A atuação coordenadora do governo do Rio Grande do Norte no combate à covid-19: inovação em tempos de crise? / The coordination role of Rio Grande do Norte state government in response to covid-19: Innovation in times of crisis?

Resumo A partir de um estudo de caso do Rio Grande do Norte, este artigo discute o papel dos estados na coordenação da saúde durante a pandemia do novo coronavírus. A ausência de coordenação federal no enfrentamento do surto pandêmico no Brasil tem sido compreendida por diversos analistas como algo inédito na federação brasileira, rompendo com um padrão recorrente de normatização e indução nacional por diferentes governos desde a Constituição de 1988. Nesse sentido, estados e municípios passaram a adotar iniciativas próprias para o enfrentamento da pandemia. A partir de uma pesquisa qualitativa baseada em dados documentais - mídia local, boletins epidemiológicos e regulamentações estaduais - e em entrevistas semiestruturadas com gestores estaduais e municipais, foi possível identificar mudanças na relação estado-municípios durante a pandemia no Rio Grande do Norte, caso marcado, historicamente, pela ausência de cooperação estadual. A pandemia, dessa forma, funcionou como um choque exógeno, que induziu uma mudança no padrão de atuação do governo estadual na saúde. Não está claro, porém, se essas alterações são pontuais ou permanentes, na medida em que o peso do autorreforço - especificação dos efeitos do legado histórico - atua como um mecanismo que produz dinâmicas inerciais de difícil rompimento com o passado.

Abstract From a case study of the State of Rio Grande do Norte, in Brazil, this article discusses the role of states in coordinating healthcare with its local governments in the context of the new coronavirus pandemic. The absence of federal government initiatives in responding to the pandemic in Brazil have been acknowledged by several specialists as an unprecedented event in the Brazilian federation, breaking with a recurrent pattern of national coordination and regulation by different governments since the 1988 Constitution. In this sense, states and municipalities had to adopt their own initiatives to respond to the pandemic. Qualitative research based on the collection of documents (local media, epidemiological reports, and state regulations) and in-depth interviews with state and municipal managers reveals significant changes in the state-municipal relationship throughout the pandemic period in Rio Grande do Norte, a state historically characterized by the lack of state coordination. The pandemic, thus, functioned as an exogenous shock, which induced changes in the pattern of state coordination in healthcare. It is unclear, however, whether these changes are one-off or permanent since the weight of increasing returns - a specification of a path dependency process - seem to work as a mechanism producing inertial dynamics of difficult disruption with the past.

Efectores pretendidamente específicos: problemáticas, tensiones y obstáculos para la construcción de redes de cuidados / Pretending to be specific effectors: problems, tensions and obstacles for the construction of care networks

El Hospital Interzonal Especializado en Toxicología y Salud Mental Reencuentro, del cual formamos parte como residentes posbásicos, no estuvo exento de las modificaciones que fueron necesarias implementar durante el período pandémico, en pos de garantizar la atención y acompañamiento de usuarios ya atendidos en el Hospital o demandas nuevas que comenzaban a llegar efecto de la situación sanitaria reinante. La virtualidad y los contactos telefónicos con lxs pacientes fueron los recursos principales para sostener la asistencia durante ese período. Este modo de acompañamiento a distancia facilitó el acceso de usuarixs que no se encontraban georreferenciados con la institución. La situación pandémica puso así de relieve una lógica de derivación al efector pretendidamente específico en determinada problemática, anteriormente imperante, aunque ahora acrecentada. Se dará cuenta en el presente escrito de las problemáticas, tensiones y obstáculos que nos hemos encontrado para la atención y la construcción de redes de cuidados en el territorio, de usuarixs de otros barrios y comunidades no georreferenciadas con el Hospital sede

Inter-institutional Variation in Intensity-modulated Radiotherapy for Breast Cancer in Korea (KROG 19-01).

BACKGROUND/AIM: To present the variations in the target delineation and the planning results of intensity-modulated radiation therapy (IMRT) for breast cancers. PATIENTS AND METHODS: We requested the target volumes and organs at risk delineation for two cases of left breast cancers, and evaluated the IMRT plans including the supraclavicular and internal mammary node irradiation. RESULTS: Twenty-one institutions participated in this study. Differences in the planning target volume among institutions reached up to three-times for breast-conserving surgery (BCS) case and five-times for mastectomy case. Mean heart doses ranged from 3.3 to 24.1 Gy for BCS case and from 5.0 to 26.5 Gy for mastectomy case. Ipsilateral lung volumes receiving more than 20 Gy ranged from 4.7 to 57.4% for BCS case and from 16.4 to 55.5% for mastectomy case. CONCLUSION: There were large variations in the target delineation and planning results of IMRT for breast cancers among institutions. Considering the increased use of breast IMRT, more standardized protocols are needed.

Religion and the World Health Organization: an evolving relationship.

Much has been written about WHO. Relatively little is known, however, about the organisation's evolving relationship with health-related personal beliefs, 'faith-based organisations' (FBOs), religious leaders and religious communities ('religious actors'). This article presents findings from a 4-year research project on the 'spiritual dimension' of health and WHO conducted at the University of Zürich. Drawing on archival research in Geneva and interviews with current and former WHO staff, consultants and programme partners, we identify three stages in this relationship. Although since its founding individuals within WHO occasionally engaged with religious actors, it was not until the 1970s, when the primary healthcare strategy was developed in consultation with the Christian Medical Commission, that their concerns began to influence WHO policies. By the early 1990s, the failure to roll out primary healthcare globally was accompanied by a loss of interest in religion within WHO. With the spread of HIV/AIDS however, health-related religious beliefs were increasingly recognised in the development of a major quality of life instrument by the Division of Mental Health, and the work of a WHO expert committee on cancer pain relief and the subsequent establishment of palliative care. While the 1990s saw a cooling off of activities, in the years since, the HIV/AIDS, Ebola and COVID-19 crises have periodically brought religious actors to the attention of the organisation. This study focusses on what we suggest may be understood as a trend towards a closer association between the activities of WHO and religious actors, which has occurred in fits and starts and is marked by attempts at institutional translation and periods of forgetting and remembering.

Leveraging Academic-Clinical Partnerships to Create an Operating Room Nurse Pipeline.

This article describes an academic-clinical partnership program between a school of nursing and an American Nurse Credentialing Center Magnet®- and National Cancer Institute-designated Comprehensive Cancer Center based on a shared vision and multifaceted for optimal new graduate operating room (OR) recruitment and use of clinical partner resources. The program, now in its 3rd year, has a 100% retention rate among the cohorts. Implementing a multifaceted OR partnership program based on nursing theory is a strategy for workforce development to increase retention of new graduate OR nurses.

The costs and benefits of duality: Colombia's decentralization and the response to the COVID-19 pandemic / Custos e benefícios da dualidade: a descentralização da Colômbia e a resposta à pandemia de COVID-19 / Los costos y efectos de la dualidad: descentralización en Colombia y la respuesta a la pandemia de COVID-19

Abstract Colombia's duality between the relative strength of the central government and the broad process of decentralization towards subnational and local governments has shaped the country's response to the COVID-19 pandemic. Substantial tensions have arisen between the national and subnational governments in the handling of the crisis. Thus, blurred policy boundaries challenge multi-level government coordination. Yet, intergovernmental relations and multi-level governance have worked at some extent. Meanwhile, leadership styles, the level of political support, the local governance environment and the level of local institutional capacity have affected the strategies of local government leaders and their success to tackle the pandemic. Moreover, uneven healthcare capacity across the Colombian territory posits further challenges for a national response to the pandemic that ensures both effectiveness and equity.

Resumo A dualidade da Colômbia, entre a força relativa do governo central e o amplo processo de descentralização com fortalecimento de governos subnacionais e locais, estabeleceu os contornos da resposta do país à pandemia de COVID-19. Testemunhou-se uma substancial tensão entre os governos nacional e subnacionais no tratamento da crise. Os limites pouco claros das políticas desafiam a coordenação governamental em vários níveis. No entanto, as relações intergovernamentais e a governança em vários níveis funcionaram até certo ponto. Enquanto isso, os estilos de liderança, o nível de apoio político, o ambiente local de governança e o nível local de capacidade institucional, afetaram as estratégias das lideranças governamentais locais e seu sucesso no combate à pandemia. Além disso, as desigualdades na capacidade de prover serviços de saúde em todo o território colombiano apresentam desafios adicionais para uma resposta nacional à pandemia que garanta efetividade e equidade.

Resumen La dualidad del modelo unitario descentralizado de Colombia, entre la fuerza relativa del gobierno central y el amplio proceso de descentralización hacia los gobiernos subnacionales y locales ha influido en la respuesta del país frente a la pandemia de COVID-19. Algunas tensiones sustanciales han aparecido entre los gobiernos nacional y subnacionales en el manejo de la crisis. Un contexto con algunos límites jurisdiccionales borrosos impone un reto a la coordinación gubernamental multinivel. Sin embargo, las relaciones intergubernamentales y la gobernanza multinivel parecen haber funcionado en alguna medida. Por otro lado, los estilos de liderazgo, el nivel de apoyo político, el entorno local de gobernanza y el nivel local de capacidad institucional han afectado las estrategias de las autoridades locales y su éxito al enfrentar la pandemia. Más aun, las disparidades en la capacidad de protección en salud a lo largo del territorio colombiano plantean desafíos adicionales para una respuesta coordinada nacional a la pandemia que asegure tanto efectividad como equidad.

Desterritorializando el encuentro con la urgencia / Deterritorializing the meeting with the urgency

El equipo Red7 despliega sus acciones, fundamentalmente, en el abordaje integral de la urgencia en salud mental en el territorio de la Región VII. A su vez, su propuesta incluye un trabajo de comunicación, articulación y enlace con otros efectores y dispositivos que conforman la red de salud general, incorporando dimensiones interdisciplinarias e intersectoriales. Estructurado sobre la lógica de redes en salud y las líneas de cuidado, Red7 trabaja cotidianamente de forma entrelazada con todos estos otros actores del campo, buscando consolidar un modelo de abordaje de la urgencia que contemple una posición desterritorializante, lo cual favorece las estrategias posibles y amplía el campo de intervención, contemplando siempre el horizonte el cuidado de la salud mental de la persona a la que se dirige y su grupo familiar. Así, el presente trabajo busca desarrollar este esquema de trabajo, exponiendo sus bases y movimientos nodales, buscando fomentar una dinámica de trabajo conjunta e integral entre los equipos de salud de la Región

"Ruidos": otras formas de abordaje con jóvenes / Noises, other ways of approaching young people

En esta presentación se pretende exponer el trabajo que se realiza desde el año 2015 con jóvenes en situación de vulnerabilidad de la ciudad de Pehuajó, en un dispositivo con base comunitaria, ante la dificultad de abordaje de esta franja etaria desde el espacio ambulatorio con el que cuenta el CPA. Este proyecto denominado "Ruidos" habilita la posibilidad de acercamiento e intervención con estos adolescentes, que portan una doble exclusión; no solo están caídos del relato social como sujetos de derecho, moviéndose en los márgenes que le permite el sistema, sino también, por sus problemáticas, padecen fuerte rechazo y a veces exclusión del ámbito familiar. Enmarcados en la Ley Nacional de Salud Mental Nº 26.657 se trabaja para promover instancias de inclusión y rehabilitación, desde una perspectiva integral de la salud mental, mediante la participación de los adolescentes en actividades recreativas, deportivas, artísticas y culturales. Se posibilita así ampliar la oferta institucional para atender necesidades y demandas específicas y particulares de dicha población. Nos planteamos como objetivo ofrecer otro lugar de pertenencia generando diversas tareas que adquieran un fuerte sentido para los jóvenes, donde puedan anudar algo de su inquietud personal en el marco de un espacio grupal. Para esta labor se requiere un trabajo interdisciplinario en articulación con instituciones provinciales, nacionales y áreas municipales a fin del armado del equipo profesional y de todo lo concerniente a la tarea que se realiza. Compartiremos en este trabajo un aporte sobre otros posibles modos de intervención que se realizan, para intentar que estos jóvenes se impliquen en la construcción de un proyecto de vida saludable

Dispositivo de orientación de consumos problemáticos en un hospital general (2007-2020): peripecias en el armado de una RED / Guidance Device for Problematic Consumption in a General Hospital (2007-2020): ups and downs in a network creation

La propuesta es dar cuenta del surgimiento y trayectoria de un dispositivo de orientación de adicciones dependiente de la Subsecretaría, que en el año 2007 se instaló en la guardia de un Hospital General. En sus inicios el objetivo fue cumplir con una de las metas de gestión (2003-2007) que implicaba incrementar la cobertura asistencial, articulando con estructuras de la administración pública ya existentes; favoreciendo además la visibilidad de la Red. A partir de estas premisas entendimos que abrir un espacio de adicciones dentro del contexto de Emergencias de un Hospital General, abocado a la recepción de pacientes con consumo, beneficiaría a "la población de consumidores de drogas y alcohol, altamente resistente a demandar asistencia especializada"(Planificación de Gestión 2003-2007). Cabe remarcar que la Ley Nacional de Salud Mental no había sido sancionada y los usuarios parecían carecer de derechos a una cobertura sanitaria. Desde el año 2007 hasta el presente, diferentes fueron las estrategias de abordaje siendo el eje de trabajo la interdisciplina y el enlace con organizaciones e instituciones ocupadas en el tema. El armado y consolidación de la red fue lo que hizo posible la continuidad del dispositivo y la ampliación de espacios de abordaje. El quehacer cotidiano no hubiese sido posible sin la participación y la colaboración activa de diferentes sectores, pues hubiera quedado reducido a un trabajo monodisciplinar en el que nuestro proyecto quizás, hubiera naufragado

Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental / Lucha contra la COVID-19 bajo el federalismo bolsonarista: un caso de descoordinación intergubernamental / Combating COVID-19 under Bolsonaros federalism: a case of intergovernmental incoordination

Resumo Este artigo analisa como o federalismo brasileiro tem afetado o combate à COVID-19. Tendo por base uma análise histórico-institucional do caso brasileiro, busca-se compreender como o modelo federativo construído pelo governo Bolsonaro influenciou as respostas ao combate da pandemia no país, bem como os resultados do confronto de dois modelos federativos nesse processo. De um lado, o ideário e as estruturas institucionais da Constituição de 1988 com características cooperativas e forte coordenação federal. De outro, o federalismo bolsonarista baseia-se numa visão dualista de relações intergovernamentais, com menor participação da União na redução de desigualdades territoriais e no apoio a governos subnacionais, além da postura centralizadora e hierárquica nas questões de impacto nacional. O estudo mostra que o federalismo bolsonarista aumentou o conflito com governos subnacionais e tem descoordenado políticas públicas de enfrentamento à pandemia. Conclui-se que as crises sanitária e federativa caminham juntas e trazem à tona uma questão chave: a importância da coordenação governamental nas políticas públicas de enfrentamento à pandemia.

Resumen Este artículo analiza cómo el federalismo brasileño ha afectado la lucha contra la COVID-19. A partir de un análisis histórico-institucional del caso brasileño, buscamos comprender cómo el modelo federativo construido por el gobierno de Bolsonaro influyó en las respuestas para combatir la pandemia en el país, así como los resultados de la confrontación de dos modelos federativos en este proceso. Por un lado, el ideario y las estructuras institucionales de la Constitución de 1988 con características cooperativas y una fuerte coordinación federal. Por otro, el federalismo bolsonarista que se basa en una visión dualista de las relaciones intergubernamentales, con menos participación del Gobierno Federal en la reducción de las desigualdades territoriales y en el apoyo a los gobiernos subnacionales, además de la postura centralizadora y jerárquica en materias de impacto nacional. El estudio muestra que el federalismo bolsonarista ha aumentado el conflicto con los gobiernos subnacionales y ha descoordinado las políticas públicas de combate a la pandemia. Se concluye que las crisis sanitaria y federativa van juntas y plantean una cuestión clave: la importancia de la coordinación gubernamental en la implementación de políticas públicas de enfrentamiento a la pandemia y sus efectos sociales y económicos.

Abstract This article analyzes how federalism has affected policy responses to the COVID-19 pandemic in Brazil. Through historical-institutional analysis, the study examines how the model of federalism adopted by President Bolsonaro's government influenced policy responses to the pandemic in the country. In addition, the research points out the existence of two models of federalism in the case analyzed, addressing the outcomes of the confrontation between them. The first model refers to ideas and institutional structures that have emerged since the 1988 Brazilian Federal Constitution with cooperative features and strong federal coordination. The second, named "Bolsonaro's federalism," is based on a dualistic view of intergovernmental relations with little participation of the federal government in reducing territorial inequalities and supporting subnational governments, while centralizing issues of national importance and adopting a hierarchical stance. The study shows that Bolsonaro's government increased the conflict with subnational governments and jeopardized the coordination of policy responses to the COVID-19 pandemic. We conclude that healthcare and federative crises go together and raise a key question: what is the importance of governmental coordination to implement policies to respond to the pandemic and its social and economic effects?

Tobacco Industry Interference Index: Implementation of the World Health Organization's Framework Convention on Tobacco Control Article 5.3 in India.

In India, there has been no attempt to measure the implementation of World Health Organization's Framework Convention on Tobacco Control Article 5.3, which provides guidelines to address tobacco industry interference (TII). This study draws on a desk review conducted to assess the frequency and severity of TIIs and the government's response, reported between January and December 2017. This study highlights that the government of India does not allow tobacco industry to participate in policy development. However, the industry interferes by collaborating with the government's allied organizations. The tobacco industry has diversified as food industry in India, and directly or indirectly supports various government programs, by investing through their corporate social responsibility schemes. In addition, there are limited legislative measures to allow transparency in adoption of Article 5.3 guidelines across the country. Hence, the findings of this study underscore an exigent need to adopt and implement Article 5.3 at the national level in India.

The Intersection of Hand Surgery Practice and Industry.

This article focuses on the working relationship between practicing hand surgeons and company representatives. The basic job of reps is to influence surgeon behavior to use their products. Surgeons must make certain that nothing of value is received in a quid pro quo for using industry products. Physicians have an ethical obligation to only use industry devices that are in the best interests of their patients. Hand surgeons may become involved in product development and thereby come into contact with industry. Several key steps are required to protect any intellectual property surgeons develop in their interactions with industry.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative.

BACKGROUND: Racial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2-3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. METHODS: Translating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. CONCLUSION: TRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Fostering Partnerships with the Safety Net: An Evaluation of Kaiser Permanente's Community Ambassador Program in the Mid-Atlantic States.

INTRODUCTION: Kaiser Permanente (KP) Mid-Atlantic States has partnered with communities in its service area since 2011 to provide health services to underserved individuals. As part of KP's Community Benefit investment, the Community Ambassador Program places KP advanced-practice clinicians in safety-net clinics to share best practices and to improve access and quality of care. OBJECTIVE: To report program outcomes and disseminate lessons learned. METHODS: Using data from participating clinics, we retrospectively evaluated the program and estimated Community Ambassadors' contributions to clinic capacity, patient access, evidence-based care, and clinical quality measures. Furthermore, we conducted 29 semistructured phone interviews with stakeholders. Questions focused on program benefits, challenges, learning, and sustainability. RESULTS: From 2013 to 2017, Community Ambassadors filled up to 32.8 full-time equivalent positions and conducted 294,436 patient encounters in 19 clinics. In certain years and for subsets of clinics, Community Ambassadors performed above average on 2 high-priority quality measures: Cervical cancer screening for women aged 21 to 64 years and diabetes (blood glucose) control. Interviews with 15 Community Ambassadors, 15 health centers leaders, and 7 KP Mid-Atlantic States staff members revealed that Community Ambassadors improved patient access, clinic capacity, and care quality. Ambassadors also exported KP best practices and supported KP's community relations. Challenges included patient acuity, clinic resources, staff turnover, and long-term sustainability. CONCLUSION: The Community Ambassador Program achieved its goals and had clear benefits, offering a model for large health care systems wanting to collaborate with community-based clinics. Careful planning is needed to ensure that positive results are sustained.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries.

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

Notes From the Field: Creating a Typology of Childhood Obesity Intervention Strategies.

Classification systems can be useful for evaluating and communicating the impact of interventions. We describe how a typology was created to inform the development of a community intervention dose index (CIDI) intended to measure the strength of impacts attributed to multiple childhood obesity intervention strategies implemented in a large, diverse urban jurisdiction in the United States during 2000-2016. The categorization system was constructed via a three-stage process: (Stage 1) identify relevant constructs for categorizing intervention strategies; (Stage 2) review peer-reviewed literature and program requests for proposals to identify and integrate common attributes of intervention strategies based on Stage 1 constructs; and (Stage 3) vet the results from prior stages to develop a final version of the typology, slated for research application and for use in program improvement. The final system grouped strategies into four macrolevel and five microlevel categories. Macrolevel strategies included government/public institutional policies, infrastructure investments, and business practices. Microlevel strategies included group education, counseling, health communication and social marketing, home visitation, and screening and referral. Grouping intervention strategies in a purposeful, classified manner facilitated communications among researchers and practitioners during the gathering and quantifying of intervention data for the CIDI project and may be used to guide scarce public health resource allocation decisions.