Decentralizing referral prioritization to general practitioners at the primary care level: A qualitative case study based on the Grounded Theory.

BACKGROUND: Patient referral prioritizations is an essential process in coordinating healthcare delivery, since it organizes the waiting lists according to priorities and availability of resources. OBJECTIVE: This study aims to highlight the consequences of decentralizing ambulatory patient referrals to general practitioners that work as family physicians in primary care clinics. METHODS: A qualitative case study was carried out in the municipality of Rio de Janeiro. The ten health regions of Rio de Janeiro were visited during fieldwork, totalizing 35 hours of semi-structured interviews and approximately 70 hours of analysis based on the Grounded Theory. RESULTS: The findings of this study show that the obstacles to adequate referrals are beyond the management of vacancies, ranging from the standardization of prioritization criteria to ensuring the proper employment of referral protocols in diverse locations assisted by overloaded health workers with different backgrounds and perceptions. Efforts in decentralizing patient referral to primary care still face the growing dilemmas and challenges of expanding the coverage of health services while putting pressure on risk assessment, as well as sustaining the autonomy of physicians' work while respecting the eligibility when ordering waiting lists. CONCLUSION: A major strength of this work is on the method to organize and aggregate qualitative data using visual representations. Limitations concerning the reach of fieldwork in vulnerable and hardly accessible areas were overcame using snowball sampling techniques, making more participants accessible.

Limite ético para confirmar identidade pelos caracteres morfológicos / Ethical limits to confirming identity by morphological features / Límite ético para confirmar la identidad por caracteres morfológicos

Resumo O desenvolvimento de novas tecnologias fez nascer ferramentas que auxiliam no processo de identificação de indivíduos, possibilitando confirmar identidades e ajudando a solucionar crimes, ao permitir confirmar o encontro de pessoas desaparecidas ou vítimas de acidentes, por exemplo. Entretanto, um importante questionamento ético precisa ser observado: os fins sempre justificam os meios? A identificação facial a partir de imagens coletadas por câmeras de circuito fechado de televisão ou a análise de registros fotográficos são capazes de confirmar a identidade de alguém inequivocamente? Impressões digitais ou labiais podem ser utilizadas, em qualquer hipótese, em um confronto dactiloscópico? O conhecimento sobre as limitações dos métodos técnicos científicos utilizados em comparações de caracteres morfológicos permite que o resultado do perito papiloscopista atenda a dois princípios basilares constitucionais: a legalidade e o direito da pessoa humana. Ao respeitá-los, estará agindo conforme os limites éticos.

Abstract Technological advancements have generated tools to help with identifying individuals, allowing to verify identities and solve crimes by confirming found missing persons or accident victims, for example. An important ethical question, however, arises: do the ends always justify the means? Can facial identification from images collected by closed-circuit television cameras or analysis of photographic records confirm someone's identity unequivocally? Can fingerprints or lip prints be used for any dactyloscopy? Knowing the limitations of scientific technical methods used in morphological comparisons allows examiners to comply with two fundamental constitutional principles: that of legality and right of the human person. By respecting them, examiners will be acting according to ethical limits.

Resumen El desarrollo de nuevas tecnologías dio lugar a herramientas que ayudan en el proceso de identificación de personas, lo que posibilita la confirmación de identidades y contribuye a la resolución de delitos al permitir confirmar, por ejemplo, a personas desaparecidas o víctimas de accidentes. Sin embargo, es necesario observar una cuestión ética importante: ¿el fin siempre justifica los medios? ¿La identificación facial desde imágenes captadas por cámaras de circuito cerrado de televisión o el análisis de registros fotográficos puede confirmar inequívocamente la identidad de una persona? ¿Se pueden utilizar huellas dactilares o labiales, bajo cualquier circunstancia, en un enfrentamiento dactiloscópico? El conocimiento sobre las limitaciones de los métodos técnicos y científicos utilizados en las comparaciones de caracteres morfológicos permite que el resultado del perito en papiloscopía responda a dos principios constitucionales básicos: la legalidad y el derecho de la persona humana. Al respetarlos se estará actuando dentro de los límites éticos.

Assessment of IGF-1 expression in the peripheral blood of women with recurrent breast cancer.

Breast cancer is the most common malignancy affecting women worldwide. The insulin-like growth factor 1 (IGF-1) gene encodes a protein responsible for a wide variety of physiological processes, including differentiation and cell proliferation. Despite several studies on tumor tissues, no study has evaluated IGF-1 expression in the peripheral blood of women with recurrent breast cancer.In this cross-sectional study, IGF-1 expression in the peripheral blood of 146 women with breast cancer treated approximately 5 years ago was quantified by quantitative reverse transcription polymerase chain. The women were divided into 2 groups: non-recurrence (n = 85) and recurrence (n = 61). Statistical analysis of the data was performed using ANOVA, Mann-Whitney, and Chi-squared tests (P < .05).The results showed no significant difference in IGF-1 expression between the non-recurrence and recurrence groups (P = .988). In the subgroups of patients with lymph node involvement, no statistically significant difference was observed in IGF-1 expression between women with recurrence and those non-recurrence (P = .113). In patients without lymph node metastases, IGF-1 messenger ribonucleic acid (mRNA) expression levels were significantly higher in the non-recurrence group than in the recurrence group (P = .019). Furthermore, using the median IGF-1 mRNA expression as the cutoff point, it was obtained a statistically significant difference in tumor histological grade among women with recurrent breast cancer (P = .042).These data showed significantly higher IGF-1 expression in women without lymph node metastases in the non-recurrence group compared with the recurrence group. In addition, a significant difference was observed in median IGF-1 mRNA expression in relation to tumor histological grade in women with recurrent breast cancer.

Expression of Nrf2 and NF-κB transcription factors in breast cancer and breast fibroadenoma: Insights for a new therapeutic approach.

Background: Cancer and fibroadenoma are the most common breast tumors in women of reproductive age. Nuclear factor erythroid 2-related factor 2 (Nrf2) and the nuclear factor kappaB (NF-κB) transcription factor play an important role in the inflammatory process and in cell proliferation. However, few studies have analyzed these markers in breast cancer and fibroadenoma in women of reproductive age. Results: Light microscopy showed a higher concentration of anti-Nrf2 and anti-NF-κB-stained nuclei in breast cancer than in fibroadenoma. The mean percentage of stained nuclei for Nrf2 was 7.12 ± 5.2 and 43.21 ± 19.83 in the control and study groups, respectively (p < 0.0001). The mean percentage of anti-NF-κB was 10.75 ± 7.09 and 56.14 ± 21.19 (mean ± standard deviation) in the control and study groups, respectively (p < 0.0001). Histological grade 3 tumors showed a significantly higher expression of Nrf2 and NF-κB than grade 1 tumors (p < 0.05). Material and methods: This study was approved by the Institutional Review Board of Federal University of Piaui and all patients assigned an inform consent term prior to the study initiation. Nrf2 and NF-κB expression was evaluated by immunohistochemistry in 66 patients, divided into two groups, control (fibroadenoma, n = 36) and study (cancer, n = 30). The data were analyzed using ANOVA test and the statistical significance was established at p < 0.05. Conclusion: Nrf2 and NF-κB expression was significantly higher in breast cancer than in fibroadenoma, in addition to having a greater association with more aggressive tumors.

CYP19A1 gene expression in the peripheral blood of Brazilian women with breast cancer relapse.

BACKGROUND: The CYP19A1 gene, which encodes the enzyme responsible for androgen aromatization into estrogens, may play an important role in breast cancer aggressiveness. However, no study has evaluated CYP19A1 gene expression in the peripheral blood of women with relapsed breast cancer. METHODS: In this cross-sectional study, CYP19A1 gene expression was quantified by RT-PCR in the peripheral blood of 146 women with breast cancer who were first divided into two groups according to the expression of CYP19A1 (low and high); each group had 73 patients. Subsequently, women were divided into two groups: those without recurrence (control, n = 85) and those with recurrence (study, n = 61). Statistical analysis of the data was performed using ANOVA, the Mann-Whitney, Chi-square or Fisher's exact test (p <  0.05). RESULTS: There were no significant differences between the relative expression of CYP19A1 mRNA in the low expression group and the high expression group according to the variables studied. There were no significant differences in CYP19A1 gene expression in the study and control groups (p = 0.8461). In the relapse group, CYP19A1 gene expression was significantly higher in the hybrid luminal subtype than in the triple-negative subtype (p = 0.0321), whereas it was significantly lower in HER2-negative cases than in HER2-positive cases (p <  0.0376). Women with locoregional recurrence showed higher expression than women with distant recurrence (p <  0.0001). CONCLUSIONS: The present study found no significant differences between women with high and low expression of the CYP19A1 gene mRNA or between those in the study group and the control group. However, in women with recurrence, there was increased expression of CYP19A1 mRNA in those who had the luminal hybrid subtype and locoregional relapse and decreased expression in those negative for HER2.

Pharmacological Effects and Toxicogenetic Impacts of Omeprazole: Genomic Instability and Cancer.

Omeprazole (OME) is commonly used to treat gastrointestinal disorders. However, long-term use of OME can increase the risk of gastric cancer. We aimed to characterize the pharmacological effects of OME and to correlate its adverse effects and toxicogenetic risks to the genomic instability mechanisms and cancer-based on database reports. Thus, a search (till Aug 2019) was made in the PubMed, Scopus, and ScienceDirect with relevant keywords. Based on the study objective, we included 80 clinical reports, forty-six in vitro, and 76 in vivo studies. While controversial, the findings suggest that long-term use of OME (5 to 40 mg/kg) can induce genomic instability. On the other hand, OME-mediated protective effects are well reported and related to proton pump blockade and anti-inflammatory activity through an increase in gastric flow, anti-inflammatory markers (COX-2 and interleukins) and antiapoptotic markers (caspases and BCL-2), glycoprotein expression, and neutrophil infiltration reduction. The reported adverse and toxic effects, especially in clinical studies, were atrophic gastritis, cobalamin deficiencies, homeostasis disorders, polyp development, hepatotoxicity, cytotoxicity, and genotoxicity. This study highlights that OME may induce genomic instability and increase the risk of certain types of cancer. Therefore, adequate precautions should be taken, especially in its long-term therapeutic strategies and self-medication practices.

Effect of Diets, Familial History, and Alternative Therapies on Genomic Instability of Breast Cancer Patients.

This study evaluates a correlation between family history, micronutrients intake, and alternative therapies with genetic instability, before and during breast cancer treatment. For this study, a total of 150 women were selected. Among those, 50 women were breast cancer patients on chemotherapy, while 50 breast cancer patients were on radiotherapy, and 50 were healthy females. All the participants signed the informed consent form and answered the public health questionnaire. Samples of buccal epithelial and peripheral blood cells were collected and analyzed through micronucleus and comet assays. The cells were evaluated for apoptosis and DNA damage. Results showed the association of patients' family history with an increase in toxicogenetic damage before and during cancer therapy. On the other hand, patients with late-onset cancer also presented genetic instability before and during therapy, along with those who did not take sufficient vegetables and alternative therapies. A positive correlation was observed between the genetic instability and alternative therapies, while inverse correlation was recorded with the vegetable consumption. Results clearly explain that the nutritional aspects and alternative therapies influence the genetic instability before and during cancer therapies especially in radiotherapy treated patients. Our data could be used for the monitoring therapies and management of breast cancer patients.

Persistent Increased Frequency of Genomic Instability in Women Diagnosed with Breast Cancer: Before, during, and after Treatments.

This study aimed to evaluate DNA damage in patients with breast cancer before treatment (background) and after chemotherapy (QT) and radiotherapy (RT) treatment using the Comet assay in peripheral blood and the micronucleus test in buccal cells. We also evaluated repair of DNA damage after the end of RT, as well as the response of patient's cells before treatment with an oxidizing agent (H2O2; challenge assay). Fifty women with a mammographic diagnosis negative for cancer (control group) and 100 women with a diagnosis of breast cancer (followed up during the treatment) were involved in this study. The significant DNA damage was observed by increasing in the index and frequency of damage along with the increasing of the frequency of micronuclei in peripheral blood and cells of the buccal mucosa, respectively. Despite the variability of the responses of breast cancer patients, the individuals presented lesions on the DNA, detected by the Comet assay and micronucleus Test, from the diagnosis until the end of the oncological treatment and were more susceptible to oxidative stress. We can conclude that the damages were due to clastogenic and/or aneugenic effects related to the neoplasia itself and that they increased, especially after RT.

Assessment of chemotherapy on various biochemical markers in breast cancer patients.

Chemotherapy is a standard treatment method for the patients with locally advanced breast cancer. Lately, cyclophosphamide (CYP) and doxorubicin (DOX) are used as the major chemotherapeutic agents especially for the treatment of breast cancer. Till date, no serum biomarker has been able to provide an early diagnosis of breast cancer. This study aimed to assess inflammatory, cardiac, renal and hematological markers in 56 breast cancer patients (BCP) before, during and after termination of chemotherapy with CYP and DOX. Blood samples were collected from the patients at the each treatment stages mentioned above. These samples were assessed for interleukin 6 (IL-6), interleukin 10 (IL-10), lactate dehydrogenase (LDH), creatine kinase (CK), creatinine, hemoglobin (Hb), leukocyte, platelet and Na+ /K+ -ATPase levels either by ELISA or colorimetric methods. The results suggest a significant increase in IL-6 level at all the stages in BCP as compared to control group. On the other hand, IL-10, CK and Na+ /K+ -ATPase levels were found to be significantly declined during all the stages. Moreover, the majority of hematological parameters remained unchanged throughout the treatment period with the exception of creatinine and Hb which showed slight modulation in their level at different stages. Based on the results, we conclude that breast cancer and co-treatment with CYP and DOX, interfere arious biological markers, thereby, showing the physiological imbalance.

Impact of collection on bark regeneration from Stryphnodendron rotundifolium Mart. in northeastern Brazil.

The growing commercial demand for products with medicinal use has caused overexploitation of several plant species worldwide. To prevent the decline of these populations, the collection of these resources should be done in a sustainable way considering the time of its replacement in natural stocks. This study was designed to identify the relationship between different intensities of extraction of bark from the trunk of Stryphnodendron rotundifolium Mart. and its regeneration speed. For this, we selected two areas of Cerrado in the Northeast of Brazil, where a monitoring experiment with duration of 24 months was performed. This experiment consisted in simulating different extractive damage to assess the regeneration of bark. In each area, we selected 20 individuals, among which four treatments with five repetitions were implemented. The data showed that in both study areas, the trees regenerated their shells faster when subjected to higher collection intensities. However, this regeneration was not related to variations in rainfall in the environment.

Correlations between Risk Factors for Breast Cancer and Genetic Instability in Cancer Patients-A Clinical Perspective Study.

Molecular epidemiological studies have identified several risk factors linking to the genes and external factors in the pathogenesis of breast cancer. In this sense, genetic instability caused by DNA damage and DNA repair inefficiencies are important molecular events for the diagnosis and prognosis of therapies. Therefore, the objective of this study was to analyze correlation between sociocultural, occupational, and lifestyle risk factors with levels of genetic instability in non-neoplastic cells of breast cancer patients. Total 150 individuals were included in the study that included 50 breast cancer patients submitted to chemotherapy (QT), 50 breast cancer patients submitted to radiotherapy (RT), and 50 healthy women without any cancer. Cytogenetic biomarkers for apoptosis and DNA damage were evaluated in samples of buccal epithelial and peripheral blood cells through micronuclei and comet assay tests. Elder age patients (61-80 years) had higher levels of apoptosis (catriolysis by karyolysis) and DNA damage at the diagnosis (baseline damage) with increased cell damage during QT and especially during RT. We also reported the increased frequencies of cytogenetic biomarkers in patients who were exposed to ionizing radiation as well as for alcoholism and smoking. QT and RT induced high levels of fragmentation (karyorrhexis) and nuclear dissolution (karyolysis) and DNA damage. Correlations were observed between age and karyorrhexis at diagnosis; smoking and karyolysis during RT; and radiation and karyolysis during QT. These correlations indicate that risk factors may also influence the genetic instability in non-neoplastic cells caused to the patients during cancer therapies.

Serum Oxidative Stress Markers and Genotoxic Profile Induced by Chemotherapy in Patients with Breast Cancer: A Pilot Study.

The aim of this study was to evaluate the oxidative parameters of erythrocytes and genotoxicity in leukocytes of patients with breast cancer. Oxidative parameters were detected by spectrophotometry and genotoxic damage by single cell gel electrophoresis. Twenty-eight women with breast cancer were monitored before chemotherapy and after the second and fourth cycles of therapy with cyclophosphamide and doxorubicin. After the fourth cycle, increases (P < 0.05) in the reactive substances to thiobarbituric acid levels, nitrite content, and superoxide dismutase activity and high rates of DNA damage in leukocytes were observed when compared with healthy women group and baseline levels. Similarly, after the second cycle, the same parameters were increased (P < 0.05) when compared with baseline levels. Increase in catalase activity was detected only after the fourth cycle and reduced glutathione levels and glutathione peroxidase activity were decreased in all cycles when compared with healthy women, as well as after the second and fourth chemotherapy cycles compared to baseline (P < 0.05). Patients with breast cancer presented an indicative of oxidative stress before, during, and after chemotherapy, as well as increased genotoxic damage in all stages of treatment, demonstrating the clinical applicability of this investigation.

Desastres naturais: sistemas de informação e vigilância: uma revisão da literatura / Natural disasters: information systems and surveillance system: a review of literature

Objetivo: realizar revisão bibliográfica sobre a construção e implementação de sistemas de informação e vigilância sobre desastres naturais. Metodologia: o presente artigo apresenta uma revisão de literatura de artigos científicos realizada nas bases de dados Pubmed e Scielo. Resultados: demonstraram que os sistemas de informação e/ou vigilância utilizados tinham como objetivos principais a análise da extensão dos danos, identificação das áreas e populações vulneráveis e avaliação das necessidades em saúde de grupos populacionais mais expostos à ocorrência dos desastres. Conclusões: há a necessidade de sistemas de informação e vigilância integrados entre áreas como Saúde Pública, Defesa Civil e Ambiental para a análise dos efeitos dos desastres sobre a saúde das populações.

Objective: literature review on the construction and implementation of information systems and surveillance of natural disasters. Methodology: this article presents a literature review of papers held in the databases Pubmed and Scielo. Results: showed that information systems and/or surveillance were used as main objectives the analysis of the extent of the damage, identifying areas and vulnerable populations and assessment of health needs of population groups most exposed to the occurrence of disasters. Conclusions: there is need for information systems and integrated monitoring within areas such as Public Health, Civil and Environmental Defense to analyze the effects of disasters on the health of populations.

Modelo de organização de indicadores para operacionalização dos determinantes socioambientais da saúde / Model of organization of indicators for operationalizing the social-environmental determinants of health

O tema dos determinantes sociais e suas relações com o processo saúde-doença entre diferentes grupos populacionais é de grande relevância para a Saúde Pública e vêm ganhando cada vez mais destaque. Nesse processo, modelos teórico-conceituais vêm sendo adotados para explicar como os determinantes sociais geram iniquidades em saúde, de modo a subsidiar ações voltadas para as "causas das causas" e indicadores relacionados aos diferentes determinantes vêm sendo organizados por meio de metodologias que possibilitem análises integradas. Apesar desses avanços, os problemas ambientais que hoje se constituem em importantes elementos indutores da geração de doenças por meio da degradação dos ecossistemas e das mudanças climáticas têm sido pouco considerados como determinantes ambientais da saúde em conjunto com os sociais. Este artigo tem o objetivo de ampliar as discussões teóricas sobre os determinantes socioambientais da saúde, apresentando, para isso, uma metodologia de organização de indicadores de saúde ambiental denominada Força Motriz-Pressão-Situação-Exposição-Efeito-Ação, a fim de operacionalizar os determinantes sociais da saúde.

Immunohistochemical expression of E-cadherin in sclerosing adenosis, ductal carcinoma in situ and invasive ductal carcinoma of the breast.

E-cadherin (EC) is an important glycoprotein cell-adhesion molecule that appears to play a significant role in the progression of breast lesions. The objective of this study was to evaluate EC expression in sclerosing adenosis, ductal carcinoma in situ and invasive ductal carcinoma. Samples of breast lesions from 44 women were used in this study, comprising cases of sclerosing adenosis (n = 11), ductal carcinoma in situ (DCIS) (n = 10) and invasive ductal carcinoma (n = 23). Immunohistochemical evaluation of EC expression was assessed semiquantitatively and considered negative (<10% of cells with stained cytoplasmic membranes), positive+ (10-50% of cells stained) or positive++ (> 50% of cells stained). Fisher's exact test was used to compare the distribution of staining intensity in the lesions (P< 0.05). There was a progressive loss of EC expression from benign to malignant lesions. This difference was statistically significant when sclerosing adenosis was compared with DCIS (P < 0.0002), when sclerosing adenosis was compared with invasive ductal carcinoma (P < 0.008) and when DCIS was compared with invasive ductal carcinoma (P < 0.007). The present findings point to a significant association between reduced EC expression and the progression and aggressivity of breast lesions. Diagn. Cytopathol. 2010. (c) 2009 Wiley-Liss, Inc.