Assessment of integration of the Leprosy Program into primary health care in Aracaju, State of Sergipe, Brazil

Introduction: The aim of this study was to assess the epidemiological and operational characteristics of the Leprosy Program before and after its integration into the Primary Healthcare Services of the municipality of Aracaju-Sergipe, Brazil. Methods: Data were drawn from the national database. The study periods were divided into preintegration (1996-2000) and postintegration (2001-2007). Annual rates of epidemiological detection were calculated. Frequency data on clinico-epidemiological variables of cases detected and treated for the two periods were compared using the Chi-squared (chi(2)) test adopting a 5% level of significance. Results: Rates of detection overall, and in subjects younger than 15 years, were greater for the postintegration period and were higher than rates recorded for Brazil as a whole during the same periods. A total of 780 and 1,469 cases were registered during the preintegration and postintegration periods, respectively. Observations for the postintegration period were as follows: I) a higher proportion of cases with disability grade assessed at diagnosis, with increase of 60.9% to 78.8% (p < 0.001), and at end of treatment, from 41.4% to 44.4% (p < 0.023); II) an increase in proportion of cases detected by contact examination, from 2.1% to 4.1% (p < 0.001); and III) a lower level of treatment default with a decrease from 5.64 to 3.35 (p < 0.008). Only 34% of cases registered from 2001 to 2007 were examined. Conclusions: The shift observed in rates of detection overall, and in subjects younger than 15 years, during the postintegration period indicate an increased level of health care access. The fall in number of patients abandoning treatment indicates greater adherence to treatment. However, previous shortcomings in key actions, pivotal to attaining the outcomes and impact envisaged for the program, persisted in the postintegration period.

“Features of two proteins of Leptospira interrogans with potential role in host-pathogen interactions”

Abstract Background Leptospirosis is considered a re-emerging infectious disease caused by pathogenic spirochaetes of the genus Leptospira. Pathogenic leptospires have the ability to survive and disseminate to multiple organs after penetrating the host. Leptospires were shown to express surface proteins that interact with the extracellular matrix (ECM) and to plasminogen (PLG). This study examined the interaction of two putative leptospiral proteins with laminin, collagen Type I, collagen Type IV, cellular fibronectin, plasma fibronectin, PLG, factor H and C4bp. Results We show that two leptospiral proteins encoded by LIC11834 and LIC12253 genes interact with laminin in a dose - dependent and saturable mode, with dissociation equilibrium constants (KD) of 367.5 and 415.4 nM, respectively. These proteins were named Lsa33 and Lsa25 (Leptospiral surface adhesin) for LIC11834 and LIC12253, respectively. Metaperiodate - treated laminin reduced Lsa25 - laminin interaction, suggesting that sugar moieties of this ligand participate in this interaction. The Lsa33 is also PLG - binding receptor, with a KD of 23.53 nM, capable of generating plasmin in the presence of an activator. Although in a weak manner, both proteins interact with C4bp, a regulator of complement classical route. In silico analysis together with proteinase K and immunoflorescence data suggest that these proteins might be surface exposed. Moreover, the recombinant proteins partially inhibited leptospiral adherence to immobilized laminin and PLG. Conclusions We believe that these multifunctional proteins have the potential to participate in the interaction of leptospires to hosts by mediating adhesion and by helping the bacteria to escape the immune system and to overcome tissue barriers. To our knowledge, Lsa33 is the first leptospiral protein described to date with the capability of binding laminin, PLG and C4bp in vitro.

Assessment of integration of the leprosy program into primary health care in Aracaju, state of Sergipe, Brazil

INTRODUCTION: The aim of this study was to assess the epidemiological and operational characteristics of the Leprosy Program before and after its integration into the Primary healthcare Services of the municipality of Aracaju-Sergipe, Brazil. METHODS: Data were drawn from the national database. The study periods were divided into preintegration (1996-2000) and postintegration (2001-2007). Annual rates of epidemiological detection were calculated. Frequency data on clinico-epidemiological variables of cases detected and treated for the two periods were compared using the Chi-squared (χ2) test adopting a 5% level of significance. RESULTS: Rates of detection overall, and in subjects younger than 15 years, were greater for the postintegration period and were higher than rates recorded for Brazil as a whole during the same periods. A total of 780 and 1,469 cases were registered during the preintegration and postintegration periods, respectively. Observations for the postintegration period were as follows: I) a higher proportion of cases with disability grade assessed at diagnosis, with increase of 60.9% to 78.8% (p < 0.001), and at end of treatment, from 41.4% to 44.4% (p < 0.023); II) an increase in proportion of cases detected by contact examination, from 2.1% to 4.1% (p < 0.001); and III) a lower level of treatment default with a decrease from 5.64 to 3.35 (p < 0.008). Only 34% of cases registered from 2001 to 2007 were examined. CONCLUSIONS: The shift observed in rates of detection overall, and in subjects younger than 15 years, during the postintegration period indicate an increased level of health care access. The fall in number of patients abandoning treatment indicates greater adherence to treatment. However, previous shortcomings in key actions, pivotal to attaining the outcomes and impact envisaged for the program, persisted in the postintegration period.

A baixa estatura leve está associada ao aumento da pressão arterial em adolescentes com sobrepeso

FUNDAMENTO: Estudos têm demonstrado que a desnutrição pré/pós-natal leva a um maior risco de doenças não transmissíveis, como diabetes, hipertensão e obesidade na idade adulta. OBJETIVO: Determinar se os adolescentes com sobrepeso e desnutrição leve [escores-Z altura/idade (HAZ) na faixa de <-1 a > -2] têm pressão arterial mais elevada do que os indivíduos com sobrepeso e com estatura normal (HAZ > -1). MÉTODOS: Os participantes foram classificados como de baixa estatura leve ou de estatura normal, e estratificados de acordo com os percentis de massa corporal para a idade, como sobrepeso, peso normal ou abaixo do peso. As pressões arteriais sistólica (PAS) e diastólica (PAD) foram determinadas de acordo com as diretrizes e a gordura abdominal foi analisada por absorciometria de dupla emissão de raios-X. RESULTADOS: Indivíduos com baixa estatura leve e sobrepeso apresentaram valores mais elevados da PAD (p = 0,001) do que suas contrapartes de baixo peso (69,75 ± 12,03 e 54,46 ± 11,24 mmHg, respectivamente), mas semelhantes àqueles com IMC normal. Não foram encontradas diferenças nos valores de PAD em indivíduos normais, indivíduos com sobrepeso e com baixo peso entre os grupos de estatura normal. Foi encontrado um aumento na PAS (p = 0,01) entre os indivíduos com baixa estatura leve quando comparados os indivíduos com sobrepreso com suas contrapartes de baixo peso e IMC normal (114,70 ± 15,46, 97,38 ± 10,87 e 104,72 ± 12,24 mmHg, respectivamente). Embora não tenham sido observadas diferenças nas médias de PAS entre os grupos de baixa estatura leve e estatura normal, foi encontrado um intercepto significativo (p = 0,01), revelando maior PAS entre os indivíduos com baixa estatura leve. Houve correlação entre PAS e gordura abdominal (r = 0,42, ρ = 0,02) no grupo com baixa estatura leve. CONCLUSÃO: Indivíduos de baixa estatura leve com sobrepeso apresentaram maior PAS do que os de estatura normal e sobrepeso. Esses achados confirmam que a baixa estatura leve aumenta o risco futuro de hipertensão e essas alterações são evidentes em indivíduos jovens.

Effect of incorporation of amaranth on the physical properties and nutritional value of cheese bread

At the present celiac disease has no known cure, and its only treatment is a strict lifelong adherence to a gluten-free diet. Cheese bread is a traditional Brazilian product and a safe option for celiacs. However, like other gluten-free breads, it has inherent low levels of fibers and minerals. The objective of this study was to evaluate the effect of incorporation of whole amaranth flour on the physical properties and nutritional value of cheese bread. Amaranth flour was incorporated at 10, 15, and 20% proportions in different formulations. The increasing amaranth levels darkened the product, reduced specific volume, and increased compression force. Ten percent amaranth-content cheese breads exhibited slight differences in physical properties compared with the controls. These results demonstrated the possibility of incorporating 10% of whole amaranth flour in the formulation of cheese bread resulting in a product with higher dietary fiber and iron contents and the same level of acceptance as that of the conventional formulation. The aim of this approach is to increase the availability of gluten-free bakery products with added nutritional value contributing to increase the variety of the diet of celiac patients.

Adesão às precauções-padrão de profissionais de enfermagem de um hospital universitário

OBJETIVO: Descrever e comparar os escores de adesão às precauções padrão (PP) de profissionais de enfermagem que atuavam nas unidades de internação de um hospital universitário do Estado de São Paulo. MÉTODOS: Trata-se de estudo quantitativo transversal, comparativo, com a aplicação da escala psicométrica de adesão às PP, desenvolvido por Gershon et al. (1995), traduzida e validada por Brevidelli e Cianciarullo (2009), entre primeiro de setembro de 2009 e 31 de março de 2010, com 256 profissionais de enfermagem. RESULTADOS: Evidenciou-se que 152 (59,4%) profissionais apresentaram escores médios altos para a adesão às PP, igual ou acima de 4,5; 98 (38,3%) escores intermediários, entre 3,5 e 4,49 e 6 (2,3%) baixos, ou seja, menor que 3,5. CONCLUSÕES: Não houve diferenças estatisticamente significativas entre os escores e outras variáveis, entretanto, destacou-se a importância do resultado positivo encontrado pela valorização das ações de educação permanente pela instituição.

Adesão ao seguimento nutricional ambulatorial pós-cirurgia bariátrica e fatores associados

OBJETIVO: Estimar a prevalência da adesão ao seguimento nutricional ambulatorial pós-cirúrgico e avaliar sua associação com fatores selecionados em indivíduos submetidos à cirurgia bariátrica. MÉTODOS: Estudo de coorte retrospectiva com base na revisão de dados pós-operatórios de 241 prontuários de adultos submetidos à gastroplastia redutora com derivação em Y de Roux entre 2006 e 2008. Considerou-se aderente o indivíduo que compareceu a quatro ou mais consultas nutricionais nos 12 primeiros meses após a cirurgia. Para investigar a associação entre adesão ao seguimento nutricional e idade, sexo, estado conjugal, escolaridade, situação empregatícia, distância entre a residência e o hospital, estratégias para perda de peso no período pré-operatório, índice de massa corporal no pré-cirúrgico imediato, presença de comorbidades e duração da internação pós-operatória, foram calculadas razões de prevalência e utilizou-se regressão múltipla de Poisson. RESULTADOS: A prevalência de adesão foi de 56% (IC95%=49,7-62,3) nessa população predominantemente feminina (80,9%), com média de idade de 44,4 anos (DP=11,6) e de IMC pré-operatório de 47,2kg/m² (DP=6,2). Dos fatores estudados, somente a duração da internação pós-operatória igual ou superior a 6 dias mostrou-se significativamente associada à adesão após análise ajustada por sexo e idade (RP=1,46; IC95%=1,15-1,86). CONCLUSÃO: A prevalência de adesão encontrada foi semelhante às de estudos internacionais, mas baixa considerando-se 75% como referência. A maior adesão observada nos indivíduos com internação pós-operatória prolongada pode sugerir que o maior contato com a equipe multiprofissional aumente a percepção da necessidade de cuidados com a saúde em longo prazo.

Mesoscale dynamics and boundary-layer structure in topographically forced low-level jets

Two types of mesoscale wind-speed jet and their effects on boundary-layer structure were studied. The first is a coastal jet off the northern California coast, and the second is a katabatic jet over Vatnajökull, Iceland. Coastal regions are highly populated, and studies of coastal meteorology are of general interest for environmental protection, fishing industry, and for air and sea transportation. Not so many people live in direct contact with glaciers but properties of katabatic flows are important for understanding glacier response to climatic changes. Hence, the two jets can potentially influence a vast number of people. Flow response to terrain forcing, transient behavior in time and space, and adherence to simplified theoretical models were examined. The turbulence structure in these stably stratified boundary layers was also investigated. Numerical modeling is the main tool in this thesis; observations are used primarily to ensure a realistic model behavior. Simple shallow-water theory provides a useful framework for analyzing high-velocity flows along mountainous coastlines, but for an unexpected reason. Waves are trapped in the inversion by the curvature of the wind-speed profile, rather than by an infinite stability in the inversion separating two neutral layers, as assumed in the theory. In the absence of blocking terrain, observations of steady-state supercritical flows are not likely, due to the diurnal variation of flow criticality. In many simplified models, non-local processes are neglected. In the flows studied here, we showed that this is not always a valid approximation. Discrepancies between simulated katabatic flow and that predicted by an analytical model are hypothesized to be due to non-local effects, such as surface inhomogeneity and slope geometry, neglected in the theory. On a different scale, a reason for variations in the shape of local similarity scaling functions between studies is suggested to be differences in non-local contributions to the velocity variance budgets.

Molecole bioattive naturali e sintetiche per la terapia di malattie da aumentato riassorbimento osseo

Le terapie convenzionali per le malattie da aumentato riassorbimento osseo sono limitate dalla tossicità sistemica, bassa biodisponibilità farmacologica e scarsa aderenza alle terapie. In questo studio sono stati considerati approcci terapeutici innovativi basati su composti naturali e sintetici. I) Valutazione dell'attività biologica di composti naturali. Evidenze sperimentali hanno dimostrato l’attività antiproliferativa ed antiapoptotica di piante della Medicina ayurvedica. Queste proprietà sono sfruttabili nel trattamento di malattie da aumentato riassorbimento osseo, come l'osteoporosi. Per chiarire i possibili effetti terapeutici di questi composti, sono stati studiati i decotti di Rubia cordifolia, Hemidesmus indicus, Emblica officinalis, ed Asparagus racemosus. Hemidesmis indicus si è dimostrato il più efficace. II) Valutazione dell'attività biologica di composti sintetici. I bisfosfonati (BP) sono farmaci capaci di legarsi alle superfici minerali ossee e all’idrossiapatite, nei siti di rimodellamento osseo. Poiché i BP inibiscono la funzione degli osteoclasti, sono convenzionalmente impiegati nel trattamento di malattie da aumentato riassorbimento osseo, come l'osteoporosi. Tuttavia, gli elevati costi e gli effetti collaterali legati alla somministrazione determinano una scarsa aderenza al trattamento condizionandone l’efficacia. Scopo di questo studio è stato quello di valutare l'attività biologica di BP chimicamente innovativi, meno tossici e sintetizzati con strategie catalitiche semplificate ed ecocompatibili, in modo da ridurre i costi di produzione. È stato valutato l’effetto citotossico e antiosteoclastico dei composti e confrontato con quello dei BP comunemente impiegati in clinica (neridronato, pamidronato e alendronato). I risultati sono stati considerati raggiunti qualora fossero identificati BP di nuova sintesi non citotossici e capaci di conservare almeno il 90% della capacità dei substrati di base di inibire il riassorbimento osseo. Tutti i composti di nuova sintesi sono risultati meno tossici del BP convenzionale, anche a concentrazioni più elevate ed i più efficaci sono stati un BP coniugato con acido biliare, un BP aromatico contenente azoto ed un BP alifatico contenente zolfo.

Evidence-based polytherapies and long-term mortality after acute myocardial infarction in very old subjects compared with elderly and adults: a nested case-control study

Background: Clinical trials have demonstrated that selected secondary prevention medications for patients after acute myocardial infarction (AMI) reduce mortality. Yet, these medications are generally underprescribed in daily practice, and older people are often absent from drug trials. Objectives: To examine the relationship between adherence to evidence-based (EB) drugs and post-AMI mortality, focusing on the effects of single therapy and polytherapy in very old patients (≥80 years) compared with elderly and adults (<80 years). Methods: Patients hospitalised for AMI between 01/01/2008 and 30/06/2011 and resident in the Local Health Authority of Bologna were followed up until 31/12/2011. Medication adherence was calculated as the proportion of days covered for filled prescriptions of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), β-blockers, antiplatelet drugs, and statins. We adopted a risk set sampling method, and the adjusted relationship between medication adherence (PDC≥75%) and mortality was investigated using conditional multiple logistic regression. Results: The study population comprised 4861 patients. During a median follow-up of 2.8 years, 1116 deaths (23.0%) were observed. Adherence to the 4 EB drugs was 7.1%, while nonadherence to any of the drugs was 19.7%. For both patients aged ≥80 years and those aged <80 years, rate ratios of death linearly decreased as the number of EB drugs taken increased. There was a significant inverse relationship between adherence to each of 4 medications and mortality, although its magnitude was higher for ACEIs/ARBs (adj. rate ratio=0.60, 95%CI=0.52–0.69) and statins (0.60, 0.50–0.72), and lower for β-blockers (0.75, 0.61–0.92) and antiplatelet drugs (0.73, 0.63–0.84). Conclusions: The beneficial effect of EB polytherapy on long-term mortality following AMI is evident also in nontrial older populations. Given that adherence to combination therapies is largely suboptimal, the implementation of strategies and initiatives to increase the use of post-AMI secondary preventive medications in old patients is crucial.

Lo sviluppo di disturbi psichiatrici in pazienti hcv+ sottoposti a terapia antivirale: L'impatto dei nuovi farmaci

Introduzione:l’interferone (IFN) usato per l’eradicazione del virus dell’Epatite C, induce effetti collaterali anche riferibili alla sfera psichica. I dati sugli eventi avversi di tipo psichiatrico dei nuovi farmaci antivirali (DAA) sono limitati. Lo scopo di questo studio è di valutare lo sviluppo di effetti collaterali di tipo psichiatrico in corso di due distinti schemi di trattamento: IFN-peghilato e ribavirina [terapia duplice (standard o SOC)]; DAA in associazione a IFN-peghilato e ribavirina (terapia triplice). Metodi: pazienti HCV+ consecutivi seguiti presso l’Ambulatorio delle Epatiti Croniche della Semeiotica Medica del Dipartimento di Scienze Mediche e Chirurgiche dell’Università di Bologna in procinto di intraprendere un trattamento antivirale a base di IFN, sottoposti ad esame psicodiagnostico composto da intervista clinica semistrutturata e test autosomministrati: BDI, STAXI-2, Hamilton Anxiety Scale, MMPI – 2. Risultati: Sono stati arruolati 84 pazienti, 57/84 (67.9%) nel gruppo in triplice e 27/84 nel gruppo SOC. Quasi tutti i pazienti arruolati hanno eseguito l’intervista clinica iniziale (82/84; 97.6%), mentre scarsa è stata l’aderenza ai test (valori missing>50%). Ad eccezione dell’ansia, la prevalenza di tutti gli altri disturbi (irritabilità, astenia, disfunzioni neurocognitive, dissonnia) aumentava in corso di trattamento. In corso di terapia antivirale 43/84 (51.2%) hanno avuto bisogno di usufruire del servizio di consulenza psichiatrica e 48/84 (57.1%) hanno ricevuto una psicofarmacoterapia di supporto, senza differenze significative fra i due gruppi di trattamento. Conclusioni : uno degli elementi più salienti dello studio è stata la scarsa aderenza ai test psicodiagnostici, nonostante l’elevata prevalenza di sintomi psichiatrici. I risultati di questo studio oltre ad evidenziare l’importanza dei sintomi psichiatrici in corso di trattamento e la rilevanza della consulenza psicologica e psichiatrica per consentire di portare a termine il ciclo terapeutico previsto (migliorandone l’efficacia), ha anche dimostrato che occorre ripensare gli strumenti diagnostici adattandoli probabilmente a questo specifico target.

Procedimento legislativo e qualita' della legislazione. Criticita' e prospettive

La tesi riprende un tema che è stato oggetto in passato di studi anche molto approfonditi; oggi sembra essere tornato alla ribalta grazie ad alcuni contributi che hanno nuovamente stimolato la dottrina a confrontarsi su aspetti così delicati anche alla luce della crisi economica. E'stato da sempre rilevato che la buona scrittura delle norme è un fattore fondamentale per il rilancio dell’economia del paese, per la semplificazione e per garantire ordine, coerenza e chiarezza all’ordinamento giuridico. La prima parte è incentrata su una ricostruzione storica e giuridica delle fonti che hanno disciplinato le “regole per la qualità delle regole”, oltre ad una panoramica della dottrina che si è occupata in passato del tema. Segue l’individuazione specifica di quali sono le regole formali e sostanziali di drafting. In particolare, una parte è dedicata alla giurisprudenza costituzionale per comprendere se esiste o meno un aggancio per la Corte Costituzionale da permetterle il sindacato sulle “regole oscure” e dichiararle illegittime. La seconda parte analizza le pressai, in particolare si è scelto di analizzare il rapporto tra Governo e Parlamento nelle problematiche principali che attengono al procedimento legislativo e alla cornice entro la quale viene esplicato in relazione alla decretazione d’urgenza, maxiemendamenti, questione di fiducia, istruttoria in commissione, gruppi di pressione. Ciò che è stato rilevato, è una scarsa aderenza ai principi e ai criteri di better regulation, peraltro difficilmente giustiziabili da parte della Corte costituzionale e sottratti al controllo di chi, al contrario, ha competenza in questo settore, ossia il Comitato per la legislazione e il DAGL. Le conclusioni, pertanto, prendono le mosse da una serie di criticità rilevate e tentano di tracciare una strada da percorrere che sia rispettosa dei canoni della “better regulation” anche alla luce delle riforme costituzionali e dei regolamenti parlamentari in corso di approvazione.

Topical curcumin can inhibit deleterious effects of upper respiratory tract bacteria on human oropharyngeal cells in vitro: potential role for patients with cancer therapy induced mucositis?

Curcumin exerts its anti-inflammatory activity via inhibition of nuclear factor κB. Oropharyngeal epithelia and residing bacteria closely interact in inflammation and infection. This in vitro model investigated the effects of curcumin on bacterial survival, adherence to, and invasion of upper respiratory tract epithelia, and studied its anti-inflammatory effect. We aimed to establish a model, which could offer insights into the host-pathogen interaction in cancer therapy induced mucositis.

Monospecific high-affinity and complement activating anti-GM1 antibodies are determinants in experimental axonal neuropathy

It has been difficult to replicate consistently the experimental model of axonal Guillain-Barré syndrome (GBS). We immunized rabbits with two lipo-oligosaccharides (LOS1 and LOS2) derived from the same C. jejuni strain and purified in a slightly different way. LOS1 did not contain proteins whereas several proteins were present in LOS2. In spite of a robust anti-GM1 antibody response in all animals the neuropathy developed only in rabbits immunized with LOS1. To explain this discrepancy we investigated fine specificity, affinity and ability to activate the complement of anti-GM1 antibodies. Only rabbits immunized with LOS1 showed monospecific high-affinity antibodies which activated more effectively the complement. Although it is not well understood how monospecific high-affinity antibodies are induced these are crucial for the induction of experimental axonal neuropathy. Only a strict adherence to the protocols demonstrated to be successful may guarantee the reproducibility and increase the confidence in the animal model as a reliable tool for the study of the human axonal GBS.

Longitudinal patterns in survival, comorbidity, healthcare utilization and quality of care among older women following breast cancer diagnosis

OBJECTIVES To compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer. DESIGN Prospective five-year longitudinal comparison of cases and matched controls. SUBJECTS Newly identified breast cancer patients recruited during 1997–1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656). OUTCOMES Survival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening. RESULTS Five-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases. CONCLUSION Breast cancer survivors’ health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.