There is no shortage, but inequality: demographic evolution of neurologists in Brazil (2010-2020) / Não há escassez, mas sim desigualdade: evolução demográfica de neurologistas no Brasil (2010-2020)

Abstract Background Neurology is a medical specialty that deals with prevalent diseases such as stroke, headache, epilepsy, and neurodegenerative diseases. Many countries, such as Brazil, struggle to provide neurological care for their populations, but the inadequacy and unequal distribution of the neurologist workforce are real challenges. Objective To analyze the demographic evolution of neurologists and the first-year Neurology residency positions in Brazil during the last decade (2010-2020) and the distribution imbalance between regions. Methods The demographic and geographic distribution of neurologists was calculated based on data extracted from the Brazilian Federal Medical Council reports, and the number of Neurology residency positions was based on the Brazilian National Commission of Medical Residency reports. Indicators of wealth were associated with demographic data. Results The number of neurologists per 100,000 population has increased since 2011, with a similar increase in the geographic distribution of neurologists. However, there was a marked inequality of distribution of neurologists through regions, with a gap between the Northern (lowest) and Southeastern (highest) regions. Furthermore, the imbalance of distribution of neurologists strongly correlated with social inequality. The number of Neurology residency positions increased, but with an imbalance between North and Southeast regions. Conclusions Brazil has advanced in providing neurologists. However, instead of a shortage, inequality between regions is the greatest challenge regarding the neurological workforce. The training of new neurologists is unequal between regions and occurs at a slower rate than needed. Neurologists, public health authorities, and patients should discuss solutions for these issues.

Resumo Antecedentes A Neurologia é uma especialidade médica que lida com doenças prevalentes, como acidente vascular cerebral, cefaleia, epilepsia e doenças neurodegenerativas. Muitos países, como o Brasil, se esforçam para oferecer assistência neurológica à população, mas a distribuição insuficiente e desigual da força de trabalho de neurologistas são desafios. Objetivo Analisar a evolução demográfica dos médicos neurologistas e das vagas de Programas de Residência Médica em Neurologia no Brasil durante a última década (2010-2020) e o desequilíbrio de distribuição entre as regiões. Métodos A distribuição demográfica e geográfica de neurologistas foi calculada com base nos dados extraídos de relatórios do Conselho Federal do Medicina do Brasil, e o número de vagas em Programas de Residência Médica em Neurologia foi extraído de dados da Comissão Nacional de Residência Médica. Os indicadores de riqueza foram associados aos dados demográficos. Resultados O número de neurologistas por 100.000 habitantes aumentou desde 2011, com um aumento similar na distribuição geográfica de neurologistas. Entretanto, houve uma nítida desigualdade na distribuição de neurologistas entre as regiões, com um hiato entre as regiões Norte e a Sudeste. Além disso, a desigualdade da distribuição de neurologistas se correlacionou fortemente com a desigualdade social. O número de vagas em Programas de Residência Médica aumentou, porém com desigualdade entre as regiões Norte e Sudeste. Conclusões O Brasil tem avançado na geração de neurologistas. Porém, ao invés de uma escassez, a desigualdade entre regiões é o maior desafio em relação à força de trabalho neurológica. O treino de novos neurologistas é desigual entre regiões e ocorre em um ritmo mais lento do que o necessário. Neurologistas, autoridades em saúde pública e pacientes devem discutir soluções para estes problemas.

Perception of newly graduated physicians toward ethical education in medical schools: a Brazilian cross-sectional nationwide study

SUMMARY OBJECTIVE: The objective of this study was to evaluate fresh medical graduates' perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients' families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants' medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

Attitude and knowledge of medical students toward donation after circulatory death

SUMMARY OBJECTIVE: A survey among medical students in a Brazilian public university was performed to investigate the acceptance of organ donation in Brazil, particularly donation after circulatory death (DCD). METHODS: A questionnaire including 26 objectives and Likert scale questions was validated and sent to all medical students of our institution. The answers were analyzed considering the whole set of individuals as well as by dividing the medical students into two groups: less graduated students and more graduated students. RESULTS: From 1050 students, 103 spontaneous answers (9.8%) were retrieved after 3 weeks. A total of 89.3% agreed totally with deceased donor organ donation and 8.7% agreed partially. However, only 50.5% of the students agreed totally and 31.1% agreed partially to living donation. Students revealed that 82.6% know the concept of brain death. On the other hand, 71.8% of them declared not knowing the concept of planned withdrawal of life-sustaining therapy, mainly cardiorespiratory support. A total of 85.4% of students agreed totally with donation after brain death and 11.7% agreed partially. However, when questioned about donation in awaiting circulatory death after a planned withdrawal of life-sustaining therapy, only 18.4% agreed totally and 32% agreed partially. Both groups of less and more graduated students showed similar results. CONCLUSIONS: Our study found a clear lack of information and consequently in acceptance of DCD. Education in the field of end-of-life management may improve not only the acceptance of DCD donation but also the whole understanding of planned withdrawal of life-sustaining therapy.

C-peptide level as predictor of type 2 diabetes remission and body composition changes in non-diabetic and diabetic patients after Roux-en-Y gastric bypass

OBJECTIVES: Several predictors of type 2 diabetes mellitus (T2DM) remission after metabolic surgery have been proposed and used to develop predictive scores. These scores may not be reproducible in diverse geographic regions with different baseline characteristics. This study aimed to identify predictive factors associated with T2DM remission after Roux-en-Y gastric bypass (RYGB) in patients with severe obesity. We hypothesized that the body composition alterations induced by bariatric surgery could also contribute to diabetes remission. METHODS: We retrospectively evaluated 100 patients with severe obesity and T2DM who underwent RYGB between 2014 and 2016 for preoperative factors (age, diabetes duration, insulin use, HbA1c, C-peptide plasma level, and basal insulinemia) to identify predictors of T2DM remission (glycemia<126 mg/dL and/or HbA1c<6.5%) at 3 years postoperatively. The potential preoperative predictors were prospectively applied to 20 other patients with obesity and T2DM who underwent RYGB for validation. In addition, 81 patients with severe obesity (33 with T2DM) underwent body composition evaluations by bioelectrical impedance analysis (InBody 770®) 1 year after RYGB for comparison of body composition changes between patients with and those without T2DM. RESULTS: The retrospective analysis identified only a C-peptide level >3 ng/dL as a positive predictor of 3-year postoperative diabetes remission, which was validated in the prospective phase. There was a significant difference in the postoperative body composition changes between non-diabetic and diabetic patients only in trunk mass. CONCLUSION: Preoperative C-peptide levels can be useful for predicting T2DM remission after RYGB. Trunk mass is the most important difference in postoperative body composition changes between non-diabetic and diabetic patients.

COVID-19-related hospital cost-outcome analysis: The impact of clinical and demographic factors

ABSTRACT Introduction: Although patients' clinical conditions have been shown to be associated with coronavirus disease (COVID-19) severity and outcome, their impact on hospital costs are not known. This economic evaluation of COVID-19 admissions aimed to assess direct and fixed hospital costs and describe their particularities in different clinical and demographic conditions and outcomes in the largest public hospital in Latin America, located in São Paulo, Brazil, where a whole institute was exclusively dedicated to COVID-19 patients in response to the pandemic. Methods: This is a partial economic evaluation performed from the hospitaĺs perspective and is a prospective, observational cohort study to assess hospitalization costs of suspected and confirmed COVID-19 patients admitted between March 30 and June 30, 2020, to Hospital das Clínicas of the University of São Paulo Medical School (HCFMUSP) and followed until discharge, death, or external transfer. Microand macro-costing methodologies were used to describe and analyze the total cost associated with each patient's underlying medical conditions, itinerary and outcomes as well as the cost components of different hospital sectors. Results: The average cost of the 3254 admissions (51.7% of which involved intensive care unit stays) was US$12,637.42. The overhead cost was its main component. Sex, age and underlying hypertension (US$14,746.77), diabetes (US$15,002.12), obesity (US$18,941.55), chronic renal failure (US$15,377.84), and rheumatic (US$17,764.61), hematologic (US $15,908.25) and neurologic (US$15,257.95) diseases were associated with higher costs. Age strata >69 years, reverse transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19, comorbidities, use of mechanical ventilation or dialysis, surgery and outcomes remained associated with higher costs. Conclusion: Knowledge of COVID-19 hospital costs can aid in the development of a comprehensive approach for decision-making and planning for future risk management.

Incidence and associated factors of type 2 diabetes mellitus onset in the Brazilian HIV/AIDS cohort study

ABSTRACT Background: People living with HIV (PLH) under combined antiretroviral therapy (cART) are at risk of developing type 2 diabetes mellitus (T2DM). Objective: We examined the incidence of T2DM, associated factors and mean time to outcome in PLH under cART. Method: Data for this multicenter cohort study were obtained from PLH aged over 18, who started cART in 13 Brazilian sites from 2003 to 2013. Factors associated with incident T2DM were evaluated by Cox multiple regression models. Results: A total of 6724 patients (30,997.93 person-years) were followed from January 2003 to December 2016. A T2DM incidence rate of 17.3/1000 person-years (95%CI 15.8-18.8) was observed. Incidence of isolated hypertriglyceridemia and impaired fasting glucose (IFG) were 84.3 (95%CI 81.1-87.6) and 14.5/1000 person-years (95%CI 13.2-15.9), respectively. Mean time to T2DM onset was 10.5 years (95%CI 10.3-10.6). Variables associated with incident T2DM were age 40-50 [Hazard Ratio (HR) 1.7, 95%CI 1.4-2.1] and ≥ 50 years (HR 2.4, 95%CI 1.9-3.1); obesity (HR 2.1, 95%CI 1.6-2.8); abnormal triglyceride/HDL-cholesterol ratio (HR 1.8, 95%CI 1.51-2.2). IFG predicted T2DM (HR 2.6, 95%CI 1.7-2.5) and occurred on average 3.3 years before diabetes onset. Exposure to stavudine for ≥ 2 years was independently associated with incident T2DM [HR 1.6, 95%CI 1.0-2.2). Conclusion: Brazilian PLH under cART are at significant risk of developing T2DM and share risk factors for diabetes onset with the general population, such as older age, obesity, and having metabolic abnormalities at baseline. Moreover, stavudine use was independently associated with incident T2DM. Identifying PLH at a higher risk of T2DM can help caretakers trigger health promotion and establish specific targets for implementation of preventive measures.

Cultural adaptation and updating of the Risk assessment and management of exposure of health care workers in the context of covid-19 questionnaire / Adaptación cultural y actualización del cuestionario Risk assessment and management of exposure of health care workers in the context of covid-19 / Adaptação cultural e atualização do questionário Risk assessment and management of exposure of health care workers in the context of covid-19

Objective: to translate and culturally adapt the Risk assessment and management of exposure of health care workers in the context of covid-19 questionnaire to the Brazilian context and to develop and evaluate a sociodemographic and occupational characterization questionnaire to compose the adapted questionnaire. Method: five stages were conducted to adapt the Risk assessment and management of exposure of health care workers in the context of covid-19 questionnaire, namely: translation, synthesis of the translations, evaluation by a committee of judges, back translation and pre-test. As for the complementary questionnaire, it was elaborated and evaluated by a committee of judges and a pre-test was carried out. Results: the questionnaires were validated and the pre-test stage was conducted with health workers and students. Conclusion: the final version adapted to the Brazilian context was called Questionário de avaliação de risco e gestão da exposição de trabalhadores e estudantes de saúde no contexto da covid-19 and is available for use, together with the final version of the Sociodemographic and occupational questionnaire: Risk assessment and management of exposure of health care workers and students in the context of covid-19. These questionnaires may assist in mitigating the risks of infection, illness and death of health workers and students due to covid-19.

Objetivo: traducir y adaptar culturalmente el cuestionario Risk assessment and management of exposure of health care workers in the context of covid-19 al contexto brasileño y elaborar y evaluar un cuestionario de caracterización sociodemográfica y ocupacional para formular el cuestionario adaptado. Método: se llevaron a cabo cinco pasos para adaptar el cuestionario Risk assessment and management of exposure of health care workers in the context of covid-19: traducción, síntesis de traducciones, evaluación por un comité de jueces, retrotraducción y pretest. En cuanto al cuestionario complementario, fue elaborado y evaluado por un comité de jueces y se realizó una prueba previa. Resultados: se validaron los cuestionarios y se realizó la etapa de pretest con trabajadores y estudiantes del área de la salud. Conclusión: la versión final adaptada al contexto brasileño se denominó Questionário de avaliação de risco e gestão da exposição de trabalhadores e estudantes de saúde no contexto da covid-19 y está disponible para su uso, junto con la versión final del Questionário de avaliação de risco e gestão da exposição de trabalhadores e estudantes de saúde no contexto da COVID-19. Estos cuestionarios pueden ayudar a disminuir los riesgos de infección, enfermedad y muerte de los trabajadores y los estudiantes del área de la salud por covid-19.

Objetivo: traduzir e adaptar culturalmente o questionário Risk assessment and management of exposure of health care workers in the context of covid-19 para o contexto brasileiro e elaborar e avaliar um questionário de caracterização sociodemográfica e ocupacional para compor o questionário adaptado. Método: cinco etapas foram realizadas para adaptação do questionário Risk assessment and management of exposure of health care workers in the context of covid-19: tradução, síntese das traduções, avaliação por comitê de juízes, retrotradução e pré-teste. Quanto ao questionário complementar, foi construído e avaliado por um comitê de juízes e realizado pré-teste. Resultados: os questionários foram validados e a etapa de pré-teste foi realizada com trabalhadores e estudantes da área de saúde. Conclusão: a versão final adaptada para o contexto brasileiro foi denominada Questionário de avaliação de risco e gestão da exposição de trabalhadores e estudantes de saúde no contexto da covid-19 e está disponibilizada para uso, juntamente com a versão final do questionário sociodemográfico e ocupacional: avaliação de risco e gestão da exposição de trabalhadores e estudantes da área de saúde no contexto da covid-19. Estes questionários podem auxiliar na mitigação dos riscos de infecção, adoecimento e morte de trabalhadores e estudantes da área de saúde pela covid-19.

Demografia Médica no Brasil - 2020

A publicação Demografia Médica no Brasil 2020, com resultado da colaboração entre o Conselho Federal de Medicina (CFM) e a Universidade de São Paulo (USP), é uma produção científica que atualiza os conhecimentos acumulados na última década e traz novas informações detalhadas sobre a população de médicos e seu exercício profissional. Em 2020, o Brasil passou a contar com mais de 500 mil médicos. Esse marco vem acompanhado da persistência de desigualdades na distribuição dos profissionais, do aumento desenfreado de cursos e vagas de graduação e da ociosidade de vagas de Residência Médica. Da mesma forma, o crescimento dessa população ocorre com a exposição dos médicos ao aumento do número de vínculos e de jornadas de trabalho. Portanto, o número de médicos no país cresceu, nos últimos anos, na mesma proporção em que se impuseram novos desafios para a profissão médica e o funcionamento do sistema de saúde no país. Assim, a Demografia Médica 2020 do CFM se impõe no debate qualificado, baseado em dados e evidências, com a oferta de subsídios para a atuação das entidades e governantes comprometidos com a valorização da Medicina e as melhorias das condições de saúde da população.

Hepatitis B viremia in HIV-coinfected individuals under antiretroviral therapy

ABSTRACT Background: Antiretroviral therapy (ART) has decreased AIDS incidence and mortality, rendering comorbidities, such as hepatitis B more relevant for people living with human immunodeficiency virus (HIV). Since antiretroviral drugs may also inhibit hepatitis B virus (HBV) replication, analyzing the impact of ART on management of hepatitis B in this population is important. Objective: To assess HBV viremia among HIV/HBV coinfected individuals on ART and its associated factors. Method: For this cross-sectional study, HIV/HBV-coinfected individuals, aged over 18 years, who were on ART for over six months and receiving care at an outpatient clinic in São Paulo were recruited. Sociodemographic characteristics, information about viral exposure, clinical and laboratory data, including evaluation of liver fibrosis were obtained. Plasma HBV DNA was measured by polymerase chain reaction. Viral genome sequencing was conducted for genotyping and identification of drug resistance-conferring mutations if viral load exceeded 900 IU/mL. Results: Out of 2,946 patients who attended the clinic in 2015, 83 were eligible and 56 evaluated. Plasma HBV DNA was detected in 16 (28.6%) (95% CI: 18.0-41.3%), all on lamivudine and tenofovir treatment. HBV DNA detection was associated with lower education (p = 0.015), higher international normalized ratios (p = 0.045), history of an AIDS-defining illness [OR: 3.43 (95% CI: 1.10-11.50)], and HBeAg detection [OR: 6.60 (95% CI: 1.84-23.6)]. In contrast, a last CD4+ count above 500 cells/mm3 in the year prior to inclusion [OR: 0.18 (95% CI: 0.04-0.71)] and detection of anti-HBe [OR: 0.21 (95% CI: 0.04-0.99)] were negatively associated. Patients with HBV DNA above 900 IU/mL were infected with subgenotypes A1 (n = 3) and D2 (n = 1), and exhibited viral mutations associated with total resistance to lamivudine and partial resistance to entecavir. Conclusions: Despite being on ART, a significant proportion of HIV/HBV-coinfected individuals present HBV viremia. Characterization of factors that are associated with this finding may help professionals provide better management to these patients.

Who and Where are the University of São Paulo Medical School Graduates?

OBJECTIVE: To evaluate the impact of a complex-care-based medical school in the context of the Brazilian health care system on students' career choices. METHODS: This was a retrospective cross-sectional study based on medical regulatory organization records. It included records for 7,419 physicians who graduated from FMUSP. Geographic data were analyzed using Kernel maps, and the statistical analysis was performed with SPSS® version 24.0. A p-value less than 0.05 was considered significant. RESULTS: Of the 7,419 physicians, 68.6% (95% CI 67.5-69.7) were male, and 20.7% (95% CI 19.8%-21.7%) had no medical specialty, compared to 46.4% nationwide. Internal medicine and surgery-based specialties were more popular, accounting for 39.4% (95% CI 38.3%-40.5%) and 16.8% (95% CI 15.5%-17.6%) of our study group, compared to the Brazilian averages of 25.9% and 13.5%. Our graduates also had a higher probability of staying in São Paulo City, especially when born outside the city. CONCLUSION: We believe that FMUSP remains an interesting model for studying the impact of a highly specialized center on the education and career choices of medical students.

Stray dogs in urban fragments: relation between population's perception of their presence and socio-demographic factors / Cães errantes em fragmentos urbanos: relação entre o relato de visualização de cães errantes e fatores sociodemográficos da população local

Stray dogs are associated with environment and public health impacts. São Paulo is a city with approximately 2.5 million owned dogs and until the time of writing no studies describing the distribution of the stray dog population have been conducted in this city. Therefore, no scientific support for intervention plans is available. The objective of this study was to evaluate the association of local sociodemographic and environmental factors with the population perception of presence of stray dogs in urban fragments of São Paulo city. A convenience sample of six urban fragments was selected. In-depth interviews were performe, using a systematic random sample of households in each study area, between October/2010 and January/2011 to identify socio-demographic factors of interest and determine the population's perception of stray dogs. Additionally, the presence of stray dogs was estimated by photographic mark-recapture method. The degree of human-dog proximity and environmental factors such as waste handling were associated to the sighting of stray dogs. Stray dogs were observed in two of the six study areas, agreeing with the greater population perception of this issue on those areas. Intervention in these factors and encouragement of responsible ownership are two potential solutions for management and reduction of problems associated with the presence of stray dogs.(AU)

A presença de cães errantes está associada a impactos no meio ambiente e na saúde pública. São Paulo é uma cidade com aproximadamente 2.5 milhões de cães domiciliados e até o presente momento, não foram desenvolvidos estudos que descrevam a distribuição da população errante na cidade. Desta forma, não há suporte científico para planejar intervenções. O objetivo deste estudo foi avaliar a associação entre os fatores sociodemográficos e ambientais da população local com a frequência com que relataram a visualização de cães errantes em fragmentos urbanos da cidade de São Paulo. Foi definida uma amostra de conveniência composta por seis fragmentos urbanos, onde um questionário foi aplicado em uma amostra sistemática dos domicílios de cada área de estudo. Este questionário, aplicado entre outubro de 2010 e janeiro de 2011, determinou os fatores socio-econômicos de interesse e a percepção da presença de cães errantes pela população. Também foi estimada a presença de cães pelo método de marcação e recaptura fotográfica. Foi possível estabelecer uma relação entre a visualização de cães errantes pela população local e o grau de proximidade com cães e o manejo de resíduos do domicílio. Cães errantes foram observados em duas das seis áreas trabalhadas, em concordância com a maior percepção da sua presença pela população local. Intervenções nestes fatores e incentivo a guarda responsável são duas ações com potencial de contribuir para redução dos problemas causados pela presença de cães errantes.(AU)

Demografia médica no Brasil - 2018 / Medical Demographics in Brazil - 2018

A avaliação da disponibilidade, da distribuição e da capacidade da força de trabalho médico é essencial para o futuro de um sistema de saúde que precisa oferecer serviços qualificados à população. A quarta edição da Demografia Médica traz informações atualizadas e oferece novos dados que permitem melhor compreensão da realidade da prática médica no País. Desenvolvida com metodologia consistente, oferece condições para o dimensionamento do impacto das decisões de gestores (públicos e privados) nas esferas política, administrativa e no campo da assistência em saúde. No momento em que o Sistema Único de Saúde (SUS) completa 30 anos, em um cenário de crise causada por subfinanciamento e falta de infraestrutura, a Demografia Médica torna mais evidente a necessidade de estratégias que facilitem a distribuição de médicos qualificados no território nacional. Assim, estimula uma visão crítica sobre a autorização indiscriminada de abertura de escolas médicas no Brasil. Este trabalho contou com as participações da Universidade de São Paulo (USP) e do Conselho Regional de Medicina do Estado de São Paulo (Cremesp). Foram recebidos ainda subsídios da Associação Médica Brasileira (AMB) e da Comissão Nacional de Residência Médica (CNRM). Em síntese, esta publicação sinaliza o compromisso do CFM com a pesquisa científica de excelência e destinada à contribuição para um projeto de Nação mais justo, ético e solidário.

Brazilian infectious diseases specialists: who and where are they?

Abstract Background The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions. Objectives The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil. Methods This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists. Results A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3–58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7 yrs; 95% CI 7.9–9.5) than physicians trained elsewhere in the country (13.6 yrs: 95% CI 11.8–15.5). Conclusion Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

Saúde nas metrópoles – doenças infecciosas / Health in metropolises - Infectious Diseases

A urbanização é um processo irreversível em escala mundial e estima-se que o número de pessoas que vivem em cidades deverá atingir 67% da população do planeta até 2050. Os países de baixa ou média renda, por sua vez, possuem 30% a 40% da população urbana vivendo atualmente em favelas, em situação de risco para diversos agravos de saúde. No Brasil, embora 84,3% da população residissem em áreas urbanas já em 2010, não se verificam no momento ações consistentes voltadas ao enfrentamento das questões de saúde urbana. Neste artigo discute-se a situação epidemiológica de agravos infecciosos de interesse para a saúde pública (dengue, infecção por HIV/aids, leptospirose, hanseníase e tuberculose) a partir do ano 2000 nas 17 metrópoles do país, de modo a esclarecer o papel atual das doenças infecciosas no contexto da saúde urbana brasileira...

Urbanization is an irreversible global process and the number of people living in cities is estimated to reach 67% of the world population by 2050. In low- and middle-income countries, 30% to 40% of the population currently lives in slum areas, under risk of several diseases. Even though 84.3% of the Brazilian population already lived in urban areas in 2010, no consistent initiatives have been implemented to address urban health issues. We discuss here the epidemiological features of communicable diseases that are relevant to public health (dengue, HIV/aids, leptospirosis, leprosy and tuberculosis) in Brazil’s 17 metropolitan areas since 2000 to help clarify the current role of infections in the context of Brazilian urban health...

Demografia médica no Brasil - 2015 / Medical demography in Brazil - 2015

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O controle do câncer de mama na atenção primária: desafios na elaboração do plano amostral / Breast cancer control in primary health care: challenges in building a sampling plan

Objetivo: descrever a amostragem para identificar as ações no controle do câncer de mama na atenção básica. Mé- todo: estudo descritivo. Apresentam-se os critérios de escolha do objeto e local de pesquisa, dos informantes- chave e da técnica amostral. Resultados: para identificar as ações consensuadas, na região sudeste de São Paulo, selecionaram-se amostras de serviços, usuárias, gestores e enfermeiros. Várias fontes informatizadas foram consulta- das devido à incompletude dos cadastros locais. A hetero- geneidade populacional conduziu a um plano complexo de amostragem em dois estágios. Considerou-se o nível de confiança de 95%, efeito de delineamento igual a dois com erro amostral de 5%, resultando em amostra de 760 usuárias e a totalidade de gestores e enfermeiros de 38 ser- viços. Conclusão: os critérios adotados foram adequados para definição de uma amostra que satisfizesse aos obje- tivos propostos. No entanto a incompletude e a incon- sistência das informações nas bases de dados consultadas foram os principais desafios deste estudo.

Objective: Describe sampling to identify the breast cancer control actions in primary health care. Methods: Descriptive study. We present the criteria for selecting the study object and locale, as well as the key respondents and sampling techniques. Results: Samples from services, users, managers, and nurses were selected to identify consensual breast cancer control actions in the southeast region of São Paulo. The incompleteness of local records led us to consult several computerized sources to carry out the sampling. A complex, two-stage sampling plan was employed due to the heterogeneity of the main population. A 95% confidence interval, a design effect of 2, with a sampling error of 5%, was considered, resulting in a sample of 760 users and a universe of managers and nurses from 38 services. Conclusion: The criteria used were adequate to define a sample that met the intended goals. However, the incompleteness and inconsistency of the information in the databases consulted were the main challenges in this study.

A feminização da medicina no Brasil / The feminization of Medicine in Brazil

Objetivando traçar a evolução histórica da distribuição de médicos no Brasil segundo sexo, foi realizado estudo epidemiológico do tipo ecológico, por meio do cruzamento de bancos de dados secundários (linkage). Para a caracterização geral dos médicos foram consideradas as bases de dados dos 27 conselhos regionais de medicina, complementadas pelas bases de dados da Comissão Nacional de Residência Médica e da Associação Médica Brasileira. Os resultados mostram que, desde 2009, entre os novos médicos registrados há mais mulheres que homens. Na população de médicos em atividade os homens ainda predominam (60,1 por cento), mas no grupo com 29 anos ou menos as mulheres já são maioria. A tendência consistente de maior participação das mulheres na profissão médica no Brasil, observada ao longo das últimas décadas e acentuada nos últimos anos, indica a necessidade de reavaliar e readequar as propostas para implementação de políticas públicas na área.

Aiming to settle the historical evolution of physicians’ distribution in Brazil by gender, an ecological study wasconducted by secondary database cross-checking (linkage). For a general characterization of the physicianswere considered the 27 Regional Medicine Council, complemented by the National Medical Residency andthe Brazilian Medical Association databases. The results show that since 2009, among new registered doctorsthere are more women than men. Although men still prevail (60.1%) in the active physicians population, inthe group aged less than 29 years old, women have become majority. The consistent trend of increased participation of women in the medical profession in Brazil, observed over the past decades and intensified overthe past few years, indicates the need to reassess and readjust the proposals for implementation of publicpolicies in the area.

Análise do controle dos contatos intradomiciliares de pessoas atingidas pela hanseníase no Brasil e no estado de São Paulo de 1991 a 2012 / Analysis of control household contacts of people affected by leprosy in Brazil and the state of São Paulo de 1991 a 2012

A hanseníase constitui um relevante problema de Saúde Pública no Brasil, e o controle dos comunicantes é fundamental para o controle da endemia e o alcance das metas de eliminação. Objetivo: Descrever e analisar a evolução das medidas de controle dos comunicantes intradomiciliares das pessoas atingidas pela hanseníase e seu impacto prático no Brasil e no estado de São Paulo, entre 1991 a 2012.Métodos: Trata se de revisão narrativa, realizada em teses, portarias, manuais, dissertações, artigos de periódicos e boletins informativos, disponíveis em Bases de Dados online, de relevância no meio científico, filtrando apenas publicações entre 1991 a 2012.Os dados foram inicialmente catalogados e, posteriormente aplicadas técnicas de leituras/fichamento com a formação de um banco de dados. Resultados e Discussão: Todas as normatizações aqui citadas, com relação à vigilância dos contatos que foram sendo expedidas e revogadas a partir de 1991, não causaram impacto significativo no controle dos comunicantes. O controle não foi incrementado e/ou priorizado pelos órgãos oficiais e unidades de saúde, contribuindo para que dezenas de comunicantes intra domiciliares continuem alimentando o “iceberg” da endemia. Conclusão: Defendemos a ampliação do conceito de comunicante para além dos contatos intradomiciliares. As intervenções devem ser constantes e mantidas,para que se assegure a redução da ocorrência dos casos,que não serão alcançadas caso as atividades de eliminação fiquem restritas apenas ao diagnóstico e tratamento dos casos novos, deixando para segundo plano a vigilância epidemiológica, o exame rotineiro dos comunicantes, a vacinação, o tratamento, a educação do paciente, da família e da comunidade.

Leprosy is still a significant public health problem in Brazil, and the control of house hold contacts is primordialto control this endemic and achieve the eliminationgoal. Objective: To describe and analyzethe evolution of the control measures of household contacts of people affected by leprosy and its practical impact in Brazil and in the state of São Paulo, from1991 to 2012. Methods: This was a narrative review, held in thesis, ordinances, manuals, dissertations, journal articles and newsletters, available in online databases, of relevance in scientific circles, filteringout only publications from 1991 to 2012. The datawere first cataloged and subsequently it was applie dreading techniques, forming a database. Results and Discussion: All standardizations cited here, related to the surveillance of contacts that have been issued andrevoked since 1991, did not have significant impacton the evaluation of the contacts. The control was not incremented and/or prioritized by official agencies and health units, contributing to dozens of household contacts continue feeding the problem of endemics.Conclusion: We support the expansion of the conceptof communicating beyond the household contacts. Interventions should be constant and maintained to ensure the reduction of cases that will not be achieved if elimination activities remain restricted only to the diagnosis and treatment of new cases, leaving behind the epidemiological surveillance, routine examination of communicating, vaccination, treatment, patient education, family and community.

Demografia médica no Brasil: cenários e indicadores de distribuição - volume 2 / Medical demography in Brazil: scenarios and distribution indicators - volume 2

Somente com vontade política, financiamento adequado e gestão qualificada romperemos com o ciclo histórico da desigualdade que tem mantido o Brasil, em diversos indicadores de saúde, em posições incompatíveis com os anunciados progressos na área econômica. É preciso que o governo demonstre sua compreensão de que o investimento em saúde ­ assim como em educação ­ coloca o cidadão como fim maior de sua existência, provando que no país o desenvolvimento econômico andará de braços dados com avanços sociais. Os governantes devem entender que a condução de um sistema nacional de saúde como o brasileiro ­ baseado nas diretrizes da universalidade, integralidade e equidade no acesso ­ necessita de uma visão estruturante. Ou seja, as decisões devem ser permanentes e as respostas não devem ser meramente midiáticas ou guiadas pelo imediatismo. Neste terreno, a falta de informações baseadas em evidências termina por fortalecer posicionamentos equivocados, que confundem a sociedade e protelam a tomada de decisões. Por isso, o Conselho Federal de Medicina (CFM) e o Conselho Regional de Medicina do Estado de São Paulo (Cremesp) estabeleceram parceria para produzir novo trabalho que oferece dados e análises sobre o perfil do médico em atividade no país. O estudo Demografia Médica no Brasil ­ Volume II ­ Cenários e Indicadores de Distribuição traz informações preciosas e inéditas que agregam elementos importantes ao debate sobre o tema nas esferas pública e privada da saúde. Assim, as tendências reveladas podem nortear a adoção de medidas que assegurem a construção de um projeto de país e de um sistema de saúde mais justo e solidário, orientado pelos compromissos com a qualidade da assistência, a equidade, a justiça e a ética.