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Background Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil’s National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. Methods and findings For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. Conclusions Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

This article presents an analysis of the production of care networks for persons with disabilities in the state of Paraíba, Brazil. We employed a qualitative methodology with a cartographic approach, involving the participation of four users-citizens-guides. Weekly virtual meetings were held throughout the second half of 2020, in which we were able to collect, systematize, and theorize on four issues: 1) guilt and (non) life expectancy on the part of persons with disabilities; 2) the place of disability in family dynamics; 3) the production of specific core relational dependency networks; and 4) the public vs. private care offerings for persons with disabilities. Based on these findings, we were able to lend visibility to and explicitly affirm the ways in which these user-citizens participate in the complex process of care building for persons with disabilities and their families.En este artículo analizamos la producción de redes de atención para personas con discapacidad, en el estado de Paraíba, Brasil. Se trata de un estudio cualitativo, con enfoque cartográfico, en el que participaron cuatro usuarias-ciudadanas-guías. Se realizaron reuniones virtuales semanales a lo largo del segundo semestre de 2020, en las que pudimos recolectar, sistematizar y producir consistencia teórica, a partir de cuatro analizadores: 1) culpabilidad y (no) esperanza de vida de la persona con discapacidad; 2) el lugar de la discapacidad en la dinámica familiar; 3) la producción de núcleos de dependencia relacional específicos; y 4) el público vs. ofertas privadas de atención para las personas con discapacidad. A partir de ellos, fue posible producir visibilidades y enunciabilidades sobre las formas en que estas usuarias-ciudadanas son parte del complejo proceso de construcción de cuidados para las personas con discapacidad y sus familias.

Background: Many governments have introduced pay-for-performance programmes to incentivise health providers to improve quality of care. Evidence on whether these programmes reduce or exacerbate disparities in health care is scarce. In this study, we aimed to assess socioeconomic inequalities in the performance of family health teams under Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ). Methods: For this longitudinal study, we analysed data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November, 2011, to March, 2013), round 2 (April, 2013, to September, 2015), and round 3 (October, 2015, to December, 2019). The primary outcome was the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we examined the PMAQ score by income ventile. We used ordinary least squares regressions to examine the association between PMAQ scores and the income of each local area across implementation rounds, and we did an analysis of variance to assess geographical variation in PMAQ score. Findings: Of the 40 361 family health teams that were registered as ever participating in PMAQ, we included 13 934 teams that participated in the three rounds of PMAQ in our analysis. These teams were located in 11 472 census areas and served approximately 48 million people. The mean PMAQ score was 61·0% (median 61·8, IQR 55·3–67·9) in round 1, 55·3% (median 56·0, IQR 47·6–63·4) in round 2, and 61·6% (median 62·7, IQR 54·4–69·9) in round 3. In round 1, we observed a positive socioeconomic gradient, with the mean PMAQ score ranging from 56·6% in the poorest group to 64·1% in the richest group. Between rounds 1 and 3, mean PMAQ performance increased by 7·1 percentage points for the poorest group and decreased by 0·8 percentage points for the richest group (p

BackgroundEvidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities.MethodsWe conducted a fixed effect panel data analysis over the period of 2009–2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs.ResultsThe results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0–64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (−0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected.ConclusionWe find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.

In recent years, the number of cases with severe Plasmodium vivax malaria has shown an increasing trend. It is, therefore, important to identify routine laboratory markers that best characterize the acute disease phase and can serve as a tool for clinical follow-up of patients. In a cohort study, we followed 87 patients with acute P. vivax monoinfection acquired in an endemic region of the Brazilian Amazon. Forty-two different biochemical and hematological parameters frequently tested in clinical routine were evaluated at the acute phase and the convalescent phase. A total of 42 laboratory tests were performed: biochemical parameters measured were serum lipids levels, aminotransferases, bilirubin, amylase, glucose, urea, creatinine, albumin, globulin, uric acid, C-reactive protein, and alpha-1-acid glycoprotein. Hematological parameters included total and differential white blood cell and platelet counts, hemoglobin concentration, mean platelet volume, platelet width distribution, and plateletcrit. Our results show that several biochemical and hematological parameters were associated with acute phase P. vivax malaria and these parameters reverted to normal values in the convalescent phase. The use of these parameters during diagnosis and follow-up of the infection is a useful clinical tool to evaluate the clinical course and therapeutic response of patients with uncomplicated vivax malaria.

Objective: To analyze the influence of socioeconomic, demographic, epidemiological factors, and the health system structure in the evolution of the COVID-19 pandemic in Brazil. Methods: Ecological study with variables extracted from databases, having the incidence and mortality by COVID-19 until August 23, 2020, in Brazilian states, as response variables. The magnitude of the associations was estimated using Spearman’s correlation coefficient and multiple regression analysis. Results: In the Brazilian states, 59.8% of variation in the incidence of COVID-19 was justified by income inequality, significant home densification, and higher mortality. In the case of mortality, those same variables explained 57.9% of the country’s variations in federal units. Conclusion: Our results indicate that socioeconomic factors influenced the evolution and impact of COVID-19 in Brazil. Thus, we suggest comprehensive actions to ensure economic conditions and strengthening of health networks for populations with socioeconomic vulnerability. Objetivo: Analisar a influência de fatores socioeconômicos, demográficos, epidemiológicos e da estrutura do sistema de saúde na evolução da pandemia da COVID-19 no Brasil. Métodos: Estudo ecológico com variáveis extraídas de bancos de dados, tendo a incidência e mortalidade por COVID 19 até 23 de agosto de 2020, nos estados brasileiros, como variáveis-resposta. A magnitude das associações foi estimada usando o coeficiente de correlação de Spearman e análise de regressão múltipla. Resultados: Nos estados brasileiros, 59,8% da variação da incidência de COVID-19 foi justificada pela desigualdade de renda, maior adensamento domiciliar e maior letalidade. No caso da mortalidade, essas mesmas variáveis explicaram 57,9% das variações encontradas nas Unidades Federativas do país. Conclusão: Nossos resultados indicam que fatores socioeconômicos influenciaram a evolução e impacto da COVID-19 no Brasil. Dessa forma, sugerimos ações abrangentes a fim de garantir condições econômicas e o fortalecimento das redes de saúde para populações com vulnerabilidade socioeconômica. Objetivo: Analizar la influencia de factores socioeconómicos, demográficos, epidemiológicos y estructura del sistema de salud en la evolución del COVID-19 en Brasil. Métodos: Estudio ecológico con variables extraídas de bancos de datos, teniendo la incidencia y mortalidad por COVID-19 hasta 23 de agosto de 2020, en estados brasileños, como variables respuesta. Las relaciones han estimadas usando el coeficiente de correlación de Spearman y análisis de regresión múltiple. Resultados: En los estados brasileños, 59,8% de la variación de la incidencia de COVID-19 ha justificada por la desigualdad de renta, mayor densificación domiciliar y mayor letalidad. En la mortalidad, esas mismas variables explicaron 57,9% de las variaciones encontradas en las Unidades Federativas del país. Conclusión: Nuestros resultados indican que factores socioeconómicos influenciaron la evolución e impacto de COVID-19 en Brasil. Así, sugerimos acciones abarcadoras para garantizar condiciones económicas y el fortalecimiento de las redes de salud para poblaciones con vulnerabilidad socioeconómica.

Acute infection with Plasmodium vivax, classically associated with benign disease, has been presenting as serious and even fatal disease in recent years. Severe disease is mainly due to biochemical and hematological alterations during the acute phase of infection. In the present cross-sectional study, the aspartate aminotransferase-to-platelet ratio index (APRI) was evaluated as a method for identifying patients at risk of severe vivax malaria. This retrospective study included 130 patients with confirmed P. vivax infection between June 2006 and January 2018. Clinical-epidemiological data were obtained from medical records. Hematological and biochemical parameters were determined using automated equipment. The criteria of severity for infection by Plasmodium falciparum, established by the World Health Organization (WHO), were adapted to classify patients with danger signs of severe vivax malaria. Of the 130 patient's records evaluated, 19 (14.6%) had one or more signs and symptoms of severe malaria. The mean APRI values among patients with and without severe malaria were 2.11 and 1.09, respectively (p = 0.044). Among those with severe disease, the proportion with an APRI value above 1.50 was 30% compared to the 10% among those without severe disease (p = 0.007). The area under the receiver operating characteristic curve (95% CI), calculated to assess the accuracy of the APRI in discriminating between patients with and without severe disease, was 0.645 (0.494; 0.795). An APRI cutoff of 0.74 resulted in sensitivity of 74.0%, specificity of 56.0%, and accuracy of 65.0%. This study shows that the APRI is elevated in patients with evidence of infection by P. vivax. Based on the good sensitivity found in this study, we conclude that this simple index can serve as a diagnostic biomarker to identify patients at risk of severe disease during the acute phase of P. vivax infection.

Although serum lipids are known to be altered in Plasmodium falciparum-induced malaria, little is known about such changes due to Plasmodium vivax infection. This cohort study assessed serum concentrations of triglycerides, total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) in 164 patients in the acute phase of malaria caused by P. vivax and characterized these changes in the convalescent phase after treatment with chloroquine and primaquine. Compared to reference values, serum total cholesterol, LDL, and HDL levels were lower and triglyceride levels were higher in the acute phase. Moreover, the parasite density was negatively correlated with LDL (r=-0,189; p=0.027) and HDL (r=-0,256; p=0.001) serum levels. Eighty patients returned for clinical and laboratory revaluation 7-12days after treatment initiation. All patients showed parasite clearance and the absence of symptoms during the convalescent phase. Analysis of the serum lipids of these 80 patients showed significant increases in the serum levels of total cholesterol (p0.0001), LDL (p0.0001), and HDL (p0.0001) as well as a significant reduction in triglycerides (p=0.004), indicating a trend towards a return to normal levels. This transient change in lipid profile between the acute and convalescent stages may be useful for the clinical monitoring of patients treated for vivax malaria.

INTRODUCTION Uric acid is one of the compounds associated with the inflammatory process in malaria. It acts as an indicator of cellular damage by activating the immune response and inflammatory process. METHODS: We measured serum concentrations of uric acid in 60 symptomatic patients before and after treatment for malarial infections caused by Plasmodium vivax. RESULTS: Lower serum concentrations of uric acid were found during the acute phase of P. vivax malaria compared to those in its convalescent phase (p < 0.0001). CONCLUSIONS: Patients in the acute phase of malaria had lower uric acid levels than those in its convalescent phase.

The application of sewage sludge (SS) in the soil can be a valuable way to increase its content of organic matter. However, the concentration of potentially toxic metal (PTM) in both SS and soil can hinder this route of management. Thus, the main objective of this work was to evaluate the compliance with the restrictions related to PTM contained in SS from wastewater treatment plants (WWTP) for agricultural land application. The regulatory constraints associated with SS and soil in respect to PTM (Cd, Cr, Cu, Ni, Pb, and Zn) were analyzed. These metals showed a deleterious effect on germination of Lepidium sativum seeds, and their phytotoxicity may be ranked as Cd > Cu > Cr(VI) > Cr(III) ~ Zn ~ Ni > Pb. Portuguese SS samples from different WWTP, from a national sludge management operator, and from the literature were considered. The results revealed that the content of these metals, in general, complies with the regulatory threshold values. The content of PTM in the soil is not restrictive to receive SS in at least 90% of the national territory. The assessment of ecological risk based on the geoaccumulation index (Igeo), pollution index (PI), and potential ecological risk index (PERI) showed low risk for all metals. The exception was Igeo of Cd, Cu, and Zn, which presented moderate to high level of pollution. According to the state of the art, no significant negative impacts have been detected on human health and the environment due to SS applications in the soil. Thus, in a country with low carbon content in the land and whenever compliance with regulations is achieved, the main route for SS management may be agricultural soil.

This study aims to investigate the sewage sludge (SS) drying process by incorporating a by-product formed in the pulp and paper industry (green liquor dregs - GLD) as drying adjuvant. Through an innovative approach, the drying kinetics was modelled, and the final dried product was tested for soil applications. After the characterization phase, small cylinders of SS without and with 0.15 g GLD g SS−1wb (SS_GLD) were dried in isothermal conditions at 70, 100, and 130 °C. The experimental data were fitted by Fick's second law and thin-layer models, and good results were achieved in both cases (R2 > 0.98 and RMSE

To evaluate the prevalence, location, length, diameter, and distances related to the incisive canal (IC) and the need for cone beam computed tomography (CBCT) as a complementary exam prior to surgery in the mental region. One hundred CBCT images from patients of both genders aged 27 to 73 years were evaluated. At every 3 mm, the diameter (DIAM) of the right and left ICs and their location, their distance to base of the jaw (BIC), the buccal (BAIC) and lingual (LAIC) aspects, and their length were measured. The 100 patients comprised 50 men (50%) and 50 women (50%). The IC was detected in 78 patients, more frequently in women (80%) than in men (76%). Measurements were taken in millimeters. The mean measurements for the two sides and for men and women combined were as follows: BIC = 10.0, BAIC = 4.0, LAIC = 6.2, ICL = 19.9, and DIAM = 1.4. The measurements show the need for care from professionals when performing intraosseous surgical procedures in the mental region. The distances between the IC and the references studied must be observed. Thus, CBCT becomes essential for surgical planning in the mental region. The mental region of the mandible is considered a safe area to perform surgical procedures such as the placement of osseointegrated implants, orthognathic surgery, and the removal of bone grafts. However, this region includes important neurovascular structures that must be considered or else hemorrhage and neurologic disorders can be experienced.

The Program for Access and Quality Improvement in Primary Care (PMAQ-AB) aimed to improve healthcare public service quality. The purpose of this study was to identify the main factors that influence user satisfaction in Brazilian primary health care services. This research was carried out using secondary data from the first cycle of the PMAQ-AB. A cluster analysis was carried out to find the dependent variable of user satisfaction; and logistic regression was applied in order to obtain the decision model. From the resulting regression model, two factors can be highlighted as regards influencing user satisfaction in Brazil: the user's perception that the team did not attempt to address their needs/problems within the health unit; and the user not feeling respected by the professionals in relation to cultural habits, customs, and religion or only sometimes feeling so. This study revealed the importance of continued commitment of teams and managers to improving care access, meeting user needs, and improving organizational aspects and the health professional-user relationship. Resumo: O Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) tem como objetivo melhorar a qualidade dos serviços públicos de saúde. O objetivo do estudo foi identificar os principais fatores que influenciam a satisfação dos usuários com os serviços de atenção básica no Brasil. O estudo utilizou dados secundários do primeiro ciclo do PMAQ-AB. A análise de clusters foi utilizada para identificar a variável-desfecho satisfação de usuários, e a regressão logística foi aplicada para obter o modelo decisório. A partir do modelo de regressão, destacam-se dois fatores relacionados à influência sobre a satisfação de usuários no Brasil: a percepção do usuário de que a equipe de saúde não procurou atender suas necessidades e problemas internos da unidade de saúde; a sensação do usuário de não se sentir respeitado pelos profissionais, ou de sentir respeitado apenas eventualmente, em relação a seus hábitos culturais, costumes e religião. O estudo revelou a importância do compromisso de equipes e gestores na melhoria do acesso, satisfação das necessidades dos usuários e melhoria dos aspectos organizacionais e da relação entre profissionais e usuários. Resumen: El Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ-AB) tiene como objetivo mejorar la calidad de los servicios públicos de salud. El objetivo del estudio fue identificar los principales factores que influencian la satisfacción de los usuarios con los servicios de atención básica en Brasil. El estudio utilizó datos secundarios del primer ciclo del PMAQ-AB. El análisis de clústeres se utilizó para identificar la variable-desenlace satisfacción de usuarios, y la regresión logística se aplicó para obtener el modelo decisorio. A partir del modelo de regresión, se destacan dos factores relacionados con la influencia sobre la satisfacción de usuarios en Brasil: la percepción del usuario de que el equipo de salud no procuró atender sus necesidades y problemas internos de la unidad de salud; la sensación del usuario de no sentirse respetado por los profesionales, o de sentirse respetado sólo eventualmente, en relación a sus hábitos culturales, costumbres y religión. El estudio reveló la importancia del compromiso de equipos y gestores en la mejora del acceso, satisfacción de las necesidades de los usuarios y mejora de los aspectos organizativos y de relación entre profesionales y usuarios.

Transfusion-transmitted malaria is a severe disease with high fatality rate. Most Brazilian blood banks in the Amazon region perform malaria screening using microscopic examination (thick smears). Since low parasite concentrations are expected in asymptomatic blood donors a high sensitivity test should be used for donor screening. This study determined the sensitivity of a nested-PCR for plasmodium detection in pooled samples. We performed a one-stage criterion validation study with 21 positive samples pooled with samples from ten negative volunteer until three different concentrations were reached (0.33; 0.25; 0.20 parasites/μL - p/μL). Nested PCR was performed as described by Snounou et al. (1993). Sensitivities (and confidence intervals) were determined by stratum of final parasite concentration on the pooled samples. All samples with parasitemia values of 0.33 and 0.25 p/μL had 100% sensitivity (95%CI=86.3-100). One negative result was obtained from a sample with 0.20 p/μL sensitivity=95.2% (95%CI=76.2-99.9). Compared to parasitemia detectable under ideal conditions of thick smear, this nested-PCR in pooled sample was able to detect 40 times more parasites per microliter. Nested-PCR in pooled samples should be considered as a high sensitive alternative to thick smear for donor screening in blood banks at endemic regions. Local authorities need to assess cost:benefit advantages of this method compared to alternatives.

Introduction: In remote areas of the Amazon Region, diagnosis of malaria by microscopy is practically impossible. This study aimed to evaluate the performance of two rapid diagnostic tests (RDTs) targeting different malaria antigens stored at room temperature in the Brazilian Amazon Region. Methodology: Performance of the OptiMal Pf/Pan test and ICT-Now Pf/Pan test was analyzed retrospectively in 1,627 and 1,602 blood samples, respectively. Tests were performed over a 15-month period. Kits were stored at room temperature in five community health centres located in the Brazilian Amazon Region. RDT results were compared with thick blood smear (TBS) results to determine sensitivity, specificity, and accuracy of the RDT. Results: The sensitivities of the OptiMal Pf/Pan test were 79.7% for Plasmodium falciparum malaria diagnosis and 85.7% for non-P. falciparum infections. The results showed a crude agreement of 88.5% for P. falciparum, and 88.3% for non-P. falciparum infections (Kappa index = 0.74 and 0.75, respectively). For the ICT-Now Pf/Pan test (CI 95%), the sensitivities were 87.9% for P. falciparum malaria diagnosis and 72.5% for non-P. falciparum infection. Crude agreement between the ICT-Now Pf/Pan test and TBS was 91.4% for P. falciparum and 79.7% for non-P. falciparum infection. The Kappa index was 0.81 and 0.59 for the final diagnosis of P. falciparum and non-P. falciparum, respectively. Higher levels of parasitaemia were associated with higher crude agreement between RDT and TBS. Conclusions: The sensitivities of RDTs stored at room temperature over a 15-month period and performed in field conditions were lower than those previously reported.

The National Program for Access and Quality Improvement in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ-AB) aimed to improve healthcare public service quality and satisfaction of health service users. This study's objective was to identify the main factors influencing user satisfaction with primary care (PC) services by region in Brazil. Using secondary data from the 1st Cycle of PMAQ-AB, logistic regression models were developed by region, with user satisfaction as the dependent variable, as defined by cluster analysis. Based on the obtained models, the health unit's ability to solve users' problems and feeling respected by the health providers were the most important factors for user satisfaction in all regions in Brazil. However, other important factors by region included the following: the health unit's hours of operation meeting the user's needs (Northeast); providers asking about family members (North); providers asking about other health needs (Midwest); users being seen without an appointment (South); and users asking questions after the appointment (Southeast). In conclusion, the factors influencing user satisfaction with PC vary according to region and are mainly associated with access quality, meeting users' needs, and work process organization.

Dengue fever (DF) is an acute infection caused by a flavivirus. Although most patients present mild symptoms, some progress to a severe condition characterized by hypovolemic shock and hemorrhagic phenomena. The main feature of this severe form of DF is plasma leakage. Gallbladder wall thickening (GBWT), ascites and pleural effusion represent the sonographic triad of plasma leakage in DF. To evaluate the plasma leakage triad in severe DF with emphasis on the GBWT. Thirty-seven children with severe DF underwent abdominal US on the day of admittance and on the day of discharge, or 7 days after the first examination if the child was still hospitalized. Of the 37 children, 33 (89.2%) presented GBWT, 29 (78.4%) ascites and 26 (70.3%) pleural effusion. All of these findings had resolved by the second examination. Of the 33 GBWTs, 29 (87.9%) presented a reticular pattern, which could be considered typical of plasma leakage in patients with severe DF. GBWT, ascites and pleural effusion are transient findings in DF. The authors have described a typical reticular pattern of GBWT that can be used to diagnose and follow up on patients with severe DF and should not be considered an acalculous cholecystitis.

This article aims to analyze levels of exhaled carbon monoxide, carboxyhemoglobinand cardiopulmonary variables in old people practicing exercise in external environments, and correlate them with climate and pollution factors. Temporal ecological study with118 active elderly people in the city of Cuiabá, in the state of Mato Grosso, Brazil. Data were obtained on use of medication, smoking, anthropometric measurements, spirometry, peak flow, oxygen saturation, heart rate, exhaled carbon monoxide, carboxyhemoglobin, climate, number of farm fires and pollution. Correlations were found between on the one hand environmental temperature, relative humidity of the air and number of farmers' fires, and on the other hand levels of carbon monoxide exhaled and carboxyhemoglobin (p0.05).There was a correlation between heart rate and changes in environmental temperature, time of exposure to the sun and relative humidity (p0.05). In elderly people, environmental factors influence levels of exhaled carbon monoxide, carboxyhemoglobin and heart rate. There is thus a need for these to be monitored during exercise. The use of a carbon monoxide monitor to evaluate exposure to pollutants is suggested.

The polymerase chain reaction (PCR)-based methods for the diagnosis of malaria infection are expected to accurately identify submicroscopic parasite carriers. Although a significant number of PCR protocols have been described, few studies have addressed the performance of PCR amplification in cases of field samples with submicroscopic malaria infection. Here, the reproducibility of two well-established PCR protocols (nested-PCR and real-time PCR for the Plasmodium 18 small subunit rRNA gene) were evaluated in a panel of 34 blood field samples from individuals that are potential reservoirs of malaria infection, but were negative for malaria by optical microscopy. Regardless of the PCR protocol, a large variation between the PCR replicates was observed, leading to alternating positive and negative results in 38% (13 out of 34) of the samples. These findings were quite different from those obtained from the microscopy-positive patients or the unexposed individuals; the diagnosis of these individuals could be confirmed based on the high reproducibility and specificity of the PCR-based protocols. The limitation of PCR amplification was restricted to the field samples with very low levels of parasitaemia because titrations of the DNA templates were able to detect < 3 parasites/µL in the blood. In conclusion, conventional PCR protocols require careful interpretation in cases of submicroscopic malaria infection, as inconsistent and false-negative results can occur.

Introduction: We evaluated the in vitro antimalarial activity of tigecycline as an alternative drug for the treatment of severe malaria. Methods: A chloroquine-sensitive Plasmodium falciparum reference strain, a chloroquine-resistant reference strain, and three clinical isolates were tested for in vitro susceptibility to tigecycline. A histidine-rich protein in vitro assay was used to evaluate antimalarial activity. Results: The geometric-mean 50% effective concentration (EC50%) of tigecycline was 535.5 nM (confidence interval (CI): 344.3-726.8). No significant correlation was found between the EC50% of tigecycline and that of any other tested antimalarial drug. Conclusions: Tigecycline may represent an alternative drug for the treatment of patients with severe malaria.

Introduction Angiogenic factors such as angiopoietin 1 (Ang-1) and angiopoietin 2 (Ang-2) are biomarkers produced during activation and dysfunction of the vascular endothelium in several infectious diseases. The aim of this study was to determine the serum levels of Ang-1 and Ang-2 and to establish their relationship with the main indicators of worst-case prognosis in patients with P. vivax malaria. Methods This is a retrospective case-control study nested within a cohort of symptomatic malaria patients. A potentially severe case was defined as a patient that presented at least one of the main indicators of the worst-case prognosis for falciparum malaria, as established by the World Health Organization. Ang-2 and Ang-1 and the Ang-2/Ang-1 ratio were used to analyze the role of angiopoietins as biomarkers in signaling potentially severe vivax malaria. ROC curves were generated to identify a cut-off point discriminating between the angiopoietin concentrations that were most strongly associated with potential infection severity. Results The serum levels of Ang-2 and the Ang-2/Ang-1 ratio were higher in the case group. In contrast, the serum levels of Ang-1 were lower in the cases than in the control patients. The blood count for platelets showed a positive correlation with Ang-1 and a negative correlation with Ang-2 and with the Ang-2/Ang-1 ratio. The area under the ROC curve (AUC) for serum angiopoietins, as an indicator of worst-case prognosis in a potentially severe P. vivax malarial infection, was larger in the subgroup of patients with platelet counts

Quantification of parasite density is an important component in the diagnosis of malaria infection. The accuracy of this estimation varies according to the method used. The aim of this study was to assess the agreement between the parasite density values obtained with the assumed value of 8,000 cells/μL and the automated WBC count. Moreover, the same comparative analysis was carried out for other assumed values of WBCs. The study was carried out in Brazil with 403 malaria patients who were infected in different endemic areas of the Brazilian Amazon. The use of a fixed WBC count of 8,000 cells/μL to quantify parasite density in malaria patients led to overestimated parasitemia and resulted in low reliability when compared to the automated WBC count. Assumed values ranging between 5,000 and 6,000 cells/μL, and 5,500 cells/μL in particular, showed higher reliability and more similar values of parasite density when compared between the 2 methods. The findings show that assumed WBC count of 5,500 cells/μL could lead to a more accurate estimation of parasite density for malaria patients in this endemic region.

This open retrospective cohort study aimed to describe the incidence of recurrent Plasmodium vivax malaria and associated factors in Porto Velho, Rondônia State, Brazil, in 2009. Data were collected from the National Information System for Malaria Epidemiological Surveillance. There were 23,365 reported P. vivax malaria cases in 2009, 23% of which were classified as relapses. Incidence density of P. vivax recurrence was 45.1/100 patient-years, mostly occurring between the 4th and 13th week after initiating treatment. Male gender, shorter time since onset of symptoms, and higher parasitemia in the initial infection increased the risk of relapse during the year, with a 10% reduction in relative risk for longer symptoms and 11% and 15% increases in relative risk for males and higher initial parasitemia, respectively. However, the results show low clinical relevance for these associations, thereby limiting their applicability to decision-making at the public health level.

This article reviews the Brazilian literature on popular health education, a theoretical area that includes a relevant group of the country's public health researchers and political activists. This was a qualitative, exploratory, analytical study. Based on a search in the SciELO database and books and book chapters, we systematized the academic output on popular health education in Brazil. The article discusses the historical process in which popular health education was constructed by various social movements. We further analyze the general characteristics of popular health education and its main agendas, the ways by which authors with this perspective view the educational work of health services for the population, and their critiques and disputes with the hegemonic approach to the organization of education and health care. Finally, we identify several additional contributions to popular health education's foundations and principles.

Neuromuscular blockers (NMB) are used to induce relaxation of skeletal muscles and facilitate tracheal intubation (TI). According to the literature, two effective doses (ED95) of NMB are ideal for TI. Rocuronium is a steroid-type, synthetic, non-depolarizing neuromuscular blocker of medium duration. The objective of this study was to evaluate and compare the conditions of tracheal intubation with one and two effective doses (ED95) of rocuronium, following the criteria of the Copenhagen Consensus Conference.Sixty patients of both genders, ages 20 to 60 years, physical status ASA I and II, Mallampati 1 and 2, body mass index (BMI)35, who underwent general anesthesia, randomly divided in two groups of 30 patients, were evaluated. Group 1 (G1) received 0.3 mg kg(-1) of rocuronium (1 ED95, and Group 2 (G2) received 0.6 mg kg(-1) (2 DE95). Parameters used to evaluate TI were based on the criteria of the Copenhagen Consensus Conference (Good Clinical Research Practice): laryngoscopy, vocal cords (position and movements), reaction to the insertion of the tube and/or filling of the cuff (movements of limbs and cough).All intubations were considered excellent or good (acceptable); therefore, there were no cases of failure or any intubation considered bad (unacceptable). The results of the statistical analysis were not significant. Consequently, we did not observe any clinically significant differences in the parameters evaluatedBoth doses of rocuronium, 0.3 mg kg(-1) and 0.6 mg kg(-1) ED95, provided clinically satisfactory parameters of TI in elective procedures.

Background The identification of epitopes in proteins recognized by medically relevant antibodies is useful for the development of peptide-based diagnostics and vaccines. In this study, epitopes in the cytoplasmic repetitive antigen (CRA) and flagellar repetitive antigen (FRA) proteins from Trypanosoma cruzi were identified using synthetic peptide techniques and pooled sera from Chagasic patients. The epitopes were further assayed with an ELISA assay based on synthetic peptides. Methods Twenty-two overlapping synthetic peptides representing the coding sequence of the T. cruzi CRA and FRA proteins were assessed by a Spot-synthesis array analysis using sera donated by patients with Chagas disease. Shorter peptides were selected that represented the determined epitopes and synthesized by solid phase synthesis to evaluate the patterns of cross-reactivities and discrimination through an ELISA-diagnostic assay. Results The peptide Spot-synthesis array successfully identified two IgG antigenic determinants in the CRA protein and four in FRA. Bioinformatics suggested that the CRA antigens were unique to T. cruzi while the FRA antigen showed similarity with sequences present within various proteins from Leishmania sp. Subsequently, shorter peptides representing the CRA-1, CRA-2 and FRA-1 epitopes were synthesized by solid phase synthesis and assayed by an ELISA-diagnostic assay. The CRA antigens gave a high discrimination between Chagasic, Leishmaniasis and T. cruzi-uninfected serum. A sensitivity and specificity of 100% was calculated for CRA. While the FRA antigen showed a slightly lower sensitivity (91.6%), its specificity was only 60%. Conclusions The epitopes recognized by human anti-T. cruzi antibodies have been precisely located in two biomarkers of T. cruzi, CRA and FRA. The results from screening a panel of patient sera through an ELISA assay based on peptides representing these epitopes strongly suggest that the sequences from CRA would be useful for the development of diagnostic reagents that could improve upon the sensitivity and specificity of currently available diagnostic tests. Overall, the results provide further evidence of the usefulness of identifying specific linear B-cell epitopes for improving diagnostic tools.