Analysis of relationship of psychosocial factors with patient safety culture in a Brazilian hospital: Study with structural equation modeling analysis.

INTRODUCTION AND OBJECTIVES: The scenario of the health system can develop physical and emotional impacts on health professionals, due to work overload and failure to manage the system. It is necessary to consolidate the theory that the safety of care provided by health services is affected by organizational conditions. The aim of this study is to assess whether safety culture is related to job satisfaction, depressive symptoms, and burnout syndrome among hospital professionals. MATERIALS AND METHODS: This is an analysis with structural equation modeling, conducted in a teaching hospital in Brazil. Data collection was made via psychometric instruments, which sought to analyze job satisfaction (Job Satisfaction Survey), depressive symptoms (Patient Health Questionnaire), burnout syndrome (Maslach Burnout Inventory), as well as the relationship between this factors and patient safety culture (Safety Attitudes Questionnaire). The Pearson correlation coefficient (r) and the partial least squares structural equation modeling (PLS-SEM) were used for analysis. RESULTS: A higher work satisfaction was associated with a higher perception of safety culture (r=0.69; P<0.001). Depressive symptoms and burnout dimensions showed an inverse relationship with the safety culture (P<0.05). PLS-SEM enabled us to understand the behavior of this association. Thus, satisfaction at work and the absence of burnout proved to be predictive factors for the implementation of an ideal patient safety culture (P<0.001). CONCLUSIONS: Patient safety culture is related to job satisfaction and burnout among hospital professionals. These findings suggest that the psychosocial work environment influences the quality of care provided.

Beyond weakness: Characterization of pain, sensory profile and conditioned pain modulation in patients with motor neuron disease: A controlled study.

BACKGROUND: Motor neuron diseases (MND) represent a group of disorders that evolve with inexorable muscle weakness and medical management is based on symptom control. However, deeper characterization of non-motor symptoms in these patients have been rarely reported. METHODS: This cross-sectional study aimed to describe non-motor symptoms in MND and their impact on quality of life and functional status, with a focus on pain and sensory changes. Eighty patients (31 females, 55.7 ± 12.9 years old) with MND underwent a neurological examination, pain, mood, catastrophizing and psychophysics assessments [quantitative sensory testing (QST) and conditioned pain modulation (CPM)], and were compared to sex- and age-matched healthy controls (HC). RESULTS: Chronic pain was present in 46% of patients (VAS =5.18 ± 2.0). Pain of musculoskeletal origin occurred in 40.5% and was mainly located in the head/neck (51%) and lower back (35%). Neuropathic pain was not present in this sample. Compared to HC, MND patients had a lower cold detection threshold (p < 0.002), and significantly lower CPM scores (4.9 ± 0.2% vs. 22.1 ± 0.2%, p = 0.012). QST/CPM results did not differ between MND patients with and without pain. Pain intensity was statistically correlated with anxiety, depression and catastrophism, and spasticity scores were inversely correlated with CPM (ρ = -0.30, p = 0.026). CONCLUSIONS: Pain is frequently reported by patients with MNDs. Somatosensory and CPM changes exist in MNDs and may be related to the neurodegenerative nature of the disease. Further studies should investigate the most appropriate treatment strategies for these patients. SIGNIFICANCE: We report a comprehensive evaluation of pain and sensory abnormalities in motor neuron disease (MND) patients. We assessed the different pain syndromes present in MND with validated tools, and described the QST and conditioned pain modulation profiles in a controlled design.

Bleeding risk in atrial fibrillation patients taking vitamin K antagonists: systematic review and meta-analysis.

Vitamin K antagonists (VKAs) prevent stroke in atrial fibrillation (AF) at the cost of bleeding risk. To determine major bleeding rates in AF patients, we conducted a systematic review that identified 51 eligible studies including more than 342,699 patients. The pooled estimate of the rate of major bleeding was 2.51 (99% confidence interval: 2.03-3.11) bleeds per 100 patient-years. The results represent the best estimates of bleeding risk that most patients contemplating VKA use may expect.

[Complementary exams and headaches]. / Pruebas complementarias y cefaleas.

INTRODUCTION: In view of the high prevalence of headache in the general population, the availability of well defined criteria that will guide the physician regarding the request of complementary exams is highly desirable. AIM: To analyze the requests of complementary exams during the investigation of headache. PATIENTS AND METHODS: The data were obtained by reviewing medical records of all patients who had been scheduled to be seen in a tertiary Headache Outpatient Clinic in 2004. RESULTS: The exam most frequently requested was computed tomography of the head and the exams that most contributed to a change in clinical diagnosis or medical conduct were computed tomography of paranasal sinuses, simple radiography of paranasal sinuses, and magnetic resonance image of the brain. The exams that did not contribute to a change in diagnosis or medical conduct were computed tomography and simple radiography of the cervical spine. As expected, the most expensive exams for the institution were computed tomography and magnetic resonance image. CONCLUSION: The importance of complementary exams in the investigation of headache is indisputable in many cases. However, it is necessary the availability of more studies that evaluate the request of complementary exams for headache patients.

Effect of hydroxycobalamin on the inhibition of cytochrome c oxidase by cyanide. I - In intact mitochondria.

The effects of hydroxycobalamin on inhibition of cytochrome c oxidase by cyanida in isolated intact mitochondria were studied. No effect of hydroxycobalamin (HCo) and cyanocobalamin (CNCo) was observed on normal mitochondria. When mitochondria inhibited by cyanida were treated with HCo the respiration with ADP, the respiration after ADP and respiratory coefficient (RC) were increased. No effect was observed with CNCo. Difference spectra of the effect of HCo on the inhibition of cytochrome c oxidase by cyanida and azide in isolated intact mitochondria were recorded using a split beam spectrophotometer. The results presented herein suggest that HCo reverses the cyanide inhibition because part of cytochrome a3 is free from cyanide as a consequence of dissociation of the complex, resulting in CNCo formation. If this reaction continues to occur together with a probable by pass between cytochrome a and oxygen throught the HCo (which was not transformed in CNCo), oxygen consumption and most of the respiratory chain will be maitened in the active state.

Effect of hydroxycobalamin on the inhibition of cytochrome c oxidase by cyanide. II - In isolated cytochrome C oxidase.

The effects of hydroxycobalamin on inhibition of the isolated cytochrome c oxidase (EC 1.9.3.1) by cyanide were studied. No effect of hydroxycobalamin (HCo) and cyanocobalamin (CNCo) was observed on isolated cytochrome c oxidase. When cytochrome c oxidase inhibited by cyanide was treated with HCo the reversal of inhibition could be observed through the spectrum of cytochrome c oxidase without reversal of activity; CNCo had no effect. The treatment of cyano-cytochrome c oxidase with HCo suggests that there is the formation of cobalamin-cytochrome c oxidase complex plus CNCo, and it is possible that complex formation would be between the cobalt of cobalamin and proteic part of cytochrome c oxidase.

Immunolocalization of tubulin isoforms and post-translational modifications in the protists Tritrichomonas foetus and Trichomonas vaginalis.

In the present report we show the distribution of multiple tubulin isoforms in Trichomonas vaginalis and Tritrichomonas foetus, flagellated parasitic protists of the urogenital tracts of human and cattle, respectively, using immunofluorescence and immunoelectron microscopy. We used several monoclonal and polyclonal anti-tubulin antibodies from different sources and recognizing variant tubulin isoforms. Our results demonstrate that: (1) there is a heterogeneous distribution of the different tubulin isoforms in the main microtubular cell structures, such as axostyle, flagella, basal bodies, and mitotic spindle, (2) the axostyle-pelta junction is a structure with high affinity for glutamylated tubulin antibodies in T. foetus, (3) the spindle labeling is positive to anti-glutamylated tubulin and anti-alpha-tubulin (TAT1 and purchased from Amersham) antibodies in T. vaginalis but it is negative in T. foetus, (4) the nuclear matrix and the cytosol presented positive reaction using glutamylated and TAT1 (anti-alpha-tubulin) antibodies only in T. vaginalis, and (5) the Golgi complex exhibited staining using the glutamylated tubulin antibody. The present data corroborate with the idea of the existence of a heterogeneous population of microtubules in these protists and of a subset of intracytoplasmic microtubules. Microtubule diversity may reflect distinct tubulins, diverse microtubule-associated proteins, or a combination of both.

Studies of practolol on mitochondrial metabolism.

The possible effect of practolol (ICI 50,172) on mitochondrial metabolism was studied. The drug inhibited the oxidation of glutamate, alpha-ketoglutarate and succinate by heart mitochondria. The polarographic determinations showed that practolol is an inhibitor of the oxidative phosphorylation. The activity of NADH-oxidase, NADH-ferricyanide reductase, NADH-cytochrome c redutase was inhibit by the drug; no effect was observed on the succinate dehydrogenase. The electron microscopy of isolated mitochondria treated with practolol showed that the drug promote conformational changes of the mitochondrial membrane, probably concerning with the detergent characteristics of the drug.

Methotrexate: studies on cellular metabolism. II--Effects on mitochondrial oxidative metabolism and ion transport.

Effects of methotrexate (MTX) on mitochondrial oxidative metabolism and ion transport were studied. MTX decreases the membrane potential (delta psi) upon energization of the mitochondrial membrane by NAD+-linked substrates and decreases the amplitude and velocity of swelling induced by glutamate and alpha-ketoglutarate. MTX also has an inhibitory effect on the activities of the oxidation enzymes of NAD+-linked substrates without interfering with the oxidation systems of FAD-linked substrates. The effects of MTX could be interpreted as a consequence of a decrease in the ionic conductivity of the mitochondrial inner membrane.

Biochemical aspects of the mechanism of action of antiarrhythmic drugs on mitochondria. VIII. Effect on Ca2+ transport.

The effect of antiarrhythmic drugs (propranolol, lidoflazine, perhexiline maleate and iproveratril) on Ca2+ uptake and Na+-induced Ca2+ release by isolated rat heart mitochondria has been studied using arsenazo III as Ca2+ indicator. It was concluded that those drugs are not selective inhibitors either for Na+-induced Ca2+ release or for Ca2+ uptake. It seems possible that those drugs act by complexation with some components of the membrane, presumably with phospholipids.

Methotrexate: studies on the cellular metabolism. I. Effect on mitochondrial oxygen uptake and oxidative phosphorylation.

Effect of methotrexate (MTX) on mitochondrial oxygen uptake, oxidative phosphorylation and on the activity of several enzymes linked to respiratory chain was studied. MTX was able to inhibit state III respiration activated by ADP and to decrease the respiratory coefficient with the substrates alpha-ketoglutarate and glutamate; these effects became pronounced when mitochondria were pre-incubated with MTX for 10 min. No effect was observed on ATPase activity of undamaged or broken mitochondria; the same was true for NADH-oxidase, NADH-dehydrogenase, NADH-cytochrome c reductase, succinate oxidase, and cytochrome c oxidase activity. The effect on the steady-state of cytochrome b, as well as, the inhibitory effect on state III of respiration with NAD+-linked substrates, offers a reasonable possibility to suggesting that the inhibition site of MTX could be in a place anterior to cytochrome b region, and not linked to respiratory chain.

Biochemical aspects of the mechanism of action of antiarrhythmic drugs on mitochondria. VII. Effect on energy-linked reactions and on membrane potential.

Effects of the antiarrhythmic drugs (propranolol, perhexiline maleate, lidoflazine and iproveratril) on energy-linked reactions and on membrane potential were studied. Propranolol, perhexiline maleate and lidoflazine inhibit the ATPase activity of undamaged and broken mitochondria, and of submitochondrial particles. All drugs are inhibitors of either ATP-driven or of succinate-driven reduction of NADP+. The antiarrhythmics promote a decrease in the membrane potential upon energization of the mitochondrial membrane by alpha-ketoglutarate, succinate, or ATP. It was suggested that these drugs have a primary action on the mitochondrial membrane, thus altering the activities of membrane proteins (channels and enzymes).

Restaging of colorectal cancer based on the identification of lymph node micrometastases through immunoperoxidase staining of CEA and cytokeratins.

The present study was performed to identify tumor cells in lymph nodes from colorectal adenocarcinomas considered free of disease by the classic hematoxylin-eosin stain, based on the detection of the carcinoembryonic antigen (CEA) and cytokeratins in neoplastic epithelial cells. For this purpose, 603 lymph nodes from 46 lesions were stained by the peroxidase-antiperoxidase technique. Tumor cells were detected in 22 nodes from 12 patients, mainly in the subcapsular sinuses, permitting a restaging of these patients into two groups: those now considered to have metastatic disease and those free of metastases. However, the 5-year follow-up showed no statistical differences in survival between the two groups.

Efeitos da fonte de enxofre sobre a população de protozoários e degradabilidade no rúmen / Effects of sulfur source on protozoa population and ruminal degradability

Estudaram-se os efeitos de fontes de enxofre na dieta sobre os parâmetros ruminais de bovinos Nelore, utilizando-se oito novilhos canulados no rúmen e submetidos a quatro tratamentos, segundo a fonte de enxofre. Os animais do grupo-controle não receberam suplementação de enxofre. Os dos outros três grupos receberam flor de enxofre ou metionina ou carboquelatado, como suplementação. Os animais foram arraçoados com dieta total, utilizando cana-de-açúcar picada como volumoso. O período experimental foi de 76 dias, dividido em quatro subperíodos de 19 dias, dos quais 14 eram para adaptação à dieta e cinco para as colheitas. Não foram encontradas diferenças entre as fontes de enxofre na degradabilidade da matéria seca, proteína bruta e fibras em detergente ácido e neutro e no pH ruminal. O tratamento com carboquelatado resultou em maior número de protozoários ciliados e o tratamento metionina em menor contagem. O carboquelatado pode ser uma boa alternativa para a suplementação de enxofre para bovinos em confinamento.

This research was carried out at FZEA/USP to compare the effects of different sulphur sources in diets of Nellore cattle on ruminal parameters. Eight steers were rumen cannulated and submitted to four treatments, using the following sulphur sources: control (no supplement), elemental sulphur, methionine, and carboquelated. Animals were fed a total ration using sugarcane as the roughage. The proportion roughage:concentrate was 40:60. The experimental period lasted 76 days, divided in four 19-days sub-periods. The first 14 days of each sub-period were used to adapt the animals to the diet and the last five days to collect the samples. During the sample period, ruminal liquid was sampled to protozoa count and pH determination. Also, nylon bags were incubated in rumen to determinate the degradability of dietary dry matter, crude protein, and acid and neutral detergent fiber. Treatments did not affect dietary dry matter, crude protein, acid and neutral detergent fiber degradability, and the ruminal pH. However, carboquelated provided the higher total amount of ciliate protozoa and methionine provided the lowest values. Carboquelated can be a good alternative to supplement sulphur to bovines in a feedlot.

Avaliação das prescrições de isoflavonas para mulheres no climatério em cidade de médio porte do Estado de São Paulo / Assesment of the prescription of isoflavones for women in the climacteric period in a medium-sized city in State of São Paulo

No Brasil, a ANVISA aprova o uso de isoflavonas para o tratamento dos fogachos e como adjuvante na redução dos níveis séricos do colesterol. Assim, a proposta do presente estudo é avaliar o modo como as isoflavonas estão sendo prescritas segundo a dose, posologia ecritérios de indicação, comparando os resultados às informações descritas na literatura. Para obtenção das informações foram entrevistados 59 médicos ginecologistas que atendem em consultório particular em uma cidade de médio porte no interior do estado de São Paulo. As informações foram coletadas através de questionário estruturado padronizado e pré-testado, contendo 10 questões específicas sobre a forma de utilização, critério de indicação e avaliação de seguimento terapêutico. Dos 59 entrevistados, apenas 54,2% (n igual 32) prescreviam isoflavonas. Os resultados obtidos junto aos médicos prescritores de isoflavonas mostraram que oreferencial teórico utilizado para a indicação, a dose e a posologia, estão inadequados quando comparado às informações encontradas na literatura em trabalhos de metanálises ou consensos da área. Vale ressaltar que este uso inadequado pode predispor as pacientes à falhas terapêuticas, indicação não regulamentadas e sem respaldo científico. Cabe ao clínico a tarefa de atualizar-se continuamente utilizando fontes que apontem as evidências clínicas que justifiquem a indicação e o esquema posológico adequado.

A influência da margem de lucro na comercialização de medicamentos / The influence of the profit margin on the marketing of medicines

Este trabalho pretende identificar a variação da margem de lucro a partir da comparação entre o preço real decompra e o preço máximo ao consumidor de medicamentos de referência, genéricos e similares, eestabelecer a relação entre este parâmetro e a comercialização de medicamentos, sob o ponto de vista ético e legal. A amostra foi composta por 14 fármacos, 295 especialidades, sendo 14 medicamentos de referência, 112 genéricos e 169 similares. Para a análise dos dados foi calculada a margem de lucro de cada medicamento. Os medicamentos similares foram divididos em dois grupos, A e B, considerando as semelhanças na margem de lucro. Para avaliar a diferença de preço que o consumidor pode pagar ao optar por um dos produtos contendo o mesmo fármaco, na mesma apresentação, calculou-se a porcentagem de variação do preço máximo ao consumidor entre a especialidade mais cara e a mais barata. A margem de lucro observada situa-se entre 44 e 57% (referência); 98-199% (genéricos); 49-57% (similares A) e 147-236% (similares B). Os resultados obtidos e as reflexões apresentadas destacam a importância do governo no controle da qualidade e naregulação do mercado farmacêutico brasileiro, e o que se pode constatar indiretamente é que as regras de comercialização, muitas vezes, se contrapõem aos compromissos social, ético e legal necessários para caracterizar as farmácias e drogarias como estabelecimentos de saúde.

The objective in this article is to identify the profit margin on medicines (original brands, generic drugs and branded similar drugs) from the actual purchase price and the maximum allowed price to consumers, and then to analyze the relationship between this margin and drugs marketing from both the ethical and legal standpoints. The sample was composed of 14 drugs in 295 products, 14 being original ('reference') brand medicines, 112 generics and 169 copy ('similar') brands. To analyze the data, the markup of each medicine was calculated. Similar brands were divided into two groups, A and B, based on the two observed markup bands. The observed profit margin lay in the ranges 44-57% (original brands), 98-199% (generics), 49-57% (similar A) and 147-236% (similar B). To evaluate the difference between the prices the consumer can pay when choosing one of the products containing the same drug in the same presentation, the percent variation in the maximum allowed price to the consumer, between the most expensive and the cheapest product, was calculated. The results and commentary presented in this paper emphasize the importance of a government role in controlling the quality of medicines and regulating the Brazilian pharmaceutical market and it is revealed, indirectly, that trade rules frequently go against the social, ethical and legal commitments needed to characterize pharmacies and drugstores as primary care units in the national health system.

Caracterização do uso de alendronato de sódio no tratamento de osteoporose por clínicos da rede privada de duas cidades do interior de São Paulo / Survey of the use of sodium alendronate in osteoporosis treatment by physicians in the private health system in two towns in São Paulo

O estudo mostrou como os clínicos da rede privada de Amparo e Pedreira, no interior do estado de São Paulo, utilizam o alendronato de sódio como recurso terapêutico na osteoporose. Esta enfermidade é de alta prevalência na população idosa, sendo tratada por médicos de diferentes especialidades. Este estudo, do tipo observacional, transversal e descritivo, foi realizado pormeio de entrevistas com 32 médicos para obtenção de dados sobre indicação, forma de utilização, seguimento de tratamento, medidas não farmacológicas e referencial teórico utilizado pelos entrevistados. Os resultadosmostraram que há concordância com o preconizado em consensos e guias terapêuticos em relação à indicação,doses recomendadas e medidas não farmacológicas, porém, foram verificadas falhas no seguimento dotratamento e na orientação dada ao paciente para a administração correta do medicamento, além de descrição imprecisa de fontes de informação. Concluiu-se que a atualização científica em fontes referenciais (ensaios randomizados controlados, metanálises) é indispensável para ajudar os clínicos na promoção do uso racional do alendronato de sódio no tratamento de osteoporose.

This is a study of how physicians working in the private health system in the towns of Amparo and Pedreira (upstate São Paulo, 75 miles away from the State capital) use sodium alendronate in the treatment of osteoporosis. This disease is highly prevalent in the elderly population and is treated by consultant clinicians/various specialities. The paper describes an observational, cross-sectional study that was carried out by interviewing 32 clinicians to evaluate: indication, usage, follow-up and evaluation of treatment, non pharmacological measures and source of information used by interviewees. The results show that clinical practice is in conformity with what is recommended in clinical guidelines and the general consensus, concerning indication, doses, and nonpharmacological measures. However, some faults were found in the course of treatment and in the advice given to the patients on how to take the drug, as well as imprecise descriptions of the sources of information by the doctors interviewed. It is concluded that constant scientific updating based on sources of reference (Randomized Controlled Trial, Meta- Analysis) is an indispensable aid to these clinicians in promoting the rational use of sodium alendronate inthe treatment of osteoporosis.

Pruebas complementarias y cefaleas / Complementary exams and headaches

Resumen. Introducción. En vista de la elevada prevalencia de cefaleas entre la población general, es muy conveniente disponer de criterios bien definidos que orienten al médico a la hora de solicitar pruebas complementarias. Objetivo. Analizar las peticiones de pruebas complementarias durante el estudio de las cefaleas. Pacientes y métodos. Los datos se obtuvieron al revisar las historias clínicas de todos los pacientes que estaba previsto que fueran visitados en una consulta externa de cefaleas terciaria en 2004. Resultados. La prueba solicitada con más frecuencia fue la tomografía computarizada (TC) craneal, y las exploraciones que más contribuyeron a un cambio del diagnóstico clínico o la conducta médica fueron la TC de los senos paranasales, la radiografía simple de los senos paranasales y la resonancia magnética (RM) del cerebro. Las pruebas que no contribuyeron a un cambio del diagnóstico clínico ni de la conducta médica fueron la TC y la radiografía simple de la columna cervical. Tal como era de esperar, las exploraciones más caras para la institución fueron la TC y la RM. Conclusión. La importancia de las pruebas complementarias en el estudio de las cefaleas es indiscutible en muchos casos. Sin embargo, es necesario disponer de más estudios que evalúen la petición de pruebas complementarias para los pacientes con cefalea (AU)

Summary. Introduction. In view of the high prevalence of headache in the general population, the availability of well defined criteria that will guide the physician regarding the request of complementary exams is highly desirable. Aim. To analyze the requests of complementary exams during the investigation of headache. Patients and methods. The data were obtained by reviewing medical records of all patients who had been scheduled to be seen in a tertiary Headache Outpatient Clinic in 2004. Results. The exam most frequently requested was computed tomography of the head and the exams that most contributed to a change in clinical diagnosis or medical conduct were computed tomography of paranasal sinuses, simple radiography of paranasal sinuses, and magnetic resonance image of the brain. The exams that did not contribute to a change in diagnosis or medical conduct were computed tomography and simple radiography of the cervical spine. As expected, the most expensive exams for the institution were computed tomography and magnetic resonance image. Conclusion. The importance of complementary exams in the investigation of headache is indisputable in many cases. However, it is necessary the availability of more studies that evaluate the request of complementary exams for headache patients (AU)