El profesional de enfermería especializado. ¿hace el mejor uso de la tecnología en el cuidado? / Compliance with the recommendations for physical activity set by the WHO by public bicycle users in a Spanish municipality

Introducción: La percepción de la integralidad del cuidado se logra cuando el profesional de enfermería integra con elevado nivel las competencias científicas, sociales, éticas y el uso de herramientas tecnológicas con la finalidad de conservar y recuperar la salud, a la medida de las necesidades y expectativas del ser cuidado. Objetivo: Analizar el desarrollo de evidencias científicas sobre el modo en que el profesional de enfermería especialista hace uso de la tecnología en el proceso de cuidado de la persona. Material y Métodos: Se realizó una búsqueda bibliográfica en las bases de datos Scielo, Lilacs, Medline, Redalyc, Scopus y Google Académico, en español, inglés y portugués. La información se consultó durante el periodo de 2019-2020, se utilizó un total de 25 referencias para su desarrollo. Resultados: El profesional de enfermería especialista utiliza los recursos tecnológicos en el proceso de cuidado y en otros pilares de su ejercicio laboral con ello se logra el cuidado integral al ser humano. Conclusiones: el profesional de enfermería especialista realiza dos grandes usos de los recursos tecnológicos en el proceso de cuidados: durante la asistencia del paciente para restaurar, mantener la salud, conservando la interacción con la familia y en los grandes pilares del ejercicio profesional: la gestión de los procesos de tratamiento y continuidad del cuidado; la docencia que asegura la excelencia de futuros profesionales y la investigación, de esta manera se aproxima a la oferta del cuidado humanizado, que constituye el ideal moral de la profesión(AU)

Introduction: The perception of the integrality of care is achieved when the nursing professional integrates, at a high level, the scientific, social, and ethical competencies and the use of technological tools to preserve and recover health, tailored to the needs and expectations of the being cared for. Objective: To analyze the development of scientific evidence on how the specialized nursing professional makes use of technology in the process of caring for the person. Material and Methods: A bibliographic search was carried out in the Scielo, Lilacs, Medline, Redalyc, Scopus, and Google Scholar databases in Spanish, English, and Portuguese. The information was consulted during the 2019-2020 period; a total of 25 references were used for its development. Results: The specialized nursing professional uses technological resources in the care process and other pillars of the work practice that contribute to providing comprehensive care to human beings. Conclusions: The specialized nursing professional makes two major uses of technological resources in the care process: during patient care itself to restore and maintain health, preserving interaction with the family; and in the great pillars of professional practice: management of treatment processes and continuity of care, teaching that ensures the excellence of future professionals, and research, thus approaching the offer of humanized care which is the moral ideal of the profession(AU)

From Inflammation to the Onset of Fibrosis through A2A Receptors in Kidneys from Deceased Donors.

Pretransplant graft inflammation could be involved in the worse prognosis of deceased donor (DD) kidney transplants. A2A adenosine receptor (A2AR) can stimulate anti-inflammatory M2 macrophages, leading to fibrosis if injury and inflammation persist. Pre-implantation biopsies of kidney donors (47 DD and 21 living donors (LD)) were used to analyze expression levels and activated intracellular pathways related to inflammatory and pro-fibrotic processes. A2AR expression and PKA pathway were enhanced in DD kidneys. A2AR gene expression correlated with TGF-ß1 and other profibrotic markers, as well as CD163, C/EBPß, and Col1A1, which are highly expressed in DD kidneys. TNF-α mRNA levels correlated with profibrotic and anti-inflammatory factors such as TGF-ß1 and A2AR. Experiments with THP-1 cells point to the involvement of the TNF-α/NF-κB pathway in the up-regulation of A2AR, which induces the M2 phenotype increasing CD163 and TGF-ß1 expression. In DD kidneys, the TNF-α/NF-κB pathway could be involved in the increase of A2AR expression, which would activate the PKA-CREB axis, inducing the macrophage M2 phenotype, TGF-ß1 production, and ultimately, fibrosis. Thus, in inflamed DD kidneys, an increase in A2AR expression is associated with the onset of fibrosis, which may contribute to graft dysfunction and prognostic differences between DD and LD transplants.

Genetic Variants Associated with Chronic Kidney Disease in a Spanish Population.

Chronic kidney disease (CKD) patients have many affected physiological pathways. Variations in the genes regulating these pathways might affect the incidence and predisposition to this disease. A total of 722 Spanish adults, including 548 patients and 174 controls, were genotyped to better understand the effects of genetic risk loci on the susceptibility to CKD. We analyzed 38 single nucleotide polymorphisms (SNPs) in candidate genes associated with the inflammatory response (interleukins IL-1A, IL-4, IL-6, IL-10, TNF-α, ICAM-1), fibrogenesis (TGFB1), homocysteine synthesis (MTHFR), DNA repair (OGG1, MUTYH, XRCC1, ERCC2, ERCC4), renin-angiotensin-aldosterone system (CYP11B2, AGT), phase-II metabolism (GSTP1, GSTO1, GSTO2), antioxidant capacity (SOD1, SOD2, CAT, GPX1, GPX3, GPX4), and some other genes previously reported to be associated with CKD (GLO1, SLC7A9, SHROOM3, UMOD, VEGFA, MGP, KL). The results showed associations of GPX1, GSTO1, GSTO2, UMOD, and MGP with CKD. Additionally, associations with CKD related pathologies, such as hypertension (GPX4, CYP11B2, ERCC4), cardiovascular disease, diabetes and cancer predisposition (ERCC2) were also observed. Different genes showed association with biochemical parameters characteristic for CKD, such as creatinine (GPX1, GSTO1, GSTO2, KL, MGP), glomerular filtration rate (GPX1, GSTO1, KL, ICAM-1, MGP), hemoglobin (ERCC2, SHROOM3), resistance index erythropoietin (SOD2, VEGFA, MTHFR, KL), albumin (SOD1, GSTO2, ERCC2, SOD2), phosphorus (IL-4, ERCC4 SOD1, GPX4, GPX1), parathyroid hormone (IL-1A, IL-6, SHROOM3, UMOD, ICAM-1), C-reactive protein (SOD2, TGFB1,GSTP1, XRCC1), and ferritin (SOD2, GSTP1, SLC7A9, GPX4). To our knowledge, this is the second comprehensive study carried out in Spanish patients linking genetic polymorphisms and CKD.

Three cases of monoclonal gammopathy of renal significance after kidney transplantation. De novo C3 glomerulopathy. / Tres casos de gammapatía monoclonal de significado renal postrasplante renal: nefropatía c3 de novo.

Monoclonal gammopathy of renal significance includes all renal disorders caused by a monoclonal immunoglobulin secreted by a non-malignant B-cell clone. Patients with MGRS do not, by definition, meet criteria for multiple myeloma, with haematological disorders generally considered to be monoclonal gammopathy of undetermined significance. Nevertheless, the renal involvement can be serious and require specific treatment. Monoclonal gammopathy of renal significance is associated with a wide spectrum of disorders, including the recently discovered C3 glomerulopathy. Development of C3 glomerulopathy in the context of monoclonal gammopathy of renal significance after kidney transplantation is uncommon and very few cases have been published to date. We report on three cases of C3 glomerulopathy in the context of de novo monoclonal gammopathy after kidney transplantation.

Morpho-anatomy of leaves and yield of pineapple plant in intercropping with cassava / Morfoanatomia foliar e produtividade de abacaxizeiro consorciado com mandioca

The aims of this study were to evaluate the effects of shade in pineapple plant with cassava, on the yields of pineapple fruit sand cassava roots, on the morph-anatomical variation, damage by solar radiation and chlorophyll content of pineapple leaves. Pineapple plants were cultivated in plots comprising three parallel row sunder different shade conditions provided by cassava plants grown at various spacings within single rows located on either side of the plots. The experiment was of a randomized block design with five treatments (cassava spacings of 0.50, 0.75, 1.00 and 1.25 m and a pineapple monoculture) and four replications. Yields of fruits and roots, together with the morphological, chemical and histological characteristics of the "D" leaves of pineapple, were determined14 months after planting the pineapples plant. Data were submitted to analysis of variance with the Scott-Knott test or Friedman test (P< 0.05) and to regression analysis. Pineapple plants grown under the majority of shade conditions presented higher fruit weight and overall yield per hectare in comparison with plants grown in direct sunlight. The maximum productivities of pineapple fruit were achieved when cassava plants were spaced 0.75 m apart and, under these shade conditions, fruits were fully protected against burning by the sun. The "D" leaves of shaded plants were longer and thicker, with higher content of chlorophyll a and total chlorophyll, reduced stomatal density and dimensions of stomatal pores, narrower guard cells, thinner aquiferous hypodermis, and reduced abaxial and adaxial epidermis. The yield of cassava roots per plant increased linearly with increasing distance between the plants, but the yield per hectare decreased with decreasing plant density.

Os objetivos desse trabalho foram avaliar o efeito do sombreamento no abacaxizeiro com mandioca, sobre a produtividade de abacaxi e raízes de mandioca, sobre a variação morfoanatômica, queimadura do abacaxi pela radiação e os teores de clorofilas nas folhas do abacaxizeiro. As plantas de abacaxizeiro foram cultivadas em parcelas compreendendo linhas triplas paralelas (segundo um arranjo triangular) sob diferentes condições de sombreamentos proporcionadas por plantas de mandioca cultivadas em linhas simples em cada lado das parcelas. O delineamento utilizado foi de blocos casualizados com cinco tratamentos (sombreamento com mandioca em espaçamentos de 0,50, 0,75, 1,00 e 1,25 m e monocultivo de abacaxi) e quatro repetições. As produtividades de abacaxi e mandioca, juntamente com as características morfológicas, químicas e histológicas da folhas "D" dos abacaxizeiros, foram determinadas 14 meses após o plantio. Os dados foram submetidos à análise de variância com teste de Scott-Knott ou teste de Friedman (P< 0,05) bem como análise de regressão. Abacaxizeiros cultivados sob sombreamento produziram frutos com maior peso médio e maior produtividade por hectare em comparação com plantas cultivadas sob luz solar direta. A máxima produtividade de abacaxi foi alcançada quando o espaçamento entre as plantas de mandioca foi de 0,75 m e, sob essas condições, os frutos ficaram completamente protegidos da radiação solar. As folhas "D" dos abacaxizeiros sombreados foram mais longas e espessas, apresentaram maior concentração de clorofila a e total, densidade estomática reduzida, poros estomáticos menores, células guarda mais estreitas, hipoderme aquífera mais fina e epidermes abaxial e adaxial reduzidas. A produtividade de mandioca por planta aumentou linearmente com o espaçamento crescente, porém a produtividade por hectare diminuiu com o decréscimo da densidade das plantas.

Mineral metabolism disorders, vertebral fractures and aortic calcifications in stable kidney transplant recipients: The role of gender (EMITRAL study).

BACKGROUND AND OBJECTIVES: The relationship between mineral metabolism disorders, bone fractures and vascular calcifications in kidney transplant recipients has not been established. METHOD: We performed a cross-sectional study in 727 stable recipients from 28 Spanish transplant clinics. Mineral metabolism parameters, the semi-quantification of vertebral fractures and abdominal aortic calcifications were determined centrally. RESULTS: Vitamin D deficiency (25OHD3<15ng/ml) was more common in female recipients at CKD-T stages I-III (29.6% vs 44.4%; p=0.003). The inverse and significant correlation between 25OHD3 and PTH was gender-specific and women exhibited a steeper slope than men (p=0.01). Vertebral fractures (VFx) with deformity grade ≥2 were observed in 15% of recipients. Factors related to VFx differed by gender; in males, age (OR 1.04; 95% CI 1.01-1.06) and CsA treatment (OR: 3.2; 95% CI: 1.6-6.3); in females, age (OR 1.07; 95% CI: 1.03-1.12) and PTH levels (OR per 100pg/ml increase: 1.27; 95% CI: 1.043-1.542). Abdominal aortic calcifications were common (67.2%) and related to classical risk factors but not to mineral metabolism parameters. CONCLUSIONS: Vitamin D deficiency is more common among female kidney transplant recipients at earlier CKD-T stages, and it contributes to secondary hyperparathyroidism. Prevalent vertebral fractures are only related to high serum PTH levels in female recipients.

Radiosensitivity in patients suffering from chronic kidney disease.

PURPOSE: Patients suffering from chronic kidney disease (CKD) exhibit a high incidence of cancer, as well as high levels of genetic damage. We hypothesized that these patients show genomic instability detected as an increased chromosomal radiosensitivity in front of the genetic damage induced by ionizing radiation. MATERIAL AND METHODS: The background levels of genetic damage and the net genetic damage after in vitro irradiation with 0.5 Gy were analyzed using the micronucleus (MN) assay in peripheral blood lymphocytes. A total number of 552 individuals (179 controls and 373 CKD patients) were included in the study. RESULTS: The net radiation-induced genetic damage was significantly higher in CKD patients than in controls; but no differences between those patients submitted to hemodialysis and those in pre-dialytic stages were detected. A positive correlation was observed between basal and net micronucleus frequencies in CKD patients what would indicate an underlying genetic background modulating DNA damage levels. CONCLUSIONS: Our results indicate that CKD patients present genomic instability, measured as an increased chromosomal radiosensitivity in front of ionizing radiation.

Genomic damage as a biomarker of chronic kidney disease status.

Patients suffering from chronic kidney disease (CKD) exhibit a high incidence of cancer and cardiovascular diseases, as well as high levels of genomic damage. To confirm the association of CKD with genomic damage we have carried out the largest study to date addressing this issue, using a total of 602 subjects (187 controls, 206 pre-dialysis CKD patients and 209 CKD patients in hemodialysis). DNA oxidative damage was measured in all individuals using the comet assay. Our results indicate that CKD patients have significantly higher levels of DNA damage than controls, but no significant differences were observed between pre-hemodialysis (pre-HD) and hemodialysis (HD) patients. When oxidative damage was measured, no differences were observed between patients and controls, although HD patients showed significantly higher levels of oxidative damage than pre-HD patients. In addition, a positive relationship was demonstrated between genomic damage and all-cause mortality. Our study confirms that genomic damage can be predictive of prognosis in CKD patients, with high levels of DNA damage indicating a poor prognosis in HD patients.

HLA-DQA1 and PLA2R1 polymorphisms and risk of idiopathic membranous nephropathy.

BACKGROUND AND OBJECTIVES: Single nucleotide polymorphisms (SNPs) within HLA complex class II HLA-DQ α-chain 1 (HLA-DQA1) and M-type phospholipase A2 receptor (PLA2R1) genes were identified as strong risk factors for idiopathic membranous nephropathy (IMN) development in a recent genome-wide association study. Copy number variants (CNVs) within the Fc gamma receptor III (FCGR3) locus have been associated with several autoimmune diseases, but their role in IMN has not been studied. This study aimed to validate the association of HLA-DQA1 and PLA2R1 risk alleles with IMN in a Spanish cohort, test the putative association of FCGR3A and FCGR3B CNVs with IMN, and assess the use of these genetic factors to predict the clinical outcome of the disease. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: A Spanish cohort of 89 IMN patients and 286 matched controls without nephropathy was recruited between October of 2009 and July of 2012. Case-control studies for SNPs within HLA-DQA1 (rs2187668) and PLA2R1 (rs4664308) genes and CNVs for FCGR3A and FCGR3B genes were performed. The contribution of these polymorphisms to predict clinical outcome and renal function decline was analyzed. RESULTS: This study validated the association of these HLA-DQA1 and PLA2R1 SNPs with IMN in a Spanish cohort and its increased risk when combining both risk genotypes. No significant association was found between FCGR3 CNVs and IMN. These results revealed that HLA-DQA1 and PLA2R1 genotype combination adjusted for baseline proteinuria strongly predicted response to immunosuppressive therapy. HLA-DQA1 genotype adjusted for proteinuria was also linked with renal function decline. CONCLUSION: This study confirms that HLA-DQA1 and PLA2R1 genotypes are risk factors for IMN, whereas no association was identified for FCGR3 CNVs. This study provides, for the first time, evidence of the contribution of these HLA-DQA1 and PLA2R1 polymorphisms in predicting IMN response to immunosuppressors and disease progression. Future studies are needed to validate and identify prognostic markers.

Clinical utility of genetic testing in children and adults with steroid-resistant nephrotic syndrome.

BACKGROUND AND OBJECTIVES: The increasing number of podocyte-expressed genes implicated in steroid-resistant nephrotic syndrome (SRNS), the phenotypic variability, and the uncharacterized relative frequency of mutations in these genes in pediatric and adult patients with SRNS complicate their routine genetic analysis. Our aim was to compile the clinical and genetic data of eight podocyte genes analyzed in 110 cases (125 patients) with SRNS (ranging from congenital to adult onset) to provide a genetic testing approach. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Mutation analysis was performed by sequencing the NPHS1, NPHS2, TRPC6, CD2AP, PLCE1, INF2, WT1 (exons 8 and 9), and ACTN4 (exons 1 to 10) genes. RESULTS: We identified causing mutations in 34% (37/110) of SRNS patients, representing 67% (16/24) familial and 25% (21/86) sporadic cases. Mutations were detected in 100% of congenital-onset, 57% of infantile-onset, 24 and 36% of early and late childhood-onset, 25% of adolescent-onset, and 14% of adult-onset patients. The most frequently mutated gene was NPHS1 in congenital onset and NPHS2 in the other groups. A partial remission was observed in 7 of 26 mutation carriers treated with immunosuppressive agents and/or angiotensin-converting enzyme inhibitors. Patients with NPHS1 mutations showed a faster progression to ESRD than patients with NPHS2 mutations. None of these mutation carriers relapsed after kidney transplantation. CONCLUSIONS: We propose a genetic testing algorithm for SRNS based on the age at onset and the familial/sporadic status. Mutation analysis of specific podocyte-genes has a clinical value in all age groups, especially in children.

Mortalidade de Blattella germanica (L., 1767) (Blattodea: blattellidae) sob diferentes áreas e períodos de exposição a diferentes inseticidas / Mortality of Blatella germanica under different exposure area and duration to insecticides

A maior importância das baratas como praga domiciliar é devida ligada à sua capacidade de disseminar microorganismos nocivos ao homem e à outros animais. Durante o dia repousam em ambientes sépticos, escuro, úmidos e quentes como em esgotos. À noite exploram armazéns e cozinhas ou locais de manipulação e depósito de alimentos como padarias, restaurantes, hospitais e residências que requerem higienização constante. Neste trabalho objetivou-se avaliar a mortalidade de Blattella germanica (L., 1767) (Blattodea: Blattellidae) em laboratório sob diferentes períodos e áreas de exposição em superfícies tratadas com inseticidas. Os testes foram realizados no Departamento de Fitossanidade da UNESP, Campus de Jaboticabal, SP. A aplicação dos inseticidas foi realizada em torre de Potter sobre placas de Petri, em três tempos de exposição (2, 8 e 32 min) e quatro áreas de exposição (25, 50, 75 e 100%). Foram utilizados os inseticidas piretróides gamacialotrina, deltametrina, lambdacialotrina, alfacipermetrina e cipermetrina e o carbamato bendiocarb, nas dosagens recomendadas pelos fabricantes, comparados a uma testemunha sem aplicação. Foram confinadas cinco baratas adultas sobre a placa para os dois experimentos. A avaliação da mortalidade foi realizada 0, 1, 2, 4, 24, 48 e 72 horas após confinamento na superfície tratada. Para o período de exposição, os produtos resultaram em uma boa eficiência e para “área de exposição” o inseticida cipermetrina apresentou uma maior mortalidade. Em relação aos períodos de exposição, todos tempos resultaram em uma mortalidade eficiente. Para a área de exposição, a maior mortalidade foi observada para a aplicação do produto na área total.

The great importance of cockroaches as household pest have been on their ability to spread microorganisms harmful to humans and animals. Rest during the day in dark, humid and hot as sewerage. At night go into stores and kitchens or places to deposit and manipulation of food as bakeries, restaurants, hospitals and homes wich requires clinig operations. This work aimed to evaluate mortality of B. germanica (L., 1767) (Blattodea: Blattellidae) under different periods and exposure area treated by insecticides in laboratory. The tests were carried out at Department of Fitossanidade at UNESP, Campus of Jaboticabal, SP, Brasil. The insecticides were applied by Potter's tower sprayer on Petri dishes. Three times of exposure (2, 8 and 32 min) and four exposure areas (25, 50, 75 and 100%) and volume of 0,5 ml for the second experiment were tested. It was used the insecticides Pyrethroids gammacyalothrine, deltamethrine, lambdacialothrine, alfacipermethrine, cipermethrine and carbamates bendiocarb, in the dosages recommended by the manufacturers, and I was used control without application. Five adult cockroaches was confined in the dishes for both experiments. The mortality evaluation was done 0, 1, 2, 4, 24, 48 and 72 hours after of the confinement on the treated surface. It was concluded that for exposure duration experiment all the insecticides have a good efficiency. The exposure area experiment the insecticide cipermethrine was what the one which had the higher mortality. Regarding to the effect of exposure duration on the accumulated mortality every duration times had a high mortality. In relation to the exposure area the highest mortality reached to 100% of treated area.

Cuidado, autocuidado e cuidado de si: uma compreensão paradigmática para o cuidado de enfermagem / Cuidado, auto cuidado y cuidado de sí: una comprensión paradigmática para el cuidado de enfermería / Care, self-care and caring for yourself: a paradigmatic understanding thought for nursing care

Este artigo tem como objetivo apresentar uma reflexão sobre os conceitos de cuidado, autocuidado e o cuidado de si, estabelecendo suas relações com os paradigmas da totalidade e da simultaneidade. Na primeira parte do texto, contextualiza-se o cuidado nos seus aspectos gerais; na segunda parte aborda-se o cuidado na perspectiva filosófica de Martin Heidegger; na terceira parte explora-se o autocuidado na concepção de Dorothea Orem; na quarta parte discute-se o cuidado de si preconizado por Michael Foucault; e finalmente, na quinta parte, busca-se estabelecer a relação entre os conceitos autocuidado e o cuidado de si, com os paradigmas da totalidade e da simultaneidade. O autocuidado e o cuidado de si estão atrelados ao objetivismo da totalidade, e ao subjetivismo da simultaneidade havendo, para a Enfermagem, a necessidade de se compreender esta herança paradigmática e suas implicações para o cuidado de enfermagem.

This article presents a reflection about care, self-care and caring for oneself and establishes these issues' relations with the paradigms of totality and simultaneity. On the first part of the text, care and its general aspects are contextualized; the second part discusses about care in Martin Heidegger's philosophical perspective; the third part explores self-care on Dorothea Orem's conception; the fourth part considers Michel Foucault's care of oneself. And finally, the fifth part aims to establish the relationship between the concepts of self-care and care of oneself, and the totality and simultaneity paradigms. Self-care and care of oneself are connected to the objectivism of the totality, and to the subjectivism of the simultaneity. These subjects lead nursing to comprehend such paradigmatic inheritance and its implications on the nursing care.

Este artículo tiene como objetivo presentar una reflexión sobre los conceptos de cuidado, auto cuidado y el cuidado de sí, estableciendo sus relaciones con los paradigmas de la totalidad y de la simultaneidad. En la primera parte del texto se contextualiza el cuidado en sus aspectos generales; en la segunda parte se aborda el cuidado en la perspectiva filosófica de Martin Heidegger; en la tercera parte se explora el auto cuidado en la concepción de Dorothea Orem; en la cuarta parte se discute el cuidado de sí preconizado por Michael Foucault, y finalmente en la quinta parte, se busca establecer la relación entre los conceptos auto cuidado y el cuidado de sí, con los paradigmas de la totalidad y de la simultaneidad. El auto cuidado y el cuidado de sí están unidos al objetivismo de la totalidad, y al subjetivismo de la simultaneidad habiendo, para la Enfermería, la necesidad de comprender esta herencia paradigmática y sus implicaciones para el cuidado de enfermería.

Infecção do sítio cirúrgico: uma contribuição de enfermagem à prevenção / Infection of small farm cirurgico: a contribution the nursing prevention

O estudo teve como objetivos determinar a incidência das infecções do sítio cirúrgico (ISC) na Clínica Cirúrgica de Abdome, do Hospital Público Ofir Loyola (HOL), no Estado do Pará, descrever os casos de ISC e identificar os fatores de risco relacionados a essas infecções. Metodologia: Trata-se de um estudo descritivo de corte seccional, que acompanhou um grupo de pacientes submetidos à cirurgia no período de maio a outubro de 2002. ...

Síndrome de Ellis Van Creveld: apresentaçäo de um caso / Ellis-Van Creveld syndrome: report of a case

Apresenta-se um caso de displasia condroectodérmica, em criança de 36 meses de idade. Discutem-se as características clínicas e tecem-se consideraçöes sobre o diagnóstico diferencial