Contaminated water confirmed as source of infection by bioassay in an outbreak of toxoplasmosis in South Brazil.

The protozoan Toxoplasma gondii is a causative agent of toxoplasmosis, an important and widespread zoonotic disease. The transmission of this disease in humans includes ingestion of sporulated oocysts present in contaminated water or food. T. gondii oocysts are widely distributed and toxoplasmosis is considered a major food- and waterborne pathogen worldwide, making drinking water containing sporulated T. gondii oocysts a major source of contamination for people. In the first half of 2018, an unprecedented outbreak of toxoplasmosis was reported in the city of Santa Maria, southern Brazil. The temporal and spatial distribution of the cases strongly suggested a waterborne infection. Thus, the aim of this study was to investigate a possible involvement of treated water as a source of the outbreak. For this, piglets received potentially contaminated water ad libitum for 21 days and the infection was monitored by serology through IFAT and investigation of T. gondii DNA in tissues by PCR amplification of a 529 bp followed by mouse bioassays. All piglets receiving test water ad libitum for 21 days as well as positive controls seroconverted to T. gondii. T. gondii DNA was detected in 62.5% of the piglets that received test water. All mice inoculated with tissues from each positive piglet were PCR-positive. These results strongly indicated the presence of viable oocysts in the test water administered to the animals during the study.

Microshear bond strength of universal adhesives to enamel and dentin: an eighteen-month in vitro study / Resistência de união ao microcisalhamento de adesivos universais ao esmalte e dentina: estudo in vitro de dezoito meses

Objective: The aim of this study was to evaluate the microshear bond strength of Universal adhesives to enamel and dentin after one week and eighteen months of water storage. Material and Methods: Fragments from the buccal surfaces of 80 bovine teeth were prepared (12x5x1.0 mm) and ground to obtain flat surfaces of enamel and dentin. Samples were randomly assigned to 8 experimental groups (n=10), according to four adhesive systems (Adper Single Bond Plus/control ­ not a Universal adhesive/ASB; Ambar Universal/AUN; Prime&Bond Active/PBA and Scotchbond Universal/SBU) and two water-storage times (one week and eighteen months after sample preparations). Adhesives were applied according to the manufacturers' instructions and molds were positioned over bonded surfaces. A flowable composite was poured into the molds to fill up their internal diameter and obtain resin cylinder (1.0mm height/0.7mm internal diameter) after light-curing. Bond strength was determined using a testing machine (0.5 mm/min) and data were statistically analyzed by two-way analysis of variance (ANOVA) and the post-hoc Tukey's test (alpha=0.05). Failure patterns were analyzed for all resin cylinder tested. Results: For enamel, differences among adhesives were observed only at 18 months, in which SBU produced lower bond strength values (15.9±3.0 MPa) than the others universal adhesives (AUN: 19.3±4.8 and PBA: 21.4±2.1 MPa) (p<0.05). For dentin, there were differences among adhesives only at 7 days, with PBA showing the highest bond strength (37.4±4.9 MPa) and ASB the lowest one (19.4±3.9 MPa) (p<0.05). Enamel and dentin bond strength of all adhesives decreased significantly after 18 months and reduction percentage varied from 36.9 to 52.4 for enamel and from 35.1 to 62.8 for dentin. Adhesive and mixed failures showed high incidences. Conclusion: Results suggested that adhesives presented differences among them depending on type of hard dental tissue and evaluation time. Enamel and dentin bond strengths of control and all universal adhesives tested were not stable, decreasing at eighteen months. (AU)

Objetivo: O objetivo deste estudo foi avaliar a resistência de união ao microcisalhamento de adesivos universais ao esmalte e dentina após uma semana e dezoito meses de armazenamento em água. Material e Métodos: Fragmentos da superfície vestibular de 80 dentes bovinos foram preparados (12x5x1,0 mm) até o obtenção de superfícies planas de esmalte e dentina. As amostras foram distribuídas aleatoriamente em 8 grupos experimentais (n=10), de acordo com quatro sistemas adesivos (Adper Single Bond Plus / controle - não universal; Ambar Universal; Prime & Bond Active e Scotchbond Universal) e dois tempos de armazenamento em água (uma semana e dezoito meses após o preparo das amostras). Os adesivos foram aplicados de acordo com as instruções dos fabricantes e as matrizes foram posicionadas sobre as superfícies aderidas. Um compósito fluido foi aplicado nas matrizes para preencher seu diâmetro interno e obter o cilindro do compósito por fotopolimeração (1,0 mm de altura / 0,7 mm de diâmetro interno). A resistência de união foi determinada em uma máquina universal de ensaios (0,5mm/min). Os dados foram analisados estatisticamente pela análise de variância dois fatores (ANOVA) e teste de Tukey (alfa 0,05). Resultados: Para o esmalte, foram obtidas diferenças apenas aos 18 meses, em que Scotchbond Universal produziu menor média de resistência de união do que os demais adesivos universais. Para dentina, houve diferenças entre os adesivos apenas aos 7 dias, com o Prime & Bond Active apresentando a maior resistência de união e o Adper Single Bond Plus a menor. Os resultados sugeriram que os adesivos apresentaram diferenças entre si dependendo do substrato e do tempo de avaliação. Conclusão: As resistências de união em esmalte e dentina do controle e de todos os adesivos universais testados não foram estáveis, diminuindo aos dezoito meses (AU)

Isolation, genetic and immunohistochemical identification of Toxoplasma gondii from human placenta in a large toxoplasmosis outbreak in southern Brazil, 2018.

The present study aimed to describe a molecular analysis of environmental and pork samples, the isolation, genetic identification and immunohistochemistry (IHC) of Toxoplama gondii from placenta and amniotic fluid from five pregnant women that miscarried during a toxoplasmosis outbreak in 2018, Santa Maria, Rio Grande do Sul. Environmental and pork samples were submitted to polymerase chain reaction (PCR); placenta and amniotic fluid samples to histopathology, IHC, mouse bioassay and PCR. All samples were genotyped by PCR-RFLP with 11 loci. Histopathologic and IHC were compatibles with toxoplasmosis. All pregnants were positive in PCR and bioassay, the genotypes were compared, and all were equal suggesting a same source of infection. Among the environmental and food samples, a sludge sample from a water tank and two porks samples were positive in PCR, and the genotypes were different from the pregnant women isolates. It is concluded that obtain and compare isolates is essential to elucidate outbreak source.

Management problems and strategies: The vulnerability of small-sized municipalities. / Problemas e estratégias de gestão do SUS: a vulnerabilidade dos municípios de pequeno porte.

The decentralization process has a strong impact on the finances of small-sized municipalities (SSMs), which are the most vulnerable entity of the Federative Republic of Brazil. This paper aims to analyze the main problems and management strategies used by SSMs to address the inequalities resulting from the decentralization process. This qualitative research is developed through operative groups with 55 workers from the management teams of SSMs in the northern macroregion of Paraná. A comprehensive and interpretative analysis was conducted using the Social Game Theory as a theoretical reference. Among the problems examined are the insufficient capacity to manage municipalities and provide comprehensive health care to citizens. The formation of Intermunicipal Health Consortia, the purchase of services through parallel contracts with private providers, and the adhesion to state and federal programs are strategies to address the problems, but they trigger problems of their own. To minimize the vulnerability of SSMs, it is necessary to empower the municipal manager, implement processes of listening to the SSMs, and foster a culture of facing problems in a collective and shared way among the federated entities to create interfederative management.

Isolation and molecular characterization of Toxoplasma gondii from placental tissues of pregnant women who received toxoplasmosis treatment during an outbreak in southern Brazil.

Toxoplasma gondii is a protozoan that has great genetic diversity and is prevalent worldwide. In 2018, an outbreak of toxoplasmosis occurred in Santa Maria, Brazil, which was considered the largest outbreak ever described in the world. This paper describes the isolation and molecular characterization of Toxoplasma gondii from the placenta of two pregnant women with acute toxoplasmosis who had live births and were receiving treatment for toxoplasmosis during the outbreak. For this, placental tissue samples from two patients underwent isolation by mice bioassay, conventional PCR and genotyping using PCR-RFLP with twelve markers. Both samples were positive in isolation in mice. The isolate was lethal to mice, suggesting high virulence. In addition, the samples were positive in conventional PCR and isolates submitted to PCR-RFLP genotyping presented an atypical genotype, which had never been described before. This research contributes to the elucidation of this great outbreak in Brazil.

Problemas e estratégias de gestão do SUS: a vulnerabilidade dos municípios de pequeno porte / Management problems and strategies: The vulnerability of small-sized municipalities

Resumo O processo de descentralização exerce forte impacto nas finanças dos Municípios de Pequeno Porte (MPP) e estes são o ente mais vulnerável da federação. Objetivou-se analisar os principais problemas e as estratégias de gestão utilizadas pelos MPP para enfrentar as desigualdades decorrentes do processo de descentralização. Pesquisa qualitativa desenvolvida por meio de grupos operativos com 55 trabalhadores das equipes gestoras de MPP da macrorregião norte do Paraná. Foi realizada análise compreensiva e interpretativa utilizando a Teoria do Jogo Social como referencial teórico. Dentre os problemas, estão a insuficiente capacidade para fazer a gestão dos municípios e para ofertar atenção integral à saúde aos munícipes. A constituição de Consórcios Intermunicipais de Saúde, a compra de serviços por contratos paralelos com prestadores privados e a adesão a programas do estado e da União são estratégias para o enfrentamento dos problemas, porém estas desencadeiam um intercâmbio de problemas. Para minimizar a vulnerabilidade dos MPP, é preciso fomentar o empoderamento do gestor municipal, implantar processos de escuta dos MPP e de uma cultura de enfrentamento dos problemas de forma coletiva e compartilhada entre os entes federados, para que haja uma gestão interfederativa.

Abstract The decentralization process has a strong impact on the finances of small-sized municipalities (SSMs), which are the most vulnerable entity of the Federative Republic of Brazil. This paper aims to analyze the main problems and management strategies used by SSMs to address the inequalities resulting from the decentralization process. This qualitative research is developed through operative groups with 55 workers from the management teams of SSMs in the northern macroregion of Paraná. A comprehensive and interpretative analysis was conducted using the Social Game Theory as a theoretical reference. Among the problems examined are the insufficient capacity to manage municipalities and provide comprehensive health care to citizens. The formation of Intermunicipal Health Consortia, the purchase of services through parallel contracts with private providers, and the adhesion to state and federal programs are strategies to address the problems, but they trigger problems of their own. To minimize the vulnerability of SSMs, it is necessary to empower the municipal manager, implement processes of listening to the SSMs, and foster a culture of facing problems in a collective and shared way among the federated entities to create interfederative management.

Fatores associados à eficiência na Atenção Básica em saúde, nos municípios brasileiros / Factors associated with efficiency in Primary Health Care, in brazilian municipalities

RESUMO Este artigo tem por objetivo identificar os fatores que influenciam a eficiência na aplicação dos recursos destinados à Atenção Básica nos municípios brasileiros. Para isso, utilizou-se o modelo de regressão beta inflacionado, uma vez que a variável dependente apresenta valores no intervalo (0,1]. De acordo com os resultados, o índice Firjan de desenvolvimento municipal na saúde e serviços de saneamento básico são fatores que influenciam positivamente a eficiência média na Atenção Básica de um município. Por outro lado, o gasto per capita de um município, em Atenção Básica, exerce efeito negativo na eficiência média.

ABSTRACT This article aims to identify the factors that influence the efficiency in the application of resources destined to Primary Health Care in brazilian municipalities. To this end, the inflated beta regression model was used, since the dependent variable presents values in the interval (0,1]. According to the results, the Firjan Index of Municipal Development in health and basic sanitation services are factors that positively influence the average efficiency in the Primary Health Care of a municipality. On the other hand, the per capita expenditure of a municipality, in primary care, exerts a negative effect on the average efficiency.

Difficulties in accessing services that are of medium complexity in small municipalities: a case study. / Dificuldade de acesso a serviços de média complexidade em municípios de pequeno porte: um estudo de caso.

The study aimed to describe the specialized health services and to identify areas of greater difficulty of access to specialized consultations offered by SUS in small cities in the 18th Regional Health Area of Paraná State, Brazil, using case study methodology. The data were collected between January and April 2015. Managers, management teams and the board of directors of the CIS (Consórcio Intermunicipal de Saúde) were interviewed. The 21 studied specialist areas were rated like Sufficient Quota, Insufficient Quota, Inexistent Supply, and Assistance Gap. The services with more difficulty of access were Vascular Surgery, Proctology, Geriatrics, Endocrinology, and Neurology, considered Inexistent Supply/Assistance Gap, and Orthopedics, Neuro-pediatrics, Urology, Rheumatology, Ophthalmology, and Otorhinolaryngology, were considered Insufficient Share. Contribute to the magnitude of the problem: lack of specialist doctors, private sector dependence and de decrease of the Federal and State Governments in financing the Health Sistem. Therefore, the gap in specialized healthcare is complex and difficult to solve in the short-terms, proving that this services have become a "bottleneck" in the SUS.

Dificuldade de acesso a serviços de média complexidade em municípios de pequeno porte: um estudo de caso / Difficulties in accessing services that are of medium complexity in small municipalities: a case study

Resumo O estudo visou analisar a oferta de consultas especializadas pelo SUS de maior dificuldade de acesso em municípios de pequeno porte na 18ª Regional de Saúde do Paraná, utilizando a metodologia de Estudo de Caso. Os dados foram coletados de janeiro a abril de 2015, por meio de entrevistas com gestores, membros das equipes gestoras e a diretoria do Consórcio Intermunicipal de Saúde. As 21 especialidades estudadas foram categorizadas em Cota Suficiente, Cota Insuficiente, Oferta Inexistente e Vazio Assistencial. As áreas de maior dificuldade de acesso na região são: Cirurgia Vascular, Proctologia, Geriatria, Endocrinologia e Neurologia, que foram consideradas oferta inexistente/vazio assistencial. Enquanto que Ortopedia, Neuro-pediatria, Urologia, Reumatologia, Oftalmologia e Otorrinolaringologia foram consideradas insuficientes. Contribuem para a magnitude do problema: carência de especialistas com consequente insuficiência de consultas, dependência do setor privado e redução da participação da União e do Estado na oferta de serviços e no financiamento. A situação da atenção especializada na região é complexa e de difícil solução a curto prazo, reforçando a tese de que a atenção neste nível é atualmente o gargalo do SUS.

Abstract The study aimed to describe the specialized health services and to identify areas of greater difficulty of access to specialized consultations offered by SUS in small cities in the 18th Regional Health Area of Paraná State, Brazil, using case study methodology. The data were collected between January and April 2015. Managers, management teams and the board of directors of the CIS (Consórcio Intermunicipal de Saúde) were interviewed. The 21 studied specialist areas were rated like Sufficient Quota, Insufficient Quota, Inexistent Supply, and Assistance Gap. The services with more difficulty of access were Vascular Surgery, Proctology, Geriatrics, Endocrinology, and Neurology, considered Inexistent Supply/Assistance Gap, and Orthopedics, Neuro-pediatrics, Urology, Rheumatology, Ophthalmology, and Otorhinolaryngology, were considered Insufficient Share. Contribute to the magnitude of the problem: lack of specialist doctors, private sector dependence and de decrease of the Federal and State Governments in financing the Health Sistem. Therefore, the gap in specialized healthcare is complex and difficult to solve in the short-terms, proving that this services have become a "bottleneck" in the SUS.