How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's Sao Paulo and Maranhao states

Background: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world’s most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. Methods: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. Results: We found the concept of ‘health sector crisis’ to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible–if insecure–working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. Conclusions: The ‘plates’ of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded

Avaliação do estado nutricional de idosos institucionalizados

OBJETIVO: Identificar o estado nutricional, segundo o índice de massa corporal, e fornecer informações sobre medidas antropométricas de idosos institucionalizados no município de Florianópolis (SC). MÉTODOS: Estudo transversal, no qual a população em estudo foi composta por 232 idosos, com idade a partir de 60 anos, residentes em instituições geriátricas do município de Florianópolis (SC). A avaliação antropométrica foi realizada obtendo-se o valor do índice de massa corporal, da prega cutânea triciptal e da circunferência da panturrilha. O diagnóstico do estado nutricional foi realizado utilizando-se os pontos de corte preconizados pela Organização Pan-Americana de Saúde para índice de massa corporal. Os dados são apresentados sob a forma de média e desvio-padrão. Foi realizado o teste t de Student para verificar a diferença entre os valores médios das variáveis entre os sexos. RESULTADOS: A amostra constituiu-se de 167 idosos de ambos os sexos. Encontrou-se uma prevalência de 45,5% de baixo peso, 33,5% de peso normal, 7,8% de pré-obesidade e 13,2% de obesidade. Para todas as variáveis antropométricas, o valor médio das mulheres foi superior ao dos homens. CONCLUSÃO: Os resultados encontrados indicaram a prevalência de 66,5% da amostra com estado nutricional inadequado, evidenciando a necessidade de medidas de promoção ou reabilitação da saúde dos idosos. Os dados mostram que há diferenças entre os sexos com relação ao estado nutricional e às variáveis índice de massa corporal e prega cutânea triciptal, além de contribuírem para a ampliação do referencial antropométrico de idosos institucionalizados.OBJECTIVE: The objective of this study was to identify the nutritional status, according to body mass index, and provide information regarding anthropometric measurements of institutionalized seniors in the city of Florianópolis (SC), Brazil. METHODS: This is a cross-sectional study. The research population consisted of 232 senior citizens, aged 60 or more, living in geriatric institutions in Florianópolis (SC), Brazil. Anthropometric assessment included determining the body mass index, tricipital skinfold, and calf circumference. Diagnosis of the nutritional status was performed using the cut-off points determined by the Pan-American Health Organization for body mass index. The data are presented as means and standard deviation. The Student's " t" test was used to detect differences in mean values of the variables between both genders. RESULTS: The sample consisted of 167 senior citizens of both genders. A prevalence of 45.5% of low weight, 33.5% of normal weight, 7.8% of overweight and 13.2% of obesity was observed. The mean values for women were higher than those for men for all anthropometric variables. CONCLUSION: The data obtained showed that 66.5% of the sample presented inadequate nutritional status, clearly evidencing the need to take some measures that promote or recover the health of senior citizens. In addition, the data obtained show that there are differences between both genders regarding the nutritional status and the variables body mass index and tricipital skinfold and contribute to increase the anthropometric references of institutionalized senior citizens

Correlation among immune response, morphogenesis of the granulomatous reaction and spleen lymphoid structure in murine experimental paracoccidioidomycosis

We studied the correlation among cellular immune response, the pattern of lung granulomatous lesions and alterations in spleen lymphoid structure in Swiss mice inoculated intravenously with Paracoccidioides brasiliensis strain 18. The animals were evaluated at 24, 48 and 96 h after infection and further studied weekly for 18 weeks by: (i) the macrophage migration inhibition test with phytohemagglutinin (PHA) and P. brasiliensis antigen (PbAg); and (ii) histopathology of the lung and spleen lesions. One group of animals was gamma -irradiated (8 Gy), infected under the same conditions and evaluated for the pattern of lung granulomatous lesions and spleen lymphoid structure at 24, 48 and 96 h after infection. During the first week of infection, the non-irradiated animals presented a positive response to PHA and PbAg, compact granulomas in the lungs and a typical hyperplasia of the spleen white pulp. However, from weeks 2 to 5, a depression of the cell-mediated immunity (CMI) response to PHA and PbAg was observed in association with granulomas presenting only large mononuclear cells and lacking both giant cells and a peripheral halo of small mononuclear cells. This pattern of granuloma formation was similar to that seen in gamma -irradiated animals, whose cells involved in CMI were absent. After week 7, the non-irradiated animals showed granulomas characterized by the presence of giant cells and a peripheral halo of small mononuclear cells. This type of granuloma was formed concomitantly with recovery of the CMI and of the lymphoid structure of the spleen. The results showed a correlation among granulomas composed of large mononuclear cells, hypoplasia of the splenic tissue and impaired CMI. This correlation indicated that although granuloma morphogenesis per se does not depend on the activation of CMI, this response is important at later stages during modulation of the cellular composition of the granulomas.São Paulo State Univ, Inst Biosci, Dept Microbiol & Immunol, Botucatu, SP, BrazilOsvaldo Cruz Fdn, Goncalo Moniz Res Ctr, Lab Immunopharmacol, Salvador, BA, BrazilSão Paulo State Univ, Inst Biosci, Dept Microbiol & Immunol, Botucatu, SP, Brazi

Cell-free antigens from precocious Paracoccidioides brasiliensis culture induce a typical delayed-type hypersensitivity reaction

Cell-free antigens (CFAg) derived from Paracoccidioides brasiliensis have typically been used in immunodiffusion reactions for serodiagnosis or therapeutic follow-up of paracoccidioidomycosis patients. Thus, we investigated the usefulness of CFAg obtained from cultures at different ages, to evaluate cellular immunity by the footpad test, in experimental murine paracoccidioidomycosis. Male mice infected with P. brasiliensis 265 strain were challenged in the footpad with CFAg obtained from four- (4d CFAg) or 11-day-old cultures (11d CFAg). The increase in footpad swelling provoked by 4d CFAg and 11d CFAg was similar and showed significant difference in relation to control groups. However, the infiltrate pattern was strikingly different: 4d CFAg induced a predominant mononuclear infiltrate whereas 11d CFAg provoked a predominant polymophonuclear infiltrate. These different inflammatory patterns were associated with distinct electrophoretic characteristics. By comparison with 11d CFAg, 4d CFAg showed more numerous and intense bands, including a strong one of 43 kDa (gp43). These results suggest that CFAg derived from Pb 265 isolate can be used as a reagent to evaluate cellular immunity; however, the culture's age is critical because only young cultures are able to induce a typical mononuclear infiltrate. The efficacy of this new paracoccidioidin to assay the cellular immunity in infections caused by other P. brasiliensis isolates is under investigation

Role of Paracoccidioides brasiliensis cell wall fraction containing beta-glucan in tumor necrosis factor-alpha production by human monocytes: correlation with fungicidal activity

The polysaccharide fraction of Paracoccidioides brasiliensis mycelial cell wall (F1 fraction), the active component of which is composed of beta-glucan, was investigated in regard to the activation of human monocytes for fungal killing. The cells were primed with interferon-gamma (IFN-gamma) or F1 (100 and 200 mug ml(-1)) or F1 (100 and 200 mug ml(-1)) plus IFN-gamma for 24 h and then evaluated for H2O2 release. In other experiments, the cells were pretreated with the same stimuli, challenged with a virulent strain of P. brasiliensis and evaluated for fungicidal activity and levels of tumor necrosis factor (TNF-alpha) in the supernatants. F1 increased the levels of H2O2 in a similar manner to IFN-gamma. However, a synergistic effect between these two activators was not detected. on the contrary, a significant fungicidal activity was only obtained after priming with IFN-gamma plus F1. This higher activity was associated with high levels of TNF-alpha in the supernatants of the cocultures. Overall, P. brasiliensis F1 fraction induced human monocytes to release relatively high levels of TNF-alpha, which, in combination with IFN-gamma, is responsible for the activation of human monocytes for effective killing of P. brasiliensis