Audit and feedback : effects on professional obstetrical practice and health care outcomes

Orientadores: Jose Guilherme Cecatti, Helaine Maria Besteti Pires MilanezDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Introdução: Auditoria e Feedback, estratégia de intervenção na prática médica, sendo um resumo da atuação durante certo período, com posterior formulação de recomendações para a melhoria do serviço estudado. Sua efetividade ainda é incerta em Obstetrícia. Objetivo: Estudar o processo de Auditoria e Feedback em Obstetrícia e implementar o uso do material da Reproductive Health Library. Avaliar o possível efeito da intervenção sobre as taxas de parto por cesárea, com a utilização da classificação de Robson. Métodos: coleta prospectiva de dados sobre os seis parâmetros obstétricos selecionados segundo publicações baseadas em evidência, antes e depois de um período de intervenção, preparado após análise dos índices de prevalência de cada prática: episiotomia seletiva, cardiotocografia contínua durante o trabalho de parto em gestações de baixo risco, antibioticoprofilaxia no parto por cesárea, uterotônico no terceiro período do parto, indução de parto às 41 semanas em gestações de baixo risco e suporte contínuo durante o trabalho de parto. Realizado agrupamento de todos os partos segundo a classificação de Robson, em 10 grupos, levando em conta o antecedente obstétrico, tipo de gestação, curso do trabalho de parto e idade gestacional. Resultados: os dois períodos foram similares quanto às características obstétricas gerais. Com relação aos parâmetros selecionados, foi observada redução significativa do uso de episiotomia seletiva (RR 0.84 IC95% 0.73-0.97), embora o mesmo não tenha ocorrido entre as primigestas (p=0,315), aumento na presença de acompanhante durante o trabalho de parto (RR 1.42; 1.24-1.63) e adequação de uso de uterotônico (ocitocina 10UI) no terceiro período (p<0,0001). Segundo a classificação de Robson, não ocorreu alteração no índice global de partos cesárea nos dois períodos estudados (respectivamente 45.5% e 43.3%). Houve predomínio do Grupo 3 (multipara sem cesárea anterior, feto único, cefálico, de termo, trabalho de parto espontâneo) com índices de 28.5 e 26.8% respectivamente. O segundo mais prevalente foi o Grupo 1 (nulípara, feto único, cefálico, termo e trabalho de parto espontâneo), com 25.5 e 22.6% do total de partos, seguido pelo Grupo 5 (multípara com cesárea prévia, feto único, cefálico, gestação de termo), com taxas de 22.9 e 21.3% respectivamente. O Grupo 5 foi também responsável pela maior contribuição ao número total de cesáreas (36.4 e 34.6% nos dois períodos). Os Grupos 2 (nulípara, feto único, cefálico, de termo, em trabalho de parto induzido ou cesárea antes de trabalho de parto) e 4 (multípara, feto único, cefálico, de termo, em trabalho de parto induzido ou cesárea antes de trabalho de parto), embora tenham pouca contribuição ao número total de partos, demonstraram altos índices de cesárea dentro do seus grupos. O grupo 10, composto por prematuros, foi o quarto mais prevalente, também com altos índices de cesárea no seu grupo, porém com redução significativa entre os períodos pré e pós-intervenção (p=0.0058). Conclusão: o processo de Auditoria e feedback pode ser utilizado como mecanismo de implementação em obstetrícia, sobretudo quando a equipe é receptiva a mudanças.Abstract: Background: Audit and feedback is a widely used strategy to improve professional practice and can be defined as any summary of clinical performance of health care over a period of time, which may include recommendations for clinical action. Its effectiveness is still uncertain in Obstetrics. Objectives: to assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to implement the use of RHL material as a routine in medical practice; to evaluate the effect of the intervention over the incidence of caesarean sections, according to the Robson's classification, in 10 groups. Methods: The study proposed has an audit and feedback design and was conducted in the obstetric Unit of the University of Campinas, Brazil, between the years 2007- 2008. It started by providing up to date estimates of prevalence rates of six audit standards underwritten by evidence-based recommendations: selective episiotomy; continuous electronic fetal monitoring during uncomplicated labour of low risk pregnant women; antibiotic prophylaxis for women undergoing caesarean section; use of oxytocin after delivery as one of the procedures of active management of third stage of labour; routine induction of labour at 41 weeks for uncomplicated pregnancies and continuous support for women during childbirth. The results were then analyzed and presented as feedback to clinical practice. Active information based on the WHO Reproductive Health Library (RHL) was prepared to remind important and reliable health care interventions during meetings with the whole maternity staff. After four months, the same practices were again measured and analyzed to compare data and assess if the intervention was effective. All caesarean sections were evaluated according to Robson's Classification to study a possible effect of the intervention on caesarean rates. Results: both periods studied showed equivalency in the total number of deliveries, vaginal and caesarean births, forceps and deliveries in nulliparous. Considering the obstetric practices evaluated, there was a significant reduction in selective episiotomy (RR 0.84 95%CI 0.73-0.97), but not in nulliparous (p=0.315); an increase in continuous support for women during childbirth (RR 1.42; 1.24-1.63). There was also a change in the institution protocol for the use of uterotonic (oxitocyn) during third stage of labor, with a shift to the WHO recommended dosage of 10UI (p<0.0001). There was no change observed in the use of continuous electronic fetal monitoring, routine induction of labour at 41 weeks for uncomplicated pregnancies and antibiotic prophylaxis in caesarean sections. Considering caesarean sections, there was no prevalence change after intervention. Robson's classification was applied and Group 3 (multiparous excluding previous CS, single, cephalic, =37 weeks, spontaneous labour) accounted for the largest proportion of deliveries, 28.5% and 26.8% in both periods. Group 1 (nulliparous, single, cephalic, =37 weeks, spontaneous labour) was the second largest one, with 25.5% and 22.6% respectively, while Group 5 (previous caesarean section, single, cephalic, =37 weeks) was the third, with percentages of 22.9% and 21.3% respectively. Group 5 also represented the most prevalent when considering only caesarean sections, accounting for 36.4% and 34.6% in both periods. Groups 2 (nulliparous, single, cephalic, =37 weeks, induction or CS before labour) and 4 (multiparous excluding previous CS, single, cephalic, =37 weeks, induction or CS before labour) had low contribution for the total number of deliveries, however they had higher rates of caesarean sections within each group. Group 10 (all single, cephalic, = 36 weeks, including previous CS) represented the fourth largest among all deliveries, with respectively 6.6% and 8.6%. Within its group, the rate of caesarean section was high, with a significant decrease from 70.5% to 42.6%, from pre to post intervention period (p=0.0058). Conclusion: Audit and feedback can be used as a successful implementation tool in obstetrics, especially when the medical staff is open and receptive to change.MestradoTocoginecologiaMestre em Tocoginecologi

Municipality of Naples: Parco metropolitano delle Colline di Napoli - Case Studies

The area included in the “Parco Metropolitano delle Colline di Napoli” is not exclusively devoted to production, but also affected by an agricultural activity whose conservation has the safeguard and the restoration of the land as their main purposes. In fact, this area is interested by transformations aimed to the development of semi-natural ecosystems. The area is mainly characterized by steep slopes and rough tracts: the hydrogeological stability of these lands has been possible thanks to the terracing technique; nevertheless, this stability is often threaten by the building expansion. The farmed lands are often bordering on the residential areas or, conversely, some buildings arise from areas devoted to the agriculture. Some remains of the past agricultural activities still present agricultural systems of remarkable importance, both historical and ecological. The progressive isolation of these lands, effectively involved the conservation of traditional factors, such as the cultivated species and the farming techniques. The urban farms, characterized by a subsistence agriculture of the family run and scarce plots, are considered as valuable sources of biodiversity, with a high ecological importance. Therefore, archaic techniques of farming are easy to be found in these rural areas, which produced some varieties of trees nowadays considered in extinction or superseded by industrial cultivars. Apart from the agricultural use, the areas less suitable for farming are characterized by chestnut coppices, maquis vegetation and spontaneous intercropping. The whole set represents a complex environmental system; besides, the abandoned quarries nearby, which used to cause discontinuity in the agricultural landscape, nowadays represent an evocative scenario, together with the cultivated lands

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This study aimed to understand the importance of the practice of binge watching in behavioral intentions and in the use of Video On Demand platforms, based on the transformations observed in series consumption and content distribution technologies. The literature review reached through the analysis of studies on consumer culture, entertainment consumption, binge watching and works involving models for adoption of technologies, identification of determinants and their relation with the constructs of interest of the research, obtaining as a result 11 hypotheses to be tested. The methodological procedures involve the elaboration of a structured questionnaire, with items of scales validated and adapted to the context of this study. The collected data were analyzed based on an initial exploratory analysis, multivariate analysis techniques, processed in SPSS 22 and modeling of structural equations using SmartPLS 3 to verify the hypothesis of the research. As results we have that the relationships of the constructs performance expectation, social interaction, facilitative conditions, hedonic motivations, price value, habit and content are determinants of the behavioral intention construct, which significantly predicts the use of Video On Demand platforms by users of binge watching. Therefore, this study brings an adaptation of the UTAUT2 model to the application in the Brazilian context of the platforms of streaming before the modifications in the habits of series binge watching.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPESEste estudo objetivou compreender a importância da prática de binge watching nas intenções comportamentais e no uso de plataformas de Video On Demand, a partir das transformações observadas no consumo de seriados e nas tecnologias de distribuição de conteúdo. A revisão bibliográfica alcançou por meio da análise de estudos sobre cultura de consumo, consumo de entretenimento, binge watching e trabalhos envolvendo modelos para adoção de tecnologias, a identificação de fatores e sua relação com os construtos de interesse da pesquisa, obtendo como resultado a elaboração de 11 hipóteses a serem testadas. Os procedimentos metodológicos envolveram a elaboração de um questionário estruturado, com itens de escalas validadas e adaptadas ao contexto trabalhado neste estudo. Os dados coletados foram analisados com base em uma análise exploratória inicial, técnicas de análise multivariada, processadas no SPSS 22 e modelagem de equações estruturais utilizando-se o SmartPLS 3 para verificar as hipóteses da pesquisa. Como resultados tem-se que as relações dos construtos expectativa de desempenho, interação social, condições facilitadoras, motivações hedônicas, valor do preço, hábito e conteúdo são determinantes do construto intenção comportamental o qual prediz significantemente o uso das plataformas de Video On Demand por praticantes de binge watching. Assim, este estudo traz uma adaptação do modelo UTAUT2 para a aplicação no contexto brasileiro das plataformas de streaming perante as modificações nos hábitos de maratonas de seriados

Concetualização de um modelo de indexação da volatilidade do preço das matérias-primas ao preço do produto final na grande distribuição

As relações estabelecidas na cadeia de abastecimento do leite são, em Portugal e muitos outros países, caracterizadas pela disparidade de poder e dimensão entre os intervenientes da cadeia, resultando num ambiente instável e de elevada precariedade no setor. Em particular, os produtores, no primeiro nível da cadeia, são altamente dependentes do preço das matérias-primas agroalimentares, o seu principal custo de produção, que tem registado um elevado grau de volatilidade. Atualmente, os contratos celebrados entre grande distribuição, indústria e produtor, tipicamente fixam um preço ao produtor, válido durante a vigência do contrato, sem qualquer consideração por aquela volatilidade. Esta tese procura avaliar o impacto, para todos os intervenientes da cadeia, de contratos alternativos, que procurem levar em consideração a volatilidade das matérias-primas agroalimentares. Para tal, de forma a estudar-se a dinâmica do mercado, procedeu-se à estimação de três modelos de previsão, nos quais se analisou o impacto da variação no preço, desde o momento inicial da cadeia, do produtor, até ao momento final, na procura de leite pelo consumidor. Com os resultados estimados, procedeu-se a construção de cenários de três cenários: i) o primeiro relativo a uma indexação do preço das matérias-primas ao preço do produtor; ii) o segundo, adaptado de um contrato da Tesco com os seus fornecedores; iii) o terceiro relativo à fixação de um preço do produtor, desconsiderando o âmbito da indexação; Os principais resultados do estudo, indicaram que existe simetria na transmissão de preços na cadeia de abastecimento do leite e a procura de leite revela-se inelástica. Nos contratos estudados, o contrato indexado à bolsa de matérias-primas seria o mais justo para todos os intervenientes da cadeia. Permitindo ao produtor, proteção face à instabilidade no mercado das matérias-primas e equidade pela diluição dos custos das matérias-primas por toda a cadeia de valor.The relationships established in the milk supply chain, are in Portugal and other countries, characterized by the disparity of power and the size of the chain stakeholders, the environment becomes unstable and highly precarious in the sector. Particularly, producers, at the first level of the chain, are highly dependent on the price of agrifood raw materials, their main cost of production, which shows a high degree of volatility. Nowadays, the contracts signed between the retailers, the industry and the producer, typically, fix the producer price without addressing this question of volatility. This thesis seeks to assess the impact, for all stakeholders, of alternative contracts that seek to take in account the volatility of price agrifood raw materials. Thus, in order to study the dynamics of the market, three prevision models were estimated, in which the impact of price variation was analysed, from the initial moment of the chain, at the producer, until the final moment, at the demand for milk by final consumer. With the estimated results, proceed with the construction of three revenue scenarios contracts: i) the first, related to the indexation of the price od agrifood raw materials to the producer price; ii) the second, an adaptation of a Tesco contract; iii) the third, related with the formation of a fixed price without taking into account the indexation problem; The main results of the study indicate that there is symmetry in price transmission in the milk supply chain and the demand for milk is inelastic. In scenario analysis, the contract indexed to the stock exchange of raw materials would be fairer for all stakeholders in the supply chain. Protecting the producer from instability raw materials market and equity with the pass-through of raw material costs through the entire value chain

Pregnancy In Women Undergoing Hemodialysis: Case Series In A Southeast Brazilian Reference Center.

To describe maternal and neonatal outcomes in pregnant women undergoing hemodialysis in a referral center in Brazilian Southeast side. Retrospective and descriptive study, with chart review of all pregnancies undergoing hemodialysis that were followed-up at an outpatient clinic of high- risk prenatal care in Southeast Brazil. Among the 16 women identified, 2 were excluded due to follow-up loss. In 14 women described, hypertension was the most frequent cause of chronic renal failure (half of cases). The majority (71.4%) had performed hemodialysis treatment for more than one year and all of them underwent 5 to 6 hemodialysis sessions per week. Eleven participants had chronic hypertension, 1 of which was also diabetic, and 6 of them were smokers. Regarding pregnancy complications, 1 of the hypertensive women developed malignant hypertension (with fetal growth restriction and preterm delivery at 29 weeks), 2 had acute pulmonary edema and 2 had abruption placenta. The mode of delivery was cesarean section in 9 women (64.3%). All neonates had Apgar score at five minutes above 7. To improve perinatal and maternal outcomes of women undergoing hemodialysis, it is important to ensure multidisciplinary approach in referral center, strict control of serum urea, hemoglobin and maternal blood pressure, as well as close monitoring of fetal well-being and maternal morbidities. Another important strategy is suitable guidance for contraception in these women.375-

Environmental restoration of urban rivers in the metropolitan region of Rio de Janeiro, Brazil

Cet article porte sur les discours environnementaux et les pratiques concernant la restauration des eaux urbaines au Brésil en se penchant sur les rapports entre l’environnement et l’occupation urbaine. Une analyse est menée sur les travaux de restauration environnementale des fleuves et cours d’eau entrepris dans le cadre du Projet Iguaçu à la Baixada Fluminense, dans l’état de Rio de Janeiro. Il s’agit dans un premier temps de dresser un portrait de l’expérience de la restauration environnementale et du paysage, puis de cerner les aspects sociaux et environnementaux de la Baixada Fluminense. Une discussion est ensuite menée sur l’action des pouvoirs publics sur cet espace en mettant l’accent sur le développement des parcs riverains. L’article se termine en soulignant que la prise en compte de la spécificité culturelle est essentielle pour améliorer l’efficacité des actions de restauration.This paper aims to expand our understanding of environmental discourses and practices in Brazil pertaining to urban water restoration, by focusing on the interrelations between environmental structure and urban occupation. For this purpose, it examines river and stream environmental restoration proposals within the Iguaçu Project located in Baixada Fluminense, in the state of Rio de Janeiro. The discussion begins with a brief description of the environmental restoration and landscape experience, followed by an exploration of the Baixada Fluminense social and environmental contexts. A program launched by the government is analyzed, emphasizing the development of riverside parks. The paper concludes by arguing that environmental restoration must be culturally specific in order to improve its efficacy

Renovar la mirada e innovar las prácticas en el aprendizaje de la ciudad: ¿Para qué nos sirven los libros de urbanismo?

La enseñanza de la asignatura Urbanismo promueve la relación entre teoría y proyecto urbano y se pregunta cómo transformar la ciudad desde la densidad conceptual de la disciplina, representada en este artículo por referencias bibliográficas. La materia, que antes era abierta a otras carreras, se enfoca ahora específicamente en las de diseño, pretendiendo mantener una mirada amplia y un interés interdisciplinar que consideramos imprescindible.Fil: Costa, Camila. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Santa Fe; Argentina. Universidad Nacional del Litoral. Facultad de Arquitectura, Diseño y Urbanismo; ArgentinaFil: Bertuzzi, Maria Laura. Universidad Nacional del Litoral. Facultad de Arquitectura, Diseño y Urbanismo; Argentina. Fundacion Carolina.; Españ

Enzymatic Potential Of Heterotrophic Bacteria From A Neutral Copper Mine Drainage

Copper mine drainages are restricted environments that have been overlooked as sources of new biocatalysts for bioremediation and organic syntheses. Therefore, this study aimed to determine the enzymatic activities (esterase, epoxide hydrolase and monooxygenase) of 56 heterotrophic bacteria isolated from a neutral copper mine drainage (Sossego Mine, Canaa dos Carajas, Brazil). Hydrolase and monooxygenase activities were detected in 75% and 20% of the evaluated bacteria, respectively. Bacterial strains with good oxidative performance were also evaluated for biotransformation of organic sulfides. Fourteen strains with good enzymatic activity were identified by 16S rRNA gene sequencing, revealing the presence of three genera: Bacillus, Pseudomonas and Stenotrophomonas. The bacterial strains B. megaterium (SO5-4 and SO6-2) and Pseudomonas sp. (SO5-9) efficiently oxidized three different organic sulfides to their corresponding sulfoxides. In conclusion, this study revealed that neutral copper mine drainages are a promising source of biocatalysts for ester hydrolysis and sulfide oxidation/bioremediation. Furthermore, this is a novel biotechnological overview of the heterotrophic bacteria from a copper mine drainage, and this report may support further microbiological monitoring of this type of mine environment. (C) 2016 Sociedade Brasileira de Microbiologia. Published by Elsevier Editora Ltda.47484685