Impactos psicossociais sobre trabalhadores da saúde: narrativas 10 anos após o desastre / Psychosocial impacts on health workers: narratives 10 years after the disaster

Resumo O artigo tem como objetivo compreender os impactos psicossociais vivenciados por trabalhadores de saúde após situação de desastre no estado de Santa Catarina, na região Sul do Brasil. Para tal, realizou-se estudo qualitativo de múltiplos casos e entrevistas narrativas com profissionais de serviços de saúde mental, atenção primária à saúde e gestores municipais em Itajaí, Blumenau e Rio do Sul. A análise das narrativas seguiu as etapas do método de Fritz Schütze. Descreveram-se os impactos psicossociais sobre a saúde e o trabalho dos entrevistados, afetados direta e/ou indiretamente pelo desastre natural ocorrido em 2008 na região, e subsequentes eventos de menor intensidade. Nos três casos, os impactos foram percebidos semelhantemente, ainda que as consequências do evento na rede municipal tenham sido enfrentadas de formas diferentes em cada localidade. Os resultados revelam a importância da promoção da saúde no trabalho e do desenvolvimento de habilidades pessoais, a resiliência frente a situações adversas e a necessidade de educação contínua e permanente.

Abstract The article aims to understand the psychosocial impacts experienced by health workers after a disaster situation in the state of Santa Catarina in Southern region of Brazil. To that end, a qualitative study of multiple cases and narrative interviews with professionals from mental health services, primary health care, and municipal managers in Itajaí, Blumenau, and Rio do Sul was carried out. The analysis of the narratives followed the steps of the Fritz Schütze method. The psychosocial impacts on the health and work of respondents, directly and/or indirectly affected by the natural disaster that happened in 2008 in the region, and subsequent events of lesser intensity, were described. In the three cases the impacts were perceived similarly, although the consequences of the event in the municipal network were faced differently in each location. The results reveal the importance of promoting health at work and developing personal skills, resilience in the face of adverse situations, and need for continuing and constant education.

Muscle pain induced by static contraction is modulated by transient receptor potential vanilloid 1 and ankyrin 1 receptors

Abstract Molecular mechanisms involved in the development of muscle pain induced by static contraction are not completely elucidated. This study aimed to evaluate the involvement of the transient receptor potential vanilloid 1 (TRPV1) and the transient receptor potential ankyrin 1 (TRPA1) receptors expressed in peripheral and central terminals of primary afferents projected to gastrocnemius muscle and spinal cord in muscle pain induced by static contraction. An electrical stimulator provided the contraction of rat gastrocnemius muscle and mechanical muscle hyperalgesia was quantified through the pressure analgesimeter Randall-Selitto. AMG9810 and HC030031 were used. When administered in ipsilateral, but not contralateral gastrocnemius muscle, drugs prevented mechanical muscle hyperalgesia induced by static contraction. Similar results were obtained by intrathecal administrations. We propose that, in an inflammatory muscle pain, peripheral and central TRPV1 and TRPA1 work together to sensitize nociceptive afferent fibers, and that TRPV1 and TRPA1 receptors are potential target to control inflammatory muscle pain.

Novel rearrangements between different chromosomes with direct impact on the diagnosis of 5p- syndrome

Abstract Objectives Copy Number Variations (CNVs) in the human genome account for common populational variations but can also be responsible for genetic syndromes depending on the affected region. Although a deletion in 5p is responsible for a syndrome with highly recognizable phenotypical features, other chromosomal abnormalities might overlap phenotypes, especially considering that most studies in 5p use traditional cytogenetic techniques and not molecular techniques. Methods The authors have investigated 29 patients with clinical suspicion of 5p- syndrome using Chromosomal Microarray (CMA), and have gathered information on previous tests, clinical signs, symptoms, and development of the patients. Results The results showed 23 pure terminal deletions, one interstitial deletion, one deletion followed by a 3 Mb duplication in 5p, three cases of 5p deletion concomitant to duplications larger than 20 Mb in chromosomes 2, 9, and 18, and one 5p deletion with a chromosome Y deletion. CMA showed relevant CNVs not typically associated with 5p- that may have contributed to the final phenotype in these patients. Conclusions The authors have identified three novel rearrangements between chromosomes 5 and 2 (Patient 27), 5 and 18 (Patient 11), and 5 and Y (Patient 22), with breakpoints and overlapped phenotypes that were not previously described. The authors also highlight the need for further molecular investigation using CMA, in different chromosomes beyond chromosome 5 (since those cases did not show only the typical deletion expected for the 5p- syndrome) to explain discordant chromosomal features and overlapped phenotypes to unravel the cause of the syndrome in atypical cases. HIGHLIGHTS The authors The authors have described three novel rearrangements between chromosomes 5 and 2, 5 and 18, and 5 and Y with chromosomal breakpoints and overlapped phenotypes that were not previously described. One of the main atypical features for 5p- syndrome that the authors report was the presence of seizures that was found in the three patients with rearrangements between different chromosomes and in a patient with a deletion followed by duplication in 5p. The authors suggest physicians conduct further molecular investigation in the presence of atypical clinical features for patients with 5p- syndrome suspicion.

Prevalência de infecção pelo SARS-CoV-2 em profissionais de saúde em um Hospital Universitário no Rio de Janeiro durante a pandemia de COVID-19 em 2020 / Prevalence of SARS-CoV-2 infection in healthcare professionals at a University Hospital in Rio de Janeiro during the COVID-19 pandemic in 2020

A soroprevalência do SARS-CoV-2 foi determinada a partir de um inquérito epidemiológico transversal realizado no Hospital Universitário Gaffrée e Guinle, na cidade do Rio de Janeiro, Brasil, nos meses de outubro a novembro de 2020, durante a pandemia de COVID-19, na população de funcionários que exercia atividade laboral naquele período. A caracterização sociodemográfica foi realizada, além da análise das associações entre as variáveis de interesse ou exposição com a infecção pelo SARS-CoV-2, para estabelecer quais sinais e sintomas foram de maior prevalência. Para o estudo foram coletadas amostras de sangue e utilizados ensaios imunocromatográficos (COVID-19 IgG/IgM ECO Test® e Medtest® Coronavírus (COVID-19) IgG/IgM), para detectar IgG e IgM anti-SARS-CoV-2. Um cálculo amostral obtendo-se 391 profissionais de saúde demonstrou que 173 (44,2%) indivíduos apresentaram ao menos um resultado positivo para infecção pelo SARS-CoV-2. Não houve diferença significativa entre as medianas das idades dos pacientes que apresentaram infecção pelo SARS-CoV-2 (mediana 40 anos, IIQ 34-53) e dos que não apresentaram infecção (mediana 39 anos, IIQ 32-49), valor de P= 0,148. Também não houve diferença entre o sexo dos profissionais com infecção e sem infecção pelo SARS-CoV-2 (OR = 1,02; IC 95% 0,59 ­ 1,78). Dos 173 profissionais que apresentaram infecção pelo SARS-CoV-2, 70 (40,5%) relataram sintomas relacionados à COVID-19, enquanto 41 (23,7%) profissionais relataram que não apresentaram nenhum sintoma e 62 (35,8%) não informaram sobre presença ou não de sintomas, sendo excluídos da análise. Os sintomas mais frequentemente apresentados pelos profissionais infectados foram: cefaleia 46,5% (59/127); perda de olfato 32,3% (41/127); perda de paladar 30,7% (39/127); tosse seca 27,6% (35/127); diarreia 24,4% (31/127); dores no corpo 27,6% (35/127); outros 13,4% (17/127); dores nas pernas 11,8% (15/127); tonteira 11,8% (15/127) e febre 9,4% (12/127). Estabelecer um protocolo de vigilância com um teste fácil e rápido para as políticas de COVID-19 entre os profissionais na linha de frente e atuantes na assistência é imperativo para o controle da transmissão de SARS-CoV-2 e definir critérios epidemiológicos que orientem a tomada de decisão quanto ao isolamento de profissionais infectados sintomáticos e assintomáticos.

The seroprevalence of SARS-CoV-2 was determined from a cross-sectional epidemiological survey carried out at the Gaffrée and Guinle University Hospital in the city of Rio de Janeiro, Brazil from October to November 2020 during the COVID-19 pandemic in the population of employees who worked in that period. Sociodemographic characterization was performed in addition to the analysis of associations between the variables of interest or exposure with SARS-CoV-2 infection to establish which signs and symptoms were more prevalent. For the study, blood samples were collected and immunochromatographic assays (COVID-19 IgG/IgM ECO Test® and Medtest® Coronavirus (COVID-19) IgG/IgM) were used to detect IgG and IgM anti-SARS-CoV-2. A sample calculation obtaining 391 health professionals showed that 173 (44.2%) individuals had at least one positive result for SARS-CoV-2 infection. There was no significant difference between the median ages of patients who had SARS-CoV-2 infection (median 40 years, IIQ 34-53) and those who did not have infection (median 39 years, IIQ 32-49), P value = 0.148. There was also no difference between the sex of professionals with and without SARS-COV-2 infection (OR = 1.02; 95% CI 0.59 ­ 1.78). Of the 173 professionals who had SARS-COV-2 infection, 70 (40.5%) reported symptoms related to COVID-19, while 41 (23.7%) professionals reported that they had no symptoms and 62 (35.8%) did not report on the presence or absence of symptoms, being excluded from the analysis. The symptoms most frequently presented by the infected professionals were: headache 46.5% (59/127); loss of smell 32.3% (41/127); loss of taste 30.7% (39/127); dry cough 27.6% (35/127); diarrhea 24.4% (31/127); body pain 27.6% (35/127); another 13.4% (17/127); leg pain 11.8% (15/127); dizziness 11.8% (15/127) and fever 9.4% (12/127). Establish a surveillance protocol with an easy and quick test for COVID-19 policies among frontline and care professionals is imperative to control the transmission of SARS-CoV-2 and define epidemiological criteria that guide the decision-making regarding the isolation of symptomatic and asymptomatic infected professionals.

Three-dimensional digitalized and printed tongue models of the cow, dog, pig, and horse for undergraduate veterinary educationh / Modelos tridimensionales digitalizados e impresos de lengua de vaca, perro, cerdo y caballo para la educación veterinaria de pregrado

SUMMARY: This study aimed to construct three-dimensional (3D) anatomical models of the tongue of domestic mammals of veterinary interest. The tongues were obtained from the didactic collection of the Laboratory of Veterinary Macroscopic Anatomy in the Surgery Department of the School of Veterinary Medicine and Animal Science, University of Sao Paulo. Tongues from a cow, dog, horse, and pig were selected for scanning and creation of the 3D-printed models. The printer used a filamentous thermoplastic material, acrylonitrile-butadiene-styrene (ABS), which was deposited together with a support resin. In addition to the printing of models, an interactive 3D PDF was generated, creating a didactic collection for students. The anatomical characteristics and peculiarity of the tongues were easily identified in the scanned and printed images. The 3D scanning and printing offered an innovative method of visualizing different anatomical structures and, together with the existing methods, can optimize anatomy teaching in an educational context.

RESUMEN: Este estudio tuvo como objetivo construir modelos anatómicos tridimensionales (3D) de la lengua de mamíferos domésticos de interés veterinario. Las lenguas se obtuvieron de la colección didáctica del Laboratorio de Anatomía Macroscópica Veterinaria del Departamento de Cirugía de la Facultad de Medicina Veterinaria y Zootecnia de la Universidad de São Paulo. Se seleccionaron lenguas de vaca, perro, caballo y cerdo para escanear y crear los modelos impresos en 3D. La impresora utilizó un material termoplástico filamentoso, acrilonitrilo-butadieno-estireno (ABS), que se depositó junto con una resina de soporte. Además de la impresión de modelos, se generó un PDF 3D interactivo, creando una colección didáctica para los estudiantes. Las características anatómicas y la peculiaridad de las lenguas se identificaron fácilmente en las imágenes escaneadas e impresas. El escaneo e impresión 3D ofrecieron un método innovador para visualizar diferentes estructuras anatómicas y, junto con los métodos existentes, puede optimizar la enseñanza de la anatomía en un contexto educativo.

Antibacterial activity and inhibition against Staphylococcus aureus NorA efflux pump by ferulic acid and its esterified derivatives

Objective: To evaluate the inhibitory activity of ferulic acid and four of its esterified derivatives (methyl, ethyl, propyl, and butyl) against resistance mechanisms in Staphylococcus aureus strains. Methods: Ferulic acid derivatives were obtained by esterification with methanol, ethanol, propanol, and butanol, and then characterized by hydrogen and carbon-13 nuclear magnetic resonance analysis. The minimum inhibitory concentrations (MIC) of ferulic acid and its esterified derivatives, ethidium bromide, and norfloxacin were obtained using the microdilution test, while the efflux pump inhibition test was conducted by examining reduction in the MICs of norfloxacin and ethidium bromide. Molecular docking was also carried out using the Schrodinger Suite 2015 molecular modeling software. A three-dimensional model of NorA efflux pump was generated using I-TASSER. The best scoring model was used as a receptor for ligand-receptor docking. Results: The methyl and butyl ester derivatives did not demonstrate significant antimicrobial activity. However, a significant synergic effect was evidenced when norfloxacin was combined with the ethyl and propyl esterified derivatives. The docking study demonstrated favorable energy of interaction between ferulate derivatives and NorA, and amino acid residues TYR57, TYR58, and LEU255 were present commonly in stabilizing all complexes. The PCA analysis corroborated the docking hypothesis that the lipophilic character and hydrogen bond interactions were the most relevant characteristics involved with NorA inhibitors. The pharmacokinetic parameters of ferulic acid derivatives showed good ADMET properties, demonstrating that they can be easily absorbed and have no effect or inhibit the cytochrome P450 enzyme complex, revealing their potential as drug candidates. Conclusions: This study provides strong evidence that the molecular basis for this activity is potentially due to the NorA efflux pump.

Antibacterial activity and inhibition against Staphylococcus aureus NorA efflux pump by ferulic acid and its esterified derivatives

Objective: To evaluate the inhibitory activity of ferulic acid and four of its esterified derivatives (methyl, ethyl, propyl, and butyl) against resistance mechanisms in Staphylococcus aureus strains. Methods: Ferulic acid derivatives were obtained by esterification with methanol, ethanol, propanol, and butanol, and then characterized by hydrogen and carbon-13 nuclear magnetic resonance analysis. The minimum inhibitory concentrations (MIC) of ferulic acid and its esterified derivatives, ethidium bromide, and norfloxacin were obtained using the microdilution test, while the efflux pump inhibition test was conducted by examining reduction in the MICs of norfloxacin and ethidium bromide. Molecular docking was also carried out using the Schrodinger Suite 2015 molecular modeling software. A three-dimensional model of NorA efflux pump was generated using I-TASSER. The best scoring model was used as a receptor for ligand-receptor docking. Results: The methyl and butyl ester derivatives did not demonstrate significant antimicrobial activity. However, a significant synergic effect was evidenced when norfloxacin was combined with the ethyl and propyl esterified derivatives. The docking study demonstrated favorable energy of interaction between ferulate derivatives and NorA, and amino acid residues TYR57, TYR58, and LEU255 were present commonly in stabilizing all complexes. The PCA analysis corroborated the docking hypothesis that the lipophilic character and hydrogen bond interactions were the most relevant characteristics involved with NorA inhibitors. The pharmacokinetic parameters of ferulic acid derivatives showed good ADMET properties, demonstrating that they can be easily absorbed and have no effect or inhibit the cytochrome P450 enzyme complex, revealing their potential as drug candidates. Conclusions: This study provides strong evidence that the molecular basis for this activity is potentially due to the NorA efflux pump.

Perfil de egressos de residências multiprofissionais em saúde no Rio Grande do Sul / Profile of graduates from multiprofessional health residencies in Rio Grande do Sul / Perfil de los egresados de las residencias multiprofesionales en salud en el Rio Grande do Sul

No Brasil, desde o final dos anos 70, as Residências em Saúde se constituem como uma possibilidade de formação para diferentes profissões da saúde, especialmente no Rio Grande do Sul (RS). Entretanto, somente no início dos anos 2000 a implantação de Programas de Residências Multiprofissionais em Saúde (RMS) é estimulada em âmbito nacional. Este artigo analisa o perfil de 72 profissionais egressos(as), no período de 2005 a 2014, de cinco programas de RMS desenvolvidos no RS. Os(as) participantes da pesquisa responderam a um formulário elaborado no FORMSUS do DATASUS composto de questões fechadas e abertas, analisadas com o uso do Software SPSS v. 18. A análise apresenta o perfil dos(as) egressos(as) participantes considerando as variáveis gênero, raça e cor, idade; cursos de graduação; instituições de graduação; inserção no mundo do trabalho em saúde e avaliação quanto à formação em RMS, apontando a relevância das RMS para a qualificação no trabalho no Sistema Único de Saúde (SUS).

In Brazil, since the end of the 1970s, Health Residency Programs have been a training possibility for distinct health careers, especially in the state of Rio Grande do Sul (RS). However, it was not until the early 2000s that the implementation of these programs was stimulated in the national scope. The participants filled a form on DATASUS FormSUS, and the answers were analyzed by means of SPSS v. 18. This paper analyses the profile of 72 residents who graduated between 2005 and 2014 from five Health Residency Programs developed in the state. The analysis introduces the profile of the graduates considering the following variables: gender; race/skin color; age; undergraduate courses; undergraduate institutions; insertion in the health work world; appraisal of the training developed in the programs, indicating their relevance for the qualification of the work in the National Unified Health System.

En Brasil, desde los fines de la década de 70, las Residencias en Salud se constituyen como una posibilidad de formación para diferentes profesiones de la salud, en especial en el Rio Grande del Sur. Sin embargo, es solamente desde el principio de los años 2000 que se estimula, en ámbito nacional, la implementación del Programa de Residencia Multiprofesional en Salud (RMS). Este artículo produce un análisis del perfil de 72 profesionales egresados, en el periodo de 2005 a 2014, de cinco programas de RMS desarrollados en el Rio Grande del Sul (RS). Los participantes de la investigación respondieron a un formulario preparado en el FORMUSUS del DATASUS, que detenía preguntas cerradas y abiertas, y analizadas con el uso de los Softwares SPSS v. 18. El análisis presenta el perfil de los egresados participantes considerando las variaciones de género; raza/color; edad; cursos de graduación; instituciones de graduación; inserción en el mundo del trabajo en salud; Evaluación sobre la formación en RMS, y apunta la relevancia de las RMS para la cualificación en el trabajo en el Sistema Único de Salud (SUS).

Effect of racial crossing on the seminal parameters of rams submitted to heat stress / Efeito do cruzamento racial nos parâmetros seminais de carneiros submetidos ao estresse de calor

The aim of this study was to evaluate the effect of racial crossing on seminal parameters of eight Santa Inês and crossbred (Santa Inês x Dorper) rams submitted to heat stress, and to monitor the return of these parameters to previously reported. Before to place the insulation bags, two collects of semen through electroejaculation were performed. The insulation pouches were made with double-layer plastic, internally lined with cotton, and fixed around the spermatic funiculus and scrotum with adhesive tape and bandage remaining on the testes of the animals for seven days. The first collect was performed on the day that the pouches were taken (day 0) and thereafter, every seven days, totalizing 15 measurements. Data were submitted to analysis of variance (ANOVA). The analyzed variables were subjected to Dunnett test at 5% probability to compare the values obtained before treatment with those obtained in the following days. In this study it was found that the animals restored normal seminal parameter after the insulation effects, however, the return rate differed slightly among the studied breeds. The crossbred animals restored the seminal patterns, on average, a week before Santa Inês. It is concluded that the racial crossing influences the semen parameters of rams submitted to heat stress.

O objetivo deste estudo foi avaliar o efeito do cruzamento racial sobre parâmetros seminais de oito carneiros Santa Inês e mestiços, submetidos ao estresse térmico e monitorar o retorno desses parâmetros aos relatos anteriormente. Antes de colocar as bolsas de insulação, foram realizadas duas coletas de sêmen por meio de eletroejaculação. As bolsas de insulação foram confeccionadas com plástico de camada dupla, revestidas internamente com algodão, fixadas ao redor do funículo espermático e escroto com fita adesiva e bandagem, permanecendo nos testículos dos animais por sete dias. A primeira coleta foi realizada no dia em que as bolsas foram retiradas (dia 0) e a partir daí, a cada sete dias, totalizando 15 coletas. Os dados foram submetidos à análise de variância (ANOVA). As variáveis analisadas foram submetidas ao teste de Dunnett a 5% de probabilidade para comparar os valores obtidos antes do tratamento com aqueles obtidos nos dias seguintes. Neste estudo verificou-se que os animais restauraram os parâmetros seminais normais após os efeitos da insulação, porém, a taxa de retorno diferiu ligeiramente entre as raças estudadas. Os animais mestiços restauraram os padrões seminais, em média, uma semana antes da Santa Inês. Conclui-se que o cruzamento racial influencia os parâmetros seminais de carneiros submetidos ao estresse térmico.

Cultura de segurança do paciente: percepções e atitudes dos trabalhadores de centro cirúrgico / Patient safety culture: perceptions and attitudes of surgical center workers

Objetivo: Avaliar a cultura de segurança por meio das percepções e atitudes dos profissionais que atuam no centro cirúrgico de um hospital de ensino. Método: Trata-se de um estudo exploratório, descritivo e transversal, com abordagem quantitativa, desenvolvido com 110 profissionais que atuam no centro cirúrgico, utilizando o Safety Attitudes Questionnaire. Resultados: A média geral dos escores evidenciou uma cultura de segurança incipiente. Ao avaliar a cultura por domínios, satisfação do trabalho e percepção do estresse foram avaliados como positivos, e clima de trabalho em equipe, clima de segurança, percepção da gerência da unidade/hospital e condições de trabalho, como negativos. Conclusão: O nível de cultura de segurança encontrado está abaixo do preconizado na literatura. As ações gerenciais e as condições de trabalho foram consideradas os principais fatores que contribuíram para a fragilidade dessa cultura, entretanto os profissionais demonstraram-se satisfeitos com a unidade de trabalho.

Objective: To evaluate safety culture based on the perceptions and attitudes of professionals who work in the surgical center of a teaching hospital. Method: This is an exploratory descriptive cross-sectional study, with a quantitative approach, developed with 110 professionals who work in the surgical center, using the Safety Attitudes Questionnaire. Results: The general mean scores showed an incipient safety culture. When evaluating the culture by domains, job satisfaction and stress recognition were assessed as positive, and teamwork climate, safety climate, perceptions of unit/hospital management, and working conditions, as negative. Conclusion: The level of safety culture found is below that recommended in the literature. Management actions and working conditions were considered the main factors that contributed to the fragility of this culture. However, the professionals were satisfied with their work unit.

Objetivo: evaluar la cultura de seguridad, a través de las percepciones y actitudes de los profesionales que trabajan en el centro quirúrgico de un hospital universitario. Método: Estudio exploratorio, descriptivo y transversal, con enfoque cuantitativo, desarrollado con 110 profesionales que trabajan en quirófano, aplicando el Cuestionario de Actitudes de Seguridad (Safety Attitudes Questionnaire). Resultados: El promedio de la puntuación general mostró una incipiente cultura de seguridad. Al evaluar la cultura por dominios, la "satisfacción laboral" y la "percepción del estrés" se evaluaron como positivas, y el "clima de trabajo en equipo", el "clima de seguridad", la "percepción de gestión de la unidad/hospital" y las "condiciones de trabajo" como negativas. Conclusión: El nivel de cultura de seguridad encontrado es inferior al recomendado en la literatura. Las acciones de gestión y las condiciones de trabajo se consideraron los principales factores que contribuyeron a la fragilidad de esta cultura. Sin embargo, los profesionales estaban satisfechos con la unidad de trabajo.

Study of reliability and concordance between two VDRL tests for syphilis investigation in patients with HIV followed-up at a university hospital in Rio de Janeiro in 2017-2019 / Estudo de confiabilidade e concordância entre dois testes VDRL para investigação de sífilis em pacientes com HIV em acompanhamento em um hospital universitário na cidade do Rio de Janeiro, entre os anos de 2017­2019

Introduction: The laboratory diagnosis of syphilis is given by a positive treponemal test and a non-treponemal test, with VDRL (Veneral Disease Research Laboratory) being the "gold standard". Objective: To compare two tests commercially validated for biological fluids and analyzed by different operators, in order to assess their performance in detecting high (≥:8) and low (≤1:2) titrations, as well as to determine the agreement between results in paired serum samples from patients with syphilis and living with HIV. Methods: Cross-sectional study, approved by the Research Ethics Committee of the teaching hospital Gaffrée e Guinle (HUGG), under CAAE 66558117.0.0000.5258. The study population was composed by patients diagnosed with syphilis and confirmed by the positivity of one or more treponemal tests. All samples were analyzed simultaneously by two different operators, each using a kit: VDRL WAMA Diagnóstica®, São Carlos, SP, Brazil; VDRL Brás, Laborclin®, Pinhais, PR, Brazil. The SPSS statistical program was used. Results: 110 serum samples from patients diagnosed with syphilis treated at HUGG were analyzed. The frequency of high VDRL titrations among patients, following the VDRL criterion ≥1:8, was practically the same in both tests, with 68% in VDRL Laborclin and 69% in VDRL WAMA (p = 0.87) and VDRL ≤1:2, 80% for WAMA and 83% for Laborclin (p = 0.72). The results of VDRL were tabulated in pairs; then the Cohen's Kappa coefficient of agreement was calculated (Κ) 0.32 (95%CI 0.21­0.41; p<0.00001), as well as the weighted Kappa (Kw) and the intraclass correlation coefficient (ICC) 0.89 (95%CI 0.84­0.92; p<0.00001). The Bland-Altman diagram was also used. We found poor agreement between the VDRL tests when results were nominally concordant, that is, with the same titles in both tests. However, if partial agreement is considered, the interpretation of the magnitude of agreement estimators was almost complete (≥0.80). Conclusion: Reliability and agreement were high between the VDRL tests of both manufacturers when considering the close titrations (up to two dilutions). Further reliability and agreement studies are essential between the non-treponemal tests available and used in Brazil.

Introdução: O diagnóstico laboratorial da sífilis é realizado por meio da positividade de um teste treponêmico e de um teste não treponêmico, sendo o VDRL (do inglês Veneral Disease Research Laboratory) o "padrão ouro". Objetivo: Comparar dois testes comercialmente validados para fluidos biológicos e analisados por operadores diferentes, com o intuito de avaliar o desempenho dos testes em detectar titulações altas (≥ :8) e baixas (≤1:2), bem como determinar a concordância entre ambos os resultados em amostras pareadas de soro de pacientes com sífilis vivendo com HIV. Métodos: Estudo transversal, aprovado pelo Comitê de Ética em Pesquisa do Hospital Universitário Gaffrée e Guinle (HUGG), sob o CAAE: 66558117.0.0000.5258. A população estudada foi a de pacientes que obtiveram o diagnóstico de sífilis confirmado por meio da positividade de um ou mais testes treponêmicos. Todas as amostras foram analisadas simultaneamente por dois operadores diferentes, cada um utilizando um kit: VDRL WAMA Diagnóstica®, São Carlos, SP, Brasil; VDRL Brás, Laborclin®, Pinhais, PR, Brasil. Utilizou-se o programa estatístico SPSS. Resultados: Foram analisadas 110 amostras de soro de pacientes com diagnóstico de sífilis atendidos no HUGG. A frequência de altas titulações de VDRL entre os pacientes, seguindo o critério de VDRL ≥1:8, foi praticamente a mesma em ambos os testes, com 68% no VDRL Laborclin e 69% no VDRL WAMA (p=0,87) e para VDRL ≤1:2, 80% para WAMA e 83% para Laborclin (p=0,72). Os resultados dos títulos de VDRL foram tabulados em pares; em seguida, foram calculados o coeficiente de concordância Kappa de Cohen (Κ) 0,32 (IC95% 0,21­0,41; p<0,00001), o Kappa ponderado (Kw) e o coeficiente de correlação intraclasse (CCI) 0,89 (IC95% 0,84­0,92; p<0,00001), bem como utilizado o diagrama de Bland-Altman. O estudo encontrou fraca concordância entre os testes de VDRL, se considerados os resultados nominalmente concordantes, isto é, com os mesmos títulos em ambos os testes. Entretanto, se considerado a concordância parcial, a interpretação da magnitude dos estimadores de concordância passou a ser quase completa (≥0,80). Conclusão: A confiabilidade e a concordância foram altas entre os testes de VDRL dos dois fabricantes, quando consideradas as titulações próximas (até duas diluições). Mais estudos de confiabilidade e concordância são fundamentais entre os testes não treponêmicos disponíveis e utilizados no Brasil.

Mapping of spatiotemporal distribution of Tibraca limbativentris Stal (Hem.: Pentatomidae) in flooded rice crop in Southern Brazil

ABSTRACT The rice stem bug, Tibraca limbativentris Stal (Hem.: Pentatomidae), is one of the main insect pests in Brazilian rice crops. Knowledge of its spatiotemporal distribution can support the development of an effective sampling system and improve IPM strategies. This study aimed to map the spatiotemporal distribution of rice stem bug in flooded rice crop in Southern Brazil. Flooded rice crop was scouted for two seasons to estimate insect densities. Four occurrence categories were observed: no insect, only adults, only nymphs, and both phases. The relationship between phenological stages and insect categories was established. Interpolation (mapping) of occurrence categories of T. limbativentris was performed by multiquadric equations. In two seasons during the rice cycle, the results indicate that rice stem bug "adults" were the most abundant category until the mid-vegetative phase of the rice; "nymphs" were the most abundant from the end of vegetative phase; "adults + nymphs" occurred from the beginning of reproductive phase; there were no rice stem bugs in more than 66% of the area, as they were most concentrated near the edge of the crop. The information presented here provides further knowledge about T. limbativentris spatiotemporal dynamics that can be applied to improve IPM strategies, such as developing sampling plans and localized control measures at the edge of rice fields.

Technical-tactical development: validity evidence of measurement scales for pedagogical contents in sports / Desenvolvimento técnico-tático: evidências de validade de escalas de medida de conteúdos pedagógicos no esporte

ABSTRACT The objective of this research was to show the first pieces of evidence on the validity of two scales for favoring the development of pedagogical contents in sports among children and youths (development of motor and strategic skills). To do so, their internal structures were estimated, their stabilities were tested, and their internal consistencies were assessed. A sample of 210 coaches and Physical Education teachers aged between 20 and 75 years old, both males and females, answered the scales referring to development of motor and tactical-strategic skills, whose structures were composed of three factors, with significant saturations (Satf > 0.40) and respectively explaining 70.19% and 74.29% of the total variance of the constructs. Results for model goodness-of-fit were overall satisfactory (χ2/gl < 1.567; AGFI = 1.000; RMSEA < 0.052; CFI > 0.995). Results concerning internal consistency analyses (0.736 < α < 0.908 for factors; αMS = 0.869; αTS = 0.921) ensure the accuracy of the measurements and the reliability of their use as to the purposes for which they are intended. The results meet the research general and specific objectives and indicate the possibility of a safe use of both scales.

RESUMO O objetivo desta pesquisa foi demonstrar as primeiras evidências de validade de duas escalas de favorecimento ao desenvolvimento de conteúdos pedagógicos no esporte infantojuvenil (desenvolvimento de habilidades motoras e estratégico-tático). Para tanto, foram estimadas suas estruturas internas, testadas suas estabilidades e avaliadas suas consistências internas. Uma amostra de 210 treinadores e professores de Educação Física de 20 a 75 anos, de ambos os sexos, respondeu às escalas referentes ao desenvolvimento de habilidades motoras e estratégico-tático, as quais apresentaram estruturas compostas por três fatores, com saturações significativas (Satf > 0,40) e explicando respectivamente 70,19% e 74,29% da variância total dos construtos. Os resultados relativos ao ajuste do modelo foram, de forma geral, satisfatórios (χ2/gl < 1,567; AGFI = 1,000; RMSEA < 0,052; CFI > 0,995). Os resultados do estudo de consistência interna (0,736 < α < 0,908 para os fatores; αHM = 0,869; αET = 0,921) asseguram a precisão das medidas e a confiabilidade de sua utilização aos objetivos a que se propõe. Os resultados respondem aos objetivos central e específicos da pesquisa e indicam a possibilidade da segura utilização das duas escalas.

Physical activity level and lifestyle perception in prebariatric surgery patients / Nível de atividade física e percepção do estilo de vida de pacientes pré-cirurgia bariátrica

Abstract Objective To determine sociodemographic characteristics, lifestyle perception and physical activity levels in obese prebariatric surgery patients. Methods A quantitative, cross-sectional study. The sample comprised 96 male and female morbidly obese prebariatric surgery patients. Questionnaires addressing sociodemographic profile, lifestyle perception and physical activity levels were applied. Results Patients were aged 40.3±11.45 years. Inadequate levels of physical activity were reported by 47.8% of patients; most respondents (79.2%) attributed scores defined as inadequate to the physical activity domain of the lifestyle questionnaire. Time spent on physical activity practice per week differed significantly between patients reporting being physically active or physically inactive in adolescence (p=0.046). Conclusion Most obese prebariatric surgery patients perceive their lifestyle as inadequate, in spite of eligibility for bariatric surgery. Results also indicate that physical activity practice and nutrition are the domains with greatest impacts on patient lifestyle, and that physical activity practice in adolescence may contribute to adoption of a more active behavior in adulthood, which may represent a vital tool for health promotion in patients undergoing bariatric surgery.

Resumo Objetivo Identificar as características sociodemográficas, a percepção do estilo de vida e o nível de atividade física dos pacientes obesos em pré-cirurgia bariátrica. Métodos Pesquisa de abordagem quantitativa, do tipo transversal. A amostra foi composta por 96 pacientes obesos mórbidos pré-cirurgia bariátrica de ambos os sexos. Foram aplicados questionários contendo informações sobre o perfil sociodemográfico, a percepção do estilo de vida e o nível de atividade física. Resultados A média de idade dos pacientes foi de 40,3±11,45 anos. O nível inadequado de atividade física avaliado foi verificado em 47,8% dos pacientes, e o domínio atividade física do questionário sobre estilo de vida foi pontuado como inadequado pela maioria dos entrevistados (79,2%). Foram encontradas diferenças estatisticamente significantes entre o tempo de prática de atividade física semanal dos praticantes e não praticantes na adolescência (p=0,046). Conclusão A maioria dos pacientes obesos pré-cirurgia bariátrica apresenta percepção de estilo de vida inadequada, apesar de terem sido considerados aptos à cirurgia bariátrica. A prática da atividade física e a nutrição são os domínios que exercem maior impacto no estilo de vida desses pacientes, e a realização de atividades físicas na adolescência pode contribuir para a adoção de um comportamento mais ativo na idade adulta, o que pode representar ferramenta fundamental para promoção da saúde, a ser considerada com os pacientes após a cirurgia bariátrica.

Cognição, condições socioeconômicas e estado nutricional de idosos cadastrados em uma unidade básica de saúde / Cognition, socio-economic conditions and nutritional status of elderly registered in a basic health unit

Introdução: estudos de avaliação cognitiva mostram que indivíduos idosos apresentam distúrbios cognitivos, que podem estar associadosàs condições socioeconômicas, ao estado nutricional, ao sexo e à idade. Objetivo: verificar a associação entre capacidade cognitiva, condições socioeconômicas e estado nutricional de idosos cadastrados em uma unidade básica de saúde. Casuística e Método: estudo transversal, quantitativo, com coleta de dados primários e secundários. Pesquisa foi realizada no domicílio dos idosos, que estavam cadastrados na Unidade Básica de Saúde, no período de 18 de janeiro a 29 de fevereiro de 2016 na cidade de Porto Rico ­ PR, localizada no noroeste do Paraná. Avaliou-se a capacidade cognitiva pelo mini exame do estado mental, as condições socioeconômicas com auxílio de formulário e o estado nutricional, pelo índice de massa corporal. A associação entre as variáveis foi medida utilizando o teste Qui-quadrado ou teste exato de Fisher. Resultados: participaram do estudo 180 idosos. Associação estatisticamente significativa foi observada entre capacidade cognitiva e sexo e foi superior no sexo feminino entre capacidade cognitiva e escolaridade que foi entre 1 a 4 anos de estudo. Conclusão: grande parte da população estudada apresentou distúrbio cognitivo e excesso de peso, sem associação entre essas variáveis. A pesar do resultado, podemos dizer que esses idosos necessitam de atendimentos especializados, afim de que problemas cognitivos e nutricionais sejam identificados precocemente.

Introduction: cognitive evaluation studies show that elderly individuals present cognitive disorders, which may be associ-ated with socioeconomic conditions, nutritional status, gender and age. Objective: verify the association between cognitive ability, socioeconomic conditions, and nutritional status of elderly people enrolled at a basic health unit. Casuistry and Method: a cross-sectional, quantitative study with primary and secondary data collection. The study was carried out at the home of the elderly, who were enrolled in the Basic Health Unit, from January 18 to February 29, 2016 in the city of Puer-to Rico - PR, located in the northwest of Paraná. Results: 180 elderly people participated in the study. Statistically significant association was observed between cognitive ability and gen-der and was higher in females and between cognitive ability and schooling that was between 1 and 4 years of study. The association between variables was measured using the chi-square test or Fisher's exact test. Conclusion: a large part of the studied population presented cognitive and overweight, but did not hear a statistically significant association between these variables. Even though there is no association between these variables, we can say that these elderly people need specialized care so that cognitive and nutritional problems are identified early.

Efeitos do exercício físico sobre diabetes mellitus tipo 1: uma revisão sistemática de ensaios clínicos e randomizados / Effects of physical exercise on type 1 diabetes mellitus: a systematic review of clinical and randomized tests

RESUMO Diabetes mellitus tipo 1 (DM1) caracteriza-se como patologia crônica autoimune. Exercício físico (EF) é considerado estratégia positiva no processo terapêutico do DM1. O objetivo do estudo foi avaliar evidências científicas sobre os efeitos do EF em indivíduos com DM1. Trata-se de revisão sistemática de literatura, de estudos clínicos e randomizados. Realizou-se levantamento em periódicos indexados nas bases de dados PUBMED, SCOPUS, COCHRANE, LILACS e SCIELO. Os Descritores em Ciências da Saúde utilizados foram: diabetes mellitus, type 1 AND exercise e seus correspondentes em português e espanhol. Foram incluídos 28 artigos publicados entre os anos de 2012 e 2016. Todos os estudos abordaram a relação entre o gerenciamento da patologia e diferentes tipos, frequência, volume, duração e intensidade de exercícios. Diferentes assuntos foram abordados, como: pâncreas artificiais, dieta, suplementação, insulina e hipoglicemia. Um dos grandes desafios para assegurar boa gestão do DM1 com prática de EF são relacionados ao controle da glicemia e à hipoglicemia durante, logo depois ou tardiamente após a intervenção. Os EF aeróbicos, resistidos, pilates e intermitentes, em conjunto com dieta adequada, horários de refeições e suplementação mostraram-se eficazes no gerenciamento de diversas váriáveis metabólicas e clínicas dos pacientes com DM1.

ABSTRACT Type 1 Diabetes mellitus (DM1) is characterized as chronic autoimmune pathology. Physical exercise (PE) is considered a positive strategy in DM1 therapy. The aim of the study was to systematize scientific evidence linking EF interventions in individuals with DM1. This is a systematic review of the literature, from clinical and randomized studies. A survey was carried out in indexed journals in the PUBMED, SCOPUS, COCHRANE, LILACS and SCIELO databases. The Descritors Health Sciences used were: diabetes mellitus, type 1 AND exercise and their correspondents in portuguese and spanish. We included 28 articles published between the years 2012 and 2016. All studies addressed the relationship between pathology management and different types, frequency, volume, duration and intensity of exercises. Different subjects were approached, such as: artificial pancreas, diet, supplementation, insulin and hypoglycemia. One of the great challenges to ensure good management of DM1 with EF practice is related to glycemic control and hypoglycemia during, shortly after or after intervention. The aerobic, resisted, pilates and intermittent PE, along with adequate diet, meal times and supplementation were effective in managing the various metabolic and clinical variables of patients with DM1.

Clinical demographic characteristics of total knee arthroplasty in a university hospital

ABSTRACT Objective: To assess socio-demographic characteristics of patients undergoing total knee arthroplasty (TKA) in a public university hospital, evaluating the outcome infection and associated factors. Method: A retrospective study was carried out with 78 patients undergoing TKA, from 2013 to 2014. The socio-demographic and clinical characteristics of the patients were collected. Comparison between infected and non-infected patients was performed to find out which variables were possibly associated to this complication. Result: Of 81 arthroplasties performed, patients were older (mean age 64 years), women (79%), with primary osteoarthritis as main etiology (87.6%) and most had comorbidities (82.7%). Infection occurred in 16% of patients, and this outcome associated with age older than 65 years (p=0.023) and the occurrence of deep vein thrombosis (p=0.027). Conclusion: Patients undergoing TKA are mostly elderly women with primary osteoarthritis in the knee and comorbidities who developed infection in 16% of cases. More studies need to be conducted aimed at creating specific protocols in order to improve the quality of clinical practice. Level of Evidence III, Retrospective Comparative Study.

Geostatistics applied to the study of the spatial distribution of Tibraca limbativentris in flooded rice fields / Geoestatística aplicada ao estudo da distribuição espacial de Tibraca limbativentris em arrozal irrigado por inundação

Tibraca limbativentris (rice stem bug) is an insect highly injurious to the rice crop in Brazil. The aim of this research was to define the spatial distribution of the T. limbativentris and improve the sampling process by means of geostatistical application techniques and construction of prediction maps in a flooded rice field located in the "Planalto da Campanha" Region, Rio Grande do Sul (RS), Brazil. The experiments were conducted in rice crop in the municipality of Itaqui - RS, in the crop years of 2009/10, 2010/11 and 2011/12, counting fortnightly the number of nymphs and adults in a georeferenced grid with points spaced at 50m in the first year and in 10m in the another years. It was performed a geostatistical analysis by means adjusting semivariogram and interpolation of numeric data by kriging to verify the spatial dependence and the subsequent mapping population. The results obtained indicated that the rice stem bug, T. limbativentris, has a strong spatial dependence. The prediction maps allow estimating population density of the pest and visualization of the spatial distribution in flooded rice fields, enabling the improvement of the traditional method of sampling for rice stem bug.

Tibraca limbativentris (percevejo-do-colmo) é um inseto altamente prejudicial à cultura do arroz no Brasil. O objetivo com este trabalho foi definir a distribuição espacial de T. limbativentris e aperfeiçoar o método de amostragem por meio da aplicação de técnicas geoestatísticas e construção de mapas de predição em arrozal irrigado por inundação, no Planalto da Campanha do Rio Grande do Sul. Os experimentos foram realizados em lavoura de arroz situada no município de Itaqui - RS, nos anos agrícolas de 2009/10, 2010/11 e 2011/12, efetuando-se amostragens quinzenais para contagem de ninfas e adultos, conforme grids georreferenciados com pontos espaçados em 50m na primeira safra e em 10m nas demais safras. Realizou-se a análise geoestatística via ajuste de semivariogramas e da interpolação dos dados numéricos por krigagem ordinária para verificar a dependência espacial e posterior mapeamento populacional. Os resultados obtidos indicaram que o percevejo do colmo, T. limbativentris, possui forte dependência espacial. Os mapas de predição permitem estimar a densidade populacional da praga e a visualização de sua distribuição espacial em lavoura de arroz irrigado por inundação, possibilitando o aperfeiçoamento do método de amostragem tradicional para o percevejo-do-colmo.

Comparação da potência anaeróbia entre as posições táticas em jogadores de futebol: estudo retrospectivo / Comparison of anaerobic power between tactical positions in soccer players: a retrospective study

O objetivo do estudo foi comparar a Potência anaeróbia máxima (Pmáx); Potência Anaeróbia Média (Pmed) e índice de fadiga (IF) entre atletas de diferentes posições táticas no futebol. Para isso, 248 atletas profissionais de futebol de campo (25,8±1,72 anos, 77,52±4,90 Kg e 178,48±5,63 cm), pertencentes a 1ª e 2ª divisão do estado do Rio Grande do Sul, avaliados durante o período de 1999-2010, divididos em cinco posições táticas: goleiros (GO) (n=28), laterais (LA) (n=35), zagueiros (ZA) (n=54), meio-campistas (MC) (n=81) e atacantes (AT) (n=50). Os atletas executaram o RAST test para determinar a Pmáx, Pmed e IF. Foi utilizada a ANOVA one way e post hoc de Tukey adotando-se o valor de significância de p<0,05. Diferenças significativas para a Pmáx (p<0,05) dos LA comparadas aos GO, ZA e MC; da Pmed dos LA para os GO, ZA e MC e dos AT e MC em relação aos GO (p<0,05). Na potência relativa de cada sprint, houve manutenção durante o 1º e 2º sprint entre as posições, exceto os MC e durante o 5º e 6º sprint, independente da posição, não houve decréscimo do desempenho de potência. Visto que foram encontradas diferenças significativas de Pmáx e da Pmed, dos LA em relação aos GO, ZA e MC, concluímos que esta evidência confirma que atletas de diferentes posições táticas apresentam variação quanto às características de suas ações.

This study aimed to compare the maximal anaerobic power (Pmáx), mean anaerobic power (Pm) and fatigue index (FI) among soccer players of different tactical positions. For this purpose, 248 professional soccer players (25.8±1.72 years old, 77.52±4.90 kg and 178.48±5.63 cm) from the 1st and 2nd division of the Rio Grande do Sul State, Brazil, participated in this study. They were evaluated between 1999 and 2010 and divided into five positions: goalkeepers (GK) (n=28), external defenders (ED) (n=35), central defenders (CD) (n=54), midfielders (MF) (n=81), and forwards (F) (n=50). The RAST test was performed to evaluate their Pmáx, Pmed, and FI. ANOVA one-way and Tukey's post hoc were used to evaluate the relationship between the variables; significant level was p<0.05. Significant differences (p<0.05) were found for Pmáx of ED compared to GK, CD and MF. Similarly, Pm of ED also presented significant difference when compared to GK, CD and MF, as well as of F and MF compared to GK (p<0.05). In the relative power of each sprint, the athletes maintained the velocity during the 1st and 2nd sprint regardless of their positions, except for MF, and during the 5th and 6th sprint. There was no decrease in power performance for all positions. Since significant differences were found in Pmáx and Pm of ED compared to GK, CD and MF, we conclude that athletes of different tactical positions presented variation regarding the characteristics of their actions.

Atendimento da população masculina em unidade básica saúde da família: motivos para a (não) procura / Health care for male population in basic unit of family health: reasons for (not) attendance / Cuidado de la población masculina en unidad básica de salud de la familia: motivos para la (no) búsqueda

Estudo exploratório descritivo, que objetivou conhecer os motivos que levam homens a procurar atendimento de saúde e compreender os motivos que os afastam de uma Unidade Básica de Saúde da Família (UBSF) no sul do Brasil. Pela análise dos prontuários, identificaram-se 175 atendimentos a homens entre 25 e 59 anos em 2010. Problemas agudos acometeram 93 (52,2%) usuários, a dor desencadeou 42 (23,6%) dos problemas crônicos, hipertensão arterial acometeu 37 (21,4%) clientes. Com entrevistas apreenderam-se os motivos de afastamento daquela UBSF. Sentiam-se saudáveis, por isso frequentavam pouco o serviço de saúde, ficando dez anos ou mais sem procurá-lo. Além de questões de gênero, alegaram incompatibilidade de horário, medo de detectarem doença grave, número insuficiente de fichas e falta de especialistas. Para atender às peculiaridades da população masculina, é necessário que os profissionais de saúde se capacitem, problematizem a realidade de cada UBSF e, juntamente com os gestores, vislumbrem e operacionalizem estratégias inclusivas de atendimento.

This exploratory and descriptive study aimed to know the reasons that lead men to seek healthy care and understand the reasons that depart them from the Basic Unit of Family Health in the southern tip of Brazil. For the analysis of the records, 175 attendances to men ranging from 25 to 59 years old in 2010 were identified. Acute problems were reported by 93 (52.2%) users, the pain triggered 42 (23.6%) of chronic problems, hypertension, struck 37 (21.4%) clients. Through interviews it was possible to understand what moves them away from the Basic Unit of Family Health. Notably, men felt healthy, so little did they attend the health service, thus, it might take them ten years or more to look for it. In addition to gender issues, alleged scheduling conflict, fear to detect any serious disease, insufficient number of appointments and a lack of specialists. In order to accomplish the peculiarities of the male population it urges qualification on health professionals, so as to problematize the reality of each Basic Unit of Family Health and, along with managers, resolve and enable inclusive service.

Este estudio tuvo como objetivo conocer las razones que conducen los hombres a buscar atención de salud y entender por qué se apartan de una Unidad Básica de Salud de la Familia (UBSF) en el sur de Brasil. Por el análisis de los registros fueron identificados 175 atendimientos prestados a hombres entre 25 y 59 años en 2010. Problemas agudos acometieran 93 (52,2%) usuarios, el dolor desencadenó 42 (23,6%) de los problemas crónicos, hipertensión arterial golpeó 37 (21,4%) pacientes. Con las entrevistas se aprehendieron los motivos que los alejaban de aquella UBSF. Ellos se sentían sanos, por lo que asistían poco a los servicios de salud, permaneciendo diez años o más sin buscarlo. Además de las cuestiones de género, alegaron conflicto de programación, el miedo de detectar cualquier enfermedad grave, un número insuficiente de fichas y la falta de especialistas. Para hacer frente a las peculiaridades de la población masculina es necesario que los profesionales de salud se califiquen, cuestionen la realidad de cada UBSF y juntamente con gestores, vislumbren y realicen estrategias de inclusión de atención.