Heath care utilization after birth in Brazil: a national study

Background

The Brazilian Ministry of Health recommends primary health care actions for women and babies in the first week after birth, with the aim of monitoring health status, screening for diseases, vaccination, support for breastfeeding and promoting contraception. However, data on these actions are not available at the national level. This study aims to estimate the use of outpatient health services in the postpartum period and to verify the demographic, socioeconomic and obstetric factors associated with this use.

Methods

National hospital-based study, conducted in 2011-2012, with an interview of 23,894 women. Estimates were calculated for eight indicators of health service use with performance assessed as “satisfactory” (75-100%), “partial” (50-74%) and “unsatisfactory” (<50%). Multiple logistic regression was performed to verify the association between women's characteristics and each of the analyzed indicators.

Results

”Demand for postpartum consultation” (73.9%; 95% CI: 72.4-75.3%), “demand for newborn consultation” (91.6%; 95% CI: 90.6% - 92.5%), “BCG vaccination” (99.0%; 95% CI 98.7% - 99.2%) and “Hepatitis B vaccination” (96.8%; 95% CI 96.0%-97.5%) were considered satisfactory. “Neonatal screening test in the first week of life” was considered partial (60.1%; 95% CI 57.6% - 62.6%), while “consultation of the woman in the first 15 days after delivery” (37.0% 95% CI 35.0-39.0%),”consultation of the newborn in the first seven days of life”(21.8% 95% CI 20.2% - 23.5%) and “receiving the result of neonatal screening in the first month of life” (29.8% CI 95% 27.6%-32.2%) were considered unsatisfactory. Regional and social inequalities were identified, with the worst performance of all indicators in the less developed North and Northeast regions and in the most vulnerable women.

Conclusions

There is a need for better organization and provision of services, aiming to increase the coverage of postpartum and childcare actions and to reduce health inequalities.

Key messages

Low coverage of postnatal actions limits access to effective health care practices, putting mothers and babies at greater risk of illness and death. Regional and social inequalities and worse performance of health actions that depend exclusively on primary care services suggest barriers to access and failures in the organization of services.

Determination of Aflatoxin B1 in Baby Food (Infant Formula) by Immunoaffinity Column Cleanup Liquid Chromatography with Postcolumn Bromination: Collaborative Study

A collaborative study was conducted to evaluate the effectiveness of an immunoaffinity column cleanup liquid chromatography (LC) method for determination of aflatoxin B1 in a milk powder based infant formula at a possible future European regulatory limit (0.1 ng/g). The test portion was extracted with methanol–water (8 + 2 [v + v]), filtered, diluted with water, and applied to an immunoaffinity column. The column was washed with water to remove interfering compounds, and the purified aflatoxin B1 was eluted with methanol. The separation and determination of the aflatoxin B1 was performed by reversed-phase LC and detected by fluorescence after postcolumn derivatization (PCD) involving bromination. PCD was achieved with either pyridinum hydrobromide perbromide (PBPB) or an electrochemical (Kobra) cell by addition of bromide to the mobile phase. The baby food (infant formula) test samples, both spiked and naturally contaminated with aflatoxin B1, were sent to 14 laboratories in 13 different European countries. Test portions were spiked at levels of 0.1 and 0.2 ng/g for aflatoxin B1. Recoveries ranged from 101 to 92%. Based on results for spiked test samples (blind pairs at 2 levels) and naturally contaminated test samples (blind pairs at 3 levels), the relative standard deviation for repeatability (RSDr) ranged from 3.5 to 14%. The relative standard deviation for reproducibility (RSDR) ranged from 9 to 23%. Nine participants used PBPB derivatization, and 5 particpants used the Kobra cell. There was no evidence of method performance depending on the derivatization method used. The method showed acceptable within- and between-laboratory precision for baby food matrix, as evidenced by HORRAT values, at the target levels of determination for aflatoxin B1.

P2618Association of left ventricular ejection fraction with mortality and hospitalizations

Background

Although 2-dimensional echocardiography (2DE) is widely used to measure left ventricular ejection fraction (LVEF), the prognostic value of 2DE-derived LVEF has not been clearly demonstrated in a broad range of patients, including those acutely hospitalized as well as ambulatory patients. In particular, the prognostic value of echocardiographic LVEF has not been demonstrated for cardiovascular and heart failure hospitalizations.

Purpose

To determine if greater degrees of LV dysfunction are associated with progressively increasing risks of death or cardiovascular hospitalizations among patients undergoing echocardiography in hospital or outpatient settings.

Methods

We examined quantitative LVEFs from patient-level echocardiographic reports at 3 large hospital laboratories, which were linked to the Canadian Institute for Health Information hospitalization database and to death registries in Ontario, Canada. LVEF was categorized as <25%, 25–35%, 36–45%, or 46–55% (reference). Analyses were performed using cause-specific hazard competing risk models and stratified by: a) outpatient vs. inpatient echocardiogram, and b) if inpatient study, whether the reason for hospitalization was cardiac or noncardiac in nature.

Results

In the echocardiographic cohort of 27,323 patients (median age 68 [IQR: 58–77], 14,828 women [31.7%]), greater reductions in LVEF were associated with higher rates of all-cause mortality, with adjusted hazard ratios (95% CI) of 1.67 (1.57, 1.77) for LVEF <25%, 1.30 (1.24, 1.36) for LVEF 25–35%, and 1.17 (1.11, 1.23) for LVEF 36–45%, compared to LVEF 46–55% (all p<0.001). The cumulative incidence of cardiovascular death was higher as LVEF progressively worsened (Figure). The rate of heart failure hospitalizations was also increased with hazard ratios of 1.71 (1.59, 1.85) for LVEF <25%, 1.39 (1.31, 1.48) for LVEF 25–35%, and 1.21 (1.13, 1.29) for LVEF 36–45%, compared to LVEF 46–55% (all p<0.001). Cardiovascular hospitalizations were also increased with hazard ratios of 1.35 (1.27, 1.42), 1.21 (1.16, 1.27), and 1.13 (1.07, 1.18) for LVEFs <25%, 25–35%, and 36–45%, respectively (all p<0.001). The risk of mortality and hospitalizations increased comparably with greater reductions in LVEF during both inpatient cardiac or noncardiac admissions (p<0.001).

Cumulative incidence of CV death

Conclusions

Quantitative LVEF assessed by 2DE is potent prognostically and was able to stratify the risk of both death and hospitalization outcomes in a wide range of clinical settings. Patients with reduced LVEF measured on inpatient or outpatient echocardiograms, and even in the context of non-cardiac admission, should be considered an at-risk group in whom quality of care metrics could be evaluated in future studies.

Acknowledgement/Funding

Canadian Institutes of Health Research, Heart and Stroke Foundation, and the Ted Rogers Centre for Heart Research

Endothelin receptor antagonist therapy in congenital heart disease with shunt-associated pulmonary arterial hypertension: a qualitative systematic review

BACKGROUND

Congenital heart disease (CHD) with systemic-topulmonary shunting is associated with pulmonary arterial hypertension (PAH). There are similar clinical and pathophysiological features between CHD with shunt-associated PAH and idiopathic PAH. Endothelin-receptor antagonists (ERAs) are oral medications that improve pulmonary hemodynamics, symptoms and functional capacity in many PAH patients. However, the role of ERAs in CHD with shunt-associated PAH is unclear.

METHODS

MEDLINE, EMBASE and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases were searched for articles published from 1966 through September 2006, as well as bibliographies of all retrieved papers. All published English-language studies of adult CHD patients with shunt-associated PAH treated with ERAs were reviewed for clinical, functional and hemodynamic outcomes.

RESULTS

Ten studies of 174 adult CHD subjects with shunt-associated PAH were identified. Other than one placebo-controlled, randomized clinical trial, all studies were open-label, uncontrolled observational trials. Subjects were treated with the ERA bosentan for a mean (+/- SD) of 9+/-7 months. Nine studies reported improved World Health Organization (WHO) modification of the New York Heart Association functional class, with 95 of 164 subjects (58%) improving by at least one functional class. The 6 min walk distance improved in all eight studies in which it was assessed. Bosentan was generally well tolerated; 2.3% of subjects withdrew because of elevated liver enzymes. Two patients with WHO functional class IV PAH died during bosentan therapy.

CONCLUSION

Treatment of CHD patients with shunt-associated PAH with the ERA bosentan is associated with an improvement in functional class and objectively measured exercise capacity. The consistency of the uncontrolled data and the positive results of a single randomized clinical trial suggest a role for ERA therapy in CHD patients with shunt-associated PAH. Caution is suggested when considering bosentan therapy for CHD patients with WHO functional class IV PAH.

Sulfur metabolism in bacteria associated with cheese

Metabolism of sulfur in bacteria associated with cheese has long been a topic of interest. Volatile sulfur compounds, specifically methanethiol, are correlated to desirable flavor in Cheddar cheese, but their definitive role remains elusive. Only recently have enzymes been found that produce this compound in bacteria associated with cheese making. Cystathionine beta- and gamma-lyase are found in lactic acid bacteria and are capable of producing methanethiol from methionine. Their primary function is in the metabolism of cysteine. Methionine gamma-lyase produces methanethiol from methionine at a higher efficiency than the cystathionine enzymes. This enzyme is found in brevibacteria, bacilli, and pseudomonads. Addition of brevibacteria containing this enzyme improves Cheddar cheese flavor. Despite recent progress in sulfur metabolism more information is needed before cheese flavor associated with sulfur can be predicted or controlled.