Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

Proposing an Affordable Plasma Device for Polymer Surface Modification and Microbial Inactivation.

This study proposes an affordable plasma device that utilizes a parallel-plate dielectric barrier discharge geometry with a metallic mesh electrode, featuring a straightforward 3D-printed design. Powered by a high-voltage supply adapted from a cosmetic plasma device, it operates on atmospheric air, eliminating the need for gas flux. Surface modification of polyethylene treated with this device was characterized and showed that the elemental composition after 15 min of plasma treatment decreased the amount of C to ~80 at% due to the insertion of O (~15 at%). Tested against Candida albicans and Staphylococcus aureus, the device achieved a reduction of over 99% in microbial load with exposure times ranging from 1 to 10 min. Simultaneously, the Vero cell viability remained consistently high, namely between 91% and 96% across exposure times. These results highlight this device's potential for the surface modification of materials and various infection-related applications, boasting affordability and facilitating effective antimicrobial interventions.

Comparison Between the Veillon and the Symons-Fanning CT Classification Systems for Otosclerosis.

OBJECTIVE: To analyze the correlation between outcomes of stapes surgery and preoperative and postoperative audiometric results with different radiological staging classifications such as the Veillon classification (VC) and the Symons-Fanning classification (SFC). STUDY DESIGN: Retrospective observational study. SETTING: One tertiary hospital center. PATIENTS: Adult patients submitted to stapes surgery due to otosclerosis from January 2017 to December 2022. INTERVENTION: Evaluation of different radiological classifications such as the VC and SFC. MAIN OUTCOME MEASURES: Preoperative and postoperative pure-tone audiometric data, outcomes of stapes surgery success (closure of the ABG, rates of AC threshold less than or equal to 30 dB), and postoperative sensorineural hearing loss. RESULTS: A total of 87 patients and 97 operated ears were included. The SFC was associated with preoperative BC (p = 0.041) and AC (p = 0.018) and postoperative BC (p = 0.026) with an increase in thresholds with higher radiological stages. The VC was associated with postoperative AC (p = 0.045) with an increase in AC thresholds with increasing radiological stages. Lastly, both the VC (p = 0.032) and the SFC (p = 0.023) were associated with a decrease in rates of postoperative AC thresholds ≤30 dB with higher radiological stages. CONCLUSIONS: The SFC seems to be more useful to predict preoperative AC and BC and postoperative BC. On the contrary, the VC was more useful to predict postoperative AC. Both scales were similarly associated with the rate of AC thresholds ≤30 dB.

From Shamans to Priests of Sekhmet: A Review of the Literature in Search for the Origins of Doctors in Ancient Egypt.

This review suggests that shamans were in charge of the healing process in pre-dynastic Egypt. After the unification of Lower and Upper Egypt by Narmer in 3100 BC, shamans evolved into the Sem priests, who were responsible for the king's health. With the change in Egyptian religion in the fourth dynasty (2613-2494 BC), Ra, the sun god, was revered as the supreme power, replacing the king. The emergence of mass festivities to celebrate Ra led to the priests of Sekhmet in the fifth dynasty (2494-2345 BC) checking the sanitation of bull meat that was provided to the populace in an attempt to avoid infectious epidemics. This seems to be the first recognition that disease might be transmitted from animals to humans. They used medical folklore, incantations, spells, and charms available at the House of Life, previously used by the lector priest. By 2487 BC, the first medical curative procedure was performed by Ni-Ankh-Sekhmet who cured the bleeding of a king's nose.

Effect of spirulina on risk of hospitalization among patients with COVID-19: the TOGETHER randomized trial.

BACKGROUND: Algae-derived nutraceuticals, such as spirulina, have been reported to have biological activities that may minimize clinical consequences to COVID-19 infections. OBJECTIVES: This study aimed to determine whether spirulina is an effective treatment for high-risk patients with early COVID-19 in an outpatient setting. METHODS: The TOGETHER trial is a placebo-controlled, randomized, platform trial conducted in Brazil. Eligible participants were symptomatic adults with a positive rapid test for SARS-CoV-2 older than 50 y or with a known risk factor for disease severity. Patients were randomly assigned to receive placebo or spirulina (1 g twice daily for 14 d). The primary end point was hospitalization defined as either retention in a COVID-19 emergency setting for >6 h or transfer to tertiary hospital owing to COVID-19 at 28 d. Secondary outcomes included time-to-hospitalization, mortality, and adverse drug reactions. We used a Bayesian framework to compare spirulina with placebo. RESULTS: We recruited 1126 participants, 569 randomly assigned to spirulina and 557 to placebo. The median age was 49.0 y, and 65.3% were female. The primary outcome occurred in 11.2% in the spirulina group and 8.1% in the placebo group (odds ratio [OR]: 1.24; 95% credible interval: 0.84, 1.86). There were no differences in emergency department visit (OR: 1.21; 95% credible interval: 0.81, 1.83), nor time to symptom relief (hazard ratio: 0.90; 95% credible interval: 0.79, 1.03). Spirulina also not demonstrate important treatment effects in the prespecified subgroups defined by age, sex, BMI, days since symptom onset, or vaccination status. CONCLUSIONS: Spirulina has no any clinical benefits as an outpatient therapy for COVID-19 compared with placebo with respect to reducing the retention in an emergency setting or COVID-19-related hospitalization. There are no differences between spirulina and placebo for other secondary outcomes. This trial was registered at clinicaltrials.gov as NCT04727424.

Factors Associated With Elder Abuse According to the Levels of Social Determinants in Brazil.

OBJECTIVE: The aim of this study was to analyze the factors associated with elder abuse according to the levels of social determinants. METHODOLOGY: This is a quantitative and multicentric study, with a cross-sectional cut. It was developed in two teaching hospitals in Paraíba, Brazil, with 323 older adults, from July 2019 to February 2020. Data were collected using the Hwalek-Sengstock Elder Abuse Screening Test and Conflict Tactics Scale-1 and then analyzed using descriptive and inferential statistics. RESULTS: There was a significant association between risk for violence and female gender (p = 0.004), residing with grandchildren (p = 0.025), and having four or more comorbidities (p < 0.00). Physical violence was associated with income (p = 0.048). A positive correlation was observed between the number of comorbidities and the risk for violence score (p < 0.001), psychological violence (p = 0.004), and physical violence (p = 0.005). The probability of presenting a risk to violence increased by 2.08 times for women, 1.03 times for those who were illiterate, and 7.03 times for those with four or more comorbidities. CONCLUSION: The social determinants of health that integrate the macrosystem, such as income and number of comorbidities, correlate with situations of violence.

Clinical Study of Photobiomodulation Effect at Postoperative Clefted Alveolar Ridge Bone Grafting.

This study aimed to evaluate photobiomodulation (PBM) adjunct effect on pain, swelling, and face temperature in individuals with oral cleft submitted to alveolar ridge bone grafting (ABG). The sample consisted of 46 patients with either incomplete or complete unilateral cleft lip and palate aged from 9 to 18 years, both sexes, who underwent ABG with chin donor area. Subjects were randomly divided into 3 groups: (1) Control (C): ABG (n=17); (2) PBM: ABG with PBM (n=14); (3) Simulated photobiomodulation (SPBM): ABG with SPBM (n=15). Aluminum Gallium Arsenide (GaAlAs) infrared laser was used at 808±10 nm and power of 100 mW±20%. GaAlAs infrared laser was applied on 14 points in the subject's face at 4J per point, at 2 times: Immediate postoperative period and 24 hours postoperative. The authors evaluated pain, swelling, and face temperature at 24 hours postoperative; at 7-day postoperative, the authors evaluated pain, medication use, and swelling decreasing perception. No statistically significant difference occurred between groups C, PBM, and SPBM. At 24 hours postoperative, pain values showed statistically significant difference (P=0.04) between group C and SPBM. PBM at the tested parameters did not reduce pain and swelling and did not significantly change face temperature of individuals submitted to ARBG.

Revealing the diversity of Parasmittina Osburn, 1952 (Bryozoa, Cheilostomatida) from the Southwest Atlantic: Species complexes, non-native and new species.

Parasmittina is the most representative cheilostome genus of the family Smittinidae, often reported in the fouling non-indigenous marine community. Here, we present a review of Parasmittina species reported in the Southwestern Atlantic including the characterization of one species from Argentina (P. dubitata) and ten from the Brazilian coast: P. abrolhosensis, P. alba, P. bimucronata, P. ligulata comb. nov., P. longirostrata, P. pinctatae, P. serrula, P. simpulata, P. winstonae and the new species Parasmittina falciformis sp. nov. The new species is characterized by a smooth distally primary orifice with 1-2 oral spines, large lyrula, serrated condyles with hooked tips, and two types of avicularia-small and subtriangular and large sublanceolate. This study does not recognize four species previous recorded in Brazil: reports of P. betamorphaea and P. trispinosa are now assigned to P. pinctatae; records of P. munita belong to P. falciformis sp. nov.; and reports of P. spathulata encompass at least two taxa, including P. abrolhosensis and P. simpulata. In this study, five species complexes (P. alba, P. longirostrata, P. serrula, P. simpulata and P. winstonae) were identified and require further investigations. While six species characterized here were first described based on specimens from the Southwestern Atlantic (P. abrolhosensis, P. alba, P. dubitata, P. ligulata comb. nov., P. simpulata and P. falciformis sp. nov.), the remaining species are mainly known from the Indo-Pacific. These taxa are here recognized as exotic (P. longirostrata) and cryptogenic (P. bimucronata, P. pinctatae, P. serrula and P. winstonae) in the studied area. Most of the non-native taxa are widespread along the Brazilian coast, growing on both artificial and natural surfaces, indicating that they are well-established in the area. As non-native bryozoans can negatively influence the environment, affecting human economic activities and beach usage, further studies on the fauna presented here are suggested to determine the origin of these taxa and help prevent bioinvasion events along the SW Atlantic.

Role of myocardial microRNAs in the long-term ventricular remodelling of patients with aortic stenosis.

Aims: We hypothesize that miRs are key players in the dynamics of the hypertrophy phenotype in aortic stenosis (AS) patients. In our study, we aimed to identify the transcriptional patterns (protein-coding transcripts and miRs) from myocardial sample biopsies that could be associated with the absence of left ventricular (LV) mass regression after aortic valve replacement (AVR) in patients with severe AS and LV hypertrophy. Methods and results: We prospectively included 40 patients with severe AS, LV hypertrophy, and preserved ejection fraction undergoing AVR. Myocardial biopsies obtained during surgery were analysed for transcriptomic analysis performed by next-generation sequencing. At a 1-year follow-up, no hypertrophy reversal was observed in about half of the patients in the absence of patient-prosthesis mismatch and prosthesis dysfunction of uncontrolled hypertension. Predictors of mass regression were assessed from clinical, echocardiographic, and biochemical variables as well as from 300 miRs obtained from myocardial specimens, allowing the identification 29 differentially expressed. miR-4709-3p was found as a positive independent predictor of hypertrophy regression together with high-sensitivity troponin T (cTNT-hs) as a negative predictor. Gene transcripts RFX1, SIX5, MAPK8IF3, and PKD1 were predicted as simultaneous targets of five upregulated miRs suggesting its importance in LV hypertrophy. Conclusion: In our cohort, tissue miR-4709-3p and cTNT-hs were independent predictors of hypertrophy regression. The hypertrophy reversal process will likely depend from a complex network where miRNAs may have an important role, allowing a potential opportunity for therapy.

Emergency care in Brazil: factors leading to clinically inappropriate use of emergency care among young adult users in the Brazilian context.

BACKGROUND: This study aims to investigate the prevalence and associated risk factors of inappropriate use of emergency services among young adults in Vitória, Brazil. METHODS: A cross-sectional study was conducted over 30 consecutive days in November and December 2019, involving systematic random sampling of young adults (aged 18-39) visiting the municipal emergency care unit. Data were collected through structured interviews, utilizing the Hospital Urgency Appropriateness Protocol (HUAP) to identify inappropriate use. Demographic characteristics, healthcare utilization patterns, and medical diagnoses were assessed. Poisson regression models were employed to explore associations between variables. RESULTS: Among the 631 young adults surveyed, 30.6% exhibited inappropriate use of the emergency care unit. Factors associated with higher rates of inappropriate use included not seeking previous care in other healthcare services; having specific medical diagnoses like diseases of the respiratory system (PR: 2.03), diseases of the skin (PR: 4.13), and diseases of the ear and mastoid (PR: 3.74). CONCLUSION: The study underscores the significance of addressing inappropriate use of emergency services among young adults. Though the prevalence of inappropriate use was not significantly different from other age groups, the demographic characteristics and healthcare utilization patterns of young adults contribute to their unique challenges. To mitigate inappropriate use, efforts should focus on improving access to primary healthcare services, enhancing continuity of care, and raising awareness about appropriate healthcare-seeking behaviors among young adults. Ultimately, these interventions can foster a more effective and sustainable healthcare system that better serves the needs of the community.

Intestinal Microbiome Profiles in Broiler Chickens Raised with Different Probiotic Strains.

The composition of the intestinal microbiota can influence the metabolism and overall functioning of avian organisms. Therefore, the objective of this study was to evaluate the effect of three different probiotics and an antibiotic on the microbiomes of 1.400 male Cobb® broiler raised for 42 days. The experiment was conducted with the following treatments: positive control diet (basal diet + antibiotic); negative control diet (basal diet without antibiotic and without probiotic); basal diet + Normal Avian Gut Flora (NAGF); basal diet + multiple colonizing strain probiotics (MCSPs); and basal diet + non-colonizing single strain probiotics (NCSSPs). The antibiotic (enramycin-antibiotic growth promoter) and probiotics were administered orally during all experiment (1 to 42 days), mixed with broiler feed. To determine the composition of the microbiota, five samples of ileal digesta were collected from 42-day-old chickens of each experimental group. The alpha and beta diversity of the ileal microbiota showed differences between the groups. MCSPs presented greater richness and uniformity compared to the positive control, negative control, and NCSSPs treatments, while the negative control exhibited greater homogeneity among samples than NCSSPs. MCSPs also showed a higher abundance of the genus Enterococcus. There were differences between the groups for low-abundance taxa (<0.5%), with NAGF showing higher levels of Delftia, Brevibacterium, and Bulleidia. In contrast, NCSSPs had a higher abundance of Ochrobactrum, Rhodoplanes, and Nitrospira. It was concluded that the treatments analyzed in this study induced modulations in the ileal microbiota of the chickens examined.

Immunostaining and gene expression of epidermal growth factor receptors (HER1/HER2) in canine cutaneous squamous cell carcinoma.

Cutaneous squamous cell carcinoma (cSCC) is a neoplasm type often diagnosed in dogs. However, studies focused on further investigating its molecular biology, mainly biomarkers to help implementing new therapies, remain scare in the literature. Thus, immunostaining and the gene expression of epidermal growth factor receptors (HER1 and HER2) in canine cSCC presenting different cell differentiation degrees were herein assessed. Thirty-two (32) canine cSCC were selected, classified based on to their cell differentiation degree and subjected to immunohistochemical study to assess HER1 and HER2 immunostaining intensity and distribution. In addition, HER1 and HER2 gene expression was investigated through real-time PCR. Membranous and cytoplasmic immunostaining were observed in both markers. HER2 prevailed in poorly differentiated cSCC; there was positive protein expression correlation between both markers. Mean HER1 gene expression was higher in moderately differentiated, whereas mean HER2 gene expression was higher in poorly differentiated cSCC. Moreover, there was gene expression correlation between markers, regardless of cell differentiation degree. Thus, HER2 protein immunostaining and gene expression were higher in poorly differentiated canine cSCC and it enabled understanding that increase observed in this epidermal growth factor receptor is proportional to this neoplasm's cell differentiation degree in canine species. Results in the current study helped better understanding canine cSCC's molecular biology; however, it is relevant studying other markers aiming to investigate signaling pathways.

Bioprospecting, Synergistic Antifungal and Toxicological Aspects of the Hydroxychalcones and Their Association with Azole Derivates against Candida spp. for Treating Vulvovaginal Candidiasis.

Vulvovaginal candidiasis (VVC) remains a prevalent fungal disease, characterized by challenges, such as increased fungal resistance, side effects of current treatments, and the rising prevalence of non-albicans Candida spp. naturally more resistant. This study aimed to propose a novel therapeutic approach by investigating the antifungal properties and toxicity of 2-hydroxychalcone (2-HC) and 3'-hydroxychalcone (3'-HC), both alone and in combination with fluconazole (FCZ) and clotrimazole (CTZ). A lipid carrier (LC) was also developed to deliver these molecules. The study evaluated in vitro anti-Candida activity against five Candida species and assessed cytotoxicity in the C33-A cell line. The safety and therapeutic efficacy of in vivo were tested using an alternative animal model, Galleria mellonella. The results showed antifungal activity of 2-HC and 3'-HC, ranging from 7.8 to 31.2 as fungistatic and 15.6 to 125.0 mg/L as fungicide effect, with cell viability above 80% from a concentration of 9.3 mg/L (2-HC). Synergistic and partially synergistic interactions of these chalcones with FCZ and CTZ demonstrated significant improvement in antifungal activity, with MIC values ranging from 0.06 to 62.5 mg/L. Some combinations reduced cytotoxicity, achieving 100% cell viability in many interactions. Additionally, two LCs with suitable properties for intravaginal application were developed. These formulations demonstrated promising therapeutic efficacy and low toxicity in Galleria mellonella assays. These results suggest the potential of this approach in developing new therapies for VVC.

Three-Dimensional Anthropometric Analysis of the Effect of Lip Reconstructive Surgery on Children with Cleft Lip and Palate at Three Different Times.

OBJECTIVES: This investigation aimed to assess the optimal timing for lip repair in children with cleft lip and palate via 3D anthropometric analysis to evaluate their maxillofacial structures. METHODS: The sample comprised 252 digitized dental models, divided into groups according to the following timing of lip repair: G1 (n = 50): 3 months; G2 (n = 50): 5 and 6 months; G3 (n = 26): 8 and 10 months. Models were evaluated at two-time points: T1: before lip repair; T2: at 5 years of age. Linear measurements, area, and Atack index were analyzed. RESULTS: At T1, the intergroup analysis revealed that G1 had statistically significant lower means of I-C', I-C, C-C', and the sum of the segment areas compared to G2 (p = 0.0140, p = 0.0082, p = 0.0004, p < 0.0001, respectively). In addition, there was a statistically significant difference when comparing the cleft area between G2 and G3 (p = 0.0346). At T2, the intergroup analysis revealed that G1 presented a statistically significant mean I-C' compared to G3 (p = 0.0461). In the I-CC' length analysis, G1 and G3 showed higher means when compared to G2 (p = 0.0039). The I-T' measurement was statistically higher in G1 than in G2 (p = 0.0251). In the intergroup growth rate analysis, G1 and G2 showed statistically significant differences in the I-C' measurement compared to G3 (p = 0.0003). In the analysis of the Atack index, there was a statistically significant difference between G1 and the other sample sets (p < 0.0001). CONCLUSION: Children who underwent surgery later showed better results in terms of the growth and development of the dental arches.

Binding studies of promethazine and its metabolites with human serum albumin by high-performance affinity chromatography and molecular docking in the presence of codeine.

"Purple Drank", a soft drink containing promethazine (PMZ) and codeine (COD), has gained global popularity for its hallucinogenic effects. Consuming large amounts of this combination can lead to potentially fatal events. The binding of these drugs to plasma proteins can exacerbate the issue by increasing the risk of drug interactions, side effects, and/or toxicity. Herein, the binding affinity to human serum albumin (HSA) of PMZ and its primary metabolites [N-desmethyl promethazine (DMPMZ) and promethazine sulphoxide (PMZSO)], along with COD, was investigated by high-performance affinity chromatography (HPAC) though zonal approach. PMZ and its metabolites exhibited a notable binding affinity for HSA (%b values higher than 80%), while COD exhibited a %b value of 65%. To discern the specific sites of HSA to which these compounds were bound, displacement experiments were performed using warfarin and (S)-ibuprofen as probes for sites I and II, respectively, which revealed that all analytes were bound to both sites. Molecular docking studies corroborated the experimental results, reinforcing the insights gained from the empirical data. The in silico data also suggested that competition between PMZ and its metabolites with COD can occur in both sites of HSA, but mainly in site II. As the target compounds are chiral, the enantioselectivity for HSA binding was also explored, showing that the binding for these compounds was not enantioselective.

From percentages to narratives: Giving silence a voice in child sexual abuse within the Portuguese Catholic Church, 1950-2022.

BACKGROUND: Over the last two decades, several studies have examined the extent and expression of child sexual abuse (CSA) in religious institutions. In 2021, following new Vatican guidelines and under intense public pressure, the Portuguese Episcopal Conference commissioned a study on CSA in Portugal by members of the Portuguese Catholic Church (PCC) and others associated with it (from 1950 to 2022). OBJECTIVE AND METHODS: The study draws on a web-based survey and a respondent driven sample. The questionnaire included categorical questions about victims, abusers, types of abuse, and open-ended questions. We characterized victims and abusers and developed a social cartography of abuse using Correspondence Analysis. Victims' narratives are also part of the model of analysis. RESULTS: We validated 512 of CSA by members of the PCC. Boys were more frequently abused (57.2 % vs. 42.2 %); male abusers predominate (96.7 %); most victims were abused more than once (57 %); the average age of victims when the first abuse occurred was 11.2 years. More invasive forms of abuse predominate (80 % manipulation of sexual organs or penetration; only 20 % had no body touching). There are patterns of abuse, and space plays a pivotal role in understanding the forms that CSA takes within Catholic environments. The richness of individual narratives was an unexpected outcome that enables us to better understand the organisational and symbolical power structures in which abuse takes place. CONCLUSION: Given the characteristics of our sample, these cases are the tip of the iceberg, with CSA within the PCC likely involved thousands of children. Further research should strive to consider victims' narratives.

Unusual Anastomosis between Branches of the Ulnar Nerve (Kaplan Type Anastomotic Variant) - Case Report.

The Kaplan anastomosis is a rare communication originally described between the superficial and dorsal branches of the ulnar nerve, distal to the ulnar tunnel, and in strict relation with the pisiform bone. It reveals, by its particular location, a formation of high clinical-surgical expressiveness. In this paper, we describe a Kaplan-type communication from a left upper limb with an unusual loop conformation between branches of the ulnar nerve in the pisiform bone.