Access to emergency care services: a transversal ecological study about Brazilian emergency health care network.

OBJECTIVES: Studies of health geography are important in the planning and allocation of emergency health services. The geographical distribution of health facilities is an important factor in timely and quality access to emergency services; therefore, the present study analyzed the emergency health care network in Brazil, focusing the analysis at the roles of small hospitals (SHs). STUDY DESIGN: Cross-sectional ecological study. METHODS: Data were collected from 9429 hospitals of which 3524 were SHs and 5905 were high-complexity centers (HCCs). For analytical purposes, we considered four specialties when examining the proxies of emergency care capability: adult, pediatrics, neonatal, and obstetric. We analyzed the spatial distribution of hospitals, identifying municipalities that rely exclusively on SHs and the distance of these cities from HCCs. RESULTS: More than 14 and 30 million people were at least 120 km away from HCCs with an adult intensive care unit (ICU) and pediatric ICU, respectively. For neonatal care distribution, 12% of the population was more than 120 km away from a health facility with a neonatal ICU. The maternities situation is different from other specialties, where 81% of the total Brazilian population was within 1 h or less from such health facilities. CONCLUSION: Our results highlighted a polarization in distribution of Brazilian health care facilities. There is a concentration of hospitals in urban areas more developed and access gaps in rural areas and the Amazon region. Our results demonstrate that the distribution of emergency services in Brazil is not facilitating access to the population due to geographical barriers associated with great distances.

The functional changes of the pituitary gonadotrophs during the menstrual cycle.

Submaximal doses of LRF, administered over a period of several hours, either by repeated pulses (10 mug at 2 h intervals X 5) or by constant infusion (0.2 mug/min X 4 h), have permitted the assessment of changes in the releasable gonadotropin during the menstrual cycle. Quantitations in the acute releasable and ultimately releasable gonadotropins were made which represent, respectively, the sensitivity and reserve of the gonadotrophs. The functional expression of these two components of gonadotropin release exhibited profound changes during the menstrual cycle and were in synchrony with the cyclicity of ovarian steroid levels; during the early follicular phase, both sensitivity and reserve were at a minimum, but with increasing levels of E2, a preferential increase in reserve over sensitivity (P less than 0.005) was found. Although both sensitivity and reserve increased dramatically near the midcycle, the relative change in these two components was reversed from the late follicular phase to the midcycle surge. The presence of this phenomenon may be causally related to the development of a self-priming effect of LRF at this time, as evidenced by an augmentation of gonadotropin release to the 2nd pulse of LRF. Thus, a build-up in pituitary store consequent to the greater increase in reserve than in sensitivity, together with the appearance of the self-priming effect of LRF induced by progressively rising levels of E2, may constitute the essential dynamics required for the development of the midcycle gonadotropin surge. Pituitary sensitivity and reserve continued to be high during the early luteal phase but reduced progressively thereafter. In all studied, FSH responses were less obvious but showed remarkable parallelism to the pattern of LH responses. We have concluded that the functional capacity of the gonadotrophs exhibits a remarkable cyclic change and that the adenohypophysis represents a critical feedback site in the development of pre-ovulatory gonadotropin surge.

Skin test reactions to Mycobacterium tuberculosis purified protein derivative and Mycobacterium avium sensitin among health care workers and medical students in the United States.

SETTING: Health care workers and medical students in the United States subject to annual tuberculin skin testing. OBJECTIVE: To use skin testing with Mycobacterium avium sensitin (MAS) to determine contemporary rates of infection with non-tuberculous mycobacteria (NTM) and their effect on reactions to M. tuberculosis purified protein derivative (PPD). DESIGN: Dual skin testing was performed with PPD and MAS on 784 health care workers and medical students in the northern and southern US. MAS reactions that were > or = 5 mm and also > or = 3 mm larger than the PPD reaction were defined as MAS dominant and due to NTM. RESULTS: MAS reactions were > or = 5 mm in 40% and > or = 15 mm in 18% of subjects; 95% were MAS dominant. MAS dominant reactions were more common in the south than the north (P < 0.001). PPD reactions were > or = 15 mm in 3% of subjects. PPD reactions > or = 15 mm were more common among males, foreign born subjects and subjects with BCG immunization (all P < 0.001). MAS dominant reactions were found in 82% of subjects with 5-9 mm PPD reactions and 50% with 10-14 mm PPD reactions; these reactions were more common among whites (P = 0.046), US-born (P = 0.038) and subjects without BCG immunization (P = 0.004). CONCLUSIONS: Infections with NTM are responsible for the majority of 5-14 mm PPD reactions among US-born health care workers and medical students subject to annual tuberculin testing.

Sources of disseminated Mycobacterium avium infection in AIDS.

OBJECTIVES: To identify the sources of disseminated Mycobacterium avium complex (MAC) infection in AIDS. METHODS: HIV positive subjects with CD4 counts <100/mm(3) in Atlanta, Boston, New Hampshire and Finland were entered in a prospective cohort study. Subjects were interviewed about potential MAC exposures, had phlebotomy performed for determination of antibody to mycobacterial lipoarabinomannin and for culture. Patient-directed water samples were collected from places of residence, work and recreation. Patients were followed for the development of disseminated MAC. Univariate and multivariate risk factors for MAC were analyzed. RESULTS: Disseminated MAC was identified in 31 (9%) subjects. Significant risks in univariate analysis included prior Pneumocystis carinii pneumonia (PCP) (hazard ratio 1.821), consumption of spring water (4.909), consumption of raw seafood (34.3), gastrointestinal endoscopy (2.894), and showering outside the home (0.388). PCP, showering and endoscopy remained significant in a Cox proportional hazards model. There was no association between M. avium colonization of home water and risk of MAC. In patients with CD4<25, median OD antibody levels to lipoarabinomannin at baseline were 0.054 among patients who did not develop MAC and 0.021 among patients who did develop MAC (P=0.077). CONCLUSIONS: MAC infection results from diverse and likely undetectable environmental and nosocomial exposures. Mycobacterial infection before HIV infection may confer protection against disseminated MAC in advanced AIDS.

In vitro cellular and cytokine responses to mycobacterial antigens: application to diagnosis of tuberculosis infection and assessment of response to mycobacterial vaccines.

Mycobacterial infection leads to the development of specific cell-mediated immune responses that have been measured clinically by assessing delayed-type hypersensitivity with Mantoux skin testing. Several characteristics of Mantoux skin testing for tuberculosis infection can make the procedure inaccurate, inconvenient, and sometimes misleading. It is also a poor predictor of immunity to tuberculosis in bacille Calmette-Gúerin vaccinees, yet decisions to revaccinate often are based on skin test responses after initial immunization. Skin testing with other mycobacterial antigens has similar limitations. In vitro assessment of cellular immunity to mycobacteria offers multiple, potential advantages over skin testing and has become technically feasible in recent years. Measurement of the effector functions that comprise cell-mediated immunity (eg, cytokine secretion and cytotoxicity) rather than cutaneous delayed-type hypersensitivity responses is more likely to reflect meaningfully specific mycobacterial immunity and, therefore, provide a means for determining mycobacterial immunity after immunization. Eliminating the variability in placement and interpretation inherent in skin testing could provide a more stable foundation for comparative studies in populations and improve decision making for individuals. Finally, in vitro testing permits the use of discrete mycobacterial antigens instead of crude protein preparations, allowing greater specificity in the detection of infection as well as assessment of responses to defined candidate vaccine antigens. Several studies have compared skin testing with in vitro proliferation of lymphocytes stimulated by mycobacterial antigens for the detection of Mycobacterium tuberculosis infection. Preliminary veterinary and human studies suggest that in vitro assessment of gamma-interferon production in response to mycobacterial antigens can be used to detect prior infection with organisms of the M tuberculosis complex. Streamlined techniques for in vitro testing of cellular immunity may allow its practical adoption in the clinical setting and lead to its use as a replacement for Mantoux skin testing.

Effects of long-term treatment with bovine somatotropin on follicular dynamics and subsequent oocyte and blastocyst yield in an OPU-IVF program.

Fourteen Holstein-Friesian heifers between 15 and 22 months of age with normal reproductive tracts were used in an experimental set up to investigate the effect of a long term rBST-treatment on the follicular population prior to transvaginal ovum pick-up (OPU). The estrous cycle of the animals was synchronized by means of a double injection of 2 ml cloprostenol 11 days apart. The heifers were divided in 2 equal groups (n = 7) in which the animals had the same average body weight, one group receiving a weekly subcutaneous injection of 640 mg recombinantly derived bovine somatotropin (rBST) on Mondays (rBST-treatment group) and a control group, being injected with 10 ml of saline. Heifers in both groups were submitted to OPU twice a week on Mondays and Thursdays using a 5 Mhz transducer and a disposable, 55 mm long, 20-g short bevelled needle at a vacuum pressure corresponding to approximately 13 ml water/min. The experimental period lasted for 10 weeks (April to June), each animal receiving a total of 10 injections and being submitted to OPU for 20 times. Oocytes were subsequently matured and cultured in a separate drop per cow following conventional IVF procedures. A blood sample was taken on heparin immediately after each OPU session, for determination of blood progesterone concentrations to assess the influence of treatment and OPU procedure on the cow's estrous cycle. Although results show a significant increase in the total number of follicles and medium sized follicles in the rBST-treated group, no statistically significant different number of retrieved oocytes between the rBST-treated and nontreated group could be detected. The average number of retrieved oocytes per session per cow was comparable, being 6.4 for the treated and 6.0 for the control group. Additionally, the average number of blastocysts per cow per session did not differ significantly between groups, being 1.41 in the rBST-treated group and 1.53 in the control group. The number of cultured oocytes which developed to the blastocyst stage was 22% in the rBST-treated group, which was not significantly different from 25% in the control group. Repeated OPU appeared to induce a certain degree of acyclicity in both treated and nontreated animals.

[A pig farm with chronic fertility problems]. / Een varkensbedrijf met jarenlange fertiliteitsproblemen.

A herd with 320 sows with chronic fertility problems is described. About 20 to 30% of the inseminated sows returned to oestrus, for unknown reasons. When the interval from insemination to return to oestrus was analysed, it appeared that 20% of the sows returned between 24 and 28 days. A thorough and extensive control of the pig-farmer's oestrus detection technique revealed that nearly all sows were inseminated between 4 to 6 days post-weaning. However, this was too early for a number of sows. These sows showed optimal oestrus symptoms 6-8 days post-weaning. This was also the explanation for the high number of sows returning to oestrus 'irregularly' between 24 and 28 days. Thus when analysing insemination intervals, the interval between 24 and 35 days should not be considered as one period but should be divided into the periods, 24-28 days and 29-35 days. In this way it is possible to distinguish between sows inseminated too early and sows returning to oestrus irregularly.

[Changes in the lymphatic vessels of the upper extremity following a radical mastectomy (based on lymphographic data)]. / Izmeneniia limfaticheskikh sosudov verkhnei konechnosti posle radikal'noi mastéktomii (po dannym limfografii).

The study group included 171 patients suffering from postmastectomy syndrome which had developed either after combined treatment for breast cancer or after radical mastectomy alone. Lymphographic examination of 146 cases carried out long after treatment for primary treatment revealed frequent roentgenologic features characteristic of all patterns of secondary obstructive lymphatic edema. In 20 patients, lymphographically-detectable changes were followed at early stages (until day 40 after radical mastectomy) before edema became clinically apparent. Radiation therapy and erysipelatous inflammation were shown to have an effect on lymphatic lesions.

[Computed tomography in the diagnosis of intervertebral disk hernias]. / Komp'iuternaia tomografiia v diagnostike gryzh mezhpozvonkovykh diskov.

Computed tomography (CT) was conducted in 75 patients with discogenic radiculitis. In 15 patients the study was carried out without intensified contrasting of the spinal cord meningeal spaces (native CT), in 60 with contrasting of the meningeal spaces with air (42 patients) or Omnipaque (18 patients). The CT was analysed at the level of the bony and articular segments of the spinal canal. Deformity of the dural sac of the spinal cord was the most frequent sign of Schmorl's body. It was encountered in 96.2% of verified cases. CT is one of the methods for establishing the diagnosis of Schmorl's body.