Resumo em Espanhol:

Objetivos. Con el propósito de explorar las variables que pudieran tener mayor impacto sobre los índices larvarios de Aedes aegypti, principal vector del dengue, se realizó un estudio descriptivo y longitudinal en la ciudad mexicana de Colima, ubicada en la costa central del Pacífico. Métodos. Se inspeccionaron 187 domicilios en los que se determinó el índice de viviendas (IV) y el número de contenedores positivos por casa (C+/C) durante las temporadas lluviosa y seca. Como variables independientes se analizaron la temperatura ambiental, la temporada, la aplicación de malatión en rociados a volumen ultrabajo (ULV), el índice de calidad de la vivienda (ICV) y el grado de conocimientos, actitudes y prácticas (CAP). Resultados. Tanto el análisis de regresión logística multivariada como el de regresión lineal múltiple mostraron una reducción del IV y del C+/C atribuible a un efecto de la temporada seca. Paradójicamente, la temperatura mostró una correlación negativa con los índices larvarios, la cual se hizo más aparente en la temporada seca. El ICV tuvo la mayor asociación con el IV y con el C+/C, independientemente de las demás variables. Las nebulizaciones de malatión mostraron un discreto efecto negativo sobre los índices, mientras que los CAP no mostraron ninguna asociación con ellos. Conclusiones. Se concluye que la temperatura alta puede reducir el número de criaderos durante la temporada seca, que el ICV puede ser un buen estimador de la infestación por Ae. aegypti, que el uso de malatión ULV reduce los criaderos y que el índice de CAP presenta escasa asociación con la presencia de los mismos.

Resumo em Inglês:

Objective. In order to investigate the variables that could have the greatest impact on larval indices of Aedes aegypti, the main vector of dengue, a descriptive, longitudinal study was carried out in the city of Colima, which is located in the Mexican Pacific coastal state of the same name. Methods. A total of 187 dwellings were inspected to determine the house index (HI) and the number of positive containers per house (C+/H), during the rainy season and the dry season. The following were recorded as independent variables: the air temperature, the season, the use of ultra low volume (ULV) spraying of malathion, the Premise Condition Index (PCI), and the score on a survey of knowledge, attitudes, and practices (KAP). Results. Both the multivariate logistic regression and the multivariate lineal regression showed a reduction of HI and C+/H due to the effect of the dry season. Paradoxically, the temperature seemed to have a negative correlation with the larval indices, and this effect was more pronounced during the dry season. The PCI showed the most significant correlation with HI and C+/H, independently of the other variables. The ULV sprayings showed a small negative effect on the indices, while the KAP score did not indicate any association at all. Conclusions. Some conclusions that can be drawn from this study are as follows: higher temperatures can reduce the larval indices during the dry season, the PCI can be an adequate estimator of the Ae. aegypti infestation rate, ULV spraying reduces the number of larval breeding sites, and the KAP score has little association with the larval indices.

Resumo em Espanhol:

Objetivos. El objetivo de este estudio consistió en determinar si la realización rutinaria de pruebas clínicas antes de la cirugía de cataratas reduce la tasa de complicaciones perioperatorias en adultos. Métodos. El estudio se realizó en un centro médico universitario de Brasil entre el 10 de febrero de 2000 y el 10 de enero de 2001. Los pacientes con operaciones de cataratas programadas fueron asignados aleatoriamente a un grupo en el que las pruebas preoperatorias se realizaron de forma rutinaria (grupo R) o a un grupo en el que se realizaron de forma selectiva (grupo S). A los pacientes asignados al grupo S solo se les solicitaron pruebas preoperatorias en caso de que presentaran un problema médico nuevo o agravado que justificara su realización. En el grupo R se practicaron tres pruebas preoperatorias de forma rutinaria: un electrocardiograma de 12 derivaciones, un hemograma completo y una determinación de la glucemia. Resultados. De los 1 025 pacientes estudiados, 512 fueron asignados al grupo R y 513 al grupo S. La proporción de intervenciones canceladas y no programadas nuevamente fue similar en ambos grupos: 2% en cada uno. La tasa acumulada de complicaciones médicas también fue similar en ambos grupos: 9,6% en el grupo R y 9,7% en el S (P = 0,923). Lo mismo ocurrió con los tipos de complicaciones médicas observadas. Conclusiones. Los resultados de este estudio indican que la realización rutinaria de pruebas médicas antes de la cirugía de cataratas no reduce la tasa de complicaciones perioperatorias y que parece ser más eficiente no solicitar pruebas preoperatorias, a no ser que la historia clínica o la exploración física del paciente indiquen su realización.

Resumo em Inglês:

Objective. The objective of this study was to investigate whether routine medical testing before cataract surgery reduces the rate of complications during the perioperative period in adults. Methods. The study was carried out in an academic medical center in Brazil, between 10 February 2000 and 10 January 2001. The scheduled cataract operations were randomly assigned to one of two groups: 1) to be preceded by routine testing (the "routine-testing group") or 2) not to be preceded by routine medical testing (the "selective-testing group"). If the patient was assigned to the selective-testing group, it was requested that no preoperative testing be performed unless the patient presented with a new or worsening medical problem that would warrant medical evaluation with testing. In the case of patients assigned to the routine-testing group, three tests were requested: a 12-lead electrocardiogram, a complete blood count, and measurements of serum glucose. Results. The sample of 1 025 patients scheduled to undergo cataract surgery was comprised of 512 assigned to the routine-testing group and of 513 assigned to the selective-testing group. The two groups had similar proportions of operations canceled and not subsequently rescheduled, 2% in each group. The cumulative rate of medical events was similar in the two groups, 9.6% in the routine-testing group and 9.7% in the selective-testing group (P = 0.923). The types of medical events were also similar in both groups. Discussion. The results of this study suggest that routine medical testing before cataract surgery does not reduce the rate of complications during the perioperative period. The results also suggest it would be more efficient not to request routine preoperative tests unless indicated by patient history or physical examination.

Resumo em Espanhol:

Objetivos. Este estudio usa tres dimensiones de acceso a los servicios médicos que contribuyen a una distribución social equitativa: (disponibilidad, accesibilidad y aceptabilidad) para examinar la equidad de dos sistemas médicos en los Estados Unidos de América (EE. UU.): el sistema tradicional de indemnización, en el que se paga una "cuota por servicio" o "pago por acto" (PPA) y el nuevo sistema de organizaciones de servicios médicos prepagados (health maintenance organizations: HMO). Se compara la equidad entre tres grupos de adultos mayores: euroamericanos (el grupo mayoritario) y latinoamericanos y afroamericanos (las minorías). Métodos. Los datos provienen de una encuesta nacional representativa que incluye un total de 858 latinoamericanos, 970 afroamericanos y 8 622 euroamericanos de la tercera edad (65 años o más) de áreas urbanas. Para comparar los grupos se usan la ji² y la regresión logística. Resultados. Los datos indican que las personas de la tercera edad pertenecientes a grupos minoritarios, caracterizadas por tener los recursos económicos más bajos y mayores necesidades de servicios médicos, se benefician más en el sistema de HMO porque este les proporciona mayor disponibilidad y acceso a los servicios médicos en comparación con el sistema de PPA. Esta mejora se debe a que el sistema de HMO reduce las barreras económicas para los pacientes. Sin embargo, los latinoamericanos afiliados a HMO en EE. UU. manifiestan una menor satisfacción con sus médicos de cabecera. Conclusiones. El sistema de HMO incrementa el acceso a la atención médica pero no necesariamente mejora la calidad de la relación entre paciente y médico para las personas de la tercera edad de EE. UU. pertenecientes a grupos minoritarios. Este estudio demuestra que es posible evaluar la equidad de los servicios médicos durante un proceso de reforma y, que para asegurarse de su validez, se deben incluir poblaciones vulnerables y diferentes dimensiones de acceso.

Resumo em Inglês:

Objective. This study examined three dimensions of access to medical services that contribute to social equity in distribution--availability, accessibility, and acceptability--in order to examine the equity of two medical system arrangements in the United States of America: the traditional fee-for-services scheme and the newer, health maintenance organization (HMO) approach. Equity was compared among three racial/ ethnic groups of older adults in the country: European-Americans (the majority in the United States), African-Americans, and Latin Americans (Latinos). Methods. The data came from a representative national survey that included 858 Latinos, 970 African-Americans, and 8 622 European-Americans. All the survey participants were 65 years of age or older, living in urban areas, and using services through the United States Government's Medicare program for older persons. The three groups were compared through chi-square tests and logistic regression analysis. Results. The data indicated that the older persons belonging to minority groups--who have fewer economic resources but a greater need for medical services--benefit more from HMOs, which provide them with greater availability and access to medical services than does the fee-for-services system. This difference is due to the fact that HMOs reduce the economic barriers for patients. However, the Latinos in HMOs reported lower satisfaction with their HMOs' primary-care physicians than did the European-Americans. Conclusions. The HMO approach increases access to medical care but does not necessarily improve the quality of the patient-physician interpersonal relationship for older minority persons in the United States. This study demonstrates that in health systems that are going through a reform process it is possible to monitor equity in medical care, and that an accurate assessment needs to focus on vulnerable populations as well as to distinguish between different dimensions of access.

Resumo em Português:

Objetivo. Avaliar a sobrevida dos pacientes com diagnóstico de aids em Ribeirão Preto, Brasil, de 1986 a 1997. Métodos. Foram revisadas retrospectivamente as fichas epidemiológicas de 2 214 pacientes diagnosticados no período do estudo. Foram incluídos 1 231 participantes com acompanhamento de no mínimo 30 dias após a data do diagnóstico. Informações sobre óbitos foram obtidas junto a hospitais e cartórios de registro civil de Ribeirão Preto. Resultados. A sobrevida para o grupo foi de 310 dias (10,3 meses). De 1986 até 1997, a mediana de sobrevivência passou de 362 dias (1986 a 1990) para 260 dias (1991 a 1995) e 864 dias (1996 e 1997). As curvas de Kaplan-Meier e o teste log rank evidenciaram diferenças significativas para as variáveis sexo, idade, época do diagnóstico, presença de candidíase e de neurotoxoplasmose. A regressão de Cox revelou associação entre redução da sobrevivência e as seguintes variáveis: idade (razão de risco = 1,435 para idade entre 15 e 34 anos e 1,681 para idade acima de 35 anos em relação a indivíduos abaixo de 15 anos); época do diagnóstico (razão de risco = 1,682 para o período de 1986 a 1990 e 2,324 para o período de 1991 a 1995 em relação ao período de 1996 a 1997); presença de candidíase (razão de risco = 1,391). A razão de risco para presença de neurotoxoplasmose foi 1,063, com valor de probabilidade próximo do limite de significância. Conclusões. Foi marcante o aumento na sobrevida verificado em 1996 e 1997, coincidindo com a disponibilização e utilização em larga escala das drogas anti-retrovirais.

Resumo em Inglês:

Objective. To assess survival in patients diagnosed with AIDS in the city of Ribeirão Preto, Brazil, between 1986 and 1997. Methods. The epidemiological records of 2 214 patients diagnosed during the study period were retrospectively reviewed. From those, 1 231 patients with at least 30 days of follow-up after the date of diagnosis were included in the study. Information concerning deaths was obtained from hospitals and vital-records offices. Results. Survival for the group as a whole was 310 days (10.3 months) over the period of 1986 through 1997. Median survival was 362 days for 1986 to 1990, 260 days for 1991 to 1995, and 864 days for 1996 and 1997. The Kaplan-Meier survival curves and the log-rank test showed significant differences for the following variables: sex, age, period when diagnosis was made, and presence of candidiasis and of cerebral toxoplasmosis. Cox's regression showed an association between reduction of survival and the following variables: age (in comparison to individuals younger than 15 years, hazard ratio = 1.435 for age between 15 and 34 years, and 1.681 for age above 35 years); period of diagnosis (in comparison to the period of 1996 and 1997, hazard ratio = 1.682 for the period from 1986 to 1990, and 2.324 for the period from 1991 to 1995); and presence of candidiasis (hazard ratio = 1.391). The hazard ratio for the presence of cerebral toxoplasmosis was 1.063, with a probability value close to the limit of significance. Conclusions. Our results show a striking increase in survival in 1996 and 1997, coinciding with the availability and utilization of highly active antiretroviral drugs.

Resumo em Espanhol:

Objetivos. Evaluar los métodos utilizados y los resultados obtenidos en dos encuestas realizadas en 1984 y 1995 que mostraron una gran reducción de la prevalencia y gravedad de la caries dental en niños jamaiquinos, prestando especial atención a las diferencias metodológicas entre las dos encuestas y a los factores biológicos que podrían explicar la gran disminución de la caries. Métodos. En 1984 se utilizó una modificación de los métodos de encuesta exploratoria de la Organización Mundial de la Salud para determinar la prevalencia y gravedad de la caries dental en niños jamaiquinos de 6, 12 y 15 años. En 1995 se realizó una encuesta similar. Resultados. Las dos encuestas emplearon los mismos criterios diagnósticos y procedimientos clínicos, pero la de 1984 incluyó una mayor proporción de residentes rurales que la de 1995. La comparación de ambas encuestas reveló una reducción del 84% en la gravedad de la caries dental a los 12 años de edad. Los datos muestran una transición epidemiológica entre 1984, cuando la caries dental tenía gran prevalencia y gravedad, y 1995, cuando ambas habían disminuido notablemente. Conclusiones. La reducción de la caries dental entre 1984 y 1995 es atribuible en su mayor parte a la introducción en 1987 de la fluoración de la sal. Aunque la encuesta de 1995 abarcó menos áreas rurales que la de 1984, esto no invalida la reducción de la caries dental que se observó. El uso de dentífricos fluorados, los suplementos dietéticos de fluoruros y el acceso a los servicios curativos, preventivos y de promoción de la salud dental no parecen haber contribuido de forma importante a la reducción observada.

Resumo em Inglês:

Objective. To assess the methods used and results found in two surveys, one conducted in 1984 and the other in 1995, that indicated a large reduction in the prevalence and severity of dental caries among children in Jamaica, with special attention focused on methodological differences between the two surveys and the biological factors that may explain the large reduction in caries. Methods. In 1984 a modified "pathfinder" methodology was used to measure the prevalence and severity of dental caries in 6-, 12-, and 15-year-old children in Jamaica. A similar survey was conducted in 1995. A comparison of the two surveys showed an 84% reduction in the severity of dental caries at age 12. Both surveys used the same diagnostic criteria and clinical procedures, but the 1984 survey included a higher proportion of rural residents than did the 1995 one. Results. The data show an epidemiological transition between 1984, when dental caries was highly prevalent and severe, and 1995, when the disease was less prevalent and was concentrated in a smaller proportion of the population. Conclusions. Most of the reduction in dental caries between 1984 and 1995 is attributable to the introduction, in 1987, of salt fluoridation. While the 1995 survey included fewer rural areas than the 1984 survey did, that does not invalidate the observed reduction in dental caries. The use of fluoride toothpaste and dietary fluoride supplements as well as access to dental health promotion and preventive and curative services do not seem to be major contributors to the reductions observed.

Resumo em Espanhol:

Objetivo. Determinar las distintas variantes que ha tenido el concepto de la hospitalización domiciliaria a lo largo del tiempo, para así contribuir al debate sobre las circunstancias que inciden en la gestión sanitaria frente a futuros retos. Métodos. Se revisa la literatura sobre la atención domiciliaria como modalidad asistencial de salud mediante una exploración de las publicaciones indizadas en MEDLINE, LILACS y el Índice Médico Español durante el período de 1995-2000. Resultados. La hospitalización domiciliaria ha tenido un desarrollo desigual a lo largo del tiempo en diferentes países y son varios los modelos de este tipo de atención, cada uno con sus respectivas ventajas y desventajas. Conclusiones. Se definen algunos criterios y propuestas que podrían enmarcar una gestión domiciliaria innovadora, efectiva y de calidad. Se concluye que la atención domiciliaria podría contribuir a diseñar y establecer un modelo consensuado y armonioso de organización y financiación entre los niveles de atención primaria y hospitalaria.

Resumo em Inglês:

Objective. To establish the different forms that the concept of home care has taken over time as a modality for providing health care, so as to contribute to the debate on the circumstances affecting health care management in the face of future challenges. Methods. The literature is reviewed on home care as a method for delivering health care, by researching publications indexed during the period of 1995-2000 in three medical bibliographical databases: MEDLINE, LILACS (Latin American and Caribbean Health Sciences) and the Índice Médico Español (Spanish Medical Index). Results. Home hospitalization has developed differently over time in various countries, with an assortment of models for this type of care, each with its respective advantages and disadvantages. Conclusions. There are some criteria and proposals that could provide a framework for home care that is innovative, effective, and of high quality. Home care could help in the design and creation of a consensus on an organizational and financing model that fits in harmoniously between primary care and care in a hospital.

Resumo em Inglês:

This piece summarizes a document entitled "Critical Issues in Health System Performance Assessment," which was prepared for the Regional Consultation of the Americas on Health Systems Performance Assessment, a meeting held in Washington, D.C., 8 to 10 May 2001. That gathering came about in response to the publication, by the World Health Organization (WHO), of its World Health Report 2000. Done by an advisory group, the Report focused on a comparative evaluation of the performance of the health systems of the WHO Member States. The task of preparing the Report was hindered by a series of factors, from the scar-city of basic data in some countries to the lack of reliable indicators--and especially uniform ones--that would make it possible to draw general conclusions. With a view to overcoming these deficiencies, an innovative methodology was conceived for the Report, based on the evaluation of processes and outcomes, which would make it possible to make valid comparative analyses. Unfortunately, the suitability of the methodology that was used in the Report has been criticized internationally and has led the WHO Director-General to take concrete steps for the next Report, which will come out in October 2002, in order to have improved results. This piece describes measures that need to be taken conceptually and methodologically, with an emphasis on changes in the system for evaluating health system performance and on involving every WHO Member State in the analysis of the data.

Resumo em Inglês:

This piece presents the recommendations of the Advisory Committee on Immunization Practices of the United States of America concerning the use of aluminum hydroxide adsorbed cell-free anthrax vaccine (Anthrax Vaccine Adsorbed, or AVA) and the use of chemoprophylaxis against Bacillus anthracis in the United States. The recommended vaccination schedule consists of three subcutaneous injections, at 0, 2, and 4 weeks, and three booster vaccinations, at 6, 12, and 18 months. To maintain immunity, an annual booster injection is recommended. Approximately 95% of vaccinees seroconvert, with a fourfold rise in anti-PA (protective antigen) IgG titers after three doses. Analysis of data from the United States' Vaccine Adverse Event Reporting System has documented no pattern of serious adverse events clearly associated with the vaccine, except injection-site reactions. Vaccination is contraindicated in the case of a previous history of anthrax infection or anaphylactic reaction following a previous dose of AVA or any of the vaccine components. In addition, vaccination should be postponed in the case of moderate or severe acute illness. Pregnant women should be vaccinated against anthrax only if the potential benefits of vaccination outweigh the potential risks to the fetus. Vaccination during breast-feeding is not medically contraindicated. Routine preexposure vaccination with AVA is indicated for persons engaged in: a) work involving production quantities or concentrations of B. anthracis cultures or b) activities with a high potential for aerosol production. For the military and other select populations or for groups for which a calculable risk can be assessed, preexposure vaccination may be indicated. Following confirmed or suspected exposure to B. anthracis, postexposure antibiotic prophylaxis should be administered with ciprofloxacin, ofloxacin, doxycycline, penicillin VK, or amoxicillin. If the vaccine is available, prophylaxis should continue for 4 weeks (until three doses of vaccine have been administered); otherwise, prophylaxis should continue for 30-60 days.