Incremental Role of New York Heart Association Class and Cardiopulmonary Exercise Test Indices for Prognostication in Heart Failure: A Cohort Study. / Papel Incremental da Classificação da New York Heart Association e dos Índices do Teste de Exercício Cardiopulmonar para Prognóstico na Insuficiência Cardíaca: um Estudo de Coorte.

BACKGROUND: Central Illustration : Incremental Role of New York Heart Association Class and Cardiopulmonary Exercise Test Indices for Prognostication in Heart Failure: A Cohort Study LVEF: left ventricular ejection fraction; HR: hazard ratio; CI: confidence interval; NYHA: New York Heart Association; VO 2: oxygen consumption. BACKGROUND: The accuracy of the New York Heart Association (NYHA) classification to assess prognosis may be limited compared with objective cardiopulmonary exercise test (CPET) parameters in heart failure (HF). OBJECTIVE: To investigate the prognostic value of the NYHA classification in addition to Weber class. METHODS: Adult outpatients with HF undergoing CPET in a Brazilian tertiary care center were included. The physician-assigned NYHA class and the CPET-derived Weber class were stratified into "favorable" (NYHA I or II; Weber A or B) or "adverse" (NYHA III or IV; Weber C or D). Patients with one favorable class and one adverse class were defined as "discordant." The primary endpoint was time to all-cause mortality. A 2-sided p value < 0.05 was considered statistically significant. RESULTS: A total of 834 patients were included. Median age was 57 years; 42% (351) were female, and median left ventricular ejection fraction was 32%. Among patients with concordant NYHA and Weber classes, those with adverse NYHA and Weber classes had significantly higher all-cause mortality compared to those with favorable classes (hazard ratio [HR]: 5.65; 95% confidence interval [CI]: 3.38 to 9.42). Among patients with discordant classes, there was no significant difference in all-cause mortality (HR: 1.38; 95% CI: 0.82 to 2.34). In the multivariable model, increments in NYHA class (HR: 1.55 per class increase; 95% CI: 1.26 to 1.92) and reductions in peak VO 2 (HR: 1.47 per 3 ml/kg/min decrease; 95% CI: 1.28 to 1.70) significantly predicted mortality. CONCLUSIONS: Physician-assigned NYHA class and objective CPET measures provide complementary prognostic information for patients with HF.

Papel Incremental da Classificação da New York Heart Association e dos Índices do Teste de Exercício Cardiopulmonar para Prognóstico na Insuficiência Cardíaca: um Estudo de Coorte / Incremental Role of New York Heart Association Class and Cardiopulmonary Exercise Test Indices for Prognostication in Heart Failure: A Cohort Study

Resumo Fundamento A precisão da classificação da New York Heart Association (NYHA) para avaliar o prognóstico pode ser limitada em comparação com os parâmetros objetivos do teste de exercício cardiopulmonar (TECP) na insuficiência cardíaca (IC). Objetivo Investigar o valor prognóstico da classificação da NYHA e da classe Weber. Métodos Foram incluídos pacientes ambulatoriais adultos com IC submetidos a TECP em um centro terciário brasileiro. A classe NYHA atribuída pelo médico e a classe Weber derivada do TECP foram estratificadas como "favorável" (NYHA I ou II com Weber A ou B) ou "adversa" (NYHA III ou IV com Weber C ou D). Pacientes com uma classe favorável e uma classe adversa foram definidos como "discordantes". O desfecho primário foi o tempo para mortalidade por todas as causas. Um valor de p bilateral < 0,05 foi considerado estatisticamente significativo. Resultados Foram incluídos 834 pacientes. A mediana de idade foi de 57 anos; 42% (351) eram do sexo feminino e a mediana da fração de ejeção do ventrículo esquerdo foi de 32%. Entre os pacientes com classes NYHA e Weber concordantes, aqueles com classes NYHA e Weber adversas tiveram mortalidade por todas as causas significativamente maior em comparação com aqueles com classes favoráveis ( hazard ratio [HR]: 5,65; intervalo de confiança de 95%: 3,38 a 9,42). Entre os pacientes com classes discordantes, não houve diferença significativa na mortalidade por todas as causas (HR: 1,38; intervalo de confiança de 95%: 0,82 a 2,34). No modelo multivariado, incrementos na classe NYHA (HR: 1,55 por aumento na classe; intervalo de confiança de 95%: 1,26 a 1,92) e reduções no VO 2 pico (HR: 1,47 por diminuição de 3 ml/kg/min; intervalo de confiança de 95%: 1,28 a 1,70) previu significativamente a mortalidade. Conclusões A classe NYHA atribuída pelo médico e as medidas objetivas do TECP fornecem informações prognósticas complementares para pacientes com IC.

Abstract Background The accuracy of the New York Heart Association (NYHA) classification to assess prognosis may be limited compared with objective cardiopulmonary exercise test (CPET) parameters in heart failure (HF). Objective To investigate the prognostic value of the NYHA classification in addition to Weber class. Methods Adult outpatients with HF undergoing CPET in a Brazilian tertiary care center were included. The physician-assigned NYHA class and the CPET-derived Weber class were stratified into "favorable" (NYHA I or II; Weber A or B) or "adverse" (NYHA III or IV; Weber C or D). Patients with one favorable class and one adverse class were defined as "discordant." The primary endpoint was time to all-cause mortality. A 2-sided p value < 0.05 was considered statistically significant. Results A total of 834 patients were included. Median age was 57 years; 42% (351) were female, and median left ventricular ejection fraction was 32%. Among patients with concordant NYHA and Weber classes, those with adverse NYHA and Weber classes had significantly higher all-cause mortality compared to those with favorable classes (hazard ratio [HR]: 5.65; 95% confidence interval [CI]: 3.38 to 9.42). Among patients with discordant classes, there was no significant difference in all-cause mortality (HR: 1.38; 95% CI: 0.82 to 2.34). In the multivariable model, increments in NYHA class (HR: 1.55 per class increase; 95% CI: 1.26 to 1.92) and reductions in peak VO 2 (HR: 1.47 per 3 ml/kg/min decrease; 95% CI: 1.28 to 1.70) significantly predicted mortality. Conclusions Physician-assigned NYHA class and objective CPET measures provide complementary prognostic information for patients with HF.

Doping control analysis at the Rio 2016 Olympic and Paralympic Games.

This paper summarises the results obtained from the doping control analyses performed during the Summer XXXI Olympic Games (August 3-21, 2016) and the XV Paralympic Games (September 7-18, 2016). The analyses of all doping control samples were performed at the Brazilian Doping Control Laboratory (LBCD), a World Anti-Doping Agency (WADA)-accredited laboratory located in Rio de Janeiro, Brazil. A new facility at Rio de Janeiro Federal University (UFRJ) was built and fully operated by over 700 professionals, including Brazilian and international scientists, administrative staff, and volunteers. For the Olympic Games, 4913 samples were analysed. In 29 specimens, the presence of a prohibited substance was confirmed, resulting in adverse analytical findings (AAFs). For the Paralympic Games, 1687 samples were analysed, 12 of which were reported as AAFs. For both events, 82.8% of the samples were urine, and 17.2% were blood samples. In total, more than 31 000 analytical procedures were conducted. New WADA technical documents were fully implemented; consequently, state-of-the-art analytical toxicology instrumentation and strategies were applied during the Games, including different types of mass spectrometry (MS) analysers, peptide, and protein detection strategies, endogenous steroid profile measurements, and blood analysis. This enormous investment yielded one of the largest Olympic legacies in Brazil and South America. Copyright © 2017 John Wiley & Sons, Ltd.

O efeito da função orçamentária alocativa na redução da desigualdade de renda no Brasil: uma análise dos gastos em educação e saúde no período de 1995 a 2012 / El efecto de la función asignativa en la reducción de la desigualdad de ingresos en Brasil: un análisis del gasto en educación y salud 1995-2012 / The effect of allocation function in budgeting to reduce income inequality in Brazil: an analysis of spending on education and health from 1995 to 2012

Resumo A desigualdade de renda é apontada como um dos grandes problemas da sociedade atual. A fim de reverter o cenário desigual, o Estado pode atuar utilizando a função orçamentária alocativa. Este estudo buscou identificar os impactos da função alocativa do orçamento sobre a desigualdade de renda, para as unidades federativas brasileiras no período de 1995 a 2012. Foram considerados como proxy da função alocativa os gastos com educação e saúde, enquanto foram utilizados como proxy da desigualdade de renda o coeficiente de Gini, o coeficiente de Theil, a proporção entre os 10% mais ricos e os 40% mais pobres, e a proporção entre os 20% mais ricos e os 20% mais pobres. A relação funcional entre os dois conjuntos de variáveis foi explorada a partir da análise de dados em painel e da regressão tobit em painel. Considerando-se os gastos agregados em educação e saúde de estados e municípios no período, concluiu-se que as unidades da federação que investiram mais em saúde conseguiram reduzir as desigualdades de renda com maior intensidade, ocorrendo efeito oposto com as despesas com ensino. Quando os gastos em saúde e ensino foram desagregados em várias rubricas, concluiu-se que as unidades da federação com maior volume de gastos nas seguintes subfunções (2o nível da função): atenção básica, assistência hospitalar, suporte profilático e ambulatorial, e educação infantil conseguiram reduzir as desigualdades de renda com maior intensidade.

Resumen La desigualdad de ingresos se ve como un problema importante de la sociedad contemporánea. Con el fin de revertir la situación desigual, el Estado puede actuar mediante la función asignativa de presupuesto. Este estudio trata de identificar los impactos de la función de la asignación de recursos del presupuesto en la desigualdad de ingresos para los estados de Brasil 1995 a 2012. Fueron considerados como un indicador de la función asignativa el gasto en educación y salud, mientras que se utilizaron como apoderado la desigualdad de ingresos el coeficiente de Gini, el coeficiente de Theil, la relación entre el 10% más rico y el 40% más pobre, y la relación entre el 20% más rico y el 20% más pobre. La relación funcional entre los dos conjuntos de variables se exploró a partir del análisis de datos de panel y el panel de regresión Tobit. Teniendo en cuenta los gastos agregados sobre la educación y la salud de los estados y municipios en el período, se concluyó que las Unidades de la Federación que han invertido más en salud han logrado reducir la desigualdad de ingresos con mayor intensidad, que se producen efecto contrario con el costo de la educación. Cuando el gasto en salud y educación ha sido dividido en varias secciones, se concluyó que las unidades de la federación con mayor volumen de gasto en la siguientes subfunciones (segundo nivel de función): atención primaria, atención hospitalaria, asistencia preventiva y la atención ambulatoria, y educación de la primera infancia han logrado reducir la desigualdad de ingresos con mayor intensidad.

Abstract Income inequality is seen as a major problem of contemporary society. In order to reverse inequality the state can use allocation function in budgeting. This study sought to identify the impacts of allocation function in budgeting on income inequality for Brazilian states from 1995 to 2012. Spending on education and health was considered as an allocative function proxy, while the Gini coefficient, the Theil coefficient, was used as a proxy for income inequality. This found the ratio between the richest 10% and the poorest 40%, and the ratio between the richest 20% and poorest 20%. The functional relationship between the two sets of variables was explored in the analysis of panel data and tobit regression. Considering aggregate expenditure on education and health of states and municipalities in the period, it was concluded that federative units that invested more in health have been better at reducing income inequality, with the opposite effect occurring for the cost of education. When spending on health and education are broken down into several sections, it can be seen that the federation units with higher volume of spending in the following sub-functions (2nd level of function) — Primary health care, hospital and outpatient care, prophylactic and therapeutic support and early childhood education — have made greater gains in reducing income inequality.

Pharmacological interventions for sleepiness and sleep disturbances caused by shift work

BACKGROUND: Shift work results in sleep-wake disturbances, which cause sleepiness during night shifts and reduce sleep length and quality in daytime sleep after the night shift. In its serious form it is also called shift work sleep disorder. Various pharmacological products are used to ameliorate symptoms of sleepiness or poor sleep length and quality. OBJECTIVES: To evaluate the effects of pharmacological interventions to reduce sleepiness or to improve alertness at work and decrease sleep disturbances whilst of work, or both, in workers undertaking shift work. METHODS: Search methods: We searched CENTRAL, MEDLINE, EMBASE, PubMed and PsycINFO up to 20 September 2013 and ClinicalTrials.gov up to July 2013. We also screened reference lists of included trials and relevant reviews. Selection criteria: We included all eligible randomised controlled trials (RCTs), including cross-over RCTs, of pharmacological products among workers who were engaged in shift work (including night shifts) in their present jobs and who may or may not have had sleep problems. Primary outcomes were sleep length and sleep quality while of work, alertness and sleepiness, or fatigue at work. Data collection and analysis: Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We performed meta-analyses where appropriate. ...

Pharmacological interventions for sleepiness and sleep disturbances caused by shift work.

BACKGROUND: Shift work results in sleep-wake disturbances, which cause sleepiness during night shifts and reduce sleep length and quality in daytime sleep after the night shift. In its serious form it is also called shift work sleep disorder. Various pharmacological products are used to ameliorate symptoms of sleepiness or poor sleep length and quality. OBJECTIVES: To evaluate the effects of pharmacological interventions to reduce sleepiness or to improve alertness at work and decrease sleep disturbances whilst of work, or both, in workers undertaking shift work. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, PubMed and PsycINFO up to 20 September 2013 and ClinicalTrials.gov up to July 2013. We also screened reference lists of included trials and relevant reviews. SELECTION CRITERIA: We included all eligible randomised controlled trials (RCTs), including cross-over RCTs, of pharmacological products among workers who were engaged in shift work (including night shifts) in their present jobs and who may or may not have had sleep problems. Primary outcomes were sleep length and sleep quality while of work, alertness and sleepiness, or fatigue at work. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We performed meta-analyses where appropriate. MAIN RESULTS: We included 15 randomised placebo-controlled trials with 718 participants. Nine trials evaluated the effect of melatonin and two the effect of hypnotics for improving sleep problems. One trial assessed the effect of modafinil, two of armodafinil and one examined caffeine plus naps to decrease sleepiness or to increase alertness.

A organização do acesso aos serviços de saúde bucal na estratégia de saúde da família de um município da Bahia / The organization of the access to dental health services within the family healthcare strategy in a municipality in Bahia

O objetivo desse estudo foi conhecer a forma de organização da oferta dos serviços de saúde bucal na Estratégia de Saúde da Família de um município da Bahia. Trata-se de pesquisa qualitativa baseada em entrevistas semiestruturadas com usuários, agentes comunitários de saúde e cirurgiões-dentistas. Os resultados permitiram inferir que a oferta da primeira consulta odontológica aproxima-se mais do modelo tradicional de atendimento à demanda espontânea. Constatou-se que a participação da comunidade na organização dos serviços de saúde bucal é ausente. As barreiras de acesso recaíram sobre a falta de materiais e deficiência na manutenção de equipamentos, além da baixa cobertura do serviço.

The objective of this study was to investigate the organization of available dental health services within the Family Healthcare Strategy in a Bahia State's municipality. This is a qualitative research study using semi-structured interviews with users, community health agents and dentists. The results showed that the availability of the initial dental consultation is similar to the traditional model of healthcare by spontaneous demand. Community participation in the organization of oral healthcare services proved to be non-existent. Barriers to access are due to the lack of supplies and inadequate equipment maintenance, in addition to the limited services provided.

Multidimensional aspects related to shiftworkers' health and well-being.

The impact of shift and night work on health shows a high inter- and intra-individual variability, both in terms of kind of troubles and temporal occurrence, related to various intervening factors dealing with individual characteristics, lifestyles, work demands, company organisation, family relations and social conditions. The way we define "health" and "well-being" can significantly influence appraisals, outcomes and interventions. As the goal is the optimisation of shiftworkers' health, it is necessary to go beyond the health protection and to act for health promotion. In this perspective, not only people related to medical sciences, but many other actors (ergonomists, psychologists, sociologists, educators, legislators), as well as shiftworkers themselves. Many models have been proposed aimed at describing the intervening variables mediating and/or moderating the effects; they try to define the interactions and the pathways connecting risk factors and outcomes through several human dimensions, which refer to physiology, psychology, pathology, sociology, ergonomics, economics, politics, and ethics. So, different criteria can be used to evaluate shiftworkers' health and well-being, starting from biological rhythms and ending in severe health disorders, passing through psychological strain, job dissatisfaction, family perturbation and social dis-adaptation, both in the short- and long-term. Consequently, it appears rather arbitrary to focus the problem of shiftworkers' health and tolerance only on specific aspects (e.g. individual characteristics), but a systemic approach appears more appropriate, able to match as many variables as possible, and aimed at defining which factors are the most relevant for those specific work and social conditions. This can support a more effective and profitable (for individuals, companies, and society) adoption of preventive and compensative measures, that must refer more to "countervalues" rather than to "counterweights".

Multidimensional aspects related to shiftworkers' health and well-being

O impacto do trabalho noturno e em turnos sobre a saúde demonstra ter grande variabilidade entre os indivíduos e num mesmo indivíduo, em termos tanto dos tipos de problemas como da ocorrência temporal, relativas a vários fatores interferentes como características pessoais, estilo de vida, exigências do trabalho, organização da empresa, relações familiares e condição social. O modo como "saúde" e "bem-estar" são definidos pode interferir significativamente com a avaliação, resultados e intervenções. Como o objetivo é otimizar a saúde dos trabalhadores em turnos, é necessário ir além da proteção da saúde e agir para a promoção da saúde e ter a participação de não apenas profissionais da área das ciências médicas, mas também outros agentes (ergonomistas, psicólogos, sociólogos, educadores, legisladores), assim como dos próprios trabalhadores. Foram propostos vários modelos com o propósito de descrever as variáveis interferentes que intermedeiam e/ou moderam os efeitos. Esses modelos buscam definir as interações e conexões entre os fatores de risco e resultados por meio de várias dimensões humanas, que remetem à fisiologia, psicologia, sociologia, ergonomia, economia, política e ética. Assim, podem ser usados diferentes critérios para avaliar a saúde e o bem-estar dos trabalhadores em turnos, de ritmos biológicos a graves transtornos de saúde, passando por tensão psicológica, insatisfação no trabalho, transtorno familiar e má adaptação social a curto e longo prazo. Como resultado, parece um tanto arbitrário enfocar o problema da saúde e tolerância dos trabalhadores em turnos apenas sob aspectos específicos (por exemplo, características pessoais) e parece ser mais apropriada uma abordagem sistemática, capaz de combinar o maior número possível de variáveis e direcionada a definir os fatores mais relevantes aos tipos particulares de trabalho e condições sociais. Isso pode servir de respaldo para a adoção de medidas preventivas e compensatórias mais eficazes e proveitosas (para indivíduos, empresas e sociedade) que precisam remeter mais a "contravalores" do que a "contrapesos".