Evaluation of health services’ waste management systems: a case study in a Brazilian regional public hospital

O objetivo desta pesquisa é propor uma avaliação dos Sistemas de Gestão de Resíduos de Serviços de Saúde (SGRSS) e sua aplicação ao contexto de um Hospital Público Regional localizado no interior do estado de São Paulo, Brasil. A metodologia adotada na pesquisa foi um estudo de caso, do tipo exploratório e de ordem qualitativa. Sua relevância é atestada, pois vai além da dimensão operacional que é comumente abordada em outras pesquisas, agregando, assim, as dimensões administrativa, ambiental e financeira. Para tanto, apresenta-se variáveis e indicadores em uma avaliação integrada à sua aplicabilidade gerencial. Os resultados indicam que o SGRSS do Hospital Público estudado necessita ser aperfeiçoado, tendo a dimensão operacional, bem como seu modelo preponderante, uma maior relevância gerencial. A contribuição desta pesquisa, ancorada nas informações dos modelos de avaliação encontrados na literatura, recai sobre a aplicação de um modelo de Avaliação dos Sistemas de Gestão de Resíduos de Serviços de Saúde mais abrangente, assim como no direcionamento para o Gerenciamento integrado de resíduos nas organizações hospitalares, que servirá como instrumento de avaliação para os gestores no sistema de Gestão dos RSS.The main goal of this paper is to propose an evaluation of the Health Services Waste Management Systems (SGRSS) and its application in the context of a Regional Public Hospital located in the countryside of São Paulo, Brazil. The methodology adopted in this research was an exploratory and qualitative case study. The relevance is given due to a broader view of the operational dimension that is usually addressed in other studies by aggregating the administrative, environmental, and financial dimensions. For this, this article presents some variables and indicators in an integrated assessment for their managerial applicability. The results indicate that the SGRSS of the Public Hospital needs to be improved through the most relevant operational dimension available, as well as its predominant model. The contribution of the research, based on the information of the evaluation models found in the literature, is focused on the elaboration of a more embracing Health Services Waste Management Systems Evaluation model and related to the direction for Integrated Waste Management in hospital organizations, which will be used as an assessment tool for managers in the RSS Management system

Biomicroscopia ultrassônica após procedimentos cirúrgicos paliativos na ceratopatia bolhosa: estudo comparativo descritivo

Purpose:To describe quantitative and qualitative features of eyes with advanced bullou keratopathy assessed using ultrasound biomicroscopy, before and after anterior stromal puncture (ASP) or amniotic membrane transplantation (AMT) procedures to relieve chronic pain.Methods:The present descriptive comparative study included 40 eyes of 40 patients with chronic intermittent pain due to bullous keratopathy who were randomly assigned to one of the two treatments (AMT or ASP). Ultrasound biomicroscopy (Humphrey, UBM 840, 50 MHz transducer, immersion technique) was used, and a questionnaire about pain intensity was completed preoperatively and postoperatively at days 90 and 180, respectively. Exclusion criteria were age<18 years, presence of concurrent infection, ocular hypertension, and absence of pain.Results:In a 180-day follow-up, the AMT group exhibited mean central corneal thicknes (CCT), 899.4 µm preoperatively and 1122.5 µm postoperatively (p<0.001); mean epithelial thickness (ET), 156.4 µm preoperatively and 247.8 µm postoperatively (p<0.001); and mean stromal thickness (ST), 742.9 µm preoperatively and 826.3 µm postoperatively (p=0.005). The ASP group exhibited mean CCT, 756.7 µm preoperatively and 914.8 µm postoperatively (p<0.001); mean ET, 102.1 µm preoperatively and 245.2 µm postoperatively (p<0.001); and mean ST, 654.6 µm preoperatively and 681.5 µm postoperatively (p<0.999). Correlations between CCT and pain intensity in the AMT group (p=0.209 pre- and postoperatively) and the ASP group (p=0.157 preoperatively and p=0.426 at the 180-day follow-up) were not statistically significant. Epithelial and stromal edema, Descemet’s membrane folds, epithelial bullae, and the presence of interface fluid were frequently observed qualitative features.Conclusion:CCT increased over time in both groups. The magnitude of CCT did not correlate with pain intensity in the sample studied. The presence of interface fluid was a qualitative feature specifically found in some patients who underwent AMT.Objetivo:Descrever as características quantitativas e qualitativas da biomicroscopia ultrassônica (UBM) em olhos com ceratopatia bolhosa avançada, antes e após o procedimentos de punção estromal anterior (ASP) ou transplante de membrana amniótica (AMT) para alívio de dor crônica.Métodos:Estudo comparativo descritivo incluindo 40 olhos de 40 pacientes com dor crônica intermitente devido a ceratopatia bolhosa, randomizados em duas modalidades de tratamento (AMT e ASP). Biomicroscopia ultrassônica (Humphrey, UBM 840, transdutor de 50 MHz, técnica de imersão) foi utilizada, e um questionário de avaliação da intensidade da dor foi aplicado no pré-operatório, e após 90 e 180 dias de pós-operatório. Critérios de exclusão foram: idade abaixo de 18 anos, presença de infecção, hipertensão ocular, e ausência de dor.Resultados:No seguimento de 180 dias, o grupo Transplante de membrana amniótica apresentou: média da espessura corneana central (CCT): 899,4 µm (pré), 1.122,5 µm (pós-operatório) (p<0,001); média da espessura epitelial (ET): 156,4 µm (pré), 247,8 µm (pós-operatório) (p<0,001); média da espessura estromal (ST): 742,9 µm (pré), 826,3 µm (pós-operatório) (p=0,005), e, grupo ASP apresentou: CCT média: 756.7 µm (pré), 914,8µm (pós-operatório) (p<0,001); ET média: 102,1 µm (pré), 245,2 µm (pós-operatório) (p<0,001); ST média: 654,6 µm (pré), 681.5 µm (pós-operatório) (p<0,999). A correlação entre intensidade da dor e espessura corneana central no grupo AMT (p=0,209 pré e pós-operatórios) e no grupo ASP (p=0,157 pré-operatório e p=0,426 aos 180 dias de seguimento) não foi significativa. Edema epitelial e estromal, dobras na membrana de Descemet, bolha epiteliais, e presença de fluido na interface foram características qualitativa frequentemente observadas.Conclusão:A espessura corneana central aumentou ao longo do tempo em ambos os grupos. A magnitude da espessura corneana central não interfere na intensidade da dor na amostra estudada. Presença de fluido na interface foi uma característica qualitativa especificamente encontrada em alguns pacientes submetidos a transplante de membraa amniótica.Foundation for Support to Research of Sao Paulo State, (FAPESP)Federal University of São Paulo Department of Ophthalmology and Visual SciencesUNIFESP, Department of Ophthalmology and Visual Sciences2001/07036-3SciEL

The germline mutational landscape of BRCA1 and BRCA2 in Brazil

The detection of germline mutations in BRCA1 and BRCA2 is essential to the formulation of clinical management strategies, and in Brazil, there is limited access to these services, mainly due to the costs/availability of genetic testing. Aiming at the identification of recurrent mutations that could be included in a low-cost mutation panel, used as a first screening approach, we compiled the testing reports of 649 probands with pathogenic/likely pathogenic variants referred to 28 public and private health care centers distributed across 11 Brazilian States. Overall, 126 and 103 distinct mutations were identified in BRCA1 and BRCA2, respectively. Twenty-six novel variants were reported from both genes, and BRCA2 showed higher mutational heterogeneity. Some recurrent mutations were reported exclusively in certain geographic regions, suggesting a founder effect. Our findings confirm that there is significant molecular heterogeneity in these genes among Brazilian carriers, while also suggesting that this heterogeneity precludes the use of screening protocols that include recurrent mutation testing only. This is the first study to show that profiles of recurrent mutations may be unique to different Brazilian regions. These data should be explored in larger regional cohorts to determine if screening with a panel of recurrent mutations would be effective.This work was supported in part by grants from Barretos Cancer Hospital (FINEP - CT-INFRA, 02/2010), Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, 2013/24633-2 and 2103/23277-8), Fundação de Apoio à Pesquisa do Rio Grande do Norte (FAPERN), Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS), Ministério da Saúde, the Breast Cancer Research Foundation (Avon grant #02-2013-044) and National Institute of Health/National Cancer Institute (grant #RC4 CA153828-01) for the Clinical Cancer Genomics Community Research Network. Support in part was provided by grants from Fundo de Incentivo a Pesquisa e Eventos (FIPE) from Hospital de Clínicas de Porto Alegre, by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, BioComputacional 3381/2013, Rede de Pesquisa em Genômica Populacional Humana), Secretaria da Saúde do Estado da Bahia (SESAB), Laboratório de Imunologia e Biologia Molecular (UFBA), INCT pra Controle do Câncer and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). RMR and PAP are recipients of CNPq Productivity Grants, and Bárbara Alemar received a grant from the same agencyinfo:eu-repo/semantics/publishedVersio

III Diretriz Brasileira de Insuficiência Cardíaca Crônica

Universidade de São Paulo Faculdade de Medicina Hospital das ClínicasUniversidade Federal do Rio Grande do Sul Hospital de Clínicas de Porto AlegreUniversidade de Pernambuco Faculdade de Ciências Médicas de PernambucoUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de Minas Gerais Faculdade de MedicinaFaculdade de Medicina de São José do Rio PretoFundação Universitária de Cardiologia do Rio Grande do Sul Instituto de CardiologiaRede Labs D'OrUniversidade Federal FluminenseUniversidade do Estado do Rio de Janeiro Faculdade de Ciencias MédicasInstituto Dante Pazzanese de CardiologiaSanta Casa de MisericórdiaUniversidade de Pernambuco Pronto Socorro Cardiológico de PernambucoHospital Pró CardíacoHospital de MessejanaPontifícia Universidade Católica do ParanáUniversidade Federal de Goiás Faculdade de MedicinaUniversidade de São Paulo Faculdade de Medicina de Ribeirão PretoReal e Benemerita Sociedade de Beneficência PortuguesaFaculdade de Ciências Médicas de Minas GeraisUNIFESP, EPMSciEL

Pervasive gaps in Amazonian ecological research

Biodiversity loss is one of the main challenges of our time,1,2 and attempts to address it require a clear un derstanding of how ecological communities respond to environmental change across time and space.3,4 While the increasing availability of global databases on ecological communities has advanced our knowledge of biodiversity sensitivity to environmental changes,5–7 vast areas of the tropics remain understudied.8–11 In the American tropics, Amazonia stands out as the world’s most diverse rainforest and the primary source of Neotropical biodiversity,12 but it remains among the least known forests in America and is often underrepre sented in biodiversity databases.13–15 To worsen this situation, human-induced modifications16,17 may elim inate pieces of the Amazon’s biodiversity puzzle before we can use them to understand how ecological com munities are responding. To increase generalization and applicability of biodiversity knowledge,18,19 it is thus crucial to reduce biases in ecological research, particularly in regions projected to face the most pronounced environmental changes. We integrate ecological community metadata of 7,694 sampling sites for multiple or ganism groups in a machine learning model framework to map the research probability across the Brazilian Amazonia, while identifying the region’s vulnerability to environmental change. 15%–18% of the most ne glected areas in ecological research are expected to experience severe climate or land use changes by 2050. This means that unless we take immediate action, we will not be able to establish their current status, much less monitor how it is changing and what is being lostinfo:eu-repo/semantics/publishedVersio

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97\ub71 (95% UI 95\ub78-98\ub71) in Iceland, followed by 96\ub76 (94\ub79-97\ub79) in Norway and 96\ub71 (94\ub75-97\ub73) in the Netherlands, to values as low as 18\ub76 (13\ub71-24\ub74) in the Central African Republic, 19\ub70 (14\ub73-23\ub77) in Somalia, and 23\ub74 (20\ub72-26\ub78) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91\ub75 (89\ub71-93\ub76) in Beijing to 48\ub70 (43\ub74-53\ub72) in Tibet (a 43\ub75-point difference), while India saw a 30\ub78-point disparity, from 64\ub78 (59\ub76-68\ub78) in Goa to 34\ub70 (30\ub73-38\ub71) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4\ub78-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20\ub79-point to 17\ub70-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17\ub72-point to 20\ub74-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations