Fatores de prognóstico para os resultados de sucesso da fisioterapia multimodal em utentes com dor cervical crónica

RESUMO: Introdução: O conhecimento acerca da influência das características dos indivíduos com dor cervical crónica (DCC) no prognóstico dos resultados alcançados com a Fisioterapia é ainda inconsistente, sendo escassos os estudos desenvolvidos neste âmbito. Objetivo: Este relatório pretende determinar se um modelo baseado em fatores de prognóstico é capaz de prever os resultados de sucesso da Fisioterapia, a curto prazo, em utentes com DCC, ao nível da incapacidade funcional, intensidade da dor e perceção global de melhoria. Metodologia: Trata-se de estudo de coorte prospetivo com 112 participantes. Os utentes foram avaliados na primeira semana de tratamento e sete semanas após o início da intervenção. Os instrumentos utilizados foram o Neck Disability Index–Versão Portuguesa (NDI-PT) e a Escala Numérica da Dor (END) nos dois momentos de avaliação, um Questionário de Caracterização Sociodemográfica e Clínica da Amostra na baseline e a Patient Global Impression Change Scale–Versão Portuguesa (PGIC-PT) no follow-up. As características sociodemográficas e clínicas foram incluídas como potenciais fatores de prognóstico e estes foram definidos com base nas diferenças mínimas clinicamente importantes (DMCI) dos instrumentos NDIPT (DMCI≥6) e END (DMCI≥2) e no critério de pontuação ≥5 na PGIC-PT. A análise dos dados foi realizada através do método de regressão logística (backward conditional procedure) para identificar as associações entre os indicadores e as variáveis de resultado (p<0.05). Resultados: Dos 112 participantes incluídos no estudo, 108 completaram o follow-up (média de idade: 51.76±10.19). No modelo multivariado relativo à incapacidade funcional, os resultados de sucesso encontram-se associados a elevados níveis de incapacidade na baseline (OR=1.123; 95% IC 1.056–1.194) e a duração da dor inferior a 12 meses (OR=2.704; 95% IC 1.138–6.424). Este modelo explica 30.0% da variância da melhoria da funcionalidade e classifica corretamente 74.1% dos utentes (sensibilidade: 75.9%; especificidade: 72.0%). O modelo relativo à intensidade da dor identificou apenas a associação do outcome com níveis elevados de intensidade da dor na baseline (OR=1.321; 95% IC 1.047–1.668), explicando 7.5% da variância da redução da mesma e classificando corretamente 68.2% dos utentes (sensibilidade: 94.4%; especificidade: 16.7%). O modelo final referente à perceção global de melhoria apresentou uma associação com a intensidade da dor na baseline (OR=0.621; 95% IC 0.465–0.829), com a presença de cefaleias e/ou tonturas (OR=2.538; 95% IC 0.987–6.526) e com a duração da dor superior a 12 meses (OR=0.279; 95% IC 0.109–0.719). Este modelo explica 27.5% da variância dos resultados de sucesso para este outcome e classifica corretamente 73.1% dos utentes (sensibilidade: 81.8%; especificidade: 59.5%). Conclusões: Utentes com DCC com elevada incapacidade na baseline e queixas de dor há menos de 12 meses apresentam maior probabilidade de obter melhorias ao nível da incapacidade funcional. Elevados níveis de intensidade da dor na baseline predizem resultados de sucesso na redução da dor após sete semanas de tratamento. Utentes com DCC com baixos níveis de dor na baseline, com cefaleias e/ou tonturas e com queixas de dor há mais de 12 meses apresentam maior probabilidade de obter uma melhor perceção de melhoria.--------------- ABSTRACT:Introduction: The influence of the characteristics of individuals with chronic neck pain (CNP) on the prognosis of physiotherapy outcomes is still inconsistent, there being few studies developed in this context. Aim: This study seeks to determine whether a model based on prognostic factors can predict the short-term physiotherapy successful outcomes in CNP patients, regarding functional disability, pain intensity and perceived recovery. Methodology: This is a prospective cohort study with 112 participants. Patients were assessed during the first week of treatment and seven weeks after the start of the intervention. The instruments used were the Neck Disability Index–Portuguese Version (NDI-PT) and the Numerical Rating Scale (NRS) at both moments of assessment, a Sample Sociodemographic and Clinical Characterization Questionnaire at baseline and Patient Global Impression Change Scale–Portuguese Version (PGIC-PT) at the follow-up. The sociodemographic and clinical characteristics were included as potential predictors of successful outcomes, and these were defined on the basis of minimal clinically important differences (MCID) of NDI-PT (MCID≥6) and END (MCID≥2) and the criteria score ≥5 on the PGIC-PT. Data analysis was performed using logistic regression (backward conditional procedure) to identify associations between predictors and outcomes (p<0.05). Results: Of the 112 participants included in the study, 108 completed the follow-up (mean age: 51.76±10.19). In the multivariate model of functional disability, the successful outcomes are associated with high levels of disability at baseline (OR = 1.123; 95% CI 1.056-1.194), and pain duration shorter than 12 months (OR=2.704; 95% CI 1.138–6.424). This model explains 30.0% of the variance of improved functional capacity and correctly classifies 74.1% of the patients (sensitivity: 75.9%, specificity: 72.0%). The model for pain intensity solely identified an outcome association with high pain intensity at baseline (OR=1.321; 95% CI 1.047-1.668), explaining 7.5% of the variance of pain reduction and correctly classifying 68.2% of the patients (sensitivity: 94.4%, specificity: 16.7%). The final model of perceived recovery showed an association with pain intensity at baseline (OR=0.621; 95% CI 0465-0829), with the presence of headache and/or dizziness (OR=2.538; 95% CI 0.987-6.526) and the duration of pain over 12 months (OR=0.279; 95% CI 0.109-0.719). This model explains 27.5% of the variance of successful outcomes and correctly classifies 73.1% of the patients (sensitivity: 81.8%, specificity: 59.5%). Conclusions: Patients with CNP with high disability at baseline and complaints of pain for less than 12 months are more likely to obtain improvements in functional disability. High levels of pain intensity at baseline predict successful outcomes in pain reduction after seven weeks of treatment. Patients with CNP with low levels of pain at baseline, with headache and/or dizziness and with pain complaints for more than 12 months are more likely to get a better perceived recovery.

Curso clínico da dor lombar crónica após alta da fisioterapia : trajetórias de dor no follow-up aos quatro e seis meses

RESUMO:Introdução: O conhecimento acerca da influência das características dos indivíduos com dor cervical crónica (DCC) no prognóstico dos resultados alcançados com a Fisioterapia é ainda inconsistente, sendo escassos os estudos desenvolvidos neste âmbito. Objetivo: Este relatório pretende determinar se um modelo baseado em fatores de prognóstico é capaz de prever os resultados de sucesso da Fisioterapia, a curto prazo, em utentes com DCC, ao nível da incapacidade funcional, intensidade da dor e perceção global de melhoria. Metodologia: Trata-se de estudo de coorte prospetivo com 112 participantes. Os utentes foram avaliados na primeira semana de tratamento e sete semanas após o início da intervenção. Os instrumentos utilizados foram o Neck Disability Index–Versão Portuguesa (NDI-PT) e a Escala Numérica da Dor (END) nos dois momentos de avaliação, um Questionário de Caracterização Sociodemográfica e Clínica da Amostra na baseline e a Patient Global Impression Change Scale–Versão Portuguesa (PGIC-PT) no follow-up. As características sociodemográficas e clínicas foram incluídas como potenciais fatores de prognóstico e estes foram definidos com base nas diferenças mínimas clinicamente importantes (DMCI) dos instrumentos NDIPT (DMCI≥6) e END (DMCI≥2) e no critério de pontuação ≥5 na PGIC-PT. A análise dos dados foi realizada através do método de regressão logística (backward conditional procedure) para identificar as associações entre os indicadores e as variáveis de resultado (p<0.05). Resultados: Dos 112 participantes incluídos no estudo, 108 completaram o follow-up (média de idade: 51.76±10.19). No modelo multivariado relativo à incapacidade funcional, os resultados de sucesso encontram-se associados a elevados níveis de incapacidade na baseline (OR=1.123; 95% IC 1.056–1.194) e a duração da dor inferior a 12 meses (OR=2.704; 95% IC 1.138–6.424). Este modelo explica 30.0% da variância da melhoria da funcionalidade e classifica corretamente 74.1% dos utentes (sensibilidade: 75.9%; especificidade: 72.0%). O modelo relativo à intensidade da dor identificou apenas a associação do outcome com níveis elevados de intensidade da dor na baseline (OR=1.321; 95% IC 1.047–1.668), explicando 7.5% da variância da redução da mesma e classificando corretamente 68.2% dos utentes (sensibilidade: 94.4%; especificidade: 16.7%). O modelo final referente à perceção global de melhoria apresentou uma associação com a intensidade da dor na baseline (OR=0.621; 95% IC 0.465–0.829), com a presença de cefaleias e/ou tonturas (OR=2.538; 95% IC 0.987–6.526) e com a duração da dor superior a 12 meses (OR=0.279; 95% IC 0.109–0.719). Este modelo explica 27.5% da variância dos resultados de sucesso para este outcome e classifica corretamente 73.1% dos utentes (sensibilidade: 81.8%; especificidade: 59.5%). Conclusões: Utentes com DCC com elevada incapacidade na baseline e queixas de dor há menos de 12 meses apresentam maior probabilidade de obter melhorias ao nível da incapacidade funcional. Elevados níveis de intensidade da dor na baseline predizem resultados de sucesso na redução da dor após sete semanas de tratamento. Utentes com DCC com baixos níveis de dor na baseline, com cefaleias e/ou tonturas e com queixas de dor há mais de 12 meses apresentam maior probabilidade de obter uma melhor perceção de melhoria.-----------ABSTRACT: Introduction: The influence of the characteristics of individuals with chronic neck pain (CNP) on the prognosis of physiotherapy outcomes is still inconsistent, there being few studies developed in this context. Aim: This study seeks to determine whether a model based on prognostic factors can predict the short-term physiotherapy successful outcomes in CNP patients, regarding functional disability, pain intensity and perceived recovery. Methodology: This is a prospective cohort study with 112 participants. Patients were assessed during the first week of treatment and seven weeks after the start of the intervention. The instruments used were the Neck Disability Index–Portuguese Version (NDI-PT) and the Numerical Rating Scale (NRS) at both moments of assessment, a Sample Sociodemographic and Clinical Characterization Questionnaire at baseline and Patient Global Impression Change Scale–Portuguese Version (PGIC-PT) at the follow-up. The sociodemographic and clinical characteristics were included as potential predictors of successful outcomes, and these were defined on the basis of minimal clinically important differences (MCID) of NDI-PT (MCID≥6) and END (MCID≥2) and the criteria score ≥5 on the PGIC-PT. Data analysis was performed using logistic regression (backward conditional procedure) to identify associations between predictors and outcomes (p<0.05). Results: Of the 112 participants included in the study, 108 completed the follow-up (mean age: 51.76±10.19). In the multivariate model of functional disability, the successful outcomes are associated with high levels of disability at baseline (OR = 1.123; 95% CI 1.056-1.194), and pain duration shorter than 12 months (OR=2.704; 95% CI 1.138–6.424). This model explains 30.0% of the variance of improved functional capacity and correctly classifies 74.1% of the patients (sensitivity: 75.9%, specificity: 72.0%). The model for pain intensity solely identified an outcome association with high pain intensity at baseline (OR=1.321; 95% CI 1.047- 1.668), explaining 7.5% of the variance of pain reduction and correctly classifying 68.2% of the patients (sensitivity: 94.4%, specificity: 16.7%). The final model of perceived recovery showed an association with pain intensity at baseline (OR=0.621; 95% CI 0465-0829), with the presence of headache and/or dizziness (OR=2.538; 95% CI 0.987-6.526) and the duration of pain over 12 months (OR=0.279; 95% CI 0.109- 0.719). This model explains 27.5% of the variance of successful outcomes and correctly classifies 73.1% of the patients (sensitivity: 81.8%, specificity: 59.5%). Conclusions: Patients with CNP with high disability at baseline and complaints of pain for less than 12 months are more likely to obtain improvements in functional disability. High levels of pain intensity at baseline predict successful outcomes in pain reduction after seven weeks of treatment. Patients with CNP with low levels of pain at baseline, with headache and/or dizziness and with pain complaints for more than 12 months are more likely to get a better perceived recovery.

Experimental and modeling studies on reverse electrodialysis for sustainable power generation

A potentially renewable and sustainable source of energy is the chemical energy associated with solvation of salts. Mixing of two aqueous streams with different saline concentrations is spontaneous and releases energy. The global theoretically obtainable power from salinity gradient energy due to World’s rivers discharge into the oceans has been estimated to be within the range of 1.4-2.6 TW. Reverse electrodialysis (RED) is one of the emerging, membrane-based, technologies for harvesting the salinity gradient energy. A common RED stack is composed by alternately-arranged cation- and anion-exchange membranes, stacked between two electrodes. The compartments between the membranes are alternately fed with concentrated (e.g., sea water) and dilute (e.g., river water) saline solutions. Migration of the respective counter-ions through the membranes leads to ionic current between the electrodes, where an appropriate redox pair converts the chemical salinity gradient energy into electrical energy. Given the importance of the need for new sources of energy for power generation, the present study aims at better understanding and solving current challenges, associated with the RED stack design, fluid dynamics, ionic mass transfer and long-term RED stack performance with natural saline solutions as feedwaters. Chronopotentiometry was used to determinate diffusion boundary layer (DBL) thickness from diffusion relaxation data and the flow entrance effects on mass transfer were found to avail a power generation increase in RED stacks. Increasing the linear flow velocity also leads to a decrease of DBL thickness but on the cost of a higher pressure drop. Pressure drop inside RED stacks was successfully simulated by the developed mathematical model, in which contribution of several pressure drops, that until now have not been considered, was included. The effect of each pressure drop on the RED stack performance was identified and rationalized and guidelines for planning and/or optimization of RED stacks were derived. The design of new profiled membranes, with a chevron corrugation structure, was proposed using computational fluid dynamics (CFD) modeling. The performance of the suggested corrugation geometry was compared with the already existing ones, as well as with the use of conductive and non-conductive spacers. According to the estimations, use of chevron structures grants the highest net power density values, at the best compromise between the mass transfer coefficient and the pressure drop values. Finally, long-term experiments with natural waters were performed, during which fouling was experienced. For the first time, 2D fluorescence spectroscopy was used to monitor RED stack performance, with a dedicated focus on following fouling on ion-exchange membrane surfaces. To extract relevant information from fluorescence spectra, parallel factor analysis (PARAFAC) was performed. Moreover, the information obtained was then used to predict net power density, stack electric resistance and pressure drop by multivariate statistical models based on projection to latent structures (PLS) modeling. The use in such models of 2D fluorescence data, containing hidden, but extractable by PARAFAC, information about fouling on membrane surfaces, considerably improved the models fitting to the experimental data.

Equidade na despesa com cuidados de saúde em Portugal

RESUMO - O acesso com equidade aos cuidados de saúde é uma das pedras angulares da constituição da nossa República e do SNS. A garantia de igual utilização para iguais necessidades seguindo os princípios de equidade é parte integrante da legislação Portuguesa. Os indivíduos com menor estatuto-socioeconómico são apontados unanimemente pela literatura internacional como possuindo pior estado de saúde que os mais abastados, sendo por isso de prever uma maior utilização dos cuidados de saúde. Através deste trabalho pretendemos aferir a equidade da despesa com cuidados de saúde, partindo da premissa que pior estatuto socioeconómico está relacionado com pior estado de saúde, serão os indivíduos com menor capacidade financeira a utilizar mais os cuidados de saúde e portanto a apresentar maior despesa. Utilizando o INS 05/06, e, através de uma regressão multivariada, ajustámos os resultados em relação às variáveis comummente associadas com necessidades em cuidados de saúde, e verificámos que efectivamente existem iniquidades na despesa com cuidados de saúde. Analisando o rendimento líquido total da família do utente no mês anterior ao inquérito existe uma clara gradação, em que maior rendimento se reflecte em maior despesa. Verificámos que as despesas com cuidados de saúde são superiores nos indivíduos com idade superior a 34 anos, com uma educação de nível terciário ou superior, com rendimento superior ou igual a 700,20 euros, com estado de saúde auto-reportado Muito Mau, com seguro de saúde e com doenças crónicas. A despesa não variou significativamente tendo em conta o sexo. Na idade, apenas a categorias etárias 18 a 34 anos e maiores de 75 anos apresentaram uma diferença estatisticamente significativa em relação à despesa com cuidados de saúde. À luz dos resultados obtidos, concluímos que existem efectivamente iniquidades favoráveis aos mais ricos na despesa com cuidados de saúde em Portugal.

Factors of poor prognosis of visceral leishmaniasis among children under 12 years of age. A retrospective monocentric study in Belo Horizonte, State of Minas Gerais, Brazil, 2001-2005

INTRODUTION: A major concern with the visceral leishmaniasis (VL) is its high lethality rate, even with proper treatment. Low age, prior malnutrition, disease duration prior to diagnosis, severe anemia, fever for more than 60 days, diarrhea and jaundice are known poor prognostic factors. The goals of this study are to describe the clinical and laboratory characteristics of VL among children under 12 years of age and to identify the factors associated with VL poor outcome. METHODS: Two hundred and fifty children under 12 years of age with confirmed VL admitted to Hospital João Paulo II (FHEMIG), Belo Horizonte, Brazil, between January 2001 and December 2005 were evaluated retrospectively. The primary outcome was the poor clinical evolution: sepsis, and/or pneumonia, and/or urinary tract infection, and/or of bleeding (expect epistaxis), and/or severe neutropenia (neutrophil < 500 cells/mm3). Odds ratio (crude and adjusted) and its 95% confidence interval for each variable were calculated. Values less than 0.05 were considered significant. RESULTS: Average age was 3.3 years (3.6 months-11.6 years), 71.2% were younger than 5 years and 47.2% lived in Metropolitan Area of Belo Horizonte. The mean fatality rate was 3.6%. Sixty-six (26.4%) patients presented poor evolution. After a multivariate analysis, age <18 months, abnormal respiratory physical examination on hospital admission, and platelets <85,000/mm3 remained associated with increased chance of poor evolution. CONCLUSIONS: The results suggest that patients aged between 12 and 18 months, with platelet counts bellow 85,000/mm3, and respiratory abnormalities at admission should be considered potentially severe.

Impact of corporate social responsibility in the European pharmaceutical market

The objective of this master thesis is to evaluate the impact of CSR measures in the financial performance of the European pharmaceutical industry. By definition, CSR measures is quantified as corporate social disclosure considering the published CSR keywords on the annual reports of the selected companies, over four fiscal years (2010-2013). The financial performance of the companies were measured as return on assets (ROA) and Tobin’s Q. In order to defend the hypothesis developed, a multivariate regression is performed. The results obtained show no significant impact on the financial performance of a company nor in the short-time, nor in the long-time. Moreover, by comparison with other studies, it was possible to conclude that the financial performance is differently affected when considering different industries.

Prevalence and risk factors for Toxoplasma gondii infection among pregnant and postpartum women attended at public healthcare facilities in the City of Niterói, State of Rio de Janeiro, Brazil

IntroductionTo determine the prevalence of immunoglobulin G (IgG) and immunoglobulin M (IgM) anti-Toxoplasma gondii antibodies among pregnant and postpartum women attended within the public healthcare system in Niterói, State of Rio de Janeiro, and to detect possible exposure factors associated with T. gondii infection in this population.MethodsIgM and IgG anti-T. gondii antibodies were investigated in 276 pregnant and 124 postpartum women by using the indirect immunofluorescence (IFAT) and immunoenzymatic assay (ELISA) techniques. The participants were selected by convenience sampling. All these 400 patients filled out a free and informed consent statement, answered an epidemiological questionnaire and were informed about the disease.ResultsAmong the 400 samples analyzed, 234 (58.5%) were reactive to IgG anti-T. gondii antibodies, according to the IFAT and/or ELISA assay. One pregnant woman was found to be reactive to IgM anti-T. gondii antibodies, with an intermediate IgG avidity test. Risk factor analysis showed that seropositivity was significantly associated (p<0.05) with age, contact with cats and presence of rodents at home. Through a logistic regression model, these associations were confirmed for age and contact with cats, while education at least of the high school level was found to be a protective factor.ConclusionsThe prevalence rate of IgG anti-T. gondii antibodies in the City of Niterói was high and the risk factors for infection detected after multivariate analysis were: age over 30 years, contact with cats and education levels lower than university graduate level.

Positive serology for viral hepatitis and donor self-exclusion in Southern Brazil

Introduction Despite the great advances in serological testing for transfusion-transmitted infections, the selection of blood donors by blood bank operators remains the only way to avoid transmission within the testing window period. Part of this selection is the self-exclusion form, on which the donors can exclude their blood from donation without any explanation. This study assessed the clinical and epidemiological characteristics related to positivity for viral hepatitis and to the use of the confidential self-exclusion (CSE) form. Methods This transversal study analyzed the data collected from blood donors' files in a hospital in Southern Brazil. Univariate and multivariate analyses identified the clinical and epidemiological variables related to positive serologies of viral hepatitis and to whether the donor was self-excluded. Results Of the 3,180 donors included in this study, 0.1% tested positive for HBsAg, 2.1% for anti-HBc, and 0.9% for anti-HCV. When the 93 donors with positive serologies for viral hepatitis were compared with those who were negative, a greater proportion of the positive serology group was found to have had a history of blood transfusions (OR=4.908; 95%CI=1.628 - 14.799; p<0.01), had repeatedly donated (OR=2.147; 95%CI=1.236 - 3.729; p<0.01), and used the CSE form for self-exclusion (OR=7.139; 95%CI=2.045 - 24.923; p<0.01). No variables were independently associated with self-exclusion. Conclusions A history of blood transfusion, repeated donations, and self-exclusion are factors that should be considered during viral hepatitis screenings in blood banks.

Contributions of culture and antimicrobial susceptibility tests to the retreatment of patients with pulmonary tuberculosis

Introduction This study evaluated the efficacy of retreatment of pulmonary tuberculosis (TB) with regard to treatment outcomes and antimicrobial susceptibility testing (ST) profiles. Methods This retrospective cohort study analyzed 144 patients treated at a referral hospital in Brazil. All of them had undergone prior treatment, were smear-positive for TB and received a standardized retreatment regimen. Fisher's 2-tailed exact test and the χ2 test were used; RRs and 95% CIs were calculated using univariate and multivariate binary logistic regression. Results The patients were cured in 84 (58.3%) cases. Failure was associated with relapsed treatment and abandonment (n=34). Culture tests were obtained for 103 (71.5%) cases; 70 (48.6%) had positive results. ST results were available for 67 (46.5%) cases; the prevalence of acquired resistance was 53.7%. There were no significant differences between those who achieved or not therapeutic success (p=0.988), despite being sensitive or resistant to 1 or more drugs. Rifampicin resistance was independently associated with therapeutic failure (OR: 4.4, 95% CI:1.12-17.37, p=0.034). For those cases in which cultures were unavailable, a 2nd model without this information was built. In this, return after abandonment was significantly associated with retreatment failure (OR: 3.59, 95% CI:1.17-11.06, p=0.026). Conclusions In this cohort, the general resistance profile appeared to have no influence on treatment outcome, except in cases of rifampicin resistance. The form of reentry was another independent predictor of failure. The use of bacterial culture identification and ST in TB management must be re-evaluated. The recommendations for different susceptibility profiles must also be improved.