Análise de Custo-Efetividade da Terapia com Evolocumabe em Pacientes com Alto Risco de Eventos Cardiovasculares no Contexto do SUS - Brasil / Cost-Effectiveness Analysis of Evolocumab Therapy in Patients at High Risk of Cardiovascular Events in the Context of the Brazilian Unified Health System

Resumo Fundamento: Em associação às estatinas, os inibidores da pró-proteína convertase subtilisina/kexina tipo 9 (PCSK9) demonstraram ser eficazes na redução de eventos cardiovasculares em pacientes de alto risco. Objetivo: Analisar a custo-efetividade da implementação de evolocumabe para pacientes com alto risco de eventos cardiovasculares no contexto do Sistema Único de Saúde (SUS) no Brasil. Métodos: Um modelo de Markov foi utilizado, baseando-se em uma amostra ambulatorial de pacientes com doença arterial coronariana. Os desfechos primários analisados foram infarto agudo do miocárdio, acidente vascular cerebral isquêmico (AVCi), revascularização do miocárdio e morte cardiovascular. O resultado foi expresso por meio da razão de custo-efetividade incremental (RCEI), considerando-se uma taxa de desconto de 5% ao ano, e uma análise de sensibilidade foi realizada, tendo em vista a imprecisão de valores. Resultados: Selecionaram-se 61 pacientes com risco cardiovascular estimado em 35% em 10 anos, se em uso de atorvastatina 80mg/dia, e em 22,75%, se adicionado o evolocumabe. O custo global por paciente no período de 10 anos foi de R$ 46.522,44 no grupo em monoterapia com atorvastatina versus R$ 236.141,85 na terapia combinada, com uma efetividade global de 0,54 e 0,73, respectivamente. Isso resultou em uma RCEI R$ 1.011.188,07 (R$ 864.498,95 a R$ 1.296.748,43) por desfecho cardiovascular evitado. Conclusões: Apesar de não existirem padrões nacionais para custo-efetividade, os dados encontrados sugerem que a estratégia de associação do evolocumabe à terapia com estatina não é, no momento, custo-efetiva.

Abstract Background: Hypertrophic cardiomyopathy (HCM) and left ventricular hypertrophy (LVH) secondary to systemic hypertension (HTN) may be associated with left atrial (LA) functional abnormalities. Objectives: We aimed to characterize LA mechanics in HCM and HTN and determine any correlation with the extent of left ventricular (LV) fibrosis measured by cardiac magnetic resonance (CMR) in HCM patients. Methods: Two-dimensional speckle tracking-derived longitudinal LA function was acquired from apical views in 60 HCM patients, 60 HTN patients, and 34 age-matched controls. HCM patients also underwent CMR, with measurement of late gadolinium enhancement (LGE) extension. Association with LA strain parameters was analyzed. Statistical significance was set at p<0.05. Results: Mean LV ejection fraction was not different between the groups. The E/e' ratio was impaired in the HCM group and preserved in the control group. LA mechanics was significantly reduced in HCM, compared to the HTN group. LA strain rate in reservoir (LASRr) and in contractile (LASRct) phases were the best discriminators of HCM, with an area under the curve (AUC) of 0.8, followed by LA strain in reservoir phase (LASr) (AUC 0.76). LASRr and LASR-ct had high specificity (89% and 91%, respectively) and LASr had sensitivity of 80%. A decrease in 2.79% of LA strain rate in conduit phase (LASRcd) predicted an increase of 1cm in LGE extension (r2=0.42, β 2.79, p=0.027). Conclusions: LASRr and LASRct were the best discriminators for LVH secondary to HCM. LASRcd predicted the degree of LV fibrosis assessed by CMR. These findings suggest that LA mechanics is a potential predictor of disease severity in HCM.

The role of the State, the private sector and the social sector in the different health political cycles in Portugal / O papel do Estado, do setor privado e do setor social nos diferentes ciclos políticos de saúde em Portugal

Abstract The Portuguese health system comprises three critical sectors: The State, which intervenes as a regulator of the entire system, and as a planner, provider, and financer of the National Health Service (NHS); the social sector, with a relevant intervention, mainly in continued care; and the private sector, with an essential role in the provision of some types of care. During the last forty years, the State, social, and private sectors' roles have changed either in its definition or terms of the relationship between them. In general, it is possible to identify, and we shall present them in this opinion article, eight political cycles that reflect the political contexts in Portugal, and, consequently, the ideological framework of each cycle.

Resumo O sistema de saúde português é constituído por três importantes setores: o Estado, que intervém como regulador de todo o sistema, como planeador, como prestador e financiador do Serviço Nacional de Saúde (SNS); o setor social, com relevante intervenção, principalmente, nos cuidados continuados; e o setor privado, com importante papel na prestação de alguns tipos de cuidados. Durante os últimos 40 anos, os papéis do Estado, do setor social e do setor privado mudaram, quer na sua definição, quer nas relações entre eles. De um modo geral, é possível identificar, e serão apresentados neste artigo de opinião, oito ciclos políticos que refletem os contextos políticos em Portugal e, consequentemente, o enquadramento ideológico de cada um deles.

A relevância de um ecossistema tecnológico no enfrentamento à Covid-19 no Sistema Único de Saúde: o caso do Rio Grande do Norte, Brasil / The relevance a technology ecosystem in the Brazilian National Health Service's Covid-19 response: the case of Rio Grande do Norte, Brazil

Resumo É inegável o papel dos avanços tecnológicos para o fortalecimento da saúde. No tocante às tecnologias digitais, trata do uso crescente dos sistemas de informação e análise de dados em saúde nas ações de preparo, vigilância e resposta a surtos epidemiológicos, tema abordado neste artigo no contexto da pandemia provocada pelo vírus Sars-CoV-2 no estado do Rio Grande do Norte. Este estudo parte do pressuposto de que é possível potencializar a gestão da resposta à Covid-19 por meio da saúde digital. Assim, a pesquisa desenvolveu um Ecossistema tecnológico que integra diferentes sistemas de informação para atender as necessidades previstas nas normativas internacionais frente à pandemia. Este artigo descreve, além do Ecossistema e sua estrutura, um conjunto de análises sobre a aplicação desse dispositivo por diversos atores institucionais. O Ecossistema foi a principal ferramenta em uso no estado para o processo decisório em resposta à Covid-19, sendo um modelo para a intervenção de saúde digital no Sistema Único de Saúde. A experiência do Rio Grande do Norte reúne, portanto, elementos que contribuem para os estudos sobre resiliência de sistemas e análises de políticas públicas em saúde em situações de emergência.

Abstract Technological advances play an undeniable role in strengthening health systems. With regard to digital technologies, information systems and the analysis of health data are playing a growing role in health surveillance and preparing for and responding to disease outbreaks, the theme addressed by this article within the context of the Covid-19 pandemic in the State of Rio Grande do Norte. This study departs from the assumption that digital health interventions can increase Covid-19 response capacity. We developed a technology ecosystem that integrates different information systems to meet the needs outlined in international regulations governing the response to the pandemic. In addition to the main elements of the ecosystem, this article describes the application of this instrument by different institutional actors. The main decision making tool used in the state government's Covid-19 response, the ecosystem is a model for digital health interventions in Brazil's national health service. This experience in Rio Grande do Norte brings together elements that can contribute to studies investigating the resilience of health systems and analyzing health policies in emergency situations.

Puntaje total, calificación médica nacional y cupos según programa de especialidad en el Concurso de Ingreso al Sistema Nacional de Servicios de Salud. Período 2017-2019 / National health services system entrance contest for specialties in Chile. Quotas and scores obtained by applicants

Among the several programs that allow access to medical specialization in Chile, the National Health Services System Entrance Contest (CONISS) is held annually for newly graduated physicians, which has a high number of applicants. The academic qualifications expressed as National Medical Qualification (CMN) are the main item of the scoring system. We reviewed the total scores and the CMN of the different medical specialization programs that exist in the country, which constitutes novel and relevant information for future medical graduates interested in applying to the program. In addition, the quotas of the different programs are reported, expressed as total, free, and used quotas.

Sistema Nacional de Saúde britânico: trajetória de reformas, 1990-2002 / Sistema Nacional de Salud británico: trayectoria de reformas, 1990-2002 / The British National Health Service: a history of reforms, 1990-2002

Resumo: Nas últimas décadas, assistimos importantes transformações nos serviços públicos que implicam mudanças no papel do Estado como agente central no processo de regulação das relações público-privado e na definição dos níveis de financiamento público. As propostas de reforma dos sistemas de saúde formam parte do processo de transformações sociais que afetaram os diferentes países. No entanto, as mudanças na articulação das diferentes dimensões são resultado tanto de processos amplos de transformação social como também de experiências e temporalidades específicas, fundamentais para entender os resultados desse processo. O Sistema Nacional de Saúde britânico (NHS) passou nas últimas décadas pelo processo de reforma mais importante desde a sua criação em 1948. Esse processo começou com um conjunto de medidas implantadas pelo governo conservador em 1991, mas que foram continuadas pelas alterações realizadas em 1997 e em 2002. Ao analisar a reforma realizada no NHS, para além de aportar elementos que permitam compreender o debate atual proporcionado pelas iniciativas lideradas por Boris Johnson que visam a empreender nova reforma no NHS, a partir de 2021, é possível encontrar convergências com outras propostas de reforma de sistemas públicos de saúde, que se inspiraram em sua conformação no modelo britânico, como por exemplo no caso do Brasil. O objetivo do presente texto é discutir e analisar um caso de reforma no sistema de saúde que pode ser considerado como paradigmático no desenvolvimento de grandes tendências na área. O artigo busca analisar especificamente o processo de reformas realizadas, a partir da década de 1990, no NHS, e suas consequências do ponto de vista da reestruturação do sistema de saúde.

Resumen: En las últimas décadas asistimos a importantes transformaciones en los servicios públicos que implican cambios en el papel del Estado, como agente central en el proceso de regulación de las relaciones público-privadas, así como en la definición de los niveles de financiación pública. Las propuestas de reforma de los sistemas de salud forman parte del proceso de transformaciones sociales que afectaron a diferentes países. No obstante, los cambios en la coordinación de las diferentes dimensiones son resultado, tanto de procesos amplios de transformación social, como también de experiencias y factores temporales específicos fundamentales para entender los resultados de ese proceso. El Servicio Nacional de Salud británico (NHS) pasó en las últimas décadas por el proceso de reforma más importante desde su creación en 1948. Este processo comenzó con un conjunto de medidas implementadas por el gobierno conservador en 1991, pero que continuaron con las modificaciones realizadas en 1997 y en 2002. Al analizar la reforma realizada en el NHS, además de aportar elementos que permitan comprender el debate actual, debido a las iniciativas lideradas por Boris Johnson que tienen como objetivo emprender una nueva reforma en el NHS, a partir de 2021, es posible encontrar convergencias con otras propuestas de reforma de sistemas públicos de salud, que se inspiraron en su conformación en el modelo británico, como, por ejemplo, en el caso de Brasil. El objetivo de este trabajo es discutir y analizar un caso de reforma en un sistema de salud que puede ser considerado como paradigmático en el desarrollo de grandes tendencias en el área. El texto busca analizar específicamente el processo de reformas realizadas, a partir de la década de 1990, en el NHS, y sus consecuencias desde el punto de vista de la reestruturación del sistema de salud.

Abstract: Recent decades have witnessed important transformations in public services that involve changes in the State's role as central agent in the regulation of public-private relations and the definition of levels of public financing. Health system reform proposals are part of the process of social transformations that have affected various nations. However, changes in the linkage between different dimensions are the result of both broad processes of social transformation and specific experiences and timelines, essential for understanding the results of this process. In recent decades, the British National Health Service (NHS) underwent the most important reform process since its creation in 1948. This process began with a set of measures implemented by the Conservative government in 1991, which were continued through alterations introduced in 1997 and 2002. An analysis of the NHS reform not only provides elements for understanding the current debate sparked by the initiatives led by Boris Johnson and aimed at a new NHS reform starting in 2021; such analysis also allows identifying convergences with other reform proposals in public health systems that were shaped under inspiration from the British model, as in the case of Brazil. The current article aims to discuss and analyse a case of health system reform that can be considered paradigmatic for the development of major trends in this field. The article seeks to specifically analyse the reform processes carried out since the 1990s in the NHS and their consequences for the health system's restructuring.

La migración en cuarentena: una aproximación a la noción de sujeto político en tiempos del bienestar digital / Quarantine migration: an approach to the notion of a political subject in times of digital well-being

A partir de la primera pandemia experimentada en simultáneo a nivel global, se postula una reflexión sobre el sentido de las respuestas en el contexto de la sociedad global del 2020. Dos reflexiones se entretejen en este escrito. La primera tiene que ver con el proceso de despolitización y des-ciudadanización que se puede experimentar en momentos como los actuales en los cuales una crisis de legitimidad se cruza con una situación que demanda un estado de excepción. La segunda reflexión tiene que ver con el establecimiento de la manifestación tecnológica del ser humano como signo vital para su cuidado control. Se concluye conjugando ambas reflexiones en torno a la constitución de un nuevo dispositivo social humano en el aparato productivo y de seguridad en el presente.

At the emergence of a first contagious disease experimented almost simultaneously around the globe, a reflection on the meaning of the responses from the national states and the global society in 2020 is presented. There are two threads intertwined. The first one is a process of de-politization and loss of citizenship that can occur at the time that state of exception are considered as the appropriate answer in societues facing legitimacy crisis. The second one is referred to the establishment of a technological-driven approach of human being as subject of care and control. Both reflections are merfed around the appearance of a new social-human device in the productive and policy making at the present.

A enfermagem em Portugal aos 40 anos do Serviço Nacional de Saúde / Nursing in Portugal in the National Health Service at 40

Resumo Retratamos a evolução da enfermagem em Portugal desde a criação do Serviço Nacional de Saúde (SNS) em 1979, focando sobre os efetivos, a formação, as condições de trabalho, a carreira, e a organização profissional. Utilizamos a literatura sobre a evolução do sector da saúde em Portugal, e fontes de dados estatísticos da Ordem dos Enfermeiros e do SNS. Nos últimos 40 anos, o número de enfermeiros aumentou de 233%, mas o rácio enfermeiro/médico só passou de 1.15 para 1.4. A maioria exerce funções nos hospitais, apesar dos repetidos compromissos políticos a favor da expansão dos cuidados de saúde primários. No SNS, 55% são funcionários públicos com contrato por tempo indeterminado; os outros detêm um contrato individual de trabalho de direito privado. O curso de licenciatura em enfermagem é oferecido em 20 escolas do sector público e 16 do sector privado. Em 2019, a carreira de enfermagem foi revista em 3 categorias: enfermeiro, enfermeiro especialista e enfermeiro gestor. Apesar de queixas em relação as condições de trabalho, a remuneração e ao progresso na carreira, os enfermeiros continuam moderadamente satisfeitos. O papel do enfermeiro, mudou pouco ao longo dos anos e há resistência por parte da Ordem dos Médicos à sua expansão.

Abstract We describe the development of nursing in Portugal since the creation of the National Health Service (SNS) in 1979, focusing on staff numbers, education, work conditions, career, and professional organization. We used the literature on the evolution of the Portuguese health sector and statistical data from the Nursing Council and the SNS. The number of nurses grew by 233% in the last 40 years, but the nurse/physician ratio only increased from 1.15 to 1.4. Most work in hospitals, despite repeated political commitments to expand primary health care. In the SNS, 55% are public servants, and the others are employed through private law contracts. The basic nursing course is currently offered in 20 public and 16 private institutions. In 2019, the career structure was revised and now comprises three categories: nurse, specialist nurse, nurse manager. Nurses remain moderately satisfied despite complaints about working conditions, remuneration, and lack of career progress. Nurses' role barely changed over the years, and the Medical Association is resisting to its expansion.

Acesso aos cuidados de saúde em Portugal no rescaldo da crise. Nem tudo é dinheiro? / Access to healthcare in Portugal in the wake of the crisis. Not everything is money? / Acceso a los cuidados de salud en Portugal después de la crisis. ¿No todo es dinero?

As necessidades de cuidados de saúde não satisfeitas têm sido usadas para avaliar o acesso a cuidados de saúde. Em cenários de recessão e restrições financeiras impostas às políticas públicas, é importante identificar que fatores, para além do rendimento, podem ser usados para mitigar as barreiras no acesso. Este é o objetivo deste artigo, para o caso português, durante o rescaldo da crise. Usaram-se 17.698 observações do 5º Inquérito Nacional de Saúde (2014). Analisaram-se as necessidades não satisfeitas (autorreportadas) para as consultas e tratamentos médicos, cuidados de saúde dentários e medicamentos prescritos. Recorreu-se ao modelo de seleção bivariado, acomodando o fato de as necessidades não satisfeitas apenas poderem ser observadas na subamostra de indivíduos que sentiram necessidade de cuidados de saúde. O risco de necessidades de cuidados de saúde não satisfeitas diminui para rendimentos e níveis de educação mais altos bem como no grupo dos idosos e homens. Beneficiar apenas do Serviço Nacional de Saúde aumenta o risco de necessidades não satisfeitas na saúde oral. A ausência de um círculo de pessoas próximas a quem pedir ajuda e a falta de confiança nos outros tornam mais prováveis as necessidades de cuidados de saúde não satisfeitas. Mais saúde diminui o risco de necessidades de cuidados não satisfeitas. Sendo o rendimento um importante preditor das necessidades não satisfeitas, encontrou-se impacto de outros fatores como sexo, idade e educação. Participar em grupos informais reduz a probabilidade de necessidades não satisfeitas. Aqueles com mais necessidades de cuidados de saúde acabam por sofrer um risco acrescido por essa via.

Unmet healthcare needs have been used to assess access to healthcare. In scenarios of recession and financial constraints on public policies, it is important to identify which factors besides income can be used to mitigate barriers to access. This was the focus of our study on Portugal's case in the wake of the crisis. We used 17,698 observations from the 5th National Health Survey (2014). We analyzed self-reported unmet needs for medical appointments and treatments, dental healthcare, and prescribed medications. We used a bivariate selection model, considering the fact that unmet needs could only be observed in the subsample of individuals that felt the need for healthcare. The risk of unmet needs for healthcare decreased in individuals with higher income and schooling levels and in the elderly and men. Exclusive coverage by the National Health Service increased the risk of unmet dental healthcare needs. The absence of a circle of close friends to whom one can ask for help and lack of trust in others increased the likelihood of unmet healthcare needs. Better health decreased the risk of unmet needs. While income is an important predictor of unmet needs, we found the impact of other factors such as gender, age, and education. Participation in informal groups reduced the likelihood of unmet needs. Individuals with more healthcare needs end up suffering additional risk.

Las necesidades de cuidados de salud sin satisfacer se han usado para evaluar el acceso a los cuidados de salud. En escenarios de recesión y restricciones financieras, impuestas a las políticas públicas, es importante identificar qué factores, más allá del rendimiento, pueden ser usados para mitigar las barreras en el acceso. Este es nuestro objetivo para el caso portugués tras la crisis. Se realizaron 17.698 observaciones de la 5ª Encuesta Nacional de Salud (2014). Analizamos las necesidades no satisfechas (auto-informadas) en consultas y tratamientos médicos, cuidados dentales de salud y medicamentos prescritos. Recurrimos al modelo de selección bivariado, ajustando el hecho de que las necesidades no satisfechas solamente podrían ser observadas en la submuestra de individuos que sintieron la necesidad de cuidados de salud. El riesgo de necesidades de cuidados de salud no satisfechas disminuye en el caso de las rentas y niveles de educación más altos, así como en el grupo de los ancianos y hombres. Beneficiar solamente el Servicio Nacional de Salud aumenta el riesgo de necesidades no satisfechas en la salud oral. La ausencia de un círculo de personas cercanas a quién pedir ayuda y la falta de confianza en los otros hacen más probables las necesidades de cuidados de salud no satisfechos. Más salud disminuye el riesgo de necesidades de cuidados no satisfechos. Siendo el rendimiento un importante predictor de las necesidades no satisfechas, encontramos impacto de otros factores como sexo, edad y educación. Participar en grupos informales reduce la probabilidad de necesidades no satisfechas. Aquellos con más necesidades de cuidados de salud acaban por sufrir un riesgo más grande por esta vía.

Public health nursing: regulation and public health policies / La enfermería de salud pública: regulación y las políticas públicas de salud / A enfermagem de saúde pública: regulação e políticas públicas de saúde

ABSTRACT Objective: To analyze regulation and public policies related to nursing and the specialist nurse in community and public health nursing. Methods: Analysis of the legal and normative framework of community and public health nursing in Portugal, as well as current public health policies, regarding the competences and intervention of this nurse, articulated with the attributions of the Public Health Unit. Results: The intervention of this nurse deserves a broad reflection, in the sense of maximizing the activities of community and public health, essential for the implementation of public policies and obtaining health gains. Final considerations: This nurse has competences foreseen in the regulations and standards for public health interventions, in line with the attributions of the Public Health Unit, of the National Health Service, in which specialties are identified for their performance in the current structure.

RESUMEN Objetivo: Analizar la regulación y las políticas públicas relacionadas con la enfermería y el enfermero especializado en salud comunitaria y enfermería en salud pública. Métodos: Análisis del marco legal y normativo de la enfermería de salud pública y comunitaria en Portugal, así como las políticas actuales de salud pública, con respecto a las habilidades e intervención de este enfermero, articuladas con los deberes de la Unidad de Salud Pública. Resultados: La intervención de este enfermero merece una amplia reflexión, en el sentido de maximizar las actividades de salud comunitaria y pública, fundamentales para la implementación de políticas públicas y la obtención de beneficios para la salud. Consideraciones finales: Este enfermero tiene las competencias previstas en los reglamentos y normas para las intervenciones de salud pública, de acuerdo con las obligaciones de la Unidad de Salud Pública, del Servicio Nacional de Salud, en el que se identifican especialidades por su desempeño en la estructura actual.

RESUMO Objetivo: Analisar a regulação e as políticas públicas relativas à enfermagem e ao enfermeiro especialista em enfermagem de saúde comunitária e de saúde pública. Método: Análise do enquadramento legal e normativo da enfermagem de saúde comunitária e pública em Portugal, bem como das atuais políticas públicas de saúde, no que diz respeito às competências e intervenção desse enfermeiro, articuladas com as atribuições da Unidade de Saúde Pública. Resultados: A intervenção desse enfermeiro merece uma reflexão alargada, no sentido da maximização das atividades de âmbito comunitário e de saúde pública, fundamental para a implementação das políticas públicas e obtenção de ganhos em saúde. Considerações finais: Esse enfermeiro tem previstas competências nos regulamentos e normas para intervenções de saúde pública, em linha com as atribuições da Unidade de Saúde Pública, do Serviço Nacional de Saúde, em que se identificam especialidades para o seu desempenho na atual estrutura.

Trabajo, miserias y recompensas: Asistentes sociales, enfermeras y matronas en la construcción de la política sanitaria chilena a mediados del siglo XX / Work, miseries and rewards: Social workers, nurses and midwives in the construction of Chilean health policy in the mid-twentieth century

RESUMEN El artículo busca mostrar el aporte realizado por asistentes sociales, enfermeras y matronas a la exitosa política de salud pública de mediados del siglo XX en Chile, llevada a cabo por el Servicio Nacional de Salud en el marco de un modelo de desarrollo estatista y benefactor. Se han utilizado fuentes documentales de diverso tipo y testimonios de asistentes, enfermeras y matronas entrevistadas para la investigación. Las profesionales, encargadas fundamentalmente de tareas operativas y en contacto directo con la población usuaria del Servicio Nacional de Salud, fueron artífices de la instalación de una verdadera pedagogía sanitaria que cambió el patrón epidemiológico y trastocó la cultura de la población chilena, incidiendo en la valoración del autocuidado y la prevención. Como ejecutoras, sortearon las dificultades inherentes al trabajo burocratizado de los programas sociales pero, a la vez, recibieron gratificaciones diversas de tipo afectivo y altruista, que las hizo sentirse protagonistas de una construcción histórica.

ABSTRACT The article seeks to show the contribution made by social workers, nurses and midwives to the successful public health policy implemented in the mid-twentieth century in Chile by the National Health Service in the context of a statist and welfare development model. Documentary sources of different types and testimonies of social workers, nurses and midwives who were interviewed for this research were used. These professionals, mainly responsible for operational tasks and in close contact with the users of the National Health Service, were responsible for the establishment of a true health pedagogy that changed the epidemiological pattern and touched the culture of the Chilean population, influencing its estimation of self-care and prevention. As executors of the policy, they avoided the difficulties inherent to the bureaucratized work of social programs, gaining, at the same time, satisfaction at the affective and altruistic level, which made them feel like the protagonists of a historical process.

La Medicina Estatal en América Latina (1880-1930) / State-owned medicine in Latin America/1 (1880-1930)

Durante las últimas décadas del siglo XXI y las tres primeras de este siglo, en América Latina se registra la creación de órganos de sanidad de carácter nacional. La centralización de los servicios de sanidad se explicaría como parte de un proceso más amplio de transformación de la superestructura jurídico-política del Estado, transformación requerida para que esta correspondiera con la fase inicial de la implantación del capitalismo y realizada en los países de la América Latina por la burguesía surgida de la producción capitalista de materias primas y de productos alimenticios destinados al mercado exterior. El surgimiento de la medicina estatal fue posible también debido a los cambios que se habían operado en el campo médico como resultado de su vinculación con el proceso de producción capitalista y que la afecta en su conceptualización, en su práctica y en la forma como organiza sus actividades. Por lo tanto, el análisis de la medicina estatal en el período de 1880 a 1930 deberá iniciarse con una presentación breve de las formas de vinculación de la medicina en el capitalismo y su transformación conceptual y técnica. El segundo paso en la exposición, bajo el título de El surgimiento de la Medicina Estatal, trata sobre los factores que llevan a la creación de órganos estatales de sanidad, considerando a la sanidad, hasta cierto punto, como sinónimo de medicina estatal ya que la sanidad adquiere para el Estado una importancia mayor que otros tipos de prácticas médicas. El tercero y último capítulo se refiere a la forma como se desarrolló la medicina estatal, en el período considerado, finalizando con las transformaciones que se producen en el campo de la atención médica y que se han de desenvolver en todas sus posibilidades a partir de 1930. LA MEDICINA EN EL CAPITALISMO En el modo de producción capitalista la medicina se desplaza del espacio religioso y político, donde se encuentra en los modos de producción precapitalistas, para articularse con el proceso de producción económica. En este modo de producción el trabajador pierde el control y la propiedad de los medios de trabajo y tiene, en consecuencia, que vender su fuerza de trabajo para sobrevivir. Entonces, la región económica juega el papel dominante en la estructura social y, también, a éste se vincula la medicina, variando...(AU)

Gênese da atenção domiciliária no Brasil no início do século XX / Génesis de la atención domiciliaria en Brasil al inicio del siglo XX / Genesis of home care in Brazil at the start of the twentieth century

RESUMO Objetivo problematizar as condições de possibilidade para o aparecimento da atenção domiciliária no início do século XX no Brasil. Método estudo de inspiração genealógica sobre a atenção domiciliária. O material empírico foi constituído por dois documentos legais sobre o tema publicados no Diário Oficial. A análise documental utilizou as ferramentas analíticas poder, poder disciplinar e biopolítica, inspiradas em Foucault. Resultados foram elaboradas duas categorias: “Vigilância no domicílio: as enfermeiras visitadoras e a tuberculose” e “Registros: o aparelho político e econômico”. Considerações finais A tuberculose, a nova profissão das enfermeiras visitadoras, os registros produzidos pela vigilância e a análise minuciosa das cidades conferiram à atenção domiciliária um caráter de vigilância, inspeção e controle voltado a conduzir as condutas dos indivíduos.

RESUMEN Objetivo problematizar las condiciones de posibilidad para el aparecimiento de la atención domiciliaria al inicio del siglo XX. Método se trata de un estudio de inspiración genealógica sobre atención domiciliaria. El material empírico fue constituido por documentos legales sobre el tema, publicados en el Diario Oficial. El análisis documental utilizó las herramientas analíticas poder, poder disciplinar y biopolítica, inspiradas en Foucault. Resultados fueron elaboradas dos categorías analíticas, “vigilancia en el domicilio: enfermeras visitadoras y la tuberculosis” y “registros: aparato político y económico”. Consideraciones finales la tuberculosis, la nueva profesión de las enfermeras visitadoras, los registros producidos por la vigilancia, y el análisis minucioso de las ciudades configuran la atención domiciliaria con carácter de vigilancia, inspección y control para mejor conducir las conductas de individuos.

ABSTRACT Objective to discuss the conditions that enabled home care at the beginning of the twentieth century. Method study of the genealogic inspiration on home care. The empirical material consisted of legal documents on the subject that were published in the Official Journal. The documents were studied using analytical tools, such as Power, Discipline and Biopolitics, which were inspired in Foucault. Results two analytical categories were established, “home inspection: visiting nurses and tuberculosis” and “records: political and economic apparatus”. Final considerations tuberculosis, the new profession of visiting nurses, inspection records and the detailed analysis of the cities grant home care a nature of surveillance, inspection and control to conduct the behaviour of individuals.

Evaluation of Pulmonary Reperfusion Injury in Rats Undergoing Mesenteric Ischemia and Reperfusion and Protective Effect of Postconditioning on this Process

ABSTRACT INTRODUCTION: Some publications have demonstrated the presence of lung reperfusion injury in mesenteric ischemia and reperfusion (I/R), but under to diverse methods. Postconditioning has been recognized as effective in preventing reperfusion injury in various organs and tissues. However, its effectiveness has not been evaluated in the prevention of lung reperfusion injury after mesenteric ischemia and reperfusion. OBJECTIVE: To evaluate the presence of pulmonary reperfusion injury and the protective effect of ischemic postconditioning on lung parenchyma in rats submitted to mesenteric ischemia and reperfusion. METHODS: Thirty Wistar rats were distributed into three groups: group A (10 rats), which was held mesenteric ischemia (30 minutes) and reperfusion (60 minutes); group B (10 rats), ischemia and reperfusion, interspersed by postconditioning with two alternating cycles of reperfusion and reocclusion, for two minutes each; and group C (10 rats), ischemia and reperfusion interleaved by postconditioning with four alternating cycles of reperfusion and reocclusion of 30 seconds each. Finally, it was resected the upper lung lobe for histological analysis. RESULTS: There were mild lung lesions (grade 1) in all samples. There was no statistical difference between groups 1 and 2 (P >0.05). CONCLUSION: The mesenteric ischemia and reperfusion in rats for thirty and sixty minutes, respectively, caused mild reperfusion injury in lung. Postconditioning was not able to minimize the remote reperfusion injury and there was no difference comparing two cycles of two minutes with four cycles of 30 seconds.

Cardiovascular Surgery Residency Program: Training Coronary Anastomosis Using the Arroyo Simulator and UNIFESP Models

ABSTRACT OBJECTIVE: Engage the UNIFESP Cardiovascular Surgery residents in coronary anastomosis, assess their skills and certify results, using the Arroyo Anastomosis Simulator and UNIFESP surgical models. METHODS: First to 6th year residents attended a weekly program of technical training in coronary anastomosis, using 4 simulation models: 1. Arroyo simulator; 2. Dummy with a plastic heart; 3. Dummy with a bovine heart; and 4. Dummy with a beating pig heart. The assessment test was comprised of 10 items, using a scale from 1 to 5 points in each of them, creating a global score of 50 points maximum. RESULTS: The technical performance of the candidate showed improvement in all items, especially manual skill and technical progress, critical sense of the work performed, confidence in the procedure and reduction of the time needed to perform the anastomosis after 12 weeks practice. In response to the multiplicity of factors that currently influence the cardiovascular surgeon training, there have been combined efforts to reform the practices of surgical medical training. CONCLUSION: 1 - The four models of simulators offer a considerable contribution to the field of cardiovascular surgery, improving the skill and dexterity of the surgeon in training. 2 - Residents have shown interest in training and cooperate in the development of innovative procedures for surgical medical training in the art.

Factors Associated With the Development of Chronic Post-Sternotomy Pain: a Case-Control Study

ABSTRACT OBJECTIVE: The aim of the present study was to investigate the factors associated with chronic post-sternotomy pain in heart surgery patients. METHODS: Between January 2013 and February 2014, we evaluated 453 patients with >6 months post-sternotomy for cardiac surgery at a surgical outpatient clinic. The patients were allocated into a group with chronic post-sternotomy pain (n=178) and a control group without pain (n=275). The groups were compared for potential predictors of chronic post-sternotomy pain. We used Cox proportional hazards regression to determine which independent variables were associated with the development of chronic post-sternotomy pain. RESULTS: In total, 39.29% of the patients had chronic poststernotomy pain. The following factors were significantly associated with chronic post-sternotomy pain: (a) use of the internal thoracic artery in coronary bypass grafting (P =0.009; HR=1.39; 95% CI, 1.08 to 1.80); (b) a history of antidepressant use (P =0.0001; HR=2.40; 95% CI, 1.74 to 3.32); (c) hypothyroidism (P =0.01; HR=1.27; 95% CI, 1.03 to 1.56); (d) surgical wound complication (P =0.01; HR=1.69; 95% CI, 1.08 to 2.63), and (e) patients on disability benefits or scheduled for a consultative medical examination for retirement (P =0.0002; HR=2.05; 95% CI, 1.40 to 3.02). CONCLUSION: The factors associated with chronic poststernotomy pain were: use of the internal thoracic artery; use of antidepressants; hypothyroidism; surgical wound complication, and patients on disability benefits or scheduled for a consultative examination.

Adjunctive Hyperbaric Oxygen Therapy or Alone Antibiotherapy? Methicillin Resistant Staphylococcus aureus Mediastinitis in a Rat Model

ABSTRACT OBJECTIVE: In the post-sternotomy mediastinitis patients, Staphylococcus aureus is the pathogenic microorganism encountered most often. In our study, we aimed to determine the efficacy of antibiotic treatment with vancomycin and tigecycline, alone or in combination with hyperbaric oxygen treatment, on bacterial elimination in experimental S. aureus mediastinitis. METHODS: Forty-nine adult female Wistar rats were used. They were randomly divided into seven groups, as follows: non-contaminated, contaminated control, vancomycin, tigecycline, hyperbaric oxygen, hyperbaric oxygen + vancomycin and hyperbaric oxygen + tigecycline. The vancomycin rat group received 10 mg/kg/day of vancomycin twice a day through intramuscular injection. The tigecycline group rats received 7 mg/kg/day of tigecycline twice a day through intraperitoneal injection. The hyperbaric oxygen group underwent 90 min sessions of 100% oxygen at 2.5 atm pressure. Treatment continued for 7 days. Twelve hours after the end of treatment, tissue samples were obtained from the upper part of the sternum for bacterial count assessment. RESULTS: When the quantitative bacterial counts of the untreated contaminated group were compared with those of the treated groups, a significant decrease was observed. However, comparing the antibiotic groups with the same antibiotic combined with hyperbaric oxygen, there was a significant reduction in microorganisms identified (P<0.05). Comparing hyperbaric oxygen used alone with the vancomycin and tigecycline groups, it was seen that the effect was not significant (P<0.05). CONCLUSION: We believe that the combination of hyperbaric oxygen with antibiotics had a significant effect on mediastinitis resulting from methicillin-resistant Staphylococcus aureus. Methicillin-resistant Staphylococcus aureus mediastinitis can be treated without requiring a multidrug combination, thereby reducing the medication dose and concomitantly decreasing the side effects.

Partial Left Ventriculectomy: Have Well-Succeeded Cases and Innovations in the Procedure Been Observed in the Last 12 Years?

ABSTRACT OBJECTIVE: In 1996, the Brazilian cardiovascular surgeon, Dr. Randas Batista, introduced a surgical technique called partial left ventriculectomy, where he admitted the possibility of reducing the diameter of the left ventricle through the sectioning of one section of its wall. After the publication of this study, thousands of case reports and procedure analysis have been published, and due to several disappointing results, many doctors and institutions failed to execute it. As the main objective of this study, stands out the search for success cases of ventriculectomy in the last 12 years and if during this period it was achieved some significant development in this procedure that allows obtaining lower mortality rate postoperatively. METHODS: Systematic review of indexed scientific literature over the past 12 years and the term "Partial Left Ventriculectomy". RESULTS: There has been a considerable number of reported successful cases and highly significant findings in regard to determining the most suitable region for the section, proper selection of the patients indicated to the procedure, including the influence of the coronary artery anatomy in the nomination procedure and the need for preservation of ventricular geometry to ensure better quality of ventricular contractions after the sectioning. CONCLUSION: This surgical procedure has been successfully performed, mainly in Japan, improvements in its efficiency were found and the need for a mathematical modeling of the slice to be severed is a prominent factor in many studies.

Experimental Study and Early Clinical Application Of a Sutureless Aortic Bioprosthesis

ABSTRACT INTRODUCTION: The conventional aortic valve replacement is the treatment of choice for symptomatic severe aortic stenosis. Transcatheter technique is a viable alternative with promising results for inoperable patients. Sutureless bioprostheses have shown benefits in high-risk patients, such as reduction of aortic clamping and cardiopulmonary bypass, decreasing risks and adverse effects. OBJECTIVE: The objective of this study was to experimentally evaluate the implantation of a novel balloon-expandable aortic valve with sutureless bioprosthesis in sheep and report the early clinical application. METHODS: The bioprosthesis is made of a metal frame and bovine pericardium leaflets, encapsulated in a catheter. The animals underwent left thoracotomy and the cardiopulmonary bypass was established. The sutureless bioprosthesis was deployed to the aortic valve, with 1/3 of the structure on the left ventricular face. Cardiopulmonary bypass, aortic clamping and deployment times were recorded. Echocardiograms were performed before, during and after the surgery. The bioprosthesis was initially implanted in an 85 year-old patient with aortic stenosis and high risk for conventional surgery, EuroSCORE 40 and multiple comorbidities. RESULTS: The sutureless bioprosthesis was rapidly deployed (50-170 seconds; average=95 seconds). The aortic clamping time ranged from 6-10 minutes, average of 7 minutes; the mean cardiopulmonary bypass time was 71 minutes. Bioprostheses were properly positioned without perivalvar leak. In the first operated patient the aortic clamp time was 39 minutes and the patient had good postoperative course. CONCLUSION: The deployment of the sutureless bioprosthesis was safe and effective, thereby representing a new alternative to conventional surgery or transcatheter in moderate- to high-risk patients with severe aortic stenosis.

Association of Angiotensin-Converting Enzyme Genotype, Insertion/Deletion Polymorphism and Saphenous Vein Graft Atherosclerosis in Iranian Patients

ABSTRACT OBJECTIVE: The aim of this study was to evaluate possible interactions among Angiotensin-I converting enzyme genotype, insertion/deletion polymorphism and atherosclerosis of vein grafts in Iranian patients, and characterize their clinical and demographic profile. METHODS: In this cross-sectional study, patients who underwent coronary artery bypass graft surgery more than five years ago, were included for angiographic analysis. Atherosclerosis was determined by quantitative angiography and adjusted Gensini score. The gene angiotensin converting enzyme I/D polymorphism was detected by polymerase chain reaction. RESULTS: A total of 102 patients participated in this study. Eighty-four patients were male. The frequency distribution of DD, ID and II polymorphism were 23.6%, 62.7% and 13.7% respectively. There were no differences among genotypic groups in age, sex, number of risk factors, number of vein grafts and months since bypass surgery. According to adjusted Gensini score [0.18±0.12 (II) vs. 0.11±0.09 (ID) and 0.1±0.09 (DD) P=0.021] the II genotype was associated with severity of vein graft atherosclerosis. CONCLUSION: Although there are conflicting results about gene angiotensin converting enzyme I/D polymorphism and the degree of venous bypass graft degeneration, this study suggests an association between ACE genotype II and atherosclerosis of saphenous vein grafts, however, large samples considering clinical, demographic and ethnic profile are necessary to confirm these results.