The House of the Brazilian Woman: impacts of a cross-sectoral public health policy for abused women

Issue

Violence against women is a serious public health concern in Brazil; the country ranks 5th globally for femicide and has high rates of intimate partner violence. In response, a national policy created the House of the Brazilian Woman (HBW). HBWs aimed at caring for abused women, are staffed 24/7 with multi-disciplinary teams; cross-sectoral services include: psychosocial support; healthcare; specialized police; courts; public attorney's offices; temporary shelter; and access to financial support.

Description of the Problem

The purpose of this study was to characterize the preliminary impacts of the HBW of Curitiba. Based on mixed-methods participatory action-research, data were collected between 2018-2020. We present quantitative measures describing the individuals served and a thematic analysis of in-depth interviews with HBW staff.

Results

Since its opening, in 2016, the HBW of Curitiba has served around 50,000 users, including women and perpetrators. The most prevalent type of violence reported was psychological (67%, n = 14,343), followed by physical (25.8%, n = 5,531), economic (5.2%, n = 1,104) and sexual (2%, n = 428). Positive qualitative impacts perceived by staff were: 1) improved women's empowerment; 2) the importance of centralized resources; 3) acting as a support to ensure existing legal protections. The main challenges were: 1) high demand; 2) discontinuous care; 3) negative impacts on staff's health.

Lessons

The HBW of Curitiba is a key cross-sectoral service for abused women, part of a greater national policy to prevent violence and support women. Despite serving a large number of women in a short period of time challenges remain including integration with other parts of the network and considerations of staff burnout.

Key messages

Effective cross-sectoral policies for abused women are paramount for comprehensive women’s health. Having cross-sectoral services in just one place operating 24/7 has high impact for abused women.

Mortality event involving larvae of the carpet shell clam Ruditapes decussatus in a hatchery: isolation of the pathogen Vibrio tubiashii subsp. europaeus

Diseases caused by bacteria belonging to the genus Vibrio are a common, as yet unresolved, cause of mortality in shellfish hatcheries. In this study, we report the results of routine microbiological monitoring of larval cultures of the carpet shell clam Ruditapes decussatus in a hatchery in Galicia (NW Spain). Previous episodes of mortality with signs similar to those of vibriosis affecting other species in the installation indicated the possibility of bacterial infection and led to division of the culture at the early D-veliger larval stage. One batch was cultured under routine conditions, and the other was experimentally treated with antibiotic (chloramphenicol). Differences in larval survival were assessed, and culturable bacterial population in clams and sea water was evaluated, with particular attention given to vibrios. Severe mortalities were recorded from the first stages of culture onwards. The pathogen Vibrio tubiashii subsp. europaeus was detected in both batches, mainly associated with larvae. Moreover, initial detection of the pathogen in the eggs suggested the vertical transmission from broodstock as a possible source. Experimental use of antibiotic reduced the presence and diversity of vibrios in sea water, but proved inefficient in controlling vibrios associated with larvae from early stages and it did not stop mortalities.

Phytoplankton production systems in a shellfish hatchery: variations of the bacterial load and diversity of vibrios

AIMS

Outbreaks of disease caused by some Vibrio species represent the main production bottleneck in shellfish hatcheries. Although the phytoplankton used as food is one of the main sources of bacteria, studies of the associated bacterial populations, specifically vibrios, are scarce. The aim of the study was the microbiological monitoring of the microalgae as the first step in assessing the risk disease for bivalve cultures.

METHODS AND RESULTS

Two phytoplankton production systems were sampled weekly throughout 1-year period in a bivalve hatchery. Quantitative analysis revealed high levels of marine heterotrophic bacteria in both systems throughout the study. Presumptive vibrios were detected occasionally and at low concentrations. In most of the cases, they belonged to the Splendidus and Harveyi clades.

CONCLUSIONS

The early detection of vibrios in the microalgae may be the key for a successful bivalve culture. Their abundance and diversity were affected by factors related to the hatchery environment.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work represents the first long study where the presence of vibrios was evaluated rigorously in phytoplankton production systems and provides a suitable microbiological protocol to control and guarantee the quality of the algal cultures to avoid the risk of transferring potential pathogens to shellfish larvae and/or broodstock.

Vibrios in hatchery cultures of the razor clam, Solen marginatus (Pulteney)

Hatchery culture of the razor clam, Solen marginatus (Pulteney), has recently been developed in Galicia (NW Spain). However, recurrent episodes of mortalities of larval and post-larval cultures have been recorded during the course of various studies. The disease signs were similar to those described for other bivalve species in outbreaks caused by bacteria of the genus Vibrio. In this article, we present the results of microbiological monitoring of two batches of razor clams with different survival rates. All fermentative isolates were identified as members of the Splendidus clade within the genus Vibrio. Some of these isolates, identified as Vibrio splendidus-like, were clearly associated with the batch suffering mortalities, indicating their possible role as pathogens. Similar strains were found in the broodstock, suggesting vertical transmission of these bacteria. This is the first study of the microbiota associated with hatchery culture of S. marginatus, and the results will provide useful information for the optimization of a protocol for hatchery culture of this bivalve species.

Recurrent ovarian dysgerminoma after laparoscopy

To our knowledge, recurrent dysgerminoma at the site of tumor removal by laparoscopy in a patient with stage IA disease has not been previously reported. A woman with ovarian dysgerminoma treated by laparoscopy and tumor removed through the cul-de-sac recurred the 17 months later at the site of tumor removal. She was successfully treated with etoposide, bleomycin, and cisplatin chemotherapy with complete response. This case illustrates the potential for surgical site implant of an ovarian dysgerminoma; surgeons should follow strict guidelines when performing laparoscopic procedures for ovarian malignancies in order to prevent this type of incident.

Recurrent ovarian dysgerminoma after laparoscopy

To our knowledge, recurrent dysgerminoma at the site of tumor removal by laparoscopy in a patient with stage IA disease has not been previously reported. A woman with ovarian dysgerminoma treated by laparoscopy and tumor removed through the cul-de-sac recurred the 17 months later at the site of tumor removal. She was successfully treated with etoposide, bleomycin, and cisplatin chemotherapy with complete response. This case illustrates the potential for surgical site implant of an ovarian dysgerminoma; surgeons should follow strict guidelines when performing laparoscopic procedures for ovarian malignancies in order to prevent this type of incident.

Phase III randomized pilot study comparing interferon alpha-2b in combination with radiation therapy versus radiation therapy alone in patients with stage III-B carcinoma of the cervix

This randomized pilot study was designed to determine whether the addition of interferon alpha-2b to standard radiation therapy offered an advantage in loco-regional control and survival over radiation therapy alone in a homogeneous group of patients with stage IIIB carcinoma of the cervix. Thirty-six patients were treated with a combination of interferon alpha-2b plus radiation therapy, and 38 patients were treated with radiation therapy alone. Patients with evidence of ureteral obstruction were excluded from the study. Evaluation of loco-regional response was determined by pelvic examination, cervical cytology, biopsies and CT scans when indicated. Survival time was measured from initiation of treatment to date of death or last follow-up. Patient characteristics were comparable between both study arms. The objective complete response rate was 67% in the combined therapy group and 55% in the radiation alone group (P = 0.454). With a median follow-up of 17 months for all patients and 31 months for live patients, 50% of the combined group survived vs. 39.5% of the radiation alone group (P = 0.424). We conclude that the addition of interferon alpha-2b to standard radiation therapy did not significantly improve loco-regional response or survival, although such a trend was noted. We encourage the design of a larger randomized study with sufficient power to detect meaningful differences to prove whether the tendency observed in the present investigation holds any promise to improve the outcome of these patients.

Phase III randomized pilot study comparing interferon α- 2b in combination with radiation therapy versus radiation therapy alone in patients with stage III-B carcinoma of the cervix

This randomized pilot study was designed to determine whether the addition of interferon α-2b to standard radiation therapy offered an advantage in loco-regional control and survival over radiation therapy alone in a homogeneous group of patients with stage IIIB carcinoma of the cervix. Thirty-six patients were treated with a combination of interferon α-2b plus radiation therapy, and 38 patients were treated with radiation therapy alone. Patients with evidence of ureteral obstruction were excluded from the study. Evaluation of loco-regional response was determined by pelvic examination, cervical cytology, biopsies and CT scans when indicated. Survival time was measured from initiation of treatment to date of death or last follow-up. Patient characteristics were comparable between both study arms. The objective complete response rate was 67% in the combined therapy group and 55% in the radiation alone group (P = 0.454). With a median follow-up of 17 months for all patients and 31 months for live patients, 50% of the combined group survived vs. 39.5% of the radiation alone group (P = 0.424). We conclude that the addition of interferon α-2b to standard radiation therapy did not significantly improve loco-regional response or survival, although such a trend was noted. We encourage the design of a larger randomized study with sufficient power to detect meaningful differences to prove whether the tendency observed in the present investigation holds any promise to improve the outcome of these patients.

Cyfra 21-1 marker in carcinoma of the cervix

Cyfra 21-1 has been reported to be an effective tumor marker for epithelial carcinomas. The purpose of this investigation was to determine its value in evaluating response to treatment in patients with carcinoma of the cervix. Cyfra 21-1 levels were measured by immunoassay in the serum of 55 untreated patients with cervical cancer; a second sample was obtained in all of them after conventional treatment for association with clinical response. Pre-therapy levels were elevated in only 45% (25 of 55) of the patients, with a slight tendency to increase according to clinical stage: 33% (5/15) in stage I, 36% (8/22) in stage II and 67% (12/18) in stage III. In regards to association with response to therapy, and including patients with either normal or elevated pretreatment values, 46% (19/41) of women with a complete clinical response either persisted with or developed elevated levels after treatment completion. All 14 patients with persistent disease after therapy continued to have or developed elevated values. No patient with persistent disease had normal values after therapy, and all patients with negative values after treatment were truly complete clinical responders. The results of our study suggest that the test has a low sensitivity therefore and, despite our findings, a negative level after treatment may not be a safe indicator of disease-free status. On the other hand, an elevated post-treatment level is not a reliable indicator of persistence, proven by the fact that 46% of clinical responders fell in this category. Therefore, Cyfra 21-1 has a very limited role in correlating with response to treatment in carcinoma of the cervix.

Nature of blood-labyrinth barrier in experimental conditions

The blood-labyrinth barrier is concept that has evolved based on marked difference in chemical composition between perilymph and blood. Studies reported here have been designed to manipulate physiologic, metabolic, and pharmacologic conditions in experimental animals in order to determine the characteristics of this regulatory mechanisms. Tracer studies of uptake of sodium, calcium, and albumin from blood into perilymph showed that these substances penetrate into inner ear fluids quite slowly. Injections of ototoxic substances (kanamycin, furosemide) show limited transport of these agents into perilymph. Administration of an osmotic agent (urea) resulted in a parallel but delayed elevation of perilymph concentration. The possible role of a alteration of blood-labyrinth barrier in inner ear disorders has been discussed.

Effect of urea on osmolality of perilymph

Blood osmolality was altered in chinchillas by intravenous administration of urea. Serum osmolality peaked rapidly at 30 minutes after administration and decreased slightly to a plateau for 180 minutes. Perilymph and CSF osmolality lagged substantially behind the increase in serum osmolality and equaled serum osmolality only after one hour. Perilymph osmolality followed changes in the serum up to 60 minutes with a definite time lag. This phenomenon suggests the existence of a selective blood-labyrinth barrier that is permeable to urea and water. However, the time lag due to the barrier may permit the reduction of hydrostatic pressure in the labyrinth. The results of the present study seem to render partial explanation of improved hearing in patients with Meniere's disease who were treated with urea.

Osmolality changes in perilymph after systemic administration of glycerin

Blood osmolality was altered in guinea pigs by intravenous administration of glycerin (glycerol). After glycerin administration, serum osmolality increased rapidly, reaching a plateau within 15 minutes. Perilymph osmolality lagged significantly behind the increase of serum osmolality and equalled serum osmolality only after one hour. While perilymph osmolality responded to changes of serum osmolality, there was some time lag noted in the response of perilymph, suggesting the existence of a blood-labyrinth barrier. It was observed that this barrier is permeably to glycerin and water, suggesting the possibility of transient reduction of hydrostatic pressure in the labyrinth by the injection of an osmotic agent into the systemic circulation.