A reforma dos Cuidados de Saúde Primários: êxitos e desafios da experiência portuguesa

Em Portugal, o Sistema Nacional de Saúde (SNS) foi implementado em meados da década de 1970, com forte comprometimento da política de saúde voltada aos Cuidados de Saúde Primários – CSP (equivalente no Brasil à Atenção Primária à Saúde – APS). A partir de 2005, Portugal realizou a sua reforma mais profunda nos CSP, com o objetivo de garantir maior equidade de acesso à saúde para sua população, tornando-se uma experiência exitosa no contexto da União Europeia (UE). O presente trabalho tem por objetivo apresentar a reforma dos CSP em Portugal, procurando identificar seu contexto histórico, seus êxitos e os principais desafios que cercam a experiência portuguesa. O trabalho empírico da pesquisa repousou na combinação de duas atividades de coleta de dados: (1) a pesquisa bibliográfica e (2) dados secundários previamente sistematizados. Alguns desafios cercam a experiência portuguesa: ampliação no número das Unidades de Saúde Familiar (USF); carência de médicos de família; no campo da prevenção é necessária a intensificação da contratualização com indicadores que reflitam a realidade da população portuguesa e que levem em conta a sua transição epidemiológica; e, finalmente, é importante que se estabeleça uma agenda de acompanhamento sobre os potenciais efeitos negativos das medidas de contenção de gastos em saúde e da transferência de responsabilidade para o âmbito familiar

Large-scale, multidirectional larval connectivity among coral reef fish populations in the Great Barrier Reef Marine Park

Larval dispersal is the key process by which populations of most marine fishes and invertebrates are connected and replenished. Advances in larval tagging and genetics have enhanced our capacity to track larval dispersal, assess scales of population connectivity, and quantify larval exchange among no-take marine reserves and fished areas. Recent studies have found that reserves can be a significant source of recruits for populations up to 40 km away, but the scale and direction of larval connectivity across larger seascapes remain unknown. Here, we apply genetic parentage analysis to investigate larval dispersal patterns for two exploited coral reef groupers (Plectropomus maculatus and Plectropomus leopardus) within and among three clusters of reefs separated by 60-220 km within the Great Barrier Reef Marine Park, Australia. A total of 69 juvenile P. maculatus and 17 juvenile P. leopardus (representing 6% and 9% of the total juveniles sampled, respectively) were genetically assigned to parent individuals on reefs within the study area. We identified both short-distance larval dispersal within regions (200 m to 50 km) and long-distance, multidirectional dispersal of up to similar to 250 km among regions. Dispersal strength declined significantly with distance, with best-fit dispersal kernels estimating median dispersal distances of similar to 110 km for P. maculatus and similar to 190 km for P. leopardus. Larval exchange among reefs demonstrates that established reserves form a highly connected network and contribute larvae for the replenishment of fished reefs at multiple spatial scales. Our findings highlight the potential for long-distance dispersal in an important group of reef fishes, and provide further evidence that effectively protected reserves can yield recruitment and sustainability benefits for exploited fish populations

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

A História da Alimentação: balizas historiográficas

Os M. pretenderam traçar um quadro da História da Alimentação, não como um novo ramo epistemológico da disciplina, mas como um campo em desenvolvimento de práticas e atividades especializadas, incluindo pesquisa, formação, publicações, associações, encontros acadêmicos, etc. Um breve relato das condições em que tal campo se assentou faz-se preceder de um panorama dos estudos de alimentação e temas correia tos, em geral, segundo cinco abardagens Ia biológica, a econômica, a social, a cultural e a filosófica!, assim como da identificação das contribuições mais relevantes da Antropologia, Arqueologia, Sociologia e Geografia. A fim de comentar a multiforme e volumosa bibliografia histórica, foi ela organizada segundo critérios morfológicos. A seguir, alguns tópicos importantes mereceram tratamento à parte: a fome, o alimento e o domínio religioso, as descobertas européias e a difusão mundial de alimentos, gosto e gastronomia. O artigo se encerra com um rápido balanço crítico da historiografia brasileira sobre o tema

Democratic struggle or national uprising? The Canadian rebellions in British political thought, 1835–1840

This article argues that the role of the 1837–38 Canadian rebellions in early nineteenth-century British political thought has been under-appreciated. It shows that they were the occasion of major reconceptualizations of two important terms that would later become central to the political lexicon of modern Britain: ‘democracy’ and ‘nationality’. From the perspective of the Tories and Whigs who framed the rebellions in terms of ‘nationality’, the Canadian debate required reconfiguring previous uses of the word, in order to argue that some ‘nationalities’ were more worthy of respect than others, and that protecting ‘nationality’ could be compatible with membership of an imperial, multi-national state. Additionally, it also reinforced previous negative uses of ‘democracy’ by critics of the rebellions relying on familiar tropes inherited from the French Revolution. But the debate also showcased the quickly shifting Radical uses of both words. For the Radicals, who framed the Canadian crisis in terms of ‘democracy’, it provided a platform to deploy emerging Tocquevillian understandings of democracy in the North American context and reintroduce the word in British political discourse. Via the Durham report of 1839, it also established more civic-minded Radical redefinitions of ‘nationality’ as a core argument for British imperialist policy

“Prawa wyborcze kobiet osłabiłyby stabilną podstawę, na której opiera się rząd demokratyczny” ‒ brytyjscy demokratyczni antysufrażyści (1904‒1914)

From 1904 to 1914, the British debate on women’s suffrage was at its height. Suffragism has been the subject of numerous studies, however, few have paid attention to its opponent, “antisuffragism”. This article focuses on antisuffragists’ speeches, pamphlets and books to examine their uses of “democracy” and grasp the conceptual struggles at play. Most “Antis” painted women’s suffrage as a step towards a degenerate democratic society. However, more surprisingly, some also mobilised the democratic vocabulary positively, as a reason to disallow women the vote. Several authors considered that “democracy” rested on the capacity of the majority to impose its decisions through physical force–thus rendering a government elected by women impotent. Politicians also opposed granting women suffrage on a censorial basis since it went against the “democratic spirit of the time”. These findings demonstrate the increased importance of “democracy” in Britain and how a “conservative subversion” of the concept was attempted.Między 1904 a 1914 rokiem brytyjska debata na temat prawa wyborczego kobiet osiągnęła szczyt intensywności. Tymczasem, choć sufrażyzm był jak dotąd przedmiotem licznych badań, niewiele uwagi poświęcono przeciwnikom praw wyborczych kobiet ‒ antysufrażystom. Artykuł koncentruje się na przemówieniach, broszurach i książkach, publikowanych przez antysufrażystów, i ma na celu prześledzenie ich intelektualnych zmagań z pojęciem demokracji. Jak się okazuje, większość z nich przedstawiała nadanie kobietom praw wyborczych jako krok w kierunku degeneracji społeczeństwa demokratycznego. Jednak, co bardziej zaskakujące, niektórzy antysufrażyści używali również demokratycznego języka w sposób pozytywny, wskazując za jego pomocą powody, dla których kobiety nie powinny głosować. Kilku z analizowanych w tekście autorów uważało, że „demokracja” opiera się na zdolności do narzucania woli większości siłą, co czyniłoby bezsilnymi rządy, wybrane przez kobiety. Sprzeciwiano się również sufrażyzmowi dlatego, że był on postrzegany jako nurt, rozwijający się wbrew “demokratycznemu duchowi” tamtych czasów. Poszczególne przykłady, zgromadzone w tekście, wskazują na rosnące znaczenie pojęcia demokracji w Wielkiej Brytanii w początkach XX wieku, oraz odkrywają próby zdefiniowania go jako kategorii konserwatywnej

From mixed government to “Real Democracy” : A conceptual history of the word democracy in Britain, 1770-1920

Vilipendé à travers l’Occident, associé au désordre et à la foule, le mot democracy devient, au cours du 19e siècle, un synonyme de bon gouvernement. Combinant histoire conceptuelle, humanités numériques et théorie politique, cette thèse retrace les usages britanniques de ce terme. Pour ce faire, différentes sources (débats parlementaires, traités politiques, ouvrages de référence, presse périodique) et outils méthodologiques sont mobilisés. L’analyse se concentre sur quatre moments clefs, correspondant à des crises politiques internes et externes de la Grande-Bretagne, marqués par un emploi intensif du vocabulaire démocratique. En examinant les principaux sens dénotatifs et connotatifs de democracy en Grande-Bretagne de 1770 à 1920, cette thèse met en relief une transition : celle d’un imaginaire politique britannique structuré par la théorie du gouvernement mixte à un régime parlementaire considéré comme démocratique.Cette thèse permet de souligner l’appropriation tardive de democracy par les forces politiques britanniques, à contraster avec les cas français et étatsuniens, qui adoptent l’étiquette démocratique beaucoup plus tôt. Elle démontre également la persistance d’une opposition conceptuelle forte entre régime mixte et democracy, puis entre cette dernière et le gouvernement parlementaire. Elle atteste du monopole conservateur sur le vocabulaire démocratique durant la période étudiée, tout en signalant la dichotomie oubliée entre people et democracy au même moment. Ces résultats permettent de remettre en cause la lecture téléologique de la démocratisation britannique opportunément amenée par plusieurs approches tant historiques que théoriques de cette question.Vilified throughout the West, associated with disorder and crowds, the word democracy became, during the 19th century, synonymous with good government. Combining conceptual history, digital humanities and political theory, this thesis traces the British uses of the term. To do so, different sources (parliamentary debates, political treatises, reference works, periodical press) and methodological tools are mobilized. The analysis focuses on four key moments, corresponding to internal and external political crises in Great Britain, marked by an intensive use of democratic vocabulary. By examining the main denotative and connotative meanings of “democracy” in Great Britain between 1770 and 1920, this thesis highlights a transition from a British political imaginary structured by the theory of mixed government to a parliamentary regime now considered democratic.This thesis thus makes it possible to underline the late appropriation of “democracy” by British political forces, in contrast to the French and American cases, which adopted the democratic label much earlier. It also demonstrates the persistence of a strong conceptual opposition between “mixed government” and “democracy”, and then between the latter and parliamentary government. It attests to the Conservative quasi-monopoly on democratic vocabulary during the period under study, while pointing to the forgotten dichotomy between “people” and “democracy” at the same time. These results make it possible to question the teleological reading of British democratization that has been opportunely brought about by several historical and theoretical approaches to this question