Impacto clínico e econômico da redefinição dos critérios diagnósticos de infarto do miocárdio

Introdução: Estudos sobre implicações clínicas da nova definição de infarto do miocárdio (IAM), incorporando novos marcadores de lesão miocárdica, são escassos na literatura. A prevalência de IAM e das suas complicações são diretamente dependentes do critério diagnóstico utilizado. Objetivo: Avaliar o impacto diagnóstico, prognóstico e econômico da nova definição de IAM proposta pela AHA/ ESC usando troponina T (TnT) como marcador de lesão cardíaca. Métodos: Um total de 740 pacientes com dor torácica admitidos na Emergência do Hospital de Clínicas de Porto Alegre no período de julho/ 1999 a janeiro/ 2002 foram incluídos no estudo. Creatina quinase total (CK), CK-MB atividade e TnT foram dosados em uma amostra de 363 pacientes, representativa de toda a coorte. Para redefinição de IAM foram utilizados como ponto de corte valores pico de TnT > 0,2 mg/dl. Os desfechos avaliados foram classificados como eventos cardíacos maiores (angina recorrente, insuficiência cardíaca congestiva, choque cardiogênico e óbito) e como procedimentos de revascularização. Também foram avaliados o manejo prescrito, os custos e o faturamento hospitalar. Resultados: Nos 363 pacientes com marcadores dosados, foram diagnosticados 59 casos de IAM (16%) pelos critérios clássicos; enquanto 40 pacientes (11%) tiveram o diagnóstico de IAM pelo critério redefinido, o que corresponde a um incremento de 71% na incidência. Pacientes com IAM redefinido eram significativamente mais idosos e do sexo masculino, apresentaram mais dor atípica e diabetes mellitus. Na análise multivariada, pacientes com infarto redefinido tiveram um risco 5,1 [IC 95% 1,0-28] vezes maior para óbito hospitalar e 3,4 [IC 95% 1,1-10] vezes maior para eventos combinados em relação aqueles sem IAM. O manejo dos casos de IAM redefinido foi semelhante ao manejo daqueles com IAM tradicional, exceto pelos procedimentos de revascularização que foram menos freqüentes (25% vs. 51%, P < 0,001). O grupo com IAM redefinido permaneceu mais tempo internado e foi submetido a procedimentos mais tardiamente. Do ponto de vista institucional, o uso dos novos critérios para IAM poderia resultar em um aumento de 9% (mais R$ 2.756,00 por grupo de 100 pacientes avaliados) no faturamento baseado em diagnóstico segundo a tabela do SUS. Conclusões: O novo diagnóstico de IAM acrescenta um número expressivo de indivíduos com infarto aos serviços de emergência. A incorporação deste critério é importante na medida que estes pacientes têm um prognóstico semelhante aos demais casos tradicionalmente diagnosticados. Como a identificação destes casos poderia resultar em um manejo mais qualificado e eficiente destes pacientes, esforços deveriam ser adotados para reforçar a adoção da redefinição de IAM.

Crisis communication: organization's reactions to unexpected events

A reputação é considerada o ativo mais importante das empresas. Ela permite o estabelecimento de relações comerciais e garante um bom funcionamento da organização. Quando um evento inesperado surge, a reputação pode ser ameaçada. Os gerentes, líderes da organização, têm então que demonstrar reatividade e capacidade em responder as necessidades dos stakeholders, e capacidade de detectar e consertar as falhas dentro da organização através de um processo de aprendizagem, para evitar conseqüências negativas que poderiam danificar a reputação e impactar o desenvolvimento operacional da empresa. Através da comunicação de crise, observamos que depois da queda do avião AF 447, a companhia Air France adotou diferentes posturas adaptadas ao pedido dos stakeholders e ao grau de ameaça sofrido. Logo depois do acidente, a empresa decidiu adotar a estratégia do reconhecimento, assumindo uma responsabilidade simbólica e comunicando prioritariamente para as famílias das vitimas e para a mídia. Nas seguintes semanas ela utilizou a estratégia do silêncio que consiste em não comunicar diretamente a mídia. Finalmente, ela usou a estratégia do “bode expiatório” quando ela foi sujeita a ataques diretos. As reações da empresa somadas ao avanço das investigações judiciais revelaram falhas organizacionais “históricas” dentro da própria empresa, como por exemplo, a falta de comunicação entre pilotos e gerentes ou uma falha de sensibilidade técnica e operacional da parte dos gerentes. Apesar de problemas interno e externo, a Air France demonstrou que uma comunicação de crise bem gerenciada limita os impactos financeiros e de reputação. As conseqüências negativas sofridas pela companhia Air France foram limitadas.

Optimal exchange rate policy, optimal incomplete taxation and business cycles

Implementation and collapse of exchange rate pegging schemes are recur- rent events. A currency crisis (pegging) is usually followed by an economic downturn (boom). This essay explains why a benevolent government should pursue Þscal and monetary policies that lead to those recurrent currency crises and subsequent periods of pegging. It is shown that the optimal policy induces a competitive equilibrium that displays a boom in periods of below average de- valuation and a recession in periods of above average devaluation. A currency crisis (pegging) can be understood as an optimal policy answer to a recession (boom).

Bayesian analysis of extreme events with threshold estimation

The aim of this paper is to analyze extremal events using Generalized Pareto Distributions (GPD), considering explicitly the uncertainty about the threshold. Current practice empirically determines this quantity and proceeds by estimating the GPD parameters based on data beyond it, discarding all the information available be10w the threshold. We introduce a mixture model that combines a parametric form for the center and a GPD for the tail of the distributions and uses all observations for inference about the unknown parameters from both distributions, the threshold inc1uded. Prior distribution for the parameters are indirectly obtained through experts quantiles elicitation. Posterior inference is available through Markov Chain Monte Carlo (MCMC) methods. Simulations are carried out in order to analyze the performance of our proposed mode1 under a wide range of scenarios. Those scenarios approximate realistic situations found in the literature. We also apply the proposed model to a real dataset, Nasdaq 100, an index of the financiai market that presents many extreme events. Important issues such as predictive analysis and model selection are considered along with possible modeling extensions.

The impact of negative social environmental events on the market value of supply chain partners

The present work analyzes the impact of negative social / environmental events on the market value of supply chain partners. The study offers a contextualized discussion around important concepts which are largely employed on the Operations Management and Management literature in general. Among them, the developments of the literature around supply chains, supply chain management, corporate social responsibility, sustainable development and sustainable supply chain management are particularly addressed, beyond the links they share with competitive advantage. As for the theoretical bases, the study rests on the Stakeholder Theory, on the discussion of the efficient-market hypothesis and on the discussion of the adjustment of stock prices to new information. In face of such literature review negative social / environmental events are then hypothesized as causing negative impact in the market value of supply chain partners. Through the documental analysis of publicly available information around 15 different cases (i.e. 15 events), 82 supply chain partners were identified. Event studies for seven different event windows were conducted on the variation of the stock price of each supply chain partner, valuing the market reaction to the stock price of a firm due to triggering events occurred in another. The results show that, in general, the market value of supply chain partners was not penalized in response to such announcements. In that sense, the hypothesis derived from the literature review is not confirmed. Beyond that, the study also provides a critical description of the 15 cases, identifying the companies that have originated such events and their supply chain partners involved.

Stochastic discount factor bounds and rare events: a review

We aim to provide a review of the stochastic discount factor bounds usually applied to diagnose asset pricing models. In particular, we mainly discuss the bounds used to analyze the disaster model of Barro (2006). Our attention is focused in this disaster model since the stochastic discount factor bounds that are applied to study the performance of disaster models usually consider the approach of Barro (2006). We first present the entropy bounds that provide a diagnosis of the analyzed disaster model which are the methods of Almeida and Garcia (2012, 2016); Ghosh et al. (2016). Then, we discuss how their results according to the disaster model are related to each other and also present the findings of other methodologies that are similar to these bounds but provide different evidence about the performance of the framework developed by Barro (2006).

A narratological analysis of D. M. Thoma`s: the white hotel (1981)

“A Narratological Analysis of D. M. Thomas’s The White Hotel (1981)” originated within a seminar on British Postmodernist Literature during the first Master’s Degree in “British and North-American Culture and Literature” (2001-04) at the Universidade da Madeira set up by the Department of English and German Studies. This dissertation seeks to present a narratological analysis of Thomas’s novel. The White Hotel stands as a paradigmatic example of the kind of literature that has dominated the British literary scene in the past three decades, commonly referred to as postmodernist fiction, owing to its formal craftsmanship (multiplicity of narrative voices and perspectives, mixing of differing genres and text types, inclusion of embedded narratives) alongside the handling of what are deemed as postmodernist topoi (the distinction between truth and lies, history and fantasy, fact and fiction, the questioning of the nature of aesthetic representation, the role the author and the reader hold in the narrative process, the instability of the linguistic sign, the notion of originality and the moral responsibility the author has towards his/her work), The narratological approach carried out in this research reveals that Thomas’s text constitutes an aesthetic endeavour to challenge the teleological drive that is inherent in any narrative, i. e., the inevitable progression towards a reassuring end. Hence, the subversion of narrative telling, which is a recurrent feature in Thomas’s remaining literary output, mirrors the contemporary distrust in totalising, hierarchised and allencompassing narratives. In its handling of historical events, namely of the Holocaust, The White Hotel invites us to reassess the most profound beliefs we were taught to take for granted: progress, reality and truth. In their place the novel proposes a more flexible conception of both the world and art, especially of literary fiction. In other terms, the world appears as a brutal chaotic place the subject is forced to adjust to. Accordingly, the literary work is deemed hybrid, fragmented and open. So as to put forth the above-mentioned issues, this research work is structured in three main chapters. The initial chapter – “What is Postmodernism?” – advances a scrutiny not only of the seminal but also of more recent studies on postmodernist literary criticism. Following this, in Chapter II – “Postmodernist British Fiction” – a brief overview of postmodernist British fiction is carried out, focusing on the fictional works that, in my opinion, are fundamental for the periodising of British postmodernism. In addition, I felt the need to include a section – “D. M. Thomas as a Postmodernist Novelist” – in which the author’s remaining literary output is briefly examined. Finally, Chapter III – “A Narratological Analysis of The White Hotel” – proposes a narratological analysis of the novel according to the particular Genettian analytical model. To conclude, my dissertation constitutes an approach to D. M. Thomas’s The White Hotel as a text whose very existence is substantiated in the foregrounding of the contingency of all discourses, meeting the postmodernist precepts of openness and subversion of any narrative that claims to be true, globalising and all-inclusive.

Benthic response to upwelling events off the SE Brazilian coast

The main aim of the present study was to evaluate and compare temporal responses of the benthos in 2 continental shelf areas (Cabo Frio and Ubatuba) off the SE Brazilian coast. In Cabo Frio (23 degrees S, 42 degrees W), the western boundary coastal upwelling of the South Atlantic Central Water (SACW) enhances primary productivity, potentially increasing food supply to the benthic communities via sinking of particulate organic carbon (POC). In contrast, POC fluxes in Ubatuba (23 degrees S, 45 degrees W) are expected to be comparatively lower because SACW remains subsurface. We analyzed the temporal and spatial input of phytodetritus (concentration of chlorophyll a in sediments) and the benthic microbial biomass (estimated by ATP-based carbon content in sediments). Median surface chlorophyll concentration was computed for all daily available SeaWiFS images (from 2001 and 2002) to follow chlorophyll a inputs. All parameters used to investigate benthic responses in the study areas showed consistently higher values in Cabo Frio than in Ubatuba. The results showed that benthic response to upwelling may last months, fueling the microbial communities in the Cabo Frio region.

Representações de professores de língua inglesa de Natal-RN: um estudo sistêmico-funcional

Teaching and learning representations have been more and more investigated in the Brazilian applied linguistics field, as it allows the understanding of the teachers representations and how they conceive the learning process. This practice facilitates the planning of actions to improve the educational system. This study aims at identifying, interpreting and discussing some representations related to the identity and professional view of English as a foreign language teachers in different school contexts of Natal-RN. The theoretical and methodological foundation for this research is Halliday s Systemic- Functional Linguistics (1994; HALLIDAY; MATHIESSEN, 2004; EGGINS, 1994, among others). Our goal was to reveal the teachers representations embedded in their language, mainly through the ideational metafunction, as language is the tool we use to express ourselves about the external world (events, qualities, things, etc) and the internal world (thoughts, beliefs, feelings, etc). The research corpus is made of 21 teacher narratives, generated from a questionnaire sent to the teachers, who were divided in two groups: Group 1 (public schools teachers) and Group 2 (private schools and English course teachers). Most of the participants seemed to be satisfied with their professional choice. Many of them see the job as a challenge and an opportunity to transmit knowledge. All of them affirmed that the English teacher is a professional, for different reasons; however, the low professional appreciation was a recurrent aspect among the studied narratives. When asked about where they work, the private school teachers seemed to be more satisfied with the teaching-learning process than the ones from the public schools. We believe that the data analyzed in this study is important to show how some English teachers from Natal-RN see their profession. The results might be used in continuing education courses as food-for-thought in group discussions, as it is extremely important to emphasize and stimulate this practice

Revisitando o eletrocorticograma intra-operatório na epilepsia mesial do lobo temporal: relevância das oscilações de alta frequência

Epilepsies are neurological disorders characterized by recurrent and spontaneous seizures due to an abnormal electric activity in a brain network. The mesial temporal lobe epilepsy (MTLE) is the most prevalent type of epilepsy in adulthood, and it occurs frequently in association with hippocampal sclerosis. Unfortunately, not all patients benefit from pharmacological treatment (drug-resistant patients), and therefore become candidates for surgery, a procedure of high complexity and cost. Nowadays, the most common surgery is the anterior temporal lobectomy with selective amygdalohippocampectomy, a procedure standardized by anatomical markers. However, part of patients still present seizure after the procedure. Then, to increase the efficiency of this kind of procedure, it is fundamental to know the epileptic human brain in order to create new tools for auxiliary an individualized surgery procedure. The aim of this work was to identify and quantify the occurrence of epilepticform activity -such as interictal spikes (IS) and high frequency oscillations (HFO) - in electrocorticographic (ECoG) signals acutely recorded during the surgery procedure in drug-resistant patients with MTLE. The ECoG recording (32 channels at sample rate of 1 kHz) was performed in the surface of temporal lobe in three moments: without any cortical resection, after anterior temporal lobectomy and after amygdalohippocampectomy (mean duration of each record: 10 min; N = 17 patients; ethic approval #1038/03 in Research Ethic Committee of Federal University of São Paulo). The occurrence of IS and HFO was quantified automatically by MATLAB routines and validated manually. The events rate (number of events/channels) in each recording time was correlated with seizure control outcome. In 8 hours and 40 minutes of record, we identified 36,858 IS and 1.756 HFO. We observed that seizure-free outcome patients had more HFO rate before the resection than non-seizure free, however do not differentiate in relation of frequency, morphology and distribution of IS. The HFO rate in the first record was better than IS rate on prediction of seizure-free patients (IS: AUC = 57%, Sens = 70%, Spec = 71% vs HFO: AUC = 77%, Sens = 100%, Spec = 70%). We observed the same for the difference of the rate of pre and post-resection (IS: AUC = 54%, Sens = 60%, Spec = 71%; vs HFO: AUC = 84%, Sens = 100%, Spec = 80%). In this case, the algorithm identifies all seizure-free patients (N = 7) with two false positives. To conclude, we observed that the IS and HFO can be found in intra-operative ECoG record, despite the anesthesia and the short time of record. The possibility to classify the patients before any cortical resection suggest that ECoG can be important to decide the use of adjuvant pharmacological treatment or to change for tailored resection procedure. The mechanism responsible for this effect is still unknown, thus more studies are necessary to clarify the processes related to it

A novel approach based on recurrent neural networks applied to nonlinear systems optimization

This paper presents an efficient approach based on recurrent neural network for solving nonlinear optimization. More specifically, a modified Hopfield network is developed and its internal parameters are computed using the valid subspace technique. These parameters guarantee the convergence of the network to the equilibrium points that represent an optimal feasible solution. The main advantage of the developed network is that it treats optimization and constraint terms in different stages with no interference with each other. Moreover, the proposed approach does not require specification of penalty and weighting parameters for its initialization. A study of the modified Hopfield model is also developed to analyze its stability and convergence. Simulation results are provided to demonstrate the performance of the proposed neural network. (c) 2005 Elsevier B.V. All rights reserved.

Prognostic factors for perioperative pulmonary events among patients undergoing upper abdominal surgery

CONTEXTO E OBJETIVO: Associações significativas entre cirurgia do abdome superior e eventos pulmonares do período perioperatório foram investigadas em pacientes com condições pulmonares pré-operatórias submetidos a anestesia geral. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo cujos dados foram retirados de banco de dados obtidos prospectivamente de forma protocolada, de 1 de janeiro de 1999 a 31 de dezembro de 2004, em hospital universitário terciário. MÉTODOS: Estudados 3107 pacientes com mais de 11 anos, American Society of Anesthesiologists (ASA) I, II, III, com cirurgia de abdome superior sob anestesia geral, enviados à sala de recuperação. Condições pré-operatórias analisadas por regressão logística foram: idade, sexo, estado físico ASA, insuficiência cardíaca congestiva, asma, doença pulmonar obstrutiva crônica, insuficiência respiratória e hábito de fumar. Os resultados estudados, ou variáveis dependentes, incluíram eventos intra- e pós-operatórios: broncoespasmo, hipoxemia, hipercapnia, intubação prolongada e secreção de vias aéreas. RESULTADOS: Dos 3.107 pacientes: 1.540 eram homens, 1.649 mulheres, tinham média de 48 anos, 1088 ASA I, 1402 ASA II, 617 ASA III, com insuficiência cardíaca havia 80, asma, 82, doença pulmonar obstrutiva, 122, insuficiência respiratória, 21, hábito de fumar, 428. Pela regressão logística, sexo feminino (p < 0.001), idade maior que 70 anos (p < 0.01), hábito de fumar (p < 0.001) e doença pulmonar obstrutiva crônica (p < 0.02) influenciaram significativamente o desenvolvimento de eventos pulmonares, principalmente hipoxemia e broncospasmo, em ambos os períodos, mas não nos mesmos pacientes. Asma e insuficiência cardíaca não se associaram com eventos pulmonares na sala de recuperação. CONCLUSÃO: em cirurgia do abdome superior sob anestesia geral, sexo feminino, idade maior que 70 anos, hábito de fumar e doença pulmonar obstrutiva crônica foram fatores de risco independentes para a ocorrência de eventos pulmonares intra- e pós-operatórios.

Association between atherosclerotic aortic plaques and left ventricular hypertrophy in patients with cerebrovascular events

Background and Purpose - the purpose of this research was to evaluate whether an association exists between the presence of atherosclerotic plaque in the thoracic aorta and left ventricular hypertrophy (LVH) in patients with a cerebrovascular event.Methods - We included 116 consecutive patients ( 79 men; mean age, 62 +/- 12.4 years) with previous history of stroke or transient ischemic attack in a cross-sectional study. Transthoracic echocardiogram was performed to diagnose LVH and transesophageal echocardiogram for the detection of atheromas of the thoracic aorta. Continuous variables were analyzed by Student t or Mann-Whitney tests and categorized variables by Goodman test. From the significant association of LVH and age with atheromatous disease of the aorta, an adjustment to the multivariate logistic model was made using high blood pressure history or age as covariates. All of the statistical tests were carried out at a level of 5% significance.Results - Almost half of the patients (43.1%) presented atherosclerotic lesions in the aorta. LVH was present in 90.0% of patients with plaque and in only 30.3% of patients without plaque. Using high blood pressure as a covariate, the risk of patients with LVH presenting atherosclerotic plaque in the aorta was 18.23-fold greater than the risk for patients without LVH (95% CI, 5.68 to 58.54; P < 0.0001). Adding age into the model, the risk increased to 26.36 ( 95% CI, 7.14 to 97.30; P < 0.0001).Conclusions - LVH detected by conventional echocardiogram is associated with high risk of atherosclerotic plaque in the aorta and would be used as a criterion for indication of transesophageal echocardiography in patients with previous stroke or transient ischemic attack LVH.

Association between distressing non-work-related events and occupational injuries

The following is a report on a case-control study whose objective was to investigate the association between distressing non-work-related events and occupational injures. Ninety three injured workers (cases) were matched with 372 non-injured controls in a large metallurgical factory in southeastern Brazil. Exposure to distressing non-work-related events was measured through a questionnaire focusing on situations pertaining to personal problems unrelated to work activities. The data were analyzed by adjusting a conditional logistic regression model, where occurrence of the work injury was the dependent dichotomous variable and answers from the questionnaire were independent continuous variables. The analysis showed an association between some distressing non-work-related events and occupational injuries. These findings imply expanding the horizon of preventive measures used in targeting. work injuries which have traditionally been focused on the control of strictly workplace risks.