Malpractice and socioeconomic aspects in neurosurgery: a developing-country reality.

OBJECTIVE: Neurosurgery occupies a prominent place in medical malpractice, but cases are still underreported in Brazil. This study describes the socioeconomic issues of medical malpractice in neurosurgery procedures and how they culminate in unfavorable outcomes in a developing country. METHODS: The authors analyzed 112 neurosurgical procedures listed in the Brazilian Hospital Information System (Sistema de Informações Hospitalares do Sistema Único de Saúde [SIHSUS]) records in the DATASUS (Departamento de Informática do SUS) database between January 2008 and February 2020. Malpractice data were collected using the JusBrasil platform, with the authors searching the name of each of the 112 neurosurgical procedures plus "medical malpractice" among the jurisprudence records for January 2008 to February 2020. A simple linear regression analysis was performed using appropriate software. Analyses were considered statistically significant at p < 0.05. RESULTS: According to DATASUS, 842,041 neurosurgical procedures were performed by the Brazilian Unified Health System between January 2008 and February 2020. The mean hospitalization cost for neurosurgical procedures was $714.06, and the average amount paid to professionals per procedure was $145.28 with variations according to the type of practice (public or private) in which they were performed, the complexity of the procedure, and the Brazilian region. The mortality rate and mean length of stay for neurosurgical procedures were 11.37% and 10.15 days, respectively. There were 79 medical malpractice lawsuits in the studied period. In these lawsuits, 26.58% of the court decisions were unfavorable to the neurosurgeons, with a mean compensation per procedure 15 times higher than the median value paid for all professionals in a neurosurgical procedure. The spine subspecialty had more lawsuits, and the brain tumor subspecialty had the most expensive compensation.A lack of resources in public healthcare negatively impacts inpatient care. The mortality rate was 1.5 times higher in public practice than in private practice and was inversely proportional to the MTCs paid for the neurosurgical procedure. Patients with the lower educational levels associated with limited access to good medical care could reflect the lower plaintiff motivation in regions with a low gross domestic product and Human Development Index. In most cases, there is no understanding from either the patient or his family about the health-disease process, nor that there was medical malpractice committed by the physician to be sued. CONCLUSIONS: The socioeconomic inequalities and the population's low awareness of their rights could explain the few malpractice cases reported in Brazil. The authors recommend better decisions regarding the investments to be made in neurosurgical procedures to reduce malpractice lawsuits.

The Comprehensive Complication Index (CCI®) is a Novel Cost Assessment Tool for Surgical Procedures.

OBJECTIVE: The aim of this study was to identify a readily available, reproducible, and internationally applicable cost assessment tool for surgical procedures. SUMMARY OF BACKGROUND DATA: Strong economic pressure exists worldwide to slow down the rising of health care costs. Postoperative morbidity significantly impacts on cost in surgical patients. The comprehensive complication index (CCI), reflecting overall postoperative morbidity, may therefore serve as a new marker for cost. METHODS: Postoperative complications and total costs from a single tertiary center were prospectively collected (2014 to 2016) up to 3 months after surgery for a variety of abdominal procedures (n = 1388). CCI was used to quantify overall postoperative morbidity. Pearson correlation coefficient (rpears) was calculated for cost and CCI. For cost prediction, a linear regression model based on CCI, age, and type of surgery was developed and validated in an international cohort of patients. RESULTS: We found a high correlation between CCI and overall cost (rpears = 0.75) with the strongest correlation for more complex procedures. The prediction model performed very well (R = 0.82); each 10-point increase in CCI corresponded to a 14% increase to the baseline cost. Additional 12% of baseline cost must be added for patients older than 50 years, or 24% for those over 70 years. The validation cohorts showed a good match of predicted and observed cost. CONCLUSION: Overall postoperative morbidity correlates highly with cost. The CCI together with the type of surgery and patient age is a novel and reliable predictor of expenses in surgical patients. This finding may enable objective cost comparisons among centers, procedures, or over time obviating the need to look at complex country-specific cost calculations (www.assessurgery.com).

HBV infection in HIV-infected subjects in the state of Piauí, Northeast Brazil.

In this study, the prevalence, genotype frequency, and risk factors for HBV infection in 768 HIV-infected subjects living in Piauí were determined. Forty-six (6.0 %) HIV-positive subjects were reactive for HBsAg and positive for HBV-DNA. Genotypes A (71.8 %), F (23.9 %) and D (4.3 %) were identified. Multivariate analysis revealed an association between HIV-HBV coinfection and male gender, older age groups, unprotected sex, reporting more than ten sexual partners throughout life, STD, and tattooing. This study shows the importance of monitoring sites and professionals who perform tattooing and practice safe sex to prevent the spread of HIV and HBV infections.

Association between asthma, rhinitis and atopic dermatitis with leprosy: A case-control study.

Background Considering the cross-regulation of Th1 and Th2 responses, we hypothesised that atopic diseases (Th2) inhibit the protective Th1 immune response to Mycobacterium leprae and exacerbates leprosy. Objective In this study, we aimed to evaluate the association between leprosy and atopic diseases. Methods To evaluate the association of atopic diseases with leprosy, we conducted a case-control study that included leprosy patients (n = 333) and their household contacts (n = 93). The questionnaire from the International Study of Asthma and Allergies in Childhood, which is validated in several countries for epidemiological diagnosis of atopic diseases, was applied to determine the occurrence of atopic diseases, allergic rhinitis, asthma, and atopic dermatitis among leprosy patients and the household contacts. Results Considering clinical and epidemiological data, among the leprosy group 51.6% (n = 172) were determined to have at least one atopic disease, while atopy was observed less frequently at 40.86% among household contacts (n = 38). When two or more atopic diseases were assessed, the frequency was significantly higher among the leprosy patients than in the household contacts (21.9% vs. 11.8%; P-value = 0.03). Likewise, the frequency of asthma was significantly higher among leprosy patients (21%) than in the household contacts (10.8%; P-value = 0.02). Thus, our analyses revealed an association of atopic diseases with leprosy, with a significant linear increase in the occurrence of leprosy with an increase in the number of atopic diseases (P-value = 0.01). Limitation Due to the difficulties in recruiting household contacts that have prolonged contact with patients, but are not genetically related to the patient, the household contacts group is smaller than the leprosy patient group. Conclusion The data reveal an association between atopic diseases and leprosy outcomes. This knowledge could improve the treatment of leprosy patients with co-incident atopic diseases.

The Brazilian Family Health Program and secondary stroke and myocardial infarction prevention: a 6-year cohort study.

OBJECTIVES: We compared the incidence of recurrent or fatal cardiovascular disease in patients using Brazil's government-run Family Health Program (FHP) with those using non-FHP models of care. METHODS: From 2005 to 2010, we followed outpatients discharged from city public hospitals after a first ever stroke for stroke recurrence and myocardial infarction, using data from all city hospitals, death certificates, and outpatient monitoring in state-run and private units. RESULTS: In the follow-up period, 103 patients in the FHP units and 138 in the non-FHP units had exclusively state-run care. Stroke or myocardial infarction occurred in 30.1% of patients in the FHP group and 36.2% of patients in non-FHP care (rate ratio [RR] = 0.85; 95% confidence interval [CI] = 0.61, 1.18; P = .39); 37.9% of patients in FHP care and 54.3% in non-FHP care (RR = 0.68; 95% CI = 0.50, 0.92; P = .01) died. FHP use was associated with lower hazard of death from all causes (hazard ratio [HR] = 0.58; P = .005) after adjusting for age and stroke severity. The absolute risk reduction for death by all causes was 16.4%. CONCLUSIONS: FHP care is more effective than is non-FHP care at preventing death from secondary stroke and myocardial infarction.

Impact of COVID-19 on Neurosurgery in Brazil's Health System: The Reality of a Developing Country Affected by the Pandemic.

BACKGROUND: The coronavirus disease identified in 2019 (COVID-19) pandemic changed neurosurgery protocols to provide ongoing care for patients while ensuring the safety of health care workers. In Brazil, the rapid spread of the disease led to new challenges in the health system. Neurooncology practice was one of the most affected by the pandemic due to restricted elective procedures and new triage protocols. We aim to characterize the impact of the pandemic on neurosurgery in Brazil. METHODS: We analyzed 112 different types of neurosurgical procedures, with special detail in 11 neurooncology procedures, listed in the Brazilian Hospital Information System records in the DATASUS database between February and July 2019 and the same period in 2020. Linear regression and paired t-test analyses were performed and considered statistically significant at P < 0.05. RESULTS: There was an overall decrease of 21.5% (28,858 cases) in all neurosurgical procedures, impacting patients needing elective procedures (-42.46%) more than emergency surgery (-5.93%). Neurooncology procedures decreased by 14.89%. Nonetheless, the mortality rate during hospitalization increased by 21.26%. Linear regression analysis in hospitalizations (Slope = 0.9912 ± 0.07431; CI [95%] = 0.8231-1.159) and total cost (Slope = 1.03 ± 0.03501; CI [95%] = 0.9511-1.109) in the 11 different types of neurooncology procedures showed a P < 0.0001. The mean cost per type of procedure showed an 11.59% increase (P = 0.0172) between 2019 and 2020. CONCLUSIONS: The COVID-19 pandemic has increased mortality, decreased hospitalizations, and therefore decreased overall costs, despite increased costs per procedure for a variety of neurosurgical procedures. Our study serves as a stark example of the effect of the pandemic on neurosurgical care in settings of limited resources and access to care.

Sentidos e significados atribuídos por professores de um curso sobre convivência escolar / Senses and meanings attributed by teachers participating in a course on school coexistence / Sentidos y significados atribuidos por profesores de un curso sobre la convivencia escolar

Fundamentada na perspectiva histórico-cultural, a presente pesquisa teve por objetivos conhecer os sentidos e os significados dos relatos das práticas docentes, atribuídos por educadores participantes de um curso de formação para o trabalho com a convivência na escola. Foi utilizada entrevista semi-estruturada com os professores participantes do curso. A análise das entrevistas, fundamentada no Paradigma Indiciário e nos Núcleos de Significação, possibilitou construir núcleos de significação, sendo focalizado o Núcleo Práticas em transformação. Os professores apresentaram relatos indicativos de que suas concepções e práticas estavam em transformação. Os resultados permitem defender a necessidade da implantação de programas que abordem questões da convivência escolar em prazos mais alargados, para que sejam possíveis transformações mais aprofundadas nas concepções pedagógicas que estão subjacentes às práticas docentes.

Based on a historical and cultural perspective, the current research had as goals to know the senses and meanings of reports of teaching practices attributed by educators participating in a training course on coexistence at school. Semi-structured interviews with the teachers participating in the course were used. The analysis of the interviews, based on the Evidential Paradigm and on the Centers of Meaning, enabled the construction of centers of meaning mainly focusing on center 1 ­ Practices undergoing transformation. The teachers presented indicative reports that their conceptions and practices were in transformation. The results make it possible to defend the need of implementing programs that address the issues of coexistence at schools in longer-term periods, in order to enable deeper changes in pedagogical concepts that are underlying to teaching practices.

Basada en la perspectiva histórica y cultural, esta investigación tuvo como objetivos conocer los sentidos y significados de los relatos de las prácticas docentes, atribuidos por educadores participantes en un curso de formación para el trabajo con la convivencia en la escuela. Fue utilizada entrevista semiestructurada con los profesores participantes del curso. El análisis de las entrevistas, fundamentado en el Paradigma Indiciario y en los Núcleos de Significación, posibilitó construir núcleos de significación, siendo focalizados el Núcleo 1 - Prácticas en transformación. Los profesores presentaron relatos indicativos de que sus concepciones y prácticas estaban en transformación. Los resultados permiten defender la necesidad de implantación de programas que aborden cuestiones de convivencia escolar a largo plazo, para que sean posibles transformaciones más profundas en las concepciones pedagógicas que están subyacentes a las prácticas docentes.

Oral Alendronate Treatment for Severe Polyostotic Fibrous Dysplasia due to McCune-Albright Syndrome in a Child: A Case Report.

Polyostotic fibrous dysplasia (FD) associated to McCune-Albright Syndrome (MAS) often leads to fractures, deformities, and bone pain resulting in bad quality of life. Parenteral bisphosphonates have been used in children and adolescents to improve these symptoms with few adverse effects. We evaluated the response to oral Alendronate in a girl with severe MAS FD and observed improved quality of life with reduction of bone pain.

[Orofacial aspects of childhood abuse and dental negligence]. / Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica.

The aim of this paper was to identify the main oral and dental aspects of childhood abuse and dental neglect, contributing to the identification of these victims in a dental office. A bibliographic research was carried out, in ADOLEC, MEDLINE, LILACS and BBO databases. The following key words were used: child abuse, oral manifestations, dentists; role; liability, legal. It was verified that violence against children happens in general at home and the resulting orofacial injuries encompass: injuries, burns and lacerations on soft and hard tissues, bite marks and gradually-healed wounds. It can have wounds in other parts of the body next to the oral cavity, such as periorbital wound and nasal injury. Regarding sexual abuse, many victims do not present any associated physic signs; therefore, behavioral indicators must be observed. The immediate recognition and report of childhood abuse and dental negligence by dental surgeon are essential for children protection. Therefore, it is critical to define more effective action from those professionals, by registration and denunciation of suspect cases to child protection agencies.

Enfermidades em bovinos associadas ao consumo de resíduos de cervejaria / Cattle diseases associated with consumption of beer residues

A utilização de subprodutos de cervejaria na alimentação de bovinos tem crescido nos últimos anos como uma excelente alternativa na manutenção ou aumento da produtividade na bovinocultura, sobretudo na Região Sudeste. Entre os resíduos mais empregados estão o bagaço de malte oriundo da "cevada" e o "levedo de cerveja", um subproduto líquido que contém álcool, muito utilizado no Estado do Rio de Janeiro. O uso incorreto ou sem os devidos cuidados, bem como o armazenamento de forma inadequada, contudo, podem ser responsáveis por quadros de intoxicação por etanol, neurotoxicose por Aspergillus clavatus, acidose ruminal e botulismo. Esse trabalho tem por intuito alertar para a importância dessas condições como causa de sérios prejuízos econômicos à pecuária e fornecer subsídios para o estabelecimento do diagnóstico, diagnóstico diferencial e profilaxia das mesmas...

The use of brewery by-products in cattle feed has grown in recent years as an excellent alternative for maintenance or increase in cattle productivity especially in Southeastern Brazil. Among the most employed by-products are malted barley waste and brewer's yeast, a liquid by-product that contains alcohol and is widely used in the State of Rio de Janeiro. Careless or incorrect use of these products, as well as inadequate storage, can cause ethanol poisoning, neurotoxicosis by Aspergillus clavatus, ruminal acidosis and botulism. This paper highlights the importance of these conditions as causes of severe economic losses to livestock, and provides support for the establishment of diagnosis, differential diagnosis and prophylaxis...

Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial.

The aim of this randomized clinical trial study was to evaluate the therapeutic effect of two varnish formulations (G1 = 5% NaF, G2 = 6% NaF + 6% CaF(2)) on the remineralization of white spot lesions (WSL). The sample was composed of 15 (7- to 12-year-old) children with 45 active WSL in anterior permanent teeth. The children were randomly divided into two groups providing 22 lesions for G1 and 23 for G2. The children were submitted to weekly varnish applications 4 times. The WSL were evaluated twice: baseline and on week 4. Maximum lesion dimensions (mesiodistal and incisogingival) were measured in millimeters and classified in four grades of size. WSL were also assessed regarding lesion activity by one calibrated examiner. The Pearson chi-square and Fisher's exact tests were used (P < 0.01). WSL reductions were observed in both varnish groups (Chi-square = 0.15, d.f. = 1, P = 0.90), and with similar magnitude (in mm): 1.19 and 1.29 for G1 and G2, respectively. Thirty-six WSL (15 in G1 and 21 in G2) were classified as inactive on week 4, reaching an overall value of 80%. No difference was observed between G1 and G2 regarding activity scores (Fisher's exact test, p > 0.01). It was concluded that after 4 applications the two varnish formulations tested produced similar clinical effects, indicating the reduction and the control of carious activity in most WSL.

Efeito protetor da acetamida em bovinos indica monofluoroacetato como princípio tóxico de Palicourea marcgravii (Rubiaceae) / Protective effect of acetamide in cattle indicates that monofluoroacetate is the toxic principle of Palicourea marcgravii (Rubiaceae)

O presente trabalho teve como objetivo avaliar e comparar o efeito protetor da acetamida nas intoxicações experimentais por monofluoroacetato (MF) e por folhas frescas de Palicourea marcgravii em bovinos, no intuito de confirmar, de forma prática, que esse composto é o princípio tóxico responsável pelo quadro clínico-patológico e pela morte dos animais intoxicados por essa planta. Três bovinos receberam MF, por via oral, na dose de 0,5mg/kg e, em seguida, a dois desses animais administraram-se acetamida, por via oral, nas doses de 0,38 e 2,0g/kg. Outros dois bovinos receberam 1,0g/kg de P. marcgravii, em seguida, a um deles administrou-se 1,0 g/kg de acetamida. Acetamida, quando administrada em quantidades suficientes (maior dose), evitou o aparecimento dos sinais clínicos e a morte de todos os animais que receberam MF ou P. marcgravii. Tal efeito protetor foi, de fato, confirmado após uma semana, quando o mesmo protocolo experimental foi repetido, para cada bovino, porém sem a administração de acetamida. Todos os bovinos não tratados com acetamida manifestaram sinais clínicos e morreram subitamente. O quadro clínico-patológico manifestado pelos bovinos intoxicados por MF ou P. marcgravii foi semelhante e, caracterizou-se por "morte súbita". Os animais em geral, apresentaram taquicardia, taquipnéia, tremores musculares, jugular repleta com pulso venoso positivo, polaquiúria, instabilidade, perda de equilíbrio, por vezes, cambaleavam e apoiavam a cabeça no flanco. Na fase final, todos os animais deitavam-se e levantavam-se com maior frequencia, deitavam ou caíam em decúbito lateral, esticavam os membros, faziam movimentos de pedalagem, apresentavam respiração ofegante, arritmia, opistótono, nistagmo, mugiam e morriam. A duração da "fase dramática" variou de 2 a 26min. À necropsia verificaram-se, em geral, aurículas, jugulares, ázigos e pulmonares leve a moderadamente ingurgitadas, leve a acentuado edema da subserosa da vesícula biliar, sobretudo, na sua inserção no fígado, bem como moderada quantidade de líquido espumoso róseo na traquéia e brônquios. O exame histopatológico revelou, no rim de todos os animais, leve até acentuada degeneração hidrópico-vacuolar das células epiteliais dos túbulos uriníferos contornados distais associada à picnose nuclear; no fígado, havia leve a moderada congestão, discreta a moderada tumefação e moderada vacuolização de hepatócitos, predominantemente, centrolobular, necrose de coagulação individual ou de grupos de hepatócitos e corpúsculos de choque. Os dados obtidos neste trabalho comprovam, de forma prática, que MF é o princípio tóxico de P. marcgravii responsável pelo quadro clínico-patológico e a morte dos animais que ingerem e se intoxicam naturalmente por essa planta, uma vez que a acetamida atua como antídoto eficaz (efeito antagônico) de forma idêntica em ambas as intoxicações.

The aim of the study was to evaluate and compare the protective effect of acetamide in experimental poisoning by fresh leaves of Palicourea marcgravii and monofluoroacetate (MF) in catlle, in order to prove in a practical way that this compound is the toxic principle responsible for the clinical signs and death of animals that ingested the plant. MF was administered orally in single doses of 0.5mg/kg to three cows; a few minutes later, two of these cows received, orally, single doses of acetamide (0.38 or 2.0g/kg). Two other cows ingested 1.0g/kg of P. marcgravii, and one of these cows received some minutes later 1.0g/kg of acetamide. Adequate doses of acetamide, administered right after the poisoning by P. marcgravii or MF, were able to prevented the onset of clinical signs and avoid the death of all animals. One week later, the experiments were repeated, but without the antidote. All animals not treated with acetamide showed symptoms of poisoning and died suddenly. MF and P. marcgravii caused the same clinical and pathological picture of "sudden death" in cattle. Clinically, the cattle presented palpitation, abdominal breathing, muscle tremors, engorged jugular vein with positive pulse, pollakiuria, slight loss of balance with sometimes swaying gait, the animals laying down and with the head on their flank. In the "dramatic phase", all the animals fell into lateral decubitus, stretched the limbs, made paddling movements, presented opistotonus, arrhythmia, nystagmus, and died. The "dramatic phase" lasted from 2 to 26 minutes. At postmortem examination, the heart auricles, jugulars and pulmonary veins were slightly to moderately ingurgitated; slight to marked edema of the subserosa was seen in fixation sites of gall bladder to the liver. In one cow, pulmonary edema was observed. Histopathology revealed in all cows slight to marked hydropic-vacuolar degeneration of the epithelial cells of the distal convoluted uriniferous tubules associated with nuclear pyknosis. Coagulation necrosis of individual or groups of hepatocytes and slight to moderate hepatic congestion with numerous shock corpuscles were also observed. The experimental results showed in practice that MF is the toxic principle responsible for the clinical-pathological picture and death of the cattle that ingested P. marcgravii, since acetamide acts as an efficient antidote (antagonistic effect), identical in both poisonings.

Sobrevivência/viabilidade de bovinos com Hematúria Enzoótica após transferência para região livre de Pteridium arachnoideum / Survival/viability of cattle with Bovine Enzootic Hematuria after transfer to area free of Pteridium arachnoideum

With the objective of explaining the question of survival of cattle affected by Enzootic Hematuria, when transferred to areas free of Pteridium arachnoideum, the study was accomplished in two parts: a) by a questionnaire regarding the epidemic aspects of that illness, which was answered by the proprietors of 73 cattle establishments visited in the areas of Southeast of Brazil, where P. arachnoideum is prevalent. The applied questionnaire to the proprietors indicates that enzootic hematuria is responsible for serious socioeconomic problems; b) clinical and laboratorial attendance of 51 cattle of this area affected by Enzootic Hematuria, between 2007 and 2011, transferred to area free of P. arachnoideum. More than 90% of the affected animals by HEB died before two years after removal from areas free of P. arachnoideum.

Com o objetivo de esclarecer a questão da sobrevida de bovinos afetados por Hematúria Enzoótica, quando transferidos para áreas livres de Pteridium arachnoideum, o estudo foi realizado em duas partes: a) aplicação de questionário versando sobre os aspectos epidemiológicos dessa enfermidade, respondido por proprietários de 73 estabelecimentos pecuários visitados nas áreas da Região Sudeste onde P. arachnoideum é prevalente. O questionário aplicado aos proprietários indica que a HEB é causa de sérios problemas sócio-econômicos. b) acompanhamento clínico e laboratorial de 51 bovinos desta região, afetados pela Hematúria Enzoótica entre 2007 e 2011, transferidos para região livre de P. arachnoideum. Verificou-se que mais de 90% dos animais afetados por HEB morre antes de dois anos após serem transferidos para áreas indenes de P. arachnoideum.

Acessibilidade da Criança e do Adolescente com Deficiência na Atenção Básica de Saúde Bucal no Serviço Público: Estudo Piloto / Accessibility of Disabled Children and Adolescents to Basic Oral Health Attention at the Public Health system – A Pilot Study

Objetivo: Verificar a confiabilidade e reprodutibilidade do instrumento de pesquisa e avaliar o acesso de crianças e adolescentes com deficiência ao serviço público de saúde bucal. Método: Participaram deste estudo piloto 67 responsáveis de crianças e adolescentes com deficiência física, mental, auditiva ou visual, cadastrados no Programa de Saúde da Família da cidade de Recife. Realizou-se uma pesquisa quantitativa do tipo observacional descritiva. Para tanto, aplicou-se um formulário que possibilitou a identificação e caracterização da população, além do levantamento de dados referentes ao acesso aos serviços básicos de saúde bucal. Os dados foram analisados através de estatística descritiva. Resultados: Constatou-se que o percentual de concordância para cada questão variou de 69,0% a 94,1% e os valores de kappa ariaram de 0,44 a 0,88. Verificou-se um baixo nível de escolaridade, como também de renda da maioria dos responsáveis. Percebeu-se que 50,7% havia procurado o atendimento na Unidade de Saúde da Família para seus filhos e, destes, apenas 50% recebeu atendimento. Foi observado que os principais motivos de não ter conseguido atendimento foram a indisponibilidade de vagas e a falta adaptação do profissional para atender pessoas com necessidades especiais. Em relação aos que não procuraram atendimento para seus filhos grande parte julgou melhor levar a outro serviço público, enquanto uma parcela considerável não achou necessária a busca pelo atendimento. Conclusão: A confiabilidade e a reprodutibilidade do instrumento de pesquisa foram satisfatórias. Entre os haviam procurado o serviço de saúde bucal da Unidade do Programa de Saúde da Família para seus filhos, a metade afirmou não ter conseguido o atendimento, citando como principal motivo a indisponibilidade de vaga.

Objective: To verify the reliability and reproducibility of the research instrument and to evaluate the access of disabled children and adolescents to the public oral health service. Method: Sixty-seven parents/caregivers of children and adolescents with physical, mental, auditory or visual disabilities enrolled at the Family Health Program of the city of Recife participated in this study. A quantitative descriptive observational study design was used. For such purpose, a form was applied to the participants to identify and characterize the population as well as to retrieve data referring to access to public oral health service. Data were analyzed by descriptive statistics. Results:The percentage of agreement for each question ranged from 69.0% to 94.1% and the Kappa values ranged from 0.44 to 0.88. The majority of the parents/caregivers had low education level and income. As much as 50.7% of them had sought treatment for their children at the Family Health Program Unit but only 50% of them actually received treatment. The main reasons for not receiving treatment were the unavailability of vacancies and lack of preparation of the professionals to treat special needs patients. Great part of those that did not seek treatment for their children at the Family Health Program Unit preferred to take them to another public service, while a considerable part of the studied population did not find necessary to seek treatment. Conclusion: The reliability and reproducibility of the research instrument were satisfactory. Half of the individuals that had thought the Family Health Program Unit’s oral health service for their children affirmed not to have received treatment, and mentioned the lack of vacancies as the main reason.

Aspectos clínico-patológicos e controle da paratuberculose em rebanho bovino leiteiro / Clinic-pathological aspects and control of paratuberculosis in a dairy cattle herd

A paratuberculose ou doença de Johne é uma enterite granulomatosa causada por Mycobacterium avium subsp. paratuberculosis. Descrevem-se os aspectos epidemiológicos, clínico-patológicos e laboratoriais da paratuberculose em rebanho bovino leiteiro no município de Rio Claro, região Sul do Estado do Rio de Janeiro. No período de 2006 a 2009, oito vacas adultas da raça Girolanda apresentaram diarreia crônico-intermitente e perda progressiva de peso. À necropsia, observaram-se linfonodos mesentéricos aumentados de volume e úmidos ao corte, vasos linfáticos subserosos das alças intestinais proeminentes, serosa do intestino com aspecto anelado e cerebroide e a mucosa espessada, pregueada e com aspecto microgranular. À microscopia havia, desde o duodeno até o reto, inflamação granulomatosa difusa, marcada dilatação dos vasos linfáticos no ápice das vilosidades, linfangiectasia e linfangite granulomatosa na submucosa, muscular e serosa. A inflamação granulomatosa também foi vista nos linfonodos mesentéricos. A coloração de Ziehl-Neelsen revelou variável quantidade de bacilos álcool-ácido resistentes no interior de macrófagos, de células gigantes de Langhans e livres na mucosa e submucosa dos intestinos delgado e grosso e em linfonodos mesentéricos. Em alguns animais, a lâmina própria da mucosa, principalmente do jejuno e íleo exibia acentuada hipertrofia. Mycobacterium avium subsp. paratuberculosis foi isolado em cultivo bacteriano de Herrold com micobactina, a partir de amostras de fezes, de raspado de mucosa intestinal e de leite e identificado pela técnica de PCR IS900. Através da avaliação sorológica semestral, foram analisadas 298 vacas do mesmo rebanho a partir de três anos de idade, observou-se cerca de 40 por cento de animais reagentes ao teste ELISA indireto no período estudado. O diagnóstico da paratuberculose foi baseado nos dados clínico-patológicos, na sorologia, no isolamento e identificação do agente através de cultivo bacteriano e PCR IS900. Após implementação de medidas de controle, tais como eliminação de animais doentes, abate seletivo dos animais soropositivos, separação dos bezerros ao nascer e utilização de banco de colostro, observou-se, nos três anos de estudo, diminuição da ocorrência de casos clínicos no rebanho, de seis casos por ano para cerca de um caso por ano.

Paratuberculosis (Johne's disease) is a granulomatous enteritis of ruminants caused by Mycobacterium avium subsp. paratuberculosis. Epidemiology, clinic-pathological and laboratorial aspects of paratuberculosis in a dairy cattle herd are described. The disease was diagnosed from 2006 to 2009 in eight cows that presented chronic-intermittent diarrhea and chronic weight loss, in the Rio Claro municipality, Rio de Janeiro. At necropsy, the subserosal lymphatic vessels were proeminent and dilated, mesenteric nodes were enlarged and intestinal mucosa was corrugated, thickened and of microgranular aspect. From duodenum to the rectum, histopathology revealed severe and diffuse granulomatous inflammation of the lamina propria and submucosa, broadened and distorted villi, dilatation of the lymphatic vessels in their apex, lymphangioectasia and granulomatous lymphangitis in the submucosa. Ziehl-Neelsen stain showed variable amounts of acid-fast bacilli in macrophages, in Langhans giant cells and freely in the mucosa and submucosa of the small intestine, colon and lymphnodes. In some cows, the lamina propria presented severe hypertrophy, mainly in the jejunum and ileum. Mycobacterium avium subsp. paratuberculosis was isolated through bacterial cultivation of samples taken from feces, intestinal mucosa and milk, and identified through IS900 PCR. From 298 cows older than three years, the percentage of reactive animals was 40 percent by indirect ELISA test. The diagnosis of paratuberculosis was based on clinic-epidemiological data, serology, bacterial isolation in Herrold egg yolk medium with micobactin and on IS900 PCR. After the adoption of control measures, as slaughter of cows with clinical signs, selective slaughter of seropositive cows, removal of the calf from the dam at birth, and use of the colostrum bank, we observed a reduction from six clinical cases to only one case per year, in the last three years of the study.

Conhecimento de Professores das Creches Municipais de JoãoPessoa Sobre Saúde Bucal Infantil / Knowledge of Public Daycare Center Teachers of João Pessoa, PB, Brazil, about Child Oral Health

Objeti vo: Avaliar o nível de conhecimento dos professores dascreches municipais da cidade de João Pessoa, PB, sobre saúdebucal infanti l.Método: Por meio de observação direta extensiva, foi aplicadoum questi onário contendo questões objeti vas, pré-testado com10% da amostra em um estudo-piloto. A amostra foi calculadapelo programa estatí sti co DIMAM 1.0 com grau de confi ançade 95%, erro de 10% e poder de 50%, correspondendo a54 profi ssionais, diante da população de 118 professorescadastrados na Secretaria de Educação do município. Aanálise dos dados foi realizada pelo programa estatí sti co SPSSv.11.0, trabalhados sob forma de estatí sti ca descriti va. Paraavaliar o nível de informações dos parti cipantes da pesquisa,foi considerada a freqüência de 0 a 50% de acerto dasrespostas como conhecimento insati sfatório, 50 a 70%, comoconhecimento razoável e acima de 70%, como conhecimentosati sfatório dos professores da pré-escola.Resultados: Todos os pesquisados relataram ter conhecimentosobre Odontologia Preventi va, sendo o cirurgião-denti staa principal fonte de informação sobre o tema (31,5%). Oseducadores conheciam adequadamente o signifi cado dobiofi lme dental e sua remoção em 31,5% e 7,4% dos casos,respecti vamente. Apenas 51,9% dos pesquisados percebiam aeti ologia multi fatorial da cárie e 55,6% acreditavam que estapatologia não era transmissível. Quando questi onados sobreOdontologia Preventi va, 98,1% dos professores acreditavamque o fl úor possuía efeito preventi vo, 92,6% sabiam ascaracterísti cas de uma escova dentária adequada e 94,4%consideravam a técnica de escovação importante para a higienebucal correta.Conclusão: Os professores pesquisados apresentaram umconhecimento limitado sobre cárie dentária, porém sati sfatóriosobre a prevenção desta patologia...

Objecti ve: To evaluate the knowledge of public daycare centerteachers of the city of João Pessoa, PB, Brazil, about child oralhealthMethod: Using an extensive direct observati on, a questi onnairewith objecti ve questi ons was used, aft er being pre-testedwith 10% of the sample in a pilot-study. The sample size wascalculated using the stati sti cal soft ware DIMAM 1.0 wih 95%confi dence level, 10% error and 50% power, corresponding to54 professionals out of a populati on of 118 teachers registeredat the Municipal Secretariat of Educati on. Data were analyzedby descripti ve stati sti cs using the SPSS v.11.0 stati sti cal soft ware.To evaluate the level of informati on of the preschool teachers,a frequency of 0 to 50% of correct answers were consideredas unsati sfactory knowledge, 50 to 70% was consideredas reasonable knowledge, and above 70%, as sati sfactoryknowledge.Results: All parti cipants reported to have knowledge ofPreventi ve Denti stry, and the denti st was considered as the mainsource of informati on about the subject (31.5%). The teachersknew adequately the meaning of dental biofi lm and its removalin 31.5% and 7.4% of the cases, respecti vely. Only 51.9% of theinterviewees were aware of the multi fatorial eti ology of cariesand 55.6% believed that this pathology was not transmissible.When asked about Preventi ve Denti stry, 98.1% of the teachersbelieved that fl uoride have preventi ve eff ect, 92.6% knewthe characteristi cs of an adequate toothbrush, and 94.4%considered the toothbrushing technique as important for acorrect oral hygiene.Conclusion: The teachers evaluated in this study presentedlimited knowledge of dental caries, but sati sfactory knowledgeof preventi on of this pathology...

Envenenamento experimental por bothropoides jararaca e bothrops jararacussu em ovinos: aspectos clínico-patológicos e laboratoriais / Experimental poisoning by bothropoides jararaca and bothrops jararacussu in sheep: clinic-pathological and laboratory aspects

Esse estudo teve como objetivo determinar as alterações clínico-patológicas e laboratoriais em ovinos inoculados com a peçonha de Bothropoides jararaca e Bothrops jararacussu, no intuito de fornecer subsídios que possam facilitar o estabelecimento do diagnóstico e do diagnóstico diferencial dessa condição. Os venenos liofilizados foram diluídos em 1 ml de solução fisiológica e administrados a quatro ovinos por via subcutânea. Três ovinos foram a óbito e um que recebeu a dose de 0,5mg/kg (B. jararaca), recuperou-se. Os sinais clínicos tiveram início entre 7 minutos e 1 hora. O período de evolução variou de 7 horas 9 minutos a 21 horas 59 minutos. O quadro clínico, independentemente das doses, caracterizou-se por aumento de volume no local da inoculação, tempo de sangramento e de preenchimento capilar aumentados, taquicardia, dispnéia, mucosas hipocoradas e apatia. Os exames laboratoriais revelaram acentuada anemia normocítica normocrômica, trombocitopenia, acentuada redução de fibrinogênio e proteínas plasmáticas totais, hematócrito diminuído em dois animais, além de acentuado aumento de creatinaquinase e desidrogenase lática em todos os animais. À necropsia, os principais achados no local da inoculação e tecidos adjacentes eram extensas hemorragias no animal que recebeu o veneno de B. jararaca e edema e acentuado edema pulmonar agudo para os dois animais envenenados por B. jararacussu. Além de hemorragia e edema a principal alteração histopatológica verificada foi necrose das fibras musculares e de vasos, no local de inoculação e adjacências. A necrose tubular renal foi atribuída ao quadro de choque. Nos ovinos deste estudo, o aumento de volume observado no local de inoculação e adjacências era constituído predominantemente por sangue (B. jararaca) e por edema (B. jararacussu).

The purpose of this study was to establish the clinic-pathological and laboratory changes in sheep inoculated with Bothropoides jararaca and Bothrops jararacussu venom to provide subsidies for the differential diagnosis of snake bites. The liofilized venoms were diluted in 1 ml saline and administrated subcutaneously to four sheep. Three of the animals died, and the one that received 0.5mg/kg (B. jararaca venom) recovered. First symptoms were observed from 7 minutes to 1 hour after inoculation, and the clinical course varied from 7 hours and 9 minutes to 21 hours and 59 minutes. The symptoms, independent of the dosage, were swelling of the inoculation site, increased bleeding time and capillary filling, tachycardia, dyspnea, pale mucous membranes and diminished reaction to external stimuli. Laboratory tests revealed pronounced normocytic and normochromic anemia, trombocytopenia, slight reduction of fibrogen and total plasmatic protein, in two animals diminished hematocrit, besides pronounced increase of creatinaquinase and lactic dehydrogenase. At necropsy, the main findings at the inoculation site and adjacent tissues were extensive hemorrhages in the sheep inoculated with jararaca venom, and predominantly edema in the two animals inoculated with jararacussu venom. In two sheep which received jararacussu venom, acute pulmonary edema was observed. Hemorrhage and edema as the main histopathological changes, besides necrosis of muscle fibers and vessels at the inoculation site and adjacent tissue was observed. The renal tubular necrosis was attributed to shock. The volume increase at the inoculation site and surroundings was mainly due to hemorrhage (B. jararaca) or edema (B. jararacussu).

Aspectos orofaciais dos maus-tratos infantis e da negligência odontológica / Orofacial aspects of childhood abuse and dental negligence

O objetivo deste artigo foi identificar os principais aspectos orofaciais dos maus-tratos infantis e da negligência odontológica, contribuindo com a identificação destas vítimas no ambiente odontológico. Foi realizada uma pesquisa bibliográfica nas bases de dados Adolec, MEDLINE, LILACS e BBO. Utilizaram-se como descritores: maus-tratos infantis, manifestações bucais, odontólogos, papel (figurativo) e responsabilidade legal. Verificou-se que os maus-tratos infantis acontecem em geral em domicílio e os ferimentos orofaciais decorrentes incluem trauma, queimaduras e lacerações dos tecidos duros e moles, marcas de mordida e hematomas em vários estágios de cura. Pode haver ferimentos que envolvem outras partes do corpo próximas à cavidade bucal, como hematoma periorbital e contusão nasal. Quanto ao abuso sexual, muitas vítimas não apresentam nenhum sinal físico associado; assim, indicadores comportamentais devem ser observados. A imediata identificação e o relato de maus-tratos infantis e da negligência odontológica pelo cirurgião-dentista são essenciais para a proteção das crianças, sendo fundamental uma maior atuação destes profissionais, através do registro e denúncia dos casos suspeitos às agências de proteção à criança.

The aim of this paper was to identify the main oral and dental aspects of childhood abuse and dental neglect, contributing to the identification of these victims in a dental office. A bibliographic research was carried out, in ADOLEC, MEDLINE, LILACS and BBO databases. The following key words were used: child abuse, oral manifestations, dentists; role; liability, legal. It was verified that violence against children happens in general at home and the resulting orofacial injuries encompass: injuries, burns and lacerations on soft and hard tissues, bite marks and gradually-healed wounds. It can have wounds in other parts of the body next to the oral cavity, such as periorbital wound and nasal injury. Regarding sexual abuse, many victims do not present any associated physic signs; therefore, behavioral indicators must be observed. The immediate recognition and report of childhood abuse and dental negligence by dental surgeon are essential for children protection. Therefore, it is critical to define more effective action from those professionals, by registration and denunciation of suspect cases to child protection agencies.

Técnicas de controle do comportamento do paciente infantil: revisão de literatura / Techniques for controlling the behavior of pediatric patients: review of literature

Introdução: É comum na prática clínica odontológica infantil, manifestações de medo e ansiedade do paciente, que, quando não controladas pelo cirurgião-dentista, podem causar danos aos mecanismos emocionais da criança e comprometimento da qualidade do atendimento odontológico. Estas situações podem ser minimizadas por meio da construção de uma relação de confiança com o profissional mediante a aplicação e conhecimentos de psicologia infantil, possibilitando um melhor entendimento do comportamento da criança em tratamento odontológico e facilitando a orientação e abordagem dos pais nesta ocasião. É oportuno, pois, que o cirurgião-dentista conheça e institua estratégias adequadas de controle do comportamento na clínica infantil, favorecendo o estabelecimento de um ambiente propício para se obter sucesso nos procedimentos clínicos propostos. Objetivo: Revisar, por meio de pesquisa bibliográfica nas bases de dados MEDLINE e BBO, na literatura nacional de periódicos e livros especializados, bem como no protocolo sobre orientações de controle de comportamento de pacientes infantis da Academia Americana de Odontopediatria (AAPD), as principais técnicas não farmacológicas de auxílio do controle do comportamento na clínica infantil (comunicação verbal, dizer - mostrar - fazer, controle de voz, comunicação não verbal, reforço positivo, distração, presença ou ausência dos pais e contenção física). Conclusão: Verificou-se que a adoção de uma abordagem adequada da criança possibilita o atendimento odontológico através de técnicas não farmacológicas, assim como estimula uma relação profissional paciente favorável à promoção da saúde bucal do paciente infantil.

Introduction: In pediatric dentistry clinical practice, fear and anxiety manifestations are common and, if not handled by the dentist, they may damage the emotional mechanisms of the child and compromise the quality of the dental treatment. Such situations may be minimized by construing a relationship of confidence with the professional by applying child psychology knowledge, leading to a better understanding of the child's behavior under dental treatment and facilitating the orientation and approach to the parents on this occasion. It is therefore opportune that the dentist knows and applies adequate behavioral control strategies in the pediatric dentistry clinic, thereby establishing a good environment for the success of the proposed clinical procedures. Objective: To review Brazilian specialized books and scientific journals retrieved form MEDLINE and BBO databases as well as the American Academy of Pediatric Dentistry's (AAPD) protocol on the guidelines for monitoring and management of pediatric patients, the main non-pharmacological techniques for helping the behavior control in the pediatric dentistry clinic (verbal communication, tell - show - make, voice control, non-verbal communication, positive reinforcement, distraction, presence or absence of parents and physical restraint). Conclusion: It was observed that the adoption of an adequate approach to the child allows for providing the dental treatment by using non-pharmacological techniques and also stimulates a favorable professional/patient relationship to oral health promotion to the pediatric patient.

Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial

The aim of this randomized clinical trial study was to evaluate the therapeutic effect of two varnish formulations (G1 = 5 percent NaF, G2 = 6 percent NaF + 6 percent CaF2) on the remineralization of white spot lesions (WSL). The sample was composed of 15 (7- to 12-year-old) children with 45 active WSL in anterior permanent teeth. The children were randomly divided into two groups providing 22 lesions for G1 and 23 for G2. The children were submitted to weekly varnish applications 4 times. The WSL were evaluated twice: baseline and on week 4. Maximum lesion dimensions (mesiodistal and incisogingival) were measured in millimeters and classified in four grades of size. WSL were also assessed regarding lesion activity by one calibrated examiner. The Pearson chi-square and Fisher's exact tests were used (P < 0.01). WSL reductions were observed in both varnish groups (Chi-square = 0.15, d.f. = 1, P = 0.90), and with similar magnitude (in mm): 1.19 and 1.29 for G1 and G2, respectively. Thirty-six WSL (15 in G1 and 21 in G2) were classified as inactive on week 4, reaching an overall value of 80 percent. No difference was observed between G1 and G2 regarding activity scores (Fisher's exact test, p > 0.01). It was concluded that after 4 applications the two varnish formulations tested produced similar clinical effects, indicating the reduction and the control of carious activity in most WSL.