El mercado de trabajo brasileño: nuevos y viejos procesos y la expansión del circuito inferior

La intensificación de la participación de Brasil en la división internacional del trabajo implica la presencia cada vez mayor de los agentes de la economía globalizada y de sus actividades modernas en las grandes metrópolis del país, sobre todo en São Paulo, que se destaca en el escenario internacional como una de las llamadas ciudades “globales”. No obstante, las metrópolis acogen también un enorme abanico de actividades realizadas por la población pobre. Por tanto, estas metrópolis contienen diferentes divisiones del trabajo que coexisten y pueden analizarse como circuitos de la economía urbana (Santos, 1978)

Sex and Gender Differences in Heart Failure

Heart failure (HF) phenotypes differ according to sex. HF preserved ejection fraction (EF) has a greater prevalence in women and HF reduced EF (HFrEF) in men. Women with HF survive longer than men and have a lower risk of sudden death. Ischemia is the most prominent cause in men, whereas hypertension and diabetes contribute to a greater extent in women. Women with HF have a greater stiffness of the smaller left ventricle and a higher EF than men. This higher stiffness of women's hearts may be based on an increase in fibrosis at old age. In younger women estrogen reduces collagen production in female cardiac fibroblasts, but stimulates it in males. Lipid and energy metabolism is better maintained in female than in male stressed hearts. Pulse pressure is a key determinant of outcome in HF women but not in men. Takotsubo and peripartum cardiomyopathy are rare diseases affecting predominantly or exclusively women. Sudden cardiac arrest affects more men than women, but women are less adequately treated. New findings in HF therapy indicate that women with HFrEF need lower doses of beta-blockers and angiotensin-converting enzyme inhibitors than men for optimal effects. The combined neprilysin inhibitor/angiotensin II receptor blockers sacubitril-valsartan led to a significant reduction in event rate versus valsartan in women, which was not observed in men. Unfortunately, only less than 10% of recent randomized controlled trial report effects and adverse drug reactions for women and men separately. More research on sex differences in pathophysiology and therapy of HF is needed

Quantitative and Qualitative Analysis on Sex and Gender in Preparatory Material for National Medical Examination in Germany and the United States

Background: Sex- and gender-based medicine (SGBM) should be a mandatory part of medical education. We compared the quantity and quality of sex- and gender-related content of e-learning materials commonly used by German and American medical students while preparing for national medical examinations. Methods: Quantitative, line-by-line analysis of the preparatory materials AMBOSS 2017 and USMLE Step 1 Lecture Notes (2017) by KAPLAN MEDICAL was performed between April and October 2017. Subjects were allocated to one of the three main fields: clinical subjects, behavioral and social science, and pharmacology. Qualitative analysis comprised binary categorization into sex- and gender-based aspects and qualification with respect to the presence of a pathophysiological explanation for the sex or gender difference. Results: In relation to the total content of AMBOSS and KAPLAN, the sex- and gender-based share of the clinical subjects content was 26.8% (±8.2) in AMBOSS and 21.1% (±10.2) in KAPLAN. The number of sex- and gender-based aspects in the behavioral and social science learning material differed significantly for AMBOSS and KAPLAN (4.4% ± 3.1% vs 10.7% ± 7.5%; P = .044). Most of the sex- and gender-related content covered sex differences. Most learning cards and texts did not include a detailed pathophysiological explanation for sex- or gender-based aspects. The knowledge provided in the preparatory documents represents only a small part of facts that are already known about sex and gender differences. Conclusions: The preparatory materials focused almost exclusively on biological sex differences and the sociocultural dimension in particular is underrepresented. A lot more evidence-based facts are known and should be integrated into the materials to reflect the importance of SGBM as an integral component of patient-centered medicine

Vergleich der Kostenrelevanz im DRG-System des Apache II-, des SAPS II-, des TISS-28-Scores und der IMKB zur Entwicklung eines optimierten Scores zur Kostenvorhersage herzchirurgischer Fälle

Der Kostendruck in Krankenhäusern nimmt stetig zu. Dies führt zu dem Wunsch der Krankenhäuser, die Kosten für die Behandlungsfälle frühzeitig zu kennen, um gegebenenfalls die vorhandenen Finanzmittel wirtschaftlich und medizinisch besser zu verteilen. Die Be- handlungskosten von Patienten zeitnah zu ermitteln, ist schwierig. Der Goldstandard in Deutschland ist hierfür die InEK-Kostenkalkulation, nach der ein Krankenhaus nach einem deutschlandweit festgelegten Verfahren die Kosten für Behandlungsfälle ermittelt. Dies ist jedoch ein retrospektives Verfahren, mit dem die Vorjahreskosten berechnet werden. Dieses Verfahren eignet sich daher nicht, um kurzfristige Kostenentwicklungen zu erkennen und darauf reagieren zu können. Somit ergaben sich für diese Arbeit mehrere Fragestellungen: Lassen sich durch me- dizinische Scores Kosten prognostizieren? Welche medizinischen Scores sollen in die Studie aufgenommen werden? Lassen sich die ausgewählten Scores mit hoher Datenqualität retrospektiv berechnen? Welcher der Scores ist am besten zur Kostenprognose geeignet? Ist eine hochqualitative Prognose der Kosten möglich? Kann man den Score auf wenige Items reduzieren, um den Aufwand der Berechnung zu minimieren? Es wurden 12.733 Behandlungsfälle ausgewählt, bei denen jeweils ein CABG, eine Herzklappenoperation oder eine Kombination aus beiden Eingriffen durchgeführt wurde. Für die Business Intelligence (BI)-Software Qlikview wurden Programme entwickelt, die für alle Behandlungsfälle mittels vier medizinischer Scoringsysteme (SAPS II, APACHE II, TISS-28 und die IMKB) retrospektiv aus den medizinischen Daten für die Jahre 2008– 2013 bzw. 2014 und 2015 die Punkte automatisiert berechneten. Die Berechnung der Scores aus den medizinischen Daten war ohne Probleme möglich. Durch Korrelationsanalysen wurde der TISS-28 ausgewählt, da von den vier ausgewählten Scores seine Ergebnisse die höchste Korrelation zu den Kosten aufwiesen. Es wurden zwei Modelle getestet, um die Kosten zu prognostizieren. Es zeigte sich, dass ein Modell, das mit dem gesamten TISS-28 die Gesamtkosten prognostiziert, am besten geeignet war. Mit den Daten aus den Jahren 2008 bis 2013 wurden somit die Jahre 2014 und 2015 prognostiziert. Da in diesen beiden Jahren zwei verschiedene ärztliche Leitungen für das Behandlungsgeschehen verantwortlich waren, konnte auch gleichzeitig nachgewiesen werden, dass der TISS-28 in seiner Kostenprognose robust genug war, um auch bei unterschiedlichen Behandlungsstrategien die Kosten sicher zu prognostizieren. Von einer Reduzierung der Anzahl der Items des TISS-28, um die Berechnung des Scores zu vereinfachen wurde abgesehen, da alle Items eine signifikante Korrelation zu den Kosten aufzeigten und mit der Reduzierung evtl. eine Fehlerquelle geschaffen würde, die nicht abzusehen war.The immense pressure of hospital costs continues to increase. This leads hospitals to want to be able to calculate the case treatment costs early on, so as to distribute the available finances in an economic and medically sound fashion. It is difficult to estimate the treatment costs of patients in advance. The gold standard in Germany is the InEK cost calculation, which enables hospitals to estimate the costs per case in accordance with a nationally defined procedure. However, this procedure is based retrospectively on the costs from the previous year. Using it, it is therefore not possible to recognize and react to short-term cost developments. For this reason this work looks at several related questions: Are medical scores able to predict costs? Which medical scores should be investigated? Is it possible to calculate the selected scores retrospectively with high data quality? Which of the scores is most suited to cost prognosis? Is high-quality projection of the costs possible? Can the score be reduced to a small number of items to simplify the calculation? A total of 12,733 treatment cases were selected in which coronary artery bypass grafting (CABG) or a heart valve operation or a combination of the two was performed. Programs were developed for the BI software Qlikview that were used to automatically calculate the points for four medical scoring systems (SAPS II, APACHE II, TISS-28 and IMKB) retrospectively from the medical data for the years 2008 2013, 2014 and 2015. Calculation of the scores from the medical data was possible without problems. Using correlation analyses the TISS-28 was selected since, of the four scores, it showed the highest correlation with the costs. Two models were tested to predict the costs; a model using the whole TISS-28 to predict the total costs was found to be the more suitable. Therefore the data from the years 2008 2013 were used for predictions for the years 2014 and 2015. In these two years the medical directorship of the institution changed, so that at the same time it was established that the TISS-28 was robust enough in its cost projection to correctly predict the costs even under different treatment strategies. The number of items of the TISS-28 was not, after all, reduced, since all items showed a significant correlation to the costs and reducing them might have introduced an unforeseeable source of error

Do capitalismo de plataforma à difusão dos aplicativos: apontamentos sobre novos nexos entre os circuitos da economia urbana em tempos de Covid-19

No período atual, o avanço da tecnificação alia-se ao crescente protagonismo da digitalização da circulação, aproximando-nos do denominado “capitalismo de plataforma”. No âmbito desse processo, novas dinâmicas têm transformado a realidade das grandes cidades, haja vista a centralidade alcançada pela capilarização dos aplicativos na redefinição de nexos entre os circuitos da economia urbana. Com a pandemia do Covid-19, certas modalidades de trabalho por plataformas de aplicativos ganham visibilidade, iluminando contradições estruturais da sociedade brasileira. A apreensão da realidade urbana passa, hoje, pela compreensão de processos multiescalares envolvidos na banalização dos aplicativos, os quais assumem expressões superlativas no contexto da pandemia.In the current period, the advance of technification is allied to the growing role of digitization of circulation, approaching the so-called "platform capitalism". In the context of this process, new dynamics have transformed the reality of large cities, given the centrality achieved by the capillarization of applications in the redefinition of relationships between the circuits of the urban economy. With the Covid-19 pandemic, certain modalities of work by application platforms gain visibility, illuminating structural contradictions of Brazilian society. The apprehension of the urban reality today involves the understanding of multiscale processes involved in the trivialization of applications, which assume superlative expressions in the context of the pandemic.En el período actual, el avance de la tecnificación se combina con el papel cada vez más importante de la digitalización de la circulación, acercándonos al llamado "capitalismo de plataforma". En este proceso, nuevas dinámicas han transformado la realidad de las grandes ciudades, dada la centralidad lograda por la capilarización de aplicaciones en la redefinición de enlaces entre los circuitos de la economía urbana. Con la pandemia de Covid-19, ciertos tipos de trabajo en plataformas de aplicaciones ganan visibilidad, iluminando contradicciones estructurales de la sociedad brasileña. La aprehensión de la realidad urbana actual implica comprender procesos multiescalares involucrados en l difusión de aplicaciones, que adquieren expresiones superlativas en el contexto de la pandemia.A l’heure actuelle, l’avancement de la technification est à l’origine de la numérisation de la circulation. Dans ce qu’on appelle « capitalisme de plataforme », des nouvelles dynamiques ont transformé la réalité des grandes villes, y compris l’importance des applications pour la redéfinition des rapports à l’intérieure des circuits de l’économie urbaine. Sous la Covid-19, certaines modalités de travail à travers des applications révèlent les contradictions structurelles de la société brésilienne en multiples échelles

O mercado de trabalho brasileiro: novos e velhos processos e a expansão do setor informal

A intensificação da participação do Brasil na divisão internacional do trabalho vem implicando a presença cada vez maior dos agentes da economia globalizada e de suas atividades modernas nas grandes metrópoles do país, sobretudo em São Paulo, que se destaca no cenário internacional como uma das ditas cidades “globais”. Não obstante, as metrópoles abrigam também uma enorme gama de atividades realizadas pela população pobre. Deste modo, estas metrópoles contêm diferentes divisões do trabalho que coexistem e que, por sua vez, podem ser analisadas como circuitos da economia urbana (Santos, 1978).La intensificación de la participación de Brasil en la división internacional del trabajo implica la presencia cada vez mayor de los agentes de la economía globalizada y de sus actividades modernas en las grandes  metrópolis  del  país,  sobre  todo  en  São  Paulo,  que  se  destaca  en  el  escenario  internacional  como una de las llamadas ciudades “globales”. No obstante, las metrópolis acogen también un enorme abanico de actividades realizadas por la población pobre. Por tanto, estas metrópolis contienen diferentes divisiones del trabajo que coexisten y pueden analizarse como circuitos de la economía urbana (Santos, 1978).The intense growth of the Brazilian participation in the international division of labor implies the increasing presence of actors of the globalized economy and its modern activities in the large metropolis of  the  country,  mainly  in  São  Paulo,  which  stands  out  in  the  international  scene  as  one  of  the  so  called “global” cities. However, these metropolises also welcome an enormous range of activities performed by the poor population. Hence, these metropolises contain different divisions of labor that coexist and that can be analyzed as circuits of the urban economy (Santos, 1978)

CONTRADIÇÕES DE FORTALEZA: ENTRE O TURISMO GLOBALIZADO E A REPRODUÇÃO DO CIRCUITO INFERIOR DA ECONOMIA

Fortaleza se destaca hoje como uma das capitais mais modernas do Nordeste, haja vista a expansão de sua área de influência e a intensificação do turismo, o qual se consolidou nos últimos anos como o principal vetor de modernização do estado do Ceará. A adoção de uma modernização pautada no turismo tem implicado, contudo, a remodelação do seu meio construído e o rearranjo de sua economia urbana, com a seleção de determinados atores e parcelas da cidade que concentram investimentos públicos e privados. Prevalece, assim, a lógica do grande empreendimento, a qual não vem suscitando a incorporação do pequeno capital e da população local, e quando o faz é de forma precária. Contudo, a economia popular também tem encontrado seus meios de se adaptar e participar de forma ativa, ainda que indiretamente, desta modernização recente de Fortaleza; uma vez que os agentes do circuito inferior da economia (SANTOS, 1975) também desenvolvem suas estratégias para adequar-se não só à internacionalização do mercado turístico, mas aos diferentes nexos do período da globalização na cidade. A feirinha da Avenida Beira-Mar representa, nesta direção, um lugar bastante representativo desta capacidade de renovação do circuito inferior em suas relações com o turismo globalizado no período atual, a qual é focada no âmbito deste artigo

Participação e representação no SINGREH: (des)equilíbrio de forças e disputas de poder nos colegiados das águas

No momento em que o Brasil completa 20 anos da aprovação de sua Lei das Águas, há diversas questões a serem analisadas no tocante ao cumprimento de suas diretrizes e à implementação do Sistema Nacional de Gerenciamento Integrado de Recursos Hídricos (SINGREH). A partir da premissa de que entre os grandes méritos dessa legislação está a democratização da gestão por meio da participação social, analisamos algumas variáveis relacionadas a esta temática, refletindo sobre desafios que seguem postos para uma efetiva governança compartilhada das águas

Determinants of career development in cardiology – results from a Swiss national survey

BACKGROUND: Despite the rising proportion of female medical students and specialised female doctors in Switzerland, the field of cardiology remains one of the most male-dominated. OBJECTIVES: The goal of this study was to identify determinants of and obstacles to career development for cardiologists with special regard to an academic and interventional career. METHODS: Under the direction of the Swiss working group Women in Cardiology (IG-WIC), an online survey was conducted among Swiss cardiologists and cardiologists in training. RESULTS: 140 participants (43.6% female, 56.4% male; median age 45.0) were included. Women were more often single (27.9% vs 10.1%, p = 0.013) and less likely to have children (52.5% vs 70.9%, p = 0.034). If they had children, they were more likely to provide childcare themselves (37.5% vs 10.7%, p = 0.006) or to have interrupted their work in favour of parenting (40.6% vs 8.9%, p <0.001). A majority of women indicated a negative impact of their gender on their career development (78.7%), and 36.3% reported sexual harassment at their workplace. Women felt less supported in their professional training, especially concerning research activities. As a hindrance for pursuit of a career in academic medicine, both sexes stated lack of compatibility of work and family (44.6%) and the competitive work environment (55.4%) being most important. Women also identified gender-specific disadvantages as one of the main reasons for not choosing an academic or interventional career. CONCLUSIONS: The overall satisfaction among Swiss cardiologists is high regarding training in health care and the working atmosphere. However, women and men plead for better compatibility of work and family and better structured training curricula. Several gender-specific aspects hindering women from advancing in cardiology training should be addressed