¿Es la atención primaria de salud integral parte de la respuesta a la pandemia de Covid-19 en Latinoamérica? / Is comprehensive primary health care part of the response to the COVID-19 pandemic in Latin America? / A atenção primária à saúde integral é parte da resposta à pandemia de Covid-19 na América Latina?

Resumen América Latina se ha convertido en uno de los epicentros de la pandemia de Covid-19, con una crisis sanitaria y humanitaria. El objetivo del artículo es analizar las medidas para enfrentar la pandemia en países de la Región y el rol de la Atención Primaria de Salud, discutiendo obstáculos y potencialidades. Son analizados los casos de Bolivia, Brasil, Chile, Colombia, Cuba, Uruguay y Venezuela. Los siete países adoptaran medidas de aislamiento social de diferentes alcances, con grados distintos de sostenibilidad. El énfasis de las respuestas estuvo más en la atención hospitalaria que en la vigilancia de la salud, identificación de casos y contactos y disposición de condiciones adecuadas para el confinamiento. En casi todos los países, se subestimó la capacidad de los servicios de atención primária en el territorio. No obstante, iniciativas de enfoque territorial y comunitario buscaron integrar la vigilancia de la salud con actividades de promoción, prevención y cuidado, aunque con alcance parcial. En este contexto la Atención Primaria Integral e integrada toma nuevo sentido y reclama desarrollos que contribuyan a recobrar el equilibrio entre sociedad y medio ambiente. Es necesario repensar los sistemas de salud y la importancia de la atención primaria de salud integrada e integral.

Abstract Latin America has become one of the epicenters of the COVID-19 pandemic, with a health and humanitarian crisis. The objective of the article is to analyze the strategies implemented by countries in the Region to face the pandemic and the role of Primary Health Care, considering obstacles and potential. The cases of Bolivia, Brazil, Chile, Colombia, Cuba, Uruguay and Venezuela were analyzed. The seven countries have adopted diverse social distancing strategies with varying degrees of sustainability. The responses emphasized hospital care more than surveillance, case identification, contact tracking, and enabling adequate conditions for isolation. In almost all cases studied, the capacity of primary care services in the territory was underestimated. Even so, primary care initiatives with a territorial and community focus sought to integrate health surveillance with promotion, prevention and care, despite partial implementation. In this context, comprehensive and integrated primary care takes on new meaning and requires new developments in order to contribute to the recovery of the balance between society and the environment. The pandemic showed the need to rethink health care systems and the importance of primary care for comprehensive and integrated health.

Resumo A América Latina tornou-se um dos epicentros da pandemia de Covid-19, com uma crise sanitária e humanitária. O objetivo do artigo é analisar as estratégias implementadas por países da Região para enfrentar a pandemia e o papel da Atenção Primária à Saúde, ponderando obstáculos e potencialidades. Foram analisados os casos de Bolívia, Brasil, Chile, Colômbia, Cuba, Uruguai e Venezuela. Os sete países adotaram estratégias de distanciamento social diversas com diferentes graus de sustentabilidade. As respostas enfatizaram mais a assistência hospitalar do que a vigilância, a identificação de casos, o rastreamento dos contatos e a viabilização de condições adequadas para isolamento. Em quase todos os casos estudados, foi subestimada a capacidade dos serviços de atenção primária no território. Ainda assim, iniciativas de atenção primária com enfoque territorial e comunitário buscaram integrar a vigilância à saúde com a promoção, prevenção e cuidado, apesar de implantação parcial. Nesse contexto, uma atenção primária integral e integrada adquire novo significado e requisita novos desenvolvimentos de forma a contribuir para a recuperação do equilíbrio entre a sociedade e o meio ambiente. A pandemia mostrou a necessidade de repensar os sistemas de atenção à saúde e a importância da atenção primária à saúde integral e integrada.

Mapping primary health care renewal in South America.

BACKGROUND: Primary health care (PHC) renewal processes are currently ongoing in South America (SA), but their characteristics have not been systematically described. OBJECTIVE: The study aimed to describe and contrast the PHC approaches being implemented in SA to provide knowledge of current conceptions, models and challenges. METHODS: This multiple case study used a qualitative approach with technical visits to health ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53 local managers, as well as field observation of 57 selected PHC providers and document analysis, using a common matrix for data collection and analysis. PHC approaches were analysed by triangulating sources using the following categories: PHC philosophy and conception, service provision organization, intersectoral collaboration and social participation. RESULTS: Primary health care models were identified in association with existing health system types and the dynamics of PHC renewal in each country. A neo-selective model was found in three countries where coverage is segmented by private and public regimes; here, individual and collective care are separated. A comprehensive approach similar to the Alma-Ata model was found in seven countries where the public sector predominates and individual, family and community care are coordinated under the responsibility of the same health care team. CONCLUSIONS: The process of implementing a renewed PHC approach is affected by how health systems are funded and organized. Both models face many obstacles. In addition, care system organization, intersectoral coordination and social participation are weak in most of the countries.

The Use of the Developmental Rate of the Aquatic Midge Chironomus riparius (Diptera, Chironomidae) in the Assessment of the Postsubmersion Interval.

Nonbiting midges (Diptera, Chironomidae) are the most abundant members of the fauna associated with submerged carcasses, but their use in the medicolegal context is very restricted because of their complex ontogeny. In this case, the corpse of a woman was recovered in late spring from a river in Granada (Iberian Peninsula). It showed obvious signs of long permanence in the aquatic environment and, along with pulmonary and microscopical analyses, led to the conclusion that the cause of death was drowning. Several larvae-like specimens were sampled from the scalp and later identified by morphological external features as IV instar larvae of Chironomus riparius Meigen, 1804 (Diptera, Chironomidae). Sequencing of cytochrome oxidase subunit I was performed to confirm the identification. The knowledge of the biology of C. riparius at low temperatures was critical to assess a postsubmersion interval of 16-17 days.

Evaluación práctica de las alteraciones postmortem debidas a la actividad de los artrópodos / Alterations practice postmortem evaluation of activity due to arthropods

Tras la muerte de un organismo vivo, la actividad de los insectos es el principal mecanismo por el que la materia orgánica en descomposición se reintegra en la cadena alimenticia. No obstante, hay que tener en cuenta que dicha actividad puede implicar modificaciones de gran interés tafonómico y forense. Si no se conoce bien su magnitud, pueden inducir al error en el posterior análisis del patólogo forense. En este artículo, damos una clasificación organizada de los diferentes fenómenos tafonómicos inducidos por insectos (adición, eliminación y modificación del cadáver) y enunciamos los caracteres diferenciales que permiten separarlos de procesos patológicos similares, centrando nuestra atención en los órdenes Coleoptera, Diptera y Lepidoptera como principales causantes de estas modificaciones...

After death of a living organism, the activity of insects is the main mechanism by which decomposing organic matter returns to the nutritional chain. However, it is necessary to consider that this activity can imply modifications of great taphonomic and forensic interest. If its magnitude is not known well, it can induce to error in the later analysis of the forensic pathologist. In this article, we give an organized classification of the different taphonomic phenomena induced by insects (addition, elimination and modification of the corpse) and enunciate the differential features that allow to separate them from similar pathological processes, focusing our attention on the orders Coleoptera, Diptera and Lepidoptera as the main responsibles of these modifications...

Occurrence of Poecilochirus austroasiaticus (Acari: Parasitidae) in forensic autopsies and its application on postmortem interval estimation.

Despite the fact that mites were used at the dawn of forensic entomology to elucidate the postmortem interval, their use in current cases remains quite low for procedural reasons such as inadequate taxonomic knowledge. A special interest is focused on the phoretic stages of some mite species, because the phoront-host specificity allows us to deduce in many occasions the presence of the carrier (usually Diptera or Coleoptera) although it has not been seen in the sampling performed in situ or in the autopsy room. In this article, we describe two cases where Poecilochirus austroasiaticus Vitzthum (Acari: Parasitidae) was sampled in the autopsy room. In the first case, we could sample the host, Thanatophilus ruficornis (Küster) (Coleoptera: Silphidae), which was still carrying phoretic stages of the mite on the body. That attachment allowed, by observing starvation/feeding periods as a function of the digestive tract filling, the establishment of chronological cycles of phoretic behavior, showing maximum peaks of phoronts during arrival and departure from the corpse and the lowest values in the phase of host feeding. From the sarcosaprophagous fauna, we were able to determine in this case a minimum postmortem interval of 10 days. In the second case, we found no Silphidae at the place where the corpse was found or at the autopsy, but a postmortem interval of 13 days could be established by the high specificity of this interspecific relationship and the departure from the corpse of this family of Coleoptera.

Las miasis como entidad de interés en Medicina del Trabajo / Myiasis as an entity of interest in occupational medicine

En escasas ocasiones se ha hecho referencia a las miasis en el ámbito de la Medicina del Trabajo. Es un error bastante generalizado pensar que este tipo de parasitación es exclusiva de países subdesarrollados o de estratos sociales carentes de las mínimas medidas de higiene. Sin embargo, es importante conocer los agentes etiológicos y advertir del riesgo que afecta a ciertos sectores laborales expuestos a materia orgánica en descomposición o a ciertos alimentos que por sus características químicas actúan de atrayentes para los dípteros. Para ello, estudiamos los casos de miasis que se diagnosticaron en varios centros sanitarios ubicados en Granada, Málaga, Almería y Jaén durante el periodo comprendido entre septiembre de 2010 y junio de2011 y consideramos con especial interés los que se iniciaron por una infestación durante el periodo laboral. Se observa en las miasis laborales un predominio de las especies Piophila casei (Linnaeus, 1758) y Sarcophaga (Bercaea) africa (Wiedemann, 1824). Asimismo, exponemos las principales características del ciclo vital de los dípteros de interés sanitario y las medidas de seguridad que deben adoptarse para evitar este tipo de accidente laboral (AU)

In few occasions, reference to myiasis in the scope of Occupational Medicine has been done. It is a generalized mistake to think that this type of parasitation is exclusive of underdeveloped countries or social layers without the minimal hygiene measures. Nevertheless, it is important to know the etiological agents and to notice the risk that affects certain occupational sectors exposed to organic matter in decay proccessor to certain foods that by their chemical characteristics act of appealing to the Diptera. We studied the cases of myiasis diagnosed in some medical centers located in Granada, Málaga, Almería and Jaén during the period between September 2010 and June 2011 and we considered with special interest those that began byan infestation during the working period. A predominance of Piophila casei (Linnaeus, 1758) and Sarcophaga (Bercaea) africa (Wiedemann, 1824) was observed in laboral myiasis. Also we exhibit the main characteristics of the vital cycle of Diptera of sanitary interest and the safety measures that must be adopted to avoid this type of occupational accident (AU)

Continuing professional development of physicians in Uruguay: lessons from a countrywide experience.

This article describes the advancement of continuing professional development (CPD) for physicians in Uruguay and explains the motivations for a CPD system, the role of the faculty of medicine and the other stakeholders, the strategic goals, and current results, including strengths and weaknesses. The work described here had three strategic objectives: (1) initiate a CPD accreditation program, (2) train physician leaders in CPD, and (3) promote the creation of a national system for CPD. By the end of 2006, the accreditation program had 34 accredited institutions. Over a 10-year period, 150 physician leaders from different regions of the country and with different specialties had been trained in the framework and methodological issues of CPD. Legislation is expected to be introduced into parliament during 2007 for coordinating CPD efforts at a national level.

[Continuing medical professional development in Uruguay as the country faces the 21st century]. / El desarrollo profesional médico continuo en el Uruguay de cara al siglo XXI.

This paper outlines the evolution of the concept of continuing medical professional development in Uruguay, as that professional development has progressed from independent and varied efforts that were not coordinated or evaluated to a plan that is aimed at improving the quality of educational activities and programs and making them accessible to all the physicians in the country. In contrast to countries where scientific societies and medical associations preside over continuing professional development, in Uruguay the Graduate School of the School of Medicine of the University of the Republic has taken on managing and developing this process. The key objective of this process is for the Graduate School to work in conjunction with other leading players in professional development to create a national system of continuing medical professional development. This system should be interinstitutional and include both public and private entities. By having the key public institutions (the Graduate School and the Ministry of Public Health) working with private entities (medical associations, scientific societies, and health care institutions), there should be an adequate balance of interests. The national professional development system should work in the most decentralized manner possible and should be based on a network of units distributed around the entire country, but with centralized coordination. The system's interinstitutional character should ensure high technical and ethical standards as well as a balance among the governmental, commercial, professional, and university components. This system should serve as the basis for extending this activity to all health personnel in Uruguay. While the national system is still being finalized, the Graduate School has implemented a process of accrediting institutions that are involved in continuing professional medical development. The aim of this accreditation process is to improve the educational offerings for physicians and to generate practical experience that will serve the future system.

El desarrollo profesional médico continuo en el Uruguay de cara al siglo XXI / Continuing medical professional development in Uruguay as the country faces the 21st century

This paper outlines the evolution of the concept of continuing medical professional development in Uruguay, as that professional development has progressed from independent and varied efforts that were not coordinated or evaluated to a plan that is aimed at improving the quality of educational activities and programs and making them accessible to all the physicians in the country. In contrast to countries where scientific societies and medical associations preside over continuing professional development, in Uruguay the Graduate School of the School of Medicine of the University of the Republic has taken on managing and developing this process. The key objective of this process is for the Graduate School to work in conjunction with other leading players in professional development to create a national system of continuing medical professional development. This system should be interinstitutional and include both public and private entities. By having the key public institutions (the Graduate School and the Ministry of Public Health) working with private entities (medical associations, scientific societies, and health care institutions), there should be an adequate balance of interests. The national professional development system should work in the most decentralized manner possible and should be based on a network of units distributed around the entire country, but with centralized coordination. The system's interinstitutional character should ensure high technical and ethical standards as well as a balance among the governmental, commercial, professional, and university components. This system should serve as the basis for extending this activity to all health personnel in Uruguay. While the national system is still being finalized, the Graduate School has implemented a process of accrediting institutions that are involved in continuing professional medical development. The aim of this accreditation process is to improve the educational offerings for physicians and to generate practical experience that will serve the future system

Estrés organizacional y exposición a ruido en trabajadores de la planta de envasado de una industria cervecera / Organizational stress and exposure to noise in workers at the packing plant of a brewering industry

El propósito de este trabajo fue identificar y evaluar los factores psicosociales productores de estrés organizacional en trabajadores de la planta de envasado de industria cervecera, y determinar la influencia del ruido industrial en la ocurrencia del estrés laboral. Se aplicó el Cuestionario de Estrés Organizacional de la OIT/OMS en 163 trabajadores para evaluar factores psicosociales en el trabajo, y se exploraron las características socio-demográficas a escala individual. Se determinó el nivel de ruido continuo equivalente (Leq) y las bandas de octava con un sonómetro, según metodología descrita en la Norma COVENIN. El estrés total resultó en una ocurrencia del 33,74 por ciento (55 trabajadores), de éstos, 25,76 por ciento (42 trabajadores) estuvieron en el nivel intermedio, y 7,98 por ciento (13 trabajadores) en el nivel de estrés (p<0,0001). La ocurrencia de estrés ponderado fue del 100 por ciento, representadas por: influencia del líder (14,00 ñ 7,27;87.7 por ciento), estructura organizacional (12,36 ñ 5,14;93,3 por ciento) y clima organizacional (11,83 ñ 5,09; 95,1 por ciento). Las medias de estrés total y ponderado mostraron una tendencia ascendente a medida que aumenta la edad y la antiguedad laboral (p<0,05). El Leq se encuentra en un rango de 87,9-100 dB(A), el cual supera el valos límite umbral. No hubo asociación entre los niveles de ruido y los niveles de estrés. El estrés total es similar a lo descrito en otros estudios. El estrés ponderado es una variable con alta sensibilidad para determinar cuales factores psicosociales producen estrés. Esto puede ser utilizado para implementar medidas de prevención y control del estrés organizacional

Antimutagenic activity of selenium-enriched green tea toward the heterocyclic amine 2-amino-3-methylimidazo[4,5-f]quinoline.

Both selenium and green tea have been reported to exhibit antigenotoxic and cancer chemopreventive properties. We compared the antimutagenic activities of regular green tea and selenium-enriched green tea obtained from Hubei Province, China, toward the heterocyclic amine, 2-amino-3-methylimidazo[4,5-f]quinoline (IQ) in the Salmonella assay. Selenium-enriched green tea obtained by foliar application of selenite exhibited concentration-dependent inhibition of IQ-induced mutagenesis in the presence of rat liver S9 and was significantly more effective than regular green tea tested under the same conditions. Analytical studies revealed no major differences in the polyphenol or caffeine content between regular green tea and selenium-enriched green tea, but the latter tea contained approximately 60-fold higher concentrations of selenium compared with regular green tea. The only soluble form of selenium was identified as selenite. The antimutagenic effects of certain individual tea constituents, such as epicatechin gallate and catechin, were enhanced by the addition of selenite to the Salmonella assay. Sodium selenite, sodium selenate, seleno-DL-cysteine, seleno-L-methionine, and L-Se-methylselenocysteine were not antimutagenic toward IQ when tested alone, but augmented significantly the inhibitory potency of green tea. The results suggested an enhancing ("coantimutagenic") effect of selenium in combination with green tea in vitro, but in vivo studies are needed to assess whether there is a synergistic effect of tea and selenium to protect against heterocyclic amine-induced mutagenesis and carcinogenesis.

[Organizational stress and noise exposure in workers at the packing plant of a brewer factory]. / Estrés organizacional y exposición a ruido en trabajadores de la planta de envasado de una industria cervecera.

The purpose of this study was to identify and to evaluate the psychosocial factors that produce organizational stress in workers at the packing plant of a brewering industry, and to determine the influence of industrial noise in the occurrence of stress at work. The Questionnaire of Organizational Stress of the ILO/WHO was applied to 163 workers to evaluate psychosocial factors at work, and the socio-demographic characteristics were explored on an individual basis. The equivalent continuous sound level (Leq) was determined and the octave band were determined with a sonometer according to the COVENIN guidelines. Total stress was found in 55 workers (33.74%). Of those, 42 workers were in an intermediate level (25.76%) and 13 workers (7.98%) were in the stress level (p < 0.0001). The occurrence of pondered stress was 100%, classified as: influences of the leader (14.00 +/- 7.27; 87.7%), organizational structures (12.36 +/- 5.14; 93.3%) and organizational climate (11.83 +/- 5.09; 95.1%). The mean of total and pondered stress showed an upward tendency as age and labor antiquity increased (p < 0.05). Leq was in a range of 87.9-100 dB(A), which exceeds the threshold value limit. There was no association between Leq was stress. The level of total stress that these workers perceive is similar to that described in other studies. The pondered stress becomes a highly sensitive variable to determine which psychosocial factors produce stress. This can be used for implementing control and preventive measures of organizational stress.