Beyond RCTs: Short-term dual antiplatelet therapy in secondary prevention of ischemic stroke and transient ischemic attack.

BACKGROUND AND PURPOSE: Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs. METHODS: READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD2 score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment. RESULTS: We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding. CONCLUSIONS: In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.

Bithalamic infarction in a tentorial dural artero-venous fistula and thalamic dementia: a case report and systematic review.

PURPOSE: To report a case of bilateral thalamic infarction (BTI) presenting as progressive thalamic dementia due to a midline tentorial dAVF (TdAVF) and to provide a systematic review of the literature. METHODS: We performed a systematic literature review of previously reported cases of bi-thalamic signal changes due to dAVF considering population characteristics, clinical presentation, imaging findings, treatments, and outcomes. RESULTS: We found 29 papers from 1985 until 2021 describing 35 cases of BTI dAVF-related. We analysed 36 cases comprehensive of our case report. The mean age was 58.7 years (range 38-79), 91.6% were males (n=33). Most cases presented with a subacute syndrome. In 86.1% (n=31) of cases a TdAVF was found; 58.3% (n=21) were type 2 Borden-Shucart fistulas, the remaining were mostly type 3. In 80.5% (n=29), a thrombosed sinus was identified. 33.3% of cases (n=12) had bi-thalamic haemorrhages. Endovascular treatment was performed in 83.3% of cases (n=30). A total of 75% (n=27) of cases had a good recovery. CONCLUSIONS: BTIs due to dAVFs may present with subacute symptoms overlapping with several differential diagnoses. Prompt identification at MRI, before venous drainage failure and bleeding, is crucial for a good prognosis.

Divergence Between Clinical Trial Evidence and Actual Practice in Use of Dual Antiplatelet Therapy After Transient Ischemic Attack and Minor Stroke.

BACKGROUND: Randomized controlled trials (RCTs) proved that short-term (21-90 days) dual antiplatelet therapy (DAPT) reduces the risk of early ischemic recurrences after a noncardioembolic minor stroke or high-risk transient ischemic attack (TIA) without substantially increasing the hemorrhagic risk. We aimed at understanding whether and how real-world use of DAPT differs from RCTs. METHODS: READAPT (Real-Life Study on Short-Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or TIA) is a prospective cohort study including >18-year-old patients treated with DAPT after a noncardioembolic minor ischemic stroke or high-risk TIA from 51 Italian centers. The study comprises a 90-day follow-up from symptom onset. In the present work, we reported descriptive statistics of baseline data of patients recruited up to July 31, 2022, and proportions of patients who would have been excluded from RCTs. We compared categorical data through the χ² test. RESULTS: We evaluated 1070 patients, who had 72 (interquartile range, 62-79) years median age, were mostly Caucasian (1045; 97.7%), and were men (711; 66.4%). Among the 726 (67.9%) patients with ischemic stroke, 226 (31.1%) did not meet the RCT inclusion criteria because of National Institutes of Health Stroke Scale score >3 and 50 (6.9%) because of National Institutes of Health Stroke Scale score >5. Among the 344 (32.1%) patients with TIA, 69 (19.7%) did not meet the RCT criteria because of age, blood pressure, clinical features, duration of TIA, presence of diabetes score <4 and 252 (74.7%) because of age, blood pressure, clinical features, duration of TIA, presence of diabetes score <6 and no symptomatic arterial stenosis. Additionally, 144 (13.5%) patients would have been excluded because of revascularization procedures. Three hundred forty-five patients (32.2%) did not follow the RCT procedures because of late (>24 hours) DAPT initiation; 776 (72.5%) and 676 (63.2%) patients did not take loading doses of aspirin and clopidogrel, respectively. Overall, 84 (7.8%) patients met the RCT inclusion/exclusion criteria. CONCLUSIONS: The real-world use of DAPT is broader than RCTs. Most patients did not meet the RCT criteria because of the severity of ischemic stroke, lower risk of TIA, late DAPT start, or lack of antiplatelet loading dose. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT05476081.

Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature.

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon's armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound's "chronicity" on its healing, comparing the mean graft take only in "acute" wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Characterization of People with Functional Limitations from ICF Components Using the Longitudinal Social Protection Survey (ELPS) of Uruguay.

Characterising people with disabilities at the population level using the ICF approach is a challenge, as it implies that researchers are able to identify variables that can account for the components that make up the multidimensional definition of disability. The purpose of this study is to generate updated information on disability in Uruguay, as there has been no in-depth analysis of how this population lives, how they access the services and benefits that affect their quality of life, and what the significant differences are between those who make up this population. A quantitative analysis was applied to the target population, consisting of participants in the Longitudinal Survey of Social Protection (2016) who reported at least one limitation in performing ADLs and who were in the age range of 18-64 years. Significant differences were found between the different groups in terms of their reported limitations in relation to obtaining necessary services due to their health condition, dropping out of education before completing the compulsory level, low labour market insertion, feelings of loneliness, and low participation. More research needs to be done as it is clear that people with disabilities do not have access to the support they need, which leads to even greater exclusion.

Tracking muscle wasting and disease activity in facioscapulohumeral muscular dystrophy by qualitative longitudinal imaging.

BACKGROUND: Facioscapulohumeral muscular dystrophy (FSHD) is one of the most frequent late-onset muscular dystrophies, characterized by progressive fatty replacement and degeneration involving single muscles in an asynchronous manner. With clinical trials at the horizon in this disease, the knowledge of its natural history is of paramount importance to understand the impact of new therapies. The aim of this study was to assess disease progression in FSHD using qualitative muscle magnetic resonance imaging, with a focus on the evolution of hyperintense lesions identified on short-tau inversion recovery (STIR+) sequences, hypothesized to be markers of active muscle injury. METHODS: One hundred genetically confirmed consecutive FSHD patients underwent lower limb muscle magnetic resonance imaging at baseline and after 365 ± 60 days in this prospective longitudinal study. T1 weighted (T1w) and STIR sequences were used to assess fatty replacement using a semiquantitative visual score and muscle oedema. The baseline and follow-up scans of each patient were also evaluated by unblinded direct comparison to detect the changes not captured by the scoring system. RESULTS: Forty-nine patients showed progression on T1w sequences after 1 year, and 30 patients showed at least one new STIR+ lesion. Increased fat deposition at follow-up was observed in 13.9% STIR+ and in only 0.21% STIR- muscles at baseline (P < 0.001). Overall, 89.9% of the muscles that showed increased fatty replacement were STIR+ at baseline and 7.8% were STIR+ at 12 months. A higher number of STIR+ muscles at baseline was associated with radiological worsening (odds ratio 1.17, 95% confidence interval 1.06-1.30, P = 0.003). CONCLUSIONS: Our study confirms that STIR+ lesions represent prognostic biomarkers in FSHD and contributes to delineate its radiological natural history, providing useful information for clinical trial design. Given the peculiar muscle-by-muscle involvement in FSHD, MRI represents an invaluable tool to explore the modalities and rate of disease progression.

E-Health Interventions for Adult and Aging Population With Intellectual Disability: A Review.

To answer the question about which e-health and e-therapy applications are being used with people with intellectual disabilities, we searched the PsycINFO, Medline, PubMed, ERIC, CINAHL, Scopus, Web of Science, and Cochrane databases. This is an extensive search. Inclusion criteria were academic journals and any design type that addressed the topic of interest. Studies that do not include adults or elderly, and studies that do not focus on people with disabilities but on third parties, were excluded. After an initial selection of 515 articles, 32 full-text articles were subjected to in-depth analysis leading to the final selection of 18 articles. We used the AAID framework definition of intellectual disability to analyze the dimensions explored by the selected studies and found that the majority of studies focused on the use of technology as supports to instrumental activities of daily life. The ISO classification of assistive products allowed us to identify that many e-health products are aimed at providing psychological or medical treatment. In summary, this review suggests that there is a very small number of studies focusing on the use of technology by older persons with intellectual disabilities. The studies present substantial limitations regarding generalization and replication and pay little attention to the maintenance of cognitive abilities in this population. These aspects, together with premature aging generally associated with many conditions that lead to intellectual disability, underscore the need to pay more attention to and develop e-health interventions for cognitive stimulation for this group.

Adaptación a población adulta montevideana de la Escala de Temperamento y Carácter Revisada (TCI-R): resultados preliminares

En los últimos años se está viviendo un proceso de transformación muy importante en lo que refiere a los modelos y teorías en salud mental (DSM-5, CIE-11 y las propuestas del National Institute of Mental Health son claros ejemplos). Un componente central de dicho proceso es la incorporación de los aportes de las neurociencias a la salud mental, siendo el modelo psicobiológico de R.C. Cloninger un referente fundamental. Por ello, los investigadores y clínicos de nuestra región (América Latina) deben contar con instrumentos de evaluación adecuados a esta nueva realidad. El Inventario de Temperamento y Carácter revisado (TCI-R) es la escala desarrollada por Cloninger y su equipo para la evaluación de las Dimensiones de Personalidad que su teoría propone. El presente artículo presenta los resultados preliminares del proceso de adaptación de dicha escala a la población montevideana, siendo la primera adaptación realizada en la América del Sur castellano parlante.

Nos últimos anos vem acontecendo um processo de transformação muito importante nos modelos e teorias em saúde mental (DSM-5, ICD-11 e as propostas do National Institute of Mental Health são exemplos claros). Um componente central deste processo é a incorporação das contribuições das neurociências para a saúde mental, com o modelo psicobiológico de R.C. Cloninger como referente fundamental. Portanto, pesquisadores e clínicos em nossa região (América Latina) devem dispor de instrumentos de avaliação adequados a esta nova realidade. O Inventário de Temperamento e Caráter (TCI-R) é a escala desenvolvida por Cloninger e sua equipe para a avaliação das Dimensões da Personalidade que a sua teoria propõe. O presente artigo apresenta os resultados preliminares do processo de adaptação da escala para a população de Montevidéu, a primeira adaptação feita em língua espanhola na América do Sul.

In recent years important there have been important developments in the models and theories on mental health (the DSM-5, the CIE-11 and the proposals of the NIMH are good examples). A central feature in this process is the incorporation of the neuroscientific approach, with the psychobiological model of R. C. Cloninger and colleagues being a salient example. For this reason, Latin American researchers and professionals should have instruments adequate for this new paradigm at their disposal. The TCI-R is a scale developed by Cloninger and colleagues for the assessment of the personality dimensions he proposed. This paper presents the preliminary results of the adaptation process of this scale in a sample of Montevidean adults,and is the first in Spanish-speaking South America.

As políticas educacionais e o estágio curricular supervisionado no curso de graduação em enfermagem / Educational policies and the supervised curricular internship in the undergraduate nursing course / Las políticas educacionales y la pasantía curricular supervisada en el curso de grado en enfermería

O artigo discute as políticas de educação e o estágio curricular supervisionado no curso de graduação em enfermagem, a influência da reestruturação produtiva e da reforma do Estado capitalista no ensino superior brasileiro. Por se tratar de um estudo reflexivo, buscou-se como referencial de discussão a literatura da área, bem como os norteamentos trazidos pelas legislações do estágio curricular supervisionado e do ensino de enfermagem. No processo histórico da profissão do enfermeiro, destacam-se o cuidado com a prática profissional e os modos possíveis de apropriação da identidade desse profissional. Assim, o estágio é visto como parte indispensável no seu processo de formação; por meio dele podem-se desenvolver habilidades e competências próprias do enfermeiro. O estágio curricular supervisionado não deve ser visto somente como uma exigência do mundo capitalista, pois é possível formar um enfermeiro capaz de refletir sobre suas condições materiais de existência utilizando a prática reflexiva na articulação entre ensino e serviço.

The article discusses the educational policies and the supervised curricular internship in the undergraduate nursing course, in addition to the influence of productive restructuring and of the reform of the capitalist State on Brazilian higher education. Because it is a reflective study, the literature on the area and the guidance introduced by the laws concerning the supervised curricular internship and nursing education were used as references. In the historical process of the nursing profession, the care with the professional practice and the possible modes of appropriation of this professional identity are under the limelight. Thus, the internship is seen as an essential part of the training process; the skills required of the nurse can be learned through it. The supervised curricular internship should not be seen merely as a requirement of the capitalist world, as it is possible to train a nurse who can reflect on his or her material conditions of existence using the reflective practice in linking teaching and work.

El artículo discute las políticas de educación y la pasantía curricular supervisada en el curso de grado en enfermería, la influencia de la restructuración productiva y de la reforma del Estado capitalista en la enseñanza superior brasileña. Por tratarse de un estudio reflexivo, buscó como referencia de discusión la literatura del área, así como las orientaciones recogidas en las legislaciones de la pasantía curricular supervisada y de la enseñanza de enfermería. En el proceso histórico de la profesión de enfermero, se destacan el cuidado con la práctica profesional y los modos posibles de apropiación de la identidad de este profesional. De esta manera, la pasantía se ve como parte indispensable en su proceso de formación; por medio de éste se pueden desarrollar habilidades y competencias propias del enfermero. La pasantía curricular supervisada no debe ser vista sólo como una exigencia del mundo capitalista, pues es posible formar un enfermero capaz de reflexionar sobre sus condiciones materiales de existencia utilizando la práctica reflexiva en la articulación entre enseñanza y servicio.

Idosos hipertensos na atenção básica em saúde: discursos e identidades / Hypertensive elderly people in primary health care: discourses and identities

O objetivo da pesquisa foi conhecer e compreender como os sujeitos se reconhecem na posição de idosos, como se percebem hipertensos e como experienciam o tratamento anti-hipertensivo. Pesquisa de abordagem qualitativa, descritiva e exploratória, realizada em unidade de saúde da família de Dourados, MS. Os aportes teóricos da análise foram os Estudos Culturais. Foram entrevistados dez idosos hipertensos, sendo dois homens e oito mulheres. Os idosos tinham entre 60 e 88 anos, sendo cinco viúvas, e todos com ensino fundamental incompleto. Os processos identitários estão vinculados a gênero, estado marital e relação com as gerações. O envelhecimento parece se concretizar quando não se sentem produtivos. A hipertensão e o tratamento decorrente estão entremeados nos processos de subjetivação dos idosos, sendo que o uso de medicamentos para alguns parece estar incorporado ao cotidiano, porém outros relataram aversão. Desse modo, os significados da velhice contemporânea pertencem a um período singular e são integrantes de processos históricos mais amplos e complexos.

The aim was to know and understand how subjects recognize themselves in the position of older men and women, how they perceive themselves with hypertension and high blood pressure, and how they experience the anti-hypertensive treatment. It is a qualitative, descriptive and exploratory research approach, performed in family health units, in Dourados. The theoretical framework of analysis was the Cultural Studies. We interviewed ten elderly hypertensive patients, two men and eight women, aged 60-88 years, five widows, and all with elementary education. The processes are linked to gender identity, marital status and relationship with the generations. Aging seems to be realized when they are not productive. Hypertension treatment and due process are interspersed in the subjectivity of the elderly, and drug use for some seems to be incorporated into everyday life, but others reported aversion. Thus, the contemporary meanings of old age belong to a unique period and are members of larger historical processes and complex.

Da educação sanitária para a educação em saúde (1980-1992): discursos e práticas / From sanitary education to health education (1980-1992): discourses and practices / De la educación sanitaria a la educación en salud (1980-1992): discursos y prácticas

Pesquisa histórica cujo objetivo foi analisar os discursos oficiais do Ministério da Saúde sobre educação em saúde na década de 1980, e verificar se ocorreu a transposição dessas proposições paras as unidades de saúde. As fontes históricas utilizadas foram os documentos sobre educação em saúde publicados pelo Ministério da Saúde entre 1980 e 1992, e as pesquisas realizadas sobre as práticas educativas em saúde implementadas em unidades de saúde. Utilizou-se análise documental ancorada nos conceitos foucaultianos de discurso e biopoder. Percebeu-se, tanto nos discursos oficiais novos quanto em outros contornos dessas práticas, a proposta não mais da coerção, mas da participação de todos. A metodologia participativa passou a ocupar a centralidade do processo educativo, tendo como fim principal romper com o ciclo de opressão instaurado sobre esses sujeitos. Ao término da década de 1980, presenciaram-se várias configurações das práticas educativas em saúde imbricadas de modelos tradicionais, de discursos emancipatórios e de estratégias do neoliberalismo.

This historical study was performed with the objective to analyze the official discourses of the Ministry of Health regarding health education in the 1980's, and to determine if these propositions have been carried forward to the health units. The historical sources used were the health education documents published by the Ministry of Health between 1980 and 1992, as well as studies regarding the health education practices implemented in health units. Documental analysis was used, anchored on the Foucault concepts of discourse and bio power. We realized there were new and different outlines of these practices in the official discourses, which no longer propose coercion, but instead encourage the participation of all. The participative methodology became the center of the educational process, with the purpose of breaking the cycle of oppression that was established over these subjects. By the end of the 1980's, we observed several configurations of health education practices overlapping with traditional models, emancipatory discourses and neoliberalism strategies.

Investigación histórica que objetivó analizar el discurso oficial del Ministerio de Salud sobre educación en salud en la década de 1980, y si ocurrió trasposición de propuestas para unidades de salud. Las fuentes históricas fueron documentos sobre educación en salud publicados por Ministerio de Salud de 1980 a 1992, e investigaciones efectuadas sobre prácticas educativas en salud implementadas en unidades de salud. Se utilizó análisis documental basado en conceptos foucaultianos de discurso y biopoder. Percibimos en el discurso oficial nuevos y otros contornos de esas prácticas, proponiendo ya no la coerción sino la participación de todos. La metodología participativa pasó a ocupar el foco del proceso educativo, apuntando a romper con el ciclo de opresión instaurado sobre tales sujetos. Hacia fines de los '80 presenciamos variadas configuraciones de prácticas educativas en salud, imbricadas de modelos tradicionales, de discursos emancipatorios y de estrategias del neoliberalismo.

A Educação Sanitária Nos Centros De Saúde De São Paulo (1925-1930): Práticas E Sujeitos / Sanitary education in health centers of São Paulo (1925-1930): practices and subjects

O objetivo dessa pesquisa foi compreender a educação sanitária e suas implicações nos centros de saúde de São Paulo no período de 1925 a 1930. Tratou-se de pesquisa histórica, com aproximações ao pensamento foucaultiano. As fontes históricas empregadas foram anais dos congressos de educação e de higiene, bem como periódicos e teses. A educação sanitária realizada nos centros de saúde pautou-se pela transmissão de informações através de profissionais, como as educadoras sanitárias, professoras primárias formadas nos saberes da higiene. A educação sanitária caracterizou-se por tentativas de moldar o outro, incentivando principalmente crianças e mulheres a adotar hábitos saudáveis, através da aquisição da consciência sanitária. A educação sanitária em suas particularidades temporais e históricas pode ser considerada como um dos dispositivos que contribuíram na construção de novas e outras subjetividades, no período histórico estudado, sem, no entanto atentar para os sujeitos em suas múltiplas dimensões.

Educação Sanitária E O Serviço Especial De Saúde Pública (1942-1960): A Doença Não Conhece Fronteiras / Sanitary education and serviço especial de saúde pública (1942 – 1960): disease does not know borders

A proposta dessa pesquisa histórica foi enfocar a compreender a educação sanitária realizada e implementada pelo Serviço Especial de Saúde Publica (SESP), entre 1942 a 1960. Assim procuramos problematizar as concepções de educação, saúde e educação sanitária presentes no SESP, bem como discorrer sobre o processo de sistematização da educação sanitária: sua estrutura organizacional, as mudanças em seu organograma e os métodos de educação sanitária. Como fontes históricas, recorremos principalmente às suas publicações nesse período, a Revista e o Boletim do SESP. A proposta sespiana para a educação sanitária teve como ênfase frear o ciclo da miséria, e assim atenuar as condições precárias de saúde dos sujeitos rurais. A educação sanitária realizada nesse contexto social foi envolta por redes complexas de relações de poder, em que ressoavam interesses federais e locais

Práticas educativas em saúde e a constituição de sujeitos ativos / Educational practices in health care and the constitution of active subjects / Prácticas educativas en salud y la constitución de sujetos activos

O objetivo do artigo é problematizar as práticas educativas em saúde contemporâneas e suas contribuições na constituição de subjetividades. Trata-se de um estudo teórico-reflexivo, procurando cotejar essas práticas com as concepções foucaultianas de segurança e liberdade, elementos-chave na fabricação do sujeito ativo. Para esse percurso reflexivo abordamos a interdependência dessas práticas com a biomedicina e seus enunciados, em conformidade com a filosofia do risco, bem como a capilarização desses discursos através das pedagogias culturais. Sendo assim, entendemos que essas práticas podem apresentar várias configurações, dentre elas as estratégias provenientes dos dispositivos de segurança, que contribuem para a formação de sujeitos ativos. Nesses emaranhados discursivos, entrelaçados por inúmeras dimensões, por práticas de saúde construídas historicamente, não se pode mais imaginar relações de poder binarizadas, e sim, múltiplas relações de poder entremeadas de interpelações, que delimitam condutas consideradas saudáveis para esse outro, alicerçadas em representações situadas em espaços e temporalidades particulares.

The objective of this article is to identify the problems of contemporary educational practices in health care and their contributions to the constitution of subjectivities. This is a theoretical, reflexive study, seeking to articulate these practices within Foucaultian conceptions of safety and freedom, key elements in manufacturing an active subject. In this reflexive examination we address the interdependence of these practices with biomedicine and its proclamations in conformity with risk philosophy, as well as the capillarization of these discourses of the active subject through cultural pedagogies. Thus, we understand that these educational practices could present many configurations, among them strategies originating from safety devices, which contribute to the formation of active subjects. In this tangle of discursive elements, interlaced by innumerous dimensions, by historically-built health practices, one can no longer imagine binary power relationships, but multiple power relationships intermingled with interpellations, which delimit conducts considered healthy for this other, grounded in representations situated in particular spaces and temporalities.

El objetivo del artículo ha sido problematizar las prácticas educativas en salud y sus contribuciones para la constitución de subjetividades. El presente es un estudio teórico-reflexivo, donde se busca cotejar las prácticas con las concepciones foucaultianas sobre seguridad y libertad, elementos claves en la creación del sujeto activo. Para realizar esa reflexión, se aborda la interdependencia de las prácticas educativas en salud con la biomedicina y sus enunciados en conformidad con la filosofía del riesgo, así como la capilaridad de esos discursos sobre el sujeto activo a través de las pedagogías culturales. De esa forma, se entiende que esas prácticas educativas pueden presentar varias configuraciones, entre ellas, estrategias provenientes de los dispositivos de seguridad, que contribuyen para la formación de sujetos activos. En ese enmarañado de elementos discursivos, entrelazados por innumerables dimensiones, por prácticas de salud construidas históricamente, no se puede más imaginar relaciones de poder polarizadas sino, múltiples relaciones de poder intercaladas por interpelaciones que delimitan conductas consideradas saludables para ese otro, fundamentadas en representaciones situadas en espacios y temporalidades particulares.

Significados e sentidos de saúde socializados por artefatos culturais: leituras das imagens de advertência nos maços de cigarro / Senses and meanings of health socialized by cultural devices: readings of the warning images on cigarettes packs

Neste artigo, analisamos imagens veiculadas nas embalagens de cigarros, que fazem parte das estratégias do Ministério da Saúde no combate ao tabagismo e disponibilizadas pelo Instituto Nacional de Câncer. Tais imagens trazem o discurso oficial de especialistas e constroem narrativas, entendidas como verdades, alicerçadas no conhecimento científico. Apoiamo-nos no referencial teórico dos estudos culturais, pois suas reflexões ajudam a compreender que as subjetividades são social e culturalmente construídas por vários discursos e artefatos. Não negamos o que está representado, mas estabelecemos diálogos com outras possibilidades de leituras que podem estar presentes nestes artefatos. Entendemos essas imagens como pedagogias culturais - que se comportam como textos a serem lidos, construindo representações, as quais podem ser assumidas como efeitos de verdade - e que atribuem ao sujeito a necessidade de controlar constantemente suas ações. Ao reforçar a biomedicina, as instituições de saúde reproduzem uma visão unidimensional e desconsideram a complexidade desse problema. Entendemos que as pedagogias culturais fazem parte de um território de lutas, onde sentidos e significados podem ser reelaborados, produzindo identidades híbridas, que constroem suas matrizes identitárias nesse emaranhado de relações de poder.

This article analyzes the images publicized on cigarettes packs that are part of the strategies from the Ministry of Health to combat the tabagism and available from the Cancer National Institute. These images bring the official speech of specialists and build narratives, understood such as truths, based on scientific knowledge. We have supported our thesis on theoretical referential of Cultural Studies, since its reflections help to understand that the subjectiveness is social and culturally built by different speeches and devices. We do not deny what is represented, but we establish dialogues with other possibilities of readings that can be present at these devices.We understand the propagated images as cultural pedagogies that behave as texts to be read, building up representations that can be assumed as true effect, and attributes to the citizen the necessity of constant control of its action. Reassuring the biomedicine and the health institutions, an onedimensional vision is propagated disregarding the complexity of this problem. We understand that the cultural pedagogies are part of competition territories, where the directions and meanings can be re-prepared producing hybrid identities that build up its own identity origins over this tangle of power relations.

As identidades dos enfermeiros em cenários de mudanças curriculares no ensino da enfermagem / The identities of nurses in scenarios of changes in the curriculum of nursing education

As discussões sobre o currículo de enfermagem remontam o início do século XX, trazendo tentativas de reorganizar o ensino desta área. As primeiras escolas tiveram o ambiente hospitalar e o modelo biomédico como aporte para o ensino e a assistência. Com a expansão da assistência médico hospitalar, afloraram os discursos da enfermagem como profissão comprometida com a ciência. Por muitos anos, predominou uma formação tecnicista, com aprimoramento da atenção curativa levando ao descompasso com as necessidades de saúde da população. Com o ideário da Reforma Sanitária nos anos 80, a enfermagem procurou articular as dimensões clínicas e epidemiológicas sob a perspectiva do coletivo, culminando na adoção de novas matrizes curriculares. Em 2001, a publicação das diretrizes curriculares preconizou uma formação generalista, humanista, crítica e reflexiva. Porém, as leituras e os significados sobre as propostas das diretrizes podem sofrer interferências locais, produzindo discussões, resistências e enfrentamentos, compondo outras subjetividades acerca desse profissional. Assim, nossa proposta é articular a (re)construção das identidades dos enfermeiros contemporâneos em cenários de propostas e mudanças curriculares nos cursos de graduação em enfermagem, procurando compreender como o passado das matrizes curriculares foi/é trazido para o presente a fim de produzir outras e novas subjetividades.

Discussions about the curriculum of nursing refer back to the beginning of the twentieth century, bringing attempts to reorganize the teaching methods of this area. The first schools had a hospital environment and a biomedical model as a contribution for education and assistance. With the expansion of medical and hospital care, the concept of nursing was viewed as a profession committed to science. For many years, technical education was predominant, enhancing curative care which lead to the inconsistency of the health needs of the population.With the ideals of the Health Reform in the 80s, nursing tried to articulate the clinical and epidemiological dimensions from a collective perspective, culminating in the adoption of new curriculum matrices. In 2001, the publication of the curriculum guidelines recommended a generalist, humanist, critical, and reflective education. However, the readings and meanings of the proposed guidelines may suffer local interferences, causing discussions, resistances, and confrontations. These elements bring on other subjectivities about this professional. Thus, our proposal is to articulate the (re)construction of contemporary nurses' identities in scenarios of proposals and curricular changes in nursing graduate programs, seeking an understanding of how the past of curriculum matrices was/is brought to the present with the objective of producing other and new subjectivities.

[The Project on a Large Scale in its first times: time for a recall]. / Os primórdios do Projeto Larga Escala: tempo de rememorar.

In this work we rebuilt the first attempts on the creation of the Program of Formation on a Large Scale of Elementary and High School people for basic health services. We examined the Program of Formation on a Large Scale from its beginning, being supported by documentary sources, such as Izabel dos Santos's interview, which filled in all the meanings of this experience. In the investigations, we went trough the purpose and the procedures of the proposal on a national scale. According to our point of view, this experience acquired a wider meaning of qualification: in which the focal point of the work, as a condition to workers' formation process, constituted as a methodological-pedagogical purpose of qualification at the work environment in order to obtain a critical professional.