The impact of the economic crisis on the quality of health services

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

An estimation of the frequency of gestational toxoplasmosis in the Brazilian Federal District

Acute infections by the protozoan Toxoplasma gondii during pregnancy (gestational toxoplasmosis) are known to cause serious health problems to the fetus (congenital toxoplasmosis). In Brasília, there have been few studies on the incidence of toxoplasmosis. This report summarizes a retrospective study performed on 2,636 selected pregnant women attended by the public health system of Guará, a satellite-city of Brasília. In this survey, 17 cases of gestational toxoplasmosis were detected; 15 of which were primary maternal infection and the remaining 2 were consistent with secondary maternal infection. These results suggest an annual seroconversion rate of 0.64 percent (90 percent confidence interval: 0.38, 0.90).

Frequency of Blastocystis hominis and other intestinal parasites in stool samples examined at the Parasitology Laboratory of the School of Pharmaceutical Sciences at the São Paulo State University, Araraquara

Blastocystis homins is a protozoan that causes an intestinal infection known as human blastocystosis. This infection is diagnosed by means of parasitological examination of stools and by permanent staining techniques. The present study was developed to evaluate the frequency of Blastocystis hominis infection among inhabitants of the Araraquara region, State of São Paulo, and to compare different methods for investigating this protozoan in feces samples. Evaluations on 503 stool samples were performed by means of direct fresh examination and using the techniques of Faust et al., Lutz and Rugai et al. In addition, the iron hematoxylin, trichrome and modified Kinyoun staining techniques were used. Out of the 503 samples examined, 174 (34.6%) were found to be positive for the presence of intestinal parasites. The most frequent protozoa and helminths were Entamoeba coli (14.6%) and Strongyloides stercoralis (6.7%), respectively. Blastocystis hominis was present in 23 (4.6%) fecal samples, with a predominately pasty consistency and without characterizing a condition of diarrhea. Despite the low frequency of Blastocystis hominis found in the Araraquara region, compared with other regions of Brazil, it is important to perform laboratory diagnostic tests for this protozoan. Its finding in fecal material is indicative of food and drinking water contamination. Since the transmission route for this parasite is accepted to be oral-fecal, this implies that the population needs guidance regarding hygiene and basic sanitation measures as a means for controlling health problems caused by enteroparasites.

Genetic and functional analysis of the bacillus subtilis BSP1 gam cluster

Mannans (linear mannan, glucomannan, galactomannan and galactoglucomannan) are the major constituents of the hemicellulose fraction in softwoods and show great importance as a renewable resource for fuel or feedstock applications. As complex polysaccharides, mannans can only be degraded through a synergistic action of different mannan-degrading enzymes, mannanases. Microbial mannanases are mainly extracellular enzymes that can act in wide range of pH and temperature, contributing to pulp and paper, pharmaceutical, food and feed, oil and textile successful industrial applications. Knowing and controlling these microbial mannan-degrading enzymes are essential to take advantage of their great biotechnological potential. The genome of the laboratory 168 strain of Bacillus subtilis carries genes gmuA-G dedicated to the degradation and utilization of glucomannan, including an extracellular -mannanase. Recently, the genome sequence of an undomesticated strain of B. subtilis, BSP1, was determined. In BSP1, the gmuA-G operon is maintained, interestingly, however, a second cluster of genes was found (gam cluster), which comprise a second putative extracellular β-mannanase, and most likely specify a system for the degradation and utilization of a different mannan polymer, galactoglucomannan. The genetic organization and function of the gam cluster, and whether its presence in BSP1 strain results in new hemicellulolytic capabilities, compared to those of the laboratory strain, was address in this work. In silico and in vivo mRNA analyses performed in this study revealed that the gam cluster, comprising nine genes, is organized and expressed in at least six different transcriptional units. Furthermore, cloning, expression, and production of Bbsp2923 in Escherichia coli was achieved and preliminary characterization shows that the enzyme is indeed a β-mannanase. Finally, the high hemicellulolytic capacity of the undomesticated B. subtilis BSP1, demonstrated in this work by qualitative analyses, suggests potential to be used in the food and feed industries.

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital

INTRODUCTION: Vancomycin-resistant enterococci (VRE) can colonize or cause infections in high-risk patients and contaminate the environment. Our objective was to describe theepidemiological investigation of an outbreak of VRE, the interventions made, and their impact on its control. METHODS: We conducted a retrospective, descriptive, non-comparative study by reviewing the charts of patients with a VRE-positive culture in the University Hospital of Campinas State University, comprising 380 beds, 40 of which were in intensive care units (ICUs), who were admitted from February 2008-January 2009. Interventions were divided into educational activity, reviewing the workflow processes, engineering measures, and administrative procedures. RESULTS: There were 150 patients, 139 (92.7%) colonized and 11 (7.3%) infected. Seventy-three percent were cared for in non-ICUs (p = 0.028). Infection was more frequent in patients with a central-line (p = 0.043), mechanical ventilation (p = 0.013), urinary catheter (p = 0.049), or surgical drain (p = 0.049). Vancomycin, metronidazole, ciprofloxacin, and third-generation cephalosporin were previously used by 47 (31.3%), 31 (20.7%), 24 (16%), and 24 (16%) patients, respectively. Death was more frequent in infected (73%) than in colonized (17%) patients (p < 0.001). After the interventions, the attack rate fell from 1.49 to 0.33 (p < 0.001). CONCLUSIONS: Classical risk factors for VRE colonization or infection, e.g., being cared for in an ICU and previous use of vancomycin, were not found in this study. The conjunction of an educational program, strict adhesion to contact precautions, and reinforcement of environmental cleaning were able to prevent the dissemination of VRE.

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.

Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support

INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.

Active surveillance to determine the impact of methicillin resistance on mortality in patients with bacteremia and influences of the use of antibiotics on the development of MRSA infection

Introduction Methicillin-resistant Staphylococcus aureus (MRSA) is among the most important pathogens of nosocomial infections, mainly in intensive care units (ICUs), and accounts for 40-60% of all healthcare-associated S. aureus infections. We evaluated the incidence of nosocomial infection by S. aureus, identified the risk factors for MRSA infection, and evaluated the effect of resistance to methicillin on mortality in patients. Methods We conducted MRSA surveillance at a university hospital in Brazil from January 1, 2010, to December 31, 2010, and performed a retrospective case-control matched study to evaluate the frequency of subsequent MRSA bacteremia and death among patients. We evaluated and compared the risk factors between patients with MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infection. Results Sepsis was the most common cause of infection (17.7/1,000 patient-days), followed by surgical site (11.4/1,000 patient-days), pneumonia (4.1/1,000 patient-days), and urinary tract infection (2.4/1,000 patient-days). The significant risk factors were time of hospitalization, use of central vascular catheter (CVC), urinary catheter, nasogastric tube, parenteral nutrition, tracheostomy, mechanical ventilation, and previous antibiotic administration, the latter of which was the only independent risk factor for MRSA infection. Mortality was significantly higher in patients with MRSA. The number of antibiotics tested was not related to increases in the frequency of MRSA/1,000 patient-days. The incidence of mortality attributable to MRSA (bloodstream infection) BSI was 50%. Conclusions Surveillance results showed that the use of high levels of antibiotics was directly related to the development of MRSA infection, and the mortality attributable to MRSA in patients with bacteremia was significant.

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.

Analysis and Treatment of a male portrait in oil and a study of the size layer with reconstructions from Vibert’s recipe (1892)

This thesis project concentrated on both the study and treatment of an early 20th century male portrait in oil from Colecção Caixa Geral de Depósitos, Lisbon, Portugal. The portrait of Januário Correia de Almeida, exhibits a tear (approximately 4.0 cm by 2.3 cm) associated with paint loss on the right upper side, where it is possible to observe an unusually thick size layer (approximately 50 microns) and an open weave mesh canvas. Size layers made from animal glue remain subject to severe dimensional changes due to changes in relative humidity (RH), thereby affecting the stability of the painting. In this case, the response to moisture of the size layer is minimal and the painting is largely uncracked with very little active flaking. This suggests that the size layer has undergone pre-treatment to render it unresponsive to moisture or water. Reconstructions based on late nineteenth century recipes using historically appropriate materials are used to explore various options for modifying the characteristics of gelatine, some of which may relate to the Portrait’s size layer. The thesis is separated into two parts: Part 1: Describes the history, condition, materials and techniques of the painting. It also details the treatment of Januário Correia de Almeida as well as the choices made and problems encountered during the treatment. Part 2: Discusses the history of commercial gelatine production, the choice of the appropriate animal source to extract the collagen to produce reconstructions of the portrait’s size layer as well as the characterization of selected reconstructions. The execution of a shallow textured infill led to one publication and one presentation: Abstract accepted for presentation and publication, International Meeting on Retouching of Cultural Heritage (RECH3), Francisco Brites, Leslie Carlyle and Raquel Marques, ‘’Hand building a Low Profile Textured Fill for a Large Loss’’.

Evaluation and treatment of the overactive bladder

The overactive bladder is characterized by symptoms of frequency, urgency, and urge incontinence, substantially affecting the quality of life of millions of people throughout the world. The symptoms are associated with significant social, psychological, occupational, domestic, physical, and sexual problems. Despite the considerable impact of this condition on quality of life, sufferers are often unwilling to discuss their problem with family members or health care professionals. This situation is unfortunate, for much can be done to alleviate the symptoms of this distressing condition. It is therefore of utmost importance that medical education about symptoms of the overactive bladder and other related problems be improved to help health care professionals identify and treat patients who will benefit from therapy. This article reviews current thinking regarding definition, epidemiology, quality of life effects, evaluation, and management of the overactive bladder.

Analysis of a controversial decision process: the case of the pumped hydro storage power plant Atdorf in Germany

Based on the report for the unit “Métodos Interactivos de Participação e Decisão A” (Interactive methods of participation and decision A), coordinated by Prof. Lia Maldonado Teles de Vasconcelos and Prof. Nuno Miguel Ribeiro Videira Costa. This unit was provided for the PhD Program in Technology Assessment in 2015/2016.

A critical review of the possible benefits associated with homeopathic medicine

OBJECTIVE: To evaluate the recent scientific research progress on homeopathy. METHODOLOGY: Homeopathy was evaluated in terms of its clinical research; in vitro research, and physical foundations. The Medline database was the main reference source for the present research, concerning data of approximately the last 10 years. Secondary references (not available in this database) were obtained by means of direct requests to authors listed in the primary references. RESULTS: Clinical studies and in vitro research indicate the inefficacy of homeopathy. Some few studies with positive results are questionable because of problems with the quality and lack of appropriate experimental controls in these studies. The most recent meta-analyses on the topic yielded negative results. One of the few previous meta-analyses with positive results had serious publication bias problems, and its results were later substantially reconsidered by the main authors. The sparse in vitro homeopathic research with positive results has not been replicated by independent researchers, had serious methodological flaws, or when replicated, did not confirm the initial positive results. A plausible mechanism for homeopathic action is still nonexistent, and its formulation, by now, seems highly unlikely. CONCLUSIONS: As a result of the recent scientific research on homeopathy, it can be concluded that ample evidence exists to show that the homeopathic therapy is not scientifically justifiable.

Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

Development of sandwich panels of customized functionalities for the rehabilitation of the built patrimony

Considering that the future of the construction sector in most European countries will mainly lie in the renovation of the existing building stock, in the next coming years thousands of energy inefficient buildings will need renovation to force EU member states to reach the EU 2020 targets and implement the Energy Performance of Buildings Directive (EPBD). Seeing the actual crisis in the construction sector as an opportunity, this work aims to develop a concept for prefabricated customizable sandwich panels for the multifunctional renovation of buildings, focusing also on technological innovation. More than a conventional solution, this proposal aims to combine sustainable and recycled building materials, available technologies and systems with advanced design and manufacturing tools within an integrated and mass-customizable approach of advanced building renovation prefabricated solutions. The adoption of these new proposed solutions would improve the living standards of the inhabitants of our cities, reducing energy inefficiency and other existing construction/renovation problems, while enabling some advanced features like the incorporation of technical modules that could even monitor the building performance during its full lifetime and the living conditions of its occupants.