A construção de colegiados de gestão: a experiência de gestão da Secretaria Municipal de Saúde analisada por um ator político implicado

Este trabalho tem como objetivo analisar as potencialidades da gestão participativa da Saúde nos municípios, considerando as tensões próprias do campo, e a necessidade de articular os interesses de usuários e funcionários no cotidiano dos serviços. O trabalho aponta dificuldades de construir o SUS constitucional numa conjuntura adversa, atravessa pelo Brasil na década de 90. O campo empírico foi a gestão do sistema municipal de saúde de Amparo, de 2001 a 2006, priorizando na análise o processo de construção de espaços coletivos de gestão, a partir de documentos institucionais, e das falas de gestores e trabalhadores em grupos focais. Partindo da situação de gestora e utilizando material empírico, foram relatados e analisados os principais desafios enfrentados para construir um modelo de atenção tendo como eixos estruturantes a atenção básica e o modelo de gestão baseado em espaços coletivos de gestão. A análise aponta a capacidade de produzir mudanças nos sistemas municipais de saúde a partir da aposta na construção de espaços compartilhados de gestão, em particular pelo deslocamento de poder dos atores envolvidos. Entre os desafios está a capacidade de lidar com o conflito nos espaços coletivos de gestão, reconhecendo que faltam ferramentas de gestão nas equipes e nos colegiados. Outro desafio é a complexidade do cenário da saúde, pois no cotidiano dos serviços, o projeto de saúde está sempre em construção. O trabalho conclui da necessidade de investir na construção de novos modos de produção da vida no plano coletivo, com projetos baseados na igualdade e na convivência democrática.This paper aims to analyze the potential of participatory management in the municipalities of Health, considering the tensions own health and the need to articulate the interests of users and staff in the daily services. The work also highlights the difficulties of building a constitutional SUS so adverse situation, like that faced by the country since the early 90s. The empirical field was the management of the municipal health system of Amparo, 2001 to 2006, emphasizing the analysis of the construction of collective spaces, from the documentary analysis, and the statements of managers and employees are made in focus groups . Starting from the position of managing and using empirical data were reported and analyzed the main challenges to build a model of attention with its central structuring primary care and a management model based on collective spaces. The analysis indicates the ability to produce changes in local health systems from the commitment to building management, shared spaces, particularly the shift of power by actors who have more prominent in the biomedical model still hegemonic. Among the challenges for these changes is the ability to deal with the conflict present in the collective spaces, recognizing that lack of management tools to deal with them, either in teams, whether in the teams. Another challenge is the sheer complexity of the health scene, which creates uncertainty regarding the outcome of this work, because in the daily services, the healthcare bill is always under construction. The study concludes that managers need the ability to invest in tension towards the construction of new modes of production of life at the collective level, investing in projects built on equality and democratic coexistence

Synthesis of beta-hydroxymalonates: the direct aldol addition of malonates to aldehydes in the presence of SiCl4 and i-Pr2EtN

The direct aldol addition of malonates to aromatic, hetero-aromatic and unsaturated aldehydes leading to beta-hydroxymalonates is described. The stability of these products, the trimethyl silyl protection of the hydroxyl group as well as the role of both SiCl4 and i-Pr2EtN in attaining the final products are also discusse

Voluntary lung function screening to reveal new COPD cases in southern Italy

Alberto Capozzolo, Giorgio Castellana, Silvano Dragonieri, Pierluigi Carratù, Vito Liotino, Maria Rosaria Vulpi, Lorenzo Marra, Emanuela Resta, Pierluigi Intiglietta, Onofrio Resta Department of Cardiac, Thoracic, and Vascular Science, Institute of Respiratory Disease, School of Medicine, University of Bari, Bari, Italy Background: Underdiagnosis of COPD is a relevant issue, and most frequently involves patients at early stages of the disease. Physicians do not routinely recommend smokers to undergo spirometry, unless they are symptomatic.Aims: To investigate the effectiveness of voluntary lung function screening in bringing to light patients with previously unknown COPD and to evaluate the relationships among symptoms, smoking status, and airway obstruction.Methods: A voluntary screening study for COPD was conducted during two editions of the annual Fiera del Levante (2014 and 2015), an international trade fair in Bari. Subjects were eligible for the study if they fulfilled the following inclusion criteria: age ≥35 years, smoker/ex-smoker ≥5 pack-years (PYs), or at least one chronic respiratory symptom (cough, sputum production, shortness of breath, and wheezing). A free post-β2-agonist spirometry test was performed by trained physicians for each participant using portable spirometers. Post-β2-agonist forced expiratory volume in 1 second (FEV1):forced vital capacity ratio <0.7 was chosen to establish the diagnosis of COPD. Sensitivity, specificity, and negative and positive predictive values (NPVs and PPVs) of symptoms for the presence of obstruction were calculated.Results: A total of 1,920 individuals were eligible for the study; 188 subjects (9.8%) met COPD criteria. There was a 10.4% prevalence of COPD in subjects with one or more symptoms who had never smoked or smoked ≤5 PYs. Among COPD patients, prevalence of symptoms increased in the presence of FEV1 <80%. COPD smokers were more symptomatic than smokers without COPD. Sensitivity and specificity in all subjects with one or more symptoms were 87% and 32%, respectively, whereas in smoker subgroups, sensitivity and specificity were 71% and 41% (≥5 PYs) and 74% and 35% (≥10 PYs), respectively. In all subjects, the presence of at least one symptom was associated with a low PPV for COPD of 11%, but a very high NPV (96%). These data did not change if the analysis was limited to smokers.Conclusion: Voluntary public lung function screening programs in Italy are effective, and may detect a large number of undiagnosed subjects with COPD in early stages. In our population, COPD symptoms had low specificity and PPV, even considering smokers only. Keywords: COPD underdiagnosis, COPD early stages, screening, spirometr

Long-term clinical outcomes after bioresorbable vascular scaffold implantation for the treatment of coronary in-stent restenosis

Background - Treatment of in-stent restenosis (ISR) is still challenging. In this setting, the use of bioresorbable vascular scaffold (BVS) seems attractive because it allows drug delivery combined with transient vessel scaffolding. We aimed to investigate the long-term results after BVS use in ISR lesions. Methods and Results - A prospective analysis was performed on all patients who underwent percutaneous coronary intervention with BVS implantation for ISR at 7 Italian Centers. Primary end point was the device-oriented composite end point (cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization) at the longest follow-up available. From April 2012 to June 2014, 116 patients (127 lesions) underwent percutaneous coronary intervention for ISR with BVS implantation. Among the ISR lesions, the majority were drug-eluting stent ISR (78, 61.6%), de novo ISR (92, 72.4%), and diffuse ISR (81, 63.8%). Procedural success was achieved for all (100%) patients. No in-hospital death, myocardial infarction, or revascularization occurred. At 15 months of follow-up, the incidence of the device-oriented composite end point estimated with the Kaplan-Meier method was 9.1%. No significant differences were reported between drug-eluting stent and bare-metal stent ISR groups in terms of device-oriented composite end point (10.9% versus 6.4%; hazard ratio, 1.7; 95% confidence interval, 0.5-6.5; P=0.425) and its singular components (cardiac death: 2.8% versus 2.0%, hazard ratio, 1.3; 95% confidence interval, 0.1-14.1, P=0.843; target vessel myocardial infarction: 1.5% versus 0%, P=0.421; ischemia-driven target lesion revascularization: 9.6% versus 4.4%, hazard ratio, 2.3; 95% confidence interval, 0.5-10.8, P=0.309). Conclusions - Our registry suggests that the use of BVS implantation for the treatment of complex drug-eluting stent and bare-metal stent ISR lesions might be associated with acceptable long-term clinical outcomes