Health technology diffusion in developing countries: a case study of CT scanners in Brazil

Background The development of products and services for health care systems is one of the most important phenomena to have occurred in the field of health care over the last 50 years. It generates significant commercial, medical and social results. Although much has been done to understand how health technologies are adopted and regulated in developed countries, little attention has been paid to the situation in low- and middle-income countries (LMICs). Here we examine the institutional environment in which decisions are made regarding the adoption of expensive medical devices into the Brazilian health care system. Methods We used a case study strategy to address our research question. The empirical work relied on in-depth interviews (N = 16) with representatives of a wide range of actors and stakeholders that participate in the process of diffusion of CT (computerized tomography) scanners in Brazil, including manufacturers, health care organizations, medical specialty societies, health insurance companies, regulatory agencies and the Ministry of Health. Results The adoption of CT scanners is not determined by health policy makers or third-party payers of public and private sectors. Instead, decisions are primarily made by administrators of individual hospitals and clinics, strongly influenced by both physicians and sales representatives of the medical industry who act as change agents. Because this process is not properly regulated by public authorities, health care organizations are free to decide whether, when and how they will adopt a particular technology. Conclusions Our study identifies problems in how health care systems in LMICs adopt new, expensive medical technologies, and suggests that a set of innovative approaches and policy instruments are needed in order to balance the institutional and professional desire to practise a modern and expensive medicine in a context of health inequalities and basic health needs.

Prevalence of cannabis use in Brazil: Data from the I Brazilian National Alcohol Survey (BNAS)

Aims: To estimate the prevalence of cannabis use in the last 12 months in the Brazilian population and to examine its association with individual and geographic characteristics. Design: Cross-sectional survey with a national probabilistic sample. Participants: 3006 individuals aged 14 to 65 years. Measurements: Questionnaire based on well established instruments, adapted to the Brazilian population. Findings: The 12-month prevalence of cannabis use was 2.1% (95%Cl 1.3-2.9). Male gender, better educational level, unemployment and living in the regions South and Southeast were independently associated with higher 12-month prevalence of cannabis use. Conclusion: While the prevalence of cannabis use in Brazil is lower than in many countries, the profile of those who are more likely to have used it is similar. Educational and prevention policies should be focused on specific population groups. (C) 2009 Elsevier Ltd. All rights reserved.

Suicidality in Obsessive-Compulsive Disorder: Prevalence and Relation to Symptom Dimensions and Comorbid Conditions

Background: Suicidal thoughts and behaviors, also known as suicidality, are a fairly neglected area of study in patients with obsessive-compulsive disorder (OCD). Objective: To evaluate several aspects of suicidality in a large multicenter sample of OCD patients and to compare those with and without suicidal ideation, plans, and attempts according to demographic and clinical variables, including symptom dimensions and comorbid disorders. Method: This cross-sectional study included 582 outpatients with primary OCD (DSM-IV) recruited between August 2003 and March 2008 from 7 centers of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. The following assessment instruments were used: the Yale-Brown Obsessive Compulsive Scale, the Dimensional Yale-Brown Obsessive Compulsive Scale, the Beck Depression and Anxiety Inventories, the Structured Clinical Interview for DSM-IV Axis I Disorders, and 6 specific questions to investigate suicidality. After univariate analyses, logistic regression analyses were performed to adjust the associations between the dependent and explanatory variables for possible confounders. Results: Thirty-six percent of the patients reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide, and 10% presented current suicidal thoughts. In the logistic regression, only lifetime major depressive disorder and posttraumatic stress disorder (PTSD) remained independently associated with all aspects of suicidal behaviors. The sexual/religious dimension and comorbid substance use disorders remained associated with suicidal thoughts and plans, while impulse-control disorders were associated with current suicidal thoughts and with suicide plans and attempts. Conclusions: The risk of suicidal behaviors must be carefully investigated in OCD patients, particularly those with symptoms of the sexual/religious dimension and comorbid major depressive disorder, PTSD, substance use disorders, and impulse-control disorders. J Clin Psychiatry 2011;72(1):17-26 (C) Copyright 2011 Physicians Postgraduate Press, Inc.

ADHD in a representative sample of the Brazilian population: estimated prevalence and comparative adequacy of criteria between adolescents and adults according to the item response theory

Background: Attention deficit hyperactivity disorder (ADHD) is a clinically significant disorder in adulthood, but current diagnostic criteria and instruments do not seem to adequately capture the complexity of the disorder in this developmental phase. Accordingly, there are limited data on the proportion of adults affected by the disorder, specially in developing countries. Method: We assessed a representative household sample of the Brazilian population for ADHD with the Adult ADHD Self-report Scale (ASRS) Screener, and evaluated the instrument according to the Rasch model of item response theory. Results: The sample was comprised by 3007 individuals, and the overal prevalence of positive screeners for ADHD was 5.8% [95% confidence interval (CI), 4.8-7.0]. Rasch analyses revealed the misfitt of the overall sample to expectations of the model. The evaluation of the sample stratified by age revealed that data for adolescents showed a signficant fittnes to the model expectations, while items completed by adults were not adequated. Conclusions: The lack of fitness to the model for adult respondents challenges the possibility of a linear transformation of the ordinal data into interval measures and the utilization of parametric analyses of data. This result suggests that diagnostic criteria and instruments for adult ADHD must take into account a developmental perspective. Moreover, it calls for further evaluation of currently employed research methods in light of modern theories of psychometrics. Copyright (C) 2010 John Wiley & Sons, Ltd.

Validation of the University of Sao Paolo Sensory Phenomena Scale: Initial Psychometric Properties

Introduction: Although obsessions and compulsions comprise the main features of obsessive-compulsive disorder (OCD), many patients report that their compulsions are preceded by a sense of ""incompleteness"" or other unpleasant feelings such as premonitory urges or a need perform action`s until feeling ""just right."" These manifestations have been characterized as Sensory Phenomena (SP). The current study presents initial psychometric data for a new scale designed to measure SP. Methods: Seventy-six adult OCD subjects were probed twice. Patients were assessed with an open clinical interview (considered as the ""gold standard"") and with the following standardized instruments: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders, Yale-Brown Obsessive-Compulsive Scale, Dimensional Yale-Brown Obsessive-Compulsive Scale, Yale Global Tic Severity Scale, Beck Anxiety Inventory, and Beck Depression Inventory. Results: SP were present in 51 OCD patients (67.1%). Tics were present in 16 (21.1%) of the overall sample. The presence of SP was significantly higher in early-onset OCD patients. There were no significant differences in the presence of SP according to comorbidity with tics or gender. The comparison between the results from the open clinical interviews and the University of Sao Paulo Sensory Phenomena Scale (USP-SPS) showed an excellent concordance between them, with no significant differences between interviewers. The inter-rater reliability between the expert raters for the USP-SPS was high, with K=.92. The Pearson correlation coefficient between the SP severity scores given by the two raters was .89. Conclusion: Preliminary results suggest that the USP-SPS is a valid and reliable instrument for assessing the presence and severity of SP in OCD subjects. CNS Spectr. 2009;14(6):315-323

The role of alcoholic beverage preference in the severity of alcohol dependence and adherence to the treatment

The severity of dependence on alcohol and the efficacy of diverse types of treatments for alcoholism have been the subject of various researches. This study focused on the types of beverages preferentially consumed by alcohol-dependent outpatients and their effects on the severity of dependence and therapeutic outcomes. Our sample comprised 153 patients, 18-60 years of age, with an International Classification of Diseases (ICD-10) diagnosis of alcohol dependence, who were randomly divided into three different groups to receive topiramate (up to 300 mg/day), naltrexone (50 mg/day), or placebo during 12 weeks of follow-up. Spirits and beer were the main beverages consumed. At the start of this research, the group of spirits drinkers showed higher severity of alcohol dependence, higher craving for alcohol, more frequent history of treatments for alcoholism, and lower income than the group of beer preference drinkers. During the study, beer preference drinkers demonstrated higher adherence to the treatment, independently of the types of medications prescribed (P = .02, odds ratio, 2.46, 95% confidence interval, 1.17-5.19). This study suggests that the severity of dependence and the adherence to the treatment can be factors that set apart beer drinkers from spirits drinkers. As the compliance with the treatment for alcoholism was lower among spirits preference drinkers, a more intensive model of treatment would be necessary. (C) 2009 Elsevier Inc. All rights reserved.

Validity of the self reporting questionnaire-20 in epidemiological studies with older adults

This study examined the validity of the self-reporting questionnaire (SRQ-20) in a population-based survey with older adults in Sao Paulo, Brazil. The study sample consisted of 2,008 individuals aged 65 years or more who were living in an economically disadvantaged area of the city. The geriatric mental state (GMS) was used as the gold standard for the assessment of common mental disorders (CMD). The optimal SRQ-20 threshold for case definition was 4/5 (sensitivity = 76.1%, specificity = 74.6%, area under ROC curve = 0.82). Women, older participants and those with lower income were more likely to be misclassified by the questionnaire. The inclusion of older persons with dementia or psychosis did not change the ability of the SRQ-20 to identify cases of CMD. The SRQ-20 may be a useful instrument to be used in large epidemiological studies in resource-poor settings for the identification of cases of depression and anxiety in later life. The performance of the SRQ-20 among older adults was similar to that observed with the adult population in Brazil.

Sex differences in the phenotypic expression of obsessive-compulsive disorder: an exploratory study from Brazil

Previous studies have shown differences in clinical features of obsessive-compulsive disorder (OCD) between men and women, including mean age at onset of obsessive-compulsive symptoms (OCS), types of OCS, comorbid disorders, course, and prognosis. The aim of this study was to compare male and female Brazilian patients with OCD on several demographic and clinical characteristics. Three hundred thirty Outpatients with OCD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], criteria) who sought treatment at 3 Brazilian public universities and at 2 private practice clinics in the city of Sao Paulo were evaluated. The assessment instruments used were the Yale-Brown Obsessive-Compulsive Scale to evaluate OCD severity and symptoms, the Beck Depression and Anxiety Inventories, the Yale Global Tic Severity Scale, and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders to assess psychiatric comorbidity. Fifty-five percent of the patients (n = 182) were men who were significantly more likely than women to be single and to present sexual, religious, and symmetry obsessions and mental rituals. They also presented earlier onset of OCS and earlier symptom interference in functioning, and significantly more comorbid tic disorders and posttraumatic stress disorder. Women, besides showing significantly higher mean scores in the Beck Depression and Anxiety Inventories, were more likely to present comorbid simple phobias, eating disorders in general and anorexia in particular, impulse control disorders in general, and compulsive buying and skin picking in particular. No significant differences were observed between sexes concerning family history of OCS or OCD, and global symptoms severity, either in obsession or compulsive subscale. The present study confirms the presence of sex-related differences described in other countries and cultures. The fact that the OCS start earlier and probably have a worse impact in men can eventually lead to more specific and efficacious treatment approaches for these patients. (C) 2009 Elsevier Inc. All rights reserved.

Classification System of Raman Spectra using Cluster Analysis to Diagnose Coronary Artery Lesions

The traditional methods employed to detect atherosclerotic lesions allow for the identification of lesions; however, they do not provide specific characterization of the lesion`s biochemistry. Currently, Raman spectroscopy techniques are widely used as a characterization method for unknown substances, which makes this technique very important for detecting atherosclerotic lesions. The spectral interpretation is based on the analysis of frequency peaks present in the signal; however, spectra obtained from the same substance can show peaks slightly different and these differences make difficult the creation of an automatic method for spectral signal analysis. This paper presents a signal analysis method based on a clustering technique that allows for the classification of spectra as well as the inference of a diagnosis about the arterial wall condition. The objective is to develop a computational tool that is able to create clusters of spectra according to the arterial wall state and, after data collection, to allow for the classification of a specific spectrum into its correct cluster.

Independent component analysis applied to raman spectra for classification of in vitro human coronary arteries

Optical diagnostic methods, such as near-infrared Raman spectroscopy allow quantification and evaluation of human affecting diseases, which could be useful in identifying and diagnosing atherosclerosis in coronary arteries. The goal of the present work is to apply Independent Component Analysis (ICA) for data reduction and feature extraction of Raman spectra and to perform the Mahalanobis distance for group classification according to histopathology, obtaining feasible diagnostic information to detect atheromatous plaque. An 830nm Ti:sapphire laser pumped by an argon laser provides near-infrared excitation. A spectrograph disperses light scattered from arterial tissues over a liquid-nitrogen cooled CCD to detect the Raman spectra. A total of 111 spectra from arterial fragments were utilized.

USE OF DISPERSIVE RAMAN SPECTROSCOPY IN THE DETERMINATION OF UNSATURATED FAT IN COMMERCIAL EDIBLE OIL- AND FAT-CONTAINING INDUSTRIALIZED FOODS

The present study aims at the use of Raman spectroscopy in the quantification of unsaturated fats in fat-containing foods, compared to the information available in the Nutritional Table, to obtain a non-destructive optical quantification of unsaturation. Raman spectra of edible oil, margarine, mayonnaise, hydrogenated fat, and butter were obtained with a near-infrared Raman spectrometer (830nm). By analyzing selected bands in the regions of 1750, 1660, 1440, 1300, and 1260cm-1, the amount of total and unsaturated fat of samples of oil, margarine, and mayonnaise were correlated with the information displayed in the Nutritional Table. The amount of unsaturated trans fat in selected samples was correlated to the Raman shift of 1660cm-1. Dispersive Raman spectroscopy was shown to be effective in quantifying the unsaturated fats in oil, margarine, and mayonnaise, and trans fat in hydrogenated oils and butter.

Gambling in Brazil Lifetime prevalences and socio-demographic correlates

Gambling has experienced world-wide growth The current study is the first national survey into household gambling conducted in a developing country The sample was a three-stage probabilistic one designed to cover individuals 14 years old or older of both genders and from all regions of the national territory 325 census sectors were visited including rural areas DSM-IV-based instruments were used to assess problem and pathological gambling individuals were asked to estimate their monthly gambling expenditure The lifetime prevalences were pathological gambling 1 0% and problem gambling 1 3% Maximum gambling expenditure corresponded to 5 4% of the household income for social gamblers 16 9% for problem gamblers and 20 0% for pathological gamblers The male female ratio among adults for pathological gambling was 3 2 1 The data suggest the existence of two subgroups of pathological gamblers one younger (33 9 +/- 4 19) and severe (7 or more DSM-IV criteria) another older (47 8 +/- 6 01) and less severe (5-6 criteria) In a multinomial logistic regression problematic gambling was associated with gender age education employment region of origin and living in metropolitan areas The data suggest that feeling active and socially inserted protects against problematic gambling Individuals who are young male unemployed or not currently pursuing further education may be at special risk for severe pathological gambling (C) 2010 Elsevier Ireland Ltd All rights reserved

Quality of life in elderly with dizziness

Dizziness is frequent in elderly people. Aims: To evaluate the Quality of Life (QoL) in elderly subjects with dizziness, relate it with gender and age. Material and Method: A prospective study comprising 120 elderly patients with dizziness evaluated with Brazilian versions of the Whoqol-bref and the dizziness handicap inventory (DHI). The factor analysis (FA), the Mann Whitney and Kruskal Wallis tests, and the Spearman correlation were applied to study the results. Results: The most compromised domains were the DHI physical domain and the Whoqol-bref physical and environment domains. FA resulted in 3 factors in the DHI and 5 factors in the Whoqol-bref. There was a moderate correlation (-0.596) in the total scores of both instruments. Males had a better QoL in the ""environment perception and introspectivity"" and ""health perception"" factors of the Whoqol-bref test. Females had a better QoL in the ""functionality perception"" factor of the Whoqol-bref test. There were no significant age differences. Conclusions: Elderly patients with dizziness have a worse QoL. Elderly females with dizziness have worse QoL scores in ""environment perception and introspectivity"" and ""health perception"" and better QoL in the ""functionality perception"" factor compared to elderly males.

Translation and Cross-Cultural Adaptation of the Brazilian Version of the International Knee Documentation Committee Subjective Knee Form Validity and Reproducibility

Background: The perception of improvement by a patient has assumed a central role in functional evaluation after a variety of knee problems. One of the instruments most used in clinical research is the International Knee Documentation Committee (IKDC) Subjective Knee Form because its psychometric properties are considered to be excellent. Nonetheless, this questionnaire was originally developed for use in the English language. Therefore, to use this questionnaire in the Brazilian population, it is essential to translate and validate it. Purpose: The aim of this study was to translate the IKDC Subjective Knee Form into a Brazilian version and to test its validity and reproducibility. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The translation of the original IKDC Subjective Knee Form into a Brazilian version was accomplished in accordance with the American Orthopaedic Society for Sports Medicine guidelines and was tested in 32 patients with knee pathologic conditions to develop the first Brazilian version. To test validity and reproducibility, 117 patients with several knee complaints completed the Brazilian IKDC Subjective Knee Form, the Short Form 36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm score. From these patients, 85 were retested within a week to achieve reproducibility. The validation was addressed by correlating the Brazilian IKDC Subjective Knee Form to the other outcome measures. The reproducibility was tested by measuring internal consistency, test-retest reliability, and agreement. Results: The Brazilian IKDC Subjective Knee Form was highly related to the physical component summary of the SF-36, the Lysholm score, and the WOMAC, and weakly related to the mental component summary of SF-36 (r=.79, .89, .85, and .51, respectively). The internal consistency was strong, with a Cronbach a value of .928 and .935 in the test and retest assessment, respectively. The test-retest reliability proved to be excellent, with a high value of the intraclass correlation coefficient (.988), as well as the agreement, demonstrated by the low differences between the means of the test and retest, and the short limit of agreement, observed in the Altman-Bland and survival-agreement plots. Conclusion: The results of this study provide evidence that the Brazilian IKDC Subjective Knee Form has psychometric properties similar to the original version. In addition, it was a reliable evaluation instrument for patients with knee-related problems.

Body dysmorphic disorder among dermatologic patients: Prevalence and clinical features

Background: An impairing preoccupation with a nonexistent or slight defect in appearance is the core symptom of body dysmorphic disorder (ODD), a psychiatric condition common in dermatology settings. Objective: We sought to determine the prevalence of ODD in dermatologic patients, comparing general and cosmetic settings, and describing some demographic and clinical characteristics. Methods: In all, 300 patients were consecutively assessed. Screening and diagnoses were performed with validated instruments plus a best estimate diagnosis procedure. The final sample comprised 150 patients in the cosmetic group, 150 patients in the general dermatology group, and 50 control subjects. Standard statistical analyses were performed (chi(2), nonparametric tests, logistic regression). Results: The current prevalence was higher in the cosmetic group (14.0%) compared with general (6.7%) and control (2.0%) groups. No patient had a previous diagnosis. Frequently the reason for seeking dermatologic treatment was not the main ODD preoccupation. Patients with ODD from the cosmetic group were in general unsatisfied with the results of dermatologic treatments. Limitations: Cross-sectional study conducted in a university hospital is a limitation. It is uncertain if the findings can be generalized. Retrospective data regarding previous treatments are not free from bias. Conclusions: BUD is relatively common in a dermatologic setting, especially among patients seeking cosmetic treatments. These patients have some different features compared with general dermatology patients. Dermatologists should be aware of the clinical characteristics of ODD to identify and refer these patients to mental health professionals. (J Am Acad Dermatol 2010;63:235-43.)