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Aim: This paper aims to analyze the EPHF in MG in Ecuador as a framework for integrating it into clinical practice. It also aims to contribute to the scientific and social debate on the MG role, considering it the most advanced science field today. Context: the Essentials Public Health Functions (EPHF) are actions for specific purposes necessary to achieve the central objective of Public Health (PH), which is to improve, promote, protect, and restore the population's health through collective action. Medical Genetics (MG) and Genomics are still in construction between public policies, especially in developing countries, and deserve an in-depth approach in this context. Discussion: We understand collective health as an inter-institutional and interdisciplinary social practice, which involves both the State and civil society, aims at protecting and improving people's health. It implies population or community interventions; it includes the responsibility to ensure access and health care quality. Within this practice are the EPHF, defined as actions carried out for specific purposes necessary to achieve the PH Practice's central objective. Each function's operation depends on a sufficient definition of contents, objectives, and activities and on the specific assignment of who is responsible for their execution. Conclusion: The EPHF guides public health policies in Latin America and Ecuador. From this perspective, medical genetics and genomics must be included as a priority in the country's public policy. In this review, we propose the activities to be implemented in this context. This challenge requires political and scientific leadership. Objetivo: Este trabajo tiene como objetivo analizar las FESP en MG en Ecuador como marco para su integración en la práctica clínica. También pretende contribuir al debate científico y social sobre el papel de la MG, considerándolo el campo científico más avanzado en la actualidad. Contexto: las Funciones Esenciales de Salud Pública (FESP) son acciones con fines específicos necesarios para lograr el objetivo central de la Salud Pública (PH), que es mejorar, promover, proteger y restaurar la salud de la población a través de la acción colectiva. La Genética Médica (MG) y la Genómica aún se encuentran en construcción entre las políticas públicas, especialmente en los países en desarrollo, y merecen un enfoque en profundidad en este contexto. Discusión: Entendemos la salud colectiva como una práctica social interinstitucional e interdisciplinaria, que involucra tanto al Estado como a la sociedad civil, tiene como objetivo proteger y mejorar la salud de las personas. Implica intervenciones poblacionales o comunitarias; incluye la responsabilidad de asegurar el acceso y la calidad de la atención médica. Dentro de esta práctica se encuentran las FESP, definidas como acciones realizadas con fines específicos necesarios para lograr el objetivo central de la Práctica de PH. El funcionamiento de cada función depende de una definición suficiente de contenidos, objetivos y actividades y de la asignación específica de quién es el responsable de su ejecución. Conclusión: Las FESP orientan las políticas de salud pública en América Latina y Ecuador. Es fundamental que desde este punto de vista, la genética médica y la genómica sean incluidas como una prioridad en la política pública del país. En está revisión, proponemos las actividades a implementar en este contexto. Este desafío requiere liderazgo político y científico. Objetivo: este artigo tem como objetivo analisar as FESP em MG, no Equador, como uma estrutura para integrá-la à prática clínica. Visa também contribuir para o debate científico e social sobre o papel do MG, considerando-o o campo mais avançado da ciência na atualidade. Contexto: as Funções Essenciais de Saúde Pública (FESP) são ações com finalidades específicas necessárias para atingir o objetivo central da Saúde Pública (AP), que é melhorar, promover, proteger e restaurar a saúde da população por meio da ação coletiva. A Genética Médica (MG) e a Genômica ainda estão em construção entre as políticas públicas, principalmente nos países em desenvolvimento, e merecem um aprofundamento neste contexto. Discussão: Entendemos a saúde coletiva como uma prática social interinstitucional e interdisciplinar, que envolve o Estado e a sociedade civil, que visa proteger e melhorar a saúde das pessoas. Implica intervenções na população ou na comunidade; inclui a responsabilidade de garantir o acesso e a qualidade dos cuidados de saúde. Dentro dessa prática estão as FESP, definidas como ações realizadas com finalidades específicas necessárias para atingir o objetivo central da Prática de HP. O funcionamento de cada função depende de uma definição suficiente de conteúdo, objetivos e atividades e da atribuição específica de quem é responsável pela sua execução. Conclusão: As FESP orientam as políticas públicas de saúde na América Latina e no Equador. É imprescindível que, desse ponto de vista, a genética médica e a genômica sejam incluídas como prioridade nas políticas públicas do país. Nesta revisão, propomos as atividades a serem implementadas neste contexto. Este desafio requer liderança política e científica.

Upper respiratory viral infections can decrease the sense of smell either by inflammatory restriction of nasal airflow that carries the odorant molecules or through interference in olfactory sensory neuron function. During the coronavirus disease 2019 (COVID-19) pandemic, triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), worldwide reports of severe smell loss (anosmia/hyposmia) revealed a different type of olfactory dysfunction associated with respiratory virus infection. Since self-reported perception of smell is subjective and SARS-CoV-2 exposure is variable in the general population, we aimed to study a population that would be more homogeneously exposed to the virus. Here, we investigated the prevalence of olfactory loss in frontline health professionals diagnosed with COVID-19 in Brazil, one of the major epicenters of the disease. We also analyzed the rate of olfactory function recovery and the particular characteristics of olfactory deficit in this population. A widely disclosed cross-sectional online survey directed to health care workers was developed by a group of researchers to collect data concerning demographic information, general symptoms, otolaryngological symptoms, comorbidities, and COVID-19 test results. Of the 1,376 health professionals who completed the questionnaire, 795 (57.8%) were working directly with COVID-19 patients, either in intensive care units, emergency rooms, wards, outpatient clinics, or other areas. Five-hundred forty-one (39.3%) participants tested positive for SARS-CoV-2, and 509 (37%) were not tested. Prevalence of olfactory dysfunction in COVID-19-positive subjects was 83.9% (454 of 541) compared to 12.9% (42 of 326) of those who tested negative and to 14.9% (76 of 509) of those not tested. Olfactory dysfunction incidence was higher in those working in wards, emergency rooms, and intensive care units compared to professionals in outpatient clinics. In general, remission from olfactory symptoms was frequent by the time of responses. Taste disturbances were present in 74.1% of infected participants and were significantly associated with hyposmia. In conclusion, olfactory dysfunction is highly correlated with exposure to SARS-CoV-2 in health care professionals, and remission rates up to 2 weeks are high.

Purpose: With this work, we intend to promote research on the application of Operations Management tools in order to assist with decision-making in health crisis situations. During the first six weeks of the COVID-19 crisis in Spain, we have contacted a large number of hospital and health department managers in the Valencian Community and other regions of Spain. The result is that very few, at least when contact was made and at the time of writing this article, had consulted staff members in the Operations Management area for advice on this situation, and they are quite reluctant to do so. This is in spite of the fact that some medical sources also consider this crisis to be one of resources, not merely a medical crisis. Our opinion is that Operations Management can make a useful and valuable contribution to anticipate and improve the management of scarce resources, even in times of crisis. If those responsible for public health or heads of hospitals do not see this usefulness, then there is a huge gap between research and practice in Operations Management and what is transmitted to the healthcare sector. Our aim is to help reduce this gap. Design/methodology/approach: In the first part of the article, we will justify that this crisis, besides being a medical crisis, is also a crisis in terms of resources. We will briefly review some of the Operations Management tools that we believe are appropriate for managing this crisis. We will focus on those that we will illustrate in the second part of the article as a practical example of the action research protocol (only the action planning phase), in which we are currently involved. Findings: Due to the peculiarities of the COVID-19 epidemic, it is reasonable to think that the evolution and duration of each outbreak, and the way it is dealt with, will be different in each hospital and/or each health department. Anticipating the number of patients who will require care and forecasting the consumption of resources over time is complex, due to the long and variable incubation times and the uncontrolled evolution of the treatments needed by each patient. Furthermore, since the evolution of new patient admissions is not homogeneous, the forecasting of requirements is difficult. Providing real-time support and detecting with a certain degree of anticipation the potential levels of demand for health care will enable hospitals to define what stages of the contingency plan to apply and how to (re)assign the available resources in the most efficient way possible. Research limitations/implications: Hardly any current data are available, not only publicly, but also through public health ministries and managers; those that are available are not very reliable and come from studies with non-representative samples. For this reason, all forecasts must be taken with a note of caution, and in particular, designing review mechanisms every time a new set of updated reliable data becomes available (something that occurs on a weekly basis). Originality/value: In this work, we will show an example of a proposal for the practical application of Operations Management tools. Our proposal may be useful to hospital managers and public administrators in the healthcare sector (regional ministries or their equivalents). Each health department, hospital or hospital group will generate the aggregate data that facilitate the calculation of needs as input parameters for the model (available and occupied beds, daily admissions, mean lengths of stay in each healing phase and the percent of patients who evolve from one stage to another in the progression of the disease/healing process) and will be able to analyze how the system responds and evaluate different strategies or mitigating actions. These tools have been shown to be useful and reliable in manufacturing and service contexts that show a strong seasonal demand (both occasional and recurring) requiring a great deal of resources. We believe these situations are analogous to those faced by hospitals and the healthcare system in an epidemic like COVID-19. With them, we could facilitate the aggregate planning of resources for hospital administrators in order to provide them operational support during the COVID-19 contingency plan. However, the array of useful tools for this crisis is not limited to those that we will illustrate. Our intent is to encourage the Operations Management academic community to demonstrate how they contribute to the service of society in this COVID-19 epidemic, providing knowledge that can be extrapolated to other similar situations in the future that we may be unfortunate enough to experience.

Background Travellers visiting friends and relatives (VFR) define a specific population of travellers exposed to higher risks for health and safety than tourists. The aim of this study was to assess differentials in pre-travel health care in VFR travellers compared to other travellers. Methods A retrospective cohort study was performed including attendees of the Travel Medicine Clinic of the Hospital Universitari de Bellvitge, Barcelona, Spain, between January 2007 and December 2017. Results Over the 10-year period, 47,022 subjects presented to the travel clinic for pre-travel health care, 13.7% of whom were VFR travellers. These showed higher rates of vaccination against yellow fever and meningococcus, but lower rates for hepatitis A, hepatitis B, influenza, rabies, cholera, polio, typhoid IM vaccine and tetanus vaccine boosters. Regarding malaria prevention measures, results highlighted that VFR travellers, when compared with tourists, were more likely to be prescribed with chemoprophylaxis, particularly with mefloquine, than with atovaquone/proguanil. Conclusions Findings from this large-scale study indicated differences in vaccination rates and completion, as well as in chemoprophylaxis for malaria, between VFR and non-VFR travellers, fostering specific interventions for promoting adherence to pre-travel health advice among migrant travellers.

Discrete choice experiments (DCEs) are a way to assess priority-setting in health care provision. This approach allows for the evaluation of individuals’ preferences as a means of adding criteria to traditional quality-adjusted life year analysis. The aim of this systematic literature review was to identify attributes for designing a DCE in order to then develop and validate a framework that supports decision-making on health technologies. Our systematic literature review replicated the methods and search terms used by de Bekker-Grob et al. 2012 and Clark et al. 2014. The Medline database was searched for articles dated between 2008 and 2015. The search was limited to studies in English that reflected general preferences and were choice-based, published as full-text articles and related to health technologies. This study included 72 papers, 52% of which focused on DCEs on drug treatments. The average number of attributes used in all included DCE studies was 5.74 (SD 1.98). The most frequently used attributes in these DCEs were improvements in health (78%), side effects (57%) and cost of treatment (53%). Other, less frequently used attributes included waiting time for treatment or duration of treatment (25%), severity of disease (7%) and value for money (4%). The attributes identified might inform future DCE surveys designed to study societal preferences regarding health technologies in order to better inform decisions in health technology assessment. info:eu-repo/semantics/acceptedVersion

This article examines the influence of early exposure to advanced markets of the United States and Germany in the growth and internationalization of health care firms from Spain, a late industrialised country. Based on the case studies of the Spanish corporations Grifols and Ferrer, the study shows that early exposure to advanced markets helped them grow in their national markets, and in the world health care industry. It shows further that the specific capabilities developed by both firms were determined by path-dependent networks with scientists and institutions, on the one hand; and strategic alliances, acquisitions and mergers with German and US corporations on the other. © 2017, © 2017 Informa UK Limited, trading as Taylor & Francis Group.

Resumo O objetivo foi analisar a percepção dos usuários sobre a consulta médica, utilizando as informações da Pesquisa Nacional de Saúde, 2013. Entre os que se consultaram com médico nos últimos 12 meses, foram analisados 12 aspectos relacionados aos serviços de saúde e à consulta médica, segundo o local de atendimento (público/privado). Por meio de regressão logística multivariada, foram estabelecidos os fatores associados à insatisfação com o atendimento recebido. Para a redução de dimensionalidade dos aspectos avaliados, utilizou-se análise de componentes principais. A PNS revelou que 74,2% se consultou com médico. Entre as diferenças por local de atendimento, destacaram-se a forma de obtenção da consulta, o tipo de médico, o tempo de espera, e o motivo da consulta. Os escores medianos se concentraram em 80 (bom), com exceção do tempo de espera entre os usuários do SUS. Proporções de avaliação muito boa foram, porém, maiores entre os usuários do setor privado. O atendimento por médicos generalistas foi significativamente associado à insatisfação. Apesar da avaliação positiva em ambos os setores, público e privado, a configuração das Unidades da Federação no plano formado pelos dois eixos principais seguiu um padrão de marcantes desigualdades regionais.

Objective Evaluate the influence of prenatal care on the occurrence of gestational hypertension. Methods The Web of Science, Scopus, Pubmed, Cochrane and ClinicalTrials electronic databases were searched for articles published between January 1st, 2012 and December 31st, 2016. No language restrictions were imposed. The following keywords were used: prenatal care, medical assistance, prenatal education, pregnancy-induced hypertension. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist was employed. Two hundred and forty articles were identified during the initial search, but only seven met the inclusion criteria. This systematic review is registered with the international prospective register of systematic reviews (PROSPERO; #CRD42017064103). Results The seven studies hada lowriskof bias,withmethodological quality scores ranging fromsix to eight points. Five studies found a positive relationship between prenatal care and pregnancy-induced hypertension, whereas two studies found no significant association between the two variables. The divergence among the studies may have been due to the type of healthcare service at which the study was conducted and the sample size. Conclusion Although the studies analyzed differed with regard to methodological aspects, the findings demonstrate the importance of prenatal care during the gestational period as a prevention and health promotion measure. Resumo Objetivo Avaliar a influência da assistência pré-natal no acometimento de síndromes hipertensivas gestacionais. Métodos A revisão buscou artigos publicados nas plataformas eletrônicas de pesquisa Web of Science, Scopus, Pubmed, Cochrane e Clinical Trials, sem restrições de linguagem e com os artigos publicados entre 01/01/2012 e 31/12/2016. Os descritores utilizados foram: assistência pré-natal, assistência médica, educação pré-natal, hipertensão induzida pela gravidez, gestação. Foi utilizado o checklist preferred reporting items for systematic reviews and meta-analyses PRISMA. A busca na literatura, de acordo com a estratégia adotada, identificou 240 artigos. Contudo, somente 7 artigos foram selecionados de acordo com os critérios de inclusão. A revisão sistemática foi incluída no registro prospectivo internacional de revisões sistemáticas (PROSPERO, na sigla em inglês; #CRD42017064103). Resultados Cinco estudos encontraram relação positiva entre a assistência pré-Natal e síndromes hipertensivas gestacionais. Dois estudos não encontraram uma associação estatística significativa entre estas duas variáveis. Os sete estudos apresentam um baixo risco de viés, com as pontuações na análise de qualidade variando entre seis e oito. As possíveis diferenças entre os achados podem ser devidas ao momento do diagnóstico das síndromes hipertensiva gestacionais, tipo de serviço onde foi realizada a pesquisa e o tamanho amostral. Conclusão Embora os estudos apresentem diferentes aspectos metodológicos, observou-se a importância da implementação da Assistência Pré-Natal durante o período gestacional, o que atuará como medida de promoção e prevenção em saúde.

This article belongs to the Special Issue Personalized Nanomedicine., Nanomedicine is an interdisciplinary research field that results from the application of nanotechnology to medicine and has the potential to significantly improve some current treatments Specifically, in the field of personalized medicine, it is expected to have a great impact in the near future due to its multiple advantages, namely its versatility to adapt a drug to a cohort of patients. In the present review, the properties and requirements of pharmaceutical dosage forms at the nanoscale, so-called nanomedicines, are been highlighted. An overview of the main current nanomedicines in pre-clinical and clinical development is presented, detailing the challenges to the personalization of these therapies. Next, the process of development of novel nanomedicines is described, from their design in research labs to their arrival on the market, including considerations for the design of nanomedicines adapted to the requirements of the market to achieve safe, effective, and quality products. Finally, attention is given to the point of view of the pharmaceutical industry including regulation issues applied to the specific case of personalized medicine. The authors expect this review to be a useful overview of the current state of the art of nanomedicine research and industrial production, and the future opportunities of personalized medicine in the upcoming years The authors encourage the development and marketing of novel personalized nanomedicines., C.F. is grateful to MINECO for their “Programa Torres Quevedo” grant. Financial support from Generalitat de Catalunya (grant 2014SGR1655) and MINECO (grant CTQ2016-80645-R) is acknowledged.

Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi’s community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi’s strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy’s implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of preexisting roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs’ expected duties and interactions with paid CHT personnel is recommended.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances. These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

BACKGROUND: Assessing the long-term cost of colorectal cancer (CRC) increases our understanding of the disease burden. The aim of this paper is to estimate the long-term costs of CRC care by stage at diagnosis and phase of care in the Spanish National Health Service. METHODS: Retrospective study on resource use and direct medical cost of a cohort of 699 patients diagnosed and treated for CRC in 2000-2006, with follow-up until 30 June 2011, at Hospital del Mar (Barcelona). The Kaplan-Meier sample average estimator was used to calculate observed 11-year costs, which were then extrapolated to 16 years. Bootstrap percentile confidence intervals were calculated for the mean long-term cost per patient by stage. Phase-specific, long-term costs for the entire CRC cohort were also estimated. RESULTS: With regard to stage at diagnosis, the mean long-term cost per patient ranged from €20,708 (in situ) to €47,681 (stage III). The estimated costs increased at more advanced stages up to stage III and then substantially decreased in stage IV. In terms of treatment phase, the mean cost of the initial period represented 24.8 % of the total mean long-term cost, whereas the cost of continuing and advanced care phases represented 16.9 and 58.3 %, respectively. CONCLUSIONS: This study is the first to provide long-term cost estimates for CRC treatment, by stage at diagnosis and phase of care, based on data from clinical practice in Spain, and it will contribute useful information for future studies on cost-effectiveness and budget impact of different therapeutic innovations in Spain. The present work is framed within different research projects of the Cancer Strategy of Catalonia and Hospital del Mar, which have received competitive public funding from the Catalan Agency for Health Information, Assessment, and Quality (AQuAS) (AATRM-GENDECAT; No. 082152004), the Fund for Health Research (FIS, PI 060990), and the Cancer Research Network (RTICC, RD 12/0036/0053) of the Carlos III Institute of Health (Instituto de Salud Carlos III/ISCIII) (co-funded by FEDER funds/European Regional Development Funds, ERDF), and the Agència de Gestió d'Ajuts Universitaris i de Recerca (AGAUR, 2014SGR0635)

Em 1861 foi inaugurado em Recife o Hospital Pedro II que, durante várias décadas, serviu como instituição de referência no estado de Pernambuco e no Nordeste. O prédio foi construído segundo o modelo francês, desenvolvido pelo médico Jacques-René Tenon: o estilo pavilhonar, que prevaleceu em Pernambuco e no Brasil por muitos anos. Em 1982, o nosocômio quase foi abandonado e, em seguida, graças à negociação entre o Instituto de Medicina Integral Prof. Fernando Figueira e a Arquidiocese de Olinda e Recife , foi restaurado e inaugurado, oferecendo diversos serviços para a sociedade. Pedro II Hospital was inaugurated in Recife in 1861 and for several decades was the leading center of its kind in the state of Pernambuco and in Northeast Brazil. Its construction followed French design, as developed by physician Jacques-René Tenon, that is, the so-called pavilion style that was the norm in Pernambuco and in Brazil for many years. After being nearly abandoned in 1982, the hospital was reformed shortly thereafter and reopened its doors to offer a variety of services, thanks to negotiations between the Instituto de Medicina Integral Professor Fernando Figueira and the Archdiocese of Olinda and Recife.

Entre los años 1940 y 1942, la Delegación de la Junta de Auxilio a los Refugiados Españoles puso en marcha, y mantuvo, un servicio sanitario propio en México D. F. , constituido por profesionales españoles recién llegados al exilio. Inicialmente se trató de una asistencia médica domiciliaria, con pago por acto médico a los especialistas y abono de las prescripciones farmacéuticas. Más tarde dispondría de una policlínica, una plantilla de especialistas y una farmacia propia. Finalmente, proyectó un pequeño hospital y un laboratorio de análisis clínicos, pero las circunstancias del momento impedirían que llegaran a ponerse en marcha. En el estudio se aborda la situación en la que surgió el Servicio Médico-Farmacéutico; su financiación, organización y funcionamiento; los profesionales que en él se integraron; líneas de actuación y proyectos inmediatos; los principales problemas que fueron surgiendo en su desarrollo y las razones que obligaron a su disolución.

Multidisciplinary teams (MDTs) are considered the gold standard of cancer care in many healthcare systems, but a clear definition of their format, scope of practice and operational criteria is still lacking. The aims of this review were to assess the impact of MDTs on patient outcomes in cancer care and identify their objectives, organisation and ability to engage patients in their care. We conducted a systematic review of the literature in the Medline database. Fifty-one peer-reviewed papers were selected from November 2005 to June 2012. MDTs resulted in better clinical and process outcomes for cancer patients, with evidence of improved survival among colorectal, head and neck, breast, oesophageal and lung cancer patients in the study period. Also, it was observed that MDTs have been associated with changes in clinical diagnostic and treatment decision-making with respect to urological, pancreatic, gastro-oesophageal, breast, melanoma, bladder, colorectal, prostate, head and neck and gynaecological cancer. Evidence is consistent in showing positive consequences for patients' management in multiple dimensions, which should encourage the development of structured multidisciplinary care, minimum standards and exchange of best practices.

Background The concept of neonatal near miss has been proposed as a tool for assessment of quality of care in neonates who suffered any life-threatening condition. However, there are no internationally agreed concepts or criteria for defining or identifying neonatal near miss. The purpose of this study was to perform a systematic review of studies and markers that are able to identify neonatal near miss cases and predict neonatal mortality. Methods Electronic searches were performed in the Medline, Embase and Scielo databases, with no time or language restriction, until December 2014. The term “neonatal near miss” was used alone or in combination with terms related to neonatal morbidity/mortality and neonatal severity scores. Study selection criteria involved three steps: title, abstract and full text of the articles. Two researchers performed study selection and data extraction independently. Heterogeneity of study results did not permit the performance of meta-analysis. Results Following the inclusion and exclusion criteria adopted, only four articles were selected. Preterm and perinatal asphyxia were used as near miss markers in all studies. Health indicators on neonatal morbidity and mortality were extracted or estimated. The neonatal near miss rate was 2.6 to 8 times higher than the neonatal mortality rate. Conclusions Pragmatic and management criteria are used to help develop the neonatal near miss concept. The most severe cases are identified and mortality is predicted with these criteria. Furthermore, the near miss concept can be used as a tool for evaluating neonatal care. It is the first step in building management strategies to reduce mortality and long-term sequelae.

The use of brief screening tools to identify inactive patients is essential to improve the efficiency of primary care-based physical activity (PA) programs. However, the current employment of short PA questionnaires within the Spanish primary care pathway is unclear. This study evaluated the validity of the Spanish version of a Brief Physical Activity Assessment Tool (SBPAAT). Methods A validation study was carried out within the EVIDENT project. A convenience sample of patients (n = 1,184; age 58.9±13.7 years; 60.5% female) completed the SBPAAT and the 7-day Physical Activity Recall (7DPAR) and, in addition, wore an accelerometer (ActiGraph GT3X) for seven consecutive days. Validity was evaluated by measuring agreement, Kappa correlation coefficients, sensitivity and specificity in achieving current PA recommendations with the 7DPAR. Pearson correlation coefficients with the number of daily minutes engaged in moderate and vigorous intensity PA according to the accelerometer were also assessed. Comparison with accelerometer counts, daily minutes engaged in sedentary, light, moderate, and vigorous intensity PA, total daily kilocalories, and total PA and ltime expenditure (METs-hour-week) between the sufficiently and insufficiently active groups identified by SBPAAT were reported. Results The SBPAAT identified 41.3%sufficiently active (n = 489) and 58.7% insufficiently active (n = 695) patients; it showed moderate validity (k = 0.454, 95% CI: 0.402–0.505) and a specificity and sensitivity of 74.3%and 74.6%, respectively. Validity was fair for identifying daily minutes engaged in moderate (r = 0.215, 95% CI:0.156 to 0.272) and vigorous PA (r = 0.282, 95% CI:0.165 to 0.391). Insufficiently active patients according to the SBPAAT significantly reported fewer counts/minute (-22%), fewer minutes/day of moderate (-11.38) and vigorous PA (-2.69), spent fewer total kilocalories/day (-753), and reported a lower energy cost (METs-hour-week) of physical activities globally (-26.82) and during leisure time (-19.62). Conclusions The SBPAAT is a valid tool to identify Spanish-speaking patients who are insufficiently active to achieve health benefits.

Objetivo: Avaliar qual o tipo de assistência médica utilizada pelo paciente que procura as "Campanhas da Catarata". Métodos: Foram realizadas 299 entrevistas com pacientes que participaram da "Campanha da Catarata" do dia 15 de abril de 2000, no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Resultados: Dos entrevistados 58,9% eram do sexo masculino e 41,1 % do sexo feminino; a idade média foi de 69,9 anos. A população estudada é composta principalmente por pessoas de baixa escolaridade (89,5% eram analfabetas ou com escolaridade até primeiro grau) e economicamente inativos em 70,9% (aposentados, 50,2%; desempregados, 8,3% e donas de casa, 12,5%). Os meios de assistência médica mais utilizados são serviço público em 87,0%, convênio médico em 8,0% e médico particular em 4,9%. Os principais motivos alegados pelos pacientes que dispunham de convênio e não o utilizaram, foram: não cobria a cirurgia em 25%, não dava cobertura para a lente intra-ocular em 33%. Conclusão: O público alvo da "Campanha da Catarata" atendido no HC-FMUSP é constituído por indivíduos de baixa escolaridade, a maioria não integrada no mercado de trabalho, e que utilizam como recurso de saúde o SUS ou convênios médicos que não cobrem os gastos da cirurgia de catarata. Projetos catarata dentro das condições realizadas por este estudo não atraem pacientes que possam pagar os custos da cirurgia de catarata. Purpose: To evaluate which kind of medical care cataract patients have. Methods: The authors of the survey conducted 299 interviews with patients who took part in the "Cataract Campaign" on April 15, 2000. Results: Among the interviewees, 58.9% were males, and 41.1% were females, with an average age of 69.9 years. Our population consisted largely of low educational level people (89.5% between illiteracy and elementary school level), and 70.9% are economically inactive (retired, 50.2%; unemployed, 8.3%; housewives 12.5%). The kind of medical care most frequently used was public health service (87.0%); followed by health insurance companies (8.0%) and private care (4.9%). The main reasons reported by patients who had health insurance but had not used it for the surgery were: the companies would not pay for the surgery (25.0%), would not provide the intraocular lens (33.0%). Conclusion: We conclude that the target public in the "Cataract Campaign" comprises low educational level individuals, most of them economically inactive. Even those who have health insurance seek for help in the campaign due to the lack of economical conditions. In the conditions of this study, the "Cataract Campaign" does not attract people who can pay for the surgery.

International audience; The design of new and more pervasive healthcare systems has been fostered by the increased expectancy of life in the coming years. In this field, distributed and networked wireless embedded systems, such as Wireless Sensor Networks (WSNs), suit well with the requirements of continuous monitoring of aged people for their own safety, without affecting their daily activities. WSN4QoL is a Marie Curie project which involves academic and industrial partners from three EU countries, and aims to propose new WSN-based technologies to meet the specific requirements of pervasive healthcare applications. This paper focuses on presenting a protocol stack architecture designed to support the solutions proposed in that project to enhance energy efficiency.

OBJECTIVES: The aim of this study was to analyse inequalities in the use of dental care services according to socioeconomic position (SEP) in individuals aged ≥50 years in European countries in 2006, to examine the association between the degree of public coverage of dental services and the extent of inequalities, and specifically to determine whether countries with higher public health coverage show lower inequalities. METHODS: We carried out a cross-sectional study of 12 364 men and 14 692 women aged ≥50 years from 11 European countries. Data were extracted from the second wave of the Survey of Health, Ageing and Retirement in Europe (SHARE 2006). The dependent variable was use of dental care services within the previous year, and the independent variables were education level as a measure of SEP, whether services were covered to some degree by the country's public health system, and chewing ability as a marker of individuals' need for dental services. Age-standardized prevalence of the use of dental care as a function of SEP was calculated, and age-adjusted indices of relative inequality (RII) were computed for each type of dental coverage, sex and chewing ability. RESULTS: Socioeconomic inequalities in the use of dental care services were higher in countries where no public dental care cover was provided than in countries where there was some degree of public coverage. For example, men with chewing ability from countries with dental care coverage had a RII of 1.39 (95%CI: 1.29-1.51), while those from countries without coverage had a RII of 1.96 (95%CI: 1.72-2.23). Women without chewing ability from countries with dental care coverage had a RII of 2.15 (95%CI: 1.82-2.52), while those from countries without coverage had a RII of 3.02 (95%CI: 2.47-3.69). CONCLUSIONS: Dental systems relying on public coverage seem to show lower inequalities in their use, thus confirming the potential benefits of such systems. This study uses data from SHARE release 2.5.0, as of 24 May 2011. The SHARE data collection has been primarily funded by the European Commission through the 5th framework programme (project QLK6-CT-2001- 00360 in the thematic programme Quality of Life), through the 6th framework programme (projects SHARE-I3, RII-CT2006-062193, COMPARE, CIT5-CT-2005-028857 and SHARELIFE, CIT4-CT-2006-028812) and through the 7th framework programme (SHARE-PREP, 211909 and SHARE-LEAP, 227822). Additional funding from the U.S. National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG4553-01 and OGHA 04-064, IAG BSR06-11, R21 AG025169)

Relay sensor networks are often employed in end-to-end healthcare applications to facilitate the information flow between patient worn sensors and the medical data center. Medium access control (MAC) protocols, based on random linear network coding (RLNC), are a novel and suitable approach to efficiently handle data dissemination. However, several challenges arise, such as additional delays introduced by the intermediate relay nodes and decoding failures, due to channel errors. In this paper, we tackle these issues by adopting a cloud architecture where the set of relays is connected to a coordinating entity, called cloud manager. We propose a cloud-assisted RLNC-based MAC protocol (CLNC-MAC) and develop a mathematical model for the calculation of the key performance metrics, namely the system throughput, the mean completion time for data delivery and the energy efficiency. We show the importance of central coordination in fully exploiting the gain of RLNC under error-prone channels.

O processo de consentimento livre e esclarecido é essencial para garantir aos pacientes o direito de opinar e decidir sobre seu tratamento médico; todavia, a expressão de coerção pode estar associada a essa prática de modo que o sujeito sente que não foi capaz de exercer sua autonomia e voluntariedade. Neste sentido, buscou-se compreender que fatores levaram os participantes a identificarem coerção ao expressarem-se em relação ao seu tratamento. O presente estudo é de caráter qualitativo e foi realizado por meio de entrevistas semiestruturadas com seis sujeitos que apresentaram algum grau de expressão de coerção. As entrevistas foram analisadas utilizando-se análise de conteúdo. Observou-se que a identificação, pelo paciente, de que não teve voz no tratamento parece interligada ao fornecimento de informação, às vivências junto ao hospital e a elementos como o tempo de vinculação à instituição, à gratidão e ao modo como as vivências foram integradas psiquicamente. The process of informed consent is essential to guarantee patients the right to opine and decide on their medical treatment. However, the expression of coercion may be associated with this practice by restricting the autonomy and willingness of the subject. Accordingly, we sought to understand what factors had influenced the perception of coercion manifested by the research subjects. This is a qualitative study, with the completion of semi-structured interviews with six subjects who had some degree of perceived coercion. The interviews were analyzed using content analysis. It is observed that this identification by the patient, who had no voice in the treatment appears linked to the provision of information, the experiences with the hospital, and the elements as time linking to the institution, to gratitude and how the experiences were integrated psychically. El proceso de consentimiento libre y esclarecido es esencial para garantir a los pacientes el derecho a opinar y decidir sobre su tratamiento médico. Sin embargo, la expresión de coerción puede estar asociada a esa práctica de manera que el sujeto sienta que no fue capaz de ejercer su autonomía y voluntariedad. Así, hemos tratado de comprender que factores llevaron a los sujetos de la pesquisa a identificar coerción para expresarse sobre su tratamiento. Es un estudio cualitativo, usando entrevistas semi-estructuradas con seis sujetos que presentaron algún grado de expresión de coerción. Las entrevistas fueron analizadas utilizando análisis de contenido. La percepción del paciente de que no tuvo voz en su tratamiento parece relacionada al suministro de información, las vivencias junto al hospital y a elementos como el tiempo de vinculación a la institución, a la gratitud y al modo como las vivencias fueron integradas psíquicamente.

Morbidade referida e utilização dos serviços de saúde no Município de São Benedito do Rio Preto, Estado do Maranhão, 1995. A morbida de referida foi feita através de inquérito domiciliar e relacionada com as variáveis sócio-econômicas e demográficas. O período recordatório em relação aos eventos informados foi de 30 dias. Buscou-se a taxa de procura por assistência médica, agente e saúde, balconista d e farmácia e benzedeira ou curandeiro. Investigou-se a assistência prestada às mulheres em idade fértil e a cobertura vacinal das crianças de 12 a 59 meses de idade. Das 1.813 pessoas da amostra, 19,7% a presentaram alguma doença, resultando nu m coeficiente d e prevalência de morbidade de 196, 91/1.000 habitantes. A taxa de procura por assistência médica foi de 25,8%, pelo agente de saúde 9,8% e igual para o balconista de farmácia e benzedeira ou curandeiro - 6.7%. Das 363 mulheres em idade fértil 27,3% engravidaram e a cobertura vacinal de pré-natal foi de 12,9%. A cobertura vacinal dascrianças de 12 a 59 meses de idade foi de 68% para a vacina Sabin, 60% para a DPT, 72,8% para a anti-sarampo e 78% para a BCG. Related morbidity and use of health services at São Benedito do Rio Preto districL state of Maranhão. The morbidity was investigated through domiciliary cross-sectional survey, and the data were analysed according to social economic and demographic variables. Considering the informed events, the surveyed period was of thirty (30) days. The demanding rate for medical assistance, health community agent, drugstore salesman and witchdoctor or shaman was searched. It was inquired about the assistance to women in fertile age and the vaccinal covering of children from 12 to 59 months of age. Among the 1,813 sampling people, 19.7% had some kind of disturbance, performing a general prevalence morbidity rate of 196.91/ 1,000 inhabitants. The demanding rate for medicai assistance was 25.8%; for the health community agent and the drugstore salesman, 9.8% for each one; and 6.7% for the witchdoctor or shaman. Among the 363 women in fertile age, 27.3% got pregnant, with a childbearing cover of 12.9%. The vaccinal cover of children from 12 to 59 months of age was 68.0% for Sabin, 60.0% for DTP, 72.8% for anti-measles, and 78.0% for BCG.

We describe conceptual innovations in palliative care epidemiology and the methods to identify patients in need of palliative care, in all settings.In middle-high-income countries, more than 75% of the population will die from chronic progressive diseases. Around 1.2-1.4% of such populations suffer from chronic advanced conditions, with limited life expectancy. Clinical status deteriorates progressively with frequent crises of needs, high social impact, and high use of costly healthcare resources.The innovative concept of patients with advanced chronic diseases and limited life prognosis has been addressed recently, and several methods to identify them have been developed.The challenges are to promote early and shared interventions, extended to all patients in need, in all settings of the social care and healthcare systems; to design and develop Palliative Care Programmes with a Public Health perspective. The first action is to identify, using the appropriate tools early in the clinical evolution of the disease, all patients in need of palliative care in all settings of care, especially in primary care services, nursing homes, and healthcare services responsible for care provision for these patients; to promote appropriate care in patients with advanced diseases with prognosis of poor survival.

Background: The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes. Methods: This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables. Results: The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p

Fundamento y objetivo: El 75% de las personas en nuestro país morirá a causa de enfermedades crónicas progresivas. La atención a la cronicidad avanzada es uno de los principales retos de los sistemas sanitarios públicos. Este estudio describe la elaboración de un instrumento de identificación de pacientes con enfermedades crónicas avanzadas y pronóstico de vida limitado que pueden requerir algún tipo de intervención paliativa en nuestro entorno sanitario y social. Material y método: Traducción al castellano del PIG/GSF, adaptación cultural y clínica, con identificación de indicadores de severidad y progresión -generales y específicos-; estudio de validez de contenido y pretest. Resultados: El instrumento NECPAL CCOMS-ICO propone una evaluación cuanticualitativa, multifac- torial, indicativa y no dicotómica que combina evaluaciones de percepción subjetiva (la pregunta sorpresa) con demanda y necesidades percibidas; parámetros de severidad y progresión, síndromes geriátricos, aspectos emocionales, comorbilidad y uso de recursos; e indicadores específicos para enfermedades seleccionadas. Conclusiones: El instrumento NECPAL CCOMS-ICO , factible y de fácil uso, permitiría identificar a los pacientes crónicos avanzados con necesidades paliativas de toda causa, de manera precoz y en todos los recursos. Background and objective: Around 75% of the population in our country will die as a consequence of chronic advanced diseases. Advanced chronic care is one of the major challenges for public health systems. This study describes the development of a tool to identify patients with advanced chronic diseases and life limited prognosis that might require some type of palliative intervention in our health and social environment. Material and methods: Spanish translation of PIG/GSF, cultural and clinical adaptation, identification of indicators of severity and progression -general and specific-; study of content validity and pre-test. Results: The NECPAL CCOMS-ICO tool proposes a quantitative-qualitative, multifactorial, indicative and not dichotomous evaluation combining subjective perception assessment (surprise question) with demand and perceived needs; parameters of severity and progression, geriatric syndromes, emotional aspects, comorbidity and use of resources; and indicators for selected pathologies.

The unprecedented prolongation of life in the United States has been accompanied by increased numbers of disabled people in their 80s and 90s, who have high needs for health care and social services. The paper reports longitudinal findings on 150 individuals, 85 years and older. Over three years, their functioning on activities of daily living significantly declined at the same time that they continued to described their health as good and to report contentment about their life. Families were active in sustaining community living of the oldest old, but those most at risk of institutionalization were the childless. Over time, 48% of the survivors stayed functionally fit, while 28% became increasingly disabled and dependent and 24% remained stable at a high level of disability. The means by which the oldest old coped with their disabilities include practical steps in simplifying their environment and narrowing their social world. They also used cognitive regulation by modifying their health beliefs and delimiting those areas over which they could exert a sense of control. O crescimento nos níveis de esperança de vida nos Estados Unidos da América tem sido acompanhado por um número crescente de pessoas inválidas nos seus 80-90 anos de idade, aumentando as demandas sobre os serviços de saúde e de assistência social. Este trabalho apresenta os resultados de investigação longitudinal, realizada com 150 indivíduos deidade superior a 85 anos. Ao longo de três anos, a capacidade funcional dos integrantes da amostra no desempenho de atividades rotineiras diárias declinou significativamente, ao mesmo tempo que os mesmos continuavam a referir sua saúde como sendo boa e a expressar contentamento sobre suas vidas. As famílias foram ativas no suporte à vida comunitária dos idosos mais velhos. Os de maior risco de institucionalização foram aqueles sem filhos. Ao longo do tempo, 48% dos sobreviventes permaneceram funcionais, enquanto 28% tornaram-se cada vez mais inválidos e dependentes, enquanto 24% permaneceram estáveis, apresentando alto grau de invalidez. As formas através das quais os idosos mais velhos lidavam com sua invalidez incluíram medidas no sentido de simplificar seu ambiente e reduzir seu mundo social. Elestambém lançaram mão de regulação cognitiva através da modificação de suas crenças sobre saúde, delimitando aquelas áreas sobre as quais eles podiam exercer algum controle.

Investiga as relações entre ensino, pesquisa e assistência médica mediante análise de documentos e relatos de nove professores do Departamento de Clínica Médica da Faculdade de Medicina da Universidade Federal do Rio de Janeiro. Os resultados apontaram forte tradição da bicentenária escola médica quanto às atividades de ensino e assistência médica e mostraram que, apesar de a atividade de pesquisa preceder a inauguração do tridecenário Hospital Universitário Clementino Fraga Filho, só depois de sua criação - paralelamente ao desenvolvimento da pós-graduação e ao surgimento da epidemiologia clínica - com a mudança radical da metodologia da pesquisa clínica, essa atividade acadêmica vem ganhando espaço na instituição. The article explores the relations between teaching, research, and health care through an analysis of documents and reports by a group of professors with the Department of Clinical Medicine at the Universidade Federal do Rio de Janeiro's School of Medicine. Findings suggest that the two-hundred year old medical school has a strong tradition in teaching and health care and that although research predated inauguration of the thirty-year-old Clementino Fraga Filho University Hospital, this academic activity has only gradually occupied a larger space within the institution following creation of the hospital, which brought a radical change in clinical research methodology, concomitant with the development of a graduate program and the emergence of clinical epidemiology.

Considerando a natureza problemática das tentativas de reformar os sistemas nacionais de prestação de serviços em saúde, este documento aborda o contexto e a lógica das reformas do setor. Após um retrospecto das abordagens do aumento de capacitação em três gerações de reformas do setor público, o documento examina as reformas aplicadas ao financiamento, organização e prestação dos serviços de saúde, e sugere estratégias para reformas que levem a capacidade em consideração. Given the problematic nature of attempts to reform national delivery systems for health care, the paper reviews the context and logic of reforms in the health sector. After a background on approaches to building capacity within three generations of public sector reforms, it examines the reforms applied to financing, organizing and delivering health services and suggests strategies for reform that take capacity into account.

Information and telecommunication technologies are called to play a major role in the changes that healthcare systems have to face to cope with chronic disease. This paper reports a telemedicine experience for the home care of chronic patients suffering from chronic obstructive pulmonary disease (COPD) and an integrated system designed to carry out this experience. To determine the impact on health, the chronic care telemedicine system was used during one year (2002) with 157 COPD patients in a clinical experiment; endpoints were readmissions and mortality. Patients in the intervention group were followed up at their homes and could contact the care team at any time through the call center. The care team shared a unique electronic chronic patient record (ECPR) accessible through the web-based patient management module or the home visit units. Results suggest that integrated home telemedicine services can support health professionals caring for patients with chronic disease, and improve their health.We have found that simple telemedicine services (ubiquitous access to ECPR, ECPR shared by care team, accessibility to case manager, problem reporting integrated in ECPR) can increase the number of patients that were not readmitted (51% intervention, 33% control), are acceptable to professionals, and involve low installation and exploitation costs. Further research is needed to determine the role of telemonitoring and televisit services for this kind of patients. This work was supported in part by the European Union under Research Grant CHRONIC (Information Society Technologies, Vth framework programme) and in part by the Spanish Ministry of Health and Consumer Affairs under Research Grant “Red de Telemedicina.”

A preventive occupational therapy program with children surviving the Kosovo conflict is examined. The objective of the program was to facilitate the emotional expression of traumatic experiences in order to prevent the development of future psychological problems. The intervention was based on a community-centred approach with spirituality as a central focus of the intervention.The Model of Human Occupation and the Occupational Performance Process Model were utilized to guide the identification and intervention of occupational performance issues.The children’s return from a land of war to a land of children demonstrates the potential of occupational therapy intervention in this field. With increasing awareness of populations facing social and political challenges, there is a growing importance of the concept of occupational justice and the need to work against occupational apartheid. Cet article décrit un programme de prévention en ergothérapie qui était destiné aux enfants ayant survécu au conflit du Kosovo. L’objectif du programme était d’aider les enfants à exprimer les émotions qu’ils avaient ressenties lors d’expériences traumatiques afin de prévenir l’apparition de problèmes psychologiques. L’intervention était basée sur une approche communautaire s’articulant autour de la spiritualité. Le Modèle de l’occupation humaine et le Modèle du processus d’intervention dans le rendement occupationnel ont été utilisés pour cibler les difficultés en matière de rendement occupationnel et pour déterminer les interventions requises. Le retour des enfants d’un monde de guerre vers le monde de l’enfance démontre la possibilité de proposer une intervention ergothérapique dans ce domaine. La conscientisation de plus en plus grand face à la détresse des populations confrontées à des problèmes politiques et sociaux entraîne une augmentation de l’importance du concept de la justice occupationnelle et du besoin de lutter contre l’apartheid occupationnel.

OBJETIVOS: identificar os fatores de risco para a mortalidade infantil pós-neonatal por diarréia e pneumonia relacionados à qualidade da assistência médica. MÉTODOS: estudo tipo caso-controle, de base populacional, de 277 óbitos infantis pós-neonatais por diarréia e pneumonia ocorridos na Região Metropolitana de Belo Horizonte, entre maio de 1991 a abril de 1992. Os casos foram comparados com controles hospitalares, emparelhados por patologia, idade e hospital. As informações sobre casos e controles foram coletadas através de prontuários médicos e entrevistas domiciliares, sendo analisadas algumas variáveis relacionadas à qualidade da assistência médica. Utilizou-se o teste de McNemar e o método de regressão logística condicional para a definição dos fatores de risco para o óbito. RESULTADOS: a regressão logística multivariada mostrou os seguintes fatores independentemente associados a maior risco de óbito pós-neonatal por diarréia e pneumonia: atraso vacinal (OR= 2,48; IC95%=1,17-5,23), estado geral (grave) à admissão hospitalar (OR=10,94; IC95%=4,91-24,34), não realização de procedimentos hospitalares (OR=10,08; IC95%= 3,55-20,59) e desnutrição presente no momento da internação (OR=3,58; IC95%=1,42-9,07). CONCLUSÕES: os resultados indicam a baixa qualidade da assistência médica como um importante fator de risco para o óbito infantil pós-neonatal por causas evitáveis. Os autores salientam a falta de integralidade entre as atividades ambulatoriais e hospitalares como importante determinante da baixa qualidade. Sem desconsiderar o papel preponderante das variáveis socioeconômicas, salienta-se a necessidade de uma ampla discussão sobre o desempenho dos serviços de saúde e mortalidade infantil evitável. OBJECTIVE: to identify the risk factors for postneonatal infant mortality caused by diarrhea and pneumonia in relation to the quality of medical assistance. METHODS: population-based case-control study of 277 postneonatal infant deaths caused by diarrhea and pneumonia occurring in the metropolitan area of Belo Horizonte, Brazil, between May/1991 and April/1992. The cases were compared with hospitalized controls, and matched by pathology, age and hospital. Information on cases and controls were collected from medical records and through home interviews. Some variables related to the quality of medical care were analyzed. McNemar test and conditional logistic regression were used to define the risk factors for postneonatal deaths. RESULTS: multiple logistic regression analysis showed the following factors independently associated with increased risk of postneonatal death induced by diarrhea and pneumonia: delayed immunization (OR = 2.48; 95%CI=1.17-5.23), general status (serious) on hospital admission (OR=10.94; 95%CI=4.91-24.34), unaccomplished hospital procedures (OR=10.08; 95%CI = 3.55-20.59) and malnutrition on hospital admission (OR=3.58; 95%CI=1.42-9.07). CONCLUSIONS: the results indicate the low quality of medical assistance as an important risk factor for avoidable causes of postneonatal deaths. The authors highlight the lack of integration between the outpatient clinic and hospital activities as an important determinant of low quality. It is necessary that the performance of health services and their effect on avoidable infant mortality be widely discussed, also taking into consideration the preponderant role of socioeconomic variables.

O presente estudo avaliou os óbitos de mulheres com idade de 10 a 49 anos, ocorridos em Recife, Pernambuco, nos anos 1992 e 1993, com a finalidade de identificar os fatores sócio-demográficos, gestacionais e da assistência médica associados a esses óbitos maternos. Foram levantadas e revisadas 1.013 declarações de óbito, sendo identificados 42 casos de morte materna. Os dados desses óbitos foram complementados com informações clínicas, de necrópsias e de entrevistas com médicos dos hospitais onde ocorreram os óbitos e com familiares das mulheres falecidas. Quase dois terços (62%) dos óbitos maternos ocorreram em mulheres de 20 a 29 anos de idade e mais da metade delas era solteira. Houve um maior número de óbitos nos partos cesarianos em relação aos vaginais. A maioria dos óbitos ocorreu nos três primeiros dias de hospitalização e aproximadamente 90% das despesas hospitalares foram custeadas pelo Sistema Único de Saúde (SUS). With the purpose of identifying the social, demographic, pregnancy-related and medical care factors associated with maternal death, this study evaluated all deaths of women aged 10 to 49 years occurring in Recife, Pernambuco, Brazil, during 1992 and 1993. The data were obtained reviewing 1,013 death certificates, with 42 cases of identified maternal deaths. The data of these deaths were complemented with information from medical records, autopsies and also interviews with physicians from the hospitals where the death took place, and with the dead women's relatives. Almost two thirds (62%) of maternal deaths occurred among women aged 20 to 29 years and more than half of them were single. There was a higher number of deaths among caesarean deliveries than among vaginal ones. The majority of deaths occurred within the first three days of hospitalization and approximately 90% of hospital charges were sponsored by the National Health System (SUS).

Foram analisadas as informações existentes em 1.646 declarações de óbito de residentes no Estado de São Paulo, falecidos em 1987, identificando-se a causa básica segundo as regras de seleção utilizadas internacionalmente. Foram calculados o indicador "Anos Potenciais de Vida Perdidos" e a mortalidade proporcional para a doença de Chagas e para a doença isquêmica do coração, considerando somente a população de 15 a 70 anos. A doença de Chagas esteve presente como causa básica em 0,9% da totalidade dos óbitos do Estado, mantendo tendência já identificada desde 1977. A participação proporcional da doença de Chagas no conjunto dos anos potenciais de vida perdidos do Estado, foi 1,1%, e da doença isquêmica do coração foi de 2,4%, enquanto que em termos de mortalidade proporcional os valores foram 1,2% e 4,0%, respectivamente. A distribuição das pessoas segundo região de residência mostra que o maior número de óbitos ocorreu na Grande São Paulo, enquanto que Ribeirão Preto apresentou o coeficiente mais elevado; 20,8% dos óbitos do Estado ocorreram em municípios diferentes daquele em que a pessoa residia, tendo essa taxa de evasão variado de 17,8% a 29,1% nas diversas regiões. A comparação desses dois subgrupos mostrou uma maior diferença em relação à variável sexo, uma vez que 22,8% dos homens faleceram num município diferente, tendo sido verificado esse fato em 17,4% das mulheres. Confirmou-se a importância desse quadro no Estado de São Paulo, e ao mesmo tempo identificou-se informações relativas à distribuição da doença em várias regiões, quer em termos de se conhecer o risco de mortalidade da população adulta, quer em termos de planejamento de atenção ao chagásico. In order to estimate the size of the population with Chagas' disease, an essential parameter for the establishment of an adequate health care policy for this group of patients, data from 1,646 death certificates from the "Fundação Sistema Estadual de Análises de Dados" in which Chagas' disease was mentioned in the State of S. Paulo in 1987 were examined. The population under study comprised adults between 15 and 70 years of age. Objectives also included the determination of Proportional Mortality, Potentially Lost Years of Life and regional distribution of the events in the counties of the State of S. Paulo. Chagas disease accounted for 0.9% of the totality of the causes of death, Proportional Mortality was 1.2% and the proportional participation of Chagas' disease in the Potentially Lost Years of Life was 1.1%. Corresponding data for Ischemic Heart Disease were, 4.0% and 1.2%. 20.8% of the deaths occurred in counties other than the county of residence, the indexes of evasion varying from 17.8% to 29.1% for different regions. Males (22.8%) more often than females (17.4%) died outside their county of residence. The largest number of deaths occurred in the metropolitan area of S. Paulo, although Ribeirão Preto county presented the highest mortality indexes.

Este trabalho relata experiência de inversão do modelo tecno-assistencial para a saúde, tendo como base a diretriz operacional do acolhimento. O acolhimento propõe que o serviço de saúde seja organizado, de forma usuário-centrada, partindo dos seguintes princípios: 1) atender a todas as pessoas que procuram os serviços de saúde, garantindo a acessibilidade universal; 2) reorganizar o processo de trabalho, a fim de que este desloque seu eixo central do médico para uma equipe multiprofissional equipe de acolhimento , que se encarrega da escuta do usuário, comprometendo-se a resolver seu problema de saúde; e 3) qualificar a relação trabalhador-usuário, que deve dar-se por parâmetros humanitários, de solidariedade e cidadania. Por meio da investigação realizada, foi possível observar um aumento significativo do rendimento profissional, dos servidores não-médicos, que passaram a atuar na assistência; esse elevado rendimento profissional determinou, por conseqüência, maior oferta e aumento extraordinário da acessibilidade aos serviços de saúde. The subject of this paper is changes in health care when "user embracement" is used as a strategic aim. According to the "user embracement" concept, health care clients are the center of the health services' organization, including the following: 1) care for everyone seeking it, thus guaranteeing universal accessibility; 2) reorganization of the work process, such that its central thrust is shifted from the physician to the multiprofessional staff, or "user embracement team", in charge of "hearing" users and becoming involved in solving their health problems; and 3) solidarity, humanity, and citizenship as parameters for the relationship between health care users and providers. The research showed improvement of non-medical health care productivity and greater accessibility by users. After nine months, the "user embracement team" solved 50% of the health problems themselves. The above-mentioned effects were also linked to workers' motivation, leading to greater creativity in the work process.

O objetivo deste estudo foi avaliar a qualidade do manejo de casos de infecções respiratórias agudas (IRA) em crianças e identificar possíveis barreiras na atenção prestada. Utilizou-se desenho transversal em amostra representativa de unidades de saúde primárias e ambulatoriais do setor público no Rio de Janeiro. Médicos foram observados atendendo menores de cinco anos com IRA. Em seguida, as crianças foram avaliadas com a utilização de normas padronizadas e os resultados comparados. Foram entrevistados os médicos e avaliados os serviços quanto à disponibilidade de medicamentos. Estudaram-se 29 unidades: 2 hospitais, 20 centros e 7 postos de saúde; observaram-se 267 crianças e entrevistaram-se 46 médicos. A sensibilidade da classificação utilizada pelos médicos para detectar pneumonia foi de 21,8 (IC 95%: 9,3-40,4), a especificidade 77,3 (IC 95%: 70,3-82,4) e a acurácia de 70,6 (IC 95%: 64,7-75,5). Em 8,9% dos casos de IRA antibióticos foram prescritos inapropriadamente. Havia disponibilidade de antibióticos padronizados em todas as unidades. Concluiu-se que a qualidade do manejo da criança com IRA pode ser aprimorada, em especial para os casos mais graves, sendo necessário reforçar a capacitação, a supervisão e a organização da atenção e dos serviços.

Realiza-se, neste artigo, uma reflexão sobre a constituição da pediatria social no Brasil, compreendendo-a como um movimento de formação de propostas de reformas da atenção à saúde da criança, que contempla uma tripla proposta reformista: do ensino, do serviço e da prática pediátricos. O trabalho inclui uma recuperação histórica e bibliográfica do campo da pediatria social que é relativo ao cuidado com a criança e a forma de prestá-lo, analisando-o através de suas relações com os movimentos mais gerais de reforma do ensino médico e da atenção à saúde. Tece, ainda, considerações sobre seu arcabouço conceitual, com base nas definições e formulações sobre o tema apontadas por alguns autores.

A crise de custos no setor saúde colocou em discussão a assistência médica, assim como a avaliação dos seus resultados enquanto investimento setorial, sendo que a importância do principal ator nessa dinâmica o médico tem sido ressaltada. Este artigo faz uma revisão das principais vertentes de análise do profissionalismo médico nas últimas décadas e discute a mudança de paradigma que se operou mais recentemente, quando emergem enfoques que procuram correlacionar as novas divisões de trabalho contidas nas especializações cada vez mais fragmentadas com as mudanças estruturais históricas do mercado de trabalho profissional e a ação coletiva desenvolvida por esses grupos na sua inter-relação com o Estado. Esse último enfoque, pode-se dizer mais vinculado à economia política, tem aportado importantes contribuições a esse debate, uma vez que permite questionar as polarizações ideológicas, e sem fundamento analítico, presentes nas propostas de reforma da assistência médica, que preconizam a retirada do Estado e o reinado do mercado, assim como deslocam a regulação para uma posição externa à própria dinâmica, mutável historicamente, das relações Estado/profissionais/clientes/sistemas de saúde. A cost crisis in the health care sector has focused discussion on health care services and an assessment of the results of investments in the health sector, underlining the importance of medical doctors as key actors in this area. This article reviews the main analytical approaches to professionalism in the last decade and discusses the most recent paradigmatic shifts. New approaches have emerged for correlating the medical division of labor (contained in specialized fields which are becoming more and more fragmented) with structural and historical changes in the professional market, as well as the collective action developed by these interest groups in their relationship to the state. These approaches, more closely linked to political economy, have made important contributions to this debate, because they allow for a questioning of the kind of ideological polarization contained in health care reform proposals aimed at a withdrawal of the state and the rule of the market (with no analytical justification), in addition to shifting regulation to a position outside the historically mutable dynamics between the state, health care providers, and clients of the health care sector and the public policy arena.

Após breve discussão de aspectos da assistência médica ambulatorial, são apresentadas as propostas de reorganização dos serviços ambulatoriais do Hospital de Clínicas da Universidade do Estado do Rio de Janeiro com vistas ao estabelecimento de um programa de medicina integral. Também são apresentados os dados de uma pesquisa sobre padrões de utilização do ambulatório. Alguns aspectos docentes do programa são discutidos. After discussing some aspects of dispensary medical care, proposals on the reorganization of the outpatient Department of the Rio de Janeiro University Teaching Hospital in an attempt to establish a Primary Health Care Programme are presented. The findings of a survey on utilization patterns of the oupatient services are also presented. Some teaching aspects of the programme are discussed.

Uma síntese histórica demonstra que o hospital tem voltado sua assistência para os aspectos da medicina curativa, para o que muito têm contribuído os progressos de diagnóstico e terapêutica. Os lazaretos e sua versão posterior, os hospitais de isolamento, por sua vez, colaboraram para que o hospital geral se mantivesse afastado, até recentemente, da assistência às doenças infecto-contagiosas e até o presente, ao mal de Hansen, sendo referidas as exceções de hospitais escolas de São Paulo. É destacada a importância da educação do corpo clínico, administração e pacientes dos hospitais, bem como do público em geral, como meio de tornar factível, a curto prazo, a integração da assistência dos portadores de hanseníase nos hospitais gerais. Como solução, é proposto o enfoque sistêmico, sendo ressaltado o valor da hanseníase ser considerada como componente normal da problemática geral de saúde e não como um aspecto isolado. As vantagens da adoção desse enfoque são apontadas, situando o hanseniano na multidão assistida pelos hospitais, de forma a torná-lo um paciente qualquer. A historical synthesis shows that the hospital has turned its attention towards the curative aspects of medicine. Diagnosis and therapeutic progress have much contributed towards this, in especial. The lazarets and their later version, the isolation hospitals, have helped in maintaining the general hospitals away, until very recently, from Hansen's disease. The medical school hospitals of São Paulo are exceptions. The importance of the education of the medical and administrative staff, the patients of the hospital, as well as the general public is stressed as being the only way of integrating assistance to the bearers of Hansen's disease in the general hospitals within a short period. A systematic approach is proposed as the solution, as Hansen's disease ought to be considered as a normal component of the general health programme. The advantages of including the patient with Hansen's disease in the general hospital's clientele in order to treat him as any other are also pointed out.

Foi feito levantamento das instituições para pessoas idosas, exceto em hospitais, no município de São Paulo, Brasil, do número de leitos nestas casas, e de aspectos de assistência prestada à saúde das pessoas nelas residentes. Formulou-se a pergunta se o número de leitos influi nesta assistência, no sentido de que instituições com grande número de leitos possa oferecer maior número e variedade dos componentes desta assistência. O resultado da indagação respondeu positivamente a esta pergunta.

Background Expert systems can help alleviate problems related to the shortage of human resources in critical care, offering expert advice in complex situations. Expert systems use contextual information to provide advice to staff. In mechanical ventilation, it is crucial for an expert system to be able to determine the ventilatory mode in use. Different manufacturers have assigned different names to similar or even identical ventilatory modes so an expert system should be able to detect the ventilatory mode. The aim of this study is to evaluate the accuracy of an algorithm to detect the ventilatory mode in use. Methods We compared the results of a two-step algorithm designed to identify seven ventilatory modes. The algorithm was built into a software platform (BetterCare® system, Better Care SL; Barcelona, Spain) that acquires ventilatory signals through the data port of mechanical ventilators. The sample analyzed compared data from consecutive adult patients who underwent >24 h of mechanical ventilation in intensive care units (ICUs) at two hospitals. We used Cohen’s kappa statistics to analyze the agreement between the results obtained with the algorithm and those recorded by ICU staff. Results We analyzed 486 records from 73 patients. The algorithm correctly labeled the ventilatory mode in 433 (89 %). We found an unweighted Cohen’s kappa index of 84.5 % [CI (95 %) = (80.5 %: 88.4 %)]. Conclusions The computerized algorithm can reliably identify ventilatory mode. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1436-9) contains supplementary material, which is available to authorized users.

Josep Franch-Nadal,1,2 Elena Labrador Barba,3 M Carmen Gómez-García,4 Pilar Buil-Cosiales,5 José Manuel Millaruelo,6 María Luisa Orera Peña3 1AEP Raval Sud, Barcelona, 2Center for Biomedical Research Network of Diabetes and Associated Metabolic Diseases (CIBERDEM), Madrid, 3Established Pharmaceuticals Division, Mylan EPD, Madrid, 4Centro de Salud Velez Norte, Málaga, 5Centro de Salud Azpilagana, Pamplona, 6Centro de Salud Torrero La Paz, Zaragoza, Spain Objective: Understanding patients’ and physicians’ perceptions of type 2 diabetes mellitus (T2DM) management and treatment has important implications for diabetes care, allowing the identification of clinical practice issues that could be improved, leading to patients’ better understanding of the illness and, consequently, healthier self-management behaviors. The objective of this study was to identify differences between physicians’ and T2DM patients’ perceptions related to health status, patient-reported outcomes assessments, and T2DM management and treatment, in routine clinical practice in Spain.Methods: This was an observational, cross-sectional study including 1,012 T2DM patients and 974 physicians from 47 and 52 Spanish provinces, respectively. An electronic structured self-administered questionnaire containing 17 questions was designed aiming to address both physicians’ and patient’s perceptions on overall T2DM health status and patient-reported outcomes.Results: T2DM patients perceived a worse health status (40% reported having a “good” and 38% a “neither good nor bad” health status) compared with physicians’ perceptions (77% thought patients had a “good” health status). Most patients answered being “satisfied” or “neither satisfied nor unsatisfied” with the given information, while physicians considered that patients were “satisfied” or “very satisfied” with the information for self-monitoring blood glucose and treatment administration. Fifty-seven percent of patients reported that medical recommendations were “important”, while 58% of physicians considered it as “very important”. Fifty-three percent of patients perceived that their current T2DM treatment suited their preferences “quite a lot”, and this was lower than the proportion of physicians (69%) that believed this for their patients. Additionally, a lower percentage of patients (53%) than physicians (79%) believed that their treatment improved their health-related quality of life “quite a lot”. All differences between patients and physicians were statistically significant (P

Background The Spanish National Health System recognised multidisciplinary care as a health priority in 2006, when a national strategy for promoting quality in cancer care was first published. This institutional effort is being implemented on a co-operative basis within the context of Spain's decentralised health care system, so a high degree of variability is to be expected. This study was aimed to explore the views of professionals working with multidisciplinary cancer teams and identify which barriers to effective team work should be considered to ensure implementation of health policy. Methods Qualitative interview study with semi-structured, one-to-one interviews. Data were examined inductively, using content analysis to generate categories and an explanatory framework. 39 professionals performing their tasks, wholly or in part, in different multidisciplinary cancer teams were interviewed. The breakdown of participants' medical specialisations was as follows: medical oncologists (n = 10); radiation oncologists (n = 8); surgeons (n = 7); pathologists or radiologists (n = 6); oncology nurses (n = 5); and others (n = 3). Results Teams could be classified into three models of professional co-operation in multidisciplinary cancer care, namely, advisory committee, formal co-adaptation and integrated care process. The following barriers to implementation were posed: existence of different gateways for the same patient profile; variability in development and use of clinical protocols and guidelines; role of the hospital executive board; outcomes assessment; and the recording and documenting of clinical decisions in a multidisciplinary team setting. All these play a key role in the development of cancer teams and their ability to improve quality of care. Conclusion Cancer team development results from an specific adaptation to the hospital environment. Nevertheless, health policy plays an important role in promoting an organisational approach that changes the way in which professionals develop their clinical practice.

Connected health devices are generally designed for unsupervised use, by non-healthcare professionals, facilitating independent control of the individuals own healthcare. Older adults are major users of such devices and are a population significantly increasing in size. This group presents challenges due to the wide spectrum of capabilities and attitudes towards technology. The fit between capabilities of the user and demands of the device can be optimised in a process called Human Centred Design. Here we review examples of some connected health devices chosen by random selection, assess older adult known capabilities and attitudes and finally make analytical recommendations for design approaches and design specifications. This research was part funded by the European Project WIISEL (Wireless Insole for Independent and Safe Elderly Living) [81] which was created to decrease the incidence of falls in the older adult population. Coordinated by CETEMMSA, it is co-funded by the European Commission (FP7-ICT, Project reference: 288878) for 3 years, with 3.9 M€ budget and 8 partners from 6 different countries. peer-reviewed

Joan Trujols,1,2 Ioseba Iraurgi,3 Eugenia Oviedo-Joekes,4,5 Joan Guàrdia-Olmos61Unitat de Conductes Addictives, Servei de Psiquiatria, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, 2Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, 3DeustoPsych – Unidad de Investigación, Desarrollo e Innovación en Psicología y Salud, Universidad de Deusto, Bilbao, Spain; 4School of Population and Public Health, University of British Columbia, 5Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, Canada; 6Departament de Metodologia de les Ciències del Comportament, Facultat de Psicologia, Institut de Recerca en Cervell, Cognició i Conducta (IR3C), Universitat de Barcelona, Barcelona, SpainBackground: Satisfaction with services represents a key component of the user's perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case.Methods: We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services.Results: Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient's perspective, the results are not as consistent as might be expected. It is not uncommon to find that “highly satisfied” patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions.Conclusion: User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted – and rarely acted on in the case of nonoptimal results – should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys.Keywords: patient satisfaction, substance abuse treatment services, harm reduction services, patient-centered evaluation, service user perspective, user involvement

Objective: Few studies have prospectively evaluated the utility of geriatric assessment tools as predictors of mortality in the oldest population. We investigated predictors of death in an oldest-old cohort after 3 years of follow-up. Methods: The Octabaix study is a prospective, community-based study with a follow-up period of 3 years involving 328 subjects aged 85 at baseline. Data were collected on functional and cognitive status, co-morbidity, nutritional and falls risk, quality of life, social risk, and long-term drug prescription. Vital status for the total cohort was evaluated after 3 years of follow-up. Results: Mortality after 3 years was 17.3%. Patients who did not survive had significantly poorer baseline functional status for basic and instrumental activities of daily living (Barthel and Lawton Index), higher co-morbidity (Charlson), higher nutritional risk (Mini Nutritional Assessment), higher risk of falls (Tinetti Gait Scale), poor quality of life (visual analog scale of the Quality of Life Test), and higher number of chronic drugs prescribed. Cox regression analysis identified the Lawton Index (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73-0.89) and the number of chronic drugs prescribed (HR 1.09, 95% CI 1.01-1.18) as independent predictors of mortality at 3 years. Conclusions: Among the variables studied, the ability to perform instrumental activities of daily living and using few drugs on a chronic basis at baseline are the best predictors of which oldest-old community-dwelling subjects survive after a 3-year follow-up period.

Background The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. Objective To assess physicians’ satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. Methods This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. Results Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. Conclusion This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.