Aspectos epidemiológicos e clínico-patológicos de um surto de miopatia nutricional em potros ˗ relato de caso / [Epidemiological and clinical-pathological aspects of an outbreak of nutritional myopathy in young horses ˗ case report]

A miopatia nutricional é uma doença degenerativa que pode afetar os músculos esqueléticos e cardíaco, causada pela deficiência dietética de selênio e/ou vitamina E. Objetivou-se relatar a ocorrência de miopatia nutricional em dois potros Puro Sangue Inglês, criados de forma extensiva, com baixa disponibilidade de forragem e sem suplementação mineral. De um lote de nove animais de diferentes idades (cinco éguas adultas, uma potra lactente de três meses,uma mula e dois potros de 16 e 17 meses), apenas os dois últimos foram afetados. Clinicamente, havia decúbito lateral ou esternal, taquicardia, taquipneia, desidratação e dor à palpação muscular na região dos glúteos.O diagnóstico presuntivo de miopatia nutricional foi realizado por meio da associação dos sinais clínicos aos dados epidemiológicos.O animal 1 foi eutanasiado cinco dias após o atendimento devido à piora gradativa do quadro, e o animal 2 recuperou-se com o tratamento adotado. O diagnóstico foi confirmado com base nos exames complementares, nos achados de necropsia e na dosagem da concentração hepática de selênio. Este relato de caso alerta para o risco da ocorrência de miopatia nutricional em equinos, sobretudo jovens, sem acesso a pastagens ou feno de boa qualidade e sem suplementação mineral adequada.(AU)

Nutritional myopathy is a degenerative disease caused by the dietary deficiency of selenium and/or vitamin E that can affect skeletal and cardiac muscles. The objective of this study was to report the occurrence of nutritional myopathy in two Thoroughbred young horses, raised in pastures with low forage availability and no mineral supplementation. From a herd of nine animals of different ages (five adult mares, one three-month-old nursing foal, one mule and two 16- and 17-month-old horses), only the last two were affected. Clinical signs were lateral or sternal recumbency, tachycardia, tachypnea, dehydration and muscle pain. Presumptive diagnosis of nutritional myopathy was made associating clinical signs and epidemiological data. Animal 1 was euthanized five days after the first evaluation due to clinical signs gets worse, and animal 2 recovered with the established treatment. Diagnosis was confirmed with complementary exams, necropsy findings and levels of hepatic selenium. This paper alerts to the risk of nutritional myopathy occurrence in horses, mainly young animals, which are not ingesting good quality hay or green forage and do not receive appropriate mineral supplementation.(AU)

Study of Serum Selenium Levels in Schizophrenic Patients.

Deficiency and excess amount of trace elements play an important role in several well recognized diseases, studies are going on to establish their role in schizophrenia. Selenium and other trace elements are indispensable components for certain enzymes responsible for various metabolic processes in different tissues including the brain as they play important functional roles in peripheral and central nervous systems. Objectives: In this study, we examined the levels of selenium in serum of patients of schizophrenia and compare them with normal healthy controls. Selenium was also measured in acute and chronic stage of schizophrenia categorized on the basis of PANSS score and correlated by Spearman’s Correlation Coefficient (ρ) in total cases, acute cases and chronic cases. Method: The study population comprised 150 patients and 150 age matched controls. We measured levels of Selenium by AAS (Atomic Absorption Spectrophotometer). Results: We found that selenium levels were significantly lower in patients with schizophrenia than in the control group. The levels of micronutrients studied were also correlated with disease severity and duration but found non-significant relation. Conclusion: Evaluation of selenium levels in patients with schizophrenia could prove useful. There may be role of Selenium in the pathogenesis and course of Schizophrenia and new therapeutic approaches warrants further study.

Selenium deficiency and the effects of supplementation on preterm infants / Deficiencia de selenio y los efectos de la suplementacion en prematuros / Deficiencia de selenio e os efeitos da suplementacao em prematuros

Objective: This study aimed to review the literature about blood concentrations of selenium associated with gestational age, feeding, supplementation and related clinical features in preterm infants. Data sources: Systematic review in the following databases: MEDLINE, PubMed, Google academics, SciELO. org, ScienceDirect (Elsevier) and CINAHL-Plus with Full Text (EBSCO). Articles published up to January 2013 with the keywords "selenium deficiency", "selenium supplementation", "neonates", "infants", "newborn" and "preterm infants" were selected. Data synthesis: The studies reported that low blood selenium levels are associated with increased risk of respiratory diseases. Preterm infants, especially with low birth weight, presented lower selenium levels. Selenium deficiency has also been associated with the use of oral infant formula, enteral and parenteral nutrition (with or without selenium addition). The optimal dose and length of selenium supplementation is not well-established, since they are based only on age group and selenium ingestion by breastfed children. Furthermore, the clinical status of the infant affected by conditions that may increase oxidative stress, and consequently, selenium requirements is not taken into account. Conclusions: Prematurity and low birth weight can contribute to low blood selenium in premature infants. Selenium supplementation seems to minimize or prevent clinical complications caused by prematurity. .

RESUMEN Objetivo: Revisar los trabajos que analizaron las concentraciones sanguíneas de selenio asociadas con la edad gestacional, alimentación, suplementación y cuadro clínico de prematuros. Fuentes de datos : Revisión sistemática de la literatura mediante búsquedas electrónicas en las bases de datos a continuación: Medline Pubmed, Google académico, SciELO. org, SienceDirect (Elsevier) y CINAHL with Full Text (EBSCO). La búsqueda se realizó con trabajos publicados hasta enero de 2013 con las palabras clave a continuación: selenium deficiency, selenium supplementation, neonates, infants, newborn and preterm infants. Síntesis de los datos: Los estudios relataron que los bajos índices de selenio están asociados al riesgo aumentado para enfermedades respiratorias. Los prematuros, principalmente con bajo peso al nacer, presentan los menores niveles de selenio. La deficiencia de selenio viene siendo asociada al uso de fórmula infantil oral, nutrición enteral y parenteral (con y sin adición de selenio). La dosis y el tiempo ideal para la suplementación de selenio todavía no están bien establecidos, puesto que se basan solamente en la franja de edad y en la ingestión de selenio de niños amamantados al pecho. Además, no se considera el estado clínico del recién nacido, que puede ser acometido por enfermedades que aumentan el estrés oxidativo y, por consiguiente, elevan las necesidades de selenio. Conclusiones: La prematuridad y el bajo peso al nacer pueden contribuir para reducir las concentraciones sanguíneas de selenio en prematuros. La suplementación parece reducir o prevenir las complicaciones clínicas causadas por la prematuridad. .

Objetivo: Revisar os trabalhos que analisaram as concentrações sanguíneas de selênio associadas à idade gestacional, à alimentação, à suplementação e ao quadro clínico de prematuros. Fontes de dados: Revisão sistemática da literatura por meio de buscas eletrônicas nas seguintes bases de dados: MEDLINE PubMed, Google acadêmico, SciELO.org, ScienceDirect (Elsevier) e CINAHL-Plus with Full Text (EBSCO). Buscaram-se trabalhos publicados até janeiro de 2013 com as seguintes palavras-chave: "selenium deficiency", "selenium supplementation", "neonates", "infants", "newborn" e "preterm infants". Síntese dos dados: Os estudos relataram que os baixos níveis selênio associam-se ao risco aumentado para doenças respiratórias. Os prematuros, principalmente com baixo peso ao nascer, apresentam os menores níveis de selênio. A deficiência do mineral tem sido associada ao uso de fórmula infantil oral, nutrição enteral e parenteral (com e sem adição de selênio). A dosagem e o tempo ideal para a suplementação de selênio ainda não estão bem estabelecidos, visto que se baseiam apenas na faixa etária e na ingestão do mineral por crianças amamentadas no peito. Além disso, não se considera o quadro clínico do recém-nascido, que pode ser acometido de doenças que aumentam o estresse oxidativo e, consequentemente, elevam as necessidades de selênio. Conclusões: A prematuridade e o baixo peso ao nascer podem contribuir para reduzir as concentrações sanguíneas de selênio em prematuros. A suplementação parece minimizar ou prevenir as complicações clínicas causadas pela prematuridade. .

Tasa de tiroidectomías por cáncer y por enfermedades benignas tiroídeas y su posible relación con un déficit de selenio ambiental / Rate of thyroidectomy by cancer and benign thyroid diseases and its possible relation with a deficit of selenium environmental

Recientemente hemos reportado el déficit de selenio ambiental, y el estatus alterado de selenio medido como actividad de Glutatión Peroxidasa en población beneficiaria del Servicio de Salud de Osorno. Estos déficits se asocian a alteraciones funcionales y estructurales del tiroides que se correlacionan con la aparición de enfermedades tiroídeas benignas y cáncer tiroídeo. El objetivo de este trabajo es mostrar la tasa de tiroidectomías por cáncer y por enfermedades benignas que se presentan en las comunas que habitan la población beneficiaria del Servicio de Salud Osorno y llamar la atención sobre su posible asociación con el estatus alterado de selenio y la menor actividad de Glutatión Peroxidasa descrita previamente.

We have recently reported the lack of environmental selenium and the altered selenium status measured as deficient glutathione peroxidase (GPx) activity in the population affiliated to the Osorno Health Service. These deficits are associated to functional and structural abnormalities of the thyroid gland that correlates with the appearance of benign thyroid pathologies and thyroid cancer. The aim of this investigation is to show the rate of thyroidectomy associated with malign and benign disease in the communities associated to the Osorno Health Service and warn about their possible link with the poor amount of selenium in the environment and the altered function of the GPx enzyme, previously described.

Quality of drinking water and high incidence rate of esoph-ageal cancer in Golestan Province of Iran: a probable link

Golestan Province in northern Iran is known to be a high-risk area for esophageal cancer [EC]. Of a long list of multiple risk factors, this study focuses on a possible link between the epidemiologic patterns of EC and the anomalous concentration of some ions and elements in the drinking water sources. A total of 183 samples from 45 villages covering a wide range of EC mortality rates are collected and analyzed. The results demonstrate that NO3, SO42, Sb, and Sr exceed the recommended maximum concentration level [MCL] in drinking water. This is more prominent in the villages with high esophageal cancer mortality rate, suggesting a possible link between EC incidence and water quality. Se concentration in drinking water increases from low to the high EC areas, a finding contrary to the expected trend. It is concluded that Se deficiency does not play a major role in the etiology of EC in the Golestan Province. The statistical results obtained from Mann-Whitney and Kruskal-Wallis tests along with cluster analysis are consistent with the observed trend of EC mortality rate in Golestan Province

Selenio y salud animal Importancia, deficiencia, suplementación y toxicidad / Selenium and animal health: importance, defficiency, supplementation and toxicity / Selênio e saúde animal importância, deficiência, suplementação e toxidez

El selenio (Se) es un mineral esencial en la nutrición animal y se considera su participación en diversos procesos asociados a la producción animal, tan diversos como la fertilidad de la especie y la prevención de enfermedades. Laglutatión-peroxidasa (GSH-Px), fue la primera enzima en que se demostró la presencia activa del selenio y su importancia al evitar el daño oxidativo de las membranas celulares. Con anterioridad se había demostrado que la conocida como “Enfermedad del músculo blanco” era consecuencia de la deficiencia de Se, determinando muerte en animales recién nacidos y ocasionalmente en animales en desarrollo y aún en adultos, en particular en rumiantes. Actualmente ha quedado claro que el Se también es crítico en la estructuración de las enzimas necesarias para la síntesis de la hormona tiroidea y para su activaciónen los tejidos periféricos, pasando de T4 a T3. La deficiencia de Se afecta seriamente la capacidad de respuesta inmune de los animales. El diagnóstico de la deficiencia debe fundamentarse en los niveles del elemento en los suelos, las plantas forrajeras y la condición del animal en sangre y tejidos. Se han instrumentado diversas formas de suplementación del elemento que pueden emplearse dependiendo de las condiciones productivas de los animales y sus niveles previos de Se. La intoxicación por Se (Selenosis) debe tenerse en cuenta en los programas de suplementación, y puede ocurrir en formas crónicas o agudas. Las formas crónicas ocurren en regiones con suelos ricos en el elemento y condiciones que favorecen su absorción por las plantas forrajeras. Las formas agudas generalmente ocurren por excesos del elemento en las dietas o las sales que se administran a los animales o por errores de dosificación en las formulaciones parenterales. La relación metabólica del Se entre la hembra gestante, el feto y el recién nacido, es un área que requiere mayor investigación.

O selênio (Se) é um mineral essencial na nutrição animal e se considera sua participação em diversos processos associados à produção animal, tão diversos como na fertilidade das espécies e prevenção de enfermidades. A glutation peroxidase (GSH-Px), foi a primeira enzima em que se demonstrou a presença ativa do selênio e sua importância para evitar o dano oxidativo nas membranas celulares. Anteriormente sabia-se que a “enfermidade do músculo branco” era conseqüência da deficiência de Se, determinando a morte em animais recém-nascidos e ocasionalmente em animais em desenvolvimento, animais adultos e em particular em ruminantes. Atualmente, está claro que o Se é crítico na estruturação das enzimas necessáriaspara a síntese de hormônios da tireóide e para sua ativação nos tecidos periféricos, passando de T3 a T4. A deficiência de Se afeta seriamente a capacidade da resposta imune dos animais. O diagnóstico da deficiência deve fundamentar-se nos níveis deste elemento no solo, nas plantas forrageiras e nas condições do animal. Indicam-se diversas formas de suplementação deste elemento, que podem ser empregadas dependendo das condições produtivas dos animais e seus níveis prévios de Se. As intoxicações por Se (selenose), devem ser consideradas nos programas de suplementação, que pode ocorrer de forma crônica ou aguda. As formas crônicas ocorrem em regiões com solos ricos no elemento e nas condições que favorecem a absorção pelas plantas forrageiras. As formas agudas geralmente ocorrem por excesso do elemento nas dietas, ou sais administrados aos animais ou por erros na dosagem das formulações parenterais. A relação metabólica do Se na fêmea gestante, o feto e orecém-nascido, é uma área que requer uma maior investigação.

Selenium (Se) is an essential trace element for animal nutrition and plays multiple actions related to animal production, fertility and prevention of diseases. Glutathione peroxidase enzyme (GSH-Px) was the first seleno enzyme to demonstrate the active presence of selenium and its importance to prevent cellular membrane oxidative damage. Formerly, White muscle disease (WMD) was recognized as resulting from Se deficiency, determining new born mortality and adult animals, especially in ruminants. Nowadays, it is clear that Se is critical for thyroid hormone synthesis and its activation in peripheral tissues – from T3 to T4. Lack of Se seriously affects the capacity of immune response by the animals. Se status in the soil, plants, animal blood and tissues can be used as a tool to diagnose Se deficiency. Several forms of Se supplementation are described which can be applied depending of the productive capacity of the animals and their previous levels of Se. Acute and chronic Se intoxication (Selenosis) should be considered in supplementation programs as it may occur in a chronic or acute way. Chronic forms are associated to regional seleniferous soils, with permanent or repeated consumption of seleniferous plants. Acute forms are associated with high ingestion of Se as a result of wrongly designed diets, salt provided to the animals or parenteral injection dosage mistakes. The metabolic relation among Se, the fetus, the newborn and the pregnant dam requires further investigations.

Selenium and selected risk factors for pre-eclampsia

A case control study was conducted in Ain Shams University Maternity Hospital postpartum ward. A hundred pregnant women included in the study, 50 with preeclampsia anc 50 healthy pregnant women as a control group. A 5 cc blood sample was taken and centrifuged where the plasma was used to measure the selenium level. Selenium levels were statistically significantly lower in preeclampsia group than the control group irrespective to risk factors included in the study [GA, age, parity, Past history of hypertension, DM]. It was found that the risk decreases by 12% with increase the selenium level by 1 mg/100 cm[3]. Low selenium level could be a risk factor for developing PE. Further studies are needed to assess the effect of dietary habit of the selenium content of different foods on the level of the selenium and its effect on preeclampsia

Selenium in atherosclerotic complications of chronic renal failure

Trace elements disturbance may occur in uraemic patients and patients on haemodialysis, as a result of renal function decline. Selenium [Sc] deficiency seems to have a synergistic effect with alterations in plasma lipids in promoting the progression of atherosclerotic lesions. The aim of this study was to investigate the possible effect of Se in the development of atherosclerotic complications in chronic renal failure patients. One hundred and seventeen individuals were randomly selected, fifty five patients with primary end stage renal failure on regular hemodialysis treatment, mean age 38.94 +/- 13.00 years, [group I], fourty patients with chronic end stage renal failure under conservative treatment, mean age 48.25 +/- 12.07 years, [group II] and twenty two healthy control volunteers with mean ages 38.09 +/- 9.66 years, [group Ill]. Full history and clinical examinations, stressing on macrovascular atherosclerotic complications were done. Laboratory investigations included serum[s] lipids profile [total lipids, total cholesterol [TC], phospholipids phosphorus [PLP], triacylglycerol [TG] and lipoproteins [alpha lipoprotein [HDL], pre-betalipoprotein [VLDL] beta lipoprotein [LDL] and lipoprotein [a] [Lp [a]]]. Determination of superoxide dismutase enzyme [SOD], Se and renal function tests and cardiovascular assessment were done. In group I and group II patients there were significant increase of the serum levels of TC [p < 0.05] and TG [p < 0.001], on contrast to significant decrease of HDL [P < 0.01], SOD and Se [p < 0.001] as compared to group III normal control. In groups I and II patients there were non significant difference of total lipids, LDL, Lp [a], PLP and VLDL [p > 0.05] on comparing with group III control. In the correlation between Se and other parameter in the patients groups there were negative correlation significant with TG, urea and creatinine and non significant with total lipids, TC, LDL, Lp [a] and insulin. On the contrary there was significant positive correlation with PLP and SOD while non significant with HDL, VLDL, glucose and age. We concluded that chronic renal failure patients have significant Se deficiency which may be contributed to the associated dyslipidemic atherosclerotic complications with high incidence in uremic patients on conservative treatment 24/40 [60%] than patients on hemodialysis 19/55 [34.5%]. We recommend to use 1-More objective evidence of atherosclerosis in more number of patients 2-Lipid lowering agents with low fat diet regimen is advisable to chronic renal failure patients 3-Se supplementation to chronic renal failure patients

Long-time fulvic acid supplementation modulates hydroxylysyl glycosylation of collagen in mice / 华中科技大学学报（医学）（英德文版）

In order to investigate the impact of fulvic acid (FA) on the hydroxylysyl glycosylation in collagen bio-synthesis, 40 NMRI mice were divided into two groups (n = 20 in each group, consisting 10 females and 10 males). The animal was maintained for two generations by different diets: control group with normal water and food and study group with water containing 30 mg/L FA and normal food. The second generation of the animal was slaughtered, and the biochemical parameters of collagen content and the degree of collagen hydroxylysyl glycosylation in skin, rib and tibia were detected by biochemical methods. The mean value of collagen in the study group was increased slightly, and no significant difference between study group and control group was found (P > 0.05), but the content of glucose-glactose-hydroxylysine (GGH) was significantly decreased in the study group in comparison with the control group (P<0.01). It was suggested that through the decrease of GGH 30 mg/L FA could inhibit the activity of galactosyl-hydroxylysylglucosyl-transferase and further disturb the post-translational modification of collagen intracellularly.

Glutathione peroxidase enzyme and selenium level in patients with Down syndrome

In recent years, it has been hypothesized that an increase in oxidative stress in patients with Down syndrome account for the appearance of different diseases such as atherosclerosis, accelerated cell aging, cellular mutagenicity and neurological disorders that often occur in these patients. The antioxidant defense system enzymes have been shown to be altered due to increased gene dosage on chromosome 21 and overproducetion of superoxide dismutase. The purpose of this study was to investigate the activity of glutathione peroxidase enzyme [GPX] and the level of selenium [Se] as indicators of antioxidative metabolism in Down syndrome patients. The study was conducted on forty patients with Down syndrome. They were 21 males and19 females. Their ages ranged between 1 year and 11 years [mean 3.95 +/- 2.5 years]. Another group was randomly chosen as a control group, it included 10 normal infants and children, 5 males and 5 females. Their ages ranged between 1 year and 11 years [mean 3.95 +/- 4.47 years]. All cases and controls were subjected to plasma glutathione peroxidase enzyme assay and plasma selenium level determination. There was a significant increase in GPX activity in Down syndrome patients compared to the control group. There was no statistical significant difference between cases and controls as regards selenium level. In Down syndrome group, there was no significant difference in GPX and selenium levels between males and females and between different age groups. There was a significant negative correlation between GPX activity and Se level in Down syndrome patients. Down syndrome patients have increased activity of glutathione peroxidase enzyme and although they have normal plasma Se level, there is a significant negative correlation between selenium level and GPX activity. This finding suggests that the selenium requirement of the enzyme is not met and there is a relative selenium deficiency

[Ecologic study of serum selenium and upper gastrointestinal cancers in Iran]

Both observational and experimental studies have shown that higher selenium status reduces the risk of upper gastrointestinal cancers in selenium deficient populations. Recent cancer registry data have shown very different rates of esophageal cancer [EC] and gastric cancer [GC] in four provinces of Iran, namely Ardabil, Mazandaran, Golestan, and Kerman. The aim of this study was to have a preliminary assessment of the hypothesis that high rates of EC in Golestan and high rates of GC in Ardabil may be partly attributable to selenium deficiency. We measured serum selenium in 300 healthy adults from Ardabil [n=100], Mazandaran [n=50], Golestan [n=100], and Kerman [n=50], using inductively coupled plasma, with dynamic reaction cell, mass spectrometry [ICP-DRC-MS] at the US Centers for Disease Control [Atlanta, Georgia]. The median serum selenium concentrations were very different in the four provinces. The medians [IQR] for selenium in Ardabil, Mazandaran, Golestan, and Kerman were 82 [75-94], 123 [111-132], 155 [141-173], and 119 [110 -128] micro g/L, respectively [p<0.001]. The results of linear regression showed that the province variable, by itself, explained 76% of the variance in log selenium [r2=0.76]. The proportion of the populations with a serum selenium more than 90 micro g/L [the concentration at which serum selenoproteins are saturated] was 100% in Golestan, Kerman, and Mazandaran but only 29% in Ardabil. Our findings suggest that selenium deficiency is not a major contributor to the high incidence of EC seen in northeastern Iran, but it may play a role in the high incidence of GC in Ardabil province

Selenium in the neonate.

Selenium is a trace element of tremendous importance in human health. It is a constituent of the antioxidant enzyme. Glutathione peroxidase and therefore is vital to antioxidant defense. Several diseases of the neonate have been shown to be caused at least in part by oxygen free radicals. These include bronchopulmonary dysplasia retinopathy of prematurity necrotising enterocolitis patient ductus arteriosus and neuronal injury of hypoxic ischemic encephalopathy. Good selenium nutrition is therefore of key importance to antioxidant defense in the neonate. The communique reviews the important role that selenium might play in neonatal health & disease.

role of selenium deficieny in dilated cardiomyopathy in Saudi Arabia

Selenium deficiency is implicated in the etiology of endemic juvenile dilated cardiomyopathy in China, and in sporadic cases in other countries. The aim of this study was to evaluate the role of selenium deficiency in the pathophysiology of dilated cardiomyopathy in the Saudi Arabian population. Patients and Plasma and urine selenium concentrations from 72 Saudi patients with confirmed dilated cardiomyopathy were compared with corresponding values from 70 control subjects of the same national origin who had normal ventricular function. Plasma and urine selenium concentrations [mean +/- SD] were 1.34 +/- 0.45 and 0.49 +/- 0.37 micro mol/L, respectively, for the patient group, and 1.32 +/- 0.41 and 0.60 +/- 0.41 micro mol/L, respectively, for the control group. The differences in the values between the two groups were statistically insignificant. In the Saudi population, dilated cardiomyopathy is not caused by selenium deficiency

Effect of experimental selenium deficiency and its supplementation on lymphoid organs.

Feeding of selenium deficient diet to albino rats for 75 days resulted in increased levels of plasma and adrenal glucocorticoids and atrophy of spleen and thymus. Supplementing the diet with selenium for 30 days resulted in recovery of atrophy of spleen and thymus; plasma and adrenal glucocorticoid levels were also restored back to the normal.

Manifestaçöes cutâneas em deficiências nutricionais / Skin manifestations in nutritional deficiencies

Säo analisadas, no material disponível, as principaiscondiçöes clínicas decorrentes de deficiências nutricionais em criança, adulto e idoso, visando as estratégias a serem empregadas em sua profilaxia e tratamento. Säo relacionadas as deficiências nutricionais específicas pelo uso de determinadas drogas no adulto e na criança, e discutidos os problemas da administraçäo de suplementos vitamínicos, nutricionais e, sobretudo, das formulaçöes ortomoleculares, que o grupo considera necessário ser objeto de debate para o próximo Congresso Brasileiro de Dermatologia. É abordada ainda a necessidade do uso da mídia para informaçäo à populaçäo de baixa renda sobre o assunto e da ênfase de sua induçäo como tema para investigaçöes nos cursos de graduaçäo da área médica.