Access to emergency surgical treatment for congenital heart diseases in the state of São Paulo

OBJECTIVE

To analyze access to surgical care for congenital heart diseases in public specialized centers in the state of São Paulo before and during the COVID-19 pandemic and availability of surgical care in specialized hospitals, to identify bottlenecks in the care path for neonatal cardiac surgery.

METHODS

This study included 1,437 children, under one year old, with congenital heart disease and formal referral to heart surgery between February 1, 2019, and February 28, 2021. Quantitative data analysis was performed using t-tests or the Mann-Whitney test.

RESULTS

Approximately 30 % of children with urgent congenital heart disease could not access recommended care, mainly those needing complex surgeries (categories RACHS 4 to 6). The main diagnoses of neonates accessing care were patency of the ductus arteriosus (10.5 %) and coarctation of the aorta (10.1 %). Referral time for children in RACHS 1 to 3 was 4 days (median), while for those in categories 4 to 6, it was 7 days (p < 0.001). Longer referral time (20 days) was associated with court orders. During the pandemic, referral time decreased to 3 days, compared to 5 days (median) in the pre-pandemic period (p < 0.001).

CONCLUSION

The emergency surgical treatment supply for congenital heart diseases is insufficient compared to the current demand. Future research should evaluate if access to care in publicly funded hospitals could be improved by better access to prenatal care for pregnant women, increased diagnostic and therapeutic capacity in pediatric cardiology, and financial incentives for complex cardiac surgeries.

Impacts of the COVID-19 pandemic on private hospitals in Brazil

The COVID-19 pandemic has significantly impacted hospital performance. To assess its effects on hospital indicators, we studied a sample of over 100 facilities. These facilities are members of a private hospital association, considered quality institutions with higher-tier socioeconomic patients, and are mostly financed by private insurers. We utilized publicly available data for 2020, the year when the pandemic effect was most acute. Sanitary restriction measures had a strong impact on usual performance indicators from a selected group of private hospitals in Brazil. P۪۪regnancies and deliveries continued to constitute an important proportion of hospital admissions because they did not depend on external restrictions. H۪۪ospital costs increased due to increased utilization of more expensive Personal Protection Equipment (due to lack of availability or much higher demand). Article extracted from the master's dissertation presented to the Master´s Program in Management for Competitiveness at Fundação Getulio Vargas , São Paulo, SP, in 2022.

OBJECTIVE

To analyze the operational and/or financial impacts of regulatory measures implemented by the National Agency for Supplementary Health and government health departments in response to the COVID-19 pandemic on a group of 118 private hospitals affiliated with the National Association of Private Hospitals.

METHODS

This study used a quantitative methodological design of descriptive, cross-sectional, and retrospective studies, utilizing secondary data provided by the National Agency for Supplementary Health.

RESULTS

There was a -20.1% reduction in hospital admissions and hospital occupancy rate and a decrease of -4.4 percentage points in earnings before interest, taxes, depreciation, and amortization margins. Additionally, the average length of hospital stay increased by +0.5, while total expenses for hospital leaves and total net revenue for hospital leaves increased by +39.4% and +23.6%, respectively. Comparing the participation of the different International Classification of Diseases, according to ICD-10 in 2019 and 2020, revealed the following variations in percentage points of hospitalizations. Hospitalizations for infectious diseases (including COVID-19), treatment of neoplasms, and pregnancy increased by +2.1, +2.4, and +1.2, respectively. However, hospitalizations for respiratory diseases decreased by -4.1.

CONCLUSION

The most critical period of the pandemic required the redirection of activities to concentrate efforts on caring for COVID-19 cases. This situation highlighted the non-prioritization of primary care, as many problems presented by patients not affected by COVID-19 had to be referred to emergency services when and if appropriate.

The Well-being of Brazilian Industry Workers on Returning to the Physical Workplace During the COVID-19 Pandemic

OBJECTIVE

Our aim was to assess the prevalence and predictors of well-being among Brazilian industry workers on returning to the physical workplace during the COVID-19 pandemic.

METHODS

Two thousand two hundred forty-one participants completed an online survey between October and November 2021. Well-being was assessed with the World Health Organization Well-being Index, and the questionnaire also addressed sociodemographic and occupational characteristics and the health of workers and their contacts. Associations were estimated with logistic regression models.

RESULTS

The prevalence of adequate well-being was 63.15%. The predictors of poor well-being included being female, younger, working exclusively from home or on a hybrid model, having comorbid disorders, and living with someone with any comorbidity.

CONCLUSIONS

The identification of vulnerable groups with poor well-being may help organizations to direct efforts to the unmet psychological needs of these employees and develop well-being programs during this transition.

User Experience Regarding Digital Primary Health Care in Santarém, Amazon: Evaluation of Patient Satisfaction and Doctor's Feedback

BACKGROUND

With the arrival of the pandemic, telemedicine has been widely used to provide medical care and can be used to assist patients in regions far from urban centers that are difficult to access, such as riverside communities in the Brazilian Amazon region. A telemedicine project connecting São Paulo, a mega-metropolis, to Paysandú, a riverside district in the Amazon, was built to serve the local population where access to the nearest medical care is 6 hours away by speedboat.

OBJECTIVE

This study aims to assess the feedback from patients and doctors regarding the use of telemedicine in outpatient care at Paysandú, a riverside district in the Amazon.

METHODS

This is a single-center study following the guidelines "Evaluating digital health products" from Public Health England, with local adaptations for the project and the Brazilian reality, that was conducted between São Paulo and Santarém in Brazil. A survey was carried out with patients who were treated by a doctor in the city of São Paulo, about 2500 km from the local basic health unit, between September 27 to December 15, 2021. At the end of each teleconsultation, the attending physician answered an administrative survey form, and the patient answered a satisfaction survey.

RESULTS

A total of 111 patients completed the satisfaction survey from a total of 220 consultations carried out during the period (95% CI margin error 0.22%). According to the survey, more than 95% of patients were satisfied with the service, 87.4% (n=97) had previous experience with videoconferencing, and 76.6% (n=85) reported that their demand was fully solved. Additionally, according to the hired doctor's feedback, the average duration of the consultations was between 15 and 20 minutes. Of the 220 teleconsultations performed, 90.9% (n=200) of the demands were solved with support from the local health team, and 99.1% (n=218) of the appointments had a problem with audio or video.

CONCLUSIONS

This teleconsultation project between São Paulo and Paysandú showed that it is possible to offer medical care from more developed locations to communities far from urban centers, as is the case with Paysandú District. Beyond the feasibility of the infrastructure, acceptance and satisfaction among patients were high. This health care supply model has proven to be functional and should be expanded nationally or perhaps internationally to regions lacking medical assistance. Escalation of the project does not seem too difficult once infrastructure issues are solved.

Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience

Background

As of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce.

Methods

We used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI).

Findings

State governments had a 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (−42·6%); Diagnostic procedures (−28·9%); Physician appointments (−42·5%); Low and medium complexity surgeries (−59·7%); High complexity surgeries (−27·9%); Transplants (−44·7%); Treatments and clinical procedures due to injuries of external causes (−19·1%); Irrepressible procedures (−8·5%); and Childbirths (−12·6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI.

Interpretation

The Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country.

Funding

MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT N^o 07/2020.

Reactions of physicians in the state of São Paulo to the use of telemedicine during the SARS-CoV-2 pandemic: cross-sectional study

BACKGROUND

Telemedicine can be a component of integrated healthcare practices and its use is not a recent phenomenon around the world. In Brazil, its more widespread use began during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, through extraordinary authorization from the Brazilian Ministry of Health.

OBJECTIVES

To describe some aspects of use of teleconsultation among a sample of physicians in the state of São Paulo during the SARS-CoV-2 pandemic.

DESIGN AND SETTING

Cross-sectional study based on a survey conducted by the São Paulo Medical Association (Associação Paulista de Medicina, APM) on medical practice during the SARS-CoV-2 pandemic between December 18, 2020, and January 18, 2021.

RESULTS

This survey generated responses from 2,052 physicians. Of these, 981 (47.8%) reported not practicing any form of telemedicine. Among those who reported practicing telemedicine, 274 (28.4%) reported not receiving remuneration directly for the attendance provided and 225 (23.3%) reported receiving remuneration equal to what they would have received from face-to-face consultations. Regarding the professional linkage of the physicians who undertook telemedicine attendance, the majority (499; 51.8%) only attended private patients. Regarding the resources used to provide telemedicine attendance, most of the respondents used specialized digital platforms (594; 61.6%), electronic health records (592; 61.4%) and electronic prescriptions (700; 72.6%).

CONCLUSION

This study demonstrates that important issues such as professional remuneration, use of electronic platforms and medical records, ensuring data protection and relationships between physicians and other stakeholders still need to be better defined, in order to achieve the desired scale and reach the outcomes defined.

Senior Manager Perceptions of The Human Dimension of Health Services Management: Australia and Brazil

Practice and research show the importance of the human dimension of health service management and related skills/competences. However, a review of curriculum content of postgraduate courses in Australia showed a lack of content in this area. It was in this context, an enquiry was undertaken to assess the perceptions of senior health service managers in Australia in this field. To provide a contrast with Australian perceptions, senior health service managers in Brazil were also asked for their understandings. Findings from this enquiry in the two countries show similar but some variance in nuance, possibly due to differences in culture and corporate environment. The result of the enquiry points to the importance given by these senior managers to skills/competences in this area, and perceptions of shortfalls, in contrast with the lack of importance given to postgraduate training in this field.

Impact on health and well-being of working at home during the SARS CoV 2 pandemic

Introduction:

After the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, many workers were forced to start working from home, creating a new dynamic that could potentially affect their health in several ways.

Objectives:

To study the impact of working at home during the SARS-CoV-2 pandemic on a sample of Brazilian workers.

Methods:

This study used a cross-sectional methodology with an online survey conducted by a Brazilian human resources website from June 1 to August 15, 2020, with a sample of employees working at home during the SARS-CoV-2 pandemic.

Results:

The sample of 653 valid responses revealed that 87.7% of the survey respondents reported that the change to home working started because of the situation caused by the pandemic. However, 550 (84.2%) people from this group stated that their employer did not conduct any health and safety evaluation of their workstation in the domestic environment. Regarding physical symptoms, there were high prevalence rates of symptoms related to musculoskeletal conditions, sleeping problems, feelings of fatigue, headaches, and migraines. The study also used the World Health Organization-5 Well-Being Index instrument and there were statistically significant associations between low scores and physical symptoms of musculoskeletal conditions, feelings of fatigue, headache or migraine, heartburn and indigestion, and leg pain.

Conclusions:

The findings of this research confirm the importance of developing strategies and programs to preserve the health and well-being of workers who start working at home, with participation of and supervision by companies’ occupational physicians. Future investigations should continue to capture data about health, well-being, and productivity and share best practices to plan support for the occupational health of those working from home.

Managing Brazil’s Health System at municipal level against Covid-19: a preliminary analysis

ABSTRACT This qualitative, observational, and exploratory study was supported by quantitative data to analyze the Brazilian Unified Health System (SUS) response to Covid-19 in three Brazilian municipalities. We used semi-structured interviews to listen to and dialogue with managers of the cities analyzed, guided by a roadmap to explore the managers’ perception during the response to the pandemic, understand the motivations that guided their strategic choices, and visualize the weaknesses and potentials of the municipal system in a public health emergency. We conducted a qualitative analysis considering the critical points of the SUS response to the pandemic, including coordination and governance, surveillance and prevention, and the health services network. In the results, we present and discuss the main characteristics of the municipalities, the 2020 pandemic course, the response actions adopted, and submit an analysis of the response pattern of municipal SUS managers in the pandemic.

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil

Abstract: Complications of chronic kidney disease (CKD) can be avoided when promptly diagnosed and treated. The objective was to describe quality indicators of CKD detection and health care in the primary care public service of a city in the State of São Paulo, Brazil. This retrospective study analyzed charts of patients who attended primary care in the public service between November 2019 and February 2020. We selected 10 health quality indicators based on their scientific relevance and availability from the medical records that could express how CKD was identified and managed in primary health care. We estimated the adequate percentage of health indicators with data from 1,066 individuals who had ≥ one risk factor for CKD: hypertension, diabetes, or > 60 years old. Among patients, 79.4% had information on serum creatinine, whereas 58.8% were investigated for proteinuria. Blood pressure data were found in 98.9% of the records. The percentage of patients with blood pressure < 140x90mmHg, glycosylated hemoglobin < 6.5% and LDL-cholesterol < 100mg/dL was 79.2%, 49.2%, and 33.3%, respectively. Renin-angiotensin system blockers were prescribed to 82.8% of the patients with hypertension and CKD. Serum potassium was measured in 35.7% for those who were using renin-angiotensin system blockers. Among those people with CKD, 16.7% had CKD assigned in the medical records as a diagnose. Among those participants at higher risk for CKD, the referral rate to a nephrologist was 31.6%. This study confirmed some missed quality indicators of CKD in primary healthcare. Our results may help administrators develop public policies that improve health care for individuals at high risk for CKD. Long-term follow-up of the health indicators we proposed here will be useful to assess the impact of policy intervention.

Gerenciando o SUS no nível municipal ante a Covid-19: uma análise preliminar

RESUMO Este é um estudo observacional, exploratório, que utilizou metodologia qualitativa, com apoio de dados quantitativos, para analisar a resposta do Sistema Único de Saúde (SUS) à Covid-19 em três municípios brasileiros. Utilizaram-se entrevistas semiestruturadas para escuta e diálogo com gestores das cidades analisadas, que foram orientadas por roteiro para explorar a percepção dos gestores durante o processo de resposta à pandemia, compreender as motivações que orientaram suas escolhas estraté- gicas e visualizar as fragilidades e potencialidades do sistema municipal em uma emergência de saúde pública. Realizou-se análise qualitativa considerando pontos-chave da resposta do SUS à pandemia, entre eles, coordenação e governança, vigilância e prevenção, e rede de serviços de saúde. Nos resultados, apresentam-se e discutem-se as principais características dos municípios, o curso da pandemia em 2020, ações de resposta adotadas; e exibe-se uma análise do padrão de resposta dos gestores do SUS municipal na pandemia.

Efficiency of exogenous zinc sulfate application reduced fruit drop and improved antioxidant activity of 'Kinnow' mandarin fruit

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Kinnow' mandarin (Citrus nobilis L.× Citrus deliciosa T.) is an important marketable fruit of the world. It is mainstay of citrus industry in Pakistan, having great export potential. But out of total production of the country only 10% of the produce meets the international quality standard for export. Pre-harvest fruit drop and poor fruit quality could be associated with various issues including the plant nutrition. Most of the farmers do not pay attention to the supply of micro nutrients which are already deficient in the soil. Furthermore, their mobility within plants is also a question. Zinc (Zn) is amongst those micronutrients which affect the quality and postharvest life of the fruit and its deficiency in Pakistani soils is already reported by many researchers. Therefore, this study was carried out to evaluate the influence of pre-harvest applications of zinc sulfate (ZnSO4; 0, 0.4%, 0.6% or 0.8%) on pre-harvest fruit drop, yield and fruit quality of 'Kinnow' mandarin at harvest. The treatments were applied during the month of October i.e. 4 months prior to harvest. The applied Zn sprays had significant effect on yield and quality of the "Kinnow" fruit. Amongst different foliar applications of ZnSO4applied four months before harvest, 0.6% ZnSO4 significantly reduced pre-harvest fruit drop (10.08%) as compared to untreated control trees (46.45%). Similarly, the maximum number of fruits harvested per tree (627), fruit weight (192.9 g), juice percentage (42.2%), total soluble solids (9.5 °Brix), ascorbic acid content (35.5 mg 100 g-1) and sugar contents (17.4) were also found significantly higher with 0.6% ZnSO4 treatment as compared to rest of treatments and control. Foliar application of 0.6% ZnSO4 also significantly improved total antioxidants (TAO) and total phenolic contents (TPC) in fruit. In conclusion, foliar spray of ZnSO4 (0.6%) four months prior to harvest reduced pre-harvest fruit drop, increase yield with improved quality of 'Kinnow' mandarin fruit.

Hospital accreditation impact on healthcare quality dimensions: a systematic review

PURPOSE

To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions.

DATA SOURCE

We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators.

STUDY SELECTION

We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review.

RESULTS OF DATA SYNTHESIS

Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet.

CONCLUSION

Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries

BACKGROUND

Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency.

METHODS

We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses.

RESULTS

Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD).

CONCLUSIONS

Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers).

TRIAL REGISTRATION

Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

HCFMUSP: Resiliência como Resposta à Pandemia de COVID-19

ABSTRACT The teaching case describes a set of emergency actions taken by HCFMUSP to manage the needs brought by the COVID-19 pandemic in Brazil. The case objective considers the issues related to the impact of the pandemic mostly in healthcare operations, emphasizing how to: (a) adapt health system governance in response to a crisis (crisis management); (b) manage the health system capacity, which traditionally is not so resilient; (c) deal with a new disease (knowledge management). Thus, it should allow gathering elements for the management of future crises.

HCFMUSP: Resilience in Response to the COVID-19 Pandemic

ABSTRACT The teaching case describes a set of emergency actions taken by HCFMUSP to manage the needs brought by the COVID-19 pandemic in Brazil. The case objective considers the issues related to the impact of the pandemic mostly in healthcare operations, emphasizing how to: (a) adapt health system governance in response to a crisis (crisis management); (b) manage the health system capacity, which traditionally is not so resilient; (c) deal with a new disease (knowledge management). Thus, it should allow gathering elements for the management of future crises.

Uso de leitos hospitalares privados por sistemas públicos de saúde na resposta à Covid-19

RESUMO Neste estudo, examinaram-se estratégias adotadas por países com sistemas públicos de saúde que expandiram a oferta de leitos por meio da utilização de hospitais privados na resposta à Covid-19. Utilizou-se estudo de casos selecionados para explorar o contexto institucional em que as medidas foram implementadas, os instrumentos de gestão utilizados e como se caracterizou a ação governamental em oito países: Austrália, Espanha, Irlanda, Itália, Chile, México e Peru, além do Brasil. Esta análise pode auxiliar a identificar mecanismos de gestão de sistema de saúde necessários para a coordenação de ações governamentais para resposta a situações de Emergência em Saúde Pública (ESP), bem como para aperfeiçoar a governança dos sistemas de saúde na relação entre os setores público e privado.

Agenda for patient-centered care research in Brazil

Patient-centered care is an incipient movement and its practice still faces obstacles in the Brazilian health system, where it is not extensively identified as healthcare quality realm. Thus, this paper aims to establish a patient/person-centered care research agenda to support its implementation in the country's healthcare services. A panel was held with nine experts to grasp different views on the subject. The face-to-face discussion was supported by a document systematizing an initial agenda proposal and a brief presentation of the patient-centered care concept and theoretical elements that underpin its practice. Panel participants defined a set of items to be explored in studies to identify implementation and to strengthen and to measure strategies for patient-centered care in the Brazilian context.

Brazil's unified health system: the first 30 years and prospects for the future

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

Cuidados continuados: uma falha na malha da rede de serviços de saúde

O rápido crescimento da população idosa portadora de doenças crônicas e degenerativas e a pressão por redução de custos nos hospitais por parte das fontes pagadoras públicas e privada têm demandado serviços de longo prazo por serem mais adequados para a população e menos onerosos. Com o envelhecimento populacional as necessidades de saúde tendem a se tornar mais crônicas e complexas. O objetivo deste artigo, após revisão bibliográfica sobre realidades de sistemas de saúde de países desenvolvidos e levantamento de dados nacionais, é propor uma reflexão sobre as mudanças no padrão saúde e doenças, necessidades de cuidados diferenciados e eficiência do sistema de saúde por meio da reorganização em redes de serviços que incluam cuidados continuados. A transformação do sistema de saúde deve estar nas agendas de instâncias superiores do governo, pois faltam políticas públicas de saúde que norteiem como iremos acompanhar os longevos, as doenças crônicas e a estruturação e implementação de redes para continuidade de cuidados. O Brasil tem um grande potencial para evoluir em um sistema de saúde que integre os cuidados continuados, incluindo aquele voltado para problemas agudos e pós agudos configurando, assim, uma rede de cuidados.

The effect of municipalization in the Brazilian hospital system: the small-sized hospitals

Hospital care accounts for part of increased health care costs. Countries have adapted their public policies to the hospital sector, focusing on larger centers, after studies of the 1990s have shown that hospitals with less than 200 beds have reduced efficiency. A total of 6,787 hospitals in Brazil were recorded in 2017, 62.3% of which had less than 50 beds. This study evaluated the National Policy for Small-sized Hospitals (PNHPP) published in 2004, and its impact on the Brazilian hospital sector. Twelve of the 27 states adhered to the PNHPP. In the absence of policies to induce the establishment of a networked hospital system, favoring comprehensive actions, the municipalization pulverized hospital care. Municipal managers believed that this was the best path to meet health needs. The number of municipal hospital units increased and their size was reduced, reaching a mean capacity of 50 beds per hospital. The reversal of this scenario involves policies that induce the qualification of hospital care until the understanding that the almost 5,000 small-sized hospital units in the country are a broad set to be studied, subdividing it into smaller groups, with different specialties.

[Management practices in medium-sized private hospitals in São Paulo, Brazil]

Traditional management practices are sometimes considered merely a necessary condition for superior performance. Other resources and competencies with higher barriers to imitation are assumed to be potential sources of competitive advantage. This study describes and analyzes the effect of traditional management practices on the performance of medium-sized hospitals. Medium-sized companies frequently display the greatest differences in management practices, and only recently did the hospital sector seek ways to develop its competitiveness in the administrative arena. The results generally indicate that basic management practices can make differences in performance, offering support for the new practice-based view (PBV). Hospitals with the highest rate of adoption of practices had the highest occupancy rate, hospital-bed admissions, and accreditation. Lack of adoption of management practices by medium-sized hospitals limits their competitive capacity and can be viewed as a component of the so-called Brazil cost, but in this case an internal component.

Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration

OBJECTIVE

To identify the perceptions of leaderships toward patient safety culture dimensions in the routine of hospitals with different administrative profiles: government, social and private organizations, and make correlations among participating institutions regarding dimensions of patient safety culture used.

METHOD

A quantitative cross-sectional study that used the Self Assessment Questionnaire 30 translated into Portuguese. The data were processed by analysis of variance (ANOVA) in addition to descriptive statistics, with statistical significance set at p-value ≤ 0.05.

RESULTS

According to the participants' perceptions, the significant dimensions of patient safety culture were 'patient safety climate' and 'organizational learning', with 81% explanatory power. Mean scores showed that among private organizations, higher values were attributed to statements; however, the correlation between dimensions was stronger among government hospitals.

CONCLUSION

Different hospital organizations present distinct values for each dimension of patient safety culture and their investigation enables professionals to identify which dimensions need to be introduced or improved to increase patient safety.

OBJETIVO

Identificar percepções das lideranças sobre as dimensões da cultura de segurança do paciente no cotidiano de hospitais de diferentes perfis administrativos: públicos, organizações sociais e privados, e realizar correlação entre as instituições participantes, de acordo com as dimensões da cultura de segurança do paciente utilizadas.

MÉTODO

Estudo transversal de aspecto quantitativo obtido por meio da aplicação do instrumento Self Assessment Questionnaire 30, traduzido para a língua portuguesa. Os dados foram tratados com análise de variância (ANOVA), além das estatísticas descritivas, considerando como de significância estatística valores de p-valor ≤ 0,05.

RESULTADOS

Segundo a percepção dos participantes do estudo, as dimensões significativas para a cultura de segurança do paciente foram Ambiente de Segurança do Paciente e Aprendizado Organizacional, com poder explicativo de 81%. A média de respostas obtidas evidenciou que nas organizações privadas houve maiores valores atribuídos às questões, porém a correlação entre as dimensões foi mais forte nas organizações públicas.

CONCLUSÃO

As dimensões da cultura de segurança do paciente têm valores distintos nas diferentes organizações hospitalares e a sua investigação possibilita identificar quais necessitam ser introduzidas ou aprimoradas para maior segurança do paciente.

Incremental health expenditure and lost days of normal activity for individuals with mental disorders: results from the São Paulo Megacity Study

Background

With the recent increase in the prevalence of mental disorders in developing countries, there is a growing interest in the study of its consequences. We examined the association of depression, anxiety and any mental disorders with incremental health expenditure, i.e. the linear increase in health expenditure associated with mental disorders, and lost days of normal activity.

Methods

We analyzed the results from a representative sample survey of residents of the Metropolitan Region of São Paulo (n = 2,920; São Paulo Megacity Mental Health Survey), part of the World Mental Health (WMH) Survey Initiative, coordinated by the World Health Organization and performed in 28 countries. The instrument used for obtaining the individual results, including the assessment of mental disorders, was the WMH version of the Composite International Diagnostic Interview 3.0 (WMH-CIDI 3.0) that generates psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Statistical analyses were performed by multilevel generalized least squares (GLS) regression models. Sociodemographic determinants such as income, age, education and marital status were included as controls.

Results

Depression, anxiety and any mental disorders were consistently associated with both incremental health expenditure and missing days of normal activity. Depression was associated with an incremental annual expenditure of R$308.28 (95 % CI: R$194.05-R$422.50), or US$252.48 in terms of purchasing power parity (PPP). Anxiety and any mental disorders were associated with a lower, but also statistically significant, incremental annual expenditure (R$177.82, 95 % CI: 79.68–275.97; and R$180.52, 95 % CI: 91.13–269.92, or US$145.64 and US$147.85 in terms of PPP, respectively). Most of the incremental health costs associated with mental disorders came from medications. Depression was independently associated with higher incremental health expenditure than the two most prevalent chronic diseases found by the study (hypertension and diabetes).

Conclusions

The fact that individuals with mental disorders had a consistent higher health expenditure is notable given the fact that Brazil has a universal free-of-charge healthcare and medication system. The results highlight the growing importance of mental disorders as a public health issue for developing countries.

Determinants of the use of health care services: multilevel analysis in the Metropolitan Region of Sao Paulo

OBJECTIVE To evaluate the individual and contextual determinants of the use of health care services in the metropolitan region of Sao Paulo. METHODS Data from the Sao Paulo Megacity study - the Brazilian version of the World Mental Health Survey multicenter study - were used. A total of 3,588 adults living in 69 neighborhoods in the metropolitan region of Sao Paulo, SP, Southeastern Brazil, including 38 municipalities and 31 neighboring districts, were selected using multistratified sampling of the non-institutionalized population. Multilevel Bayesian logistic models were adjusted to identify the individual and contextual determinants of the use of health care services in the past 12 months and presence of a regular physician for routine care. RESULTS The contextual characteristics of the place of residence (income inequality, violence, and median income) showed no significant correlation (p > 0.05) with the use of health care services or with the presence of a regular physician for routine care. The only exception was the negative correlation between living in areas with high income inequality and presence of a regular physician (OR: 0.77; 95%CI 0.60;0.99) after controlling for individual characteristics. The study revealed a strong and consistent correlation between individual characteristics (mainly education and possession of health insurance), use of health care services, and presence of a regular physician. Presence of chronic and mental illnesses was strongly correlated with the use of health care services in the past year (regardless of the individual characteristics) but not with the presence of a regular physician. CONCLUSIONS Individual characteristics including higher education and possession of health insurance were important determinants of the use of health care services in the metropolitan area of Sao Paulo. A better understanding of these determinants is essential for the development of public policies that promote equitable use of health care services.

Brazil's Mixed Public and Private Hospital System

Brazil's hospital sector is vibrant and growing. Under the 1988 Brazilian constitution all citizens have the right to health care, anticipating the global commitment to Universal Health Care. Brazil's public sector prides itself on having one of the world's largest single payer health care systems, but complementing that is a significant and larger private sector that is seeing big increase in investment, utilization and prices. This article outlines the structure of the hospital system and analyzes the nature and direction of private health sector expansion. Twenty-six percent of Brazilians have private health insurance and although coverage is concentrated in the urban areas of the Southeastern part of the country, it is growing across the nation. The disease burden shift to chronic diseases affects the nature of demand and the directly affects overall health care costs, which are rising rapidly outstripping national inflation by a factor of 3. Increasingly costs will have to be brought under control to maintain the viability of the private sector. Adaption of integrated care networks and strengthening of the public reimbursement system represent important areas for improvement.

Lifestyle factors, direct and indirect costs for a Brazilian airline company

OBJECTIVE To analyze lifestyle risk factors related to direct healthcare costs and the indirect costs due to sick leave among workers of an airline company in Brazil. METHODS In this longitudinal 12-month study of 2,201 employees of a Brazilian airline company, the costs of sick leave and healthcare were the primary outcomes of interest. Information on the independent variables, such as gender, age, educational level, type of work, stress, and lifestyle-related factors (body mass index, physical activity, and smoking), was collected using a questionnaire on enrolment in the study. Data on sick leave days were available from the company register, and data on healthcare costs were obtained from insurance records. Multivariate linear regression analysis was used to investigate the association between direct and indirect healthcare costs with sociodemographic, work, and lifestyle-related factors. RESULTS Over the 12-month study period, the average direct healthcare expenditure per worker was US$505.00 and the average indirect cost because of sick leave was US$249.00 per worker. Direct costs were more than twice the indirect costs and both were higher in women. Body mass index was a determinant of direct costs and smoking was a determinant of indirect costs. CONCLUSIONS Obesity and smoking among workers in a Brazilian airline company were associated with increased health costs. Therefore, promoting a healthy diet, physical activity, and anti-tobacco campaigns are important targets for health promotion in this study population.

Nanofocusing optics for synchrotron radiation made from polycrystalline diamond

Diamond possesses many extreme properties that make it an ideal material for fabricating nanofocusing x-ray optics. Refractive lenses made from diamond are able to focus x-ray radiation with high efficiency but without compromising the brilliance of the beam. Electron-beam lithography and deep reactive-ion etching of silicon substrates have been used in a transfer-molding technique to fabricate diamond optics with vertical and smooth sidewalls. Latest generation compound refractive lenses have seen an improvement in the quality and uniformity of the optical structures, resulting in an increase in their focusing ability. Synchrotron beamline tests of two recent lens arrays, corresponding to two different diamond morphologies, are described. Focal line-widths down to 210 nm, using a nanocrystalline diamond lens array and a beam energy of E = 11 keV, and 230 nm, using a microcrystalline diamond lens at E = 15 keV, have been measured using the Diamond Light Source Ltd. B16 beamline. This focusing prowess is combined with relatively high transmission through the lenses compared with silicon refractive designs and other diffractive optics.

The influence of lifestyle and gender on sickness absence in Brazilian workers

BACKGROUND

Despite an increasing body of knowledge concerning gender and lifestyle factors as determinants of sickness absence in well-developed countries, the relationship between these variables has not been elucidated in emerging economic power countries, where the burden of non-communicable diseases is particularly high. This study aimed to analyze the relationships among lifestyle-related factors and sick leave and to examine whether gender differences in sickness absence can be explained by differences in socio-demographic, work and lifestyle-related factors among Brazilian workers.

METHODS

In this longitudinal study with a one year follow-up among 2.150 employees of a Brazilian airline company, sick leave was the primary outcome of interest. Independent variables collected by interview at enrolment in the study were gender, age, educational level, type of work, stress, and lifestyle-related factors (body mass index, physical activity and smoking). In addition, the risk for coronary heart disease was determined based on measurement of blood pressure, total cholesterol and glucose levels. The total number of days on sick leave during 12 months follow-up was available from the company register. Logistic regression analysis was used to determine the influence of socio-demographic, type of work and lifestyle-related factors on sick leave.

RESULTS

Younger employees, those with lower educational level, those who worked as air crew members and those with higher levels of stress were more likely to have sick leave. Body mass index and level of physical activity were not associated with sick leave. After adjustment by socio-demographic variables, increased odds for 10 or more days of sick leave were found in smokers (OR=1.51, CI=1.05-2.17), and ex-smokers (OR=1.45, CI=1.01-2.10). Women were more likely to have 10 or more days of sick leave. Gender differences were reduced mainly when adjusted for type of work (15%) and educational level (7%).

CONCLUSIONS

The higher occurrence of sick leave among women than among men was partly explained by type of work and educational level. Our results suggest that type of work, a stressful life, and smoking are important targets for health promotion in this study population.

[Healthcare value chain: a model for the Brazilian healthcare system]

This article presents a model of the healthcare value chain which consists of a schematic representation of the Brazilian healthcare system. The proposed model is adapted for the Brazilian reality and has the scope and flexibility for use in academic activities and analysis of the healthcare sector in Brazil. It places emphasis on three components: the main activities of the value chain, grouped in vertical and horizontal links; the mission of each link and the main value chain flows. The proposed model consists of six vertical and three horizontal links, amounting to nine. These are: knowledge development; supply of products and technologies; healthcare services; financial intermediation; healthcare financing; healthcare consumption; regulation; distribution of healthcare products; and complementary and support services. Four flows can be used to analyze the value chain: knowledge and innovation; products and services; financial; and information.

Teaching of major communicable diseases in Sudanese medical schools: a critical look

This descriptive, cross-sectional study of Sudanese medical schools aimed to describe and analyse the proportion of their curricula currently allocated for teaching of communicable diseases and to assess the teaching methods and student assessment tools. Qualitative and quantitative data were collected from heads of departments and students in 20 of the 27 medical faculties and from ministry of health staff at federal and state levels. Curriculum designs ranged from traditional to innovative, community-oriented programmes. Problems regarding student evaluations were identified. Major limitations included shortages of staff, reference materials and teaching aids. Poor knowledge of students about different aspects of diseases endemic in Sudan was found. Recommendations include curriculum development, staff recruitment and training, and improvement of teaching and training of students.

Modelos de assistência ao parto e taxa de cesárea em diferentes países

Revisão bibliográfica que descreve as taxas de cesárea em diferentes países e os modelos de atenção ao parto de acordo com o uso de tecnologias assistenciais. Foram analisados 60 estudos publicados entre 1999 e 2010, obtidos nas bases de dados da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior e ProQuest. O modelo de assistência obstétrica praticado no país baseia-se na relação médico-paciente, ao grau de utilização de tecnologias e à realização do parto cesáreo.

Feasibility of general hospitals psychiatric units in Brazil

OBJECTIVE

To comprehend the stigma against people with mental disorders still persists in the culture of general hospitals and acts as a limiting factor in the implementation of psychiatric units in general hospitals in Brazil.

METHODOLOGICAL PROCEDURES

A qualitative social survey was outlined based on action research strategy as of the agreement to adopt a psychiatric unit in a general hospital in Taubaté, Southeastern Brazil. Data was obtained through interviews, participant observation and talks on the psychiatric unit project given to the hospital's clinical staff.

RESULTS

The investment made by the healthcare authority enabled the stigmatizing conceptions (violence, moral weakness and untreatability) present in the hospital culture in question to be resignified by means of clinical and sanitary discussions, which enabled the implementation of the psychiatric unit. The analysis showed that these concepts persist in this context because of a healthcare system that limits the access of people with mental disorders.

CONCLUSIONS

The attitude of the healthcare authority, who decided to adequately fund the general hospital's psychiatric unit and exerted his influence over the hospital, was decisive for the outcome of the case. The main difficulty in implementing psychiatric units at general hospitals is not the overcoming the existing stigma in the culture of general hospitals, but rather a difficulty which is strategic in nature: the lack of an affirmative policy for these units.

Changing spectrum of gallstone disease: an experience of 23 cases less than 10 years of age

BACKGROUND

An overall increase in the incidence of paediatric cholelithiasis forms the basis of this study, which aims to investigate the overall changing clinical pattern of cholelithiasis.

METHODS

This is a retrospective observational descriptive study including twenty three (23) patients with gallstones admitted and operated during June 2006-June 2008 in surgical department of a teaching hospital. All the patients with sonological evidence of gallstones, less than 10 years of age with history of acute or chronic abdominal symptoms are included in the study population. After admission all the subjects were investigated and finally operated by open approach (21 patients) during the same admission. The details of all the patients were recorded on a proforma and statistical analysis done on SPSS version 12.

RESULTS

Of the total study population, there were 19 (82.6%) males and 4 (17.39%) females with a mean age of 7 years and a range of 4-10 years. Ultrasound revealed gallstones in all the patients with a varying proportion of the walls of gallbladder. The commonest presentation was abdominal pain in the right upper quadrant, which was vague, and of mild to moderate intensity. In 21 (91.30%) patients, no specific underlying cause was found while two patients (8.6%) had haematological disorder as underlying cause for the gallstones.

CONCLUSION

This study indicates an alarming increase in the incidence of idiopathic gallstones in children less than 10 years of age with a distinct male predominance.

Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo

OBJETIVO: Analisar os fatores relacionados à determinação e às desigualdades no acesso e uso dos serviços de saúde por idosos. MÉTODOS: Estudo integrante do Projeto Saúde, Bem-estar e Envelhecimento (SABE), no qual foram entrevistados 2.143 indivíduos com 60 anos ou mais no município de São Paulo, SP, em 2000. A amostra foi obtida em dois estágios, utilizando-se setores censitários com reposição, probabilidade proporcional à população e complementação da amostra de pessoas de 75 anos. Foi mensurado o uso de serviços hospitalares e ambulatoriais nos quatro meses anteriores à entrevista, relacionando-os com fatores de capacidade, necessidade e predisposição (renda total, escolaridade, seguro saúde, morbidade referida, auto-percepção, sexo e idade). O método estatístico utilizado foi regressão logística multivariada. RESULTADOS: Dos entrevistados, 4,7% referiram ter utilizado a internação hospitalar e 64,4% o atendimento ambulatorial. Dos atendimentos ambulatoriais em serviço público, 24,7% ocorreram em hospital e 24,1% em serviço ambulatorial; dentre os que ocorreram em serviços privados, 14,5% foram em hospital e 33,7% em clínicas. Pela análise multivariada, observou-se associação entre a utilização de serviços e sexo, presença de doenças, auto-percepção de saúde, interação da renda e escolaridade e posse de seguro saúde. A análise isolada com escolaridade apresentou efeito inverso. CONCLUSÕES: Foram observadas desigualdades no uso e acesso aos serviços de saúde e inadequação do modelo de atenção, indicando necessidade de políticas públicas que levem em conta as especificidades dessa população, facilitem o acesso e possam reduzir essas desigualdades.

Mesh versus non-mesh repair of ventral abdominal hernias

BACKGROUND

To investigate the relative effectiveness of mesh and suture repair of ventral abdominal hernias in terms of clinical outcome, quality of life and rate of recurrence in both the techniques.

METHODS

This is a retrospective descriptive analysis of 236 patients with mesh and non-mesh repair of primary ventral hernias performed between January 2000 to December 2004 at Surgery Department, Liaquat University of Medical and Health Sciences, Jamshoro. The record sheets of the patients were analyzed and data retrieved to compare the results of both techniques for short-term and long-term results. The data retrieved is statistically analyzed on SPSS version 11.

RESULTS

There were 43 (18.22%) males and 193 (81.77%) females with a mean age of 51.79 years and a range of 59 (81-22). Para-umbilical hernia was the commonest of ventral hernia and accounted for 49.8% (n=118) of the total study population followed by incisional hernia comprising 24% (n=57) of the total number. There was a significant difference in the recurrent rate at 3 years interval with 23/101 (22.77%) recurrences in suture-repaired subjects compared to 10/135 (7.40%) in mesh repair group. Chronic pain lasting up to 1-2 years was noted in 14 patients with suture repair. Wound infection is comparatively more common (8.14%) in mesh group. The other variables such as operative and postoperative complications, total hospital stay and quality of life is also discussed.

CONCLUSION

Mesh repair of ventral hernia is much superior to non-mesh suture repair in terms of recurrence and overall outcome.

Tendências na assistência hospitalar

Este artigo analisa as tendências observadas na assistência hospitalar brasileira, no que diz respeito ao cenário, situação atual, desafios e ao que necessita ser feito, tendo em vista os itens anteriores. As variáveis com as quais se trabalhou o cenário geral foram a demografia, o perfil epidemiológico, os recursos humanos, a tecnologia, a medicalização, os custos, a revisão do papel do cidadão, a legislação, a eqüidade, o hospitalocentrismo e a regionalização, o fracionamento do cuidado e a oferta de leitos. O cenário nacional foi estudado mediante o modelo empregado na assistência médica supletiva, o financiamento e a cadeia de produção na área de serviços de saúde. A situação atual apresenta os modelos de avaliação externa, a terceirização, o relacionamento público-privado, a desospitalização e o financiamento. Os desafios a serem enfrentados analisam a necessidade de se olhar o longo prazo, a busca por novos modelos jurídicos para o "negócio", o uso da informação e a informatização, o controle de custos e a necessidade do aumento da eficiência e do cumprimento dos ditames legais, de garantia de acesso e de integralidade na assistência, a incorporação da prevenção primária ao processo de atenção, a integração entre os setores público e privado e a incorporação do médico na solução dos problemas.

Frequency of Campylobacter jejuni in diarrhoea/dysentery in children in Rawalpindi and Islamabad

OBJECTIVE

To determine the frequency of Campylobacter jejuni infection in children suffering from diarrhoea/dysentery in the Department of Microbiology, Army Medical College and Military Hospital, Rawalpindi, from 29 August 2002 to 29 November 2002.

METHODS

The study was carried out on one hundred stool samples of children up to the age of twelve years admitted with diarrhoea/dysentery in Military hospital, Rawalpindi. The samples were collected in clean polypropylene containers containing Cary Blair medium. These were transported to the Microbiology Department, Army Medical College, Rawalpindi within 1-2 hours. The samples were inoculated on Modified Preston (Oxoid) and Karmali media (Oxoid) beside other routine stool culture media. The cultures were incubated at 42 degrees C under microaerophilic conditions. The growth after 48 hours was provisionally identified by colonial morphology, oxidase test, Gram staining and motility. The organisms were identified to species level by hippurate hydrolysis, urease test, nitrate reduction, catalase test, H2S production and resistance to cephalothin.

RESULTS

Eighteen percent of samples yielded the growth of Campylobacter jejuni. Mean age of children with Campylobacter jejuni infection was 18 months with peak incidence from 12 to 21 months. Male female ratio was 1.7:1. All the children had loose motions. Seven out 18 (39%) had a combination of symptoms of loose motions, vomiting and pain abdomen. Those having fever with or without other complaints constituted 11 out of 18 (61.11%) i.e. more than 50% of all the children yielding C. jejuni had fever. About 90% of diarrhoeal stools had blood and fifty percent also had mucous. There was either history of chicken meat consumption or contact with cattle and pets in most of the cases and both in some of them.

CONCLUSION

Campylobacter jejuni is a frequent cause of diarrhoea/dysentery in children in our set up. In children it is often related to pets keeping and chicken meat consumption. In the remaining, untreated drinking water may be the source. Campylobacter jejuni frequently presents with blood and mucous in stools with sporadic cases presenting with watery diarrhoea.

Hepatitis B and C single and co-infection in chronic liver disease and their effect on the disease pattern

OBJECTIVE

To find the frequency of hepatitis B and C virus (HBV and HCV) infection and their coinfection in chronic liver disease and any differences in the clinical features of single and coinfections. METHODOLGY: All clinically recognisable adult CLD patients admitted to Military Hospital, Rawalpindi in years 1999-2000, were included in the study. Their history and clinical features were recorded. Seromarkers for HBV (HBsAg, anti-HBc) and HCV (anti-HCV) were done.

RESULTS

A total of 97 (52 male, 45 female) patients were included in the study. Mean age was 51.6 years (range 16-75 years). Cirrhosis was present in 74.2%, chronic hepatitis (Ch Hep) in 18.6% and hepatocellular carcinoma (HCC) in 7.2%. Among the 74.1% patients with cirrhosis 28.5% were HBsAg positive, 55.5% anti-HBc positive and 68.1% anti HCV positive. In the chronic hepatitis cases 27.8% were HBsAg positive, 23.6% anti-HBc positive and 61.1% anti HCV positive. Among the patients of HCC 59.7% were HBsAg positive, 71.4% anti-HBc positive and 42% anti HCV positive. Regarding coinfection 7.2% were anti-HCV and HBsAg positive while 35.1% were anti-HCV and anti-HBc positive.

CONCLUSION

Ninety percent of patients with CLD had evidence of HBV, HCV or coinfection. Disease was more severe in patients with coinfection. Anti-HBc was found to be a sensitive indicator of past HBV.

[Laboratory methods of predicting primary and recurrent nephrolithiasis]

Concentrations of Na, K, Ca ions, oxalic and uric acids, total Ca, P as well as urease activity, the ability to form crystals, speed of crystallization, crystal chemical composition, pH stability were evaluated in the urine from 40 urolithiasis patients and 40 patients with recurrent nephroliths. It was found that fast or moderate crystallization, high urease activity and ability to form crystals, unstable urine pH indicate a high risk of both primary and recurrent nephrolith formation.

Mine blast injuries: ocular and social aspects

BACKGROUND/AIMS

Landmines have long been used in conventional warfare. These are antipersonnel mines which continue to injure people long after a ceasefire without differentiating between friend or foe, soldier or civilian, women or children. This study focuses on Afghan non-combatants engaged in mine clearing operations in Afghanistan in the aftermath of the Russo-Afghan war. The patterns and types of injuries seen are described and experiences in their management, ways, and means to prevent them, and recommendations for the rehabilitation of the affected individuals are given.

METHODS

It is a retrospective and analytical study of 84 patients aged 19-56 years who sustained mine blast injuries during mine clearing operations in Afghanistan from November 1992 to January 1996. The study was carried out at a military hospital with tertiary care facilities. The patients were divided into three groups on the basis of their injuries. Group 1 required only general surgical attention, group 2 sustained only ocular injuries, while group 3 had combined ocular and general injuries. Patients in groups 2 and 3 were treated in two phases. The first phase aimed at immediate restoration of the anatomy, while restoration of function wherever possible was done in subsequent surgical procedures in the second phase.

RESULTS

It was observed that 51 out of 84 patients (60.7%) had sustained ocular trauma of a variable degree as a result of the blasts. The mean age of the victims was 29 years and they were all male. A total of 91 eyes of 51 patients (89.2%) had been damaged. Bilaterality of damage was seen in 40 (78.4%) patients. Most, 34 (37.3%), eyes became totally blind (NPL). Only a few escaped with injury mild enough not to impair vision. Foreign bodies, small and multiple, were found in the majority of eyes; most, however, were found in the anterior segment, and posterior segment injuries were proportionally less.

CONCLUSIONS

The prevalence of blindness caused by mine blast injuries is quite high. The resulting psychosocial trauma to the patients and their families is tremendous and has not been adequately highlighted. These injuries are a great drain on the country's resources. Enforcement of preventive measures and the use of protective gear and sophisticated equipment by the mine clearing personnel would prove to be far more economical in terms of human life as well as medical and economic resources. There is also need for greater attention towards the establishment of support groups and rehabilitation programmes for these individuals.

MR imaging of the type II lunate bone: frequency, extent, and associated findings

OBJECTIVE

Type II lunate bones have an "extra" facet that articulates with the hamate bone, which frequently leads to arthritis. Because the only prior studies, to our knowledge, on this common and clinically significant variant involved dissection of cadavers, we performed an MR imaging study of the type II lunate.

MATERIALS AND METHODS

We retrospectively reviewed MR images obtained at 1.5 T of 186 wrists for frequency of type II lunates, size of the extra facet, amount of hamatolunate apposition, and presence of hamate subchondral edema. Of the 186 wrists, 28 also had correlation with findings on wrist arthroscopy.

RESULTS

One hundred seven wrists (57.5%) had type II lunates with an average extra facet size of 4.6 mm (range, 1.2-12.0 mm). Apposition (articulation) of the extra lunate facet with the hamate averaged 77.4% (range, 0-100%). Hamate edema was seen in only nine wrists (4.8%), all of which had type II lunates. Arthroscopic evidence of focal hamate chondromalacia and MR imaging evidence of marrow edema were seen in six of these nine wrists; marrow edema was seen only in wrists with frank cartilage changes on arthroscopy.

CONCLUSION

An extra facet (type II lunate) was seen in approximately half of 186 wrists. On MR imaging, type II lunates usually have an innocuous appearance. A large percentage of patients with type II lunates also have chondromalacia, which often is occult on MR imaging. When visible, such chondromalacia is the cause of marrow edema similar to that seen in patients with carpal fractures.

Cidades saudáveis estratégia em aberto

O conceito de saúde vem assumindo novas dimensões com o desenvolvimento do conhecimento científico em função da cultura das populações e do reconhecimento de suas determinações biopsicossociais e econômicas no mundo contemporâneo. A questão da qualidade vem se impondo e reorientando os diferentes campos de ação, inclusive o da saúde. A proposta do movimento/programa/projeto "Cidades Saudáveis" vem se conformando e sendo assumidoacomo uma nova forma de gestão municipal e de conquista da cidadania pela população brasileira. A adesão a esta proposta exige a aceitação de novos conceitos e valores tanto por parte dos governantes como da população, entre eles a intersetorialidade, que se constitui num processo experiencial de longo prazo e difícil de ser concretizado. A avaliação constante do processo é resultados poderão colaborar para que esta proposta se torne viável.

Quality improvement issues in Brazil

BACKGROUND

In 1988 a new constitution in Brazil brought the creation of a national health system, the Unified Health System (Sistema Unico de Saúde; SUS).

A GROWING INTEREST IN QUALITY

Accountability is not yet a strong feature of the health system, even though the Ministry of Health has made efforts to encourage the federal district and 26 states to participate in some quality-of-care projects. Initiatives include certification by the International Standards Organization (ISO; Geneva); consulting services, especially in managerial processes; total quality management; patient satisfaction; and development of new technologies to increase efficiency.

ISSUES AND CONCLUSIONS

Physicians' oft-repeated claim that they know all it takes to offer patients high-quality care makes it difficult to enlist their help in quality programs in general and in establishing protocols and guidelines in particular. State licenses are a prerequisite for hospitals, but this is not always enforced; the local health authority may be relieved that hospital care is at least being provided. Similarly, the government may find it important that the population has access to health services, even if the service is not considered adequate. Government can encourage quality initiatives and assess and disseminate the findings.