and the use of new health management measures. The present work, using a qualitative research methodology examines the Affordable Care Act in order to describe its principles and enforcement mechanisms. In order to describe the reality in Portugal, the Portuguese health system and the measures imposed by Troika are also analyzed. The intention of this entire analysis is not only to disclose the innovative U.S. law, but to find some innovative measures that could serve health management in Portugal. Essentially we identified the Exchanges and Wellness Programs, described throughout this work, leaving also the idea of the possibility of using them in the Portuguese national health system.

A New Large-DNA-Fragment Delivery System Based on Integrase Activity from an Integrative and Conjugative Element.

During the past few decades, numerous plasmid vectors have been developed for cloning, gene expression analysis, and genetic engineering. Cloning procedures typically rely on PCR amplification, DNA fragment restriction digestion, recovery, and ligation, but increasingly, procedures are being developed to assemble large synthetic DNAs. In this study, we developed a new gene delivery system using the integrase activity of an integrative and conjugative element (ICE). The advantage of the integrase-based delivery is that it can stably introduce a large DNA fragment (at least 75 kb) into one or more specific sites (the gene for glycine-accepting tRNA) on a target chromosome. Integrase recombination activity in Escherichia coli is kept low by using a synthetic hybrid promoter, which, however, is unleashed in the final target host, forcing the integration of the construct. Upon integration, the system is again silenced. Two variants with different genetic features were produced, one in the form of a cloning vector in E. coli and the other as a mini-transposable element by which large DNA constructs assembled in E. coli can be tagged with the integrase gene. We confirmed that the system could successfully introduce cosmid and bacterial artificial chromosome (BAC) DNAs from E. coli into the chromosome of Pseudomonas putida in a site-specific manner. The integrase delivery system works in concert with existing vector systems and could thus be a powerful tool for synthetic constructions of new metabolic pathways in a variety of host bacteria.

Renal responses to three types of renin-angiotensin system blockers in patients with diabetes mellitus on a high-salt diet: a need for higher doses in diabetic patients?

Objective Activation of the renal renin-angiotensin system in patients with diabetes mellitus appears to contribute to the risk of nephropathy. Recently, it has been recognized than an elevation of prorenin in plasma also provides a strong indication of risk of nephropathy. This study was designed to examine renin-angiotensin system control mechanisms in the patient with diabetes mellitus.Methods We enrolled 43 individuals with type 2 diabetes mellitus. All individuals were on a high-salt diet to minimize the contribution of the systemic renin-angiotensin system. After an acute exposure to captopril (25 mg), they were randomized to treatment with either irbesartan (300 mg) or aliskiren (300 mg) for 2 weeks.Results All agents acutely lowered blood pressure and plasma aldosterone, and increased renal plasma flow and glomerular filtration rate. Yet, only captopril and aliskiren acutely increased plasma renin and decreased plasma angiotensin II, whereas irbesartan acutely affected neither renin nor angiotensin II. Plasma renin and angiotensin II subsequently did increase upon chronic irbesartan treatment. When given on day 14, irbesartan and aliskiren again induced the above hemodynamic, renal and adrenal effects, yet without significantly changing plasma renin. Irbesartan at that time did not affect plasma angiotensin II, whereas aliskiren lowered it to almost zero.Conclusion The relative resistance of the renal renin response to acute (irbesartan) and chronic (irbesartan and aliskiren) renin-angiotensin system blockade supports the concept of an activated renal renin-angiotensin system in diabetes, particularly at the level of the juxtaglomerular cell, and implies that diabetic patients might require higher doses of renin-angiotensin system blockers to fully suppress the renal renin-angiotensin system. J Hypertens 29: 2454-2461 (C) 2011 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Financial impact of introducing the Swiss-DRG reimbursement system on potentially avoidable readmissions at a university hospital.

QUESTION UNDER STUDY: Thirty-day readmissions can be classified as potentially avoidable (PARs) or not avoidable (NARs) by following a specific algorithm (SQLape®). We wanted to assess the financial impact of the Swiss-DRG system, which regroups some readmissions occurring within 18 days after discharge within the initial hospital stay, on PARs at our hospital. METHODS: First, PARs were identified from all hospitalisations recorded in 2011 at our university hospital. Second, 2012 Swiss-DRG readmission rules were applied, regrouped readmissions (RR) were identified, and their financial impact computed. Third, RRs were classified as potentially avoidable (PARRs), not avoidable (NARRs), and others causes (OCRRs). Characteristics of PARR patients and stays were retrieved, and the financial impact of PARRS was computed. RESULTS: A total of 36,777 hospitalisations were recorded in 2011, of which 3,140 were considered as readmissions (8.5%): 1,470 PARs (46.8%) and 1,733 NARs (53.2%). The 2012 Swiss-DRG rules would have resulted in 910 RRs (2.5% of hospitalisations, 29% of readmissions): 395 PARRs (43% of RR), 181 NARRs (20%), and 334 OCRRs (37%). Loss in reimbursement would have amounted to CHF 3.157 million (0.6% of total reimbursement). As many as 95% of the 395 PARR patients lived at home. In total, 28% of PARRs occurred within 3 days after discharge, and 58% lasted less than 5 days; 79% of the patients were discharged home again. Loss in reimbursement would amount to CHF 1.771 million. CONCLUSION: PARs represent a sizeable number of 30-day readmissions, as do PARRs of 18-day RRs in the 2012 Swiss DRG system. They should be the focus of attention, as the PARRs represent an avoidable loss in reimbursement.

Investigation of the composition of linear alkylbenzenes with emphasis on the identification and quantitation of some trace compounds using GS/MS system in both electron impact and chemical ionization modes

Linear alkylbenzenes, LAB, formed by the Alel3 or HF catalyzed alkylation of benzene are common raw materials for surfactant manufacture. Normally they are sulphonated using S03 or oleum to give the corresponding linear alkylbenzene sulphonates In >95 % yield. As concern has grown about the environmental impact of surfactants,' questions have been raised about the trace levels of unreacted raw materials, linear alkylbenzenes and minor impurities present in them. With the advent of modem analytical instruments and techniques, namely GCIMS, the opportunity has arisen to identify the exact nature of these impurities and to determine the actual levels of them present in the commercial linear ,alkylbenzenes. The object of the proposed study was to separate, identify and quantify major and minor components (1-10%) in commercial linear alkylbenzenes. The focus of this study was on the structure elucidation and determination of impurities and on the qualitative determination of them in all analyzed linear alkylbenzene samples. A gas chromatography/mass spectrometry, (GCIMS) study was performed o~ five samples from the same manufacturer (different production dates) and then it was followed by the analyses of ten commercial linear alkylbenzenes from four different suppliers. All the major components, namely linear alkylbenzene isomers, followed the same elution pattern with the 2-phenyl isomer eluting last. The individual isomers were identified by interpretation of their electron impact and chemical ionization mass spectra. The percent isomer distribution was found to be different from sample to sample. Average molecular weights were calculated using two methods, GC and GCIMS, and compared with the results reported on the Certificate of Analyses (C.O.A.) provided by the manufacturers of commercial linear alkylbenzenes. The GC results in most cases agreed with the reported values, whereas GC/MS results were significantly lower, between 0.41 and 3.29 amu. The minor components, impurities such as branched alkylbenzenes and dialkyltetralins eluted according to their molecular weights. Their fragmentation patterns were studied using electron impact ionization mode and their molecular weight ions confirmed by a 'soft ionization technique', chemical ionization. The level of impurities present i~ the analyzed commercial linear alkylbenzenes was expressed as the percent of the total sample weight, as well as, in mg/g. The percent of impurities was observed to vary between 4.5 % and 16.8 % with the highest being in sample "I". Quantitation (mg/g) of impurities such as branched alkylbenzenes and dialkyltetralins was done using cis/trans-l,4,6,7-tetramethyltetralin as an internal standard. Samples were analyzed using .GC/MS system operating under full scan and single ion monitoring data acquisition modes. The latter data acquisition mode, which offers higher sensitivity, was used to analyze all samples under investigation for presence of linear dialkyltetralins. Dialkyltetralins were reported quantitatively, whereas branched alkylbenzenes were reported semi-qualitatively. The GC/MS method that was developed during the course of this study allowed identification of some other trace impurities present in commercial LABs. Compounds such as non-linear dialkyltetralins, dialkylindanes, diphenylalkanes and alkylnaphthalenes were identified but their detailed structure elucidation and the quantitation was beyond the scope of this study. However, further investigation of these compounds will be the subject of a future study.

Study of the application of the high performance liquid chromatography-particle beam interface-mass spectrometry technique on some pesiticides and the reduction phenomena in the system

This work includes two major parts. The first part of the work concentrated on the studies of the application of the highperfonnance liquid chromatography-particle beam interface-mass spectrometry system of some pesticides. Factors that have effects on the detection sensitivity were studied. The linearity ranges and detection limits of ten pesticides are also given in this work. The second part of the work concentrated on the studies of the reduction phenomena of nitro compounds in the HPLC-PB-MS system. Direct probe mass spectrometry and gas chromatography-mass spectrometry techniques were also used in the work. Factors that have effects on the reduction of the nitro compounds were studied, and the possible explanation is proposed. The final part of this work included the studies of reduction behavior of some other compounds in the HPLC-PB-MS system, included in them are: quinones, sulfoxides, and sulfones.

Investigations on the host-parasite interface of a mycoparasite system /

The cell wall composition of Choanephora cucur - bitarum and the host-parasite interface, after infection with Piptocephalis virginiana , were examined in detail. The cell walls of C_. cucurbitarum were determined to be composed of chitin (17%), chitosan (28.4%), neutral sugars (7.2%),uronic acid (2.4%), proteins (8.2%) and lipids (13.8%). The structure of hyphal walls investigated by electron microscopy of shadowed replicas before and after alkali-acid hydrolysis, showed two distinct regions: microfibrillar and amorphous. The microfibrils which were composed of mainly chitin, were organized into two distinct layers: an outer, thicker layer of randomly orientated microfibrils and an inner, thin layer of parallel microfibrils.Electronmicrographs of the host-parasite interface of C_. cucurbitarum and the mycoparasite , P_. virginiana , 30 h following inoculation, showed that the sheath zone has a similar electron density to that of the host cell wall. The sheath was not present around the young (18 h old) haustorium. High-resolution autoradiographs of infected host hyphae showed that radioactive N-acetyl-D-glucosamine , a precursor of chitin, was incorporated preferentially in the host cell wall and sheath zone. Cell fractionation of label fed hyphae showed that 84% of the label was present in the cell wall and specifically in the chitin portion of the wall. The antifungal antibiotic, Polyoxin D, a specific inhibitor of the enzyme, chitin synthetase, suppressed the incorporation of the label in the cell wall and sheath zone and resulted in a decrease in electron density of the developing sheath. The significance of these results is discussed in the light of host resistance.

Letter from the Chairman of the Committee of Ways and Means to the Secretary of the Treasurer on the subject of a system of revenue to revive and maintain unimpaired the public credit, with the answer of the Secretary thereto. (1814)

October 18, 1814. Read, and committed to the Committee of the whole House on the report of the Committee of Ways and Means on so much of the President's message as relates to the finances of the United States.

Studies on the exaggerated inflammatory response caused by streptococcus suis at systemic and central nervous system levels

Streptococcus suis de type 2 est un microorganisme pathogène d’importance chez le porc. Il est la cause de différentes pathologies ayant comme caractéristique commune la méningite. C’est également un agent émergeant de zoonose : des cas cliniques humains ont récemment été rapportés en Asie. Cependant, la pathogénèse de S. suis n’est pas encore complètement élucidée. Jusqu’à présent, la réponse pro-inflammatoire initiée par S. suis n’a été étudiée qu’in vitro. L’étude du choc septique et de la méningite requiert toujours des modèles expérimentaux appropriés. Au cours de cette étude, nous avons développé un modèle in vivo d’infection chez la souris qui utilise la voie d’inoculation intra-péritonéale. Ce modèle a servi à l’étude de la réponse pro-inflammatoire associée à ce pathogène, tant au niveau systémique qu’au niveau du système nerveux central (SNC). Il nous a également permis de déterminer si la sensibilité aux infections à S. suis pouvait être influencée par des prédispositions génétiques de l’hôte. Le modèle d’infection par S. suis a été mis au point sur des souris de lignée CD1. Les résultats ont démontré une bactériémie élevée pendant les trois jours suivant l’infection. Celle-ci était accompagnée d’une libération rapide et importante de différentes cytokines pro-inflammatoires (TNF-α, IL-6, IL-12p40/p70, IFN-ɣ) et de chémokines (KC, MCP-1 and RANTES), qui ont entraîné un choc septique et la mort de 20 % des animaux. Ensuite, pour confirmer le rôle de l’inflammation sur la mortalité et pour déterminer si les caractéristiques génétiques de l’hôte pouvaient influencer la réponse inflammatoire et l’issue de la maladie, le modèle d’infection a été étendu à deux lignées murines consanguines différentes considérées comme résistante : la lignée C57BL/6 (B6), et sensible : la lignée A/J. Les résultats ont démontré une importante différence de sensibilité entre les souris A/J et les souris B6, avec un taux de mortalité atteignant 100 % à 20 h post-infection (p.i.) pour la première lignée et de seulement 16 % à 36 h p.i. pour la seconde. La quantité de bactéries dans le sang et dans les organes internes était similaire pour les deux lignées. Donc, tout comme dans la lignée CD1, la bactériémie ne semblait pas être liée à la mort des souris. La différence entre les taux de mortalité a été attribuée à un choc septique non contrôlé chez les souris A/J infectées par S. suis. Les souris A/J présentaient des taux exceptionnellement élevés de TNF-α, IL-12p40/p70, IL-1β and IFN- γ, significativement supérieurs à ceux retrouvés dans la lignée B6. Par contre, les niveaux de chémokines étaient similaires entre les lignées, ce qui suggère que leur influence est limitée dans le développement du choc septique dû à S. suis. Les souris B6 avaient une production plus élevée d’IL-10, une cytokine anti-inflammatoire, ce qui suppose que la cascade cytokinaire pro-inflammatoire était mieux contrôlée, entraînant un meilleur taux de survie. Le rôle bénéfique potentiel de l’IL-10 chez les souris infectées par S. suis a été confirmé par deux approches : d’une part en bloquant chez les souris B6 le récepteur cellulaire à l’IL-10 (IL-10R) par un anticorps monoclonal anti-IL-10R de souris et d’autre part en complémentant les souris A/J avec de l’IL-10 de souris recombinante. Les souris B6 ayant reçu le anticorps monoclonal anti-IL-10R avant d’être infectées par S. suis ont développé des signes cliniques aigus similaires à ceux observés chez les souris A/J, avec une mortalité rapide et élevée et des taux de TNF-α plus élevés que les souris infectées non traitées. Chez les souris A/J infectées par S. suis, le traitement avec l’IL-10 de souris recombinante a significativement retardé l’apparition du choc septique. Ces résultats montrent que la survie au choc septique dû à S. suis implique un contrôle très précis des mécanismes pro- et anti-inflammatoires et que la réponse anti-inflammatoire doit être activée simultanément ou très rapidement après le début de la réponse pro-inflammatoire. Grâce à ces expériences, nous avons donc fait un premier pas dans l’identification de gènes associés à la résistance envers S. suis chez l’hôte. Une des réussites les plus importantes du modèle d’infection de la souris décrit dans ce projet est le fait que les souris CD1 ayant survécu à la septicémie présentaient dès 4 jours p.i. des signes cliniques neurologiques clairs et un syndrome vestibulaire relativement similaires à ceux observés lors de méningite à S. suis chez le porc et chez l’homme. L’analyse par hybridation in situ combinée à de l’immunohistochimie des cerveaux des souris CD1 infectées a montré que la réponse inflammatoire du SNC débutait avec une augmentation significative de la transcription du Toll-like receptor (TLR)2 et du CD14 dans les microvaisseaux cérébraux et dans les plexus choroïdes, ce qui suggère que S. suis pourrait se servir de ces structures comme portes d’entrée vers le cerveau. Aussi, le NF-κB (suivi par le système rapporteur de l’activation transcriptionnelle de IκBα), le TNF-α, l’IL-1β et le MCP-1 ont été activés, principalement dans des cellules identifiées comme de la microglie et dans une moindre mesure comme des astrocytes. Cette activation a également été observée dans différentes structures du cerveau, principalement le cortex cérébral, le corps calleux, l’hippocampe, les plexus choroïdes, le thalamus, l’hypothalamus et les méninges. Partout, cette réaction pro-inflammatoire était accompagnée de zones extensives d’inflammation et de nécrose, de démyélinisation sévère et de la présence d’antigènes de S. suis dans la microglie. Nous avons mené ensuite des études in vitro pour mieux comprendre l’interaction entre S. suis et la microglie. Pour cela, nous avons infecté des cellules microgliales de souris avec la souche sauvage virulente (WT) de S. suis, ainsi qu’avec deux mutants isogéniques, un pour la capsule (CPS) et un autre pour la production d’hémolysine (suilysine). Nos résultats ont montré que la capsule était un important mécanisme de résistance à la phagocytose pour S. suis et qu’elle modulait la réponse inflammatoire, en dissimulant les composants pro-inflammatoires de la paroi bactérienne. Par contre, l’absence d’hémolysine, qui est un facteur cytotoxique potentiel, n’a pas eu d’impact majeur sur l’interaction de S. suis avec la microglie. Ces études sur les cellules microgliales ont permis de confirmer les résultats obtenus précédemment in vivo. La souche WT a induit une régulation à la hausse du TLR2 ainsi que la production de plusieurs médiateurs pro-inflammatoires, dont le TNF-α et le MCP-1. S. suis a induit la translocation du NF-kB. Cet effet était plus rapide dans les cellules stimulées par le mutant déficient en CPS, ce qui suggère que les composants de la paroi cellulaire représentent de puissants inducteurs du NF-kB. De plus, la souche S. suis WT a stimulé l’expression de la phosphotyrosine, de la PKC et de différentes cascades liées à l’enzyme mitogen-activated protein kinase (MAPK). Cependant, les cellules microgliales infectées par le mutant déficient en CPS ont montré des profils de phosphorylation plus forts et plus soutenus que celles infectées par le WT. Finalement, la capsule a aussi modulé l’expression de l’oxyde nitrique synthétase inductible (iNOS) induite par S. suis et par la production subséquente d’oxyde nitrique par la microglie. Ceci pourrait être lié in vivo à la neurotoxicité et à la vasodilatation. Nous pensons que ces résultats contribueront à une meilleure compréhension des mécanismes sous-tendant l’induction de l’inflammation par S. suis, ce qui devrait permettre, d’établir éventuellement des stratégies plus efficaces de lutte contre la septicémie et la méningite. Enfin, nous pensons que ce modèle expérimental d’infection chez la souris pourra être utilisé dans l’étude de la pathogénèse d’autres bactéries ayant le SNC pour cible.

In vivo phosphorus spectroscopy in human subjects on a clinical 3T MRI system

Alors que l’Imagerie par résonance magnétique (IRM) permet d’obtenir un large éventail de données anatomiques et fonctionnelles, les scanneurs cliniques sont généralement restreints à l’utilisation du proton pour leurs images et leurs applications spectroscopiques. Le phosphore jouant un rôle prépondérant dans le métabolisme énergétique, l’utilisation de cet atome en spectroscopie RM présente un énorme avantage dans l’observation du corps humain. Cela représente un certain nombre de déEis techniques à relever dus à la faible concentration de phosphore et sa fréquence de résonance différente. L’objectif de ce projet a été de développer la capacité à réaliser des expériences de spectroscopie phosphore sur un scanneur IRM clinique de 3 Tesla. Nous présentons ici les différentes étapes nécessaires à la conception et la validation d’une antenne IRM syntonisée à la fréquence du phosphore. Nous présentons aussi l’information relative à réalisation de fantômes utilisés dans les tests de validation et la calibration. Finalement, nous présentons les résultats préliminaires d’acquisitions spectroscopiques sur un muscle humain permettant d’identiEier les différents métabolites phosphorylés à haute énergie. Ces résultats s’inscrivent dans un projet de plus grande envergure où les impacts des changements du métabolisme énergétique sont étudiés en relation avec l’âge et les pathologies.

STUDIES ON TAXONOMY, DISTRIBUTION, ECOLOGY AND REPRODUCTIVE POTENTIAL OF ROTIFERS FROM SELECTED CENTRES IN COCHIN BACKWATER SYSTEM, KERALA

The studies were conducted in nine stations with varying ecological characteristics along Cochin backwaters and adjoining canals. Many workers opined that the distribution of rotifers is cosmopolitan. The significance of rotifers as first food for early larvae was indicated by Fujita. Aquaculture is a fast growing field in fisheries sector and it is gaining more importance as the fish landings and supply are getting irregular. A consistent supply of fish/shellfish can only be achieved through aquaculture. The success of any culture activity depends on the timely production of seeds of finfishes/shellfishes. The availability of wild seed is seasonal and erratic. So, a dependable source of seed of fishes and shellfishes is possible only through large scale production in hatchery. A successful seed production activity depends on the availability of a variety of suitable live feed organisms in sufficient quantities at the proper time for use in the larval stages. As the live feeds promote high growth rates, easy digestion, assimilation and the quality of not contaminating the culture water when compared to other artificial feeds, make the culture of live feed organisms the principal means of providing food for the larvae of finfishes and shellfishes. Rotifers are considered to be an excellent and indispensable food for larvae of many finfishes and crustaceans. It (1960) was the first to culture Brachionus plicatilis for feeding marine fish larvae, and now it is being extensively used as live feed in hatcheries all over the world. They are a group of microscopic organisms coming under the Phylum Rotifera which comprises of about 2000 species. Their slow swimming habits, ability to tolerate a wide range of salinities, parthenogenetic mode of reproduction and ability to get enriched easily, make rotifers an ideal live feed organism. The major factors such as temperature, salinity and food that influence the reproductive potential and thereby the population size of rotifer, Salinity is one of the most important aspect influencing the reproductive rate of rotifers. The feed type and feed concentration play a vital role in influencing the reproductive rate of rotifers. For culture of rotifers, the commonly used micro algae belong to Chlorella, Nannochloropsis, Isochrysis and Tetraselmis. While some studies have suggested that, algal diet has little effect on reproductive rates in 1979 while using the rotifer, Brachionus plicatilis as feed for the larvae of red sea bream, Pagrus major. It is generally accepted that rotifers play a pivotal role in the successful rearing of marine fish larvae.