Diseases caused by pathogens in the urban water system in the metropolitan region of Belém, Pará, Brazil, and their relationship with the socio-economic context of the population

The metropolitan region of Belém-PA suffers human fecal pollution in the local water supply system favoring the increase in cases of water circulating diseases in the population, especially the most socioeconomically vulnerable. Therefore, it is necessary to compile information on cases of these diseases over the years in this region, in order to better define public health policies. Thus, this work aims to contribute to the gathering of this information through a literature review selecting articles found in the SciELO, Pubmed and Google Academic databases with publications between 2005 and 2021 in Portuguese and English. The neighborhoods most affected by water circulation diseases proved were Guamá, Marco, Jurunas, Tapanã, Telegrafo and Terra Firme, located close to hydrographic basins, rivers and canals and are subject to flooding due to high tides and overflowing canals. In addition, the population in these neighborhoods is considered underprivileged. The most cited diseases and symptoms were leptospirosis, worms and diarrhea, which are easily prevented. Total and thermotolerant coliforms were also widely described, being the main indicators of fecal water contamination. The importance of sanitary measures is evidenced, as these reduce cases of water supply diseases in urban centers and improve population health. The quality of the water in the supply network is also important to mitigate the prevalence of these diseases.

Factors associated with the prevalence of antibodies against Brucella abortus in water buffaloes from Santarém, Lower Amazon region, Brazil.

We evaluated the factors associated with the prevalence of antibodies against Brucella abortus in buffaloes in the municipality of Santarém, Western Pará, northern Brazil. The study was conducted on 60 farms, representing 25.8% of the total buffalo farms in the region. From those farms, a total of 426 buffaloes were sampled, males of any age and females more than 24 months of age, to avoid a false-positive reaction in the serological test due to vaccination. The Acidified Agglutination Serum Test was carried out on serum samples using B. abortus strain 1,119-3 as the antigen. Univariate and multivariate analysis were performed to investigate the association between brucellosis and potential risk factors. Of the 426 tested buffaloes, 29 were positive, resulting in an overall animal prevalence of antibodies against B. abortus at the animal level of 6.8% (4.6-9.6; 95% confidence interval). The herd level prevalence was 30% (18 of 60) and seroprevalence range within farms was from 0% to 100%. At the animal level, buffaloes raised in the floodplains tended (p = 0.06) to present a higher seroprevalence (9.70%) of antibodies against B. abortus than buffaloes raised in dry land (4.98%) and cows tended (p = 0.054) to have a higher seroprevalence than male buffaloes. Multivariate herd-level analysis revealed association between farm type and brucellosis seroprevalence (p = 0.015); dairy farms were two times more likely to have seropositive buffalo than beef farms. Our survey demonstrated a high farm seroprevalence of B. abortus in buffalo raised in an Amazonian ecosystem with positive animals found in one third of sampled farms.

Characterization and expression analysis of P5CS (Δ1-pyrroline-5-carboxylate synthase) gene in two distinct populations of the Atlantic Forest native species Eugenia uniflora L.

Eugenia uniflora is an Atlantic Forest native species, occurring in contrasting edaphoclimatic environments. The identification of genes involved in response to abiotic factors is very relevant to help in understanding the processes of local adaptation. 1-Pyrroline-5-carboxylate synthetase (P5CS) is one interesting gene to study in this species since it encodes a key enzyme of proline biosynthesis, which is an osmoprotectant during abiotic stress. Applying in silico analysis, we identified one P5CS gene sequence of E. uniflora (EuniP5CS). Phylogenetic analysis, as well as, gene and protein structure investigation, revealed that EuniP5CS is a member of P5CS gene family. Plants of E. uniflora from two distinct environments (restinga and riparian forest) presented differences in the proline accumulation and P5CS expression levels under growth-controlled conditions. Both proline accumulation and gene expression level of EuniP5CS were higher in the genotypes from riparian forest than those from restinga. When these plants were submitted to drought stress, EuniP5CS gene was up-regulated in the plants from restinga, but not in those from riparian forest. These results demonstrated that EuniP5CS is involved in proline biosynthesis in this species and suggest that P5CS gene may be an interesting candidate gene in future studies to understand the processes of local adaptation in E. uniflora.

Effect of quercetin on E-NTPDase/E-ADA activities and cytokine secretion of complete Freund adjuvant-induced arthritic rats.

The effect of quercetin was assessed in rats induced with complete Freund adjuvant (CFA). Arthritis scores, paw oedema, latency, activities of myeloperoxidase (MPO), ectonucleoside triphosphate diphosphohydrolase (E-NTPDase), and ectoadenosine deaminase (E-ADA) in lymphocytes were determined. Furthermore, nucleotide and nucleoside levels as well as the secretion of pro- and anti-inflammatory cytokines were evaluated. Animals were treated with saline and quercetin in doses of 5, 25, and 50 mg/kg for 45 days. The result revealed that quercetin (50 mg/kg) reduced arthritis score and paw oedema, and increased the latency in the thermal hyperalgesia test. Histopathological analysis showed that all the doses of quercetin reduced infiltration of inflammatory cells. MPO activity was increased in the arthritis group; however, quercetin reduced this activity. E-NTPDase activity was increased in lymphocytes of arthritis rats, and treatment with quercetin reversed this increase. However, E-ADA activity was reduced in the arthritis group, and treatment with quercetin modulated the activity of this enzyme in arthritis rat groups. Serum adenosine levels were increased in arthritis, and the levels were lowered with quercetin treatment. Quercetin treatment in arthritis groups decreased the elevated levels of cytokines in the arthritis control group. Thus, quercetin demonstrated an anti-inflammatory effect, and this flavonoid may be a promising natural compound for the treatment of arthritis. SIGNIFICANCE OF THE STUDY: Quercetin may represent a potential therapeutic compound in the treatment of rheumatoid arthritis. Findings from this study indicate that quercetin suppresses swelling and attenuates the underlying inflammatory responses. This is the first report where quercetin was shown to modulate the immune response to arthritis via attenuation of the purinergic system (E-NTPDase and E-ADA activities) and the levels of IFN-gamma and IL-4. Thus, this work is relevant to basic research and may be translated into clinical practice.

Agente comunitário de saúde no espírito santo: do perfil às atividades desenvolvidas / Community health agent: from the profile to activities done / Agente comunitario de salud: del perfil a las actividades desarrolladas

Resumo Ao considerar a amplitude e a complexidade do papel que os agentes comunitários de saúde assumem na Estratégia Saúde da Família, constituiu-se objeto do estudo apresentado neste artigo conhecer o perfil e a realidade de trabalho desses profissionais, no sentido de contribuir para a consolidação do Sistema Único de Saúde. Tratou-se de estudo quantitativo, realizado em dez municípios com população superior a 50 mil habitantes no Espírito Santo, de julho de 2012 a agosto de 2013. Foram selecionadas unidades de saúde da família com equipes completas, totalizando 121 agentes comunitários de saúde participantes do estudo. Os dados foram coletados mediante questionário estruturado autoaplicável. Os resultados revelaram que as atividades realizadas com maior frequência pelos agentes eram: visita domiciliar, atualização de cadastro, reunião de equipe e acompanhamento dos grupos prioritários definidos pelo Ministério da Saúde. Embora grande parte dos agentes fizesse o mapa inteligente e o diagnóstico de saúde, somente 13,2% identificaram famílias de risco e 14,9% realizaram o levantamento de problemas de saúde de sua microárea. Assim, questionou-se a verdadeira finalidade do mapa inteligente e do diagnóstico de saúde, ou a forma de participação do agente na elaboração desses instrumentos, o que poderia estar restrito somente à formalização da prática.

Abstract Considering the breadth and complexity of the role that community health agents play in the Family Health Strategy, the purpose of the study presented in this article was to get to know the profile and the reality of these professionals' work to contribute to the consolidation of the Unified Health System. This was a quantitative study conducted in ten municipalities with more than 50,000 inhabitants in the state of Espírito Santo, Brazil, from July 2012 to August 2013. Family health units with complete teams were selected, and a total of 121 community health agents took part in the study. Data were collected through a self-administered structured questionnaire. The results showed that the agents' most frequent activities were home visits, registration updates, team meetings, and follow-up on the priority groups defined by the Ministry of Health. Although many of the agents completed the smart map and the health diagnosis, only 13.2 percent of them identified families at risk, and 14.9 percent surveyed the health issues of their micro-area. Thus, the true purpose of the smart map and of the health diagnosis, or of the agent's participation in the preparation of these instruments was questioned, which could be restricted only to formalize the practice.

Resumen Al considerar la amplitud y la complejidad del papel que los agentes comunitarios de salud asumen en la Estrategia Salud de la Familia, se constituyó en objeto de estudio presentado en este artículo, conocer el perfil y la realidad de trabajo de estos profesionales, desde el punto de vista de su contribución para consolidad el Sistema Único de Salud. Se trató de un estudio cuantitativo, realizado en diez municipios con población superior a 50 mil habitantes, en el estado de Espírito Santo, Brasil, de julio de 2012 a agosto de 2013. Se seleccionaron unidades de salud de la familia con equipos completos, totalizando 121 agentes comunitarios de salud participantes del estudio. Los datos se recolectaron mediante un cuestionario estructurado autoadministrado. Los resultados revelaron que las actividades realizadas con mayor frecuencia por los agentes eran: visita domiciliaria, actualización de registro, reunión de equipo y seguimiento de los grupos prioritarios definidos por el Ministerio de la Salud. Aunque gran parte de los agentes hizo el mapa inteligente y el diagnóstico de salud, sólo el 13,2% identificaron familias de riesgo y el 14.9% realizaron el relevamiento de problemas de salud de su microárea. Así, se cuestionó la verdadera finalidad del mapa inteligente y del diagnóstico de salud, o la forma de participación del agente en la preparación de estos instrumentos, que podría restringirse solamente a la formalización de la práctica.

Cross-protection to new drifted influenza A(H3) viruses and prevalence of protective antibodies to seasonal influenza, during 2014 in Portugal.

INTRODUCTION: Immune profile for influenza viruses is highly changeable over time. Serological studies can assess the prevalence of influenza, estimate the risk of infection, highlight asymptomatic infection rate and can also provide data on vaccine coverage. The aims of the study were to evaluate pre-existing cross-protection against influenza A(H3) drift viruses and to assess influenza immunity in the Portuguese population. MATERIALS AND METHODS: We developed a cross-sectional study based on a convenience sample of 626 sera collected during June 2014, covering all age groups, both gender and all administrative health regions of Portugal. Sera antibody titers for seasonal and new A(H3) drift influenza virus were evaluated by hemagglutination inhibition assay (HI). Seroprevalence to each seasonal influenza vaccine strain virus and to the new A(H3) drift circulating strain was estimated by age group, gender and region and compared with seasonal influenza-like illness (ILI) incidence rates before and after the study period. RESULTS: Our findings suggest that seroprevalences of influenza A(H3) (39.9%; 95% CI: 36.2-43.8) and A(H1)pdm09 (29.7%; 95% CI: 26.3-33.4) antibodies were higher than for influenza B, in line with high ILI incidence rates for A(H3) followed by A(H1)pdm09, during 2013/2014 season. Low pre-existing cross-protection against new A(H3) drift viruses were observed in A(H3) seropositive individuals (46%). Both against influenza A(H1)pdm09 and A(H3) seroprotection was highest in younger than 14-years old. Protective antibodies against influenza B were highest in those older than 65years old, especially for B/Yamagata lineage, 33.3% (95% CI: 25.7-41.9). Women showed a high seroprevalence to influenza, although without statistical significance, when compared to men. A significant decreasing trend in seroprotection from north to south regions of Portugal mainland was observed. CONCLUSIONS: Our results emphasize that low seroprotection increases the risk of influenza infection in the following winter season. Seroepidemiological studies can inform policy makers on the need for vaccination and additional preventive measures.

Neuroprotective effects of pretreatment with quercetin as assessed by acetylcholinesterase assay and behavioral testing in poloxamer-407 induced hyperlipidemic rats.

Hyperlipidemia is a group of disorders characterized by excessive lipids in the bloodstream. It is associated with the incidence of cardiovascular diseases and recognized as the most important factor underlying the occurrence of atherosclerosis. This study was conducted to investigate whether pretreatment with quercetin can protect against possible memory impairment and deterioration of the cholinergic system in hyperlipidemic rats. Animals were divided into ten groups (n=7): saline/control, saline/quercetin 5mg/kg, saline/quercetin 25mg/kg, saline/quercetin 50mg/kg, saline/simvastatin (0.04mg/kg), hyperlipidemia, hyperlipidemia/quercetin 5mg/kg, hyperlipidemia/quercetin 25mg/kg, hyperlipidemia/quercetin 50mg/kg and hyperlipidemia/simvastatin. The animals were pretreated with quercetin by oral gavage for a period of 30days and hyperlipidemia was subsequently induced by intraperitoneal administration of a single dose of 500mg/kg of poloxamer-407. Simvastatin was administered after the induction of hyperlipidemia. The results demonstrated that hyperlipidemic rats had memory impairment compared with the saline control group (P<0.001). However, pretreatment with quercetin and simvastatin treatment attenuated the damage caused by hyperlipidemia compared with the hyperlipidemic group (P<0.05). Acetylcholinesterase (AChE) activity in the cerebral hippocampus was significantly (P<0.001) reduced in the hyperlipidemic group compared with the control saline group. Pretreatment with quercetin and simvastatin treatment in the hyperlipidemic groups significantly (P<0.05) increased AChE activity compared with the hyperlipidemic group. Our results thus suggest that quercetin may prevent memory impairment, alter lipid metabolism, and modulate AChE activity in an experimental model of hyperlipidemia.

Percepção do condutor acidentado sobre os fatores que influenciaram no acidente motociclístico / Perception of the injured driver about the factors that influenced in the motorcycle accident / Percepción del conductor accidentado sobre los factores que influyeron el accidente de motocicleta

Objetivo: Identificar la percepción del conductor accidentado sobre los factores que influyeron en el accidente de motocicleta. Método: estudio descriptivo, cualitativo, desarrollado en septiembre de 2015, con quince víctimas de accidentes que conducían la motocicleta en el momento del accidente, en la capital de la provinciade Piauí. Los datos fueron analizados por medio de la técnica deanálisis temático. Resultados: Del estudio formaron tres categorías: la percepción de las víctimas de accidentes de motocicleta sobre su comportamiento de riesgo; asociación del accidente a la conducta de riesgo del otro conductor y factores externos relacionados alaccidente del motociclista en la concepción del conductor accidentado. Consideraciones finales:Se evidenció que el gobierno tiene dos grandes desafíos: instituir una educación en el tráfico tan eficaz como la política de venta de las motocicletas e involucrar la sociedad en los debates sobre los problemas que se producen en el tráfico.

Objetivo: identificar a percepção do condutor acidentado sobre os fatores que influenciaram no acidente motociclístico. Método: pesquisa descritiva, qualitativa, desenvolvida no mês de setembro de 2015, com quinze pessoas acidentadas, que conduziam a motocicleta no momento do acidente, na capital do Estado do Piauí. Os dados foram analisados pela técnica de análise temática. Resultados: emergiram neste estudo três categorias: percepção das vítimas de acidente motociclístico quanto ao seu comportamento de risco; associação do acidente ao comportamento de risco do outro condutor; e fatores externos relacionados ao acidente do motociclista na concepção do condutor acidentado. Considerações finais: Evidenciaram-se dois grandes desafios do poder público: instituir uma educação no trânsito tão eficaz quanto a política de venda de motocicletas e, envolver a sociedade em debates sobre os problemas que ocorrem no trânsito.

Aim: to identify the perception of the injured driver about the factors that influenced the motorcycle accident. Method: a descriptive, qualitative research, developed with fifteen accident victims who were driving the motorcycle at the time of the accident, in September 2015, in the capital of the State of Piaui. Data was analyzed using a thematic analysis. Results: three categories emerged in this study: motorcycle accident victim's perception in relation to their risk behavior; association of the accident to the risky behavior of the other driver and external factors related to the motorcycle accident from the injured driver's perspective. Final thoughts: two great challenges were evidenced: to consolidate a traffic education as effective as the motorcycle sales policy, and the other is to involve society in debates about problems that occur in traffic.

Degradação Adesiva de um Compósito Auto Aderente aos Substratos da Técnica Indireta / Bonding Degradation of a Self-Adhering Composite to Substrates used in Indirect Technique

O objetivo desse estudo foi avaliar a resistência de união - RU ao cisalhamento de um compósito fluido auto aderente em quatro substratos utilizados na técnica indireta, com uma semana e um ano de armazenamento em água destilada. Quarenta e oito amostras (5 mm largura / 15 mm comprimento / 2 mm espessura) foram preparadas em laboratório protético: 12 amostras do(a) cerômero Adoro/AD, cerâmica/leucita Empress Esthetic/EE, cerâmica/zircônia ZirCAD/ZI (Ivoclar Vivadent), mais a liga Fit Cast SB/ME (Talladium do Brasil), sendo as amostras divididas em dois grupos para cada período de tempo (uma semana e um ano). Dois compósitos fluidos (Controle / FF-Filtek Z350XT Flow / 3M ESPE e o auto aderente / DF-Dyad Flow / Kerr) foram unidos aos quatro substratos. Quatro matrizes Tygon foram posicionadas sobre as amostras, as quais foram preenchidas com os compósitos FF e DF (fotopolimerização 20s). As matrizes foram removidas para expor os corpos de prova (12 por grupo) e as amostras foram armazenadas em água destilada/ 37±2 °C por uma semana e um ano. Após estes períodos, cada amostra foi conectada a uma máquina de ensaios para realização dos ensaios de RU a uma velocidade de 1,0 mm/min, até a falha. Os resultados foram analisados por ANOVA e teste de Tukey (p<0,05). Nos ensaios de uma semana, os substratos leucita e metal apresentaram as maiores médias de RU para ambos os compósitos. Nos ensaios de um ano, os substratos não apresentaram diferença estatística nas médias de RU para ambos os compósitos, com exceção da zircônia que apresentou resultado nulo. Os valores médios de RU, no entanto, foram significativamente menores quando comparados com os resultados dos ensaios de uma semana.(AU)

The aim of this study was to evaluate the shear bond strength (SBS) of a self-adhering flowable composite on four substrates used in indirect technique, for a week and one year of storage in distilled water. Forty eight samples (5 mm wide / 15 mm length / 2 mm thick) were prepared at dental prosthetic laboratory: 12 samples of the ceromer Adoro/AD, leucite ceramic IPS Empress Esthetic/EE, zirconia ceramic ZirCAD/ZI (Ivoclar Vivadent) and the metal ceramic alloy Fit Cast SB/ME (Talladium do Brasil). Samples of each substrate were divided into two groups for each time (a week and one year). Two flowable composites (Control/FF-Filtek Z350 XT Flow/3M ESPE, and the self-adhering/DF-Dyad Flow/Kerr) were bonded to four substrates. Four Tygon tubing were positioned over each sample, which were filled in with the composites FF and DF, and visible light-cured for 20s. The tubings were removed to expose the specimens (12 per group) in format of cylinders, and the samples were stored in distilled water at 37 ± 2°C for one week and one year. After these periods, each sample was attached to testing machine and the specimens were submitted to the shear bond strength test at speed of 1.0mm/min, until failure. The results were analyzed by ANOVA and Tukey test (p<0.05). To one week tests, the substrates leucite and metal showed the highest SBS means, to both composites. For the one-year experiments, the substrates did not show differences in the SBS averages for both composites, except for zirconia that showed null result. However, the SBS averages were lower when compared to one week tests.(AU)

Healthcare management of tuberculosis: integrating a teaching hospital into primary health care / Gestión del cuidado de la tuberculosis: integrando uno hospital de docente a la atención primaria de salud / Gestão do cuidado da tuberculose: integrando um hospital de ensino à atenção primária à saúde

ABSTRACT Qualitative, exploratory and interventionist case study at a teaching hospital of Paraná, with the objective of proposing a Tuberculosis Healthcare Management model focused on the hospital discharge, with a view to comprehensive care for patients with tuberculosis. Interviews were conducted with key informants (17 subjects), using the Theory of Nursing Praxis Intervention in Collective Health as the theoretical and methodological framework, with its three interdependent dimensions used as analytical categories. Weakness was revealed in the protocols for hospitalized patient care, insufficient integration between levels of care and the need for direct communication between the hospital and primary care nurses. In view of this result, a Healthcare Management Model, expressed as a flow of care with matrix support, nursing consultation and phone contact between nurses. The implementation of this model will lead to greater integration between the levels of care, permitting improvements in patient monitoring with greater probability of treatment compliance.

RESUMEN Investigación cualitativa, exploratoria e intervencionista en un hospital universitario del Paraná, con el objetivo de proponer un modelo de Gestión del Cuidado de la Tuberculosis centrada en las altas de hospital, en busca de la atención integral de los pacientes con tuberculosis. Se realizaron entrevistas con informantes clave (17 sujetos) con la Teoría de Enfermería Praxis Intervención en Salud Colectiva como marco teórico y metodológico, con sus tres dimensiones interdependientes utilizados como categorías analíticas. Fue evidente una debilidad en los protocolos orientados a la atención del paciente hospitalizado, insuficiente integración entre niveles asistenciales y la necesidad de comunicación directa entre lo hospital y la atención primaria. Teniendo en cuenta este resultado propuso un modelo de gestión de la atención, traducido en flujo de la atención con el apoyo de la matriz, consulta de enfermería y contacto telefónico entre las enfermeras. Se cree que con la implementación de este modelo habrá mayor integración entre los niveles de atención, lo que permite una mejora en el proceso de seguimiento del enfermo con tuberculosis, haciéndolos más propensos a adherirse al tratamiento.

RESUMO Pesquisa de cunho qualitativo, exploratório e intervencionista em hospital universitário do Paraná, com o objetivo de propor um modelo de Gestão do Cuidado da Tuberculose voltado à alta hospitalar, buscando cuidado integral ao portador dessa doença. Foram realizadas entrevistas com informantes-chave (17 sujeitos), tendo a Teoria da Intervenção Práxica de Enfermagem em Saúde Coletiva como referencial teórico-metodológico, com suas três dimensões interdependentes, utilizadas como categorias analíticas. Ficou evidenciado fragilidade nos protocolos voltados ao cuidado do doente internado, insuficiente integração entre níveis de atenção e necessidade de comunicação direta entre enfermeiros do hospital e da atenção primária. Diante desse resultado, foi proposto modelo de Gestão do Cuidado, traduzido em fluxo de atendimento com apoio matricial, consulta de enfermagem e contato telefônico entre enfermeiros. Acredita-se que a implantação desse modelo trará maior integração entre os níveis de atenção, melhora no processo de acompanhamento do doente com maior probabilidade de adesão ao tratamento.

Tuberculoid leprosy presenting as a "racket" lesion.

The "racket" lesion is a rare presentation of tuberculoid leprosy, which consists of a thickened nerve branch emerging from a tuberculoid plaque. It results from centripetal damage to cutaneous nerves caused by granuloma formation. We describe a typical case of tuberculoid leprosy presenting as a "racket" lesion. The lesion persisted after treatment with paucibacillary multidrug therapy.

Melanoníquia estriada secundária a fibroma da matriz ungueal pigmentado simulando melanoma nodular / Melanonychia striata secondary to pigmented nail matrix fibroma simulating nodular melanoma

Melanoníquia é a coloração da lâmina ungueal variando do marrom ao negro. Representa um desafio diagnóstico, pois há diversos diagnósticos diferenciais incluindo entidades benignas e malignas. Não há relatos de fibroma da matriz ungueal pigmentado causando melanoníquia longitudinal. Diante disso, os autores relatam um caso de melanoníquia estriada secundária a fibroma ungueal pigmentado, com achados do exame clínico e dermatoscópico sugestivos de melanoma nodular.

Melanonychia corresponds to color patterns in the nail plate, ranging from brown to black. It is a diagnostic challenge due to the fact it has several differential diagnoses, including benign and malignant entities. There are no reports of pigmented fibroma of the nail matrix causing striata (or longitudinal) melanonychia. In light of this fact, the authors report a case of melanonychia striata secondary to pigmented fibroma of the nail, with clinical examination and dermoscopic findings suggestive of nodular melanoma.

O tratamento bem-sucedido com fototerapia UVB banda estreita em um caso raro de líquen escleroso extragenital generalizado / Successful treatment of a rare case of widespread extragenital lichen sclerosus with narrow band UVB phototherapy

O líquen escleroso é patologia incomum acometendo tanto região genital quanto extragenital, constituindo apresentação atípica da doença. O uso de corticosteroides tópicos é considerado primeira linha para tratamento da doença genital. Lesões extragenitais são menos sensíveis a essa terapêutica. Relata-se caso de líquen escleroso em paciente do sexo feminino, de 82 anos, com envolvimento extragenital generalizado e tratamento bem-sucedido com fototerapia UVB de banda estreita. O líquen escleroso é dermatose inflamatória crônica, e as formas disseminadas da doença são raras e sem consenso em relação ao tratamento da forma extragenital. A opção pela terapia com UVB de banda estreita baseou-se nos relatos da literatura.

Lichen sclerosus is an uncommon condition affecting both the genital and extragenital region, the latter constituting an atypical occurrence of the disorder. The use of topical corticosteroids is considered the first-line treatment of this genital disease. Extragenital lesions are less sensitive to this therapy. The present study describes a case of lichen sclerosus in an 82-year-old female patient, with widespread extragenital involvement and successful treatment with narrow band UVB phototherapy. Lichen sclerosus is a chronic inflammatory dermatosis and disseminated forms of the condition are rare, with an absence of consensus on the treatment of the extragenital form. The choice for narrow band UVB therapy was based on the literature.

Estudo epidemiológico do carcinoma basocelular no período de 2010 a 2013 em um hospital de referência em dermatologia na cidade de Bauru, São Paulo / Epidemiological study of basal cell carcinoma between 2010 and 2013, at a dermatology reference hospital in the city of Bauru, São Paulo State, Brazil

Introdução: O carcinoma basocelular é o câncer da pele mais comum e corresponde a 70-80% das neoplasias malignas da pele. Sua incidência vem aumentando em todos os países, configurando um problema de saúde pública mundial. Objetivo: Avaliar o perfil epidemiológico e as características dos pacientes diagnosticados com CBC nos últimos quatro anos em um hospital de referência. Métodos: Foi realizado estudo transversal e descritivo em um serviço de referência em dermatologia na cidade de Bauru (SP) incluindo pacientes com diagnóstico de carcinoma basocelular confirmado por exame histopatológico, no período de janeiro de 2010 a dezembro de 2013. As variáveis analisadas de forma descritiva foram: idade ao diagnóstico, gênero, cidade de origem, local da lesão e raça. Resultados: Observou-se maior incidência de casos de CBC em mulheres, da raça branca, com mais de 60 anos, sendo as localizações preferenciais as regiões malares e nasal. Conclusões: Há um aumento da incidência de carcinoma basocelular em jovens, embora o segmento mais afetado continue sendo a população branca e idosa. A área preferencial do câncer é a face, principalmente nos dois terços superiores. É preocupante a incidência dessa neoplasia em populações mais jovens, sendo importante o papel do dermatologista na prevenção e no tratamento precoce.

Introduction: Basal cell carcinoma is the most common skin cancer and corresponds to 70-80% of all malignant neoplasms of the skin. It is emerging as a global public health problem, with incidences of the condition increasing in all countries. Objective: To evaluate the epidemiological profile and characteristics of patients diagnosed with basal cell carcinoma in the previous four years in a reference hospital. Methods: A cross-sectional descriptive study was carried out at a dermatology reference center in the city of Bauru, São Paulo State, Brazil. Patients diagnosed with basal cell carcinoma, confirmed by histological examination from January 2010 to December 2013 were included in the study. The variables analyzed descriptively were: age at diagnosis, gender, city of origin, site of lesion, and race. Results: A higher incidence of basal cell carcinoma was observed in Caucasian women older than 60 years, with the malar and nasal regions arising as the usual locations. Conclusions: There is an increased incidence of basal cell carcinoma in young people, however the most affected population is still the elderly Caucasian population. The most common area for the cancer is the face, particularly the upper two thirds. The incidence of this cancer in younger populations is worrying, with the dermatologist having an important role in the prevention and early treatment.

Ações, Rastros e Controvérsias Online/ Offline: possibilidades metodológicas a partir da Teoria Atorrede / Actions, Traces and Controversies Online/ Offline: possibilities methodological from Actor-Network Theory / Acciones, Rastros y Controversias on-line y off-line: posibilidades metodológicas de la Teoría del Actor-Red

O processo de convergência midiática nos oferece um campo vasto ecomplexo de práticas cotidianas e comportamentais. Ações virtuais,invariavelmente, trazem à tona dimensões que envolvem, em um primeiro momento, ações simples e conversações em rede. A partir das quais, um olhar mais cuidadoso, revela com igual força condições tecnológicas,materiais, visibilidade social, questões humanas, culturais, políticas, entreoutras - com curiosa fluidez para algumas situações que transitamlivremente entre os espaços online e offline, entre o público e o privado,entre meios interpessoais e massivos etc. A partir desse cenário, e utilizandoum caso específico como ponto de partida, propomos a produção de umpequeno mapa de conexões, empregando a Teoria Ator Rede (TAR) como possibilidade metodológica. A partir de uma escrita etnográfica (em contexto virtual) buscamos rastrear vínculos e estabilizar uma rede que nospermitisse compreender, mesmo que parcialmente, os múltiplos fluxos eassociações proporcionadas pelos dispositivos de comunicação (digitais e/ou convencionais). (AU)

The media convergence process offers a wide area and everyday practices and behavioral complex. Virtual actions invariably show up dimensions involved, at first, simple actions and conversations in the network. However,that view reveals, among other things, technological conditions, social visibility, human, cultural, political affairs, etc. There is a curious fluidity to some events which pass freely between on-line and off-line spaces, betweenpublic and private spaces, and also between interpersonal and mass mediaspace etc. At this stage and using a specific area as a starting point, wepropose the production of a small connection map. Using the Actor-network Theory, often abbreviated as ANT, as a methodological possibility. From an ethnographic writing (in virtual context) we look for tracing linkage andstabilize a network that allows us to understand, even partially, the multipleflows and associations provided by the communications tools (digital orconventional). (AU)

El proceso de convergencia mediático nos ofrece un campo amplio y complejo de prácticas cotidianas y de comportamientos. Las accionesvirtuales, invariablemente, revelan dimensiones que envuelven, en unprimer momento, acciones simples y conversaciones en la red. Sin embargo,observando cuidadosamente muestra, entre otras cosas, condiciones tecnológicas, visibilidad social, cuestiones humanas, culturales, políticas, etc. Existe una fluidez curiosa para algunos eventos que transitan libremente entre diversos espacios, ya sean estos: on-line y off-line, público y privado, medios interpersonales y masivos etc. A partir de este escenario y utilizando un campo específico como punto de partida, proponemos la producción de un pequeño mapa de conexiones. Para ello, utilizamos la Teoría del ActorRed, de sus siglas en inglés ANT, como una posible metodología. A partir de una escritura etnográfica (en contexto virtual) buscamos rastrear los vínculos y estabilizar una red que nos ha permitido comprender, aunque sea parcialmente, los múltiples flujos y asociaciones proporcionadas por las herramientas de comunicación (digital o convencional). (AU)

Ações, rastros e controvérsias online/ offline: possibilidades metodológicas a partir da Teoria A torrede / Actions, traces and controversies online/ offline: possibilities methodological from Actor-Network Theory / Acciones, rastros y controversias on-line y off-line: posibilidades metodológicas de la Teoría del Actor-Red

O processo de convergência midiática nos oferece um campo vasto e complexo de práticas cotidianas e comportamentais. Ações virtuais,invariavelmente, trazem à tona dimensões que envolvem, em um primeiro momento, ações simples e conversações em rede. A partir das quais, um olhar mais cuidadoso, revela com igual força condições tecnológicas,materiais, visibilidade social, questões humanas, culturais, políticas, entre outras - com curiosa fluidez para algumas situações que transitam livremente entre os espaços online e offline, entre o público e o privado,entre meios interpessoais e massivos etc. A partir desse cenário, e utilizando um caso específico como ponto de partida, propomos a produção de um pequeno mapa de conexões, empregando a Teoria Ator Rede (TAR) como possibilidade metodológica. A partir de uma escrita etnográfica (em contexto virtual) buscamos rastrear vínculos e estabilizar uma rede que nos permitisse compreender, mesmo que parcialmente, os múltiplos fluxos e associações proporcionadas pelos dispositivos de comunicação (digitais e/ou convencionais).

The media convergence process offers a wide area and everyday practices and behavioral complex. Virtual actions invariably show up dimensions involved, at first, simple actions and conversations in the network. However,that view reveals, among other things, technological conditions, social visibility, human, cultural, political affairs, etc. There is a curious fluidity to some events which pass freely between on-line and off-line spaces, between public and private spaces, and also between interpersonal and mass mediaspace etc. At this stage and using a specific area as a starting point, wepropose the production of a small connection map. Using the Actor-network Theory, often abbreviated as ANT, as a methodological possibility. From an ethnographic writing (in virtual context) we look for tracing linkage andstabilize a network that allows us to understand, even partially, the multipleflows and associations provided by the communications tools (digital orconventional).

El proceso de convergencia mediático nos ofrece un campo amplio y complejo de prácticas cotidianas y de comportamientos. Las acciones virtuales, invariablemente, revelan dimensiones que envuelven, en unprimer momento, acciones simples y conversaciones en la red. Sin embargo,observando cuidadosamente muestra, entre otras cosas, condiciones tecnológicas, visibilidad social, cuestiones humanas, culturales, políticas, etc. Existe una fluidez curiosa para algunos eventos que transitan libremente entre diversos espacios, ya sean estos: on-line y off-line, público y privado, medios interpersonales y masivos etc. A partir de este escenario y utilizando un campo específico como punto de partida, proponemos la producción de un pequeño mapa de conexiones. Para ello, utilizamos la Teoría del ActorRed, de sus siglas en inglés ANT, como una posible metodología. A partir de una escritura etnográfica (en contexto virtual) buscamos rastrear los vínculos y estabilizar una red que nos ha permitido comprender, aunque sea parcialmente, los múltiples flujos y asociaciones proporcionadas por las herramientas de comunicación (digital o convencional).

Gestão do cuidado da tuberculose: integrando um hospital de ensino a atenção primária à saúde / Tuberculosis care management: integrating a teaching hospital with primary health care

Mesmo diante de inúmeras estratégias para o controle da tuberculose, os indicadores desse agravo ainda preocupam e apesar da importante redução dos casos na última década, os índices de abandono persistem como um desafio. Portanto, percebe-se uma insuficiência nos atuais programas de saúde voltados ao seu controle, necessitando de novas estratégias no combate de uma doença queaflige a humanidade há tanto tempo. Esse estudo de cunho qualitativo, exploratório e intervencionista, com dados coletados entre março e maio de 2014, teve como objetivo propor um modelo de Gestão do Cuidado da Tuberculose no momento da alta hospitalar para integrar um Hospital de Ensino à Atenção Primária à Saúde (APS) do município em que está localizado, buscando promover maior adesão ao tratamento. Tendo como referencial teórico e metodológico a Teoria da Intervenção Práxica da Enfermagem em Saúde Coletiva (TIPESC), foram desenvolvidas as três primeiras etapas propostas pela autora da teoria - captação e interpretação da realidade objetiva e construção do projeto de intervenção. As duas primeiras etapas foram desenvolvidas por meio de duas perspectivas: uma com a utilização de dados secundários provenientes do Serviço de Epidemiologia Hospitalar, compondo uma série histórica de cinco anos dos casos de tuberculose atendidos no hospital e outra por meio de entrevistas não estruturadas com informantes-chave. Foram dezessete participantes selecionados, sendo três enfermeiros do hospital, nove enfermeiros da APS e cinco usuários em tratamento de tuberculose pós alta hospitalar. As informações provenientes dos dados secundários e das entrevistas foram analisadas separadamente utilizando as dimensões estrutural, particular e singular propostas por Egry (1996) como categorias analíticas. Constatou-se que a população atendida no hospital cenário do estudo apresenta as formas mais agravadas da doença, coinfecção com HIV e vulnerabilidade social. Nos discursos dos enfermeiros ficou evidente a fragilidade nos padrões e protocolos voltados ao cuidado do doente de tuberculose, a insuficiente integração entre os níveis de atenção e o reconhecimento da necessidade de comunicação direta entre os enfermeiros do hospital e da APS para a condução do tratamento desse agravo. Na fala dos usuários se destacou o escasso contato deles com o enfermeiro do hospital, além da necessidade de educação em saúde e de ações direcionadas às suas singularidades. Diante dessa realidade objetiva foi proposto um modelo de Gestão do Cuidado que se traduz em um fluxo de atendimento adequado ao usuário internado com tuberculose, apresentando o enfermeiro do Serviço de Epidemiologia como apoio matricial e o enfermeiro da unidade de internação como condutor do caso responsável pela consulta de enfermagem na alta hospitalar e o contato direto com o enfermeiro da APS para comunicação do caso e pré-agendamento de consulta para o usuário que está recebendo a alta. Acredita-se que com a implantação desse modelo poderá haver integração entre os níveis de atenção, possibilitando melhora no planejamento e condução do acompanhamento do doente de tuberculose, suprindo suas necessidades em saúde de forma adequada, com maiores probabilidades de adesão ao tratamento e consequente redução dos índices de abandono.

Even with numerous strategies to control tuberculosis, the indicators of this condition still care. Despite the significant reduction in cases over the past two decades, dropout rates remain a challenge. Therefore, there is a perceived inadequacy in the current health programs aimed at their control, requiring new strategies to combat a disease that afflicts mankind so long. This study has a qualitative, exploratory and interventionist nature, and had the objective of propose a model of Care Management of Tuberculosis at the time of Hospital Discharge to integrate a Teaching Hospital to Primary Health Care (PHC) in the municipality where it is located, seeking to promote greater adherence to treatment. Grounded by the Theory of Praxis Intervention Community Health Nursing (TIPESC) , the first three steps proposed by the author of the theory were developed - capture and interpretation of the objective reality and construction of the project intervention in objective reality . The first two steps were developed through two perspectives: one with the use of secondary data from the database of the Department of Hospital Epidemiology, composing a five-year time series of TB cases treated at the hospital and another in interviews unstructured with key informants. Seventeen participants were selected, three nurses from hospital, nine nurses from PHC and five users in treatment of tuberculosis after hospital discharge. The information from the interviews and secondary data were analyzed separately using the dimensions proposals for Egry (1996) (structural, particular and singular) as analytic categories. It was found that the population treated in this hospital presents the most aggravated forms of the disease, a lot of co-infection with HIV and social vulnerability. Speeches of the nurses leave in evidence the fragility in standards and protocols aimed at care to tuberculosis patients, the disintegration between levels of care and the acknowledgement of the need for direct communication between the hospital and the nurses PHC to conduct the treatment of this disease. In the user's speech was perceived the restricted contact with their nurses at the hospital, the need for health education and actions directed at their singularities. Established this objective reality we proposed a model of Care Management that consists an adequate flowchart to listen the hospitalized with tuberculosis, presenting the nurse of the Department of Epidemiology as the matrix support and the nurse of the wards as conductor of the case, that has the responsibility of nursing consultation in the hospital and the directed contact with the nurses from PHC, where they'll communicate the case and pre-scheduling nursing consultation to the user that is getting high. It is believed that with the implementation of this model will be integration between levels of care, which enables improved planning and conducting the monitoring of tuberculosis patients, meeting their health needs adequately, with higher odds of adherence to treatment and consequent reduction in dropout rates.

Pseudoxanthoma elasticum: report of two cases.

Pseudoxanthoma elasticum is a rare inherited multisystem disorder that is characterized by a pathological mineralization of the elastic connective tissue, which involves predominantly the skin, eyes and cardiovascular system. Its cause lies on mutations in the ABCC6 gene, which lead to reduction or absence of the transmembrane transport ADP dependent protein (MRP6), causing an accumulation of extracellular material and subsequent deposition of calcium and other minerals in the elastic tissue. The authors report two cases of pseudoxanthoma elasticum, emphasizing its major clinical features and the importance of early diagnosis of the disorder, aiming for adequate therapeutic management of associated complications.

Federalism and health policy: the intergovernmental committees in Brazil.

OBJECTIVE: To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states. METHODS: The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low. RESULTS: Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees' ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast. CONCLUSIONS: The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.

Pseudoxanthoma elasticum: report of two cases

Pseudoxanthoma elasticum is a rare inherited multisystem disorder that is characterized by a pathological mineralization of the elastic connective tissue, which involves predominantly the skin, eyes and cardiovascular system. Its cause lies on mutations in the ABCC6 gene, which lead to reduction or absence of the transmembrane transport ADP dependent protein (MRP6), causing an accumulation of extracellular material and subsequent deposition of calcium and other minerals in the elastic tissue. The authors report two cases of pseudoxanthoma elasticum, emphasizing its major clinical features and the importance of early diagnosis of the disorder, aiming for adequate therapeutic management of associated complications.