Fundamentos teóricos e objectivos estratégicos de uma unidade de ética em saúde pública : caso de estudo : o gabinete de ética e responsabilidade da Direcção-Geral da Saúde

RESUMO - Este trabalho de projecto visa responder à questão de saber como gerir uma unidade de ética num serviço público central de saúde pública, “de forma racional e informada”, definindo os seus objectivos estratégicos (Baranger, citando Drucker, 1990) utilizando como caso de estudo o Gabinete de Assuntos Jurídicos, Ética e Responsabilidade, adiante designado por Gabinete, da Direcção‐Geral da Saúde. Para o efeito, fez‐se, em primeiro lugar, uma abordagem teórica descritiva das bases filosóficas da ética realçando a sua aplicação prática na determinação das características dos sistemas de saúde. Em seguida, analisa‐se a utilização do conceito de ética no âmbito da Saúde Pública, no contexto da bioética, verificando‐se elementos distintivos que parecem justificar a autonomização do conceito de ‘Ética em Saúde Pública’. Para tal, foram consultadas as principais fontes de princípios éticos em saúde, tais como a Declaração Universal dos Direitos do Homem, a Declaração de Helsínquia, bem como a Constituição da República Portuguesa e os Códigos Deontológicos das profissões de saúde. Nesta fase do trabalho é pesquisada, nas perspectivas nacional e internacional, a existência de unidades de ética, congéneres ou de âmbito similar, bem como respectivas áreas e níveis de intervenção, tendo‐se nesse sentido auscultado as entidades idóneas dos Estados‐Membros da União Europeia. Na segunda parte do trabalho de projecto, desenvolveu‐se o planeamento estratégico através da aplicação da metodologia balanced scorecard, apresentando‐se uma proposta de objectivos estratégicos e iniciativas a serem desenvolvidas pelo gabinete de ética sub judice, para um horizonte temporal fixado em três anos. Da utilização desta metodologia resultaram doze objectivos estratégicos, dos quais se destacam: ‘fomentar a discussão ética’; ‘promover a igualdade dos utentes do SNS’; e ‘identificar prioridades de actuação’. Entre as iniciativas a desenvolver salienta‐se o desenho de um questionário, a aplicar às comissões de ética do sistema de saúde com o objectivo de identificar prioridades de actuação do Gabinete. O trabalho finaliza‐se com as conclusões, recomendações e linhas de investigação que se considera deverem ser desenvolvidas, num futuro próximo, para o aprofundamento da matéria alvo deste estudo. ------------------ABSTRACT - This research‐project aims to answer the question of how to manage a unit of ethics within the directorate‐general of public health in a "rational and informed” way, defining their strategic goals (Baranger, quoting Drucker, 1990) using as case study the Office of Legal Affairs, Ethics and Responsibility, hereinafter referred as the Office, of the Directorate‐General of Health. For this purpose, the first part of the study, includes a framework description of the main philosophical basis of ethics, emphasizing that its practical application determines the characteristics of health systems; the use of the concept of ethics of Public Health in the context of bioethics was analyzed, and distinctive elements were found that seem to justify the autonomy of the concept of 'Ethics of Public Health'. The main sources of this part were the fundamental ethical principles in health, such as the Universal Declaration of Human Rights, the Helsinki Declaration, and also the Constitution of the Portuguese Republic and the Codes of Ethics of the health professions. At this stage of the study a description is also made, at both a national and international perspective, on the existence of similar units of ethics or with similar scope, and their areas and levels of intervention. For the international dimension the appropriate bodies of the Member States the European Union were consulted. In the second part of the research‐project, a strategic planning for the Office was designed, using the balanced scorecard methodology, and a proposal of the strategic objectives and initiatives to be developed within a time schedule of three years are presented. The use of this method resulted in twelve strategic objectives, among which we note the following: 'to promote the ethical discussion'; 'to promote equality of users of the NHS'; and ‘to identify priorities for action’. The design of a questionnaire to be answered by the ethics committees for health of the Portuguese health system, in order to identify priorities for the Office’s activities is also presented in the study. The work ends with the conclusions and recommendations, as well as a suggestion of lines for future research to further investigate the subject of this study.

Enzyme-linked immunosorbent assay ELISA for the detection of antibodies in the human leptospirosis

An Enzyme-linked immunosorbent assay ELISA was evaluated for the detection of IgA antibodies in the human leptospirosis. The assay proved to be sensitive and specific when compared with the ELISA-IgM, in the examinated serum samples. The results found suggest that IgA antibodies became positive later in leptospirosis, and will can be an evolutive indicator in the development of the disease

Pathology of periportal fibrosis involution in human schistosomiasis

Optical and electron microscopical evidences of focal matrix degradation were frequently seen in liver sections of periportal fibrosis caused by schistosomiasis mansoni in man. The material came from 14 wedge hepatic biopsies taken from patients with chronic advanced hepatosplenic disease and undergoing operations for the relief of portal hypertension. Besides the presence of focal areas of rarefaction, fragmentation and dispersion of collagen fibers, the enlarged portal spaces also showed hyperplasia of elastic tissue and disarray of smooth muscle fibers following destruction of portal vein branches. Eggs were scanty in the tissue sections, and matrix degradation probably represented involuting changes related to the progressive diminution of parasite-related aggression, which occurs spontaneously with age or after cure by chemotherapy. The changes indicative of matrix degradation now described are probably the basic morphological counterpart of periportal fibrosis involution currently being documented by ultrasonography in hepatosplenic patients submitted to curative chemotherapy.

Human papillomavirus detection in cervical dysplasias or neoplasias and in condylomata acuminaata by in situ hybridization with biotinylated DNA probes

Specimens from cervical dysplasias or carcinomas and genital condylomata acuminata were retrospectively analysed by in situ hybridization (ISH) with bioti-nylated DNA probes for human papillomavirus (HPV) types 6, 11, 16 and 18. In the control group no case was positive for HPV DNA. In mild/moderate dysplasias, 4 cases (14%) were positive for HPV 6 or 11 and 2 cases (7%), for HPV 16. In the severe dysplasia/in situ carcinoma group, 9 cases (31%) showed presence of DNA of HPV types 16 or 18. Six invasive carcinomas (20%) were positive for HPV type 16 or 18. Among condylomata acuminata, 22 cases (73%) were positive for HPV types 6 or 11. In all ISH-positive cases only one viral type was detected. No correlation between HPV DNA positivity and histological findings of HPV infection was observed. Although less sensitive than some other molecular biology techniques, in situ hybridization with biotinylated DNA probes proved to be simple and useful for detecting and typing HPV in samples routinely received for histopathological analysis.

Persistent organic pollutant levels in human visceral and subcutaneous adipose tissue in obese individuals - Depot differences and dysmetabolism implications

Background: The role of persistent organic pollutants (POPs) with endocrine disrupting activity in the aetiology of obesity and other metabolic dysfunctions has been recently highlighted. Adipose tissue (AT) is a common site of POPs accumulation where they can induce adverse effects on human health. Objectives: To evaluate the presence of POPs in human visceral (vAT) and subcutaneous (scAT) adipose tissue in a sample of Portuguese obese patients that underwent bariatric surgery, and assess their putative association with metabolic disruption preoperatively, as well as with subsequent body mass index (BMI) reduction. Methods: AT samples (n=189) from obese patients (BMI ≥35) were collected and the levels of 13 POPs were determined by gas chromatography with electron-capture detection (GC-ECD). Anthropometric and biochemical data were collected at the time of surgery. BMI variation was evaluated after 12 months and adipocyte size was measured in AT samples. Results: Our data confirm that POPs are pervasive in this obese population (96.3% of detection on both tissues), their abundance increasing with age (RS=0.310, p<0.01) and duration of obesity (RS=0.170, p<0.05). We observed a difference in AT depot POPs storage capability, with higher levels of ΣPOPs in vAT (213.9±204.2 compared to 155.1±147.4 ng/g of fat, p<0.001), extremely relevant when evaluating their metabolic impact. Furthermore, there was a positive correlation between POP levels and the presence of metabolic syndrome components, namely dysglycaemia and hypertension, and more importantly with cardiovascular risk (RS=0.277, p<0.01), with relevance for vAT (RS=0.315, p<0.01). Finally, we observed an interesting relation of higher POP levels with lower weight loss in older patients. Conclusion: Our sample of obese subjects allowed us to highlight the importance of POPs stored in AT on the development of metabolic dysfunction in a context of obesity, shifting the focus to their metabolic effects and not only for their recognition as environmental obesogens.

Aplastic crisis due to human parvovirus B19 infection in hereditary hemolytic anaemia

Specific anti-B19 IgM was demonstrated in sera from three children showing transient aplastic crisis. A two years-old boy living in Rio de Janeiro suffering from sickle-cell anaemia showed the crisis during August, 1990. Two siblings living in Santa Maria, RS, developed aplastic crisis during May, 1991, when they were also diagnosed for hereditary spherocytosis. For a third child from this same family, who first developed aplastic crisis no IgM anti-B19 was detected in her sera.

Fast-to-fed shift in glucose homeostasis: clues to an earlier detection of human prediabetic states

FCM: UC Bioquímica I - PhD Thesis

Respiratory complications in Brazilian patients infected with human immunodeficiency virus

PURPOSE: To determine how often and by what means an indentifiable pulmonary pathogen can be recognized in human immunodeficiency virus (HIV) infected patients with respiratory disorders in Brazil, which are the most frequently observed microorganisms and what impact specific therapy has on these agents. PATIENTS AND METHODS: Thirty-five HIV seroposiüve subjects with respiratory complaints were studied. All patients had a complete history, physical examination and blood counts. The pulmonary assessment included chest radiograms; sputum examination for bacterial and fungal pathogens; bronchoscopy with bronchoalveolar lavage and transbronchial biopsy. Patients with treatable complications received standard antimicrobial therapy. RESULTS: One or more microorganisms were found in 24 subjects and another 3 individuals showed nonspecific interstitial pneumonitis. The sputum examination identified the pulmonary pathogens in 7 cases. The bronchoalveolar lavage and the histopathologic examination were diagnostic in 14% and 83%, respectively, of the 28 individuals that were submitted to bronchoscopy. The most frequently identified microorganism was P. carinii (55%), followed by M. tuberculosis (41%) and cytomegalovirus (8%). The clinical, laboratory and radiographic findings failed to distinguish the specific pulmonary pathogens. Twenty-three individuals with P. carinii pneumonitis and/or tuberculosis received specific therapy; among the evaluable patients the therapeutic response rates were 79% for PCP and 100% for TB. CONCLUSIONS: We have determined that tuberculosis, P. carinii and cytomegalovirus pneumonitis are the most common respiratory opportunistic diseases in Brazilian patients infected with HIV. The histologic evaluation was crucial in order to identify the pulmonary pathogens. Tuberculosis in AIDS individuals displayed clinical and radiographic findings atypical for reactivation disease. However, most of the features observed in HIV infected patients had been previously described in infection of the normal host. Furthermore, the AIDS subjects showed a good therapeutic response to anti-tuberculous drugs.

Aggregatory behaviour of platelets incubated with subcellular fractions of normal and chagasic human syncytiotrophoblast

The surface of human syncytiotrophoblast does not induce maternal blood platelet aggregation even though it is not an endothelium. It can be surmised that as occurs in endothelial injury the subcellular components of the syncytiotrophoblast may have pro-or antiaggregatory activity. During congenital Chagas' disease which is associated to trophoblast lesions, platelets may play a role in the development of T. cruzi-induced placentitis. In the present work the aggregatory behaviour of normal human blood platelets was recorded after their challenging with subcellular fractions of syncytiotrophoblast isolated from normal and chagasic women. Nuclear, Mitochondrial, Microsomal and Supernatant fractions isolated from normal and chagasic syncytiotrophoblast failed to induce per se any aggregatory reaction on platelets. When samples of platelet-rich plasma (PRP) were preincubated with normal and chagasic nuclear fractions and then stimulated with collagen at threshold level (CT-PRP) an inhibition of the aggregatory response was observed. Treatment of CT-PRP with normal and chagasic mitochondrial fractions induced inhibition of platelet aggregation whereas only chagasic fraction reduced latency time. Microsornal fraction from normal placentas showed no significant effects on platelet aggregation. It is concluded that subcellular fractions of normal human syncytiotrophoblast do not exhibit any effect on platelet aggregation, whereas those subcellular fractions enriched in intracellular membrane components isolated from chagasic placentas inhibit platelet aggregation.

Reduced schedule of human anti-rabies immunization with Fuenzalida & Palacios vaccine: additional data

It was reevaluated a reduced schedule for anti-rabies post-exposure immunization with newborn mice nervous tissue vaccine (Fuenzalida 8c Palacios) in a group of 30 non exposed volunteers. The vaccine was administered by intramuscular injections on days zero, 2, 4, 16 and 27, in the deltoid area. Antibody levels were determinated by a simplified serum neutralization microtest on days zero, 16 and 37. On days 16 and 37 the antibody levels of the whole group was >0.5 IU/ml and >1.0 IU/ml, respectively. The cell mediated immunity was precociously detected (on day 4) by the delayed type hipersensitivity skin test. Our results show that this reduced schedule elicited an early and effective humoral and cellular immune response. However it is necessary other studies with larger groups of vaccinees in order to obtain definitive conclusion.

Total serum IgE and parasite: specific IgG and IgA antibodies in human strongyloidiasis

Total serum IgE, and Strongyloides - specific IgG and IgA antibodies were studied in 27 patients with parasitologically proven strongyloidiasis. Clinical manifestations in this case series were investigated by a restrospective study of the patient's records. Total serum IgE levels were elevated (greater than 250 IU/ml) in 59% of the patients (mean concentration = 1364 IU/ml). Parasite - specific IgG and IgA antibodies were detected by ELISA in the serum of 23 (85.2%) and 21 (77.8%) patients, respectively. Elevated serum IgE and clinical manifestations were not useful indexes of the presence of strongyloidiasis. On the other hand, our results support the view that serologic tests, particularly ELISA for detecting Strongyloides - specific IgG antibodies, can be usefully exploited for diagnostic purposes in strongyloidiasis.

Human lagochilascariasis treated sucessfully with ivermectin: a case report

A 15 year old male patient was diagnosed as being infected with the nematode Lagochilascaris minor, presenting as abscesses over the left mastoid region, and invading the temporal bone, mastoid sinuses and possibly the CNS. Surgical drainage and administration of cambendazole and levamisole led to improvement, followed by an early relapse and poor tolerance to the antihelminthic drugs. Repeated doses of ivermectin (an animal preparation) were used for the first time to treat this condition and resulted in complete remission of signs of infection, maintained for 15 months after the end of drug therapy, indicating cure of the disease.

Molecular fingerprint of human gastric cell line infected by Helicobacter pylori

Helicobacter pylori infection represents a serious health problem, given its association with serious gastric diseases as gastric ulcers, cancer and MALT lymphoma. Currently no vaccine exists and antibiotic-based eradication therapy is already failing in more than 20% of cases. To increase the knowledge on the infection process diverse gastric cell lines, e.g. the adenocarcinona gastric (AGS) cell line, are routinely used has in vitro models of gastric epithelia. In the present work the molecular fingerprint of infected and non-infected AGS cell lines, by diverse H. pylori strains, was acquired using vibrational infrared spectroscopy. These molecular fingerprints enabled to discriminate infected from non-infected AGS cells, and infection due to different strains, by performing Principal Component Analysis. It was also possible to estimate, from the AGS cells molecular fingerprint, the effect of the infection on diverse biochemical and metabolic cellular status. In resume infra-red spectroscopy enabled the acquisition of infected AGS cells molecular fingerprint with minimal sample preparation, in a rapid, high-throughput, economic process yielding highly sensitive and informative data, most useful for promoting critical knowledge on the H. pylori infection process. © 2015 IEEE.