Os Serviços de Verificação de Óbitos fornecem informações complementares para a epidemiologia e políticas de saúde pública que servem de instrumentos para medir a situação da saúde de uma comunidade e também para a elaboração e avaliação dos programas de saúde. A comparação entre o diagnóstico clínico de causa mortis e o diagnóstico após a autópsia é uma ferramenta utilizada para a auditoria de serviços médicos, e apesar dos avanços tecnológicos as discrepâncias ainda continuam altas. O presente trabalho teve como objetivo avaliar a casuística do Serviço de Verificação de Óbitos do Interior (SVOi), localizado no município de Ribeirão Preto, SP, no período de 2008 a 2012 e compará-la com as estatísticas gerais de mortalidade do município, disponibilizadas pelo Ministério da Saúde. Além disso, foi feita a classificação das discrepâncias diagnósticas entre os diagnósticos anotados nos pedidos de necropsias e laudos finais do exame nos óbitos ocorridos utilizando o critério Goldman modificado e a partir dos dados obtidos a fim de realizar uma análise crítica do impacto do SVOi no esclarecimento diagnóstico e sua importância nas estatísticas de mortalidade. Para a aplicação do critério foram utilizados dados secundários do encaminhamento de solicitação da necropsia, dos relatórios finais e dos dados sobre as estatísticas de mortalidade do Município obtidos do Ministério da Saúde, sendo que a análise dos dados foi realizada por meio de análise estatística descritiva. Os resultados evidenciaram que nos períodos do estudo foram realizadas 4464 necropsias no serviço, com predomínio de pacientes do sexo masculino e faixa etária dos 51 aos 90 anos. As doenças do aparelho circulatório foram as mais prevalentes registradas como causas de óbitos, seguidas das doenças respiratórias e neoplasias. Dentre todos os casos necropsiados, foi possível a aplicação do critério Goldman modificado em 3895 (83,28%) deles e as discrepâncias maiores foram atribuídas em 26,39% após o uso de critérios de analise, o que sugere a existência de alto grau de discrepâncias entre a hipótese diagnóstica e a real causa do óbito. Pode-se concluir que o SVOi desempenha um importante papel na auditoria diagnóstica, fato esse evidenciado pelos casos que não apresentaram correlação entre hipótese no encaminhamento e relatório final da necropsia. Além disso, 1228 (31,53%) casos foram encaminhados sem a hipótese, ou seja, sem suspeita da causa básica de morte, destacando a importância do SVOi para a sua definição. Ademais, a causa básica foi solucionada após a realização da necropsia em 99,54% do total dos casos analisados nesse estudo, o que revela a importância desse serviço para a elucidação dos casos e para a contribuição dos dados para as estatísticas de mortalidade. / The Death Verification Service provides complementary information for public epidemiology services and public health policies that are useful as tools for measuring the health status of a community and for the elaboration and evaluation of health programs. Diagnostic comparison between cause of death clinical diagnosis and the autopsy is a tool used for auditing medical services, and despite technological advances, discrepancies are still high. The present study sought to evaluate the casuistry in the Death Verification Service - Interior (DVSi) from 2008 to 2012 and to compare them with the general mortality statistics of the Ribeirão Preto municipality, which were made available by the Ministry of Health. In addition, it aimed to classify the diagnostic discrepancies between the requests for autopsies and final results of examinations in deaths using the Goldman revised criteria and, from the obtained data, to make a critical analysis of the DVSi impact on diagnostic clarification and its importance in mortality statistics. For the application of the criteria, secondary data from the cadaver referral, final reports and mortality data of the Ministry of Health were used, and data analysis was performed through descriptive statistical analysis. The results showed that during the study periods, 4464 autopsies were performed in the service, with a predominance of male patients and age range from 51 to 90 years. Circulatory system diseases were the most prevalent causes of death, followed by respiratory diseases and neoplasms. Among all autopsied cases, it was possible to apply the Goldman revised criteria in 3895 (83.28%) cases and large discrepancies were attributed in 26.39% cases after the use of analysis filter criteria, which suggests the existence of discrepancies between the diagnostic hypothesis and the actual cause of death. It can be concluded that the local DVSi plays an important role in the diagnostic audit, evidenced by the cases that did not present a correlation between the hypothesis in the referral and the final autopsy report. In addition, 1228 (31.53%) cases were referred without hypothesis, that is, without suspicion of the underlying cause of death, highlighting the importance of the DVSi for its definition. Furthermore, the basic cause was solved after performing the autopsy in 99.54% of the total cases analyzed in this study, which reveals the importance of this service for clarification of the cases and its contribution to mortality statistics.

Introdução: Doenças pulmonares ou infecções que ocorrem no início da vida podem ter permanente impacto na vida adulta. Pouco se sabe sobre o perfil de células do sistema imunológico em pulmões de crianças lactentes. Objetivo: Descrever o perfil de células do sistema imunológico no pulmão de lactentes sem doença pulmonar. Métodos: Amostras de pulmões histologicamente normais, obtidas através de autópsia de dez crianças que morreram de causas acidentais ou de doenças não pulmonares, foram marcadas por anticorpos contra linfócitos B e T, macrófagos, células NK (natural Killer), células citotóxicas, células dendríticas e mastócitos. As células foram quantificadas no epitélio, na camada interna, na camada externa das vias aéreas e nos septos alveolares. Membrana basal e septos alveolares foram medidos através de análise de imagem. Resultados expressos em células/mm de membrana basal epitelial brônquica ou alveolar. Resultados: A mediana das idades foi 2,5 meses (1-730 dias). Os resultados mostraram que a camada interna apresentou pequena densidade celular. No epitélio da via aérea e no parênquima houve predominância de células que estão relacionadas com a imunidade inata, tais como: CD56+, Granzyme + e CD68+. A camada externa e o parênquima alveolar apresentaram a maior densidade celular. Poucas células T CD4+ e células dendríticas foram encontradas na maioria dos compartimentos do pulmão. Conclusão: Há uma compartimentalização de células relacionadas com o sistema imunológico ao longo da via aérea e parênquima dos pulmões das crianças estudadas. Esta configuração pode estar relacionada com o desenvolvimento dos mecanismos de defesa da imunidade inata e da imunidade adquirida. Este conhecimento é importante para entender os mecanismos da imunocompetência pós-natal dos pulmões / Introduction: Pulmonary diseases or infections occurring early in life may have a permanent impact in adulthood. Little is known about the normal immune cell profile in the lungs of infants. Objective: To describe the immune cell profile of infants without lung disease. Methods: Histologically normal lung samples obtained at autopsy of ten infants that died either due to incidental or inflicted causes or non-pulmonary diseases were stained for antibodies against B and T lymphocytes, macrophages, NK cells, cytotoxic cells, dendritic cells and mast cells. Cells were quantified in the airway epithelial layer, inner layer, outer layer and alveolar septa. Basement membrane or alveolar septa lengths were assessed by image analysis. Results are expressed as cells/mm. Results: The median age of patients was 2.5 months and ranged from 1- 730 days. The inner layer of the airways was the region with the smallest density of cells. There was a predominance of cells related to the innate immunity such as CD56+, Granzyme B+ and CD68+ cells in the epithelial layer and alveolar parenchyma. The outer layer and the lung parenchyma presented the highest cellular density. There were very few CD4+ T cells or dendritic cells in most of the lung compartments. Conclusions: There was a compartmentalization of immune cells along airways and parenchyma in infants, which may be related to the development of innate and acquired lung defense mechanisms. This knowledge is important to understand mechanisms of postnatal immune competence of the lungs

Understanding mortality patterns is an essential pre-requisite for guiding public health action and for supporting development of evidence-based policy. However, such information is not sufficiently available in Vietnam. Mortality statistics and causes of death are solely collected from health facilities while most deaths occur at home without the presence of health professionals. Facility-based data cannot represent what happened in the wider community. This thesis studies the patterns and burdens of mortality as well as their relationships with socio-economic status in rural Vietnam. The overall aim is to contribute to the improvement of the current system of mortality data collection in the country for the purposes of public health planning and priority setting. The study was carried out within the framework of an ongoing Demographic Surveillance System (DSS) in Bavi district, Hatay province, northern rural Vietnam. This study used a verbal autopsy (VA) approach to identify cause of death in a cohort of approximately 250,000 person- years over a five-year period from 1999 to 2003. During the five year study, a total of 1,240 deaths were recorded and VA was successfully completed for 1,220 cases. Results revealed that VA was an appropriate and useful method for ascertaining cause of death in this rural Vietnamese community where specific data were otherwise scarce. The mortality pattern reflected a transitional pattern of disease in which the leading cause of death was cardiovascular diseases (CVD), followed by neoplasms, infectious and parasitic diseases, and external causes, accounting for 28.9%, 14.5%, 11.2%, and 9.8%, respectively. In terms of premature mortality, there were 85 and 55 Years of Life Lost (YLL) per 1,000 population for males and females respectively. The largest contributions to YLL were CVDs, malignant neoplasms, unintentional injuries, and perinatal and neonatal causes. In general, men had higher mortality rates than women for all mortality categories. In adults of 20 years and above, mortality rates increased substantially with age, and showed similar age effects for all mortality categories with the strongest association for non-communicable diseases (NCD). Education was an important factor for survival in general, and high economic status seemed to benefit men more than women. Compared with cancer and other NCD causes, higher CVD rates were observed among males, the elderly, and those without formal education, using a Cox proportional hazards model. This study is an initial effort to provide information on mortality patterns in a community using longitudinal follow-up of a dynamic cohort. Continuing the study using the VA approach as part of routine data collection in the setting will help to show trends in mortality patterns for the community over time, which may be useful for priority setting and health planning purposes, not only locally but also at the national level. Further analyses are needed to understand mortality inequality across all ages to have a comprehensive picture of mortality burdens in the setting. Validation studies and further standardization of VA methods should be carried out whenever possible to improve the performance and extension of the technique.

Biofouling, or the formation of biofilm on membrane surfaces, can decrease the performance (decreased flux and/or increased operating pressure) of a reverse osmosis (RO) membrane system in a water treatment plant. However, biofilms have been used in water treatment systems to remove organic carbon from water via biofilters and successfully reduce biofilm growth downstream. This research investigates the possibility that the heterotrophic biofilm present on membrane surfaces removes nutrients from the treatment water, thereby making it nutrient deprived as it travels along the treatment train. This may potentially be exploited as an in situ biofilter to actively remove dissolved organic carbon (DOC) from the treatment water, thereby protecting downstream membrane surfaces from biofouling. Analysis of fouled membranes from the Dunedin water treatment plant in Dunedin, FL indicates the presence of biofilm on membrane surfaces in a gradient pattern with a higher level of fouling at the front of the element. Additionally, the community structure of the biofilm at the front of the element is unique with respect to the feed-water and downstream membrane material. Additionally, a carbon (and nitrogen) mass balance study was performed at the water treatment plant in Dunedin, FL through extensive sampling of DOC at multiple locations of the RO membrane system over a 20 month period. Plant-level mass balance results indicate a significant pool of DOC was consistently unaccounted for, and presumably assimilated or otherwise removed within the membrane system. Sampling also indicated a removal of total nitrogen. Additionally, the specific UV absorbance (SUVA) of the DOC in concentrate was consistently greater than that of the feed water, suggesting the removal of labile aliphatic carbon as the feed water travels through the feed channel of the membrane system. A pilot system was designed and built to operate under plant conditions (flow rate and pressure) to test if the biofilm on the surface of the membrane can have a protective effect for downstream membrane material. A fouled membrane element was pulled from the plant at the same time and general location as an autopsied element (to determine composition on the surface) and used in the pilot system. Feed and concentrate water from the pilot was directed to flat sheet modules for performance testing and surface characterization. This allowed for characterization of the two sections without disturbing the membrane element. Differences in performance and foulant deposition were characterized for the two sections as a function of carbon addition and flow rate. The results from this testing suggest the membrane element, or the biofilm on its surface, has both a performance and a foulant deposition benefit for downstream membranes as compared to feed membrane material. This benefit also displayed an increasing trend as the concentration of organic carbon fed into the system increases.

Membrane biofouling is a common occurrence in water treatment plants that utilize reverse osmosis (RO). As bacteria and biofilm material build up on the membrane surface, it becomes more difficult for clean water to permeate through the membrane, and more pressure is required to produce the same amount of water. When pressures become critically high, membranes must be cleaned. This process is expensive in terms of chemical cost, labor, and downtime. Even after membranes have been cleaned, they can re-foul quickly if the cleaning did not effectively remove the biofilm. The water treatment plant in Dunedin, FL, which uses RO for treating groundwater, has experienced membrane biofouling since it began operation in 1992. Without the means to systematically evaluate a multitude of cleaning strategies on the bench scale, cleaning optimization must be conducted on the production skid level, which restricts the evaluation of alternative protocols. This problem is typical for many RO plants. The objectives of this project are: (1) using a multi-level and systematic approach, develop cleaning strategies for biofouled membranes that will lead to improved cleaning and decreased operational costs; (2) develop other cleaning strategies that will add to the scientific knowledge base; (3) quantify the effects of improved protocols; and (4) determine the policy implications of developed protocols in terms of cost suitability to Dunedin and elsewhere in Florida. This project consists of three phases, with phases progressively more similar to the water production environment. In the first phase, a series of bench tests were performed in the laboratory. Fouled membrane swatches were soaked and agitated in different cleaning solutions for different lengths of time, at different temperatures and pH. Protein and carbohydrate assays were then performed on both the cleaning solution and the membrane swatch to determine which conditions yield most complete removal of protein and carbohydrate from the membrane surface. Results indicate that carbohydrate removal does not appear to depend strongly on pH or temperature. Protein removal increases with increasing pH and is slightly greater at higher temperatures. The second phase of testing employed a 4"x6" stainless steel flat-sheet module in which cleanings were performed under different conditions to document corresponding changes in water flux and salt rejection. Operational parameters were based on pertinent literature and optimization results from Phase 1. Results indicate that water flux increases in response to cleaning at increasing pHs and increasing temperatures with best performances occuring after 30 minutes of cleaning. Salt rejection appears to decrease with pH. The most effective cleaning protocols, determined through trials in Phases 1 and 2, were put to the test again in Phase 3 where cleanings were performed on a specially constructed single-element cleaning system (for 8.5" x 40" elements), designed to clean a membrane element in isolation. This phase also served as final verification of new cleaning protocols before implementation on the production scale. Results from this phase were inconclusive due to mechanical problems. A multi-level, systematic cleaning evaluation leads to better understanding of the dependence of biofilm material removal and membrane performance on critical factors such as temperature, pH, time of cleaning, and chemical dose, which results in improved cleaning protocols and ultimately cost savings to RO water utilities such as Dunedin.

Due to an increase in malaria control programs in the last decade, the world has witnessed dramatic reductions in the number of infections and deaths caused by the malaria parasite. With malaria eradication on the global health agenda, a shift toward transmission-focused research has led to a renewed focus on a previously neglected stage of malaria: the sexual stage (gametocyte). Malaria's sexual stages are the only stages in the human host that are transmitted to the mosquito vector, and are therefore of critical importance for blocking transmission of this devastating disease. The process through which developing gametocytes sequester outside of the bloodstream during their 8-10 day maturation is not well understood and stands to be exploited as a potential target for therapeutic intervention. In Chapter 1, we discuss the current state of knowledge on the development of these stages in the human host. In Chapter 2, we investigate anatomical enrichment sites for developing gametocytes in the human host using autopsy tissue from cases of fatal malaria. Immunohistochemistry (IHC) and quantitative reverse transcriptase PCR-based assessments identified the bone marrow as a preferential enrichment site of developing gametocytes. Co-localization with host proteins revealed the enrichment of gametocytes inside the extravascular space of the bone marrow, often observed in contact with erythroblastic island structures. In vitro experiments with erythrocyte precursor cells, as well as in vivo co-localization studies demonstrated that gametocytes can develop within the cells of the hematopoietic system of the bone marrow. In Chapter 3, we present an assay and analysis tool for inferring the presence of young and mature asexual and sexual stages in the peripheral blood of infected patients based on gene expression data. We apply this assay to malaria patient cohorts and in vitro drug perturbation time course experiments, and demonstrate its use in identifying young and mature gametocyte carriers, as well as characterizing the effect of a given perturbation on parasite development. This body of work aims to contribute to the overall knowledge base for malaria’s elusive gametocytes as well as to establish tools for performing future assessments on these transmissible stages.

Chest compressions in cardiopulmonary resuscitation are of utmost importance although not without a risk. Many injuries are described but the incidence of these is hard to define due to methodological differences. It is strenuous to perform chest compressions and therefore mechanical chest compressions have been looked upon with interest. This thesis presents new insights on the panorama and incidence of injuries in modern CPR and a comparison of safety and efficacy between manual chest compressions and mechanical chest compressions with the LUCAS™ device. We also evaluated if computed tomography could be an aid in the detection of these injuries. Two pilot trials were conducted and one presented no difference in early survival with 26% and 31% having return of spontaneous circulation when comparing manual chest compressions with the LUCAS device in out-of-hospital cardiac arrest. The other revealed no difference in autopsy-detected injuries. A third multicentre autopsy trial revealed that in patients treated with manual chest compressions 78.3% had at least one injury and 63.9% had at least one rib fracture. The corresponding numbers for patients treated with the LUCAS device was 92.8% (p = 0.002) and 77.7% (p=0.022). Sternal fractures occurred in 54.2% and in 58.3% of the cases treated with manual chest compressions and the LUCAS device respectively (p = 0.556). The median number of rib fractures was 7 in the group receiving manual chest compressions and 6 in the group receiving chest compressions with the LUCAS device. In 31 cases a computed tomography was conducted prior to autopsy and we found a very strong correlation in the discrimination of patients with or without rib fractures (kappa=0.83). Mean difference between the two methods in detecting rib fractures was 0.16. The detection of other injuries did not have a strong correlation. In conclusion there is no difference in early survival between the two methods and mechanical chest compressions adds 14-15% more patients with rib fractures but the amount of rib fractures, sternal fractures and other injuries is equal. CT can aid but not replace autopsies in the detection of these injuries.

No description available.

Objectives This thesis is based on 4 papers that were all written with the same intent, which was to describe and demonstrate how epidemiologic concepts and data can serve as a basis for improved validity of probabilistic conclusions in forensic medicine (FM). Conclusions based on probability are common in FM, and the validity of probabilistic conclusions is dependant on their foundation, which is often no more than personal experience. Forensic epidemiology (FE) describes the use and application of epidemiologic methods and data to questions encountered in the practice of FM, as a means of providing an evidence-based foundation, and thus increased validity, for certain types of opinions. The 4 papers comprising this thesis describe 4 unique applications of FE that have the common goal of assessing probabilities associated with evidence gathered during the course of the investigation of traumatic injury and death.   Materials and Methods Paper I used a case study of a fatal traffic crash in which the seat position of the surviving occupant was uncertain as an example for describing a probabilistic approach to the investigation of occupant position in a fatal crash. The methods involved the matching of the occupants’ injuries to the vehicular and crash evidence in order to assess the probability that the surviving occupant was either the driver or passenger of the vehicle at the time of the crash. In the second and third papers, epidemiologic data pertaining to traffic crash-related injuries from the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) was used to assess the utility and strength of evidence, such as vehicle deformation and occupant injury of a particular severity and pattern, as a means of assessing the probability of an uncertain issue of interest. The issue of interest in Paper II was the seat position of the occupant at the time of a rollover crash (similar to Paper I), and the association that was investigated was the relationship between the degree of downward roof deformation and likelihood of a serious head and neck injury in the occupant. The analysis was directed at the circumstance in which a vehicle has sustained roof deformation on one side but not the other, and only one of the occupants has sustained a serious head or neck injury. In Paper III the issue of interest was whether an occupant was using a seat belt prior to being ejected from a passenger vehicle, when there was evidence that the seat belt could have unlatched during a crash, and thus it was uncertain whether the occupant was restrained and then ejected after the seat belt unlatched, or unrestrained. Of particular interest was the relative frequency of injury to the upper extremity closest to the side window (the outboard upper extremity [OUE]), as several prior authors have postulated that during ejection when the seat belt has become unlatched the retracting seat belt would invariably cinch around the OUE and cause serious injury. In Paper IV the focus of the analysis was the predictability of the distribution of skull and cervical spine fractures associated with fatal falls as a function of the fall circumstances. Swedish autopsy data were used as the source material for this study. Results In Paper I the indifferent pre-crash probability that the survivor was the driver (0.5) was modified by the evidence to arrive at a post-test odds of 19 to 1 that he was driving. In Paper II NASS-CDS data for 960 (unweighted) occupants of rollover crashes were included in the analysis. The association between downward roof deformation and head and neck injury severity (as represented by a composite numerical value [HNISS] ranging from 1 to 75) was as follows: for each unit increase of the HNISS there were increased odds of 4% that the occupant was exposed to >8 cm of roof crush versus <8 cm; 6% for >15 cm compared to <8 cm, and 11% for >30 cm of roof crush compared to <8 cm. In Paper III NASS-CDS data for 232,931 (weighted) ejected occupants were included in the analysis, with 497 coded as seat belt failures, and 232,434 coded as unbelted. Of the 7 injury types included in the analysis, only OUE and serious head injury were found to have a significant adjusted association with seat belt failure, (OR=3.87, [95% CI 1.2, 13.0] and 3.1, [95% CI 1.0, 9.7], respectively). The results were used to construct a table of post-test probabilities that combined the derived sensitivity and (1 - specificity) rates with a range of pre-crash seat belt use rates so that the results could be used in an investigation of a suspected case of belt latch failure. In Paper IV, the circumstances of 1,008 fatal falls were grouped in 3 categories of increasing fall height; falls occurring at ground level, falls from a height of <3 meters or down stairs, and falls from ≥3 meters. Logistic regression modeling revealed significantly increased odds of skull base and lower cervical fracture in the middle (<3 m) and upper (≥3 m) fall height groups, relative to ground level falls, as follows: (lower cervical <3 m falls, OR = 2.55 [1.32, 4.92]; lower cervical ≥3 m falls, OR = 2.23 [0.98, 5.08]; skull base <3 m falls, OR = 1.82 [1.32, 2.50]; skull base ≥3 m falls, OR = 2.30 [1.55, 3.40]). Additionally, C0-C1 dislocations were strongly related to fall height, with an OR of 8.3 for the injury in a ≥3 m fall versus ground level. Conclusions In this thesis 4 applications of FE methodology were described. In all of the applications epidemiologic data resulting from prior FM investigations were analyzed in order to draw probabilistic conclusions that could be reliably applied to the circumstances of a specific investigation. It is hoped that this thesis will serve to demonstrate the utility of FE in enhancing evidence-based practice in FM.

Diss. (sammanfattning) Umeå : Univ., 2008. / Härtill 5 uppsatser.